Every finding on record at Lamun-Lusk-Sanchez Texas State Veterans Home

Based on interview and record review, the facility failed to ensure that residents received mail for 11 of 14 confidential residents reviewed for rights to forms of communication for 1 of 1 facility reviewed for mail being delivered on Saturdays. The facility failed to have a system in place to ensure that residents received their mail on all days that mail was delivered by the United States Postal Service. This failure could result in a decline in residents' psychosocial well-being and potentially cause them to feel disconnected from family, friends, and current world issues. The findings include: During a confidential interview on 09/16/2026 at 03:15 PM, 11 confidential residents reported that the facility did not deliver mail on the weekends, as the staff who delivered mail was off on the weekends. During an interview with AD on 09/17/2026 at 01:40 PM the AD stated she was responsible for obtaining mail from the front desk receptionist and delivering the mail to the residents. The AD stated mail was not delivered to residents on Saturdays. The AD stated mail received on Saturdays was stored in a locked closet until the AD returned on Monday, as she was off on Saturday and Sunday. The AD stated there was not a system in place to deliver mail to residents when mail was received on the weekend. The AD stated if a resident did not receive mail that was delivered on the weekend until the following Monday, the resident may miss out on communicating with the family or loved ones. During an Interview with the ADM on 09/16/2026 at 03:30 PM the ADM stated the AD was responsible for distributing all mail to residents. The ADM stated she was not aware there was not a system in place to ensure residents received their mail on Saturdays when the AD was off. The ADM stated she planned to implement a new system to ensure residents received their mail on the weekends. The ADM stated it was her expectation that all mail be delivered to residents as soon as it was received. The ADM stated not receiving mail on weekends could have potentially impacted a resident by causing emotional frustration. Record review of the facility policy titled, Statement of Resident Rights, dated February 2017, revised January 2023, revealed the following documentation: Standard StatementThe health care center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations.Compliance Guidelines:The community should educate, encourage, and honor the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. Residents/Patients do not give up their rights when entering a [NAME] Community. Any violation of these rights is against the law. It is against the law for any nursing community employee to threaten, coerce, intimidate, or retaliate against the resident for exercising their rights.Resident/Patient Rights include:18. To receive unopened mail and to receive assistance in reading or writing correspondence;MailResidents have the right to privacy in written communications. Furthermore, residents have the right to send and promptly receive mail that is unopened. Mail will be delivered to the resident within 24 hours of delivery by the postal service. Outgoing mail will be delivered to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service (i.e., Sundays and holidays).

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 5 of 5 residents (Resident #5, Resident #8, Resident #22, Resident #139, and Resident #140) and 4 staff (LVN A, CNA B, CNA C, and Laundry Aide D) reviewed for infection control. The facility failed to ensure LVN A performed hand hygiene between all glove changes during wound care for Resident #5, Resident #22 and Resident #140. The facility failed to ensure CNA B performed hand hygiene between all glove changes during catheter care for Resident #139. The facility failed to ensure CNA C changed his gloves between dirty and clean procedures during incontinence care for Resident #8.The facility failed to ensure Laundry Aide D did not fold clean laundry against his body/clothing or use his chin to help fold the clean laundry. This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the admission record for Resident #140, dated 09/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (lung disease), type 2 diabetes mellitus (blood sugar problems) and essential hypertension (high blood pressure).Record review of the admission MDS assessment for Resident #140, dated 09/04/26, revealed a BIMS score of 13, indicating his cognition was intact. The MDS further revealed Resident #140 had one unhealed pressure ulcer. Record review of the order summary report for Resident #140, dated 09/16/26, revealed an order: Cleanse PI to sacrum/bilateral buttock with NS/Wound cleanser, pat dry, apply Gentamicin ointment, apply Acticoat [an antimicrobial dressing] and cover with foam dressing, cover with foam border gauze daily and PRN until resolved. As needed for Wound healing with a start date of 09/16/26.Record review of the care plan for Resident #140, last reviewed dated 09/08/26, revealed: Focus: Actual or at risk for skin impairment.Unstageable PI Sacrum/bilateral buttocks. Goal: My skin injury will resolve without associated complications through my review date. Date initiated: 09/02/26. During an observation on 09/16/26 at 11:05 AM, LVN A performed wound care for Resident #140's sacral pressure ulcer. LVN A put on a gown and washed her hands with soap and water. LVN A then put on clean gloves and Resident #140's pants and brief were pulled down. LVN A removed the old dressing to the sacrum and changed her gloves. No hand hygiene was performed between the glove change. LVN A then cleaned the wound bed with wound cleanser and gauze and patted the wound dry with gauze. LVN A then changed her gloves and did not perform hand hygiene between the glove change. LVN A then applied gentamicin ointment with cotton-tipped applicators and applied Acticoat to the wound bed. The wound was then covered with optifoam silicone border dressing. LVN A then changed her gloves and did not perform hand hygiene between the glove change. LVN A then pulled up the brief and shorts for Resident #140. LVN A then removed her gloves and used hand sanitizer after care. Record review of the admission record for Resident #22, dated 09/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (decline in mental ability severe enough to interfere with daily life), essential hypertension (high blood pressure), and muscle weakness.Record review of the quarterly MDS assessment for Resident #22, dated 08/30/26, revealed a BIMS score of 02, indicating severe cognitive impairment. The MDS further revealed Resident #22 had an unhealed pressure ulcer.Record review of the order summary report for Resident #22, dated 09/16/26, revealed an order: Cleanse PI to right medial foot with NS/Wound cleanser, pat dry, apply silver dressing, cover with bordered gauze. With a start date of 09/14/26.Record review of the care plan for Resident #22, last review dated 07/27/26, revealed: Focus: My skin is fragile and I am at risk for skin impairment.4/7/26 - Stage III PI [a deep, open crater in the skin, exposing layers of fat underneath] to right medial foot. Goal: My skin injury will resolve without associated complications through my review date. Date initiated: 04/08/26.During an observation on 09/16/26 at 1:47 PM, LVN A performed wound care to Resident #22's right medical foot pressure ulcer. LVN A put on a clean gown and used hand sanitizer. LVN A then put on clean gloves and removed the right footrest on Resident #22's wheelchair. LVN A changed her gloves and did not perform hand hygiene between the glove change. LVN A then removed the old dressing to Resident #22's right foot and change her gloves. LVN A did not perform hand hygiene between the glove change. LVN A then cleaned the wound bed with wound cleanser and gauze and patted the wound dry with gauze. LVN A then removed her gloves and washed her hands with soap and water. LVN A then put on clean gloves and put a Acticoat on the wound bed and covered the wound with optifoam border dressing. LVN A then changed her gloves and did not perform hand hygiene between the glove change. LVN A then put Resident #22's sock back on and put the right footrest back onto Resident #22's wheelchair. LVN A then removed her gloves and washed her hands with soap and water. Record review of the admission record for Resident #5, dated 09/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (a physical brain illness that slowly destroys memory, thinking skills, and the ability to do basic daily tasks), paroxysmal atrial fibrillation (irregular heart rate), and muscle weakness. Record review of the annual MDS assessment for Resident #5, dated 08/27/26, revealed Resident #5 had a BIMS score of 08, indicating his cognition was moderately intact. The MDS further revealed that Resident #5 had one unhealed pressure ulcer. Record review of the order summary report for Resident #5, dated 09/16/26, revealed an order: Cleanse Stage II pressure ulcer [a shallow open sore] to left heel with NS, pat dry, apply betadine, apply thin layer of Triad on skin around wound edges, apply Silvasorb on wound bed and dress with hydro conductive dressing, dress with foam heal protector until wound has resolved, one time a day with a start date of 08/11/26 and no end date. Record review of the care plan for Resident #5, last review completed on 07/27/26 revealed: Focus: My skin is fragile and I am at risk for skin impairment.7/27/26 pressure ulcer left heel. Interventions/Tasks: Skin Risk: Apply treatment as ordered. Date initiated on 08/27/26.During an observation on 09/16/26 at 2:47 PM, LVN A performed wound care to Resident #5's left heel wound. LVN A put on a gown and used hand sanitizer. LVN A then put on clean gloves and cut off the old dressing for Resident #5. LVN A then changed her gloves and did not perform hand hygiene between the glove change. LVN A then removed some more of the old dressing from Resident #5's left heel wound and changed her gloves without performing hand hygiene between the glove change. LVN A then cleaned the wound with normal saline and gauze and the wound was patted dry with gauze. LVN A changed her gloves and did not perform hand hygiene between the glove change. LVN A applied Triad cream to the healthy skin around the wound bed and applied Silvasorb to the wound bed. Calcium Alginate was put on the wound bed. LVN A changed her gloves and did not perform hand hygiene between the glove change. LVN A placed an optifoam dressing to the wound and applied and Abd pad and secured it with kerlix and tape. LVN A then removed her gloves and washed her hands with soap and water.During an interview on 09/17/26 at 11:42 AM, LVN A stated she normally took hand sanitizers in the resident room with her for wound care, but she was told not to by management staff. LVN A stated she was trained on hand hygiene recently, but she could not remember the exact date. LVN A stated a potential negative outcome to the residents was a potential for the wound to get worse or not heal properly.Record review of the admission record for Resident #139, dated 09/16/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: obstructive and reflux uropathy (conditions where a blockage or a backward flow of urine puts harmful pressure on the kidneys), unspecified atrial fibrillation (irregular heart rate), and personal history of urinary tract infections (bacteria in the urinary system).Record review of the quarterly MDS assessment for Resident #139, dated 07/24/26, revealed a BIMS score of 14, indicating his cognition was intact. The MDS further revealed Resident #139 had an indwelling catheter.Record review of the care plan for Resident #139, last review dated 08/18/26, revealed: Focus: I am at risk for infection or recurrent/chronic infection r/t compromised medical condition: Indwelling Foley Catheter. Goal: I will be free from s/s of infections and any complications related to infection through the review date. Date Initiated: 11/28/24. During an observation on 09/16/26 at 3:14 PM, CNA B performed catheter care for Resident #139. CNA B put on a gown and washed her hands with soap and water. CNA B put on clean gloves and pulled the brief down for Resident #139. CNA B then performed catheter care for Resident #139 cleansing the penis and the catheter going away from his body. CNA B then removed her gloves and stated she would apply hand sanitizer at this point. No hand sanitizer was applied. CNA B then put on clean gloves and replaced the dry brief on Resident #139. CNA B then removed her gloves and washed her hands with soap and water.During an interview on 09/17/26 at 11:28 AM, CNA B stated she received training on hand hygiene all of the time at the facility. CNA B stated she was last trained 30 days ago but she could not remember the exact date. CNA B stated she knew she should have performed hand hygiene between the glove changes, but she thought just saying when she would apply the hand sanitizer was good enough. CNA B stated she did not know she had to actually use the hand sanitizer during care. CNA B stated a potential negative outcome to the residents was they could get an infection. Record review of Resident #8s undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: type 2 diabetes mellitus (blood sugar problems), obstructive and reflux uropathy (conditions where a blockage or a backward flow of urine puts harmful pressure on the kidneys), and muscle weakness.Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. The MDS further revealed Resident #8 was dependent on toileting hygiene, meaning the helper does all of the effort.Record review of the care plan for Resident #8, last review dated 07/27/26, revealed: Focus: I am at risk for infection or recurrent/chronic infection r/t compromised medical condition.Foley catheter, recent hx UTI. Goal: I will not experience any complications or adverse reactions throughout the course of treatment, and the illness/infection will resolve through the next review date. Date initiated: 04/21/26.During an observation on 09/16/26 at 4:43 PM, CNA C provided catheter care and incontinence care for Resident #8. CNA C put on a gown, used hand sanitizer and put on clean gloves. CNA C pulled down the brief for Resident #8 and performed catheter care and incontinence care to the groin. CNA C then turned Resident #8 on his side and opened a clean brief without changing his gloves. CNA C then removed the old brief for Resident #8 and cleaned his buttocks with wipes. CNA C then placed the clean brief under Resident #8 and turned him on his back. CNA C then fastened the clean brief on Resident #8 and covered him up with a blanket. CNA C then removed his gloves and used hand sanitizer. During an interview on 09/17/26 at 11:49 AM, CNA C stated he was trained to perform hand hygiene and change his gloves when the gloves were visibly dirty and when going from dirty to clean during care. CNA C stated he did not change his gloves going from dirty to clean during incontinence care for Resident #8 because he blanked. CNA C stated he received hand hygiene training and infection control training when he was hired and during orientation. CNA C stated a potential negative outcome for the residents was a potential for infection or a more severe infection if they already had one. During an observation on 09/17/26 at 10:53 AM in the laundry room, Laundry Aide D was observed folding a clean bed pad up against his body and clothing and using his chin to help make a crease for folding. Two bed pads were observed being folded in this manner. During an interview on 09/17/26 at 11:01 AM, Laundry Aide D stated he had been trained to fold the clothing and linen away from his body. Laundry Aide D stated he was using his chin and putting the linen on his body to help fold because it made it easier to fold the bigger items. Laundry Aide D stated a potential negative outcome to the residents was they could react to his cologne or something on his clothing. During an interview on 09/17/26 at 2:30 PM, the DON stated she expected staff to perform hand hygiene between each glove change. The DON stated she expected staff to change their gloves as indicated, when going from dirty to clean during incontinence care. The DON stated the staff had been trained on hand hygiene and infection control, but she would have to look up the specific dates of the training. The DON stated the IP was also responsible for training the staff on infection control at the facility. The DON stated she did not know why LVN A and CNA B did not perform hand hygiene between the glove changes. The DON stated she did not know why CNA C did not change his gloves when going from dirty to clean during incontinence care. The DON stated a potential negative outcome to the residents was possible infections or delayed wound healing. During an interview on 09/17/26 at 2:41 PM, the HSK Supervisor stated the laundry staff were trained to fold the laundry with nothing dragging on the floor using baskets or the table and the clothing should not be up against their body at all, it was supposed to be held away from their body while folding. The HSK Supervisor stated she did not know why Laundry Aide D folding the laundry against his body and used his chin. The HSK Supervisor stated she would have to look up when Laundry Aide D was last trained on infection control procedures in the laundry. The HSK Supervisor stated a potential negative outcome to the residents was anything Laundry Aide D may have had on his clothes or he may have been carrying would contaminate the laundry all over again. The HSK Supervisor stated it was their job to keep the linen clean. During an interview on 09/17/26 at 2:51 PM, the IP stated she trained the staff all of the time regarding infection control. The IP stated she expected staff to change their gloves when going from dirty to clean skills. The IP stated she expected the staff to perform hand hygiene between glove changes. The IP stated Infection Control in-services were provided to staff frequently and they had to complete skills and competencies check offs before they were put on the floor. The IP stated the staff were not doing what they were trained and she was not sure what happened. The IP stated she would provide copies of the competencies and training for LVN A, CNA B, and CNA C. The IP stated the HSK Supervisor would have the training for Laundry Aide D. The IP stated a potential negative outcome to the residents was increased risk for infection, possibly spreading infection to other residents, and complications with the foley catheter if they had one. The IP stated a potential negative outcome to the residents with the laundry was a potential for hair or germs on the linen and also an infection risk because the linen was not clean.During an interview on 09/17/26 at 3:03 PM, the ADM stated the IP, the DON and herself were responsible for monitoring for infection control concerns at the facility. The ADM stated she did not know why there was a lack of hand hygiene during care for LVN A, CNA B, and CNA C or why Laundry Aide D was folding the linen against his body. The ADM stated all staff at the facility had been trained on infection control. The ADM stated she did not know when the last training was for the staff. The ADM stated a potential negative outcome to the residents was a risk for spreading germs. Record review of the training log for Laundry Aide D, dated 09/17/26, revealed: Infections Control Overview and Policy training was completed on 04/02/26. Record review of the facility document titled, Quarterly Mandatory In Person In-service for CNA's & CMA's, dated June 2026 revealed: .3. Infection Preventiona. WASH HANDS.CNA B's name and signature was observed on the training log.Record review of the facility document titled, CNA/Caregiver Competency Checklist, dated 06/10/26 for CNA B revealed: Infection Control: Hand Hygiene and Handwashing - met was checked off.Record review of the facility document titled, Name of skill - Hand-Washing, dated 06/18/26 for CNA B revealed: Purpose: To remove germs from hands and prevent the spread of infection.Guidelines and Precautions:1. Hand-washing is the single most important method in the prevention and control of infection.2. Hand-washing should be done at the following times:.c. before applying gloves and after removing gloves.CNA B had check- marks for Satisfactory for the steps of procedure.Record review of the facility document titled, Name of skill - Hand-Washing, dated 08/10/26 for LVN A revealed: Purpose: To remove germs from hands and prevent the spread of infection.Guidelines and Precautions:1. Hand-washing is the single most important method in the prevention and control of infection.2. Hand-washing should be done at the following times:.c. before applying gloves and after removing gloves.LVN A had check- marks for Satisfactory for the steps of procedure.Record review of the facility document titled, CNA/Caregiver Competency Checklist, dated 09/01/26 for CNA C revealed: Infection Control: Hand Hygiene and Handwashing - met was checked off.Record review of the facility document titled, Name of skill - Hand-Washing, dated 09/01/26 for CNA C revealed: Purpose: To remove germs from hands and prevent the spread of infection.Guidelines and Precautions:1. Hand-washing is the single most important method in the prevention and control of infection.2. Hand-washing should be done at the following times:.c. before applying gloves and after removing gloves.CNA C had check- marks for Satisfactory for the steps of procedure.Record review of the facility document titled, Handling, Transport and Storage of Laundry with a revised date of 10/23 reflected the following: .facility staff is required to handle, store, process and transport all linens and laundry in line with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible.Record review of the facility policy titled, Personal Laundry Procedure, undated reflected the following: Introduction: Providing clean personal clothing is essential to maintaining residents' comfort, dignity, and overall well-being in residential care settings. Proper laundering practices help prevent contamination, control odors, and preserve the integrity of garments. Each facility may have specific policies regarding the handling, laundering, and storage of residents' personal clothing, particularly during admission and throughout their stay. Staff should be familiar with these policies to ensure compliance and to accommodate residents' personal preferences while maintaining hygiene and infection control standards.For the management of clean clothing:.employees should never carry clean clothing against their bodies.Record review of the facility policy titled, Handwashing/Hand Hygiene with a revised date of January 2023 reflected the following: Guideline: This facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation:.2. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to):.between glove changes/after removing gloves.8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections.Record review of the facility policy titled, Infection Prevent and Control, with a revised date of April 2024 reflected the following: Compliance Guidelines: 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.prevention of infection.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 2 of 2 meals reviewed for palatability.The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 2 of 2 meals observed on 9/15/26 for lunch and dinner.These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.The findings included:Record review of the Resident Council Minutes dated 06/15/26 revealed resident comments related to the food served in the facility. It was documented, food is always cold to the halls.Record review of Grievance and Complaint Log, dated April 2026, revealed a complaint submitted on 4/2/26 for cold food. Record review of Grievance and Complaint Log, dated May 2026, revealed three complaints were submitted on 5/11/26 and 5/20/26 for cold hard food. There was also a complaint submitted on 5/14/26 on the taste of the food. Record review of the Resident Council Minutes dated 06/15/26 revealed resident comments related to the food served in the facility. It was documented, food is always cold to the halls.The following confidential responses were provided during the initial pool interview screening process on 9/15/26: A resident stated, The food was lacking in general. A second resident stated the food lacked flavor and was too hard to chew. A third resident stated, the food was not good, lacked spices, and lacked taste. A fourth resident stated the food was bland and cold. A fifth resident stated the food was tough and the vegetables were bland. A sixth resident stated the food lacked flavor. A seventh resident stated they were concerned with the temperature of the food and preferred it to be warmer when they received their food. On 9/15/26 at 10:30 AM the Dietary Manager was informed of a request for a test tray for the meal served at 12:30 PM (lunch).On 9/15/26 at 1:29 PM the test trays arrived at the conference room and sampling began at 1:30 PM with the following results: Regular Meal - Mechanical Soft Textureminced Philly cheese steak - lukewarm/coldcabbage - blandmashed potatoes - blandRegular Meal - Puree Texturepuree Philly steak- coarse texturepuree cabbage - blandmashed potatoes - blandpuree bread - okayOn 9/15/26 at 4:30 PM the Dietary Manager was informed of a request for a test tray for the meal served at 5:30 PM (dinner).On 9/15/26 at 6:28 PM the test trays arrived at the conference room and sampling began at 6:29 PM with the following results:Regular meal plate - Regular Texturepork ribs - bland, drysweet potato - blandside salad - warmfried Okra - blandpears - canned flavor Regular Meal - Mechanical Soft TextureMechanical soft pork ribs - okaysweet potato - blandmixed vegetables- mushy/overcooked, blandside salad - warmpears - canned flavorRegular Meal - Puree Texturepuree pork - goodpuree Cabbage - blandpuree sweet potatoes - bland, dull coloring when compared to the whole sweet potato, white colored substance observed in the center of the mound of this food item.puree mixed vegetables - bland, poor tastepuree pears - canned flavor Always available food items:beef vegetable stew- bland, poor tasteDuring a confidential interview on 9/16/26 at 3:15 PM, eleven confidential residents reported they were unhappy with the palatability of the food served in the facility. Three confidential residents stated they had spoken with the dietary staff in recent months regarding their concerns, and there had not been any improvements. Eleven confidential residents stated they did not like any of the meals that were served daily. Eleven confidential residents stated they would like the food served in the facility to be improved.During an interview on 9/17/26 at 3:59 PM, the DM stated she was aware of recent complaints of the food being cold and bland and tried to correct concerns and complaints. The DM stated she attended resident council meetings to get more specific input on concerns related to the issues with the food. The DM stated they could not add too much salt to the food due to dietary restrictions of some of the residents. The DM stated the correct texture for puree food was pudding-like and smooth and should have a similar flavor to the regular diet food. The DM stated the food should be cooked at 165 F or above and served at no lower than 135 F. The DM stated temperatures were taken of all food items when they were placed on the steam carts, however she was not sure of the temperature of the food when it left the kitchen and served to residents. The DM stated the cooks and herself were responsible for checking food temperatures. The DM stated she was not aware the puree food was not blended properly. The DM stated all puree foods should have been blended fully and one color. The DM stated if more than one color was visible in a puree food, then that would indicate the food was not properly blended. The DM stated the cook may add bread or thickening powder to the puree sweet potatoes if the form of the food did not sit properly, could have caused the color of the sweet potatoes to lighten. After reviewing the photograph of the puree sweet potatoes, the DM stated she believed the cook may have mixed mashed potatoes in the sweet potatoes to try to get the proper form. The DM stated the cook should have used thickening powder to get the right consistency instead of mixing in mashed potatoes. The DM stated she was aware the puree Philly steak meat was coarse and tried to get it smoother, but it was too hard to get it to the proper consistency. The DM stated the texture of the puree Philly steak meat needed to be smoother. The DM stated she tasted the puree Philly cheese steak meat before it was served to residents and approved it to be served but had since realized she should not have approved of that dish. The DM stated she followed spreadsheets provided to her by the facility to determine how food was supposed to be served and she tasted the food before it was served to residents to monitor the flavor of the food and ensure they followed policy. The DM stated she was trained in food palatability and food safety. The DM stated dietary staff completed food safety and preparation training called Learn which consisted of modules and a final test they had to pass. The DM stated she also provided refresher training to dietary staff periodically. The DM stated she and the cooks were responsible for ensuring the food texture, taste, temperature, and palatability followed the facility's food policy at 100 percent. The DM stated potential negative outcomes of not having the proper taste, texture, temperature, and palatability were that residents could choke or have weight loss. During an interview on 9/17/26 at 4:39 PM, [NAME] G stated she prepared the puree meal served for dinner on 9/15/26. [NAME] G stated the proper texture for the puree diet was supposed to be pudding like, smooth, with no chunks. [NAME] G stated the puree dishes should be one color as multiple colors indicated they were not properly blended. [NAME] G stated she was not aware the puree sweet potatoes were not one solid color. [NAME] G stated she added food thickener and chicken broth to the puree sweet potatoes which could have been the white color substance observed on the sample tray. [NAME] G stated food should not be served above 165 F because it was outside of the safety range. [NAME] G stated food should be at 165 F when they were done cooking, but she was not sure of temperature food was served at. [NAME] stated she tasted the food before it was served for monitoring purposes. [NAME] G stated she was trained in food safety and palatability. [NAME] G stated the DM was responsible for ensuring the food texture, taste, temperature, and palatability followed the facility's food policy. [NAME] G stated potential negative outcomes were that there would be complaints and residents would not eat, resulting in weight loss. During an interview on 9/17/26 at 4:28 PM, [NAME] F stated she prepared the puree meal served for lunch on 9/15/26. [NAME] F stated the pureed food texture should have been a pudding like consistency, with no chunks or grittiness. [NAME] stated the food should be served at 145 F or above. [NAME] F stated she was aware the Philly steak was grainy when she served it but there were no chunks. [NAME] F stated the Philly steak should not been but felt she pureed it as much as she could. [NAME] F stated she monitored the food for proper form, texture, taste and temperature by serving it on a plate to observe the form, she tasted it and used a thermometer to check the temperature. [NAME] F stated she was trained by the DM and was in-serviced on a weekly basis in proper food safety and palatability. [NAME] F stated she was responsible for ensuring meals were served according to the facility policy. [NAME] F stated bland or cold food could cause residents to not want to eat and they could lose weight. [NAME] F stated pureed food that was grainy or coarse could cause residents to choke.During an interview on 9/17/26 at 4:49 PM, the ADM stated cold food must be at 41 F or colder and hot food must be at 135 F or hotter. The ADM stated pureed food should have been a pudding-like texture and should have been smooth and not grainy. The ADM stated the taste of food was subjective, and due to how many people they served she knew not everyone was going to like it. The ADM stated she was not aware the pureed Philly steak had a coarse texture and that pureed food was not fully blended. The ADM stated pureed food should have been blended. The ADM stated she expected dietary staff to check the temperatures of all food before it was served to the residents. The ADM stated dietary staff monitored the food and sampled test trays to spot check the food to ensure it was served according to policy. The ADM stated the DM was responsible for ensuring the food followed facility policy. The ADM stated staff were trained in the dietary requirements of the facility. The ADM stated it was important for the texture of pureed food to be correct to reduce the risk of choking. The ADM stated a potential negative outcome of not following food safety and palatability requirements was that improper temperatures of the food could create food-borne illness, lack of taste could cause the residents to not want to eat the food, and they could have weight loss.Record review of the facility's, policy/guideline titled Dietary Services, revised January 2023, revealed the following in part: Compliance Guidelines: The community provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.The community employs sufficient support personnel competent to carry out the functions of the dietary service. Sufficient support personnel is defined as enough team members to prepare and serve palatable, attractive, nutritionally adequate meals at proper temperatures and appropriate times and to support proper sanitary techniques being used.Food services are managed by either a qualified dietitian or an experienced or qualified food service director. If a qualified dietitian is not employed full-time, the community has designated a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.Food The community ensures that each resident receives food prepared by methods that conserve nutritive value, flavor, and appearance.Food is prepared and served to ensure that is palatable, attractive, and at the proper temperature. The community ensures that the nutritive value of food is not compromised and destroyed by any of the following:Food should be palatable, attractive, and at the proper temperature as determined by the type of food to ensure residents' satisfaction.Food-palatability refers to the taste and flavor of the food.Food attractiveness refers to the appearance of the food when served to residents.Therapeutic diets Residents receive and consume foods and fluids in the appropriate form and appropriate nutritive content as prescribed by a physician. Therapeutic diets are developed after the interdisciplinary team assessment in accordance with the resident's treatment and plan of care.The community reconciles differences between resident preferences and therapeutic diet limitations.The purpose of the therapeutic diet is to:eliminate or decrease specific nutrients in the diet (e.g., sodium)increase specific nutrients in the diet (e.g., potassium)provide food the residents can eat (e.g., a mechanically altered diet)Food temperatures Hot foods leave the kitchen (or steam table) above 140 F, and cold foods are served at or below 41 F. Freezer temperatures are maintained at or below 0 F, whereas refrigerator temperatures will be maintained at or below 41 F.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate were less than 5 percent. The facility had a medication error rate of 23.53% based on 8 out of 34 opportunities, which involved 1 of 3 Residents (Residents #126) reviewed for medication administration.The facility failed to ensure CMA E had a physician order to crush Resident #126's medications resulting in incorrect dosage form for eight of Resident #126's medications.This failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.The findings include:Record review of Resident #126's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #126 had a medical history of Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), hypertension (high blood pressure), chronic kidney disease (kidneys are damaged and cannot filter blood the right way over a long period of time), depression, benign prostatic hyperplasia (a noncancerous increase in the size of the prostate gland) and dementia (a decline in mental abilities severe enough to interfere with daily life).Record review of Resident #126's MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 12 which indicated Resident #126 had moderate cognitive impairment. Section K-Swallowing/Nutritional Status of the MDS did not reveal Resident #126 had a swallowing disorder. Record review of Resident #126's care plan did not reveal Resident #126 had a swallowing impairment and did not reveal Resident #126 required crushed medications during medication administration.Record review of Resident #126's physician orders revealed the following medication orders:Cholecalciferol Oral Tablet 50 MCG (vitamin D) 1 tablet one time a day with a start date of 5/07/2026Multivitamin Oral Tablet (Multiple Vitamin) Give 1tablet by mouth one time a day with a start date of 07/13/2026Lyrica Capsule 150 MG (Pregabalin, medication used to treat nerve pain) Give 1 capsule by mouth every morning with a start date of 07/13/2026.Sertraline HCl Oral Tablet 50 MG (Sertraline HCl, antidepressant used to treat anxiety and depression) Give 1 tablet by mouth one time a day with a start date of 07/13/2026.Potassium Chloride ER Tablet Extended Release 10 MEQ (used to treat low potassium levels) Give 1 tablet by mouth one time a day with a start date of 07/13/2026.Finasteride Oral Tablet 5 MG (Finasteride- used to treat enlarge prostate) Give 1 tablet by mouth one time a day with a start date of 05/07/2026.Abilify Oral Tablet 2 MG (Aripiprazole- used to treat various mental health conditions) Give 0.5 tablet by mouth one time a day with a start date of 8/14/2026.DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl- prescription antidepressant and nerve-pain medication) Give 1 capsule by mouth three times a day, with a start date of 8/23/2026.Resident #126's physician orders did not reveal an order for crushed medications.Record review of facility undated document titled A wing 200 hall vital signs section Notes revealed Resident #126 had a note for Whole/pudding.During a medication administration observation on 9/16/2026 at 8:41am, CMA E prepped Resident #126's medications. CMA E prepared to enter Resident #126's room but stated, I need to crush his medication. CMA E proceeded to crush the following medications and mix with vanilla pudding in a medication cup; Cholecalciferol Oral Tablet 50 MCG 1 tablet, Multivitamin Oral Tablet 1 tablet, Sertraline HCl Oral Tablet 50 MG 1 tablet, Potassium Chloride ER Tablet Extended Release 10 MEQ 1 tablet, Finasteride Oral Tablet 5 MG 1 tablet and Abilify Oral Tablet 2 MG 1 tablet. CMA E opened the capsules of the following medications and sprinkled the contents into the pudding; Lyrica Capsule 150 MG 1 capsule, and DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG 1 capsule.During an interview and record review on 9/16/2026 at 2:57pm, CMA E stated Resident #126 liked to have his medication crushed because it was easier for him to swallow and it was his preference. She stated residents that need crushed medications usually had it listed on the top of their electronic medical chart. CMA E reviewed Resident #126's electronic medical chart and stated he did not have a special requirement for crushed medication. She stated it was also listed on the medication cart binder under Notes when a resident required something special or if they had a medication preference. CMA E reviewed the document titled A wing 200 hall vital signs under section titled Notes and stated Resident #126 did not have a special requirement for crushed medication and instead stated whole/pudding. CMA E stated she had told the nurses in the past to add Resident #126's medications as crushed because it was easier for him to swallow. CMA E stated she had been trained on medication administration, and she required a physician order to crush any resident's medication. She stated Resident #126 did not have an active order for crushed medications and she would consider the medications she crushed to be a medication error. She stated a potential negative outcome of crushing medication without a physician order could be medication not absorbing correctly. She stated she would report the medication errors to the DON and physician.During an interview on 9/16/2026 at 3:29pm, the DON stated Resident #126 did not currently have an active order for crushed medications. She stated CMA E should not have crushed the medications without a physician order. The DON stated her expectation of staff was to follow the medications rights of administration and follow facility procedures and physician orders. She stated that a potential negative outcome of crushing medications without a physician order could be a medication error, and inadequate medication absorption. She stated the capsules being opened could cause a delay in medication absorption or an increase in medication absorption. She stated staff are trained annually and quarterly on medication administration. The DON stated if a staff member feels a resident required crushed medication, they should notify the charge nurse and have them begin the process of obtaining physician orders. She stated medication administration was monitored for compliance through record review, and visual observations as needed. She stated Resident #126 did not have any adverse effects from the crushed medication.During an interview on 9/16/2026 at 4:10pm, the MD stated crushed medications required a physician order. He stated the staff member providing medications should also be aware of what medication was safe to crush or at least be capable of looking it up prior to administering a crushed medication. The MD reviewed the list of crushed medications that were given to Resident #126 and stated he did not feel any of those medications would be harmful to the resident if crushed. He stated a potential negative outcome of crushing medication without a physician order could be an increase in adverse effects, the medication lasting too long, or not lasting long enough. He stated he did not see those medications causing serious impairment or harm to the resident. He stated his expectation of the facility was to ensure an order was obtained and to ensure the medications are safe to crush prior to administration.During an interview on 9/16/2026 at 4:58pm with Resident #126, he stated he preferred to have his mediations crushed because it was easier for him to swallow. He stated he had trouble swallowing some of the larger pills and the pudding makes it easier for him to take all his medications. He stated after taking his medications today, he had not felt drowsy, sleepy, and did not feel he had any negative changes to his health. He stated he was fine and requested to keep getting his medications crushed.During a second interview on 9/16/2026 at 5:00pm with the DON, she stated they had reached out to their pharmacy consultant and were in the process of reviewing Resident#126's medications to ensure it could be crushed or switching it to a different form if needed.During an interview on 9/17/2026 at 11:56am, the PC stated he had reviewed the medications crushed for Resident #126 and there were only two of the medications that should not have been crushed as it could increase adverse effects of those medications. He stated medications should not be crushed without a physician order as it required a pharmacy review and care planning to determine if the medications are safe to be crushed.During an interview on 9/17/2026 at 2:33pm, the ADM stated staff are trained on medication administration annually and as needed. She stated the DON and nurse leadership are responsible for monitoring medication administration for accuracy and compliance. She stated staff require a physician order to crush any medication. She stated a potential risk of crushing medications without a physician order could be adverse effects, non-therapeutic doses, or the medication not being potent. She stated her expectation of staff was for them to follow the appropriate medication administration guidelines and procedures.Record review of facility policy titled Medication Administration dated March 2019 revealed Resident medications are administered in an accurate, safe, timely and sanitary manner.4. Follow safe preparation practices.e. Validate that the medication can be crushed, my[might] refer to the DO Not Crush list before crushing medications. Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on observation, interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 30 residents (Resident #8) reviewed for respect and dignity. The facility failed to ensure CNA C closed the privacy curtain all the way around Resident #8 while providing incontinence care. This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.Findings include: Record review of Resident #8's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: type 2 diabetes mellitus (blood sugar problems), obstructive and reflux uropathy (conditions where a blockage or a backward flow of urine puts harmful pressure on the kidneys), and muscle weakness.Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. The MDS further revealed Resident #8 was dependent on toileting hygiene, meaning the helper does all of the effort. During an observation on 09/16/26 at 4:43 PM of incontinence care, CNA C closed the door and the privacy curtain remained halfway pulled between Resident #8's bed and his roommate's bed. While CNA C had Resident #8 turned on his side facing the wall, with his buttocks exposed to the room, the roommate came across from his side of the room and was able to view Resident #8's exposed buttocks. Resident #8's roommate then opened the door as Resident #8 was turned on his back and Resident #8's groin was exposed to the hallway during care. During an attempted interview on 09/16/26 at 4:57 PM, Resident #8 refused interview with the surveyor.During an interview on 09/17/26 at 11:49 AM, CNA C stated he was trained on privacy and dignity during his orientation training at the facility. CNA C stated he was trained to provide privacy and dignity to the residents by knocking on the door, announcing himself to the residents, closing the door and the blinds and pulling the privacy curtain all the way around the resident. CNA C stated he did not think to close the privacy curtain all the way around Resident #8. CNA C stated a potential negative outcome to the residents was a potential for embarrassment or invasion of privacy and a lack of respect. During an interview on 09/17/26 at 2:30 PM, the DON stated she expected the CNAs to maintain dignity and privacy during care. The DON stated CNA C received dignity training on his orientation to the facility due to him being a new employee. The DON stated she did not know why CNA C did not provide privacy and dignity for Resident #8 during incontinence care. The DON stated a potential negative outcome for the residents was a potential for distress or embarrassment. During an interview on 09/17/26 at 3:03 PM, the ADM stated she expected the staff to maintain dignity and privacy for every veteran The ADM stated she did not know why CNA C did not pull the curtain all the way for Resident #8 during incontinence care. The ADM stated CNA C should have been trained on hire/during orientation. The ADM stated a potential negative outcome to the residents was it could be an emotional issue risk. Record review of the facility document titled, CNA/Caregiver Competency Checklist for CNA C dated 09/01/26 revealed a skill for Privacy (Door, Privacy Curtain, Window blinds) Knocking on doors before entering and a check mark in the met box. Record review of facility policy titled Standards for Clinical Procedures with a revised date of January 2023 reflected the following: Guideline: Appropriate care is taken to put forth the resident's right to privacy and dignity, as well as the resident's health and safety are protected during the performance of any clinical care or procedure.Compliance Guidelines:1. Prior to the initiation of any clinical procedure:.g. Pull the privacy curtain between the residents, even if the roommate is not present.Record review of the facility policy titled, Respect and Dignity with a revised date of January 2023 reflected the following: Compliance Guidelines: The community promotes care for residents in a manner and environment that enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity means that the team members carryout activities that assist the resident to maintain and enhance self-esteem and self-worth.

Based on observation, interview and record review, the facility failed to ensure residents with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents (Resident #5) reviewed for pressure ulcers. The facility failed to ensure LVN A followed physician orders for Resident #5's wound care to his left heel. This failure could place residents at risk of delayed wound healing, worsening wounds resulting in undue pain and discomfort, and deterioration on residents' general condition.Findings include: Record review of the admission record for Resident #5, dated 09/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (a physical brain illness that slowly destroys memory, thinking skills, and the ability to do basic daily tasks), paroxysmal atrial fibrillation (irregular heart rate), and muscle weakness. Record review of the annual MDS assessment for Resident #5, dated 08/27/26, revealed Resident #5 had a BIMS score of 08, indicating his cognition was moderately intact. The MDS further revealed that Resident #5 had one unhealed pressure ulcer. Record review of the order summary report for Resident #5, dated 09/16/26, revealed an order: Cleanse Stage II pressure ulcer [a shallow open sore] to left heel with NS, pat dry, apply betadine, apply thin layer of Triad on skin around wound edges, apply Silvasorb on wound bed and dress with hydro conductive dressing, dress with foam heal protector until wound has resolved, one time a day with a start date of 08/11/26 and no end date. Record review of the care plan for Resident #5, last review completed on 07/27/26 revealed: Focus: My skin is fragile and I am at risk for skin impairment.7/27/26 pressure ulcer left heel. Interventions/Tasks: Skin Risk: Apply treatment as ordered. Date initiated on 08/27/26. During an observation on 09/16/26 at 2:47 PM, LVN A provided wound care to Resident #5's left heel pressure ulcer. LVN A cleansed the wound bed with NS and gauze and patted dry with gauze. LVN A then applied Triad cream to the healthy skin around the wound and then applied Silvasorb to the wound bed and then calcium alginate to the wound bed. An optifoam dressing was then applied to cover the wound, and an Abd pad was placed over the optifoam and was secured in place with a kerlix wrap and tape. During an interview on 09/17/26 at 11:42 AM, LVN A stated she was trained to follow physician orders daily with verbal reminders. LVN A stated she normally got the order from the MD and she then made sure the supplies were put in her wound cart and she would advise the MD if any wound orders were not working. LVN A stated she normally follows the wound care orders to a T, but it slipped her mind for Resident #5. LVN A stated a potential negative outcome to the residents was a potential for delayed wound healing or the wound going back to where it started. During an interview on 09/17/26 at 2:30 PM, the DON stated she expected the orders for wound care to be followed. The DON stated the only training LVN A was provided regarding following MD orders for wound care involved medication administration training. The DON stated she would have to look up the exact dates for those trainings. The DON stated she did not know why LVN A did not follow physician orders for Resident #5's wound care. The DON stated a potential negative outcome to the residents was possible delayed wound healing and complications. During an interview on 09/17/26 at 3:03 PM, the ADM stated she expected the wound care orders to be followed. The ADM stated the DON and the IP/Director of Clinical Education were responsible for training the staff at the facility. The ADM stated she did not know without looking up when the last time LVN A had been trained regarding following physician orders. The ADM stated a potential negative outcome to the resident was the risk that the wound may not heal.Record review of the facility document titled, Staff Development/Inservice Attendance Sheet, dated 06/12/26 reflected the following: Topic/Content: Wound Care.Follow wound care orders as prescribed by NP/MD. LVN A's printed name and signature were on the bottom of the page. Record review of the facility document titled, Staff Development/Inservice Attendance Sheet, dated 07/16/26 reflected the following: Topic/Content: 6 Rights of Medication Administration.Verify the Right medication. LVN A's printed name and signature were noted on the bottom of the page.Record review of the facility policy titled, Skin and Wound Prevention and Management, with a revised date of January 2026 reflected the following: Guideline Statement: An individuals' skin is the largest organ of the body.Each resident will receive the care and services necessary to retain or regain optimal skin integrity.

Based on observations, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #126) of 3 residents reviewed for medication administration.The facility failed to ensure CMA E did not crush Resident #126 Finasteride Oral Tablet 5 MG (Finasteride- used to treat enlarge prostate) and Potassium Chloride ER 10 MEQ on 9/16/2026.This failure could place residents at risk of not receiving the full therapeutic effects of their medication and can result in a decline of their health conditions. The Findings include:Record review of Resident #126's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #126 had a medical history of Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks) , hypertension (high blood pressure), chronic kidney disease (kidneys are damaged and cannot filter blood the right way over a long period of time), depression, benign prostatic hyperplasia (a noncancerous increase in the size of the prostate gland) and dementia (a decline in mental abilities severe enough to interfere with daily life).Record review of Resident #126's MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMs score of 12 which indicated Resident #126 had moderate cognitive impairment. Section K-Swallowing/Nutritional Status of the MDS did not reveal Resident #126 had a swallowing disorder. Record review of Resident #126's care plan did not reveal Resident #126 had a swallowing impairment and did not reveal Resident #126's required crushed medications during medication administration.Record review of Resident #126's physician orders revealed the following medication orders:Potassium Chloride ER Tablet Extended Release 10 MEQ (used to treat low potassium levels) Give 1 tablet by mouth one time a day with a start date of 07/13/2026.Finasteride Oral Tablet 5 MG (Finasteride- used to treat enlarge prostate) Give 1 tablet by mouth one time a day with a start date of 05/07/2026 It is recommended that gloves be worn by the person handling or administering this product due to potential developmental or reproductive hazards.Resident #126's physician orders did not reveal an order for crushed medications.During a medication administration observation on 9/16/2026 at 8:41am, CMA E proceeded to crush the following medications and mix with vanilla pudding in a medication cup; Potassium Chloride ER Tablet Extended Release 10 MEQ 1 tablet, and Finasteride Oral Tablet 5 MG 1 tablet.During an interview and record review on 9/16/2026 at 2:57pm, CMA E stated Resident #126 liked to have his medication crushed because it was easier for him to swallow and it was his preference. CMA E stated she had told the nurses in the past to add Resident #126's medications as crushed because it was easier for him to swallow. CMA E stated she had been trained on medication administration, and she required a physician order to crush any resident's medication. She stated a potential negative outcome of crushing medication without a physician order could be medication not absorbing correctly. She stated Resident #126 had not experienced any adverse effects.During an interview on 9/16/2026 at 3:29pm, the DON stated Resident #126 did not currently have an active order for crushed medications. She stated CMA E should not have crushed the medications without a physician order. She stated that a potential negative outcome of crushing medications without a physician order could be a medication error, and inadequate medication absorption. She stated staff are trained annually and quarterly on medication administration. The DON stated if a staff member felt a resident required crushed medication, they should notify the charge nurse and have them begin the process of obtaining physician orders. She stated Resident #126 did not have any adverse effects from the crushed medication.During an interview on 9/16/2026 at 4:10pm, the MD stated crushed medications required a physician order. He stated the staff member providing medications should be aware of what medication were safe to crush or at least be capable of looking it up prior to administering a crushed medication. The MD reviewed the list of crushed medications that were given to Resident #126 and stated he did not feel any of those medications would be harmful to the resident if crushed. He stated a potential negative outcome of crushing the medication could be an increase in adverse effects, the medication lasting too long, or not lasting long enough. He stated his expectation of the facility was to ensure an order was obtained and to ensure the medications are safe to crush prior to administration.During an interview on 9/16/2026 at 4:58pm with Resident #126, he stated he preferred to have his mediation crushed because it was easier for him to swallow. He stated he had trouble swallowing some of the larger pills and the pudding makes it easier for him to take all his medications. He stated after taking his medications today, he had not felt drowsy, sleepy, and did not feel he had any negative changes to his health. He stated he was fine and requested to keep getting his medications crushed.During an interview on 9/17/2026 at 11:56am, the PC stated he had reviewed the medications crushed for Resident #126 and there were only two of the medications that should not have been crushed. He stated Potassium Chloride ER Tablet Extended Release 10 MEQ should not be crushed as it can cause irritation to the stomach lining due to its potency as well as potential for increase in adverse effects due to the entire dose being given at once rather than being extended released (formulated to release the active drug slowly and steadily into your body over an extended period, rather than all at once). He stated the Finasteride Oral Tablet 5 MG could cause reproductive harm to the individuals handling the crushed medication if not handled appropriately. He stated medications should not be crushed without a physician order as it required a pharmacy review and care planning to determine if the medications are safe to be crushed.During an interview on 9/17/2026 at 2:33pm, the ADM stated staff are trained on medication administration annually and as needed. She stated the DON and nurse leadership are responsible for monitoring medication administration for accuracy and compliance. She stated staff require a physician order to crush any medication. She stated a potential risk of crushing medications without a physician order could be adverse effects, non-therapeutic doses, or the medication not being potent. She stated her expectation of staff to for them to follow the appropriate medication administration guidelines and procedures.Record review of facility document titled Common Oral Dosage Forms that should Not Be Crushed dated November 2018 revealed Finasteride. Potassium Chloride+ [legend symbol] .+ alternative formulation (e.g. immediate release formulations oral solutions etc.) may be available. An adjustment in the dose and frequency of administration for the alternative agent may be necessary. The final choice of therapy is a decision that should be made by the prescriber based on the individual patient's characteristics and clinical solutionRecord review of facility policy titled Medication Administration dated March 2019 revealed Resident medications are administered in an accurate, safe, timely and sanitary manner.4. Follow safe preparation practices.e. Validate that the medication can be crushed, my[might] refer to the Do Not Crush list before crushing medications. Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed.

Based on observation, interview, and record review, the facility failed to follow their policy on personal resident refrigerators for 2 of 32 personal resident refrigerators reviewed for food safety (Resident #12 and #134) The facility failed on 08/07/2025 when the refrigerators located in Resident #12 and Resident #134's rooms were not being monitored for internal temperature and expiration/used by dates. These failures could place residents at risk for food borne illnesses.Findings included: Record review of the face sheet, dated 08/07/2025, revealed Resident #12 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included the following: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss that deteriorates over time), anxiety disorder (excessive worry about everyday issues and situations), and post traumatic stress disorder, chronic (mental health condition that can develop after experiencing or witnessing a traumatic event) .Record review of Resident #12's admission MDS assessment, dated 04/07/2025, revealed Resident #12 had a BIMS score of 01, which indicated severely impaired cognition. During an observation and attempted interview on 08/07/2025 at 1:05 PM, Resident #12's contained a personal refrigerator. The refrigerator contained two bottles of soda. The refrigerator was observed to be soiled with soda in the bottom of the refrigerator. An interview was attempted with Resident #12, but he did not respond. Record review of the face sheet, dated 08/07/2025, revealed Resident #134 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Type 2 Diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), anxiety disorder (excessive worry about everyday issues and situations), and age related physical disability (general decline in physical and mental functioning) .Record review of Resident #134's admission MDS assessment, dated 12/29/2024, revealed Resident #134 had a BIMS score of 15, which indicated impaired cognition. During an interview and observation on 08/07/2025 at 1:20 PM, Resident #134's room contained a personal refrigerator. The refrigerator containing perishable food items such as 4 yogurts, 5 sodas, and cheese spread. The refrigerator also contained a container of expired Greek yogurt (expiration date 07/22/2025), and two unlabeled and undated containers of an unknown food substance. The refrigerator contained a jar of salsa with an illegible expiration date. The jar of salsa appeared to have mold inside. Resident #134 stated the facility staff did not clean out her refrigerator and she cleaned it out herself. Resident #134 stated she was unaware the refrigerator contained expired food items. Resident #134 stated she was unable to see the date on the items as it was too small for her to read. Resident #134 stated she did not usually check the dates on her food items. During an interview on 08/07//2025 at 01:30 PM, RN A stated the nursing staff were responsible for cleaning resident's personal refrigerators and discarding any expired or undated food items. RN A stated this was a task completed by CNAs. RN A stated she was not aware there were any expired food items in resident's refrigerators because it was not a task for the nurses. During an interview on 08/07//2025 at 01:35 PM, CNA C stated the nursing staff were responsible for cleaning resident's personal refrigerators and discarding any expired or undated food items. CNA C stated she tried to check refrigerators daily on the halls she was assigned to. CNA C stated she was assigned to Resident #12 and Resident #134. CNA C could not recall when she last cleaned the refrigerators for Resident #12 or Resident #134. CNA C sated she was not aware of any spills or expired and undated food items in any refrigerators on her assigned hallways. CNA C stated sometimes residents did not want their refrigerators cleaned out, so she complied with their wishes. CNA C could not recall the last time a resident said they did not want their refrigerator cleaned out. CNA C stated she did not report this to the DON or ADM, and stated she did not feel it was necessary. CNA C stated she would talk with her DON. CNA C stated it was important to discard of any food items that were unlabeled or undated because it could cause the resident to get sick. CNA C stated it was important to clean each refrigerator to ensure they were sanitary. During an interview on 08/07/2025 at 2:05 PM, the DON stated the nursing staff were responsible for checking every personal refrigerator in resident's rooms daily during their shift. The DON stated the nursing staff was responsible for discarding of any expired or undated food item and cleaning the inside of the refrigerator daily. The DON stated there were a few residents who did not like to have their refrigerators cleaned, and it was her expectation that staff approach her with any concerns of residents who did not allow staff to discard of expired foods. The DON stated all nursing staff have been trained regarding this daily task. The DON stated she had not received any recent reports of residents refusing. The DON stated the nursing staff were also responsible for checking the temperatures of the refrigerators to ensure they were working properly. The DON stated if the refrigerators were not working properly it was reported to the family for further assistance, as the refrigerators belonged to the residents. The DON stated it was important to ensure expired foods were discarded promptly, as consuming expired foods could have caused food borne illness to the resident, as well as ensuring the refrigerator were clean and sanitary. The DON stated she was not aware any resident's refrigerators contained expired foods, and she stated she would have nursing staff ensure all personal refrigerators were checked as soon as possible. During an interview on 08/07/2025 at 02:35 PM, the ADM stated nursing staff were responsible for cleaning the residents' personal refrigerators daily. The ADM stated this included cleaning spills and discarding of any expired foods. The ADM stated it was her understanding that all containers of food must be dated with an expiration or use by date. The ADM stated the facility had been working on developing a good system for checking each refrigerator daily. The ADM stated she was not aware there were expired and undated food items in resident's personal refrigerators. The ADM stated it was her expectation that nursing staff discarded of undated and expired foods daily, and if a resident refused to allow the staff to clean their refrigerator, it was her expectation that staff brought the concern to the ADM or the DON for assistance. The ADM stated she has not had any reports of residents refusing to allow staff to clean their refrigerators. The ADM stated all nursing staff should have been aware of this process. The ADM stated it was important for expired and undated food items to be discarded promptly to prevent food borne illness and residents becoming sick form consuming expired foods. The ADM stated it was also important to ensure refrigerators were cleaned to ensure they were sanitary. Record review of the facility's policy titled Food: Safe Handling for Foods from Visitors, dated 9/2017, revised 7/2019, revealed the following: Policy StatementResidents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors.5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers. Have temperature monitored daily for refrigeration (less than or equal to) 41 F and freezer (less than or equal to) 0 F. Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for (greater than or equal to) 7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.) Cleaned weekly.

Based on interview, observation, and record review, the facility failed to ensure all residents were treated with respect and dignity for 1 of 3 residents (Resident #27) reviewed for dignity. The facility failed on 08/06/2025 to ensure Treatment Nurse provided privacy during wound care for Resident #27. This failure placed all residents at risk of psychosocial harm due to a diminished quality of life.Finding included: Record review of Resident #27's face sheet undated revealed a [AGE] year-old male with an admission date of 05/09/2025 with the following diagnoses: diabetes (high blood sugar), congestive heart failure (hearts ability to pump blood effectively), major depression disorder (mental illness), hypertension (high blood pressure) and muscle weakness. Record review of Resident #27's Comprehensive MDS dated [DATE] revealed a BIMS score of 15 which indicated resident cognition was not impaired. During an observation of wound care on 08/06/25 at 11:45 AM, Treatment nurse washed hands and donned (put on) PPE. DON pulled center curtain and opened wardrobe closet door at foot of bed. DON held Resident #27 's left foot up off bed exposing left leg and foot. Treatment nurse removed old dressing from Resident #27's left foot. Resident #27 room door remained opened during wound care. Resident #27's roommate was in room with 2 visitors. During an interview on 08/07/25 at 11:34 with the DON, she stated resident #27's room door should have been shut. She stated she was not aware the door was open. She stated all nursing staff have been trained to provide resident privacy during any type of care. She stated everyone was responsible for providing resident privacy. She stated the potential negative outcome could be resident dignity and embarrassment. During an interview on 08/07/25 at 11:58 AM with the ADM, she stated the residents room door should have been closed when providing any type of care. She stated all staff have been trained on resident privacy. She stated the potential negative outcome could be dignity not provided to the veteran.During an interview on 08/07/25 at 3:00 PM with the Treatment nurse, she stated the residents room door should have been closed. She stated she was not aware she left the door open. She stated she had been trained on resident privacy during wound care. She stated the potential negative outcome could be resident dignity and the resident getting upset during care. Record review of the facility policy titled Respect and Dignity dated revised January 2023 revealed the following: Compliance Guidelines:The community promotes care for residents in a manner and environment that enhances each resident's dignity and respect in full recognition of his or her individuality.Dignity means that the team members carryout activities that assist the resident to maintain and enhance self-esteem and self-worth. To activate this goal, the community strives to achieve the follow: .Private space and respect for property: Team members are trained and reminded to respect each resident's private space and property.Record review of the facility policy titled Statement of Resident Rights dated revised 10/2022 revealed the following Privacy and Confidentiality: .Residents have the right to personal privacy and confidentiality of their personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. The community is not required to provide a private room for each resident.Team members will ensure that privacy curtains are pulled, doors are closed, or residents are otherwise removed from public view or covered or draped to prevent unnecessary exposure of body parts during the provision of personal care and services. Window coverings should be closed .

The facility failed on 8/7/2025 to ensure 15 of 31 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 15 of 31 confidential residents. The facility failed on 8/7/2025 to ensure 15 of 31 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 08/6/2025 at 11:00pm, 15 of 31 confidential residents, stated they did not know they could file a Grievance anonymously, and they had not observed a posting of the Grievance procedure in prominent locations. Fifteen Residents attended the meeting, the 15 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 8/7/2025 at 10:07am; according to the facilities' Grievance policy a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 8/7/2025 at 11:30am; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were available; however, there was no access to submit a Grievance anonymously. Interview with the ADM on 8/7/2025 at 2:15pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated she was responsible for the review of Grievances and to assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station, the ADM's office, and the Activity Director's Office. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility had 5 days to resolve Grievances once they were submitted. The ADM stated she assigned the Grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. Record Review of the Grievance Policy updated February 2017 reflected the following Policy Statement:Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. The Resident and/or the representative has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint.2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing.4. Upon admission residents are provided with written information on how to file a grievance. 5. Grievances may be submitted orally or in writing and may be filed anonymously.6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission.7. The ADM has delegated the responsibility of grievance investigation to the ADM.8. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance.9. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 10. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.11. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken.12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.15. This policy will be provided to the resident or the resident's representative upon request.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 1 of 2 residents (Resident #69) and 2 of 4 staff (CNA A and CNA B) reviewed for infection control.The facility failed on 08/06/2025 when CNA A and CNA B failed to follow policy and procedure for handwashing and glove changes while providing incontinent care for Resident #69.This failure could place residents at risk for spread of infection and cross contamination. Findings included: Record review of Resident #69s face sheet dated 08/07/25 revealed a [AGE] year-old male with an admission date of 02/04/2022 with the following diagnoses: Alzheimer's disease, bladder cancer, anxiety (feeling of fear and worry), post-traumatic stress disorder (mental illness after a traumatic experience) and major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #69's quarterly MDS dated [DATE] revealed a BIMS score listed as 0 meaning severe cognitive impairment. The MDS under functional abilities for toileting (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment), listed Resident #69 as a 1 meaning: Dependent - helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity.Record review of Resident #69's Care Plan dated 09/30/2024, revealed that Resident #69 required assist x 1 for all peri care. During an observation on 08/06/2025 at 3:19 PM, CNA A and CNA B provided incontinent care for Resident #69. CNA A and CNA B donned (put on)] PPE. CNA B doffed PPE and exited the room to gather wet wipes. CNA B entered room with PPE on. CNA A cleaned foley catheter and front side. CNA A turned resident touching Resident #69 leg with dirty glove. CNA A cleaned back area. CNA A placed clean brief under Resident #69 and turn Resident #69 to other side. CNA B cleaned back area and turned Resident #69 to back touch hip with dirty glove and fastened brief. CNA A and CNA B repositioned Resident #69 in the bed. CNA B covered Resident #69 with sheet and blanket using dirty gloved hands. No observation of handwashing before starting incontinent care and none during incontinent care. No observation of changing gloves during incontinent care. During an interview on 08/06/25 at 3:54 PM, CNA B stated she should have washed hands before donning PPE. She stated she should have removed gloves and washed hands before repositioning and covering resident. She stated she had been trained on proper incontinent care and handwashing. She stated the potential negative outcome could be infection causing a UTI. During an interview on 08/06/25 at 4:35 PM, CNA A stated she should have washed hands before donning PPE. She stated she should have changed her gloves and washed hands when going from dirty to clean. She stated she was just nervous. She stated she has been trained on incontinent care and handwashing. She stated the potential negative outcome could be spread of infections. During an interview on 08/07/25 at 11:34 AM, DON stated gloves needed to be changed when going from dirty to clean. She stated handwashing should be done before starting incontinent care and between glove changes. She stated the staff had been trained and had completed competency skills checks. She stated the director of clinical education, and the DON were responsible to monitoring staff for compliance. She stated all staff have been trained on handwashing and incontinent care. She stated the potential negative outcome could be breaking infection control and prevention and spread of infections. During an interview on 08/07/25 at 11:58 AM, ADM stated gloves needed to be changed after front area cleaned. She stated handwashing should be done before starting incontinent care and with each glove change. She stated all nursing staff had been trained on handwashing and incontinent care. She stated there was multiple levels of oversite for staff compliance. She stated the potential negative outcome could be spread of germs. Record review facility-provided peri care audit tool for CNA A dated 07/09/2025 revealed all action met. Record review facility-provided Hand-Washing skill for CNA A dated 07/09/2025 revealed steps of procedure - satisfactory.Record review facility-provided peri care audit tool for CNA B dated 06/11/2025 revealed all action met. Record review facility-provided Hand-Washing skill for CNA B dated 06/11/2025 revealed steps of procedure - satisfactory. Record review facility provided tool undated titled Peri Care Audit Tool revealed: Peri Care Audit Tool - Action .2. Staff must gather supplies, have bags for linen and garbage then set up supplies. Wash hands and apply gloves. 7. Stop! Removes gloves, washes/sanitizes hands and re-gloves.8. Apply clean brief, then dress resident, clean up work area. Make sure resident is comfortable and call light within reach. Record review facility provided policy titled Handwashing/Hand Hygiene dated January 2023, revealed: Guideline: The facility considers hand hygiene the primary means to prevent the spread of infectionsPolicy Interpretation and Implementation.7. Uses an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to):Before and after direct contact with residents; .Before moving from a contaminated/soiled to clean care or procedures; .After contact with blood or bodily fluids; .Between glove changes/after removing gloves; Before and after entering isolation precaution settings; donning PPE; .After doffing PPE; hand hygiene is the final step after removing and disposing of personal protective equipment.8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. 1) Dietary/Facility staff (Dietary Aide A, B, C and CNA D) failed to use good hygienic practices during dietary duties (handwashing). 2) Dietary/Facility staff (Dietary A, B and CNA D) failed to use good hygienic practices during dietary duties (Properly wearing hair net). These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour beginning on 3/27/25 at 11:22 AM and concluded at 12:07 PM: An observation was made on 03/27/25 at 11:22 AM. Dietary Aide A's hair was exposed, outside the hairnet all, around her face and at the nape of her neck. At 11:23 AM, she was observed passing uncovered pizzas (x4). On 03/27/25 at 11:25 AM, Dietary Aide C was observed removing gloves after wiping the counter and placing a set of gloves on to open a can of peaches. No hand hygiene was observed. An observation was made on 03/27/25 at 11:38 AM of Dietary Aide C keeping the same gloves on without changing or performing hand hygiene while completing various tasks (touching multiple surfaces): touched the door to the pantry at 11:40 AM, obtained a can of peaches at 11:43 AM, placed peaches from the can into the puree machine at 11:48 AM, and at 11:50 AM (while the peaches were in the puree machine) she retrieved a towel from the sanitation bucket and wiped off the counter. At 11:56 AM, she obtained the cups and poured the peach puree into them. She obtained parchment paper, pulled a marker out of her pocket, wrote on it, covered the peach puree, and placed it in the refrigerator beside the table. At 12:00 PM, she took the serving spoon and pitcher from the puree machine to the dishwashing area. An observation was made on 03/27/25 at 11:42 AM of Dietary Aide B entering the food preparation from the facility hallway. No hand hygiene was performed. Observed her hairnet only covering her ponytail. All hair surrounding her face and around the nape of her neck was exposed. She grabbed condiments and exited the food preparation area at 11:45 AM. An observation was made on 03/27/25 at 11:47 AM, when Dietary Aide A entered the food preparation area from the facility hallway. No hand hygiene was performed. Dietary Aide A's hair was exposed outside the hairnet around her face and at the nape of her neck. She was observed opening the refrigerator and not obtaining anything. She exited the food preparation area at 11:48 AM. An observation was made on 03/27/25 at 11:49 AM , Dietary Aide C grabbing a pan of rolls from the cooling rack. She pulled a pair of gloves from her pockets and placed the gloves on without performing hand hygiene. She placed the pan of rolls on the counter. She pulled the rolls with her gloved hands and placed them inside a large bowl. At 11:59 AM, she emptied the pan of rolls. She took the empty pan to the dishwashing area and observed her washing the pan. She washed multiple trays and placed them on top of the empty serving line located in the food preparation area. She was observed not changing her gloves. At 12:01 PM, she was observed grabbing a second tray of rolls from the cooling rack. She removed three rolls and placed them in the trash. She stopped touching the rolls and was observed wrapping silverware at an alternated counter. At 12:06, she was observed back at the counter with the rolls, pulling them from the tray, and placing them in the large bowl. No glove change or hand hygiene was observed. An observation on 03/27/25 at 11:50 AM was made of Dietary Aide A and Dietary Aide B entering the food preparation area from the facility hallway. Both staff did not perform hand hygiene. Dietary Aide A's hair was exposed, outside the hairnet, around her face and at the nape of her neck. Dietary Aide B's hairnet only covered her ponytail. All hair surrounding her face and around the nape of her neck was exposed. Each staff grabbed a stack of clean plates with their bare hands. Dietary Aide B was observed with her plates pressed up against her clothing. They exited the food preparation area at 11:52 AM. An observation on 03/27/25 at 11:53 AM of CNA D entering the food preparation area from the facility hallway. She was observed not wearing a hairnet. Hand hygiene was not performed. She was observed going to the drink station and filling a pitcher with cranberry juice. She exited the food preparation area at 11:57 AM. An observation on 03/27/25 at 11:54 AM was made of Dietary Aide A and Aide B entering the food preparation area from the facility hallway. Both staff performed no hand hygiene. Dietary Aide A's hair was exposed, outside the hairnet, around her face and at the nape of her neck. Dietary Aide B's hairnet only covered her ponytail. All hair surrounding her face and around the nape of her neck was exposed. Dietary Aide B entered the dry pantry (the state surveyor did not see her exit). Dietary Aide A grabbed oven mittens and placed an unknown warm liquid on the rolling cart. Both staff were observed at 11:56 AM grabbing clean cups and exiting the food preparation area at 11:57 AM. An observation on 03/27/25 at 11:59 AM was made of Dietary Aide A and Dietary Aide B entering the food preparation area from the facility hallway. Both staff did not perform hand hygiene. Dietary Aide A's hair was exposed, outside the hairnet, around her face and at the nape of her neck. Dietary Aide B's hairnet only covered her ponytail. All hair surrounding her face and around the nape of her neck was exposed. Dietary Aide A grabbed one additional cup, and Dietary Aide B grabbed additional plates. They both exited the food preparation area at 12:00 PM. An observation on 03/27/25 at 12:03 PM was made of Dietary Aide A and Dietary Aide B entering the food preparation area from the facility hallway. Both staff did not perform hand hygiene. Dietary Aide A's hair was exposed, outside the hairnet, around her face and at the nape of her neck. Dietary Aide B's hairnet only covered her ponytail. All hair surrounding her face and around the nape of her neck was exposed. Dietary Aide B obtained condiments from a lower cabinet. Dietary Aide A obtained soup with a mitten on. When Dietary Aide A removed her mittens, gloves (latex/plastic) were observed. Dietary Aide A exited the food preparation area at 12:06 PM. Dietary Aide B exited the food preparation area at 12:07 PM. Investigator exited the food preparation area at 12:07 PM. During an interview on 03/27/25 at 1:30 PM, Dietary Aide A stated she did not notice that she was entering and exiting the food preparation area without performing hand hygiene. She stated she was unaware that all her hair was not secured in her hairnet. She said she was familiar with the facility's policy regarding handwashing and proper wearing of the hair net in the food preparation area. She stated the purpose of wearing a hair net was so hair would not get in the resident's food. She said the purpose of handwashing was, so germs did not spread. She said germs could get under their nails. She said the potential negative outcome of not correctly wearing her hairnet and exercising hand hygiene was hair and food could get all over, including residents' food. As said, she was unaware that she was not wearing her hairnet properly. She said she was unaware that she was not washing her hands each time she entered the food preparation area. She said that their system to monitor proper hand hygiene and proper wearing of the hairnet was each time they go outside, take a break, or go to the restroom, they should wash their hands. She said sometimes they remind each other to wash their hands and to fix their hairnets. She said she had been trained to ensure she had a hairnet each time she entered the food preparation area and to secure all of her hair in the hairnet. She said sometimes she did not see her hair out unless she went to the restroom. She said it was expected of her to have her hair secure in the hair net and wash her hands according to policy. She said she was responsible for washing her hands and securing her hair. She said she did not have a reason for her hair not being secure and did not wash her hands. During an interview on 03/27/25 at 1:57 PM, Dietary Aide B stated she did not notice she was entering and exiting the food preparation area without performing hand hygiene. She stated she was unaware all her hair was not secured in her hairnet. She said she was familiar with the facility's policy regarding handwashing and proper wearing of the hair net in the food preparation area. She said she did not feel her hairnet move back. She said she had been trained to wash her hands when entering the food preparation area. She said she was off on this date (03/27/25). She said she was called in to work on her day off. She said she was rushed, and she thought something had happened. She said she knew she should practice good hand hygiene and wear her hair net properly. She said the purpose of handwashing was to prevent germs from getting everywhere. She said the purpose of the hairnet was to keep hair from getting in the food. She said the potential negative outcome was germs could spread, people could get sick, and hair could get in the food. She said no one would like hair in their food. She said the system for monitoring the staff's hairnet was sometimes she physically checked her hairnet, but then the other girls in the kitchen would check. She said the shift she was working on was not her regular shift. She said she was unaware she had placed the clean plates on her shirt. She said she was usually more prepared and was caught off guard being called in. She said it was expected that she washed her hands each time she entered the food preparation area and wore her hair net in the food preparation area properly. She said she was responsible for ensuring her hairnet was worn properly and responsible for washing her hands when she entered the food preparation area. She said she failed to wash her hands because she felt rushed and was half asleep when she entered work. She said she usually washed her hands when she entered the food preparation area, typically did not place clean plates on her clothing, and wore her hair net properly. During an interview on 03/27/25 at 2:23 PM, CNA D stated she did not wash her hands when she entered the food preparation area because she washed her hands while she was in her hall before she entered the food preparation area. She said she did not have on a hairnet because there were none outside of the entrance into the food preparation area. She said she did not ask the staff in the food preparation area for one because they did not speak English. She said she was familiar with the handwashing policy and wearing the hairnet. She said the purpose of the hairnet and handwashing was so cross-contamination did not occur. She said the potential negative outcome of not wearing a hairnet and practicing proper hand hygiene in the food preparation area was they could get the resident's sick. She said there could have been something nasty on their hands. She said a potential negative outcome of not wearing a hairnet was hair could get into the food and contaminate it. She said she was aware she was not wearing the hairnet. She said she had been trained to wash her hands each time she entered the food preparation area. She usually said the kitchen staff brought their drinks, but it was not abnormal that they would go to the food preparation area at least three times a day to obtain extra drinks/juice. She said they should wash their hands and wear a hair net properly. She said everyone was responsible for hand washing and ensuring they wore a hairnet. During an interview on 03/27/25 at 2:34 PM, the [NAME] stated she had not noticed that any of her staff had entered and exited the food preparation area without performing hand hygiene. She stated she was unaware that any of the staff were not properly wearing their hair net, but at one moment, she saw Dietary Aide B's hair net only covering her ponytail. She said she was familiar with the facility's policy regarding handwashing and proper wearing of the hair net in the food preparation area. She said the purpose of handwashing was so staff would not get sick. She said it prevents illness to the residents. She said the purpose of the hair net was to keep hair from getting in the food. She said the system to monitor and ensure that hand hygiene was occurring, and the staff were properly wearing their hair nets was they should place the hairnet on before entering the food preparation area, and as soon as they entered the food preparation area, they should wash their hands. She said she had been trained on proper hand hygiene in the food preparation and how to wear the hairnet properly. She said all the staff had been trained. She said that they were trained through the original course to work in the kitchen and through in-services. She said they redirected the staff verbally. She said she would tell them and remind staff to wear a hair net and wash their hands. She said her Dietary Manager was not in the facility, but she (The Cook) was left in charge. She said she expected all staff to practice proper hand hygiene according to policy and wear their hair restraints properly. She said everyone was responsible for proper hand hygiene and properly wearing their hair restraints in the food preparation area. She said she had no reason for these procedures to not be followed on 03/27/25. During an interview on 03/27/25 at 3:06 PM, Dietary Aide C stated she remembered not changing her gloves performing multiple tasks but stated she had been trained if she was wearing gloves, this was ok. She stated she did wash her hands while washing dishes. She said she was unaware if she had done anything else. She said she had been trained to wash her hands each time she placed a new pair of gloves on and had been trained to change her gloves each time she did something different, such as a new task. She said the potential negative outcome was that she could pass germs to the residents. She said it was important to practice proper hand hygiene because they carry bacteria on their hands. She said she was unaware if she was not changing her gloves and did not have a reason; she did not change them. During an interview on 03/27/25 at 3:32 PM, the ADM stated she was familiar with the facility's policy regarding handwashing and wearing the hairnet properly. She said proper handwashing aimed to mitigate and prevent the spread of germs. She said the purpose of the hair net was to keep hair out of the food and prevent the spread of germs. She said the potential negative outcome was the residents could get sick. She said she was unaware the kitchen staff did not wash their hands when they entered or did not practice proper hand hygiene in the food preparation area. She said she was unaware kitchen staff were not properly wearing their hair nets. She said their system to monitor proper handwashing and wearing the hair nets in the food preparation area was they completed in-services, daily monitoring, and educating the staff as needed. She stated she had been trained if she entered the food preparation area and touched something (food or drinks) then she should wash her hands. She said she had been instructed to wear a hairnet before entering the food preparation area. She said she could see why, maybe the aide thought that if she washed her hands at the nurse's station, it would be okay. She said she expected handwashing to occur when they enter the food preparation area if they will be touching anything. She said everyone was responsible but would not have a reason they failed to wash their hands and wear their hairnets properly without speaking to them. During an interview on 03/27/25 at 3:45 PM, the DON stated she was familiar with the facility's handwashing policy and should wear hair nets properly in the food preparation area. She said the potential negative outcome of not adhering to the policy regarding handwashing and wearing the hairnets was germs and infection could spread to the residents. She stated the system to monitor hand washing and that staff wore hair nets when entering the food preparation area was through education using in-services. She said she had been trained, and all clinical staff had been trained on handwashing and wearing hair nets in the food preparation area. She said she expected the staff to wear a hairnet and wash their hands if they entered the food preparation area. She said everyone was responsible for proper hand hygiene and wearing a hairnet when they entered the food preparation area. She said without talking to the staff (CNA A), she would not have a reason for not having a hair net or not washing her hands. Record review of CNA A's completion certificate revealed she had a satisfactory completion of hand hygiene as of 03/12/25. Record review the Cook's completion certificate indicated she completed the Food Service Manager training on 06/29/24. Record review of Dietary Aide C's completion certificate indicated she completed the Food Handler (Employee Food Safety Online Course and Exam) on 09/03/24. Record review of Dietary Aide B's completion certificate indicated she completed the Food Handler (Employee Food Safety Online Course and Exam) on 01/03/24. Record review of Dietary Aide A's completion certificate indicated she completed the Food Handler Safety Program on 11/24/24. Record review of the facility's In-service, hairnets and handwashing, dated 12/3/24, revealed: When clocked in be sure to put your hairnets and if you have a beard put beard guard on. Also make sure you wash your hands before beginning your duty. Record review of the facility's In-service, hairnets and handwashing, dated 1/3/25, revealed: When you come in be sure to wear your hairnet and make sure your hair is in the hairnet. Make sure you wash your hands before starting. The following staff signed indicating they had been trained: The Cook Record review of the facility policy, Staff Attire, Revised September 2017, revealed: Policy Statement All employees wear approved attire for the performance of their duties. Procedures All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Record review of the facility policy, Food: Preparation, Revised September 2017, revealed: Policy Statement All foods are prepared in accordance with the FDA food Code. Procedures All staff will practice proper hand washing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Record review of 2022 Food Code U.S. Food and Drug Administration revealed: 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Duties The person in charge shall ensure EMPLOYEES are effectively cleaning their hands, by routinely monitoring the EMPLOYEES' handwashing; 2-301.11 Clean Condition The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. 2-301.12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources. Many employees fail to wash their hands as often as necessary and even those who do may use flawed techniques. 2-301.14 When to Wash. The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after the activities listed. The specific examples listed in this code section are not intended to be all inclusive. Employees must wash their hands after any activity which may result in contamination of the hands.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and at an appetizing temperature for the lunch meal observed on 02/26/2025. Resident's #1, #2, #3, and #4 complained the food was served cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. The findings included: During an interview on 02/26/2025 at 09:30 AM, an anonymous family member stated, during a visit on 1/31/2025, a resident's meal was served cold. The family member stated she was assisting the resident eat and touched the food and it was cold. The family member stated the resident ate in the dining room on this date with other residents. During an interview on 02/26/2025 at 10:55 AM, Resident #1 stated his meals were served cold almost every day. The resident stated he ate in the dining room daily. The resident stated his meals were rarely ever hot or warm enough. During an interview on 02/26/2025 at 11:13 AM, Resident #2 stated his meals were served cold often. The resident stated he ate in the dining room daily. The resident stated meal services rarely ever had hot or warm food. The resident stated his food did not taste good because it was not hot or warm enough. During an interview on 02/26/2025 at 11:22 AM, Resident #3 stated his food was served cold almost every day. The resident stated he ate in his room daily. The resident stated this had been an ongoing issue and most meals had been served cold. The resident stated he rarely ever received warm or hot food during meal services. During an interview on 02/26/2024 at 11:30 AM, the KM stated they planned to serve lunch around 11:40 AM. A test tray was requested after all residents were served. During an interview on 02/26/2024 at 12:37 PM MA stated residents complained often about food being cold. The MA stated residents' meal trays were delivered to the nursing station by the kitchen staff and the nursing staff had to double check each tray. The MA stated the trays were usually handed out immediately. The MA stated nursing staff had to reheat food often for residents who stated their food was cold. During an observation on 02/26/2024 at 1:14 PM, a test tray was provided by the KM. The test tray contained a regular diet plate that included a slice of meatloaf, a serving of scalloped potatoes, a serving of green peas, a dinner roll, and a dessert of apple cake. The test tray also included a puree diet plate that included meatloaf, potatoes, green peas, and bread. The meatloaf on the regular diet plate was cold. The potatoes on the regular diet plate were slightly warm. The peas on the regular diet plate were slightly warm. The meatloaf on the puree diet plate was slightly warm. The potatoes on the puree diet plate were cold on top and slightly warm on the bottom. After stirring the potatoes, the potatoes were less than slightly warm. The peas on the puree diet plate were warm. The regular diet and puree diet plates were served on insulated clam shells on the test tray. During an interview on 02/26/2025 at 2:15 PM. Resident #4 stated his meatloaf was served cold on this date. The resident stated he ate in his room most days. The resident stated his meals were served cold on a lot of days. The resident stated he had to request staff to warm up his food on numerous occasions due to the food being served cold when he first received it. During an interview on 02/26/2025 at 2:22 PM. Resident #3 stated his lunch was served cold on this date. The resident stated he ate in his room on this date. The resident stated he had meatloaf and potatoes on this date for lunch. Record Review of the facility's document titled, Service Line Checklist dated 2/26/2025 revealed the following under Food Temperatures : Lunch: Meat Dish (regular)- 188 degrees with a marked-out temperature that is illegible; Meat Dish (puree)- 180 degrees; Vegetable (regular)- 190 degrees; and Vegetable (puree)- 182 degrees. During an interview on 02/26/2024 at 2:40 PM the KM stated residents always complained that their food was cold, and that was nothing new. The KM stated if food was not hot enough for a resident, it was reheated. The KM stated she took temperatures of each food item before it was served to ensure it was at a proper temperature. The KM stated temperature log was showing lunch was served at proper temperatures. The KM stated she verified the temperatures were adequate. The KM stated this was logged each meal including at lunch time on this date. The KM stated she did not know why the test tray contained food that was only slightly warm and/or cold. The KM stated the test tray was served after the last tray was served to the residents. The KM stated residents' meal trays were served to their room first, and then the residents in the dining room were served. The KM stated residents' room meal trays were taken to residents on a cart. The KM stated this cart was not heated. The KM stated the meal trays were taken to nursing staff at each hall and the nursing staff distributed the food to residents after the meals were checked for accuracy. The KM stated she did not know how long it took for nursing staff to distribute residents' room trays. The KM stated it was her expectation the trays were served as soon as they were delivered. The KM stated room trays were served on insulated clam shell plates. The KM stated the plates were heated as well to keep food warm. The KM stated she did not know why the residents complained of cold food since kitchen staff ensured food was at an adequate temperature before it was sent out to residents. The KM stated residents' room trays were served from the kitchen, and residents who eat in the dining room were served from the steam table in the dining room. The KM stated she did not know why residents who ate in the dining room would complain that their food was cold. The KM stated the temperature taken on this date were from the kitchen, not the serving line. The KM stated it was her expectation that residents were served hot food. The KM stated it was the kitchen staff's responsibility to ensure food was served hot. The KM stated if food was not served at a safe temperature residents could get sick. During an interview on 02/26/2024 at 3:00 PM CNA A stated residents complained often about food being cold and nursing staff would heat up the food for the resident. During an interview on 02/26/2024 at 3:43 PM LVN A stated residents did complain about food being cold sometimes and nursing staff would heat up the food for the resident. LVN A stated the nursing staff checked each resident's tray before it was delivered to them to ensure they were getting an approved meal. LVN A stated this was usually done right away after the kitchen staff delivered the trays to the nursing station. During an interview on 02/26/2024 at 4:00 PM the ADM stated the KM was responsible for ensuring food was served at a proper temperature. The ADM stated cooks were responsible for ensuring food met proper temperatures. The ADM stated the KM was responsible for the cooks. The ADM stated they used an induction system to ensure food was served at proper temperatures. The ADM stated this included clam warmers for plates and two insulated food carts. The ADM stated nursing staff were responsible for handing out food trays after they were checked for accuracy to ensure residents receive their ordered diet. The ADM stated it was her expectation that food trays were served as soon as they were delivered to each hallway. The ADM stated all dietary staff were trained regarding safe food temperatures upon hire and through regular in-serves provided by the KM. The ADM stated if food was served cold or slightly warm, food may not be palatable since some residents would want their food to be hot. The ADM stated there was a concern for residents' safety and possible illness if food was not served at safe temperatures. During an interview on 02/26/2024 at 4:15 PM CNA B stated residents did sometimes complain about food being cold and nursing staff would request an alternative for the resident or warm the food up for them. During an interview on 02/26/2024 at 4:18 PM the DON stated she had not received any complaints about food being served cold. The DON stated some residents did prefer their food to be warmer than it was served, and they would heat up residents' food when needed. The DON sated the KM was over all kitchen staff and was ultimately responsible for ensuring food was served at proper temperatures. The DON stated residents' room trays were served on insulated shells. The DON stated when room trays were brought to the nursing staff to distribute, nursing staff were also responsible for ensuring food was not cold. The DON stated it was her expectation that food trays were served as soon as they were delivered to nursing staff. The DON stated if nursing staff were not available when meal trays were delivered to the nursing stations, the unit manager or the DON would also help distribute trays after they verified the meals were adequate for each resident's meal order. The DON stated all food should have been served at safe temperatures, and if food was cold a new tray should have been requested for the resident. The DON stated if food was not served at safe temperatures the resident could have been at risk of food borne illness or food may have not been pleasurable to the resident if it was not served warm enough. Record Review of the facility's policy titled, Food: Quality and Palatability dated 5/2014 and last revised on 02/2023 revealed the following: Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Definitions Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures 2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code.

Based on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, or preferences for 3 of 12 residents (Resident #1, #2, #6) reviewed for meal preferences. 1. The facility failed to ensure there was no cheese or Resident #1's sandwich, a documented allergy, resulting in Resident #1 having anaphylaxis symptoms and receiving an epi-pen (epinephrine, a medication that can help decrease a body's allergic reaction) on 12/15/2024. 2. The facility gave Resident #2, Resident #6's meal tray, and Resident #2 consumed the incorrect tray on 12/17/2024. 3. The facility gave Resident #6, Resident #2's meal tray, and Resident #6 consumed the incorrect tray on 12/17/2024. An Immediate Jeopardy (IJ) was identified on 12/18/24 at 9:22 AM. The IJ template was provided to the facility on [DATE] at 9:22 AM. While the IJ was removed on 12/18/24 at 6:55PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because all staff had not been trained on 12/18/2024. This failure placed residents at risk for not having their dietary restrictions and allergy restrictions followed which can result in anaphylaxis. The findings include: During an interview on 12/17/2024 at 9:12 AM with the DON and ADM, the DON stated she had been notified of Resident #1's incident on 12/15/2024 a little after 2pm. The DON stated Resident #1 had come down the hall stating he had eaten cheese and he felt like his throat was getting tight. She stated RN A assessed him, notified the FNP on call and administered an epi-pen. The DON stated RN A monitored Resident #1 for about an hour, and she followed him outside to smoke. The DON stated Resident #1 was very upset and he made some threats, and he notified the police. The DON stated the facility took immediate action and began their investigation. The DON stated she spoke to the kitchen staff, and they had all stated there was no cheese on the plate. The ADM and DON stated Resident #1 brought out a 75% eaten sandwich with ham and cheese but they could not verify where the cheese had come from. The DON stated Resident #1's allergy is posted on his meal ticket and there had been multiple steps in place to prevent cheese from being on his plate. The DON stated there had been instances where there was cheese on his plate that the facility staff had caught. The DON stated CNA A had taken the lid off Resident #1's tray and saw sandwich with meat and bread but did not see cheese. She stated CNA A did not disassemble Resident #1's sandwich but when she removed Resident #3's lid, his sandwich had cheese on it. She stated CNA A did not believe to have switched the trays because she remembered seeing the cheese on Resident #3's plate. The DON stated Resident #1 had complained of cheese being on his tray even on days they did not serve cheese with the meals, and he had ordered pizza before. The DON and ADM stated they had begun a multi focal training and education with their staff. The DON stated they had Resident #1's picture and a colored picture of a no cheese sign to make it more visible, on the serving line in the kitchen. She stated the kitchen would have a sign off sheet that they have to physically sing off what comes out of the kitchen and the nurses on the floor will have to sing off on his tray saying it had been checked as well. The DON stated the FNP did not believe Resident #1 needed to be sent to the ER as he was monitored by RN A, and his symptoms had resolved. Resident #1 Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of type 2 diabetes, lumbago(lower back pain), schizophrenia (a serious mental health condition that affects how people think, feel and behave), bipolar disorder(a mental health condition that causes extreme mood swings), post-traumatic stress disorder(a mental health condition that's caused by an extremely stressful or terrifying event) , and [NAME] encephalopathy (a neurological disorder induced by thiamine, vitamin B1, deficiency). Resident #1 had a listed allergy of gabapentin metformin, cheese, and milk. Record review of Resident #1's annual MDS dated [DATE], section C- Cognitive patterns revealed a BIMS score of 15 which indicated Resident #1 was cognitively intact. Record review of Resident #1's care plan revealed a focus initiated on 6/13/2024, of Allergic to gabapentin, metformin, milk cheese. Interventions included administer medication or allergies as ordered by MD. Record review of Resident #1's physician orders revealed EpiPen 2-Pak injection solution auto-injector 0.3mg/0.3ml (Epinephrine (Anaphylaxis) (a severe, life-threatening allergic reaction that can happen seconds or minutes after exposure to an allergen). Record review of Resident #1's a communication form dated 6/17/2024 revealed Resident #1's name, other (checked box): Allergies. Diet order: No cheese or Milk (Allergies). Message/comments: IF there is cheese or milk in any meal, please give substitute. Record review of Resident #1's progress note dated 10/08/2024 at 10:31AM revealed IDT held care plan with Resident #1. Resident will remain a DNR. Medications, weights, and diagnosis were discussed. Resident states that he no longer has faith in the facility because he keeps getting served cheese, resident states the next time he gets served cheese he is going to go to the nurse's station and eat it and for them to call 911. Resident was educated on not eating cheese as he is allergic to it. Resident was educated on the importance of taking his medication consecutively, pharmacy nurse did ask resident what medications he would like changed and resident stated he did not care because he was not going to take any of them. Resident states that he has applied to be moved to another facility. Resident is refusing to complete care plan and left the meeting. Record review of Resident #1's progress note dated 12/15/2024 13:20 by RN A, resident #1 came to nurses' station frantic after eating cheese, was served one piece of bread with ham ontop-cheese was not seen when given to resident. resident folded bread and had two bites when he realized there was a piece of cheese under the ham. Resident states feels like my throat is closing (noted to have a hoarse voice) staff member states he has anaphylaxis to cheese. EpiPen given to right thigh at 1322 (1:32pm) , heart rate increased from 80's up to 108. within a minute residents state throat isn't feeling tight. 1340 (1:40pm) resident states throat is just a little sore no longer feeling like throat is swelling. lung fields clear to auscultation. resident stayed with nurse until 1355 (1:55pm), went to his room without further incident- call light within reach- no further complaints of throat tightness, heart rate in 80's 1400 (2:00pm) resident outside to smoke tolerating without difficulty. no increased throat discomfort- tolerated smoking without incident contacted FNP for prn orders, she states no need to send to ER. Supervisor, DNS, RN on call aware of incident. Record review of Resident #1's progress note dated 12/15/2024 at 1511 (3:11pm) by RN A revealed BSPD officer arrived on scene to speak with resident-resident insistent on charging kitchen staff. Officer explained could not press charges and issue was a facility issue. officer states would give him a complaint number for his records. this nurse spoke with officer and resident- resident raised his voice towards the officer, this nurse was able to calm resident with light touch and speaking with him. 1530 (3:30pm) resident states I have to go to the store and get out of here before I kill someone 1545 (3:45pm) resident returned from the store. Record review of Resident #1's progress note dated 12/15/2024 at 1549 (3:49pm) by RN A revealed resident returned from front of facility stated, the ADM was here and now she's gone- this is bullshit asked resident if he was ready for his pain medications he stated, I'm not taking a fucking thing, not eating not taking anything from this fucking place. Record review of Resident #1's progress note dated 12/16/2024 at 12:19pm by the ADON revealed this writer went to talk to resident in his room to discuss the plan and his refusal to eat in dining room. inquired what happened over the weekend. resident stated, 'they gave me a fucking cheese' and showed me the sandwich, it has cheese in it. this writer apologized and sympathetic to resident, and stated the plan of action, resident raised his left arm and verbalized ' Stop! stop lying to yourself!' 'I have been given cheese for the last six months' 'Admin is not doing anything'. 'I am done, I am not going to eat here' this writer clarified if he wants to eat in the dining room or his room or is he going to eat outside the facility, resident verbalized 'No! I am not going to eat at all, I will starve myself to death'. writer tried to ask further but resident said, ' I am done' and left his room via scooter.' DNS made aware. Record review of Resident #1's progress note dated 12/16/2024 at 1305 (1:05pm) by the SW revealed Social worker was speaking to resident to see how he is feeling after eating cheese over the weekend. Resident stated that his throat still hurts and he is pissed When the resident was asked if he was depressed, resident that put his hand up and stated, I'm done talking. SW then left the room. Record review of Resident #1's progress note dated 12/16/2024 at 2346 (11:46pm) by LVN B revealed Resident rolled up on his scooter at supper time and looked at his tray and refused. This writer acknowledged that there was no cheese on the tray. He still declined the tray and stated that someone had purchased wings he was waiting on. Record review of Resident #1's progress note dated 12/17/2024 at 2155 (9:55pm) by the DON revealed Met with resident to discuss his verbalized fears of dying and being unsafe in the facility. Resident states that he feels safe in his room and at night but feels unsafe during mealtimes and when any food is served to him. He continues to believe that the kitchen staff is trying to kill him and does not feel safe eating the food here. When he was asked what would make him feel safe, he stated that moving to another facility would be the only thing. He states that he is willing to move anywhere else to get away from here. He denied three different times that he feels unsafe or like he is going to die right now or tonight. He stated that he will not be eating the food from here, but that we should continue to send him his trays. Record review of RN A's undated statement revealed the following On 12/15 about 1320 (1:20pm), veteran Resident #1 came to nursing station via electric wheelchair, with roommate right behind him. Resident #1 was yelling they put fucking cheese on my sandwich, and I didn't know. I didn't fucking know. I ate it! I didn't fucking know Resident grabbing at his throat saying I'm allergic to fucking cheese! My throat feels like it is getting tighter Residents face appears reddened, with noted shaking of hands. Instructed on slowing breathing, residents face getting red, noted to have tears. EpiPen injected to right thigh. Within minutes residents facial color returned to normal and no longer had complaints of throat tightness. Once resident had calmed, attempted to educate resident but was interrupted by him and he refused to listen to anything this writer had to say. I monitored him post incident and he did not have adverse reactions. I spoke with the cnas regarding the incident. The cna who served the meal stated she inspected the sandwich and did not see cheese. Document signed but RN A. Resident #3 Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #3 had a medical history of peripheral vascular disease, chronic hepatitis, liver disease, and polyneuropathy (when multiple peripheral nerves become damaged). Record review of Resident #3's annual MDS dated [DATE], section C- Cognitive patterns revealed a BIMS score of 14 which indicated Resident #3 was cognitively intact. During an interview on 12/17/2024 at approximately 10:00AM, Resident #3 stated he was roommates with Resident #1 and was in the room on Sunday 12/15/2024, when Resident #1 ate cheese. Resident #3 stated Resident #1 had made a comment about his sandwich only having one slice of bread on the bottom. He stated they even joked about the other piece of bread having the cheese on it and so they must have taken it off. Resident #3 stated he saw Resident #1 rolled the sandwich up and took a bite of the sandwich. He stated soon after Resident #1 stated his throat was closing up and he was shaking and could not talk very well. He stated what he saw was bread on the bottom, cheese, and ham. Resident #3 stated he knew Resident #1 had received an injection to his leg and has not seen him eat much since the incident. Resident #3 stated at no point were the trays switched because he ate his entire meal and, his plate had a sandwich with two slices of bread, cheese, and ham. Resident #2 Record review of Resident #2's face sheet, dated 12/17/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include unspecified dementia with mood disturbance (impaired ability to remember with mood concerns), type 2 diabetes mellitus with diabetic polyneuropathy (inability to regulate blood sugar levels), anxiety disorder (mental health concern), chronic respiratory failure with hypoxia disturbance (lack of oxygen in the blood), and other allergy, initial encounter (an allergy to an uncommon substance). Additionally, the allergies listed were Atorvastatin (medication for cholesterol), calcium/polysorbate 80 (calcium supplement with a soluble stabilizer), iodine (mineral), and shellfish. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed under Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Record review of Resident #2's Care Plan, dated 12/14/24 revealed a focus area, initiated on 6/14/24, the resident's current diet was regular texture, thin/regular consistency with large protein portions. Further review revealed a focus area, initiated on 5/30/24, that the resident was allergic to Iodine, Atorvastatin, Calcium/Polysorbate 80, and shellfish. The goal was the resident would not have any adverse reactions to allergies. The interventions initiated on 5/30/24 were to ensure a list of allergies go with the resident to the physician, pharmacy, and hospital and to ensure dietary was notified of any food allergies when he was admitted . Additional interventions were that the resident was severely allergic to shellfish (prior anaphylactic reaction), keep EpiPen available for shellfish allergy, administer medication for allergies as ordered by the medical doctor, and to notify the doctor of unresolved allergy symptoms as needed. Record Review of Resident #2's physician orders, dated 12/17/24, revealed a prescription for EpiPen 2-pak injection solution, auto-injector 0.3 MG/0.3ML (Epinephrine Anaphylaxis). Inject 1 application intramuscularly every 24 hours as needed for allergies. Physician orders further revealed, Resident #2 was on an RCS (Reduced concentrated sweets) diet with a regular texture, thin/regular consistency, provide large protein portions with meals. Record Review of Resident #2's Communication form with the dietary department, dated 5/30/24, revealed Resident #2 had a diet order of Regular and regular liquid. Additionally, the document indicated Resident #2 had an Iodine allergy and no shrimp. Resident #6 Record review of Resident #6's face sheet, dated 12/18/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on e 9/23/24 with diagnosis to include bipolar disorder (mental health concern), vascular dementia (impaired ability to remember), and type 2 diabetes mellitus without complications (inability to regulate blood sugar levels). Additionally, Resident #6 had no known allergies. Record review of Resident #6's Comprehensive Minimum Data Set, dated dated [DATE], revealed under Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #6's Care Plan, dated 12/18/24 revealed a focus area, initiated on 3/22/24, the resident's current diet was regular texture, thin/regular consistency and that the resident was at risk for nutritional deficits and/or dehydrations risks related to therapeutic diet. During an interview on 12/17/24 at 12:22 PM, Resident #2 stated he had lived here for about 3 months. He stated the facility was clean. He stated food was alright but lacked flavor and the staff was polite. He stated he was a diabetic and he was highly allergic to shrimp and all crustaceans. He stated he found out he was allergic when he was in the navy. He stated he had been served shrimp at this facility three times, but he saw it and did not eat it. He stated he told staff, and they brought him something else to eat. He stated he listed his allergies on his admission paperwork. He stated he could get choked up and die if he eats shrimp or crustaceans. He stated he was offered snacks such as sandwiches between meals. He stated he had no concerns of abuse or neglect. He stated he had no additional concerns to report. During a dining observation on 12/17/24 at 1:03 PM in the memory care unit with the following: The food was brought to the memory care unit in an insulated rolling food warmer. There were two meals on each food tray. RN C was observed looking at each tray ticket, she picked up the plate cover to observe the food, then she put that tray on the counter where she prompted the CNA's that they were inspected and ready to be passed out. The CNAs were observed performing hand hygiene and then took the trays and passed them out to the residents. During the lunch observation the surveyor observed Resident #2 eating in the dining room and had eaten about 75% of his food, as the surveyor approached him it was observed that the tray ticket had the name of Resident #6 on it. The surveyor asked Resident #2 if the name on the tray ticket was his and he said it was not. The surveyor then stopped RN C as she passed out drinks and told her that Resident #2's tray ticket had another person's name on it. RN C apologized to Resident #2 for getting the wrong plate and took the plate. CNA C stated she handed Resident #2 the wrong tray. Resident #6 was observed eating his food in the dining room as well and staff took his tray. It was observed that he had eaten about 50% of the food on the plate and the tray ticket had Resident #2's name. During an interview on 12/17/24 at 1:16 PM, Resident #6 stated he had not noticed another person's name was on the tray ticket and was not happy that he was served someone else's food. Resident #6 stated this happened to him before. During an interview with CNA A on 12/17/2024 at 2:39pm, she stated on 12/15/2024 she had finished assisting residents in the dinning hall for lunch and began helping pass out trays. She stated she saw they were having grilled cheese sandwiches and noticed Resident #1's was different. She stated it was plain ham with a piece of bread underneath it. She stated she did not see any cheese at that point and did not want to pick up his food. She stated Resident #1s meal ticket was underneath the plate and had his allergies listed. She stated she took the plate to Resident #1's room and he had asked aren't we having alfredo? and she responded no. She stated she saw him pick up the sandwich and fold it in half but exited the room before he took a bite of it. She stated Resident #3's sandwich had cheese on it and two pieces of bread while Resident #1's only had one piece of bread and that is why she assumed there was no cheese on Resident #1's sandwich. She stated Resident #1 began having symptoms about 10 minutes later and received an EpiPen to his leg. She stated this has happened a lot of times where they put cheese on his tray and Resident #1 catches it and gets upset and yells at them to go fix it. She stated sometimes it is meals like ravioli which have cheese inside or mac and cheese. She stated the mac and cheese is usually caught before being served to Resident #1. She stated they have been in-serviced on his allergies, but she believes the issue comes from the kitchen. She stated the staff will let the kitchen know but it just gets brushed off and nothing happens. She stated she is not sure why there was sandwiches for that meal. On 12/18/2024 at 6:19pm CNA A stated Resident #1's meal ticket showed a smothered turkey patty not a sandwich. CNA A stated the meal and ticket did not match up, and the meals are usually verified by the nurse, but they had not been verified that day and she is not sure why. CNA A stated she witnessed Resident #1 pick up the sandwich and fold it before exiting the room. She stated at no point did she see Resident #1 tamper with the tray, and she did not see anyone else tamper with the tray cart (the rolling cart that holds the meals for transport). CNA A stated there had been about three other incidents where Resident #1 had cheese served on his tray but does not recall the dates or times. She stated she remembers Resident #1's sandwich was not grilled and had a missing piece of bread while Resident #3's was grilled and had two pieces of bread and she is sure the trays did not get switched. During an interview with Resident #1 on 12/17/2024 at 3:20 PM he stated, I have been here 6 months and told them I'm allergic to cheese. I told them one of these days I'm going to eat cheese and wind up dead. It feels like they are trying to kill me, and it is premeditated murder because they have known about it for months and it keeps happening. On Sunday they gave everyone ham and cheese. I got two pieces of ham and 1 piece of bread. I joked and said I bet the other bread had the cheese on it. I folded it up and took a bite. I knew something was wrong because my throat felt weird, so I went up to the nurse's station and they gave me an epi pen. The cheese was yellow, and it was below the ham when I took it apart. I have had epi pens twice in my life, both from eating cheese accidently. I don't know exactly why I'm allergic to cheese, I think it has something to do with the enzymes in it, but milk doesn't give me the same reaction. Milk makes my stomach upset and diarrhea. I think the facility just didn't believe me. I don't think they believed I was really allergic to cheese. I am still mad about it. After the epi pen, I did feel better, but my throat is sore. I have avoided eating cheese my whole life, I'm glad I did notice because what if I had passed out and stopped breathing and didn't tell anyone. I did call law enforcement because I felt like it was attempted murder. Everyone has been kissing my ass and being nice since the incident. I feel unsafe and disrespected, and I haven't eaten since then. I don't trust them. Yes, I have bought pizza before, but I usually order it for the other residents, and I'll get myself some wings or a burger. I have also ordered pizza without cheese; people are surprised when I tell them it's pizza without cheese . I did not leave the facility on Sunday prior to the incident. I have an ice box and my roommate does not and he stores his pimento cheese in my ice box but that's my fridge and I let him. During an interview on 12/17/24 at 4:31 PM, the Director of Dining Services stated she spoke with Resident #1 about what happened, and he told her that he would never eat the food here anymore. She stated she asked if she could buy him dinner and he agreed so she bought him chicken wings. She stated there were twos staff that were witnesses. She stated she had bought other residents' food before. She stated Resident #1 refused his food trays yesterday and did not eat. He asked for a steak, and he got wings. She stated he was kind during their conversation. She stated she was not aware of him being served cheese before. She stated she came three times a month from [NAME]. She stated once the food comes out of the kitchen, a licensed nurse checked the trays, and the CNAs passed out the trays. She stated the Dietary Manager provides training to staff. She stated the dietary staff, and the cook were responsible for ensuring trays were correct. She stated the cook places the food on the trays. She stated staff called the tray tickets out to the cook when plating the trays. She stated a potential negative outcome was that they could get a stomachache. During an interview on 12/17/24 at 5:47 PM, with RN C she stated she was responsible to ensure residents were served the right texture in their diet during meals. She stated she looked at the tray tickets for their name, texture, and allergies and then she looked at the food to ensure the order was correct and allergies were correct. She stated then she passed the trays to the CNAs who were then responsible to pass trays to residents after she had checked them out. She stated the CNAs were supposed to ensure they give trays to the correct resident. She stated she was given an in-servicing on tray passing recently to herself and all her staff, yesterday and the day before. She stated she became aware that Resident #2 was served the wrong food tray when she passed out the drinks and saw that he had the wrong tray ticket. She stated normally they pass drinks before the food but today the drinks were late, so she passed the drinks after the food today. She stated Resident #2 and Resident #6 were served each other's meals by CNA C. She stated she was not aware if either of those two residents had any food allergies but they both ate regular diet texture. She stated Resident #2 had eaten about 20-30% of the food by the time she discovered it. She stated dietary staff were responsible to ensure the correct food was on the tray, she was responsible to double check it, and the CNAs were responsible to pass trays to the correct resident. She stated she expected staff to deliver trays to the correct residents. She stated a potential negative outcome was they could have an anaphylactic reaction or an allergy, or an obstruction from their throat swelling, or they could develop hives. She stated also if someone were to eat the incorrect diet texture, they could have difficulty swallowing the food or people that don't have teeth may not be able to eat the food. She stated she was responsible to ensure CNAs were providing care to residents according to their treatment plans. She stated she was not responsible to ensure the CNAs gave resident's the correct tray. She stated the CNAs also received training for this and she could not see everything going on in the facility. She stated after today's incident at lunch, she had a huddle meeting with the DON and the staff and reviewed the recent in-service. During an interview on 12/17/24 at 6:04 PM, CNA C stated she worked on the D-wing Memory Unit. She stated she was overstimulated today when passing the food trays during lunch because her pig tails on her hair were pulling. She stated she also felt rushed by RN C. She stated she accidentally served Resident #6 and Resident #2 each other's trays for lunch. She stated their plates were on the same tray and she switched them. She stated they both eat the same regular diet texture so luckily there was no allergy mix-up. She stated when she passed out food trays, first the nurse read every tray ticket and she compared it to the food on the plate to ensure it was correct. Then the nurse would let them know it was approved to serve to the residents. She stated she knew all the residents and did not need to ask their names to verify their identities. She stated she was aware Resident #2 had a shellfish allergy. She stated she was not aware of him being served shellfish or shrimp before. She stated a potential negative outcome could have been itching or the worst-case scenario was the resident could experience anaphylaxis or death, however it would depend on the severity of the allergy. She stated she was trained on abuse and neglect recently and received additional trainings once a month. She stated she received an in-service yesterday on tray tickets and passing out trays. She stated she went and told the DON that she mixed up the two resident's food trays today and was not given additional instructions. She stated she was made aware of the mix up when RN C told her. She stated Resident #2 had eaten about 75 % of the food on the plate and Resident #6 had eaten about 50% of his food. During an interview with RN A on 12/17/2025 at 6:13pm, she stated on Sunday 12/15/2024, Resident #1 had come up to the nurses stating saying they fucking gave me cheese again, they are trying to kill me. She stated she asked Resident #1 to slow down and explain what had happened and he explained he had eaten some cheese that was served on his sandwich. She stated the CNA's (she didn't remember who) said they didn't see the cheese. She stated one of the CNA's told her he was allergic to cheese, and she asked if he was having symptoms. She stated Resident #1 told her his throat was closing up, he had tears in his eyes, was breathing fast and was clutching his throat. She stated she notified the FNP, grabbed the epi pen from the medication cart and administered the epi pen. She stated she did check his lungs prior to, and he had clear lung sounds but did not want to risk waiting because anaphylaxis symptoms can occur rapidly. She stated she had no idea how his sandwich ended up with cheese because she had been told the food was looked at. She stated that CNA who checked it remembers checking it because it only had the one slice of bread. She stated Resident #1 had told her this was not the first time they had put cheese on his meal, but she has not been present for those other times. She stated the kitchen checks his plate, the staff checks his plate, and he checks his plate so she is unsure how it could have been missed. During an interview with the FNP on 12/18/2024 at 9:45AM, she stated she had been called on 12/15/2024 about Resident #1 having eaten cheese and having an allergy to cheese. She stated the RN A told her his vitals were normal and he did not appear hypoxic (low levels of oxygen in body tissue), so she ordered a dose of epinephrine to be given. She stated she checked back about 15 minutes later and Resident #1's symptoms had resolved and was smoking, and she did not feel he needed to go to the ER. She stated the RN A's actions were appropriate and she had no concerns with the way the situation had been handled. She stated she is not sure how he was given cheese, but his dietary restrictions need to be followed to prevent this from occurring again. During an interview on 12/18/24 at 11:49AM, Resident #3 stated he had never seen Resident #1 eat cheese. He stated he had never seen Resident #1 store cheese in his refrigerator. He stated the pimento cheese in Resident #1's refrigerator belonged to him. He stated Resident #1 did not put cheese in his sandwich, he would never have done that because he was allergic to cheese. He stated on the day of the incident Resident #1 complained to him that he only had one bread, then he folded the sandwich in half and ate it. He stated Resident #1 did not tamper with the sandwich. During an interview on 12/18/24 at 12:00 PM, Resident #1 stated the facility provided him with apartment applications this morning, but the feeling was mutual. He stated he had been talking to them about wanting to move. He stated he ate a couple of bites of the dinner last night and threw it in the trash. He stated staff looked at his tray before giving it to him. Resident #1 granted permission to take photographs of [NAME][TRUNCATED]

Resident #5 Advance Directives 07/11/24 11:23 AM observed DNR with no date by the physician signature and no date by the resident name. Resident #16 Advance Directives 07/10/24 02:15 PM signature for person signing on behalf of resident did not provide a signature and no date next to the witnesses. Resident #54 Advance Directives 07/10/24 04:18 PM observed Resident # 54 with no date next to name on DNR. Resident #120 Advance Directives 07/11/24 12:09 PM observed no date by physician signature and no date by the witness signature. 49927 Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 5 of 32 residents (Residents #5, #54, #84, #120, and #124) reviewed for advanced directives. Residents #5, #54, #84, #120, and #124 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #5: Record Review of Resident #5's face sheet, date retrieved on 07/11/2024, revealed an [AGE] year-old male, admitted on [DATE]/2021 with a primary diagnoses of: dementia (a group of thinking and social symptoms that interferes with daily functioning), hyperglycemia (high glucose), high blood pressure, depression, depression, muscle weakness, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear's down). Record Review of Resident #5's Care Plan date received 06/01/2022, revealed: my Family has completed documentation for DNR status. I wish to be designated as DNR. Record Review of Resident #5's physician orders dated 06/14/2024 revealed: phone orders placed for DNR. During Record Review of OOH-DNR records for Resident #5 on 07/11/2024 at 11:19 AM revealed: Under Section B, labeled, Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication, was not dated next to the Legal Guardian. Under the Physician Statement, next to the Physician signature was not dated. Resident #54: Record Review of Resident #54 face sheet, date retrieved on 07/11/2024, revealed an [AGE] year-old male, admitted on [DATE]/2021 with a primary diagnoses of: dementia (a group of thinking and social symptoms that interferes with daily functioning), hyperglycemia (high glucose), high blood pressure, depression, depression, muscle weakness, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear's down). Record Review of Resident #54's Care Plan dated 03/27/2024, revealed: I/Family/RP has completed documentation for DNR status. Record Review of Resident #54's physician orders dated 03/27/2024 revealed: prescriber written order placed for DNR. During Record Review of OOH-DNR records for Resident #54 on 07/11/2024 at 10:11 AM revealed: Under Section A next to Resident #54's signature was not dated. Resident #84 Record review of Resident #84's face sheet dated 07/10/2024 revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hyperlipidemia (a condition that causes high levels of lipids, such as cholesterol and triglycerides, in your blood), migraine, and generalized anxiety. Record review of Resident #84's physician's order summary dated 07/10/2024 revealed an order Do Not Resuscitate - DNR dated 10/27/2022. Record review of Resident #84's care plan, dated 11/02/2022, revealed a care plan for DNR. Record review of Resident #84's Out of Hospital Do Not Resuscitate form dated 10/27/2022 revealed under the last section, no signatures by the resident nor the witnesses. Resident #120: Record Review of Resident #120's face sheet, date retrieved on 07/11/2024, revealed an [AGE] year-old female, admitted on [DATE] with a primary diagnoses of: hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, vitamin B12 deficiency, depression, anxiety, post-traumatic stress disorder (a disorder in which a person has difficulty or witnessing a terrifying event), pulmonary fibrosis (is a condition in which the lungs become scarred over time), osteoporosis (a condition in which bones become weak and brittle), urinary tract infection, and cystic disease of liver (is a rare condition that causes cysts fluid filled sacs to grow throughout the liver), Record Review of Resident #120's Care Plan dated 05/08/2024, revealed: I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR. Record Review of Resident #120's physician orders dated 05/08/2024 revealed: prescriber written order for DNR. During Record Review of OOH-DNR records for Resident #120 on 07/11/2024 at 10:11 AM revealed: Under the Witnesses Section, there was no date next to the signature of the second witness. Resident #124 Record review of Resident #124's dated 07/10/2024 face sheet revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, type 2 diabetes mellitus, unspecified atrial fibrillation (atrial fibrillation), transient cerebral ischemic attack (a short period of symptoms similar to those of a stroke), and essential hypertension (high blood pressure). Record review of Resident #124's physician's order summary dated 07/10/2024 revealed an order Do Not Resuscitate - DNR dated 04/04/2024. Record review of Resident #124's care plan, dated 04/05/2024, revealed a care plan for DNR. Record review of Resident #124's Out of Hospital Do Not Resuscitate form dated 04/04/2024 revealed under the witness section, there were no witness signatures. Also, in the last section, there were no signatures by the resident representative nor the witnesses. An interview was conducted on 7/11/2024 at 1:20 p.m., the ADM stated DNR's were sometimes completed by other entities, prior to the resident entering the facility. She stated the facility's social services (social workers) were responsible for ensuring DNR's should be completed and updated accurately. The ADM stated it would've been the social worker's responsibility to ensure DNR's were completed thoroughly and accurately, if they were completed prior to the resident entering the facility. She stated it would be the social worker's responsibility to ensure these forms were updated, if they were missing any information or were incorrectly filled out. The ADM stated the facility was working on updating any incomplete or incorrect DNR over the past year, and staff have been trained on how to properly complete a DNR. The ADM reviewed the DNR for Resident #84 and Resident #124 and confirmed they were not completed properly. The ADM stated both social workers for the facility were not available for the interview, as they were currently on leave. The ADM stated a resident's DNR not being completed thoroughly could potentially result in a negative outcome for the resident by which the resident's wishes may not be followed. An interview was conducted on 7/11/2024 at 1:20 p.m., the NAC stated she assisted with audits of resident's DNR's recently. The NAC stated it was the responsibility of the facility's social workers to ensure DNR's were completed properly. The NAC stated the facility's social workers have received training on how to properly complete a DNR for a resident. The NAC reviewed Resident #84 and Resident #124's DNR's and confirmed they were not filled out properly. The NAC stated if a resident's DNR was not completed properly this could possibly result in the wishes of the resident not being followed. Record review of the facility's policy, Advance Directives, Revised January 2023, revealed the following documentation: Compliance Guidelines Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission A copy of the advance directive and subsequent revisions will be included in the resident's medical record. Advance Directive Modifications The resident has the right to modify the advance directive at any time. Although the resident should advise the community whenever a change is made, it is the community's responsibility to ensure that it has current copies of all advance directives. The community will survey its residents at least annually regarding any advance directives changes. Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 laundry room in that: 1. The facility failed to maintain clean lint traps in all 3 dryers in the laundry room by failing to clean the lint traps per policy. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies. The findings included: Observation on 07/11/2024, at 1:50 PM with Laundry Manager. The Laundry Manager was asked to pull out the lint traps in all three dryers to check for compliance. All three dryers were deeply covered with lint underneath the lint baskets on the bottom of the dryers and all around the fan motor. When Laundry manager began to clean the lint from the bottom of the dryers, she had to sweep it all together and it filled a five-gallon bucket. Laundry Manager had gotten a shop vac to finish cleaning the lint traps in all three dryers due to the amount of debris left from the lint. The laundry Manager stated that she could not believe that the lint traps had not been cleaned because they have been taught to clean after every load. The Laundry Manager stated that the process for checking and cleaning the lint traps is that staff is supposed to clean after every load or after every hour. During an interview on 07/11/2024 at 2:54 PM with Administrator. She stated that she expects staff to clean per policy. She stated that the policy stated that the lint traps should be cleaned after every load and every hour. She stated that the staff have been trained by in-services quarterly. She stated that the negative potential outcome is a fire could start. During an interview on 07/11/2024 at 3:08 PM with Corporate District Manager. She stated that she expects staff to clean the lint traps every hour and every two hours at the most. She stated that it is a potential fire hazard. She stated that staff is aware to make sure that lint traps are cleaned every hour. She stated that the staff all have been trained through in-services. She stated that during the in-services they went over lint trap, how and when to clean them. She stated if it needs it, then get the vacuum between every, nook and cranny. She stated that the negative potential outcome is that a fire could start and endangering the residents safety. She stated, 'It's a big concern and probably the biggest. During a record review of facility provided in-service, labeled, Lint Trap Cleaning, dated 07/11/2024, revealed: Purpose: To teach laundry personnel the proper way to clean dryer lint screens, how often they should be cleaned, and how to properly document their maintenance. A lint screen is installed in the bottom compartment of all commercial dryers. The air that leaves the dryer passes through the filter, catching lint prior to coming in contact with the filter, catching lint prior to coming in contact with the heating element as it exists the machine. If the lint is not removed frequently, it can result in extended dry times and, more importantly, create a potential fire hazard. It is highly important that the lint scree is brushed and cleaned every 2 hours. Always defer to State and Local regulations as they supersede these guidelines. To Clean Lint Screens-this should be done every 2 hours. 1. Ensure dryer is turned off. 2. Unlatch and open lint collection area of the dryer (on some models remove the lint screen). Using a broom or brush, clean the accumulated lint from the screen and surrounding areas (undercarriage of drum/bottom of lint trap area). 3. Discard accumulated lint cleaned from the dryer in the nearest trash receptacle. 4. Upon completion, return the lint screen to the lint trap area if removed and always secure the lint trap door. 5. Document the time and date on the Lint Screen cleaning log. During a record review of portion of facility provided policy, no title listed, dated 09/05/2017, revealed: Lint: A lint screen is installed in the bottom compartment of all commercial dryers. Lint that falls from the linen as it dries is caught by the lint screen, preventing lint from moving directly through the vent and blowing all over the outside of the building. These lint screens must be brushed and cleaned after every load and every hour. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperatures in the basket and causing a potentially dangerous situation, i.e., where one spark on lint can cause a fire. Torn or improperly fitted screens must be reported to the facility-to-facility maintenance personnel via work order for immediate repair. Lint may also: a). Build-up between the drum and the side of the dryers is the root cause for many dryer fires. This may cause a problem because in many dryers there is a heat sensor there. This sensor reads the heat of the basket and is programmed to shut the dryer down if the temperature gets too hot. If this sensor is covered with lint, the lint acts as insulation and fools the sensor into thinking the basket is not as hot as it really may be. So, instead of shutting the dryer down. It allows heat to continue to pour in. It is extremely important that you remove the entire front of the dryer and vacuum the entire interior. b). Build-up on the top compartment of the dryer. This is dangerous because the heat source is here.

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 31 residents (Resident #30, Resident #16, Resident #84, Resident #54) and 5 of 5 staff (CNA A, CMA A, LVN B, MA A, Laundry staff member A) reviewed for infection control. 1. CMA A failed to wash her hands or use hand sanitizer prior to medication preparation or medication administration to Resident #30 during observation of medication pass. 2. LVN B failed to wash her hands or use hand sanitizer prior to medication preparation or medication administration to Resident #16 during observation of medication pass. 3. MA A failed to wash her hands or use hand sanitizer prior to medication preparation or medication administration to Resident #84 during observation of medication pass. 4. Laundry staff member A failed to wash her hands prior to folding clean laundry and after touching dirty laundry. Laundry staff member A failed to fold clothes utilizing the folding table by resting the clean clothes against her body and dragging the clothes against the floor while trying to fold them. 5. CNA A failed to sanitize her hands between glove changes during incontinent care for Resident #54. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #30: Record Review of Resident #30's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). Record review of Physician orders for Resident #30, dated 12/05/2021, revealed: amlodipine besylate tablet 10 mg, give 1 table by mouth one time a day related to essential primary hypertension. Record review of Physician orders for Resident #30, dated 02/04/2020, revealed: Fluoxetine HCI Tablet 20 mg, give 1 tablet by mouth one time a day related to Major depressive disorder, recurring without psychotic features. Record review of Physician orders for Resident #30, dated 02/04/2020, revealed: Loratadine Tablet 10 mg, give 1 tablet by mouth one time a day for allergies. Record review of Physician orders for Resident #30, dated 02/11/2020, revealed: Lubricant eye drops solution 0.4-0.3%, instill 1 drop in both eyes four times a day for dry eyes. Record review of Physician orders for Resident #30, dated 3/11/2021, revealed: Metformin HCI tablet 1000 mg, give 1 tablet by mouth two times a day related to type 2 diabetes mellitus with other diabetic arthropathy (joint damage). Record review of Physician orders for Resident #30, dated 10/06/2022, revealed: Benztropine Mesylate Tablet 0.5 mg, give 1 tablet by mouth two times a day related to neuroleptic induced parkinsonism. Record review of Physician orders for Resident #30, dated 12/14/2022, revealed: Gabapentin Capsule 100 mg, give 1 capsule by mouth two times a day related to neuroleptic induced Parkinsonism. Record review of Physician orders for Resident #30, dated 08/09/2023, revealed: Tramadol HCI oral tablet 50 mg, give 1 tablet by mouth in the morning related to type 2 diabetes mellitus with other diabetic arthropathy. Record review of Physician orders for Resident #30, dated 11/23/2023, revealed: Glipizide Tablet 5 mg, give 1 tablet by mouth two times a day related to type 2 diabetes mellitus with other diabetic arthropathy. Record review of Physician orders for Resident #30, dated 11/28/2023, revealed: hydralazine HCI oral tablet 25 mg (hydralazine HCI), give 2 tablets by mouth three times a day related to essential primary hypertension. Record review of Physician orders for Resident #30, dated 11/28/2023, revealed: Losartan Potassium oral tablet 25 mg, give 1 tablet by mouth one time a day related to essential primary hypertension. During an observation of medication pass on 07/10/2024 at 7:04 AM with CMA A. CMA A failed to wash hands or use hand sanitizer prior to medication administration for Resident #30. CMA A administered medications as listed: gabapentin 100 mg (1 tab), cholecalciferol 25 mg (3 tabs), glipizide 5 mg (1 tab), hydralazine HCI 25 mg (2 tabs), amlodipine besylate 10 mg (1 tab), losartan 25 mg (1 tab), benztropine mesylate 5 mg (1 tab), metformin 1000mg (1 tab), fluoxetine HCI 20 mg (1 tab), loratadine 10 mg (1 tab), tramadol 50 mg (1 tab), Systane 0.3% solution (1 drop in each eye). CMA A prepared medications in a small medication cup and administered medications to Resident #30 without using gloves, washing hands, or using hand sanitizer. During an interview on 07/10/2024 at 7:20 AM with CMA Ashe stated that she did understand that she failed to wash her hands or use hand sanitizer before medication preparation or administration for Resident #30. She stated that she had been trained in handwashing by in-services approximately quarterly. She stated that she should have use hand sanitizer or washed her hands prior to medication preparation or administration but was running behind because she was working 2 halls. She stated that the policy stated that staff should wash their hands or use hand sanitizer before medication preparation and administration. She stated that the negative potential outcome for not washing hands would be the transference of germs. Resident #16: Record Review of Resident #16's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: type 2 diabetes, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), hyperlipidemia (a condition in which there are high particles of fat in the blood), cellulitis (a potentially serious bacterial skin infection), congestive heart failure (a chronic condition in which the heart doesn't pump as well as it should), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), depression, acid reflux, dysphagia (difficulty swallowing), anxiety, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), lymphedema (swelling, most often in an arm or leg caused by a lymphatic system blockage), spinal stenosis (the spaces inside the bones of the spine get too small) Record review of Physician orders for Resident #16, dated 1/14/2024, revealed: Lantus Solution 100 UNIT/ML (Insulin Glargine), Inject 30 unit subcutaneously one time a day related to type 2 diabetes mellitus with other specified complication. During an observation of medication pass on 07/10/2024 at 7:29 AM LVN B looked at orders for insulin and double-checked medication for Resident #16. LVN B took supplies out of the treatment cart to prepare to administer insulin shot for Resident #16. LVN B failed to use hand sanitizer prior to medication preparation. LVN B drew the insulin up in the needle and it was verified for 30 units of glargine-YFGN and locked the needle. LVN B carried the syringe down the hall to Resident #16's room. LVN B failed to wash hands or use hand sanitizer prior to medication administration. LVN B used an alcohol pad to prep Resident #16 to clean the arm to administer the insulin. LVN B administered the insulin and failed to wash hands after administering the medication. During an interview on 07/10/2024 at 7:31 AM with LVN B. She stated that she does know that she failed to wash her hands or use hand sanitizer before medication preparation or administration of insulin administered to Resident #16. She stated that she was not thinking and was caught off guard. She stated that the policy stated that you should wash your hands or use hand sanitizer before medication preparation or administration and after giving insulin. She stated that she had been trained in handwashing by in-services recently within the last few months. She stated that she was unsure of how often the training was held. She stated that the negative potential outcome for not washing hands is spreading germs from one person to another. Resident #84: Record Review of Resident #84's face sheet reflected she was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: type 2 diabetes, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to Manic highs), anxiety, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), polyneuropathy (is damage or disease affecting the same areas on both sides of the body), high blood pressure, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances, in and on the artery wall), acid reflux, osteoarthritis (types of arthritis that occurs when flexible tissue at the ends of bones wears down), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), depression, Record review of Physician orders for Resident #84, dated 09/28/2022, revealed: Lactobacillus Bifidus Capsule, give 1 tablet by mouth in the morning for probiotic. Record review of Physician orders for Resident #84, dated 09/28/2022, revealed: Gabapentin Capsule 300 mg, give 1 capsule by mouth four times a day for nerve pain. Record review of Physician orders for Resident #84, dated 09/28/2022, revealed: Lisinopril Tablet 10 mg, give 1 tablet by mouth one time a day for hypertension. Record review of Physician orders for Resident #84, dated 09/28/2022, revealed: Metoprolol Succinate ER Tablet extended release 24-hour 25 mg, give 0.5 tablet by mouth in the morning for hypertension. Record review of Physician orders for Resident #84, dated 12/05/2022, revealed: Glipizide-metformin HCI tablet 2.5-500 mg, give 1 tablet by mouth two times a day related to type 2 diabetes mellitus without complications. Record review of Physician orders for Resident #84, dated 12/19/2022, revealed: Rybelsus Tablet 3 mg (Semaglutide), give 1 tablet by mouth in the morning related to type 2 diabetes mellitus without complications. Record review of Physician orders for Resident #84, dated 1/29/2023, revealed: Calcium + Vitamin D3 oral tablet 600-10 mg-mcg, give 1 tablet by mouth two times a day for supplement. Record review of Physician orders for Resident #84, dated 05/31/2023, revealed: Alprazolam Tablet 1 mg, give 1 tablet by mouth two times a day related to generalized anxiety disorder. Record review of Physician orders for Resident #84, dated 10/25/2023, revealed: Topiramate Tablet 200 mg, give 1 tablet by mouth two times a day for nerve pain, headaches. Record review of Physician orders for Resident #84, dated 11/10/2023, revealed: Buspirone HCI tablet 5 mg, give 1 tablet by mouth three times a day related to generalized anxiety disorder. Record review of Physician orders for Resident #84, dated 03/28/2024, revealed: Zoloft Oral Tablet 50 mg (Sertraline HCI) give 1 tablet by mouth in the morning related to Major depressive disorder, recurrent. During an observation of medication pass on 07/10/2024 at 7:40 AM with MA A. Resident #84 was standing by the nursing station where MA A had her cart, waiting for MA A to administer his medication. MA A pulled all of the medication that she needed to prepare for Resident #84 and placed them on top of the medication cart. MA A failed to wash her hands or use hand sanitizer before preparing medication for Resident #84. The medications that were prepared were : alprazolam 1 mg (1 tab), buspirone HCI 5 mg (1 tab), gabapentin 300 mg (1 tab), glipizide metformin 2.5/500 mg (1 tab), lisinopril 10 mg (1 tab), metoprolol 25 mg (1 tab), sertraline HCI 50 mg (1 tab), topiramate F/C 100 mg (2 tabs), daily vitamin (1 tab), acidophilus with pectin (1 tab), calcium D3 600mg/10mcg (1 tab), Magnesium oxide 400 mg (1 tab), vitamin B-12, Rybelsus 3 mg (1 tab). During an interview on 07/10/2024 at 7:51 AM with MA A. She stated that she understands that she failed to wash her hands before medication preparation or administration for Resident #84. She stated that she knew that she dropped the calcium pill for Resident #84 on the medication cart, picked it up with her bare hands and administered to Resident #84. She stated she is unsure why she did this and did not think about it. She stated that they are trained regularly in handwashing by in-services. She stated that she should have discarded the medication instead of administering it to the resident. She stated that the policy stated that she should wash her hands prior to medication preparation and administration. She stated that the negative potential outcome is cross contamination or the passing of germs. During an observation and interview on 07/11/2024 at 7:40 AM with Laundry staff member A who was describing to Surveyor the process for doing soiled laundry. There were bins of clean laundry on the floor full of laundry. Laundry staff member A did not wash her hands prior to beginning to fold clothes in front of Surveyors. Laundry staff member A began folding clothes and resting the clean clothes against her body touching her scrubs. Laundry staff member A was observed dragging a clean sheet against the floor as she rested the top portion of the sheet against her body, attempting the fold the sheet. Laundry staff member A stated, I'm too short so it just touches the floor, and I don't know how else to fold it. Laundry staff member A was observed folding many different clean clothes by resting the clothes against her body to fold. Observed Laundry staff member A's scrubs were dirty with specks of debris on them. Laundry staff member A was observed touching dirty clothes and then directly to folding clean clothes without washing her hands or using hand sanitizer. During an interview on 07/11/2024 at 3:09 PM with Corporate District Manager. She stated that she expects staff when handling laundry that is soiled or laundry that had been exposed to diseases or illness, to use PPE or sorting linens and always wash hands prior to folding clean laundry. The Corporate District Manager stated that the staff should never drag clean clothes on the floor at any time and should use the folding table to fold the clothes and not fold the clean clothes against their body. She stated that staff had been trained in infection control practices by in-services just this morning on processing, folding, handling laundry, and infection control practices. She stated that the negative potential outcome for not using infection control practices is the spread of germs and the facility is here to prevent the spread of germs and take good care of the residents. During an interview on 07/11/2024 at 3:49 PM with Laundry staff member A, she stated that she should have washed her hands but did not because she was just showing the process. Laundry staff member A stated that she is short and that is why she was dragging the clean sheet on the floor. Laundry staff member A stated that she does normally use her body to fold clothes and had done it like that for many years. She stated that she does know that she is supposed to wash her hands constantly but unsure when. She stated that the policy stated that she should wash her hands, every time. She stated that the negative potential outcome for not using infection control practices would be cross contamination and the spread of germs. She stated that she had been trained in infection control practices/ handwashing by in-services approximately two to three times a month. She stated that she had been trained by another employee that is no longer in the facility to fold the clothes by resting it against her body. She stated she does see how it is not good to fold the clean clothes against her body and how it might get the clean clothes dirty or spread germs. During an interview on 07/11/2024 at 2:35 PM with Administrator and DON. The Administrator stated that she does expect staff to wash their hands or use hand sanitizer before medication preparation and administration. The Administrator stated that she does also expect staff to fold clothes immediately and not just leave them in the dryer to wrinkle and to wash their hands prior to folding clean clothes especially when going from handling dirty clothes to clean clothes. The Administrator stated that she expects staff to not drag clean clothes on the floor while trying to fold them or not to fold the clothes against their own clothes or rest the clean clothes against their uniforms while folding. The DON stated that staff is trained in handwashing and infection control practices through in-services, computer-based training, competency skills check annually and as needed. The DON stated that she is responsible for providing training for infection control practices. The Administrator stated that that the laundry department should have been trained and it is the responsibility of the housekeeping manager and the laundry supervisor to train them, and they do in-services and computer-based training annually and as needed. The Administrator stated that the negative potential outcome for not following infection control practices would be the spread of germs. Resident #54 Record review of Resident #54's face sheet reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of: type 2 diabetes, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances, in and on the artery wall), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, anxiety, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression. Record review of Resident #54's care plan dated 03/22/2024 reflected the resident is incontinent of bladder and requires assistance with incontinent care every shift and as needed. In an observation of incontinent care for Resident #54 on 07/10/2024 at 4:05 PM, observed CNA A wash her hands prior to beginning procedure and set up supplies on bedside table. CNA A explained procedure to resident and verbal permission was obtained for Surveyor to observe. CNA A observed the resident's privacy by closing the door, pulling the curtain and closing the blinds. Observed CNA A don (put on) gloves and removed resident's brief. CNA A performed male incontinent care using incontinent wipes, then assisted the resident to roll to his right side and perform incontinent care to buttocks area and apply barrier cream to buttocks and coccyx (tailbone) area. Observed CNA A change gloves and apply a new draw sheet and clean brief to Resident #54 then replace the sheet over the resident. CNA A did not sanitize her hands between glove changes or between clean and dirty aspects of incontinent care. Observed CNA A remove her gloves and wash her hands following the procedure. During an interview on 07/10/2024 at 4:19 PM, CNA A stated she did not perform hand hygiene between glove changes or between clean and dirty aspects of resident care. CNA A stated she was nervous and did not think to use sanitizer between gloves changes. She stated she has been trained on hand hygiene during incontinent care via videos, in-services and skills checks. She stated she was trained approximately monthly while working at the facility. She stated a potential negative outcome of failing to perform proper hand hygiene during incontinent care would be spreading infection to other residents or to herself. During an interview on 07/10/2024 at 4:24 PM, the DON stated the Infection Preventionist was responsible for training staff on proper hand hygiene. She stated the Director of Clinical Education does staff in-servicing and staff have been trained on proper hand hygiene as well as periodic skills checks. She stated her expectation is that all staff observe proper hand sanitizing during care. She stated a potential negative outcome of failure to perform proper hand hygiene would be increased infection rates. During an interview on 07/11/2024, the administrator stated that nursing administration is responsible for training staff on proper hand hygiene. She stated her expectation is that staff follow the guidelines for proper hand hygiene at all times. She stated a potential negative outcome of failure to perform proper hand hygiene would be the potential transmission of organisms to others. Record review of facility provided policy titled, Handwashing/Hand Hygiene, dated 2019 and revised January 2023: Guideline This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel should be trained and regularly in-serviced on the importance of band hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non antimicrobial) and water for situations such as this (including but not limited to): Before and after direct contact with residents; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated/soiled to clean care or procedures; Between patient care encounters After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; Between glove changes/ After removing gloves; After doffing PPE; hand hygiene is the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (07/10/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record review of the Resident Council Minutes dated 05/23/24 revealed resident comments related to the food served in the facility. It was documented, cold hamburger, cheese not even melted, eggs are always cold, eggs in the morning are cold. The following confidential responses were provided during the initial pool interview screening process on 7/09/24: A resident stated, The food is always cold and does not taste good when it is cold and supposed to warm. A second resident stated the food tastes terrible, bad, and it is cold and that he does not eat it most of the time. A third resident stated, food is always cold, and that he ate in his room. A fourth resident stated the food that was supposed to be warm was always cold. An additional six residents reported their meals were served cold at every meal. Four of those six residents ate in their room, and the other two ate in the dining room. On 07/10/24 at 9:30 AM the Dietary Manager was informed of a request for a test tray for the meal served at 12:00 PM (lunch) and that the test tray was to be provided after the last tray was served on the secured unit. During a confidential group interview on 07/10/2024, a resident said the food served to the residents was always cold. This resident eats in his room. A second resident stated the food was served freezing cold. This resident ate in the dining room. A third resident stated the food was often cold and that he thought fish patties were taken straight from the freezer and served cold to residents without cooking them first. This resident ate in the dining room. A fourth resident stated the food was often cold. This resident ate in his room. A fifth resident stated the food was always served cold. This resident ate in the dining room. A sixth resident stated her food was cold at every mean. This resident ate in her room. On 07/10/24 at 12:40 PM the test trays arrived at the conference room and sampling began at 12:41 PM with the following results: Regular meal plate - Regular Texture Ham with gravy, peas, sweet potatoes, and dinner roll were all hot. Regular Meal - Mechanical Soft Texture Ham with gravy, peas, sweet potatoes, and dinner roll were lukewarm. Regular Meal - Puree Texture Ham with gravy, peas, sweet potatoes, and dinner roll were lukewarm. During an interview on 7/11/24 at 2:35 PM, the Dietary Manager stated she was aware of recent complaints of the food being cold and tried to correct concerns and complaints when received. She stated they received an induction cooking system about a month ago which had improved the issued with the food being cold. She stated the complaints were mainly from residents who ate in their rooms. She stated the induction system helps keep food hot during transport to the rooms. She stated the induction system was used for delivering trays to rooms and they also use plate warmers on the food distributed in the dining hall. She stated the nursing staff were responsible for transporting to each room. She stated the dietary staff transported the food trays to the halls and then the nursing staff on those halls were responsible to distribute to them to residents. She stated the trays were in a closed insulated food cart. She stated she was not sure if there was a policy or procedure that gave the nursing staff a timeframe of how soon trays should be distributed. She stated the cooks and management staff were responsible to check food temperatures. She stated dietary staff randomly checked temperatures on test trays to monitor temperatures during the meal service. She stated they prepared the food trays in the dining room directly from the steam table to keep food warm. She stated they tempted food on steam table to ensure temperatures were accurate. She stated warm food should be above 135 degrees and cold food should be below 41 degrees. She stated she expected that staff to check temperatures and log temperatures before serving as well as correct temperatures before serving the food by heating food to the proper temperature. She stated she had received training on food palatability online and she also ensured staff completed those online trainings. She stated the potential negative outcome of serving cold food to residents were that residents could get sick or a bacterial infection from the food being under temperature. During an interview on 7/11/24 at 4:20 PM, the ADM stated she expected that food served to residents was appealing visually, tasteful, and served at the appropriate temperatures. She stated she was not aware of complaints of cold food recently but was aware there have been complaints in the past and she addressed it with dietary. She stated staff served meals directly from the steam tables to residents that ate in the dining room and food trays were transported in insulated carts and taken to the halls of the residents that ate in their rooms. She stated they also put lids on plates to keep food warm. She stated the dietary staff received a list of residents that would eat in their rooms and dining and served those trays were served first. Then the food trays were made for the left-over tickets of residents who did not show up to the dining room and taken to their rooms, and they were served last. She stated the last meal was served at 5:30 PM in the main dining room. She stated people in the dining room were served first because they were waiting for their food. She stated staff were trained by the dietary manager on palatability and temperatures as needed and annually. She stated a potential negative outcome of serving cold food was that the resident would not eat it and have weight loss or a decline in health. Record review of the facility's, policy titled Food: Quality and Palatability, revised September 2017, revealed the following documentation, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Definitions: Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2.The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of thirty-two residents (Resident #109) reviewed for quality of care. The facility failed to follow physician ordered skin treatments for edema to Resident #109's legs on 07/10/24. These failures could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. Record review of Resident #109's undated face sheet reflected Resident #109 was an [AGE] year-old male whose admitted to the facility was on 1/18/24. Resident #109 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), type 2 diabetes mellitus with unspecified complications (inability for the body to use insulin properly), chronic kidney disease stage 3B (moderate to severe loss of kidney function), essential primary hypertension (high blood pressure), chronic pain syndrome (symptoms beyond pain alone that interferes with daily life), hypothyroidism (underactive thyroid), mood disorder (mental health condition), anxiety disorder (mental health condition), and hyperlipidemia (excess of fat in the blood). Record review of Resident #109's clinical record reflected his comprehensive MDS assessment was completed on 2/1/2024 listing him with a BIMS score of 13, which indicated he was cognitively intact. Record Review of Resident #109's Care Plan, dated 1/18/24, revealed Resident #109 had an actual or would've been at risk for skin impairment: Pitting and weeping edema. Interventions were to apply treatment as ordered. Record review of Resident #109's physician active orders dated 7/10/24 revealed an order dated 7/05/24 to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema. Record review of Resident #109's licensed nurse medication administration record (LNAR) dated 7/1/24 - 7/31/24 revealed to cleanse bilateral lower extremities with normal saline/wound cleanser, or soap and water, pat dry. Apply moisturizing lotion to bilateral lower extremities and wrap with Kerlix (dressing for wounds to secure and prevent movement of primary dressing) daily from 0700 to 1900 one time a day for edema, with a start date of 7/06/24 at 0700. Furthermore, on this order revealed documentation on 07/10/24 by LVN B that the ordered skin treatment task was completed. During observation and interview on 7/9/24 at 3:34 PM, Resident #109 stated he arrived at the facility on 1/18/24 and had issues with his legs prior to entering the facility. He stated the facility was not consistent with the skin treatments on his legs which caused discomfort and itching. He stated they were supposed be wrapped from 7:00 AM to 7:00 PM, however they were not being done on time and sometimes staff came to wrap them several hours late. He stated he had received medication for pain as needed. He stated he was frustrated with these inconsistencies and felt this caused the condition of his legs not to improve. Resident #109's shin and ankle areas of both legs were observed to be wrapped with Kerlix wrap. During observation and interview on 7/10/24 at 9:37 AM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs. During observation and interview on 7/10/24 at 2:27 PM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs. During observation and interview on 7/10/24 at 5:23 PM, Resident #109 stated staff had not done the skin treatment on his legs today. He stated his legs were itching. There was no wrap observed on Resident #109's shin and ankle areas of both legs. During an interview on 7/10/24 at 5:24 PM, a Family Member stated she asked a staff that was passing out medications on the hall this morning around 10:10 AM if she was going to complete the skin treatment on Resident #109's legs and that staff member told her that was not her responsibility and was the responsibility of the TN. The Family Member stated she did not approach any other staff about it. The Family Member stated the facility had not been consistent with the skin treatment on Resident #109's legs since he admitted in January 2024. During an interview on 7/10/24 at 5:34 PM, LVN B stated she was the charge nurse for Resident #109's hall. She stated there were orders for Resident #109 to self-administer Salvaderm Cream (skin moisturizer) on his legs as well as Triamcinolone Cream (steroid cream) as needed. She stated Resident #109 was prescribed Gabapentin for nerve pain in his legs. She stated there were physician orders for staff to clean, apply lotion, and wrap Resident #109's legs daily at 7:00 AM and remove at 7:00 PM. She stated the TN was responsible for completing the skin treatment orders. She stated she believed the skin treatment on Resident #109's legs were completed today. She stated she did not know where the notes of the completion of the treatment was documented in the EHR. During an interview on 7/10/24 at 5:48 PM, the ADNS stated Resident #109 had physician orders for skin treatment on his legs. The ADNS stated the TN was responsible to complete those orders and she believed the skin treatment was completed today. She was trying to confirm with the TN but had not been able to get ahold of her. She stated the orders indicated the skin treatment was to be done at 7:00 AM and then the Kerlix wrap was to be removed at 7:00 PM daily. She stated Resident #109 had complained about the timing that staff had gone to wrap his legs. She explained to him that the time the TN could complete the skin treatment may fluctuate due to the demand of other residents in the facility. She stated Resident #109 was very particular and had refused medications and care in the past if they were not done exactly at the time listed on the order, which could be why he reported the skin treatment was not being done consistently. She stated Resident #109 was particular about staff that provided care to him. She stated she was not sure where the skin treatment task was documented in the EHR and would provide that information after she had spoken to the TN. She stated staff were supposed to document any refusal of care in the EHR and reported it to the NP and to hospice. She stated she had received training on the following physician orders and that the facility provided in-services to all staff. She stated the ADNS's as a team were responsible for ensuring staff followed physician orders. During observation and interview on 7/10/24 at 6:00 PM, the ADNS asked Resident #109 if the skin treatment was completed on his legs today. Resident #109 replied that it was not and that his legs were itchy. The ADNS asked Resident #109 to raise his pant legs which he complied. There was no wrap observed on Resident #109's shin and ankle areas of both legs. The ADNS stated since there was no wrapping observed on Resident #109's legs, this meant the skin treatment was not completed today. She stated she would follow up with the TN to determine why it was not done but did not have an answer for why it was not done. During observation and interview on 7/11/24 at 1:19 PM, Resident #109 stated staff completed skin treatment on his legs this morning around 7:00 AM. He stated staff never completed the skin treatment yesterday. Resident #109's shin areas of both legs were observed to be wrapped with Kerlix wrap. He stated he understood that staff cannot always come exactly at 7:00 AM to provide the skin treatment and had never refused the skin treatment when they come at a reasonable time. He stated he felt it was pointless for them to do it late in the afternoon when the orders say the wrap must be removed by 7:00 PM every evening. During observation and interview on 7/11/24 at 1:34 PM, the TN stated she had not administered any physician ordered skin treatments to Resident #109's legs yesterday or today. She stated she was trained that her duties as the TN were to complete the orders listed on the TAR. She stated Resident #109's orders were listed on the LNAR, which were the responsibility for the charge nurses on duty to complete. The TN pulled up the LNAR on her screen which showed that Resident #109's skin treatments were listed on the LNAR. She stated LVN B approached her this morning and told her she completed the skin treatment orders on Resident #109 for her this morning, in which she responded to her that those orders were supposed to be completed by the charge nurse since they were on the LNAR. During an interview on 7/11/24 at 2:45 PM, LVN B stated she was the charge nurse for halls 400 and 500 and worked from 6:00 AM to 6:00 PM. She stated she began working at the facility about a month and a half ago. She stated she was not sure who was responsible to complete the skin treatment on Resident #109's legs but she did not think it was her responsibility. She stated she thought it was the TN's responsibility, due to hospice ordering it. She stated charge nurses were responsible to complete physician orders listed on the LNAR and TN's completed orders listed on the TAR. She stated on the LNAR the task would turn green on the screen when the task was completed and would turn red if the task did not get completed. She observed the LNAR and verified that her initials were on the LNAR on 7/10/24, which indicated that she completed the skin treatment task for Resident #109. She stated she had not completed that task. She stated she did not know why it was not done yesterday. She stated she knew the skin treatment was supposed to be done daily for Resident #109. She stated the TN would not have done it because the task was on the LNAR because charge nurses were responsible for completing the tasks on the LNAR. She stated she checks the LNAR daily because she knew the tasks on it were her responsibility as the charge nurse. She stated she had received training that she must follow physician orders. She stated she was trained on her 2nd day of working at the facility. She stated she did not think pre-charting was best nurse practice. She stated she was trained that items on the LNAR were her duties. She stated a potential negative outcome of Resident #109 not receiving his skin treatment was that he could develop cellulitis due to scratching the itch which could cause a progression of the disease and more health complications. She stated a potential negative outcome of not documenting accurately was that the staff may not remember to go back and change the task if it was not done or of the resident refused it. She stated another negative outcome was that the staff may not remember what exactly happened in that situation. During an interview on 7/11/24 at 3:20 PM, the ADNS stated there were physician orders to wrap Resident #109's legs daily. She stated usually the TN did them, but the regular TN was out this week, so they had another one filling in. That was why it was not done yesterday. She stated the skin treatment was moved to the LNAR for the charge nurse to do it because of the amount of time it took to complete the task. She stated it was a failure on her part because the TN told her she was going to put it on the LNAR, and she forgot to relay the information to the charge nurse. She stated charge nurses were trained that they were responsible to complete tasks on the LNAR, but she also should have told her. She stated she was able to confirm the skin treatment for Resident #109 was not completed yesterday because she observed that his legs were not wrapped, and she asked him, and he said they were not. She stated she was not aware Resident #109's skin treatment was not done yesterday prior to the state surveyor intervention. She stated staff were not trained to chart a task on the LNAR before the treatment had taken place and they should not have done that. She stated herself, the TN, and charge nurses train other staff. She stated she expected for staff to document tasks completed on the LNAR after the task had been completed. She stated the facility policy stated they must follow doctor orders. She stated they use the EHR as their system for tracking when tasks were due, completed, or not completed. She stated the screen would show the item as yellow for tasks that were scheduled to be done. She stated the screen would show green when completed and red when it was not completed and past due. She stated a potential negative outcome was that the resident's EHR would be inaccurate because you don't know what the outcome would be, the order could get missed, and the resident would not get the care they were supposed to get. This could prevent wounds from healing and cause them to worsen. During an interview on 7/11/24 at 4:28 PM the DON stated she expected staff to follow physician orders. She stated herself, administrative nurses, and charge nurses were responsible for ensuring physician orders were followed. She stated charge nurses were trained that they were responsible for completing tasks on the LNAR. She stated staff should not chart (document) they completed a task in the EHR task before it was completed, it should be charted afterwards. She stated the TN was responsible for tasks on the TAR not the LNAR. She stated staff were provided this training during orientation and as needed. She stated staff were provided this training when they were getting trained on the floor by other nurses, herself, and the pharmacy nurse. She stated she was not aware staff were not following physician orders and that they were pre-charting. She stated Resident #109's skin treatment was put on the LNAR because he was particular on the times of when his care was done. She stated it was put on the LNAR for charge nurses to do so he would have it when he wanted. She stated Resident #109 gets irate when he did not get things when he wanted them done and he was very particular about his treatment. She stated a potential negative outcome was that it decreases the facility's credibility with the resident and that residents won't get the care they deserve. During an interview on 7/11/24 at 4:28 PM the ADM stated she expected staff to follow physician orders. She stated she did not know exactly what the policy said for following physician orders. She stated a potential negative outcome was that residents may not get the services they need because they think the task was completed. Record review of facility provided policy titled, Quality of Care dated February 2017, and revised January 2023 revealed: Compliance Guidelines: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Skin integrity: Pressure ulcers. Based on the comprehensive assessment of a resident, the community will ensure that: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 32 residents; The facility failed to address complaints for 2 of 10 confidential resident's that were interviewed and voiced concerns related to missing personal laundry These problems could result in residents having a lack of personal clothing to wear and low self-esteem. The findings included: During a confidential resident and family interview, the family member stated the resident has problems with clothing coming back from the laundry. The family member stated all of the residents clothing was marked with their name, so it was unknown what the problem was. The family member stated staff members have been asked about the missing laundry, but nothing gets done. During a confidential interview with a resident, it was stated that the resident had several missing clothing items and it had never been returned or found. The resident stated that when asked the nursing staff about the missing clothing that nothing gets done. The resident stated that no one from laundry brings the clothing around to the residents to locate missing clothing. The resident stated that their means of income was limited and the resident does not have the money to keep buying clothing. The resident stated that they would just like to have their clothing back. The resident stated that they do not feel that they have a choice if they are able to keep their clothing here or not because if it was sent to laundry that there was a big chance that it won't make it back. During an observation of the laundry during survey process on 07/10/24 at 3:15 PM, it was determined that a plan for missing or lost laundry had not been acquired. There was a big bin in a room in the laundry sitting in the corner that had been piled up with clothes and the top was covered. During an interview on 07/10/2024 at 5:15 PM, the ADM stated the laundry staff and housekeeping were responsible for ensuring the missing laundry or unmarked laundry gets back to the residents. The ADM stated the facility has a heat label maker for clothing and the residents should have their clothing marked with the heat label maker. The ADM stated the facility replaced any missing laundry but she was unaware of any laundry needing to be replaced recently. The ADM stated she did not know why the missing laundry bin became so large. The ADM stated a potential negative outcome to the residents was they would not have clothes to wear. During an observation on 07/11/2024 at 1:44 PM. Observed a big bin in a separate area of the laundry room, parked in a corner with a covering over the top. The bin was filled with clothes that were lost or missing. Could not observed what kind of clothing was in the bin or how many. It was not open for residents to be able to easily view or look through. During an interview on 07/11/2024 at 1:50 pm, the Laundry Staff Member stated that for missing clothing items that were missing labels they would put it in the bin until the residents came to get the item. She stated that the pile of clothes has been there for a long time but was unsure of how long exactly. She stated that they do not take the clothing around to the residents because they do not have time to do that. She stated that they have not always been able to locate the missing items. She stated that she was unsure of what the staff do if they can not locate the items in the missing clothing bin. She stated that sometimes the residents will get really mad if they were unable to locate their clothing. She stated that usually they would tell the nurse and then the nurse would go to the laundry and attempt to locate them. She stated that there was a possibility that if the nurse gets busy that she may forget to look for the items. During an interview on 7/11/2024 at 2:28 pm, the Laundry Manager stated that the lost or missing clothing items program had not been effective when the washers broke and there were no labels on the clothing to be able to locate the owners. She stated that they had to just put it in the bin. She stated that if she had to say how many clothes were in the bin it would be approximately a few months' worth. She stated that they do have a place for lost or missing clothing by putting them in the big bin in the laundry room. She stated that they were waiting for the activity director to get back next week to be able to take the clothing into the dining room and lay it all out on the tables. She stated that the Administrator will usually ask the CNA's and nurses if anyone had reported missing clothing items and then the laundry staff will look through the items to see if they can locate something that matches that description. She stated that sometimes the residents will come to them and ask about the missing clothing. She stated that sometimes they were able to locate the missing item and sometimes they were not. She stated that they do not have a schedule to where they take the clothes around to the residents. She stated they can't take the clothes around to the residents because there were too many clothes to do that. She stated that when the resident's come to look for their missing clothing she needed a description of the color of the item and the size. She stated that if they did not know the size then she would have to look at the size of the person and just guess the size. She stated that if they could not locate the missing clothing that was in the bin then they would start to donate the clothing to the residents that do not have anything. She stated that the residents have an opportunity to realize if they were missing clothing and can ask about them. She stated that for the resident's that were unable to talk they could notify the nursing staff with the communication style that they used, report it to them, and the nursing staff would come to report it to the laundry staff. During an interview on 07/11/2024 at 2:54 pm, the Account Manager stated that the facility does have a plan for the lost or missing plan. She stated that they did not have an effective plan before because the washer had broken, a staff shortage, the laundry just kept piling up and there were no labels on the clothes. She stated that the clothes that did not have a label were put into the lost or missing bin. She stated that the amount of clothing that was lost or missing had accumulated over the span of a few months, and it quickly became an overwhelming. She stated that there was no attempt to relocate the clothing because it quickly became overwhelming amount of clothing. She stated that they had come up with a plan as of last Monday (07/08/2024). She stated that the plan would start on Wednesday 07/17/2024, but if there were too many activities then it will have to wait until the next weekend. She stated that she had talked to the Administrator last week and the new plan would be to empty the large bin of missing or lost clothing out on the dining room tables in the dining room and let the residents come into the dining room and claim the clothing. If there were clothes that were unclaimed they would donate those clothes to the residents who do not have much or anything at all. She stated that they will start doing this plan once a week until all of the clothes were either located or donated. She stated that she believed the problem for not having an effective plan was a shortage in staff. She stated that when a resident came to look for their missing clothing, she would have to immediately look for it because her memory was not as good as it used to be and if she doesn't immediately do it then she will forget. She stated that they will work hard from now on to locate the missing laundry because she knew two residents on hall 600 that won't even leave their room if they do not have pants on. She stated that they did not attempt to locate the missing clothing due to a staff shortage. She stated that the negative potential outcome of residents clothing missing or lost was that they will begin to lose trust in the facility and begin to think that the facility is not capable of handling their items. She stated that it definitely impacted the resident's dignity when their clothes were missing or lost and could impact their dignity. During an interview on 07/11/2024 at 3:09 PM, the Corporate District Manager stated that they did not have an effective plan for the laundry at the time but have since come up with a plan. She stated that she had just got to this facility just a few months ago. She stated that last Monday they pulled every piece of lost clothing out of the laundry room in the big missing bin and went through it. She stated that this past Monday all the clothes were pulled out to check for names so they could attempt to identify and they were just put back into the bins because of no names. She stated that the plan was this Wednesday (07/17/2024), all the missing clothes from the missing bin, would be put on racks in the dining room. She stated that the activity director would help a section of residents at a time to look through the clothing to see if they recognized anything as their clothing. She stated that if all the clothing is not located at that point, then the facility would take around to all residents to see if then they may recognize something as theirs. She stated that for residents that can not come out of their room, they would take the racks around to them. She stated that for the residents that can not communicate they would call the family members to see if the family can come up and go through the clothing to see if they might recognize something that belonged to their loved one. She stated that there should have been a better plan in place for missing or lost clothing. She stated that this would change as of now. She stated that the negative potential outcome was that it may make the residents unhappy and feel upset. She stated that hopefully with this plan they would have a better outcome and get issues resolved. Record review of the facility policy title, Laundry Operations, revised 09/2017 reflected the following: .In long-term care, no area of laundry management is more critical to patient care and dignity issues than they are of resident clothing. Residents, residents' families, admissions, social services, administration, and, of course, nursing are all involved with laundry in creating policies for getting resident clothing collected, washed, dried, and returned to residents on a timely basis . If clothing is unmarked, do not let it accumulate in the laundry. All missing clothing grievances must be researched, answered, and clothing returned (either found or replaced) within 24-48 hours. Laundry employees must bring any unmarked clothing for the day up to the units for identification by the CNAs who are more familiar with the residents and their belongings. Once the owner of unmarked clothing is identified, label the garment immediately

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change and possible need to alter treatment in the resident's physical status for one of seven residents (Resident #1) reviewed for physician notification. The facility failed to promptly consult Resident #1's medical provider when he began to have blood in his catheter on 4/28/17. The Nurse Practitioner was not informed until 4/30/17. Resident #1 went to the hospital on [DATE] where they found his catheter in his prostate. These failures resulted in harm to one resident who had blood in his catheter and placed 7 other residents with a catheter at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Review of Resident #1's Admission Record dated 4/3/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] documented he had a catheter. Review of Resident #1's Care Plan dated 3/19/17 documented he had an indwelling 18 French, 10 cc (cubic centimeter) Foley catheter for [MEDICAL CONDITION] bladder. The identified goal was be/ remain free from catheter - related trauma through review date. Identified interventions included: Notify MD (Medical Doctor) for s/s (signs and symptoms) of discomfort, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observe and document intake and output as per community policy. Observe for s/sx of pain/ discomfort due to catheter. Review of Resident #1's Order Summary Report dated 5/04/17 documented orders dated: - 3/01/17 for 18 French Foley Cath - Change Catheter and bag every month every day shift starting on the 15th and ending on the 16th every month for Foley Catheter maintenance. - 3/01/17 Cleanse Foley Catheter insertion site every shift for Foley Catheter maintenance. Review of Resident #1's Nurse's Notes documented, in part: - 4/28/17 (Late Entry) 5:36 p.m. Received report that resident had blood noted in drainage bag. Resident unable to verbally communicate any information, but did complaint of pain to penis area, no visible signs trauma noted. Catheter emptied to continue to monitor. (No documentation the physician was notified of the blood in Resident #1's urine, no further follow up documented.) (There was no note for 4/28/17 6 p.m. - 6 a.m. shift) -4/29/17 5:38 p.m. Resident denies any further pain when asked, urine draining to gravity at bedside barely tinged, no further s/s of trauma noted. - 4/30/17 [MEDICATION NAME] - [MEDICATION NAME] Tablet 5 - 325 give 1 tablet by mouth every 6 hours as needed for pain. - 4/30/17 5:39 a.m. Resident in bed alert and awake - no s/s of pain or discomfort noted, Foley catheter in place and blood noted in urine, no fever at this time, will continue to monitor. (No documentation the physician was notified of the blood in Resident #1's urine) - 4/30/17 10:30 a.m. RN A explained that charge nurse had called Nurse Practitioner regarding blood in Resident #1's Foley and that she had received orders to send him out. This writer went down to Resident #1 bed area at approximately 10:30 a.m. and noted some abdominal distension with complaints of pain upon palpation. Resident had pain of a 5 on a 0 - 10 scale. Foley bag had approximately 150 - 175 cc's of dark red bloody urine with some noted clots in the tubing. Charge nurse and RN A obtained a set of vitals and they were within normal limits. Resident is currently stable so he will be transported via (facility) vehicle by transportation tech. Resident was informed of need for transfer and that wife would be notified and he stated ok. Charge nurse and RN A completed transfer calls and documentation. Director of Nurses notified of assessment and need for transfer. - 4/30/17 6:31 p.m. Report received from RN B. Scan showed Foley cath balloon to have moved to prostate. Pneumonia noted to bilateral bases also. Resident to be admitted to (hospital) During an interview on 5/04/17 at 1:20 p.m. RN C said she did not see any Intake/Output monitoring for Resident #1 once the nurses began documenting blood in his urine. She said the staff were monitoring his pain and the amount of blood in his catheter tubing/ bag. She said the facility had a Nurse Practitioner on 4/18 and she addressed Resident #1's UTI (Urinary Tract Infection) and gave him an antibiotic. She said the staff did something about his pain. She said on 4/29 there was no further signs of trauma so there was nothing to report to the Nurse Practitioner. She said they called on the 4/30. She acknowledged that was a 2 day delay in physician being notified During an interview on 5/05/17 at 9:55 a.m. RN C said the 24-Hour Communication Report (report used to communicate between shifts) was saved over so there was no way to verify if Resident #1's Nurse Practitioner had been notified that way. Review of the facility's 1/3/17 Policy and Procedure on Significant Change in Condition documented, in part: The community notifies the resident's physician, legal representative, or interested family member whenever there is: - a significant change in the resident's physical, mental, or psychosocial status; - a need to alter treatment significantly. Review of the MedLine Plus website (https://medlineplus.gov/ency/patientinstructions/ 0.htm) accessed on 5/15/17 documented, in part: Call your health care provider if you have signs of an infection, such as: · Pain around your sides or lower back · Urine smells bad, or it is cloudy or a different color Also call your provider if: · You notice blood in your urine. · Your catheter seems blocked. · You notice grit or stones in your urine. · You have pain near the catheter. A list provided by the facility on 5/04/17 documented there were 7 residents in the facility with catheters.

Based on interview and record review, the facility failed to ensure residents with indwelling urinary (Foley) catheters received appropriate treatment and services to prevent complications for 3 of 7 residents reviewed for Foley catheters. (Resident #1, 3 and 5). Resident #1 had blood in his catheter on 4/28/17. The facility did not document any type of monitoring on the blood or urine output until the following day. Resident #1 reported having severe pain in his penile area on 4/30/17. Resident #1's physician was not notified of the blood in his catheter until 4/30/17. The facility sent Resident #1 to the hospital. The hospital found Resident #1's catheter in his prostate. The facility was unaware of how the catheter got in his prostate. There were no Input/ Output (I/O's) (measuring of urine output to ensure that the resident's bladder was functioning properly) monitoring on 3 of 7 residents (Resident #1, 3 and 5). These failures resulted in harm to Resident #1 and could place seven residents with indwelling Foley catheters at risk for discomfort, infection, and urethral trauma. Findings included: RESIDENT #1 Review of Resident #1's Admission Record dated 4/3/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] documented he had a catheter and needed assistance from staff with transfers. Review of Resident #1's Care Plan dated 3/19/17 documented he had an indwelling 18 French, 10 cc (cubic centimeter) Foley catheter for [MEDICAL CONDITION] bladder. The identified goal was be/ remain free from catheter - related trauma through review date. Identified interventions included: Notify MD (Medical Doctor) for s/s (signs and symptoms) of discomfort, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observe and document intake and output as per community policy. Observe for s/sx of pain/ discomfort due to catheter. Review of Resident #1's Order Summary Report dated 5/04/17 documented orders dated: - 3/01/17 for 18 French Foley Cath - Change Catheter and bag every month every day shift starting on the 15th and ending on the 16th every month for Foley Catheter maintenance. - 3/01/17 Cleanse Foley Catheter insertion site every shift for Foley Catheter maintenance. Review of Resident #1's Nurse's Notes documented, in part: - 4/28/17 (Late Entry) 5:36 p.m. Received report that resident had blood noted in drainage bag. Resident unable to verbally communicate any information, but did complaint of pain to penis area, no visible signs trauma noted. Catheter emptied to continue to monitor. (No documentation the physician was notified of the blood in Resident #1's urine, no further follow up documented.) (There was no note for 4/28/17 6 p.m. - 6 a.m. shift) (by LVN E) -4/29/17 5:38 p.m. Resident denies any further pain when asked, urine draining to gravity at bedside barely tinged, no further s/s of trauma noted. (by LVN E) - 4/30/17 [MEDICATION NAME] - [MEDICATION NAME] Tablet 5 - 325 give 1 tablet by mouth every 6 hours as needed for pain. (by LVN G) - 4/30/17 5:39 a.m. Resident in bed alert and awake - no s/s of pain or discomfort noted, Foley catheter in place and blood noted in urine, no fever at this time, will continue to monitor. (by LVN G) (No documentation the physician was notified of the blood in Resident #1's urine) - 4/30/17 10:30 a.m. RN A explained that charge nurse had called Nurse Practitioner regarding blood in Resident #1's Foley and that she had received orders to send him out. This writer went down to Resident #1 bed area at approximately 10:30 a.m. and noted some abdominal distension with complaints of pain upon palpation. Resident had pain of a 5 on a 0 - 10 scale. Foley bag had approximately 150 - 175 cc's of dark red bloody urine with some noted clots in the tubing. Charge nurse and RN A obtained a set of vitals and they were within normal limits. Resident is currently stable so he will be transported via (facility) vehicle by transportation tech. Resident was informed of need for transfer and that wife would be notified and he stated ok. Charge nurse and RN A completed transfer calls and documentation. Director of Nurses notified of assessment and need for transfer. (by RN H) - 4/30/17 6:31 p.m. Report received from RN B. Scan showed Foley cath balloon to have moved to prostate. Pneumonia noted to bilateral bases also. Resident to be admitted to (hospital) (by LVN G) Review of Resident #1's 4/2017 MAR (Medication Administration Record) / NAR (Nurse's Administration Record)/ TAR (Treatment Administration Record) documented Resident #1 did not have any I/Os documented on any form. During an interview on 5/04/17 at 1:20 p.m. RN C said she did not see any I/O monitoring for Resident #1 once the nurses began documenting blood in his urine. She said the staff were monitoring his pain and the amount of blood in his catheter tubing/ bag. She said the Nurse Practitioner addressed Resident #1's UTI on 4/18 and gave him an antibiotic. She said the staff did something about his pain. She said on 4/29 there was no further signs of trauma so there was nothing to report to the Nurse Practitioner. She said they called on 4/30. She acknowledged that was a 2 day delay in physician being notified. She said on 4/30 there was no signs of trauma to the urethral tip. She said she did not see the catheter change but between 4/16 through the 4/28 the catheter was not inserted in the prostate because there were no reports of pain. During an interview on 5/04/17 at 2:11 p.m. the RN D said she and the charge nurse assessed Resident #1. She said Resident #1 was sent out due to a change of condition and the nurse practitioner was notified. She said she did assess Resident #1 and gently palpated his bladder. She said it was slightly distended. She said she was not made aware of the blood found in his catheter on 4/28. RN D said when monitoring a catheter you would check for output, color, complaints of pain, and vital signs. RN D said they noticed a change of condition and they got him sent out on the Nurse Practitioner's order because of the acute blood. She repeated she had not been made aware of the blood in Resident #1's catheter on 4/28. During an interview on 5/04/17 at 2:37 p.m. Licensed Vocational Nurse (LVN) E said 4/28/17 was her first day working the floor. She said before Resident #1 was sent out he did not have any urinary issues. She said on 4/28/17 there was blood in his urine that seemed like trauma but she had no prior reports of anything. She said they emptied the catheter bag to see if they could get a better sample. She said they checked for output. She said she documented on 4/29/17 that the urine was almost clear but she did not remember how much blood was actually in the catheter. LVN E said Resident #1 had quite a bit of output. She said she did tell the oncoming shift that day about the blood in Resident #1's catheter. She said I wasn't there when the House Manager assessed, but she did assess. LVN E did not know RN D palpated Resident #1's bladder. She said most residents did not have an order for [REDACTED].? She said she was not sure why she did not document for color. She said if she had questions she would ask the RN and if the catheter needed to be changed she would ask the RN to do it. LVN E said the RN was aware and did not give her any further instructions. She said I didn't get specific instructions to monitor on the 28th. She said she told to 6 p.m. - 6 a.m. on coming RN. LVN E said she knew Resident #1 had urine output and it was between 600 - 900 cc. She said she would have the RN check placement because she was not comfortable doing it. During an interview on 5/4/17 at 2:55 p.m. RN C said the facility's policy on catheter care said they would just follow best practice. Review of the MedLine Plus website (https://medlineplus.gov/ency/patientinstructions/ 0.htm) on 5/15/17 documented, in part: Call your health care provider if you have signs of an infection, such as: · Pain around your sides or lower back · Urine smells bad, or it is cloudy or a different color Also call your provider if: · You notice blood in your urine. · Your catheter seems blocked. · You notice grit or stones in your urine. · You have pain near the catheter. During an interview on 5/04/17 at 3:28 p.m. RN E said he remembered Resident #1. RN E said he was aware when report was called into the hospital they said the bulb was inflated in his prostate. He said he checked and Resident #1's catheter was changed on 4/15. He said if the catheter bulb was inflated in the prostate for 48 hours the penis would have been swollen and the pressure on the prostate would have cut off circulation. He said the bleed Resident #1 experienced was possibly due to him pulling on it. RN E said he was not made aware of blood in Resident #1's catheter of 4/28. She said he was aware of the blood on 4/30 and that was why they sent him out. He said to monitor residents with catheters he would look for obstruction of urine and excessive bleeding. He said he would look to see if the resident was producing a minimum of 200 cc of urine an hour and if they palpate the bladder. He said if there was no where else to document it, he would document the output in a nurse's note. He said he was the RN supervisor, not the charge nurse for that wing. During an interview on 5/05/17 at 2:15 p.m. the Administrator said the staff had made him aware of Resident #1 going to the hospital on [DATE]. He said they made him aware of the pnuemonia [DIAGNOSES REDACTED]. He said the first time he heard about the catheter was when State Surveyors informed him of it. Review of the 1/27/17 In-service on Transferring resident with Foley Catheters documented, in part: Caution must be taken when residents with Foley Catheters are transferred from one surface to another or re-positioned in bed. The Foley Catheter bag must be positioned so it does not pull the tubing tight during the transfer or position change. If the tubing is pulled tight this may causes pressure/ pain/ injury to the bladder and or urethra. Failure to properly positions the catheter bag during this process may result in dislodgement of the catheter and/or trauma to the genitals. I/O Monitoring RESIDENT #3 Review of Resident #3's Admission Record dated 4/03/17 documented he was [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS assessment dated [DATE] documented he had a catheter. Review of Resident #3's Care Plan dated 11/29/16 that he had an Indwelling 16 F (French) 10 cc Foley Catheter for his [MEDICAL CONDITIONS] and history of UTI. The identified goal was be/remain free from catheter-related trauma through review date. Identified goals included observe and documented intake and output as per community policy. Review of Resident #3's April 2017 MAR/NAR/TARS documented no I/O's anywhere on the documents. RESIDENT #5 Review of Resident #5's Admission Record dated 4/03/17 documented he was [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS assessment dated [DATE] documented he had a catheter. Review of Resident #5's Care Plan dated 3/23/17 documented, in part: Focus: Indwelling Catheter related to my [DIAGNOSES REDACTED]. The identified goal was be/ remain free from catheter related trauma through review date. Identified interventions included observe and document intake and output as per community policy. Review of Resident #5's April 2017 MAR/NAR/TARS documented no I/O's anywhere on the documents. During an interview on 5/04/17 at 1:20 RN C acknowledged there were no I/O's for the residents. She said I don't see I/O monitoring, pain, and output. She said she did not see an amount of output documented. She said the facility did not normally monitoring the I/O's unless there was an order. She said not everyone with a Foley (catheter) requires it. RN C said we do the intake with meals, but not necessarily I/Os. Review of the facility's 4/2011 policy and procedure on Indwelling Catheter Care documented, in part: Care and maintenance of indwelling catheters is essential to prevent infection and/or complications. Documentation: In the nursing progress notes, document pertinent observations and interventions. A list provided by the facility on 5/04/17 documented there were 7 residents in the facility with catheters.

Based on observations, interviews and record review the facility failed to ensure residents were free from neglect for one (Resident #1) of 10 residents reviewed for neglect. (a) Resident #1 was given a full cup of hot coffee by a staff member and the resident spilled the coffee on himself. The resident sustained [REDACTED].#1 was hospitalized 11 days after the burn, and remained hospitalized at the time of the investigation. (b) The facility failed to implement interventions or in-service staff that coffee temperatures were high, and staff continued to serve residents excessively hot coffee. Residents also continued to self-serve hot coffee from the coffee container in the dining room. On 01/25/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 01/27/17 the facility remained out of compliance at actual harm at a pattern due to the facility's need to evaluate and monitor their corrective action system. Failure to provide adequate supervision or preventive measures could place 25 residents that drank coffee and had risks of getting burned. Finding Included: Record review of Resident #1's admission record dated 01/25/17 indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 8. (8 indicates moderately impaired). · Functional status: Eating - how resident eats and drinks, regardless of skill. = 1. Supervision - oversight, encouragement or cueing. · Mobility devices: Wheelchair. Record review of Resident #1's care plan indicated in part: · Focus: Requires assistance with adls (activities of daily living) due to cognition, generalized weakness. Interventions: Staff to monitor safety with routine rounds. Eating: able to eat independently after tray setup, may need staff encouragement. Revision date 08/20/16. · Focus: resident has impaired cognitive function/impaired thought process r/t dementia. Interventions: assist with all decision making. Cue, reorient and supervise as needed. Revision on 08/20/16. · Focus: Resident has been placed in memory support due to poor safety awareness and elopement risk. Interventions: Resides on secured memory care unit. Revision on 08/20/16. Record review of Resident #1's incident report dated 01/12/17 indicated in part: · Nursing description: CNA (Certified Nurse Aide) reported resident spilled coffee on himself. Resident description: I spilled my coffee. · Description: Resident was assessed. Red area noted to left lower abdomen and left upper thigh. Areas are beginning to blister. Spoke to Nurse Practioner (NP) and received telephone orders for [MEDICATION NAME] cream twice a day (BID) until resolved. Note: [MEDICATION NAME] cream is a topical (for the skin) antibiotic used to treat or prevent infections on areas of burned skin). · Staff educated regarding letting coffee cool down before serving. During an interview on 01/26/17 at 10:03 a.m. Certified Medication Aide (CMA) G said the day Resident #1 got burned he had given him a cup of coffee prior to Resident#1 spilling it on himself. CMA G said he poured about ¾ of coffee into the cup and then poured some cold water into the same cup so it would not be that hot. During an interview on 01/25/17 at 4:01 p.m. LVN E said on 01/12/17 around 6am she had just arrived at work in the memory support unit when CNA F told her to go and check on Resident #1 because he had spilled coffee on himself. LVN E said she assessed Resident #1 and his skin was red and blistered. LVN E said she administered Resident#1 some pain medication and called the doctor who then ordered some [MEDICATION NAME] cream. LVN E said Resident #1 would fall asleep with the cup of coffee on his hand. During an interview on 01/25/17 at 9:04 a.m. CNA D said Resident #1 probably fell asleep and spilled the coffee on himself. CNA D said Resident #1 could fall asleep while holding the cup in his hand, as he could fall asleep quickly. During an interview on 01/25/17 at 9:11 a.m. CNA A said Resident #1 would fall asleep even during meal times. CNA A said they had to wake him up during meals. CNA A said if a resident wanted a coffee refill then she would go into the kitchenette, pour the coffee into the cup and serve it directly to the resident. During an interview on 01/24/17 at 4:28 p.m. the Director of Nurses (DON) said she remembered Resident #1's doctor stating [MEDICAL CONDITION] 2nd degree burns. The DON said Resident #1 had hit the coffee cup and spilled it on himself. The DON said they discussed the incident in their morning meeting the next day after the incident. The DON said they had just discussed the burn incident but had not performed a written plan. Record review of Resident #1's nurse notes indicated in part: · 01/16/17 3:01 p.m. Left lower abdomen and left upper thigh appeared blistered and red from previous coffee burn. No [MEDICAL CONDITION], no warmth at this time. However Bactrim DS (antibiotic) one tab by mouth BID (twice a day) has been ordered by NP as an infection [MEDICATION NAME]. · 01/20/17 3:11 p.m. Resident receives [MEDICATION NAME] cream application twice a day as well as [MEDICATION NAME] PO (by mouth) Bactrim DS, also has been referred to a wound care clinic for further treatment to the [MEDICAL CONDITION] on left lower abdomen and left upper thigh. Record review of Resident #1's physician's orders [REDACTED]. · Bactrim DS (antibiotic) tablet 800-160 MG (milligrams). Give 1 tablet by mouth two times a day for [MEDICATION NAME] for 10 days. Order date 01/16/17. · [MEDICATION NAME] cream 1%. Apply to left abdomen and left thigh topically every shift for burn. Order date 01/12/17. Record review of Resident #1's physician's progress note dated 01/17/17 indicated in part: · Patient spilt coffee on himself burning his abdomen and left thigh receiving wound care with [MEDICATION NAME]. · Abdomen and left upper thigh- positive 2nd degree burns, 7% TBSA (total body surface area), no purulence, mild [DIAGNOSES REDACTED]. Record review of Resident #1's emergency room notes indicated in part: · 01/23/17. 5:34 p.m. presenting complaint: Wife states He was burned by a scalding hot cup of coffee on January 12 2017. Lives at (Facility), saw by doctor there and he said it was ok, I want a second opinion presents with large open wound to left lower abdomen and on left upper thigh/groin area (not visualized in triage) wife states all they are doing is putting [MEDICATION NAME] on it. It has no dressing on it. Wife verbalizing she wants to know if he needs to go to wound care. · 01/23/17 7:46 p.m. The patient presents with a burn as a result of hot water, while at nursing home. The symptoms/episode began/occurred 10 days ago. Burn type and severity: 2nd degree: approximately 18% total body surface area of second degree injury of the left lower quadrant. · 01/23/17 7:49 p.m. Burn type and severity: 2nd degree: of the left quadriceps. Associated signs and symptoms. Patient states he was at the nursing home when hot coffee was spilled onto his lower abdomen and left anterior thigh. He states the redness is getting bigger every day. During an interview on 01/27/17 at 11:15 a.m. Resident #1's spouse said she had requested for the facility to send Resident #1 to the hospital for wound care. Resident #1's spouse said she did not think the burn wounds looked good even though the facility doctor had stated they looked good and to continue with the current treatment. Resident #1's spouse provided the surveyor multiple pictures of the burn wounds. During a telephone interview on 01/27/17 at 3:15 p.m. the hospital wound care nurse said she had assessed Resident #1's burn wounds when he first arrived at the hospital. The wound care nurse said the burn wounds had a lot of [MEDICATION NAME] medication caked on them and they had to clean it all off before they could assess it correctly. The wound care nurse said the wounds appeared to be 3rd [MEDICAL CONDITION] her because of the green slough it had on it. The wound care nurse said the resident had received several antibiotics via intra venous (IV) as a [MEDICATION NAME] measure. During an observation on 01/24/17 at 12:17 p.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 167 degrees Fahrenheit (F), the temperature of the hot water was 165 degrees F and the temperature of the decaffeinated coffee was 163 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 171 degrees F and Disp (dispense) temp 166 degrees F. Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 F 68 C 1 second 148 F 64 C 2 seconds 140 F 60 C 5 seconds 133 F 56 C 15 seconds Reference: <http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> reviewed 02/02/17. During an interview on 01/24/17 at 12:20 p.m. CNA A said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA A said she would serve the coffee in regular cups with no lids. During an interview on 01/24/17 at 12:22 p.m. CNA B said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA B said the dietary staff would bring the cups and she would use them to pour the coffee and serve the residents. During an interview on 01/24/17 at 12:26 p.m. Licensed Vocational Nurse (LVN) C said the staff would serve the residents in the memory support unit coffee from the kitchenette located in the memory support unit. LVN C said they got the new coffee machine about 2 weeks ago and someone got burned about 3 days later. During an interview on 01/24/17 at 12:38 p.m. the Dietary Manager (DM) said after the burn incident they had the temperature lowered on the machine. The DM said the temperature on the machine was now between 170 degrees F and 171 degrees F. The DM said as of 01/12/17 the dietary staff started taking the temperatures and logging it on the temperature log. The DM said the temperature was at 168 degrees F before the technician had come out to lower the temperature. During an observation on 01/25/17 at 9:25 a.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 165 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 173 degrees F and Disp temp 168 degrees F. During an interview on 01/25/17 at 10:42 a.m. The Administrator said they had discussed the burn incident during their morning meeting the day after the incident (occuring on 01/12/2017) but did not have a written plan. The Administrator said he had not been able to locate anywhere where it indicated what the safe temperature level for coffee was. The Administrator said the DM had a document indicating what the safe temperature levels were. The Administrator said he would go and obtain the document from the DM. (Note: The Administrator left the meeting but never returned to the meeting or provided the document). During an interview on 01/25/17 at 3:25 p.m. the DM said she had called the technician on 01/12/17 to come out and lower the temperatures on the coffee machines. The DM said she had taken the coffee temperature and it was 168 degrees F prior to the technician lowering it on 01/18/17. The DM said the technician lowered the temperature from 190 degrees F to 170 degrees F. The DM said she had obtained the safe temperature range that was written on the temperature logs of 155 - 175 from an article she found on the internet. The DM said she later contacted the dietician who told her the safe temperature range was between 140 - 145 degrees F. The DM said the residents in the main dining room would self-serve themselves from the coffee machine located in the main dining room. During an interview on 01/25/17 at 5:04 p.m. the Administrator said they had the technician in the facility right now to check the coffee machines. The Administrator said they had the technician here to make sure the temperatures were consistent at the temperature they should be which was 145 degrees F and 160 degrees F. The Administrator said those temperatures would be more appropriate. During an observation on 01/25/17 at 5:20 p.m. several residents in the main dining room were observed drinking coffee that was served from the coffee machine. During an observation on 01/25/17 at 5:26 p.m. the temperature display on the coffee machine in the main dining room indicated Tank temp 160 degrees F and Disp temp 155 degrees F after the technician lowered the temperatures. The temperature of the coffee was taken and it was 159 degrees F. During a telephone interview on 01/27/17 at 1:54 p.m. the coffee machine manufacturer said the temperature on the coffee machine Disp temp was the actual temperature of the coffee that came out of the spigot. Record review of the facility's coffee machine invoice report indicated in part: · Problem notes: Comments Vcafe dispense temp is too hot, customer says they have it set at 170 but when they measure the temp with their thermometer it is coming out much hotter. (Note: Vcafe is the name of the coffee machine). · Solution notes: Tank temp reading 190 had display temp at 170 turned down to where tank temp at 170 ran water to let tank reheat all good. · Completed 01/18/17 (six days after Resident #1 was burned) Record review of the facility's MSU (Memory Support Unit) coffee temperature log dated January 2017 indicated in part: · Range 155-175. · Date: 01/12/17. Temperature 168. · Date: 01/13/17. Temperature 168. · Date: 01/14/17. Temperature 168. · Date: 01/15/17. Temperature 166. · Date: 01/16/17. Temperature 168. · Date: 01/17/17. Temperature 170. · Date: 01/18/17. Temperature 168. · Date: 01/19/17. Temperature 164. · Date: 01/20/17. Temperature 166. · Date: 01/21/17. Temperature 168. · Date: 01/22/17. Temperature 166. · Date: 01/23/17. Temperature 168. · Date: 01/24/17. Temperature 165. Record review of the facility's dining room coffee temperature log dated January 2017 indicated in part: · Range 155-175. · Date: 01/12/17. Temperature 168. · Date: 01/13/17. Temperature 166. · Date: 01/14/17. Temperature 168. · Date: 01/15/17. Temperature 164. · Date: 01/16/17. Temperature 168. · Date: 01/17/17. Temperature 168. · Date: 01/18/17. Temperature 166. · Date: 01/19/17. Temperature 170. · Date: 01/20/17. Temperature 168. · Date: 01/21/17. Temperature 164. · Date: 01/22/17. Temperature 166. · Date: 01/23/17. Temperature 168. · Date: 01/24/17. Temperature 168. · Date: 01/25/17. Temperature 171. Review of the internet document dated 01/24/17 provided by the DM indicated in part: · Can you tell me what is the proper temperature to serve coffee? Thanks! ANSWER: Coffee is best served at a temperature between 155ºF and 175ºF (70ºC to 80ºC). Most people prefer it towards the higher end, at about 175ºF. Do you remember that lawsuit that MacDonalds lost when a customer scalded herself after she spilled some of her coffee? Back then the MacDonalds manual for its employees stated that coffee should be served at 195 to 205 degrees and held at 180 to 190 degrees for optimal taste. As they discovered when they lost the case, that was too hot. You won't go far wrong at 175ºF. That said, there are some coffee experts who like to drink their coffee at much lower temperatures. George Howell of George Howell Coffee who has been sourcing and tasting specialty coffee since the 1970s, likes to drink his coffee at a temperature closer to 130ºF. To you and me that would feel like tepid coffee. But according to him, it's at that temperature that many of the more subtle flavors of coffee are revealed. What he says makes sense, because if you think about coffee that is really hot, almost hot enough to burn your tongue, you really don't taste much at all. So there is a sliding scale here. At the hotter end of the scale, at about 175ºF, we feel the satisfaction of drinking a nice hot cup of coffee. At the lower end of the scale, at 150ºF and below, we get less of that hot cup of Joe experience, but are able to taste some of the more subtle flavors of the coffee. · Note: this was printed directly from the website and given to the state surveyor as evidence of where the DM determined the coffee range to be appropriate (155-175) -Hyperlink as indicated on the document. <http://www.coffeedetective.com/what-is-the-correct-temperature-for-serving-coffee.html> Record review of the undated American burn association scald injury prevention educator's guide indicated in part: · Although [MEDICAL CONDITION] happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. · When the temperature of a hot liquid is increased to 140 F/60 C it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F /71-82 C, resulting in almost [MEDICAL CONDITION] will require surgery. · Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. · Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids.[MEDICAL CONDITION] the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Reference: <http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> reviewed 02/02/17. Record review of the facility's undated neglect policy indicated in part: - Signs of neglect: Inadequate provision of care; left alone but needs supervision. Record review of the facility's accidents and incidents policy dated 02/2012 indicated in part: · The licensed nurse/and/department director/designee will conduct an investigation of the accident or incident. · The nature of the injury/illness. · The condition of the injured person. · Any corrective action taken. IMMEDIATE JEOPARDY On 01/25/17 at 6:10 p.m. the Administrator was notified of an Immediate Jeopardy. Record review of the facility's plan of action dated 01/26/17 indicated in part: The nurse aides have been in-serviced on reporting when a resident experiences a hot liquid spill to any part of their body. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. The licensed nurses and nurse aides have been in-serviced on what to do (first aid interventions) when a hot liquid spill occurs in regard to applying immediate interventions and assessing the residents skin, notification to physician and responsible party and imitating an incident report. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Team members across all departments have been in-serviced on not reheating hot drink liquid, example coffee in the microwaves. Team members, across all departments have been instructed to obtain fresh cup of coffee from coffee dispenser located in main dining and in MSU kitchenette. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Contact coffee machine equipment technician to check machine function and to lower temp to a range of 140 to 150 degrees. First contact on 01/12/17, technician checked machines for proper functioning and temps. Second contact on 01/25/17 technician returned at request of community and adjusted temperatures on both machines in the community. Initial temperature for the coffee machine on the MSU was noted to be at 162 degrees and the temperature post adjustment was noted to be at 145 degrees. Initial temperature for the coffee machine in main dining area was noted to be at 171 degrees post adjustment was noted to be at 145 degrees. Coffee machine technician to train Dietary Manager on process to adjust temperatures on the coffee machines. Completed on 01/25/17. For the first 12 hours temps will be taken on both coffee machines to validate temp is not registering above 150 degrees. If above 150, the administrator will be notified immediately. This task will be accomplished by RN supervisor. This was initiated on 01/25/17 and completed on 01/26/17. Dietary personnel will check the temperatures daily at all meals in the main dining room and enter temperatures on a monitoring form; dietary team members have been in-serviced on process and temperature range along with steps to take if too hot/cold. This in-service was initiated on 01/25/17 by the DM. This education will continue until all applicable team members have been educated. MSU staff/dietary personnel will check the temperatures of the coffee machine daily in the MSU kitchenette and enter temperatures on a monitoring form; dietary team members will be in-serviced on process and temperature range along with steps to take if too hot/cold. Initiated 01/12/17. Form updated on 01/25/17 for continued monitoring on temperatures on both machines. The Administrator or the DON or the DM will make random rounds in the dining areas and on the halls to monitor compliance of completion of the temperature logs. These rounds will happen daily for two weeks. If the temperatures in both coffee machines are maintained at or below 150 degrees, then the monitor will be changed to weekly. Findings will be brought to the morning department head meeting and the monthly QA&A for the 3 months. All residents have been assessed to identify any safety related issues in regards to hot liquids. Assessments were initiated on 01/24/17 and were completed on 01/25/17. If a resident experiences a hot liquid spill to their body, OT (occupational therapy) to screen the residents for specialty cups, needing lidded cups and the resident use of cup will be care planned. Cups with lids for safety were ordered on [DATE]. Resident #1 was provided multiple cups with lids for safety on 01/12/17. Record review of the facility's undated hot liquid/food spills policy included with the POR indicated in part: · Purpose: Residents are at risk of having any hot liquid/food spilled on their person. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal or any other dietary substance that could cause injury. · Process: If a staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. · An incident report and investigation should then be completed and determine if the resident needs further interventions, such as a screening by therapy department, etc. to prevent future occurrences. Action Plan verification activities were conducted from 01/26/17 through 01/27/17 and included the following activities: Review of in-service documentation, interviewed 4 CNAs, 5 nurses and 1 Activity Director as she also helped with pouring coffee at times to verify in-service understanding. Temperatures of both coffee machines were taken. The coffee machine in the dining room was 135 degrees F and the one in the MSU was 142 degrees F. The Administrator was notified that the IJ was removed on 01/27/17 at 3:20 p.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Room roster dated 01/24/17 and provided by the DON on 01/27/17 indicated there were 25 residents at the facility that had a risk of spilling coffee on themselves.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for abuse and neglect. (a) Resident #1 was given a full cup of hot coffee by a staff member and the resident spilled the coffee on himself. The resident sustained [REDACTED].#1 was hospitalized 11 days after the burn, and remained hospitalized at the time of the investigation. (b) The facility failed to implement interventions or in-service staff that coffee temperatures were high, and staff continued to serve residents excessively hot coffee. Residents also continued to self-serve hot coffee from the coffee container in the dining room. On 01/25/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 01/27/17 the facility remained out of compliance at actual harm at a pattern due to the facility's need to evaluate and monitor their corrective action system. Failure to provide adequate supervision or preventive measures could place 25 residents that drank coffee and had risks of getting burned. Finding Included: Record review of the facility's undated neglect policy indicated in part: - Signs of neglect: Inadequate provision of care; left alone but needs supervision. Record review of the facility's accidents and incidents policy dated 02/2012 indicated in part: · The licensed nurse/and/department director/designee will conduct an investigation of the accident or incident. · The nature of the injury/illness. · The condition of the injured person. · Any corrective action taken. Record review of Resident #1's admission record dated 01/25/17 indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 8. (8 indicates moderately impaired). · Functional status: Eating - how resident eats and drinks, regardless of skill. = 1. Supervision - oversight, encouragement or cueing. · Mobility devices: Wheelchair. Record review of Resident #1's care plan indicated in part: · Focus: Requires assistance with adls (activities of daily living) due to cognition, generalized weakness. Interventions: Staff to monitor safety with routine rounds. Eating: able to eat independently after tray setup, may need staff encouragement. Revision date 08/20/16. · Focus: resident has impaired cognitive function/impaired thought process r/t dementia. Interventions: assist with all decision making. Cue, reorient and supervise as needed. Revision on 08/20/16. · Focus: Resident has been placed in memory support due to poor safety awareness and elopement risk. Interventions: Resides on secured memory care unit. Revision on 08/20/16. Record review of Resident #1's incident report dated 01/12/17 indicated in part: · Nursing description: CNA (Certified Nurse Aide) reported resident spilled coffee on himself. Resident description: I spilled my coffee. · Description: Resident was assessed. Red area noted to left lower abdomen and left upper thigh. Areas are beginning to blister. Spoke to Nurse Practioner (NP) and received telephone orders for [MEDICATION NAME] cream twice a day (BID) until resolved. Note: [MEDICATION NAME] cream is a topical (for the skin) antibiotic used to treat or prevent infections on areas of burned skin). · Staff educated regarding letting coffee cool down before serving. During an interview on 01/26/17 at 10:03 a.m. Certified Medication Aide (CMA) G said the day Resident #1 got burned he had given him a cup of coffee prior to Resident#1 spilling it on himself. CMA G said he poured about ¾ of coffee into the cup and then poured some cold water into the same cup so it would not be that hot. During an interview on 01/25/17 at 4:01 p.m. LVN E said on 01/12/17 around 6am she had just arrived at work in the memory support unit when CNA F told her to go and check on Resident #1 because he had spilled coffee on himself. LVN E said she assessed Resident #1 and his skin was red and blistered. LVN E said she administered Resident#1 some pain medication and called the doctor who then ordered some [MEDICATION NAME] cream. LVN E said Resident #1 would fall asleep with the cup of coffee on his hand. During an interview on 01/25/17 at 9:04 a.m. CNA D said Resident #1 probably fell asleep and spilled the coffee on himself. CNA D said Resident #1 could fall asleep while holding the cup in his hand, as he could fall asleep quickly. During an interview on 01/25/17 at 9:11 a.m. CNA A said Resident #1 would fall asleep even during meal times. CNA A said they had to wake him up during meals. CNA A said if a resident wanted a coffee refill then she would go into the kitchenette, pour the coffee into the cup and serve it directly to the resident. During an interview on 01/24/17 at 4:28 p.m. the Director of Nurses (DON) said she remembered Resident #1's doctor stating [MEDICAL CONDITION] 2nd degree burns. The DON said Resident #1 had hit the coffee cup and spilled it on himself. The DON said they discussed the incident in their morning meeting the next day after the incident. The DON said they had just discussed the burn incident but had not performed a written plan. Record review of Resident #1's nurse notes indicated in part: · 01/16/17 3:01 p.m. Left lower abdomen and left upper thigh appeared blistered and red from previous coffee burn. No [MEDICAL CONDITION], no warmth at this time. However Bactrim DS (antibiotic) one tab by mouth BID (twice a day) has been ordered by NP as an infection [MEDICATION NAME]. · 01/20/17 3:11 p.m. Resident receives [MEDICATION NAME] cream application twice a day as well as [MEDICATION NAME] PO (by mouth) Bactrim DS, also has been referred to a wound care clinic for further treatment to the [MEDICAL CONDITION] on left lower abdomen and left upper thigh. Record review of Resident #1's physician's orders [REDACTED]. · Bactrim DS (antibiotic) tablet 800-160 MG (milligrams). Give 1 tablet by mouth two times a day for [MEDICATION NAME] for 10 days. Order date 01/16/17. · [MEDICATION NAME] cream 1%. Apply to left abdomen and left thigh topically every shift for burn. Order date 01/12/17. Record review of Resident #1's physician's progress note dated 01/17/17 indicated in part: · Patient spilt coffee on himself burning his abdomen and left thigh receiving wound care with [MEDICATION NAME]. · Abdomen and left upper thigh- positive 2nd degree burns, 7% TBSA (total body surface area), no purulence, mild [DIAGNOSES REDACTED]. Record review of Resident #1's emergency room notes indicated in part: · 01/23/17. 5:34 p.m. presenting complaint: Wife states He was burned by a scalding hot cup of coffee on January 12 2017. Lives at (Facility), saw by doctor there and he said it was ok, I want a second opinion presents with large open wound to left lower abdomen and on left upper thigh/groin area (not visualized in triage) wife states all they are doing is putting [MEDICATION NAME] on it. It has no dressing on it. Wife verbalizing she wants to know if he needs to go to wound care. · 01/23/17 7:46 p.m. The patient presents with a burn as a result of hot water, while at nursing home. The symptoms/episode began/occurred 10 days ago. Burn type and severity: 2nd degree: approximately 18% total body surface area of second degree injury of the left lower quadrant. · 01/23/17 7:49 p.m. Burn type and severity: 2nd degree: of the left quadriceps. Associated signs and symptoms. Patient states he was at the nursing home when hot coffee was spilled onto his lower abdomen and left anterior thigh. He states the redness is getting bigger every day. During an interview on 01/27/17 at 11:15 a.m. Resident #1's spouse said she had requested for the facility to send Resident #1 to the hospital for wound care. Resident #1's spouse said she did not think the burn wounds looked good even though the facility doctor had stated they looked good and to continue with the current treatment. Resident #1's spouse provided the surveyor multiple pictures of the burn wounds. During a telephone interview on 01/27/17 at 3:15 p.m. the hospital wound care nurse said she had assessed Resident #1's burn wounds when he first arrived at the hospital. The wound care nurse said the burn wounds had a lot of [MEDICATION NAME] medication caked on them and they had to clean it all off before they could assess it correctly. The wound care nurse said the wounds appeared to be 3rd [MEDICAL CONDITION] her because of the green slough it had on it. The wound care nurse said the resident had received several antibiotics via intra venous (IV) as a [MEDICATION NAME] measure. During an observation on 01/24/17 at 12:17 p.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 167 degrees Fahrenheit (F), the temperature of the hot water was 165 degrees F and the temperature of the decaffeinated coffee was 163 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 171 degrees F and Disp (dispense) temp 166 degrees F. Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 F 68 C 1 second 148 F 64 C 2 seconds 140 F 60 C 5 seconds 133 F 56 C 15 seconds Reference: <http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> reviewed 02/02/17. During an interview on 01/24/17 at 12:20 p.m. CNA A said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA A said she would serve the coffee in regular cups with no lids. During an interview on 01/24/17 at 12:22 p.m. CNA B said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA B said the dietary staff would bring the cups and she would use them to pour the coffee and serve the residents. During an interview on 01/24/17 at 12:26 p.m. Licensed Vocational Nurse (LVN) C said the staff would serve the residents in the memory support unit coffee from the kitchenette located in the memory support unit. LVN C said they got the new coffee machine about 2 weeks ago and someone got burned about 3 days later. During an interview on 01/24/17 at 12:38 p.m. the Dietary Manager (DM) said after the burn incident they had the temperature lowered on the machine. The DM said the temperature on the machine was now between 170 degrees F and 171 degrees F. The DM said as of 01/12/17 the dietary staff started taking the temperatures and logging it on the temperature log. The DM said the temperature was at 168 degrees F before the technician had come out to lower the temperature. During an observation on 01/25/17 at 9:25 a.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 165 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 173 degrees F and Disp temp 168 degrees F. During an interview on 01/25/17 at 10:42 a.m. The Administrator said they had discussed the burn incident during their morning meeting the day after the incident (occuring on 01/12/2017) but did not have a written plan. The Administrator said he had not been able to locate anywhere where it indicated what the safe temperature level for coffee was. The Administrator said the DM had a document indicating what the safe temperature levels were. The Administrator said he would go and obtain the document from the DM. (Note: The Administrator left the meeting but never returned to the meeting or provided the document). During an interview on 01/25/17 at 3:25 p.m. the DM said she had called the technician on 01/12/17 to come out and lower the temperatures on the coffee machines. The DM said she had taken the coffee temperature and it was 168 degrees F prior to the technician lowering it on 01/18/17. The DM said the technician lowered the temperature from 190 degrees F to 170 degrees F. The DM said she had obtained the safe temperature range that was written on the temperature logs of 155 - 175 from an article she found on the internet. The DM said she later contacted the dietician who told her the safe temperature range was between 140 - 145 degrees F. The DM said the residents in the main dining room would self-serve themselves from the coffee machine located in the main dining room. During an interview on 01/25/17 at 5:04 p.m. the Administrator said they had the technician in the facility right now to check the coffee machines. The Administrator said they had the technician here to make sure the temperatures were consistent at the temperature they should be which was 145 degrees F and 160 degrees F. The Administrator said those temperatures would be more appropriate. During an observation on 01/25/17 at 5:20 p.m. several residents in the main dining room were observed drinking coffee that was served from the coffee machine. During an observation on 01/25/17 at 5:26 p.m. the temperature display on the coffee machine in the main dining room indicated Tank temp 160 degrees F and Disp temp 155 degrees F after the technician lowered the temperatures. The temperature of the coffee was taken and it was 159 degrees F. During a telephone interview on 01/27/17 at 1:54 p.m. the coffee machine manufacturer said the temperature on the coffee machine Disp temp was the actual temperature of the coffee that came out of the spigot. Record review of the facility's coffee machine invoice report indicated in part: · Problem notes: Comments Vcafe dispense temp is too hot, customer says they have it set at 170 but when they measure the temp with their thermometer it is coming out much hotter. (Note: Vcafe is the name of the coffee machine). · Solution notes: Tank temp reading 190 had display temp at 170 turned down to where tank temp at 170 ran water to let tank reheat all good. · Completed 01/18/17 (six days after Resident #1 was burned) Record review of the facility's MSU (Memory Support Unit) coffee temperature log dated January 2017 indicated in part: · Range 155-175. · Date: 01/12/17. Temperature 168. · Date: 01/13/17. Temperature 168. · Date: 01/14/17. Temperature 168. · Date: 01/15/17. Temperature 166. · Date: 01/16/17. Temperature 168. · Date: 01/17/17. Temperature 170. · Date: 01/18/17. Temperature 168. · Date: 01/19/17. Temperature 164. · Date: 01/20/17. Temperature 166. · Date: 01/21/17. Temperature 168. · Date: 01/22/17. Temperature 166. · Date: 01/23/17. Temperature 168. · Date: 01/24/17. Temperature 165. Record review of the facility's dining room coffee temperature log dated January 2017 indicated in part: · Range 155-175. · Date: 01/12/17. Temperature 168. · Date: 01/13/17. Temperature 166. · Date: 01/14/17. Temperature 168. · Date: 01/15/17. Temperature 164. · Date: 01/16/17. Temperature 168. · Date: 01/17/17. Temperature 168. · Date: 01/18/17. Temperature 166. · Date: 01/19/17. Temperature 170. · Date: 01/20/17. Temperature 168. · Date: 01/21/17. Temperature 164. · Date: 01/22/17. Temperature 166. · Date: 01/23/17. Temperature 168. · Date: 01/24/17. Temperature 168. · Date: 01/25/17. Temperature 171. Review of the internet document dated 01/24/17 provided by the DM indicated in part: · Can you tell me what is the proper temperature to serve coffee? Thanks! ANSWER: Coffee is best served at a temperature between 155ºF and 175ºF (70ºC to 80ºC). Most people prefer it towards the higher end, at about 175ºF. Do you remember that lawsuit that MacDonalds lost when a customer scalded herself after she spilled some of her coffee? Back then the MacDonalds manual for its employees stated that coffee should be served at 195 to 205 degrees and held at 180 to 190 degrees for optimal taste. As they discovered when they lost the case, that was too hot. You won't go far wrong at 175ºF. That said, there are some coffee experts who like to drink their coffee at much lower temperatures. George Howell of George Howell Coffee who has been sourcing and tasting specialty coffee since the 1970s, likes to drink his coffee at a temperature closer to 130ºF. To you and me that would feel like tepid coffee. But according to him, it's at that temperature that many of the more subtle flavors of coffee are revealed. What he says makes sense, because if you think about coffee that is really hot, almost hot enough to burn your tongue, you really don't taste much at all. So there is a sliding scale here. At the hotter end of the scale, at about 175ºF, we feel the satisfaction of drinking a nice hot cup of coffee. At the lower end of the scale, at 150ºF and below, we get less of that hot cup of Joe experience, but are able to taste some of the more subtle flavors of the coffee. · Note: this was printed directly from the website and given to the state surveyor as evidence of where the DM determined the coffee range to be appropriate (155-175) -Hyperlink as indicated on the document. <http://www.coffeedetective.com/what-is-the-correct-temperature-for-serving-coffee.html> Record review of the undated American burn association scald injury prevention educator's guide indicated in part: · Although [MEDICAL CONDITION] happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. · When the temperature of a hot liquid is increased to 140 F/60 C it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F /71-82 C, resulting in almost [MEDICAL CONDITION] will require surgery. · Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. · Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids.[MEDICAL CONDITION] the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Reference: <http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> reviewed 02/02/17. IMMEDIATE JEOPARDY On 01/25/17 at 6:10 p.m. the Administrator was notified of an Immediate Jeopardy. Record review of the facility's plan of action dated 01/26/17 indicated in part: The nurse aides have been in-serviced on reporting when a resident experiences a hot liquid spill to any part of their body. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. The licensed nurses and nurse aides have been in-serviced on what to do (first aid interventions) when a hot liquid spill occurs in regard to applying immediate interventions and assessing the residents skin, notification to physician and responsible party and imitating an incident report. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Team members across all departments have been in-serviced on not reheating hot drink liquid, example coffee in the microwaves. Team members, across all departments have been instructed to obtain fresh cup of coffee from coffee dispenser located in main dining and in MSU kitchenette. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Contact coffee machine equipment technician to check machine function and to lower temp to a range of 140 to 150 degrees. First contact on 01/12/17, technician checked machines for proper functioning and temps. Second contact on 01/25/17 technician returned at request of community and adjusted temperatures on both machines in the community. Initial temperature for the coffee machine on the MSU was noted to be at 162 degrees and the temperature post adjustment was noted to be at 145 degrees. Initial temperature for the coffee machine in main dining area was noted to be at 171 degrees post adjustment was noted to be at 145 degrees. Coffee machine technician to train Dietary Manager on process to adjust temperatures on the coffee machines. Completed on 01/25/17. For the first 12 hours temps will be taken on both coffee machines to validate temp is not registering above 150 degrees. If above 150, the administrator will be notified immediately. This task will be accomplished by RN supervisor. This was initiated on 01/25/17 and completed on 01/26/17. Dietary personnel will check the temperatures daily at all meals in the main dining room and enter temperatures on a monitoring form; dietary team members have been in-serviced on process and temperature range along with steps to take if too hot/cold. This in-service was initiated on 01/25/17 by the DM. This education will continue until all applicable team members have been educated. MSU staff/dietary personnel will check the temperatures of the coffee machine daily in the MSU kitchenette and enter temperatures on a monitoring form; dietary team members will be in-serviced on process and temperature range along with steps to take if too hot/cold. Initiated 01/12/17. Form updated on 01/25/17 for continued monitoring on temperatures on both machines. The Administrator or the DON or the DM will make random rounds in the dining areas and on the halls to monitor compliance of completion of the temperature logs. These rounds will happen daily for two weeks. If the temperatures in both coffee machines are maintained at or below 150 degrees, then the monitor will be changed to weekly. Findings will be brought to the morning department head meeting and the monthly QA&A for the 3 months. All residents have been assessed to identify any safety related issues in regards to hot liquids. Assessments were initiated on 01/24/17 and were completed on 01/25/17. If a resident experiences a hot liquid spill to their body, OT (occupational therapy) to screen the residents for specialty cups, needing lidded cups and the resident use of cup will be care planned. Cups with lids for safety were ordered on [DATE]. Resident #1 was provided multiple cups with lids for safety on 01/12/17. Record review of the facility's undated hot liquid/food spills policy included with the POR indicated in part: · Purpose: Residents are at risk of having any hot liquid/food spilled on their person. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal or any other dietary substance that could cause injury. · Process: If a staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. · An incident report and investigation should then be completed and determine if the resident needs further interventions, such as a screening by therapy department, etc. to prevent future occurrences. Action Plan verification activities were conducted from 01/26/17 through 01/27/17 and included the following activities: Review of in-service documentation, interviewed 4 CNAs, 5 nurses and 1 Activity Director as she also helped with pouring coffee at times to verify in-service understanding. Temperatures of both coffee machines were taken. The coffee machine in the dining room was 135 degrees F and the one in the MSU was 142 degrees F. The Administrator was notified that the IJ was removed on 01/27/17 at 3:20 p.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Room roster dated 01/24/17 and provided by the DON on 01/27/17 indicated there were 25 residents at the facility that had a risk of spilling coffee on themselves.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards, and to prevent accidents for 1 of 10 residents (Resident #1) reviewed for safety. (a) Resident #1 was given a full cup of hot coffee by a staff member and the resident spilled the coffee on himself. The resident sustained [REDACTED].#1 was hospitalized 11 days after the burn, and remained hospitalized at the time of the investigation. (b) The facility failed to implement interventions or in-service staff that coffee temperatures were high, and staff continued to serve residents excessively hot coffee. Residents also continued to self-serve hot coffee from the coffee container in the dining room. (c) On 01/24/17 (12 days after Resident #1 was burned) the coffee temperature was 167 degrees Fahrenheit (F). On 01/25/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 01/27/17 the facility remained out of compliance at actual harm at a pattern due to the facility's need to evaluate and monitor their corrective action system. Failure to provide adequate supervision or preventive measures could place 25 residents that drank coffee and had risks of getting burned. Finding Included: Record review of Resident #1's admission record dated 01/25/17 indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] indicated in part: * BIMS (Brief Interview for Mental Status) summary score = 8. (8 indicates moderately impaired). * Functional status: Eating - how resident eats and drinks, regardless of skill. = 1. Supervision - oversight, encouragement or cueing. * Mobility devices: Wheelchair. Record review of Resident #1's care plan indicated in part: * Focus: Requires assistance with adls (activities of daily living) due to cognition, generalized weakness. Interventions: Staff to monitor safety with routine rounds. Eating: able to eat independently after tray setup, may need staff encouragement. Revision date 08/20/16. * Focus: resident has impaired cognitive function/impaired thought process r/t dementia. Interventions: assist with all decision making. Cue, reorient and supervise as needed. Revision on 08/20/16. * Focus: Resident has been placed in memory support due to poor safety awareness and elopement risk. Interventions: Resides on secured memory care unit. Revision on 08/20/16. Record review of Resident #1's incident report dated 01/12/17 indicated in part: * Nursing description: CNA (Certified Nurse Aide) reported resident spilled coffee on himself. Resident description: I spilled my coffee. * Description: Resident was assessed. Red area noted to left lower abdomen and left upper thigh. Areas are beginning to blister. Spoke to Nurse Practioner (NP) and received telephone orders for Silvadene cream twice a day (BID) until resolved. Note: Silvadene cream is a topical (for the skin) antibiotic used to treat or prevent infections on areas of burned skin). * Staff educated regarding letting coffee cool down before serving. Record review of Resident #1's nurse notes indicated in part: * 01/16/17 3:01 p.m. Left lower abdomen and left upper thigh appeared blistered and red from previous coffee burn. No edema, no warmth at this time. However Bactrim DS (antibiotic) one tab by mouth BID (twice a day) has been ordered by NP as an infection prophylactic. * 01/20/17 3:11 p.m. Resident receives Silvadene cream application twice a day as well as prophylactic PO (by mouth) Bactrim DS, also has been referred to a wound care clinic for further treatment to the coffee burns located on left lower abdomen and left upper thigh. Record review of Resident #1's physician's orders [REDACTED]. * Bactrim DS (antibiotic) tablet 800-160 MG (milligrams). Give 1 tablet by mouth two times a day for prophylaxis for 10 days. Order date 01/16/17. * Silvadene cream 1%. Apply to left abdomen and left thigh topically every shift for burn. Order date 01/12/17. Record review of Resident #1's physician's progress note dated 01/17/17 indicated in part: * Patient spilt coffee on himself burning his abdomen and left thigh receiving wound care with Silvadene. * Abdomen and left upper thigh- positive 2nd degree burns, 7% TBSA (total body surface area), no purulence, mild [DIAGNOSES REDACTED]. Record review of Resident #1's emergency room notes indicated in part: * 01/23/17. 5:34 p.m. presenting complaint: Wife states He was burned by a scalding hot cup of coffee on January 12 2017. Lives at (Facility), saw by doctor there and he said it was ok, I want a second opinion presents with large open wound to left lower abdomen and on left upper thigh/groin area (not visualized in triage) wife states all they are doing is putting Silvadene on it. It has no dressing on it. Wife verbalizing she wants to know if he needs to go to wound care. * 01/23/17 7:46 p.m. The patient presents with a burn as a result of hot water, while at nursing home. The symptoms/episode began/occurred 10 days ago. Burn type and severity: 2nd degree: approximately 18% total body surface area of second degree injury of the left lower quadrant. * 01/23/17 7:49 p.m. Burn type and severity: 2nd degree: of the left quadriceps. Associated signs and symptoms. Patient states he was at the nursing home when hot coffee was spilled onto his lower abdomen and left anterior thigh. He states the redness is getting bigger every day. During an interview on 01/24/17 at 4:28 p.m. the Director of Nurses (DON) said she remembered Resident #1's doctor stating the burns were 2nd degree burns. The DON said Resident #1 had hit the coffee cup and spilled it on himself. The DON said they discussed the incident in their morning meeting the next day after the incident. The DON said they had just discussed the burn incident but had not performed a written plan. During an interview on 01/25/17 at 9:04 a.m. CNA D said Resident #1 probably fell asleep and spilled the coffee on himself. CNA D said Resident #1 could fall asleep while holding the cup in his hand, as he could fall asleep quickly. During an interview on 01/25/17 at 9:11 a.m. CNA A said Resident #1 would fall asleep even during meal times. CNA A said they had to wake him up during meals. CNA A said if a resident wanted a coffee refill then she would go into the kitchenette, pour the coffee into the cup and serve it directly to the resident. During an interview on 01/25/17 at 4:01 p.m. LVN E said on 01/12/17 around 6am she had just arrived at work in the memory support unit when CNA F told her to go and check on Resident #1 because he had spilled coffee on himself. LVN E said she assessed Resident #1 and his skin was red and blistered. LVN E said she administered Resident#1 some pain medication and called the doctor who then ordered some Silvadene cream. LVN E said Resident #1 would fall asleep with the cup of coffee on his hand. During an interview on 01/26/17 at 10:03 a.m. Certified Medication Aide (CMA) G said the day Resident #1 got burned he had given him a cup of coffee prior to Resident#1 spilling it on himself. CMA G said he poured about ¾ of coffee into the cup and then poured some cold water into the same cup so it would not be that hot. During an interview on 01/27/17 at 11:15 a.m. Resident #1's spouse said she had requested for the facility to send Resident #1 to the hospital for wound care. Resident #1's spouse said she did not think the burn wounds looked good even though the facility doctor had stated they looked good and to continue with the current treatment. Resident #1's spouse provided the surveyor multiple pictures of the burn wounds. During an observation on 01/24/17 at 12:17 p.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 167 degrees F, the temperature of the hot water was 165 degrees F and the temperature of the decaffeinated coffee was 163 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 171 degrees F and Disp (dispense) temp 166 degrees F. Record review of the undated American burn association scald injury prevention educator's guide indicated in part: * Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. * When the temperature of a hot liquid is increased to 140 F/60 C it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F /71-82 C, resulting in almost instantaneous burns that will require surgery. * Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. * Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 F 68 C 1 second 148 F 64 C 2 seconds 140 F 60 C 5 seconds 133 F 56 C 15 seconds Reference: <http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> reviewed 02/02/17. During an interview on 01/24/17 at 12:20 p.m. CNA A said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA A said she would serve the coffee in regular cups with no lids. During an interview on 01/24/17 at 12:22 p.m. CNA B said she would serve the residents in the memory support unit coffee from the coffee machine in the memory support unit kitchenette. CNA B said the dietary staff would bring the cups and she would use them to pour the coffee and serve the residents. During an interview on 01/24/17 at 12:26 p.m. Licensed Vocational Nurse (LVN) C said the staff would serve the residents in the memory support unit coffee from the kitchenette located in the memory support unit. LVN C said they got the new coffee machine about 2 weeks ago and someone got burned about 3 days later. During an interview on 01/24/17 at 12:38 p.m. the Dietary Manager (DM) said after the burn incident they had the temperature lowered on the machine. The DM said the temperature on the machine was now between 170 degrees F and 171 degrees F. The DM said as of 01/12/17 the dietary staff started taking the temperatures and logging it on the temperature log. The DM said the temperature was at 168 degrees F before the technician had come out to lower the temperature. During an observation on 01/25/17 at 9:25 a.m. the temperature of the coffee in the kitchenette located in the memory support unit was taken. The coffee machine had 3 separate spigots one for regular coffee, one for hot water and one for decaffinateiated coffee. The temperature of the regular coffee was taken and it was 165 degrees F. The coffee machine also had a display displaying the coffee machine temperatures. The displayed indicated Regular ready, Decaf ready, Tank temp 173 degrees F and Disp temp 168 degrees F. During an interview on 01/25/17 at 10:42 a.m. The Administrator said they had discussed the burn incident during their morning meeting the day after the incident (occuring on 01/12/2017) but did not have a written plan. The Administrator said he had not been able to locate anywhere where it indicated what the safe temperature level for coffee was. The Administrator said the DM had a document indicating what the safe temperature levels were. The Administrator said he would go and obtain the document from the DM. (Note: The Administrator left the meeting but never returned to the meeting or provided the document). During an interview on 01/25/17 at 3:25 p.m. the DM said she had called the technician on 01/12/17 to come out and lower the temperatures on the coffee machines. The DM said she had taken the coffee temperature and it was 168 degrees F prior to the technician lowering it on 01/18/17. The DM said the technician lowered the temperature from 190 degrees F to 170 degrees F. The DM said she had obtained the safe temperature range that was written on the temperature logs of 155 - 175 from an article she found on the internet. The DM said she later contacted the dietician who told her the safe temperature range was between 140 - 145 degrees F. The DM said the residents in the main dining room would self-serve themselves from the coffee machine located in the main dining room. During an interview on 01/25/17 at 5:04 p.m. the Administrator said they had the technician in the facility right now to check the coffee machines. The Administrator said they had the technician here to make sure the temperatures were consistent at the temperature they should be which was 145 degrees F and 160 degrees F. The Administrator said those temperatures would be more appropriate. During an observation on 01/25/17 at 5:20 p.m. several residents in the main dining room were observed drinking coffee that was served from the coffee machine. During an observation on 01/25/17 at 5:26 p.m. the temperature display on the coffee machine in the main dining room indicated Tank temp 160 degrees F and Disp temp 155 degrees F after the technician lowered the temperatures. The temperature of the coffee was taken and it was 159 degrees F. During a telephone interview on 01/27/17 at 1:54 p.m. the coffee machine manufacturer said the temperature on the coffee machine Disp temp was the actual temperature of the coffee that came out of the spigot. During a telephone interview on 01/27/17 at 3:15 p.m. the hospital wound care nurse said she had assessed Resident #1's burn wounds when he first arrived at the hospital. The wound care nurse said the burn wounds had a lot of Silvadene medication caked on them and they had to clean it all off before they could assess it correctly. The wound care nurse said the wounds appeared to be 3rd degrees burns to her because of the green slough it had on it. The wound care nurse said the resident had received several antibiotics via intra venous (IV) as a prophylactic measure. Record review of the facility's coffee machine invoice report indicated in part: * Problem notes: Comments Vcafe dispense temp is too hot, customer says they have it set at 170 but when they measure the temp with their thermometer it is coming out much hotter. (Note: Vcafe is the name of the coffee machine). * Solution notes: Tank temp reading 190 had display temp at 170 turned down to where tank temp at 170 ran water to let tank reheat all good. * Completed 01/18/17. Record review of the facility's MSU (Memory Support Unit) coffee temperature log dated January 2017 indicated in part: * Range 155-175. * Date: 01/12/17. Temperature 168. * Date: 01/13/17. Temperature 168. * Date: 01/14/17. Temperature 168. * Date: 01/15/17. Temperature 166. * Date: 01/16/17. Temperature 168. * Date: 01/17/17. Temperature 170. * Date: 01/18/17. Temperature 168. * Date: 01/19/17. Temperature 164. * Date: 01/20/17. Temperature 166. * Date: 01/21/17. Temperature 168. * Date: 01/22/17. Temperature 166. * Date: 01/23/17. Temperature 168. * Date: 01/24/17. Temperature 165. Record review of the facility's dining room coffee temperature log dated January 2017 indicated in part: * Range 155-175. * Date: 01/12/17. Temperature 168. * Date: 01/13/17. Temperature 166. * Date: 01/14/17. Temperature 168. * Date: 01/15/17. Temperature 164. * Date: 01/16/17. Temperature 168. * Date: 01/17/17. Temperature 168. * Date: 01/18/17. Temperature 166. * Date: 01/19/17. Temperature 170. * Date: 01/20/17. Temperature 168. * Date: 01/21/17. Temperature 164. * Date: 01/22/17. Temperature 166. * Date: 01/23/17. Temperature 168. * Date: 01/24/17. Temperature 168. * Date: 01/25/17. Temperature 171. Review of the internet document dated 01/24/17 provided by the DM indicated in part: * Can you tell me what is the proper temperature to serve coffee? Thanks! ANSWER: Coffee is best served at a temperature between 155ºF and 175ºF (70ºC to 80ºC). Most people prefer it towards the higher end, at about 175ºF. Do you remember that lawsuit that MacDonalds lost when a customer scalded herself after she spilled some of her coffee? Back then the MacDonalds manual for its employees stated that coffee should be served at 195 to 205 degrees and held at 180 to 190 degrees for optimal taste. As they discovered when they lost the case, that was too hot. You won't go far wrong at 175ºF. That said, there are some coffee experts who like to drink their coffee at much lower temperatures. George Howell of George Howell Coffee who has been sourcing and tasting specialty coffee since the 1970s, likes to drink his coffee at a temperature closer to 130ºF. To you and me that would feel like tepid coffee. But according to him, it's at that temperature that many of the more subtle flavors of coffee are revealed. What he says makes sense, because if you think about coffee that is really hot, almost hot enough to burn your tongue, you really don't taste much at all. So there is a sliding scale here. At the hotter end of the scale, at about 175ºF, we feel the satisfaction of drinking a nice hot cup of coffee. At the lower end of the scale, at 150ºF and below, we get less of that hot cup of Joe experience, but are able to taste some of the more subtle flavors of the coffee. * Note: this was printed directly from the website and given to the state surveyor as evidence of where the DM determined the coffee range to be appropriate (155-175) -Hyperlink as indicated on the document. <http://www.coffeedetective.com/what-is-the-correct-temperature-for-serving-coffee.html> Record review of the facility's accidents and incidents policy dated 02/2012 indicated in part: * The licensed nurse/and/department director/designee will conduct an investigation of the accident or incident. * The nature of the injury/illness. * The condition of the injured person. * Any corrective action taken. IMMEDIATE JEOPARDY On 01/25/17 at 6:10 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal (POR) of Immediate Jeopardy was accepted on 01/27/17 at 3:20 p.m. and included the following: The nurse aides have been in-serviced on reporting when a resident experiences a hot liquid spill to any part of their body. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. The licensed nurses and nurse aides have been in-serviced on what to do (first aid interventions) when a hot liquid spill occurs in regard to applying immediate interventions and assessing the residents skin, notification to physician and responsible party and imitating an incident report. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Team members across all departments have been in-serviced on not reheating hot drink liquid, example coffee in the microwaves. Team members, across all departments have been instructed to obtain fresh cup of coffee from coffee dispenser located in main dining and in MSU kitchenette. This in-service was initiated on 01/25/17 by the DON and the Administrator. This education will continue until all applicable team members have been educated. Contact coffee machine equipment technician to check machine function and to lower temp to a range of 140 to 150 degrees. First contact on 01/12/17, technician checked machines for proper functioning and temps. Second contact on 01/25/17 technician returned at request of community and adjusted temperatures on both machines in the community. Initial temperature for the coffee machine on the MSU was noted to be at 162 degrees and the temperature post adjustment was noted to be at 145 degrees. Initial temperature for the coffee machine in main dining area was noted to be at 171 degrees post adjustment was noted to be at 145 degrees. Coffee machine technician to train Dietary Manager on process to adjust temperatures on the coffee machines. Completed on 01/25/17. For the first 12 hours temps will be taken on both coffee machines to validate temp is not registering above 150 degrees. If above 150, the administrator will be notified immediately. This task will be accomplished by RN supervisor. This was initiated on 01/25/17 and completed on 01/26/17. Dietary personnel will check the temperatures daily at all meals in the main dining room and enter temperatures on a monitoring form; dietary team members have been in-serviced on process and temperature range along with steps to take if too hot/cold. This in-service was initiated on 01/25/17 by the DM. This education will continue until all applicable team members have been educated. MSU staff/dietary personnel will check the temperatures of the coffee machine daily in the MSU kitchenette and enter temperatures on a monitoring form; dietary team members will be in-serviced on process and temperature range along with steps to take if too hot/cold. Initiated 01/12/17. Form updated on 01/25/17 for continued monitoring on temperatures on both machines. The Administrator or the DON or the DM will make random rounds in the dining areas and on the halls to monitor compliance of completion of the temperature logs. These rounds will happen daily for two weeks. If the temperatures in both coffee machines are maintained at or below 150 degrees, then the monitor will be changed to weekly. Findings will be brought to the morning department head meeting and the monthly QA&A for the 3 months. All residents have been assessed to identify any safety related issues in regards to hot liquids. Assessments were initiated on 01/24/17 and were completed on 01/25/17. If a resident experiences a hot liquid spill to their body, OT (occupational therapy) to screen the residents for specialty cups, needing lidded cups and the resident use of cup will be care planned. Cups with lids for safety were ordered on [DATE]. Resident #1 was provided multiple cups with lids for safety on 01/12/17. Record review of the facility's undated hot liquid/food spills policy included with the POR indicated in part: * Purpose: Residents are at risk of having any hot liquid/food spilled on their person. Examples of hot iquids/food are coffee, tea, hot soup, oatmeal or any other dietary substance that could cause injury. * Process: If a staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. * An incident report and investigation should then be completed and determine if the resident needs further interventions, such as a screening by therapy department, etc. to prevent future occurrences. Action Plan verification activities were conducted from 01/26/17 through 01/27/17 and included the following activities: Review of in-service documentation, interviewed 4 CNAs, 5 nurses and 1 Activity Director as she also helped with pouring coffee at times to verify in-service understanding. Temperatures of both coffee machines were taken. The coffee machine in the dining room was 135 degrees F and the one in the MSU was 142 degrees F. The Administrator was notified that the IJ was removed on 01/27/17 at 3:20 p.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Room roster dated 01/24/17 and provided by the DON on 01/27/17 indicated there were 25 residents at the facility that had a risk of spilling coffee on themselves.

Based on interview and record review, the facility failed to thoroughly investigate and report to the State survey agency when 1 of 13 residents reviewed for change of condition (Resident #1, who had a respiratory disease and diabetes), began showing symptoms of respiratory distress at 8:30 a.m.- 8:45 a.m. on [DATE] and RN A and the DON failed to consult with the physician or call [DATE] until approximately 10:40 a.m. Resident #1 died of respiratory distress at 3:20 p.m. These failures resulted in neglect not being identified and the alleged perpetrators (RN A and the DON) remaining in the facility providing care to residents from [DATE] through [DATE]. On [DATE] at 11:40 a.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] at 5:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The facility failure to investigate and report incidents of death of unusual circumstances could result in ongoing neglect in the facility.and could affect the 41 residents the facility identified who have respiratory diseases and the 32 residents identified as having diabetes. These failures could result in medical complications [REDACTED]. Findings included: 1. An Admission Record with no date documented that Resident #1 was an [AGE] year-old male admitted to the facility initially on [DATE]. 2. A physician's note dated [DATE], current physician's orders, and Resident #1's care plan dated [DATE] documented Resident #1's [DIAGNOSES REDACTED]. Physician's orders for Resident #1, valid from [DATE] through [DATE], revealed there was no physician's order for oxygen for the resident. These orders included an order for [REDACTED]."DC (discontinue) Iprat-Albut 0XXX,[DATE] (25) mg/3 ml 1 vial per nebulizer QID prn (medication inhaled as a mist to improve breathing, four times a day as needed)." Physician's orders for Resident #1 did not include orders for palliative or hospice care. These orders also included the following: CBG TID (capillary blood glucose three times a day) and Q HS (every hour of sleep), notify MD if less than 70 or greater than 400. [MEDICATION NAME] R 100 units/ml vial (insulin regular human: Use per sliding scale. Scale ,[DATE]- 0 units, ,[DATE] = 2.0 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units. Frequency 0630, 1130, 1630, and 2000. 3. The current care plan for Resident #1's [DIAGNOSES REDACTED]. -Assess for change in level of consciousness, coherency. Report changes. -Monitor and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, decreased breath sounds). -Monitor oxygen saturation via pulse oximetry as ordered: daily. If <92%, place on O2 at 2 L/m via NC (liters per minute via nasal cannula). The same care plan included a care plan for Resident #1's [DIAGNOSES REDACTED]. - Monitor for signs of [MEDICAL CONDITION] (increasd thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting, hypothermia, [MEDICAL CONDITION], stupor, muscle weakness -Monitor for signs of [DIAGNOSES REDACTED] (blood glucose < 60mg/dl; sweating, cold/clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination. -Monitor/record/report blood glucose per MD order: TID (three times daily) and Q HS (every hour of sleep). Notify MD if less than 70 or greater than 400. 4. A Minimum Data Set Assessment ((MDS) dated [DATE] with the type of assessment documented as "Significant change in status assessment", which was signed by the MDS Coordinator on [DATE] and the DON on [DATE] documented Resident #1 was totally dependent on two staff for transfers, dressing, and toilet use. He required extensive assistance of one staff for eating, used a wheelchair for mobility, was always incontinent of bowel and bladder. Under the section, "shortness of breath", the assessor documented that Resident #1 did not have shortness of breath when sitting, lying flat, or with exertion. Under the section of "Prognosis" the assessor documented that the resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. Under section O0100, "Special Treatments, Procedures, and Programs...Check all of the following treatments, procedures, and programs that were performed during the last 14 days," the assessor did not check oxygen, or any other respiratory therapy. 5. During an interview on [DATE] at 4:45 p.m., the DON and A-wing Unit Manager RN B said that Resident #1 died at the hospital on [DATE] after being sent to the hospital from the facility. When discussing the lack of documentation and requesting more detail about Resident #1's change of condition on [DATE], the DON said that there must be other documentation elsewhere and RN B said, "I don't know. I was off that day." RN B said that the reason oxygen and breathing treatments were discontinued in January was because Resident #1 had not needed to use them. 6. A nurse's note signed by RN A for Resident #1 dated [DATE] at 12:30 p.m. documented vital signs in a grid at the top of the page (with spaces for each shift) on the "day" shift as B/P (blood pressure) ,[DATE], T (temperature) 96.4, P (pulse) 50, R (respirations) 30, O2 Sats (oxygen saturation) 68% on 2 LNC (liters per minute by nasal cannula). The nurse's note on the same page documented that RN A went to the assisted dining room and attempted to stimulate the resident by rubbing his chest and back to wake him up and arouse him enough to eat. She documented that the food she was feeding him "dropped right out of mouth." She documented she then attempted to get the resident to drink a health shake and the resident "just let fluids run out of his mouth." She documented vital signs at 10:00 a.m. as B/P ,[DATE], P76, T 96.4, R 32, and O2 sats at 68% on room air. She documented she placed oxygen on the resident at 2 liters by nasal cannula, and his oxygen saturation went up to 78%. She documented she elevated the head of his bed. She documented that she contacted the DON, who told her to call the resident's family and ask if they wanted him sent to the hospital. RN A documented she called the resident's wife and told her the resident's status, and the resident's wife said she would call her daughter and let the nurse know. RN A documented that she waited about 30 minutes and then called the resident's daughter and informed her about the resident's status. The resident's daughter told her to send him to the hospital. RN A documented that she then telephoned the physician and called [DATE]. A late entry note by RN A on [DATE] at 1300 (1:00 p.m.) for 9:00 a.m. documented she had held all of Resident #1's morning medications due to lethargy. *RN A did not document what time she took the vital signs that she recorded in the grid at the top of the page of her [DATE] note, the time that she administered oxygen to the resident, what time Resident #1's oxygen saturation was checked and the 78% results obtained, what time she contacted the DON, how she contacted the DON, or whether or not the DON was present with her or if they spoke on the telephone. RN A did not document what time she called the resident's wife or the resident's daughter or when she called the physician, which physician she called, or when she called [DATE]. RN A did not document what time EMS arrived at the facility or what time Resident #1 left the facility in an ambulance. 7. A record review of a "CBG sheet" (document the facility used to record blood sugar readings) dated February 2013 revealed a blood sugar for Resident #1 taken on [DATE] at 0600 (6:00 a.m.) that was 166. There were no other blood sugar measurements recorded on that date. 8. A record review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 9. A nurse's note dated [DATE] at 2340 (11:40 p.m.) documented that Resident #1 was found unresponsive and with a blood sugar of 37. The nurse documented administered [MEDICATION NAME] from the emergency kit. The resident started responding and was given eight ounces of orange juice and four packs of sugar, and his blood sugar went up to 97. 10. A nurse's note dated [DATE] at 1:30 a.m. included documentation that the resident's blood sugar was 69 and "res is brittle with blood sugar at X's (times)." 11. During an initial interview on [DATE] at 10:55 a.m., RN A said that she became licensed as an RN in [DATE] and this position was her first job as a nurse. She said she had no prior medical experience, and came to work at this facility in [DATE]. RN A said that on [DATE], the nurse's aide told her Resident #1 was not eating breakfast so she (RN A) went to try and feed him. She did not remember what she tried to feed him, but stated the food fell from his mouth. She then stated, "Then we got him to drink a health shake." When referring to her progress note where she documented the health shake also fell from the resident's mouth, RN A said the documentation was accurate and the resident did not drink the health shake. She said the resident was then brought back to the unit from the dining room, and as she was doing routine vital signs (which she identified as the vital signs in the grid at the top of her progress note taken at approximately 8:30 a.m.), she noticed his blood pressure was a little low. RN A said she did not immediately assess the resident's condition at breakfast when food fell from his mouth because "he was often lethargic" and she did not see any problems with his respirations. She also added that there were "lots of times he didn't want to eat." She said she was not very concerned because the blood pressure was just slightly low. She said she went back and checked it again and it was lower. When discussing the oxygen saturation that she documented (68%), she also acknowledged that was very low, stating that "normal" oxygen levels were usually 88% or above. RN A said she checked the resident's blood sugar that morning some time after she observed his change in condition, but she did not document it and did not remember what the blood sugar reading was. She said all that she remembered was that it was "okay." She said she called the DON, who was the supervising RN that day, and the DON came to the unit and assessed the resident with her at 9:30 a.m. or 10:00 a.m. She said she told the DON Resident #1's oxygen saturation was 68%, and the DON told her to apply oxygen. RN A said she thought Resident #1 needed to go to the hospital, and asked the DON if she should send him, but the DON first asked her to check the resident's DNR status. She said she told the DON that the resident had a signed DNR, and the DON told her to call the family and see if they wanted him sent to the emergency room . RN A said she took more vital signs than those documented, but she did not write them down. RN A reported the 10:00 a.m. vital signs as, "The final vitals I got and reported to the EMT. " RN A said the DON left the unit after they applied oxygen to the resident and had told her to contact the resident's family. She said the DON came back and forth to the unit after that to check on the resident's status, and that she had informed the DON that Resident #1's blood pressure was dropping while she was waiting to hear back from the family. RN A said she called the resident's wife after the DON advised her to call the family and told her his status. RN A said the resident's wife said she would let his daughter know. RN A said she waited for a half hour to 45 minutes and never heard back from the family. She said she was concerned about the resident's decline, so she called the resident's daughter, who told her to send the resident to the hospital. RN A said she never consulted with Resident #1's physician (or any physician) during that morning, until after she talked to the resident's daughter (which she had identified as 30 to 45 minutes after applying oxygen at approximately 10:00 a.m.) RN A said that she did believe the resident was in an emergency situation, and she would have called the physician if the DON had told her to. She said the DON never mentioned calling the physician at all. RN A said she acted according to directions from the DON because that was what she was supposed to do. RN A said that if the DON had not been there, she would have called the physician. RN A said she was not knowledgeable of any facility policies regarding notification to physicians for a change of condition of residents. RN A documented in her statement on this date that the first set of vital signs that were B/P ,[DATE], T 96.4, P 50, and O2 sat of 68% were taken at approximately 8:45 a.m. RN A documented, "I told (DON) previous vitals and explained resident's condition to her while in resident's room. (DON) visually observed resident and told me to see if he was a DNR." RN A documented in her statement, "I only contacted the Dr. when family verified they wanted resident sent to E.R. I did not contact him prior because, when I told DON I wanted to send him out she said call the family and make sure they want him to be sent out due to his DNR status." RN A documented that, " Prior to calling family, resident's vital signs were ,[DATE] (B/P), 76 (P), 32 (R), and 68% (O2 sat). She documented that she had a nurse's aide in with the resident for the next 30 to 45 minutes " keeping an eye on him." She documented, " I asked aid (sic) several times if resident vitals were worsening and also visually checked on resident myself. I did not record any other vital signs in nurse's notes after 10:00 vitals. " 12. During a second interview on [DATE] at 1:50 p.m., RN A maintained the information provided during the above interview. In addition, she said that in her assessment of the resident, she did not check his pupil response, did not listen to his lung sounds, and did not listen to his heart sounds. She said that his respirations were "heavy" and "around 30" when she assessed him, and they stayed about the same through the morning, but his blood pressure continued to decline. She said she did not know what assessment the DON did or if the DON assessed the resident. She said she and the DON placed the resident on oxygen of 2 liters per minute and never changed the oxygen setting. She said his skin color was "pinkish white" but not abnormal. When discussing whether any of the nurse aides reported any concerns to her that morning, she said, "Only that he wasn't eating but otherwise, no. He wasn't cold." She then said he was not cold or clammy and that is why she did not believe it was a blood sugar issue. RN A said she left a nurse's aide in the room to monitor the resident and had him hooked up to a machine to take the resident's vital signs, but does not know how often the machine was set to take them. RN A said she wrote down the initial vital signs and the vital signs when he went out only and the nurse aide wrote down other vital signs in between. She said the nurse aide was to report if the vital signs changed at all, because she had 49 other residents to tend to. RN A said that there was talk around the facility that a nurse aide reported mottling was observed on the resident, but she did not see any mottling to the resident's arms when they were out of the blanket and she did not look at his lower extremities. She said the nurse aides did clean the resident when he had a bowel movement. RN A said it was her understanding that facility policy was that she not take any action in a situation such as change of condition of a resident until an RN supervisor assessed the resident, and that she followed that policy and did not do anything wrong. She became tearful, stating, "Yes, I knew he was dying. We all knew he was dying." She said the nurse aides were patting his hand and telling him to "Go papa." RN A said she felt guilty about the incident, but repeated she did not do anything wrong because she did what she was instructed to do by the DON. 13. During an interview with the DON on [DATE] at 1:05 p.m., when discussing whether the she was present at the facility on [DATE], the day that Resident #1 died , she said, "I don't know, I would have to look at my schedule." She then said that she believed she remembered something about RN A asking her to look at Resident #1 for a change in condition. The DON said she went to the unit and assessed the resident and he was not in any acute distress but she did think he needed to be sent to the hospital. When discussing her assessment of the resident, the DON said she did not take any of Resident #1's vital signs and she did not remember RN A telling her about any of Resident #1's vital signs. The DON said she never knew Resident #1's oxygen saturation level was 68%. She said she did not think RN A ever told her what the resident's change of condition was, and she could not say that she asked RN A. She said, "I can't remember all these details." When discussing RN A's report that the DON had instructed her and assisted her to place oxygen on the resident due to an oxygen saturation of 68%, the DON said, "I don't remember doing that." When discussing how she concluded he needed to be sent to the hospital, the DON said, "He just didn't look right." When discussing what she meant by that statement, she said he looked more lethargic than other times she had seen him. When discussing whether it would have been appropriate to take the resident's vital signs as part of her assessment of the resident, the DON said, "Vital signs are part of assessment but I'm overriding my choice to do vital signs based on a visual assessment." The DON then said, "I don't know what to tell you, I don't remember what the assessment was." She then said that she shook him and called his name. She said his eyes were closed and he appeared to try to open them, but it was a minute response. When discussing whether the physician was consulted at any time during the morning of [DATE], the DON said she did not consult with a physician or tell RN A to consult with the physician. When discussing why she chose not to instruct RN A to call the physician, she said, "I didn't know anything that we could do to make him perk up." When discussing whether she asked RN A about the DNR status of the resident or considered his DNR status when making a decision whether or not to consult the physician, the DON said she did not remember asking RN A about the resident's DNR status and the resident ' s DNR status would not make a difference in the decision to call the physician. The DON said that she did tell RN A to ask the family if they wanted him to go to the emergency room because she thought she remembered something about the family not wanting him to go in the past. The DON said Resident #1 was a hospice patient. When discussing whether she contacted hospice if he was their patient, she said, "I don't know anything about that." The DON said she left the unit after her visual assessment of the resident and did not remember what she was doing the rest of the morning. She could not verify that she documented anything with regard to this incident stating, "I thought I did, that's why I'm looking through these notes." 14. During a follow-up interview on [DATE] at 3:40 p.m., the DON said that Resident #1's change of condition on [DATE] was not an emergency. She said, "He probably could have just gone to the doctor's office." The DON said she could tell by looking at the resident that he was not in respiratory distress because his respirations were a little elevated and she did not hear any gurgling in his lungs. She said she did not use a stethoscope and just went by what she heard audibly. She described her total assessment of the resident as seeing the head of his bed elevated, saw that he had oxygen on, checked his responsiveness by shaking him, and watched his breathing. She said she decided he was not in respiratory distress even though his oxygen saturation was 78% because of the "clinical picture." She said his nail beds were not cyanotic. The DON later said that an oxygen saturation of 78% would warrant sending a resident to the hospital. When discussing why she did not just contact the physician and send Resident #1 to the hospital if she thought he needed to go, she said, "I don't know." In her written statement dated [DATE], the DON wrote that RN A did not share any of Resident #1's vital signs with her, and she did not ask for the resident's vital signs. She wrote, "Assessment of visually reveals head of bed elevated O2 on per nasal cannula, color normal for resident, no audible gurgling or active respiratory distress noted, nail beds no cynosis (sic), aroused resident by shanking and calling name, he aroused by opening his eyes. Respirtory (sic) rate did not indicate respiratory distress along with other signs. visually looked at lower extremities for color changes, none noted. Did not detect this to be a 911 call. I did not take vital signs or O2 sat during assessment, as they were taken at an earlier time." 15. During an interview on [DATE] at 9:40 a.m., CNA A said that she was working on [DATE] on the A-wing where Resident #1 resided. She said that after breakfast that day, she assisted CNA B to put Resident #1 back to bed. She said that she was not sure what time it was, but breakfast was usually served around 7:00 a.m. and ended 8:30 a.m. to 9:00 a.m. CNA A said the nurse told them to put the resident to bed because he could not hold his head up. She said that when they put the resident to bed, he was limp "like a wet noodle." She said that he was not making any sounds or noises like he usually did. She said his legs felt cold. CNA A said that she and CNA B were concerned about Resident #1 because he looked like he might be dying. She said the resident's legs were mottling. She said she knew what mottling was because she had seen it before. CNA A said when she and CNA B expressed concern to RN A about the changes to the skin color of his legs, RN A said, "No, he's just dehydrated and we'll send him out and he'll be right back." CNA A said that CNA B protested to RN A's statement stating the resident looked bad. CNA A said she knew RN A went to the room and took his vital signs afterward. CNA A said she did not recall seeing the DON on the hall or in the resident's room, but she was not in the resident's room all morning. CNA A said that CNA B did sit in Resident #1's room and held his hand until the paramedics arrived. 16. During interviews on [DATE] at 2:35 p.m. and [DATE] at 10:40 a.m. (when CNA B wrote a statement in response to interview questions), CNA B said that RN B had told her that if she (CNA B) spoke to the state surveyor, the surveyor would "trip her up". RN B told CNA B that the state surveyors had " tripped up " the nurses during their interview and made them cry. RN B suggested that she (RN B) be present when state surveyors interviewed CNA B. CNA B said that RN B also made her feel as if she was somehow responsible for the Immediate Jeopardy, stating to CNA B, "After you left, we were slapped with an IJ! " CNA B said she was initially fearful of being interviewed based on RN B 's statements. CNA B said that on [DATE] when the surveyor was attempting to speak to CNA B about a private interview, RN B stood behind the surveyor and shook her head "No!" at CNA B. CNA B said that she worked with Resident #1 on [DATE] and transferred him from bed that morning at approximately 6:30 a.m. to 7:00 a.m. She said she took him and placed him in line for his medications first as was the usual schedule. She left him there and then returned a little while later to get him to take him to the dining room for breakfast. CNA B said when she took him to the dining room and was going to help him eat, she observed that he was not responding and she could not feed him. She described him as listless, slumped over in his chair, and "asleep." She left him to finish the meal and returned him to the unit only when breakfast was over and the aides were returning everyone to the unit. CNA B said that RN A never came to the assisted dining room that morning. She said between 8:30 a.m. and 9:00 a.m. she put Resident Campbell back in his bed and he was moaning as if in pain. She said she had to change him at that time because he had a soft stool. She said it was very unusual as it was like syrup and had a peculiar smell unlike regular stool. She said the stool kept flowing from the resident each time they cleaned him and turned him, more stool would come out. She said the resident ' s skin on his face had a " silky " appearance and " he was just laying there. " She said his eyes were "fixated." She said she then reported Resident #1's condition to RN A, including that he had very loose uncontrollable bowel movements, and the nurse said she would check him. After telling the nurse about him CNA B said she went to work doing routine tasks and attending to other residents, but because she was so concerned about Resident #1, she went back to his room every chance she got, to check on him. She said when she checked on him, she would find that he had more loose stool, and estimated that she was in his room and changed his brief with stool evident each time, approximately five to six times after putting him to bed. During that time she again talked to RN A about her concern that there was something wrong with Resident #1. CNA B said the first time she saw RN A in the resident's room was at 10:40 a.m. She said she remembered the time because she was thinking about how much time she had left before she had to start getting people up for lunch and looked at her watch. CNA B said RN A took his vital signs and was going to leave the room, when CNA B told RN A to look at the resident ' s legs because they were mottled up to mid-thigh. CNA B said RN A looked at his legs and told CNA B that it was probably just dehydration. RN A reportedly left the room and returned a few minutes later to tell her she had called EMS. CNA B said she remained in the room with Resident #1 from 10:40 a.m. until the EMS arrived to take the resident to the hospital. She said that during that time she was just praying for the resident, patting his hand, and telling him that she loved him and it was going to be okay. CNA B said she never saw the DON on the unit or in the resident's room that morning. CNA B said she did not recall seeing oxygen on the resident. She said she had leaned closely to his face that morning to talk to him in his ear, and she did not recall seeing any tubing, an oxygen tank, or an oxygen concentrator. CNA B said that after Resident #1 went to the hospital, she proceeded to get residents ready and take them to lunch. When she returned to the unit after lunch was over, RN B was on the unit. CNA B said she had a conversation with RN B regarding her concerns about how bad Resident #1 had looked that morning, including telling RN B, " He was mottled all the way up to here! " (gesturing to her mid thigh area). CNA B said that RN B told her that she should not be diagnosing residents, and Resident #1 was probably just dehydrated. CNA B said she told RN B that she had sat in the room with Resident #1 and had been praying for him. She said RN B told her that she should not be telling people that she was praying for the resident. CNA B said she had a separate conversation with RN B and told RN B that RN A seemed unconcerned about Resident #1 and had no sense of urgency in caring for him on [DATE]. She said RN B told her, "Whatever you do, don't tell the state she had no sense of urgency!" 17. A hospital record of death for Resident #1, dated [DATE] documented Resident #1 died at the hospital and the cause of death was [MEDICAL CONDITION]. 18. An EMS (emergency medical services) transfer of care record dated [DATE] documented that EMS was en-route to the facility at 10:56 a.m. and arrived at 10:59 a.m. The responder documented that Resident #1's pupils were constricted, skin was cool to touch, and he had labored respirations. The resident's blood pressure was ,[DATE], heart rate was 112, and respirations were 36. 19. During an interview on [DATE] at 9:30 a.m., the EMS responder said that when he arrived in Resident #1's room on [DATE], it was obvious that Resident #1 was in respiratory distress. He said the resident was receiving O2 at 3 liters per minute by nasal cannula. He said the resident 's blood pressure was ,[DATE] and his respirations were 36. He said the resident was gasping for air and using his accessory muscles to try to breathe. The EMS responder said that a nurse who was in the resident's room told the responders that Resident #1 had been having a decreased level of consciousness and low blood pressure "for the last couple of days." 20. Nurse's notes for [DATE] and [DATE] revealed no evidence that Resident #1 had been in any distress, had abnormal vital signs, or decreased level of consciousness in the preceding days to [DATE] as reported to EMS by RN A. 21. During interviews with Resident #1's daughter on [DATE] at 1:35 p.m., [DATE] at 2:35 p.m., and [DATE] at 1:00 p.m., she said that she nor her mother had ever given the facility any instructions or impression that they would ever hesitate to send Resident #1 to the hospital if he needed to go. She said that on [DATE] the facility called her mother first, when she and her mother had instructed the facility to always call her. She said that her mother did call her to tell her the nurse had called, but her mother told her that the nurse just said that they had to put oxygen on the resident. Resident #1 ' s daughter said her mother told her that the nurse did not lead her to believe that there was any immediate need for the resident ' s daughter to call the facility or go to the facility. She said that she told her mother she planned to visit Resident #1 later that day and would check to see how he was doing. She said that she then got a phone call from the nurse telling her about her father ' s condition and she had to prompt the nurse to actually describe how serious his condition was. She said as soon as the nurse said his condition was serious, she told the nurse to send him to the hospital and she would meet him there. Resident #1 ' s daughter said the facility had never waited to get permission from them to send him to the hospital before, and had always just sent him when he needed to go, and informed the family after arrangements were made or the resident was on his way to the hospital. She said there was no reason the facility should have done it differently this time. Resident #1 ' s daughter said that Resident #1 was hospitalized in January for a severe kidney infection and when he became ill, she had to insist that the facility send him to the hospital. She said that even after she insisted, the nurse convinced her to wait an extra day before sending him. Resident #1 ' s daughter said that Resident #1 was not a hospice patient. She said hospice was not mentioned for the resident until after he went to the hospital on [DATE] and the hospital recommended hospice services. She said that was only because Resident #1 ' s death was quite imminent and she was given the choice of sending him back to the facility or admitting him to hospice. She said he died a few hours after that discussion. Resident #1 ' s daughter said she was at the facility almost every day to help ensure Resident #1 was eating and drinking sufficien

Based on interview and record review, the facility failed to immediately consult with the physician and notify interested family for a significant change of condition (change in level of consciousness, low blood pressure, and critical oxygen saturation levels) for 1 of 13 residents (Resident #1, who was a diabetic and had a respiratory disease) reviewed for change of condition as evidenced by: failure to ensure RN (registered nurse) A or the DON (director of nurses) immediately notified the physician and his family when RN A identified that Resident #1 had a change in level of consciousness and an oxygen saturation that was critically low (68%) at 8:45 a.m. on [DATE]. Resident #1's condition declined throughout the morning. RN A and the DON did not consult with Resident #1's physician and did not call [DATE] until approximately 10:45 a.m. Resident #1, who had a chronic respiratory disease, was unresponsive, hypotensive, hypoxemic (low oxygen in the blood), cyanotic (blue color of skin due to lack of oxygen), mottled (skin discoloration due to decreased circulation), and in a terminal state on arrival to the hospital when triaged at the hospital at 11:20 a.m. Resident #1 died at 1520 (3:20 p.m.). These failures resulted in the physician not being involved in the diagnosing and/or management of a critical medical condition/crisis for Resident #1 and the resident's family not being involved until Resident #1's condition had deteriorated at the nursing home for two hours. Resident #1 died of respiratory distress after arrival to the hospital on [DATE]. On [DATE] at 5:48 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] at 5:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to notify a physician regarding a resident's change in condition, such as change in level of consciousness and/or blood pressure or oxygen saturation levels that are outside of the parameters acceptable by physicians or outside parameters that are normal for the resident could affect the 41 residents the facility identified who have respiratory diseases and the 32 residents with diabetes. These failures could result in medical complications [REDACTED]. Findings included: 1. An Admission Record with no date documented that Resident #1 was an [AGE] year-old male admitted to the facility initially on [DATE]. This admission record contained the name and phone number of the resident's physician, his wife's name and phone number, and his daughter's name and phone number. Hand written instructions on this record included one handwritten note that stated, "When calling RP (responsible party) please also call (resident's daughter) per RP request. She lives in town." A second handwritten note on the admission record stated, "[DATE] Verbal consent given via phone to route call and ans. questions to (daughter's name) p.o. (per order) by (RP name). 2. A physician's note dated [DATE], current physician's orders, and Resident #1's care plan dated [DATE] documented Resident #1's [DIAGNOSES REDACTED]. 3. a) The current care plan ([DATE]) for Resident #1's [DIAGNOSES REDACTED]. -Assess for change in level of consciousness, coherency. Report changes. -Monitor and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, decreased breath sounds). -Monitor oxygen saturation via pulse oximetry as ordered: daily. If <92%, place on O2 at 2 L/m via NC b) The same care plan included a care plan for Resident #1's [DIAGNOSES REDACTED]. - Monitor for signs of [MEDICAL CONDITION] (increasd thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting, hypothermia, [MEDICAL CONDITION], stupor, muscle weakness). -Monitor for signs of [DIAGNOSES REDACTED] (blood glucose < 60mg/dl; sweating, cold/clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination. -Monitor/record/report blood glucose per MD order: TID (three times daily) and Q HS (every hour of sleep). Notify MD if less than 70 or greater than 400. 4. Physician's orders for Resident #1, valid from [DATE] through [DATE], revealed there was no physician's order for oxygen for the resident. A physician's telephone order dated [DATE] included orders to "DC (discontinue) oxygen - monitor 02 saturation" and "DC (discontinue) Iprat-Albut 0XXX,[DATE] (25) mg/3 ml 1 vial per nebulizer QID prn." These orders also included the following: CBG TID (capillary blood glucose/blood sugar three times a day) and Q HS (every hour of sleep), notify MD if less than 70 or greater than 400. [MEDICATION NAME] R 100 units/ml vial (insulin) regular human: Use per sliding scale. Scale ,[DATE]- 0 units, ,[DATE] = 2.0 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units. Frequency (of blood sugar checks and sliding scale administration): 0630 (6:30 a.m.), 1130 (11:30 a.m.), 1630 (4:30 p.m.), and 2000 (8:00 p.m.). Physician's orders for Resident #1 did not include orders for palliative or hospice care. 5. During an interview on [DATE] at 4:45 p.m., the DON and A-wing Unit Manager RN B said that Resident #1 died at the hospital on [DATE] after being sent to the hospital from the facility that day. When discussing the lack of documentation and requesting more detail about Resident #1's change of condition on [DATE], the DON said that there must be other documentation elsewhere and RN B said, "I don't know. I was off that day." When discussing why the physician discontinued orders for oxygen treatment and nebulizer treatments in January, RN B said it was because he had not been needing them. 6. A nurse's note signed by RN (Registered Nurse) A for Resident #1 dated [DATE] at 12:30 p.m. documented vital signs in a grid at the top of the page (with spaces for each shift) on the "day" shift as B/P (blood pressure) ,[DATE], T (temperature) 96.4, P (pulse) 50, R (respirations) 30, O2 Sats (oxygen saturation) 68% on 2 LNC (liters per minute by nasal cannula). The nurse's note on the same page at the bottom documented that RN A went to the assisted dining room and attempted to stimulate the resident by rubbing his chest and back to wake him up and arouse him enough to eat. She documented that the food she was feeding him "dropped right out of mouth." She documented she then attempted to get the resident to drink a health shake and the resident "just let fluids run out of his mouth." She documented vital signs at 10:00 a.m. as B/P ,[DATE], P76, T 96.4, R 32, and O2 sats at 68% on room air. She documented she placed oxygen on the resident at 2 liters by nasal cannula, and his oxygen saturation went up to 78%. She documented she elevated the head of his bed. She documented that she contacted the DON (director of nurses) who told her to call the resident's family and ask if they wanted him sent to the hospital. RN A documented she called the resident's wife and told her the resident's status, and the resident's wife said she would call her daughter and let the nurse know. RN A documented that she waited about 30 minutes and then called the resident's daughter and informed her about the resident's status. The resident's daughter told her to send him to the hospital. RN A documented that she then telephoned the physician and called [DATE]. A late entry note by RN A on [DATE] at 1300 (1:00 p.m.) for 9:00 a.m. documented she had held all of Resident #1's morning medications due to lethargy. * RN A did not document a blood sugar measurement. RN A did not document what time she took the vital signs that she recorded in the grid at the top of the page of her [DATE] note. RN A did not document the time that she administered oxygen to the resident. RN A did not document what time Resident #1's oxygen saturation was checked and the 78% results obtained. RN A did not document what time she contacted the DON, how she contacted the DON, or whether or not the DON was present with her or if they spoke on the telephone. RN A did not document what time she called the resident's wife or the resident's daughter. RN A did not document what time she called the physician or what time she called [DATE]. RN A did not document what time EMS arrived at the facility or what time Resident #1 left the facility in an ambulance. 7. A record review of a "CBG sheet" (document the facility used to record routine blood sugar test results) dated February 2013 revealed a blood sugar for Resident #1 taken on [DATE] at 0600 (6:00 a.m.) that was 166. There were no other blood sugar measurements recorded on that date. 8. A record review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 9. A nurse's note for Resident #2 dated [DATE] at 2340 (11:40 p.m.) documented that Resident #1 was found unresponsive and with a blood sugar of 37 (normal blood sugar level prior to a meal is 70 - 130 mg/dl and less than 180 mg/dl two hours after starting a meal according to the American Diabetes Association). The nurse documented that she administered [MEDICATION NAME] (hormone produced in the pancreas that is used to increase very low blood sugar) from the emergency kit. The resident started responding and was given eight ounces of orange juice and four packs of sugar, and his blood sugar went up to 97. 10. A nurse's note dated [DATE] at 1:30 a.m. included documentation that the resident's blood sugar was 69 and "res is brittle with blood sugar at X's (times)." 11. During an initial interview on [DATE] at 10:55 a.m., RN A said that she became licensed as an RN in [DATE] and this position was her first job as a nurse. She said she had no prior medical experience, and came to work at this facility in [DATE]. RN A said that on [DATE], the nurse's aide told her Resident #1 was not eating breakfast so she (RN A) went to try and feed him. She did not remember what she tried to feed him, but stated the food fell from his mouth. She then stated, "Then we got him to drink a health shake." When referring to her progress note where she documented the health shake also fell from the resident's mouth, RN A said the documentation was accurate and the resident did not drink the health shake. She said then the resident was brought back to the unit from the dining room, and as she was doing routine vital signs, she noticed his blood pressure was a little low. She did not indicate that she took his vital signs because of his observed condition at breakfast. RN A clarified that the vital signs she documented in the grid on the top of the nurse's note were the earliest vital signs taken (she said after breakfast at approximately 8:30 a.m.) She said she was not very concerned because the blood pressure was was just slightly low. She said she went back and checked it again and it was lower. When discussing the 68% oxygen saturation that she documented (which she did not mention as concerning), she also acknowledged that was very low, stating that "normal" oxygen levels were usually 88% or above. She said she called the DON, who was the supervising RN that day, and the DON came to the unit and assessed the resident with her at 9:30 a.m. or 10:00 a.m. RN A said she thought Resident #1 needed to go to the hospital, but the DON first asked her to check the resident's DNR status. She said she told the DON that the resident had a signed DNR, and the DON told her to call the family and see if they wanted him sent to the emergency room . RN A said she told the DON Resident #1's oxygen saturation was 68% and the DON told her to apply oxygen at about 10:00 a.m. RN A said they had difficulty finding a regulator, but found it and she and the DON applied the oxygen. She said it took about 10 minutes and Resident #1's oxygen saturation went up, but only to 78%. RN A said she took more vital signs than those documented, but she did not document them. RN A reported the 10:00 a.m. vital signs as " Those were the final vitals I got and reported to the EMT. " RN A said she checked the resident's blood sugar that morning some time after she observed his change of condition, but she did not document it and did not remember what the blood sugar reading was. She said that all she remembered was that his blood sugar was "okay." RN A said she called the resident's wife after the DON advised her to call the family and told her his status. RN A said the resident's wife said she would let his daughter know. RN A said she waited for a half hour to 45 minutes and never heard back from the family. RN A said Resident #1's condition continued to decline during this period of time that she waited for a phone call from the resident's family, and that she spoke to the DON and told the DON he was continuing to decline while she waited to hear something back from the resident ' s family. She said his blood pressure continued to decline. RN A said that after 30 to 45 minutes of waiting to see if the resident's daughter would call her, she decided to call the resident's daughter. She called the resident's daughter, who told her to send the resident to the hospital. RN A said she never consulted with Resident #1's physician (or any physician) during that morning, until after she talked to the resident's daughter who told her to send him to the hospital. RN A said that she did believe the resident was in an emergency situation, and she would have called the physician if the DON had told her to, or if she had not consulted with the DON. She said the DON never mentioned calling the physician at all. RN A said she acted according to directions from the DON because that was what she was supposed to do. RN A said she was not knowledgeable of any facility policies regarding notification to physicians for a change of condition of residents. 12. Following the above interview, RN A agreed to an interview in which she would write her answers on a written statement. RN A documented in her statement that she first observed Resident #1 at 7:45 a.m. RN A documented in her statement that the first set of vital signs that were B/P ,[DATE], T 96.4, P 50, and O2 sat of 68% were taken at approximately 8:45 a.m. RN A documented in her statement that, "I only contacted the Dr. when family verified they wanted resident sent to E.R. (emergency room ). I did not contact him prior because, when I told DON I wanted to send him out she said call the family and make sure they want him to be sent out due to his DNR status." She documented that the DON was informed of the resident's condition, including the vital signs she had taken. RN A documented that, "Prior to calling family, resident ' s vital signs were ,[DATE] (B/P), 76 (P), 32 (R), and 68% (O2 sat). She documented that she had a nurse's aide in with the resident for the next 30 to 45 minutes " keeping an eye on him." She documented in her written statement, "I asked aid (sic) several time if resident vitals were worsening and also visually checked on resident myself. I did not record any other vital signs in nurse' s notes after 10:00 vitals." 13. During a second interview on [DATE] at 1:50 p.m., RN A maintained the information provided during the above interview. She said that his respirations were "heavy" and "around 30." when she assessed him, and they stayed about the same through the morning, but his blood pressure continued to decline. She said she and the DON placed the resident on oxygen of 2 liters per minute and never changed the oxygen setting. RN A said she left a nurse's aide in the room to monitor the resident and had him hooked up to a machine to take the resident's vital signs, but does not know how often the machine was set to take them. RN A said she wrote down the initial vital signs and the vital signs when he went out only and the nurse aide wrote down other vital signs in between. She said the nurse aide was to report if the vital signs changed at all, because she had 49 other residents to tend to. RN A said it was her understanding that facility policy was that she not take any action in a situation such as change of condition of a resident until an RN supervisor assessed the resident, and that she followed that policy and did not do anything wrong. She became tearful, stating, "Yes, I knew he was dying. We all knew he was dying." She said the nurse aides were patting his hand and telling him to "Go papa." RN A said she felt guilty about the incident, but repeated she did not do anything wrong because she did what she was instructed to do by the DON. 14. During an interview with the DON on [DATE] at 1:05 p.m., when discussing whether the she was present at the facility on [DATE], the day that Resident #1 died , she said, "I don't know, I would have to look at my schedule." She then said that she believed she remembered something about RN A asking her to look at Resident #1 for a change in condition. The DON said she went to the unit and assessed the resident and he was not in any acute distress but she did think he needed to be sent to the hospital. When discussing her assessment of the resident, the DON said she did not take any of Resident #1's vital signs and she did not remember RN A telling her about any of Resident #1's vital signs. The DON said she never knew Resident #1's oxygen saturation level was 68%. She said she did not think RN A ever told her what the resident's change of condition was, and she could not say that she asked RN A. She said, "I can't remember all these details." When discussing RN A's report that the DON had instructed her and assisted her to place oxygen on the resident due to an oxygen saturation of 68%, the DON said, "I don't remember doing that." When discussing how she concluded he needed to be sent to the hospital, the DON said, "He just didn't look right." When discussing what she meant by that statement, she said he looked more lethargic than other times she had seen him. When discussing whether the physician was consulted at any time during the morning of [DATE], the DON said she did not consult with a physician or tell RN A to consult with the physician. When discussing why she chose not to instruct RN A to call the physician, she said, "I didn't know anything that we could do to make him perk up." When discussing whether she asked RN A about the DNR status of the resident or considered his DNR status when making a decision whether or not to consult the physician, the DON said she did not remember asking RN A about the resident's DNR status, and the resident's DNR status would not make a difference in the decision to call the physician. The DON said that she did tell RN A to ask the family if they wanted him to go to the emergency room because she "thought she remembered something" about the family not wanting him to go in the past. The DON said Resident #1 was a hospice patient. When discussing whether she contacted hospice if he was their patient, she said, "I don't know anything about that." She said that when RN A called the resident's daughter and told her he needed to be sent out, the daughter told her not to send him out until she came to the facility to see him. The DON said she left the unit after her visual assessment of the resident and did not remember what she was doing the rest of the morning. She could not verify that she documented anything with regard to this incident stating, "I thought I did, that's why I'm looking through these notes." (The DON nor facility ever provided any documentation by the DON for [DATE]. Record review of Resident #1's medical record revealed no documentation was available in the medical record). 15. During a follow-up interview on [DATE] at 3:40 p.m., the DON said that Resident #1's change of condition on [DATE] was not an emergency. She said, "He probably could have just gone to the doctor's office." The DON said she could tell by looking at the resident that he was not in respiratory distress because his respirations were a little elevated and she did not hear any gurgling in his lungs. She said she did not use a stethoscope and just went by what she heard audibly. She said she decided he was not in respiratory distress even though his oxygen saturation was 78% because of the "clinical picture." She said his nail beds were not cyanotic. The DON later said that an oxygen saturation of 78% would warrant sending a resident to the hospital. When discussing why she did not just contact the physician and send Resident #1 to the hospital if she thought he needed to go, she said, "I don't know." 16. During an interview on [DATE] at 9:40 a.m., CNA (certified nurse's aide) A said that she was working on [DATE] on the A-wing where Resident #1 resided. She said that after breakfast that day, she assisted CNA B to put Resident #1 back to bed. She said that she was not sure what time it was, but breakfast was usually served around 7:00 a.m. and ended 8:30 a.m. to 9:00 a.m. CNA A said the nurse told them to put the resident to bed because he could not hold his head up. She said that when they put the resident to bed, he was limp "like a wet noodle." She said that he was not making any sounds or noises like he usually did. She said Resident #1 was not verbal in carrying on any conversations, but that he normally always made faces and made noises when he was touched. She motioned that he would recoil from touch. She said that he was also very playful at times. She said he was not doing any of those things that morning. She said his legs felt cold. CNA A said that she and CNA B were concerned about Resident #1 because he looked so bad and they both thought he looked like he might be dying. She said the resident's legs were mottling. She said she knew what mottling was because she had seen it before. CNA A said when she and CNA B expressed concern to RN A about the resident and the changes to the skin color of his legs, RN A said, "No, he's just dehydrated and we'll send him out and he'll be right back." CNA A said that CNA B protested to RN A's statement stating the resident looked bad. CNA A said she knew RN A went to the room and took his vital signs afterward. CNA A said she did not recall seeing the DON on the hall or in the resident's room, but she was not in the resident's room all morning. CNA A said that CNA B did sit in Resident #1's room and held his hand until the paramedics arrived. 17. During interviews on [DATE] at 2:35 p.m. and [DATE] at 10:40 a.m. (when CNA B wrote a statement in response to inquiries), CNA B said that she worked with Resident #1 on [DATE] and got him out of bed that morning at approximately 6:30 a.m. to 7:00 a.m. She said she took him and placed him in line for his medications first as was the usual schedule. She left him there and then returned a little while later to get him to take him to the dining room for breakfast. CNA B said when she took him to the dining room and was going to help him eat, she observed that he was not responding and she could not feed him. She described him as listless, slumped over in his chair, and " asleep. " She left him to finish the meal and returned him to the unit only when breakfast was over and the aides were returning everyone to the unit. CNA B said that RN A never came to the assisted dining room that morning. She said between 8:30 a.m. and 9:00 a.m. she put Resident #1 back in his bed and he was moaning as if in pain. She said she had to change him at that time because he had a soft stool. She said it was very unusual as it was like syrup and had a peculiar smell unlike regular stool. She said the stool kept flowing from the resident each time they cleaned him and turned him, more stool would come out. She said the resident ' s skin on his face had a " silky " appearance and " he was just laying there. " She said his eyes were " fixated. " She said she then reported Resident #1' s condition to RN A, including that he had very loose uncontrollable bowel movements, and the nurse said she would check him. After telling the nurse about him CNA B said she went to work doing routine tasks and attending to other residents, but because she was so concerned about Resident #1, she went back to his room every chance she got, to check on him. She said when she checked on him, she would find that he had more loose stool, and estimated that she was in his room and changed his brief with stool evident each time, approximately five to six times after putting him to bed. During that time she again talked to RN A about her concern that there was something wrong with Resident #1. CNA B said the first time she saw RN A in the resident ' s room was at 10:40 a.m. She said she remembered the time because she was thinking about how much time she had left before she had to start getting people up for lunch and looked at her watch. CNA B said RN A took his vital signs and was going to leave the room, when CNA B told RN A to look at the resident ' s legs because they were mottled up to mid-thigh. CNA B said RN A looked at his legs and told CNA B that it was probably just dehydration. RN A reportedly left the room and returned a few minutes later to tell her she had called EMS. CNA B said she remained in the room with Resident #1 from 10:40 a.m. until the EMS arrived to take the resident to the hospital. She said that during that time she was just praying for the resident, patting his hand, and telling him that she loved him and it was going to be okay. CNA B said she never saw the DON on the unit or in the resident ' s room that morning. CNA B said she did not recall seeing oxygen on the resident. She said she had leaned closely to his face that morning to talk to him in his ear, and she did not recall seeing any tubing, an oxygen tank, or an oxygen concentrator. CNA B said she had been a caregiver for approximately [AGE] years and had experience sitting with hospice patients. She said that the signs that she saw on the resident made her believe that the resident was dying, and RN A did not have any sense of urgency about the resident ' s condition. 18. A hospital record of death for Resident #1, dated [DATE] documented Resident #1 died at the hospital and the cause of death was [MEDICAL CONDITION]. 19. An EMS (emergency medical services) transfer of care record dated [DATE] documented that EMS was en-route to the facility at 10:56 a.m. and arrived at 10:59 a.m. The responder documented that Resident #1 ' s pupils were constricted, skin was cool to touch, and he had labored respirations. The resident ' s blood pressure was ,[DATE], his heart rate was 112, and his respirations were 36. 20. During an interview on [DATE] at 9:30 a.m., the EMS responder said that when he arrived in Resident #1 ' s room on [DATE], it was obvious that Resident #1 was in respiratory distress. He said the resident ' s blood pressure was ,[DATE] and his respirations were 36. He said the resident was gasping for air and using his accessory muscles to try to breathe. The EMS responder said that a nurse who was in the resident ' s room told the responders that Resident #1 had been having a decreased level of consciousness and low blood pressure "for the last couple of days." 21. A review of nursing documentation from facility nurses for Resident #1 for the two days previous to his revealed the following: A) Vital signs for Resident #1 that were documented on the vital sign grid the previous day ([DATE]) were as follows: Day: B/P ,[DATE]; T 98.4; R 18; O2 sat 97% Evening: B/P ,[DATE]; T 97.6 R 20 Night: B/P ,[DATE]; T 98.5, P 86; R 20; O2 sat 97% The day nurse that signed and initialed the day shift section of this page for this date was RN A. A nurse's note by RN A dated [DATE] documented that Resident #1 ate 100% of breakfast without any difficulty, and that the resident was waiting for his shower with no signs or symptoms of distress. *Nurse ' s notes for day, evening and night shift nurses were reviewed and none of these notes described the resident has having any decreased level of consciousness, low blood pressure, or any other distress such as what the nurse reported to the EMS responder. B) Vital signs for Resident #1 that were documented on the vital sign grid for [DATE] were as follows: Day: B/P ,[DATE]; T 96.0; P76; R 18; O2 sat 95% Evening: B/P ,[DATE]; T 98.6; P 96; R 20 Night: B/P ,[DATE]; T 99.2; P 71; R 18; O2 sat 96% A nurse's note for [DATE] at 10:20 a.m. documented that the resident was readmitted to the facility [DATE] with a [DIAGNOSES REDACTED]. The nurse documented that the resident was up in his wheelchair and propelling himself with his feet across the unit and no distress was noted. A second nurse's note on [DATE] at 1515 (3:15 p.m.) documented that Resident #1 continued with gait balance and mobility with PT/OT (physical therapy/occupational therapy) services and tolerated without difficulty. * Nurse's notes for this day, evening and night shift revealed none of the notes described Resident #1 has having decreased level of consciousness, abnormally low blood pressure, or any other distress such as what the nurse reported to the EMS responder. 22. A report signed by the RN C, the hospital triage nurse, with triage time of 11:20 a.m. documented Resident #1's vital signs were T 96.2, P 92, R 44, B/P ,[DATE]; and O2 99% on 100% oxygen non rebreather mask. A hospital physician's report dated [DATE] with examination time of 11:21 a.m. documented that Resident #1 was cyanotic, mottled, unresponsive, and agonal respiration (shallow breathing) was noted. The physician documented his impression was, "[MEDICAL CONDITION], Hypoxemia, terminal state." 23. During an interview on [DATE] at 12:20 p.m., RN C, who worked in the hospital emergency room , said that she remembered when Resident #1 arrived at theER on [DATE]. She said that he was "pasty pale" and even after being on 100% oxygen on a non rebreather mask while enroute to the hospital, his oxygen saturation was still only 59%. She said his initial blood pressure was ,[DATE]. She said when the resident's daughter arrived at the hospital she was very upset and "in total shock" about the resident's condition. She said the resident's daughter kept talking about how well the resident had looked and appeared to be doing the day before when she visited him at the facility. 24. During interviews with Resident #1's daughter on [DATE] at 1:35 p.m., [DATE] at 2:35 p.m., and [DATE] at 1:00 p.m., she said that she nor her mother had ever given the facility any instructions or impression that they would ever hesitate to send Resident #1 to the hospital if he needed to go. She said that on [DATE] the facility called her mother first, when she and her mother had instructed the facility to always call her (daughter). She said that her mother did call her to tell her the nurse had called, but her mother told her that the nurse just said that they had to put oxygen on the resident. Resident #1's daughter said her mother told her that the nurse did not lead her to believe that there was any immediate need for the resident's daughter to call the facility or go to the facility or that the resident's condition was serious. She said that she told her mother she planned to visit Resident #1 later that day and would check to see how he was doing. She said that later in the morning, she then got a phone call from the nurse telling her about her father's condition, and she had to prompt the nurse to actually describe how serious his condition was. She said as soon as the nurse said his condition was serious, she told the nurse to send him to the hospital and she would meet him there. Resident #1's daughter said the facility had never waited to get permission from them to send him to the hospital before, and had always just sent him when he needed to go and informed the family after arrangement

Based on interview and record review, the facility failed to implement written policies and procedures to thoroughly investigate and report to the State survey agency when 1 of 13 residents reviewed for change of condition (Resident #1, who had a respiratory disease and diabetes), began showing symptoms of a change in level of consciousness and respiratory distress at 8:30 a.m.- 8:45 a.m. on [DATE], and RN A and the DON failed to consult with the physician or call [DATE] until approximately 10:45 a.m. Resident #1 died of respiratory distress at 3:20 p.m. These failures resulted in neglect not being identified regarding Resident #2's change of condition and death on [DATE], and the alleged perpetrators (RN A and the DON) remaining in the facility providing care to residents from [DATE] through [DATE]. On [DATE] at 11:40 a.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] at 5:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The facility failure to investigate and report incidents of death of unusual circumstances could result in ongoing neglect in the facility.and could affect the 41 residents the facility identified who have respiratory diseases and the 32 residents in the facility with diabetes. These failures could result in medical complications [REDACTED]. Findings included: 1.The facility's policy titled, "Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment dated [DATE] included the following: Page 2, #3: Any employee having knowledge or suspicions of an alleged violation involving resident abuse, neglect, exploitation, and misappropriation of resident property, involuntary seclusion or corporal punishment is required to report immediately to the Facility Administrator or to the Department Manager without fear of reprisal. Page 2, #4: All incidents including those of unknown origins will be thoroughly investigated. Potential abuse, neglect, exploitation and misappropriation of resident property, involuntary seclusion, and corporal punishment will be prevented during investigation. Results of investigation will be reported immediately to the facility Administrator or designee and other officials in accordance with Texas law... Page 4: "Neglect means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness. 2. An Admission Record with no date documented that Resident #1 was an [AGE] year-old male admitted to the facility initially on [DATE]. 3. A physician's note dated [DATE], current physician's orders, and Resident #1's care plan dated [DATE] documented Resident #1's [DIAGNOSES REDACTED]. Physician's orders for Resident #1, valid from [DATE] through [DATE], revealed there was no physician's order for oxygen for the resident. These orders included an order for [REDACTED]."DC (discontinue) Iprat-Albut 0XXX,[DATE] (25) mg/3 ml 1 vial per nebulizer QID prn (medication inhaled as a mist to improve breathing, four times a day as needed)." Physician's orders for Resident #1 did not include orders for palliative or hospice care. These orders also included the following: CBG TID (capillary blood glucose three times a day) and Q HS (every hour of sleep), notify MD if less than 70 or greater than 400. [MEDICATION NAME] R 100 units/ml vial (insulin regular human: Use per sliding scale. Scale ,[DATE]- 0 units, ,[DATE] = 2.0 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units. Frequency 0630, 1130, 1630, and 2000. 4. The current care plan for Resident #1's [DIAGNOSES REDACTED]. -Assess for change in level of consciousness, coherency. Report changes. -Monitor and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, decreased breath sounds). -Monitor oxygen saturation via pulse oximetry as ordered: daily. If <92%, place on O2 at 2 L/m via NC (liters per minute via nasal cannula). The same care plan included a care plan for Resident #1's [DIAGNOSES REDACTED]. - Monitor for signs of [MEDICAL CONDITION] (increasd thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting, hypothermia, [MEDICAL CONDITION], stupor, muscle weakness -Monitor for signs of [DIAGNOSES REDACTED] (blood glucose < 60mg/dl; sweating, cold/clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination. -Monitor/record/report blood glucose per MD order: TID (three times daily) and Q HS (every hour of sleep). Notify MD if less than 70 or greater than 400. 5. A Minimum Data Set Assessment ((MDS) dated [DATE] with the type of assessment documented as "Significant change in status assessment", which was signed by the MDS Coordinator on [DATE] and the DON on [DATE] documented Resident #1 was totally dependent on two staff for transfers, dressing, and toilet use. He required extensive assistance of one staff for eating, used a wheelchair for mobility, was always incontinent of bowel and bladder. Under the section, "shortness of breath", the assessor documented that Resident #1 did not have shortness of breath when sitting, lying flat, or with exertion. Under the section of "Prognosis" the assessor documented that the resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. Under section O0100, "Special Treatments, Procedures, and Programs...Check all of the following treatments, procedures, and programs that were performed during the last 14 days," the assessor did not check oxygen, or any other respiratory therapy. 6. During an interview on [DATE] at 4:45 p.m., the DON and A-wing Unit Manager RN B said that Resident #1 died at the hospital on [DATE] after being sent to the hospital from the facility. When discussing the lack of documentation and requesting more detail about Resident #1's change of condition on [DATE], the DON said that there must be other documentation elsewhere and RN B said, "I don't know. I was off that day." RN B said that the reason oxygen and breathing treatments were discontinued in January was because Resident #1 had not needed to use them. 7. A nurse's note signed by RN A for Resident #1 dated [DATE] at 12:30 p.m. documented vital signs in a grid at the top of the page (with spaces for each shift) on the "day" shift as B/P (blood pressure) ,[DATE], T (temperature) 96.4, P (pulse) 50, R (respirations) 30, O2 Sats (oxygen saturation) 68% on 2 LNC (liters per minute by nasal cannula). The nurse's note below the grid on the same page documented that RN A went to the assisted dining room and attempted to stimulate the resident by rubbing his chest and back to wake him up and arouse him enough to eat. She documented that the food she was feeding him "dropped right out of mouth." She documented she then attempted to get the resident to drink a health shake and the resident "just let fluids run out of his mouth." She documented vital signs at 10:00 a.m. as B/P ,[DATE], P76, T 96.4, R 32, and O2 sats at 68% on room air. She documented she placed oxygen on the resident at 2 liters by nasal cannula, and his oxygen saturation went up to 78%. She documented she elevated the head of his bed. She documented that she contacted the DON, who told her to call the resident's family and ask if they wanted him sent to the hospital. RN A documented she called the resident's wife and told her the resident's status, and the resident's wife said she would call her daughter and let the nurse know. RN A documented that she waited about 30 minutes and then called the resident's daughter and informed her about the resident's status. The resident's daughter told her to send him to the hospital. RN A documented that she then telephoned the physician and called [DATE]. A late entry note by RN A on [DATE] at 1300 (1:00 p.m.) for 9:00 a.m. documented she had held all of Resident #1's morning medications due to lethargy. *RN A did not document a blood sugar or the taking of a blood sugar in her progress note. RN A did not document what time she took the vital signs that she recorded in the grid at the top of the page of her [DATE] note, the time that she administered oxygen to the resident, what time Resident #1's oxygen saturation was checked and the 78% results obtained, what time she contacted the DON, how she contacted the DON, or whether or not the DON was present with her or if they spoke on the telephone. RN A did not document what time she called the resident's wife or the resident's daughter or when she called the physician, which physician she called, or when she called [DATE]. RN A did not document what time EMS arrived at the facility or what time Resident #1 left the facility in an ambulance. 8. A record review of a "CBG sheet" dated February 2013 revealed a blood sugar for Resident #1 taken on [DATE] at 0600 (6:00 a.m.) that was 166. There were no other blood sugar measurements recorded on that date. 9. A record review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 10. A record review of past nurse's notes and physician's orders revealed a nurse's note dated [DATE] at 2340 (11:40 p.m.) that Resident #1 was found unresponsive and with a blood sugar of 37. The nurse documented she administered [MEDICATION NAME] from the emergency kit. The resident started responding and was given eight ounces of orange juice and four packs of sugar, and his blood sugar went up to 97. 11. A nurse's note for Resident #1 dated [DATE] at 1:30 a.m. included documentation that the his blood sugar was 69 and "res is brittle with blood sugar at X's (times)." 12. During an initial interview on [DATE] at 10:55 a.m., RN A said that she became licensed as an RN in [DATE] and this position was her first job as a nurse. She said she had no prior medical experience, and came to work at this facility in [DATE]. RN A said that on [DATE], the nurse's aide told her Resident #1 was not eating breakfast so she (RN A) went to try and feed him. She did not remember what she tried to feed him, but stated the food fell from his mouth. She then stated, "Then we got him to drink a health shake." When referring to her progress note where she documented the health shake also fell from the resident's mouth, RN A said the documentation was accurate and the resident did not drink the health shake. She said the resident was then brought back to the unit from the dining room, and as she was doing routine vital signs (which she identified as the vital signs in the grid at the top of her progress note taken at approximately 8:30 a.m.), she noticed his blood pressure was a little low. RN A said she did not immediately assess the resident's condition at breakfast when food fell from his mouth because "he was often lethargic" and she did not see any problems with his respirations. She also added that there were "lots of times he didn't want to eat." She said she was not very concerned because the blood pressure was just slightly low. She said she went back and checked it again and it was lower. When discussing the oxygen saturation that she documented (68%), she also acknowledged that was very low, stating that "normal" oxygen levels were usually 88% or above. RN A said she checked the resident's blood sugar that morning some time after she observed his change in condition, but she did not document it and did not remember what the blood sugar reading was. She said all that she remembered was that it was "okay." She said she called the DON, who was the supervising RN that day, and the DON came to the unit and assessed the resident with her at 9:30 a.m. or 10:00 a.m. She said she told the DON Resident #1's oxygen saturation was 68%, and the DON told her to apply oxygen. RN A said she thought Resident #1 needed to go to the hospital, and asked the DON if she should send him, but the DON first asked her to check the resident's DNR status. She said she told the DON that the resident had a signed DNR, and the DON told her to call the family and see if they wanted him sent to the emergency room . RN A said she took more vital signs than those documented, but she did not write them down. RN A reported the 10:00 a.m. vital signs as, "The final vitals I got and reported to the EMT. " RN A said the DON left the unit after they applied oxygen to the resident and had told her to contact the resident's family. She said the DON came back and forth to the unit after that to check on the resident's status, and that she had informed the DON that Resident #1's blood pressure was dropping while she was waiting to hear back from the family. RN A said she called the resident's wife after the DON advised her to call the family and told her his status. RN A said the resident's wife said she would let his daughter know. RN A said she waited for a half hour to 45 minutes and never heard back from the family. She said she was concerned about the resident's decline, so she called the resident's daughter, who told her to send the resident to the hospital. RN A said she never consulted with Resident #1's physician (or any physician) during that morning, until after she talked to the resident's daughter (which she had identified as 30 to 45 minutes after applying oxygen at approximately 10:00 a.m.) RN A said that she did believe the resident was in an emergency situation, and she would have called the physician if the DON had told her to. She said the DON never mentioned calling the physician at all. RN A said she acted according to directions from the DON because that was what she was supposed to do. RN A said that if the DON had not been there, she would have called the physician. RN A said she was not knowledgeable of any facility policies regarding notification to physicians for a change of condition of residents. RN A documented in her statement on this date that the first set of vital signs that were B/P ,[DATE], T 96.4, P 50, and O2 sat of 68% were taken at approximately 8:45 a.m. RN A documented, "I told (DON) previous vitals and explained resident's condition to her while in resident's room. (DON) visually observed resident and told me to see if he was a DNR." RN A documented in her statement, "I only contacted the Dr. when family verified they wanted resident sent to E.R. I did not contact him prior because, when I told DON I wanted to send him out she said call the family and make sure they want him to be sent out due to his DNR status." RN A documented that, " Prior to calling family, resident's vital signs were ,[DATE] (B/P), 76 (P), 32 (R), and 68% (O2 sat). She documented that she had a nurse's aide in with the resident for the next 30 to 45 minutes " keeping an eye on him." She documented, " I asked aid (sic) several times if resident vitals were worsening and also visually checked on resident myself. I did not record any other vital signs in nurse's notes after 10:00 vitals. " 13. During a second interview on [DATE] at 1:50 p.m., RN A maintained the information provided during the above interview. In addition, she said that in her assessment of the resident, she did not check his pupil response, did not listen to his lung sounds, and did not listen to his heart sounds. She said that his respirations were "heavy" and "around 30" when she assessed him, and they stayed about the same through the morning, but his blood pressure continued to decline. She said she did not know what assessment the DON did or if the DON assessed the resident. She said she and the DON placed the resident on oxygen of 2 liters per minute and never changed the oxygen setting. She said his skin color was "pinkish white" but not abnormal. When discussing whether any of the nurse aides reported any concerns to her that morning, she said, "Only that he wasn't eating but otherwise, no. He wasn't cold." She then said he was not cold or clammy and that is why she did not believe it was a blood sugar issue. RN A said she left a nurse's aide in the room to monitor the resident and had him hooked up to a machine to take the resident's vital signs, but does not know how often the machine was set to take them. RN A said she wrote down the initial vital signs and the vital signs when he went out only and the nurse aide wrote down other vital signs in between. She said the nurse aide was to report if the vital signs changed at all, because she had 49 other residents to tend to. RN A said that there was talk around the facility that a nurse aide reported mottling was observed on the resident, but she did not see any mottling to the resident's arms when they were out of the blanket and she did not look at his lower extremities. She said the nurse aides did clean the resident when he had a bowel movement. RN A said it was her understanding that facility policy was that she not take any action in a situation such as change of condition of a resident until an RN supervisor assessed the resident, and that she followed that policy and did not do anything wrong. She became tearful, stating, "Yes, I knew he was dying. We all knew he was dying." She said the nurse aides were patting his hand and telling him to "Go papa." RN A said she felt guilty about the incident, but repeated she did not do anything wrong because she did what she was instructed to do by the DON. 14. During an interview with the DON on [DATE] at 1:05 p.m., when discussing whether the she was present at the facility on [DATE], the day that Resident #1 died , she said, "I don't know, I would have to look at my schedule." She then said that she believed she remembered something about RN A asking her to look at Resident #1 for a change in condition. The DON said she went to the unit and assessed the resident and he was not in any acute distress but she did think he needed to be sent to the hospital. When discussing her assessment of the resident, the DON said she did not take any of Resident #1's vital signs and she did not remember RN A telling her about any of Resident #1's vital signs. The DON said she never knew Resident #1's oxygen saturation level was 68%. She said she did not think RN A ever told her what the resident's change of condition was, and she could not say that she asked RN A. She said, " I can't remember all these details." When discussing RN A's report that the DON had instructed her and assisted her to place oxygen on the resident due to an oxygen saturation of 68%, the DON said, "I don't remember doing that." When discussing how she concluded he needed to be sent to the hospital, the DON said, "He just didn't look right." When discussing what she meant by that statement, she said he looked more lethargic than other times she had seen him. When discussing whether it would have been appropriate to take the resident's vital signs as part of her assessment of the resident, the DON said, "Vital signs are part of assessment but I'm overriding my choice to do vital signs based on a visual assessment." The DON then said, "I don't know what to tell you, I don't remember what the assessment was." She then said that she shook him and called his name. She said his eyes were closed and he appeared to try to open them, but it was a minute response. When discussing whether the physician was consulted at any time during the morning of [DATE], the DON said she did not consult with a physician or tell RN A to consult with the physician. When discussing why she chose not to instruct RN A to call the physician, she said, "I didn't know anything that we could do to make him perk up." When discussing whether she asked RN A about the DNR status of the resident or considered his DNR status when making a decision whether or not to consult the physician, the DON said she did not remember asking RN A about the resident's DNR status and the resident ' s DNR status would not make a difference in the decision to call the physician. The DON said that she did tell RN A to ask the family if they wanted him to go to the emergency room because she thought she remembered something about the family not wanting him to go in the past. The DON said Resident #1 was a hospice patient. When discussing whether she contacted hospice if he was their patient, she said, "I don't know anything about that." The DON said she left the unit after her visual assessment of the resident and did not remember what she was doing the rest of the morning. She could not verify that she documented anything with regard to this incident stating, "I thought I did, that's why I'm looking through these notes." 15. During a follow-up interview on [DATE] at 3:40 p.m., the DON said that Resident #1's change of condition on [DATE] was not an emergency. She said, "He probably could have just gone to the doctor's office." The DON said she could tell by looking at the resident that he was not in respiratory distress because his respirations were a little elevated and she did not hear any gurgling in his lungs. She said she did not use a stethoscope and just went by what she heard audibly. She described her total assessment of the resident as seeing the head of his bed elevated, saw that he had oxygen on, checked his responsiveness by shaking him, and watched his breathing. She said she decided he was not in respiratory distress even though his oxygen saturation was 78% because of the "clinical picture." She said his nail beds were not cyanotic. The DON later said that an oxygen saturation of 78% would warrant sending a resident to the hospital. When discussing why she did not just contact the physician and send Resident #1 to the hospital if she thought he needed to go, she said, "I don't know." In her written statement dated [DATE], the DON wrote that RN A did not share any of Resident #1's vital signs with her, and she did not ask for the resident's vital signs. She wrote, "Assessment of visually reveals head of bed elevated O2 on per nasal cannula, color normal for resident, no audible gurgling or active respiratory distress noted, nail beds no cynosis (sic), aroused resident by shanking and calling name, he aroused by opening his eyes. Respirtory (sic) rate did not indicate respiratory distress along with other signs. visually looked at lower extremities for color changes, none noted. Did not detect this to be a 911 call. I did not take vital signs or O2 sat during assessment, as they were taken at an earlier time." 16. During an interview on [DATE] at 9:40 a.m., CNA A said that she was working on [DATE] on the A-wing where Resident #1 resided. She said that after breakfast that day, she assisted CNA B to put Resident #1 back to bed. She said that she was not sure what time it was, but breakfast was usually served around 7:00 a.m. and ended 8:30 a.m. to 9:00 a.m. CNA A said the nurse told them to put the resident to bed because he could not hold his head up. She said that when they put the resident to bed, he was limp "like a wet noodle." She said that he was not making any sounds or noises like he usually did. She said his legs felt cold. CNA A said that she and CNA B were concerned about Resident #1 because he looked like he might be dying. She said the resident's legs were mottling. She said she knew what mottling was because she had seen it before. CNA A said when she and CNA B expressed concern to RN A about the changes to the skin color of his legs, RN A said, "No, he's just dehydrated and we'll send him out and he'll be right back." CNA A said that CNA B protested to RN A's statement stating the resident looked bad. CNA A said she knew RN A went to the room and took his vital signs afterward. CNA A said she did not recall seeing the DON on the hall or in the resident's room, but she was not in the resident's room all morning. CNA A said that CNA B did sit in Resident #1's room and held his hand until the paramedics arrived. 17. During interviews on [DATE] at 2:35 p.m. and [DATE] at 10:40 a.m. (when CNA B wrote a statement in response to interview questions), CNA B said that RN B had told her that if she (CNA B) spoke to the state surveyor, the surveyor would " trip her up " . RN B told CNA B that the state surveyors had " tripped up " the nurses during their interview and made them cry. RN B suggested that she (RN B) be present when state surveyors interviewed CNA B. CNA B said that RN B also made her feel as if she was somehow responsible for the Immediate Jeopardy, stating to CNA B, " After you left, we were slapped with an IJ! " CNA B said she was initially fearful of being interviewed based on RN B ' s statements. CNA B said that on [DATE] when the surveyor was attempting to speak to CNA B about a private interview, RN B stood behind the surveyor and shook her head "No!" at CNA B. CNA B said that she worked with Resident #1 on [DATE] and transferred him from bed that morning at approximately 6:30 a.m. to 7:00 a.m. She said she took him and placed him in line for his medications first as was the usual schedule. She left him there and then returned a little while later to get him to take him to the dining room for breakfast. CNA B said when she took him to the dining room and was going to help him eat, she observed that he was not responding and she could not feed him. She described him as listless, slumped over in his chair, and "asleep." She left him to finish the meal and returned him to the unit only when breakfast was over and the aides were returning everyone to the unit. CNA B said that RN A never came to the assisted dining room that morning. She said between 8:30 a.m. and 9:00 a.m. she put Resident Campbell back in his bed and he was moaning as if in pain. She said she had to change him at that time because he had a soft stool. She said it was very unusual as it was like syrup and had a peculiar smell unlike regular stool. She said the stool kept flowing from the resident each time they cleaned him and turned him, more stool would come out. She said the resident ' s skin on his face had a "silky " appearance and " he was just laying there. " She said his eyes were "fixated." She said she then reported Resident #1 ' s condition to RN A, including that he had very loose uncontrollable bowel movements, and the nurse said she would check him. After telling the nurse about him CNA B said she went to work doing routine tasks and attending to other residents, but because she was so concerned about Resident #1, she went back to his room every chance she got, to check on him. She said when she checked on him, she would find that he had more loose stool, and estimated that she was in his room and changed his brief with stool evident each time, approximately five to six times after putting him to bed. During that time she again talked to RN A about her concern that there was something wrong with Resident #1. CNA B said the first time she saw RN A in the resident's room was at 10:40 a.m. She said she remembered the time because she was thinking about how much time she had left before she had to start getting people up for lunch and looked at her watch. CNA B said RN A took his vital signs and was going to leave the room, when CNA B told RN A to look at the resident ' s legs because they were mottled up to mid-thigh. CNA B said RN A looked at his legs and told CNA B that it was probably just dehydration. RN A reportedly left the room and returned a few minutes later to tell her she had called EMS. CNA B said she remained in the room with Resident #1 from 10:40 a.m. until the EMS arrived to take the resident to the hospital. She said that during that time she was just praying for the resident, patting his hand, and telling him that she loved him and it was going to be okay. CNA B said she never saw the DON on the unit or in the resident ' s room that morning. CNA B said she did not recall seeing oxygen on the resident. She said she had leaned closely to his face that morning to talk to him in his ear, and she did not recall seeing any tubing, an oxygen tank, or an oxygen concentrator. CNA B said that after Resident #1 went to the hospital, she proceeded to get residents ready and take them to lunch. When she returned to the unit after lunch was over, RN B was on the unit. CNA B said she had a conversation with RN B regarding her concerns about how bad Resident #1 had looked that morning, including telling RN B, " He was mottled all the way up to here!" (gesturing to her mid thigh area). CNA B said that RN B told her that she should not be diagnosing residents, and Resident #1 was probably just dehydrated. CNA B said she told RN B that she had sat in the room with Resident #1 and had been praying for him. She said RN B told her that she should not be telling people that she was praying for the resident. CNA B said she had a separate conversation with RN B and told RN B that RN A seemed unconcerned about Resident #1 and had no sense of urgency in caring for him on [DATE]. She said RN B told her, "Whatever you do, don't tell the state she had no sense of urgency! " 18. A hospital record of death for Resident #1, dated [DATE] documented Resident #1 died at the hospital and the cause of death was [MEDICAL CONDITION]. 19. An EMS (emergency medical services) transfer of care record dated [DATE] documented that EMS was en-route to the facility at 10:56 a.m. and arrived at 10:59 a.m. The responder documented that Resident #1's pupils were constricted, skin was cool to touch, and he had labored respirations. The resident's blood pressure was ,[DATE], heart rate was 112, and respirations were 36. 20. During an interview on [DATE] at 9:30 a.m., the EMS responder said that when he arrived in Resident #1's room on [DATE], it was obvious that Resident #1 was in respiratory distress. He said the resident was receiving O2 at 3 liters per minute by nasal cannula. He said the resident 's blood pressure was ,[DATE] and his respirations were 36. He said the resident was gasping for air and using his accessory muscles to try to breathe. The EMS responder said that a nurse who was in the resident's room told the responders that Resident #1 had been having a decreased level of consciousness and low blood pressure "for the last couple of days." 21. Nurse's notes for [DATE] and [DATE] revealed no evidence that Resident #1 had been in any distress, had abnormal vital signs, or decreased level of consciousness in the preceding days to [DATE] as reported to EMS by RN A. 22. During interviews with Resident #1's daughter on [DATE] at 1:35 p.m., [DATE] at 2:35 p.m., and [DATE] at 1:00 p.m., she said that she nor her mother had ever given the facility any instructions or impression that they would ever hesitate to send Resident #1 to the hospital if he needed to go. She said that on [DATE] the facility called her mother first, when she and her mother had instructed the facility to always call her. She said that her mother did call her to tell her the nurse had called, but her mother told her that the nurse just said that they had to put oxygen on the resident. Resident #1's daughter said her mother told her that the nurse did not lead her to believe that there was any immediate need for the resident ' s daughter to call the facility or go to the facility. She said that she told her mother she planned to visit Resident #1 later that day and would check to see how he was doing. She said that she then got a phone call from the nurse telling her about her father ' s condition and she had to prompt the nurse to actually describe how serious his condition was. She said as soon as

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being for 1 of 13 residents (Resident #1, who had a respiratory disease and diabetes) reviewed for a change of condition as evidenced by: - failure of RN (registered nurse) A and the DON (director of nurses) to thoroughly assess the resident, consult with a physician, or call [DATE] immediately when RN A identified that Resident #1 had a change in level of consciousness and an oxygen saturation that was critically low (68%) at 8:45 a.m., and the DON was informed of his change in condition between 9:30 a.m. and 10:00 a.m. on [DATE]. RN A did not call [DATE] until after 10:30 a.m. Resident #1 was in a terminal state on arrival to the hospital and died at 3:20 p.m. These failures resulted in a two hour delay in emergency medical treatment for [REDACTED].#1. Resident #1 died of respiratory distress after arrival to the hospital on [DATE]. On [DATE] at 5:48 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] at 5:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to thoroughly assess, monitor, and obtain emergency medical treatment for [REDACTED]. Findings included: 1. An Admission Record with no date documented that Resident #1 was an [AGE] year-old male admitted to the facility initially on [DATE]. 2. A physician's note dated [DATE], current physician's orders, and Resident #1's care plan dated [DATE] documented Resident #1's [DIAGNOSES REDACTED]. 3. Physician's orders for Resident #1, valid from [DATE] through [DATE], revealed there was no physician's order for oxygen for the resident. These orders included an order for [REDACTED]."DC (discontinue) Iprat-Albut 0XXX,[DATE] (25) mg/3 ml 1 vial per nebulizer QID prn (medication inhaled as a mist to improve breathing, four times a day as needed)." These orders also included the following: CBG TID (capillary blood glucose three times a day) and Q HS (every hour of sleep), notify MD if less than 70 or greater than 400. [MEDICATION NAME] R 100 units/ml vial (insulin regular human: Use per sliding scale. Scale ,[DATE]- 0 units, ,[DATE] = 2.0 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units. Frequency 0630, 1130, 1630, and 2000. Physician's orders for Resident #1 did not include palliative or hospice care. 4. The current care plan dated [DATE] for Resident #1's [DIAGNOSES REDACTED]. -Assess for change in level of consciousness, coherency. Report changes. -Monitor and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [MEDICAL CONDITION] cyanosis, decreased breath sounds). -Monitor oxygen saturation via pulse oximetry as ordered: daily. If <92%, place on O2 at 2 L/m via NC (liters per minute via nasal cannula). The same care plan included a care plan for Resident #1's [DIAGNOSES REDACTED]. - Monitor for signs of [MEDICAL CONDITION] (increasd thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting, hypothermia, [MEDICAL CONDITION], stupor, muscle weakness -Monitor for signs of [DIAGNOSES REDACTED] (blood glucose < 60mg/dl; sweating, cold/clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination. -Monitor/record/report blood glucose per MD order: TID (three times daily) and Q HS (every hour of sleep). Notify MD if less than 70 or greater than 400. 5. A Minimum Data Set Assessment ((MDS) dated [DATE] with the type of assessment documented as "Significant change in status assessment", which was signed by the MDS Coordinator on [DATE] and the DON on [DATE] documented the following: Resident #1 re-entered the facility on [DATE] from an acute care hospital; was able to recall staff names and faces, had severely impaired cognitive skills, and had no behaviors. The MDS documented that he was totally dependent on two staff for transfers, dressing, and toilet use. He required extensive assistance of one staff for eating. He used a wheelchair for mobility. The MDS documented Resident #1 was always incontinent of bowel and bladder. Resident #1 was assessed as sometimes being understood by others and sometimes understanding others. Documentation revealed he was not on a scheduled pain medication regimen and did not receive prn (as needed) pain medication. Under the section, "shortness of breath", the assessor documented that Resident #1 did not have shortness of breath when sitting, lying flat, or with exertion. Under the section of "Prognosis" the assessor documented that the resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. Under section O0100, "Special Treatments, Procedures, and Programs...Check all of the following treatments, procedures, and programs that were performed during the last 14 days," the assessor did not check oxygen, or any other respiratory therapy. 6. During an interview on [DATE] at 4:45 p.m., the DON and A-wing Unit Manager RN B said that Resident #1 died at the hospital on [DATE] after being sent to the hospital from the facility. When discussing the lack of documentation and requesting more detail about Resident #1's change of condition on [DATE], the DON said that there must be other documentation elsewhere and RN B said, "I don't know. I was off that day." RN B said that the reason oxygen and breathing treatments were discontinued in January was because Resident #1 had not needed to use them. 7. A nurse's note signed by RN A for Resident #1 dated [DATE] at 12:30 p.m. documented vital signs in a grid at the top of the page (with spaces for each shift) on the "day" shift as B/P (blood pressure) ,[DATE], T (temperature) 96.4, P (pulse) 50, R (respirations) 30, O2 Sats (oxygen saturation) 68% on 2 LNC (liters per minute by nasal cannula). The nurse's note below the grid on the same page documented that RN A went to the assisted dining room and attempted to stimulate the resident by rubbing his chest and back to wake him up and arouse him enough to eat. She documented that the food she was feeding him "dropped right out of mouth." She documented she then attempted to get the resident to drink a health shake and the resident "just let fluids run out of his mouth." She documented vital signs at 10:00 a.m. as B/P ,[DATE], P76, T 96.4, R 32, and O2 sats at 68% on room air. She documented she placed oxygen on the resident at 2 liters by nasal cannula, and his oxygen saturation went up to 78%. She documented she elevated the head of his bed. She documented that she contacted the DON, who told her to call the resident's family and ask if they wanted him sent to the hospital. RN A documented she called the resident's wife and told her the resident's status, and the resident's wife said she would call her daughter and let the nurse know. RN A documented that she waited about 30 minutes and then called the resident's daughter and informed her about the resident's status. The resident's daughter told her to send him to the hospital. RN A documented that she then telephoned the physician and called [DATE]. A late entry note by RN A on [DATE] at 1300 (1:00 p.m.) for 9:00 a.m. documented she had held all of Resident #1's morning medications due to lethargy. *RN A did not document a blood sugar reading or the taking of blood sugar in her progress note. RN A did not document what time she took the vital signs that she recorded in the grid at the top of the page of her [DATE] note. RN A did not document the time that she administered oxygen to the resident, what time Resident #1's oxygen saturation was checked and the 78% results obtained, what time she contacted the DON, how she contacted the DON, or whether or not the DON was present with her or if they spoke on the telephone. RN A did not document what time she called the resident's wife or the resident's daughter, or when she called the physician, which physician she called, or when she called [DATE]. RN A did not document what time EMS arrived at the facility or what time Resident #1 left the facility in an ambulance. 8. A record review of a "CBG sheet" (document the facility used to record blood sugar readings) dated February 2013 revealed a blood sugar for Resident #1 taken on [DATE] at 0600 (6:00 a.m.) that was 166. There were no other blood sugar measurements recorded on that date. 9. A record review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 10. A record review of past nurse's notes and physician's orders revealed a nurse's note dated [DATE] at 2340 (11:40 p.m.) that Resident #1 was found unresponsive and with a blood sugar of 37. The nurse documented administered [MEDICATION NAME] from the emergency kit. The resident started responding and was given eight ounces of orange juice and four packs of sugar, and his blood sugar went up to 97. 11. A nurse's note for Resident #2 dated [DATE] at 1:30 a.m. included documentation that his blood sugar was 69 and "res is brittle with blood sugar at X's (times)." 12. During an initial interview on [DATE] at 10:55 a.m., RN A said that she became licensed as an RN in [DATE] and this position was her first job as a nurse. She said she had no prior medical experience, and came to work at this facility in [DATE]. RN A said that on [DATE], the nurse's aide told her Resident #1 was not eating breakfast so she (RN A) went to try and feed him. She did not remember what she tried to feed him, but stated the food fell from his mouth. She then stated, "Then we got him to drink a health shake." When referring to her progress note where she documented the health shake also fell from the resident's mouth, RN A said the documentation was accurate and the resident did not drink the health shake. She said the resident was then brought back to the unit from the dining room, and as she was doing routine vital signs (which she identified as the vital signs in the grid at the top of her progress note taken at approximately 8:30 a.m.), she noticed his blood pressure was a little low. RN A said she did not immediately assess the resident's condition at breakfast when food fell from his mouth because "he was often lethargic" and she did not see any problems with his respirations. She also added that there were "lots of times he didn't want to eat." She said she was not very concerned because the blood pressure was was just slightly low. She said she went back and checked it again and it was lower. When discussing the oxygen saturation that she documented (68%), she also acknowledged that was very low, stating that "normal" oxygen levels were usually 88% or above. RN A said she checked the resident's blood sugar that morning some time after she observed his change of condition, but she did not document it and did not remember what the blood sugar reading was. She said that all she remembered was it was "okay." She said she called the DON, who was the supervising RN that day, and the DON came to the unit and assessed the resident with her at 9:30 a.m. or 10:00 a.m. She said she told the DON Resident #1's oxygen saturation was 68%, and the DON told her to apply oxygen. RN A said she thought Resident #1 needed to go to the hospital, and asked the DON if she should send him, but the DON first asked her to check the resident's DNR status. She said she told the DON that the resident had a signed DNR, and the DON told her to call the family and see if they wanted him sent to the emergency room . RN A said she took more vital signs than those documented, but she did not write them down. RN A reported the 10:00 a.m. vital signs as, "The final vitals I got and reported to the EMT. " RN A said the DON left the unit after they applied oxygen to the resident and had told her to contact the resident's family. She said the DON came back and forth to the unit after that to check on the resident's status, and that she had informed the DON that Resident #1's blood pressure was dropping while she was waiting to hear back from the family. RN A said she called the resident's wife after the DON advised her to call the family and told her his status. RN A said the resident's wife said she would let his daughter know. RN A said she waited for a half hour to 45 minutes and never heard back from the family. She said she was concerned about the resident's decline, so she called the resident's daughter, who told her to send the resident to the hospital. RN A said she never consulted with Resident #1's physician (or any physician) during that morning, until after she talked to the resident's daughter (which she had identified as 30 to 45 minutes after applying oxygen at approximately 10:00 a.m.) RN A said that she did believe the resident was in an emergency situation, and she would have called the physician if the DON had told her to. She said the DON never mentioned calling the physician at all. RN A said she acted according to directions from the DON because that was what she was supposed to do. RN A said that if the DON had not been there, she would have called the physician. RN A said she was not knowledgeable of any facility policies regarding notification to physicians for a change of condition of residents. Following the above interview, RN A agreed to an interview in which she would write her answers on a written statement. RN A documented in her statement that the first set of vital signs that were B/P ,[DATE], T 96.4, P 50, and O2 sat of 68% were taken at approximately 8:45 a.m. RN A documented, "I told (DON) previous vitals and explained resident's condition to her while in resident's room. (DON) visually observed resident and told me to see if he was a DNR." RN A documented in her statement, " I only contacted the Dr. when family verified they wanted resident sent to E.R. I did not contact him prior because, when I told DON I wanted to send him out she said call the family and make sure they want him to be sent out due to his DNR status." RN A documented that, " Prior to calling family, resident's vital signs were ,[DATE] (B/P), 76 (P), 32 (R), and 68% (O2 sat). She documented that she had a nurse's aide in with the resident for the next 30 to 45 minutes " keeping an eye on him." She documented, " I asked aid (sic) several times if resident vitals were worsening and also visually checked on resident myself. I did not record any other vital signs in nurse's notes after 10:00 vitals. " 13. During a second interview on [DATE] at 1:50 p.m., RN A maintained the information provided during the above interview. In addition, she said that in her assessment of the resident, she did not check his pupil response, did not listen to his lung sounds, and did not listen to his heart sounds. She said that his respirations were "heavy" and "around 30" when she assessed him, and they stayed about the same through the morning, but his blood pressure continued to decline. She said she did not know what assessment the DON did or if the DON assessed the resident. She said she and the DON placed the resident on oxygen of 2 liters per minute and never changed the oxygen setting. She said his skin color was "pinkish white" but not abnormal. When discussing whether any of the nurse aides reported any concerns to her that morning, she said, "Only that he wasn't eating but otherwise, no. He wasn't cold." She then said he was not cold or clammy and that is why she did not believe it was a blood sugar issue. RN A said she left a nurse's aide in the room to monitor the resident and had him hooked up to a machine to take the resident's vital signs, but does not know how often the machine was set to take them. RN A said she wrote down the initial vital signs and the vital signs when he went out only and the nurse aide wrote down other vital signs in between. She said the nurse aide was to report if the vital signs changed at all, because she had 49 other residents to tend to. RN A said that there was talk around the facility that a nurse aide reported mottling was observed on the resident, but she did not see any mottling to the resident's arms when they were out of the blanket and she did not look at his lower extremities. She said the nurse aides did clean the resident when he had a bowel movement. RN A said it was her understanding that facility policy was that she not take any action in a situation such as change of condition of a resident until an RN supervisor assessed the resident, and that she followed that policy and did not do anything wrong. She became tearful, stating, "Yes, I knew he was dying. We all knew he was dying." She said the nurse aides were patting his hand and telling him to "Go papa." RN A said she felt guilty about the incident, but repeated she did not do anything wrong because she did what she was instructed to do by the DON. 14. During an interview with the DON on [DATE] at 1:05 p.m., when discussing whether the she was present at the facility on [DATE], the day that Resident #1 died , she said, "I don't know, I would have to look at my schedule." She then said that she believed she remembered something about RN A asking her to look at Resident #1 for a change in condition. The DON said she went to the unit and assessed the resident and he was not in any acute distress but she did think he needed to be sent to the hospital. When discussing her assessment of the resident, the DON said she did not take any of Resident #1's vital signs and she did not remember RN A telling her about any of Resident #1's vital signs. The DON said she never knew Resident #1's oxygen saturation level was 68%. She said she did not think RN A ever told her what the resident's change of condition was, and she could not say that she asked RN A. She said, " I can't remember all these details." When discussing RN A's report that the DON had instructed her and assisted her to place oxygen on the resident due to an oxygen saturation of 68%, the DON said, "I don't remember doing that." When discussing how she concluded he needed to be sent to the hospital, the DON said, "He just didn't look right." When discussing what she meant by that statement, she said he looked more lethargic than other times she had seen him. When discussing whether it would have been appropriate to take the resident's vital signs as part of her assessment of the resident, the DON said, "Vital signs are part of assessment but I'm overriding my choice to do vital signs based on a visual assessment." The DON then said, "I don't know what to tell you, I don't remember what the assessment was." She then said that she shook him and called his name. She said his eyes were closed and he appeared to try to open them, but it was a minute response. When discussing whether the physician was consulted at any time during the morning of [DATE], the DON said she did not consult with a physician or tell RN A to consult with the physician. When discussing why she chose not to instruct RN A to call the physician, she said, "I didn't know anything that we could do to make him perk up." When discussing whether she asked RN A about the DNR status of the resident or considered his DNR status when making a decision whether or not to consult the physician, the DON said she did not remember asking RN A about the resident's DNR status and the resident ' s DNR status would not make a difference in the decision to call the physician. The DON said that she did tell RN A to ask the family if they wanted him to go to the emergency room because she thought she remembered something about the family not wanting him to go in the past. The DON said Resident #1 was a hospice patient. When discussing whether she contacted hospice if he was their patient, she said, "I don't know anything about that." The DON said she left the unit after her visual assessment of the resident and did not remember what she was doing the rest of the morning. She could not verify that she documented anything with regard to this incident stating, "I thought I did, that's why I'm looking through these notes." (The DON nor facility ever provided any documentation by the DON for [DATE] and record review of Resident #1's medical record revealed no documentation was available in the medical record). 15. During a follow-up interview on [DATE] at 3:40 p.m., the DON said that Resident #1's change of condition on [DATE] was not an emergency. She said, "He probably could have just gone to the doctor's office." The DON said she could tell by looking at the resident that he was not in respiratory distress because his respirations were a little elevated and she did not hear any gurgling in his lungs. She said she did not use a stethoscope and just went by what she heard audibly. She described her total assessment of the resident as seeing the head of his bed elevated, saw that he had oxygen on, checked his responsiveness by shaking him, and watched his breathing. She said she decided he was not in respiratory distress even though his oxygen saturation was 78% because of the "clinical picture." She said his nail beds were not cyanotic. The DON later said that an oxygen saturation of 78% would warrant sending a resident to the hospital. When discussing why she did not just contact the physician and send Resident #1 to the hospital if she thought he needed to go, she said, "I don't know." 16. In her written statement dated [DATE], the DON wrote that RN A did not share any of Resident #1's vital signs with her, and she did not ask for the resident's vital signs. She wrote, "Assessment of visually reveals head of bed elevated O2 on per nasal cannula, color normal for resident, no audible gurgling or active respiratory distress noted, nail beds no cynosis (sic), aroused resident by shanking and calling name, he aroused by opening his eyes. Respirtory (sic) rate did not indicate respiratory distress along with other signs. visually looked at lower extremities for color changes, none noted. Did not detect this to be a 911 call. I did not take vital signs or O2 sat during assessment, as they were taken at an earlier time." 17. During an interview on [DATE] at 9:40 a.m., CNA (certified nurse's aide) A said that she was working on [DATE] on the A-wing where Resident #1 resided. She said that after breakfast that day, she assisted CNA B to put Resident #1 back to bed. She said that she was not sure what time it was, but breakfast was usually served around 7:00 a.m. and ended 8:30 a.m. to 9:00 a.m. CNA A said the nurse told them to put the resident to bed because he could not hold his head up. She said that when they put the resident to bed, he was limp "like a wet noodle." She said that he was not making any sounds or noises like he usually did. She said his legs felt cold. CNA A said that she and CNA B were concerned about Resident #1 because he looked like he might be dying. She said the resident's legs were mottling. She said she knew what mottling was because she had seen it before. CNA A said when she and CNA B expressed concern to RN A about the changes to the skin color of his legs, RN A said, "No, he's just dehydrated and we'll send him out and he'll be right back." CNA A said that CNA B protested to RN A's statement stating the resident looked bad. CNA A said she knew RN A went to the room and took his vital signs afterward. CNA A said she did not recall seeing the DON on the hall or in the resident's room, but she was not in the resident's room all morning. CNA A said that CNA B did sit in Resident #1's room and held his hand until the paramedics arrived. 18. During interviews on [DATE] at 2:35 p.m. and [DATE] at 10:40 a.m. (when CNA B wrote a statement in response to inquiries), CNA B said that she worked with Resident #1 on [DATE] and got him out of bed that morning at approximately 6:30 a.m. to 7:00 a.m. She said she took him and placed him in line for his medications first as was the usual schedule. She left him there and then returned a little while later to get him to take him to the dining room for breakfast. CNA B said when she took him to the dining room and was going to help him eat, she observed that he was not responding and she could not feed him. She described him as listless, slumped over in his chair, and " asleep. " She left him to finish the meal (finish serving other residents) and returned him to the unit only when breakfast was over and the aides were returning everyone to the unit. CNA B said that RN A never came to the assisted dining room that morning. She said between 8:30 a.m. and 9:00 a.m. she put Resident #1 back in his bed and he was moaning as if in pain. She said she had to change him at that time because he had a soft stool. She said it was very unusual as it was like syrup and had a peculiar smell unlike regular stool. She said the stool kept flowing from the resident each time they cleaned him and turned him, more stool would come out. She said the resident ' s skin on his face had a " silky " appearance and " he was just laying there. " She said his eyes were "fixated." She said she then reported Resident #1's condition to RN A, including that he had very loose uncontrollable bowel movements, and the nurse said she would check him. After telling the nurse about him, CNA B said she went to work doing routine tasks and attending to other residents, but because she was so concerned about Resident #1, she went back to his room every chance she got, to check on him. She said when she checked on him, she would find that he had more loose stool, and estimated that she was in his room and changed his brief with stool evident each time, approximately five to six times after putting him to bed. During that time she again talked to RN A about her concern that there was something wrong with Resident #1. CNA B said the first time she saw RN A in the resident ' s room was at 10:40 a.m. She said she remembered the time because she was thinking about how much time she had left before she had to start getting people up for lunch and looked at her watch. CNA B said RN A took his vital signs and was going to leave the room, when CNA B told RN A to look at the resident ' s legs because they were mottled up to mid-thigh. CNA B said RN A looked at his legs and told CNA B that it was probably just dehydration. RN A reportedly left the room and returned a few minutes later to tell her she had called EMS. CNA B said she remained in the room with Resident #1 from 10:40 a.m. until the EMS arrived to take the resident to the hospital. She said that during that time she was just praying for the resident, patting his hand, and telling him that she loved him and it was going to be okay. CNA B said she never saw the DON on the unit or in the resident ' s room that morning. CNA B said she did not recall seeing oxygen on the resident. She said she had leaned closely to his face that morning to talk to him in his ear, and she did not recall seeing any tubing, an oxygen tank, or an oxygen concentrator. CNA B said she had been a caregiver for approximately [AGE] years and had experience sitting with hospice patients. She said that the signs that she saw on the resident made her believe that the resident was dying, and RN A did not have any sense of urgency about the resident ' s condition. 19. A hospital record of death for Resident #1, dated [DATE] documented Resident #1 died at the hospital and the cause of death was [MEDICAL CONDITION]. 20. An EMS (emergency medical services) transfer of care record dated [DATE] documented that EMS was en-route to the facility at 10:56 a.m. and arrived at 10:59 a.m. The responder documented that Resident #1's pupils were constricted, skin was cool to touch, and he had labored respirations. The resident's blood pressure was ,[DATE], heart rate was 112, and respirations were 36. 21. During an interview on [DATE] at 9:30 a.m., the EMS responder said that when he arrived in Resident #1's room on [DATE], it was obvious that Resident #1 was in respiratory distress. He said the resident was receiving O2 at 3 liters per minute by nasal cannula. He said the resident 's blood pressure was ,[DATE] and his respirations were 36. He said the resident was gasping for air and using his accessory muscles to try to breathe. The EMS responder said that a nurse who was in the resident's room told the responders that Resident #1 had been having a decreased level of consciousness and low blood pressure "for the last couple of days." 22. Nurse's notes for [DATE] and [DATE] revealed no evidence that Resident #1 had been in any distress, had abnormal vital signs, or decreased level of consciousness in the preceding days to [DATE] as reported to EMS by RN A. 23. A report signed by the hospital triage nurse with triage time of 11:20 a.m. documented Resident #1's vital signs were T 96.2, P 92, R 44 and labored (Triage nurse RN C manually corrected report that originally said unlabored), B/P ,[DATE]; and O2 99% on 100% oxygen non rebreather mask (Triage nurse RN C manually corrected report that originally documented 99% on Room Air). 24. A hospital physician's report dated [DATE] with examination time of 11:21 a.m. documented that Resident #1 was cyanotic, mottled, unresponsive, and agonal respiration was noted. The physician documented his impression was, "[MEDICAL CONDITION] (abnormally low blood pressure), Hypoxemia (inadequate oxygen in the blood), terminal state." 25. During an interview on [DATE] at 4:20 p.m., Resident #1's physician said, " Nobody called me" when discussing Resident #1's change of condition and death on [DATE]. The physician said he did not hear from the facility until yesterday ([DATE]) when someone from the facility called him to tell him that the facility was being investigated by the State. He said they also told him that they did not contact him about the resident on [DATE] because the resident had a signed DNR and they were going to check with the family before sending the resident to the hospital. Resident #'s physician said the facility also told him yesterday that Resident #1 ' s family did not want aggressive treatment. When discussing the resident ' s status as documented by RN A on [DATE], he said he should have been contacted. He said that he would have requested the nurse give him the resident's blood sugar reading, blood pressure, skin turgor, and heart rate. He said, "With those vitals (documented on [DATE] by RN A), the resident would have been sent to the ER. " Resident #1 ' s physician said that Resident #1 had been sent to the hospital/ER on several occasions for "near death" episodes. He said that he had "perked up " and been sent back to the facility. Resident #1's physician said that if the resident ' s family did not specifically request that Resident #1 not be sent to the hospital, he did not know why the facility delayed. 26. During an interview on [DATE] at 11:36 a.m., the facility's Medical Director looked at the nurse's note of [DATE] for Resident #1 and said, "The documentation was so bad, it's hard to defend." He said he had spoken to the facility and they had asked him to review it.

Based on interview and record review, the facility failed to notify the physician with significant changes in condition (critical blood sugar values) for 2 of 9 residents reviewed for diabetes (Resident #2 and Resident #10) as evidenced by: 1) failure to ensure Licensed Vocational Nurse (LVN) A notified the physician, the in-house Registered Nurse (RN) or called 911 emergency medical service (EMS) when Resident #2 was symptomatic of [DIAGNOSES REDACTED] and her blood sugar level was at a critically low value (less than 30) on [DATE]. The first glucometer reading LVN A received of Resident #2's blood sugar registered LO on the meter (too low for a reading). Resident #2 died during the emergency where her blood glucose was at critical low values. 2) failure to ensure licensed nurses (including LVN A, LVN G, LVN D and RN F) followed facility's physician notification protocol and Resident #10's care plan to notify the physician when his blood sugar was less that 70 mg/dL or greater than 400 mg/dL. Resident #10 was an unstable diabetic with frequent fluctuations, often in critically high and low ranges. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical condition/crises for Residents #2 and #10. Resident #2 died approximately 70 minutes after the nurse first assessed that her blood sugar was critically low. On [DATE] at 4:20 p.m. an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure to notify physicians regarding residents' changes in condition, such as blood sugar that is outside of the parameters identified by physicians could affect the 39 residents the facility identified who received fingerstick blood sugar checks. These failures could result in diabetic complications and/or death. The findings included: RESIDENT #2 1. a) The record of admission revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was an [AGE] year old female. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __(A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other resident's of his he wants like every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___ (A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." f) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." g) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said, "they are supposed to call me with critical reading; they have my cell phone. I changed from a pager to a cell phone for this reason. I will reinforce this with them. I want direct contact. If they don't reach me the first time they need to call right back. I am busy but if I see the second call then I know they really need me and I always call right back. Most of the time staff are good at calling me about any blood sugar problems; I wasn't aware they didn't always though. I have a protocol for my patients; it's anything less than 70 or greater than 400 they are to call me." The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low saying, "she can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." h) The monthly physician orders [REDACTED]." i) Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60 mg. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 30 times the blood sugar was greater than 300 mg (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there were only four documented times the physician was actually spoken to by telephone. j) Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60 mg. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 15 times the blood sugar was greater than 300 mg (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. Resident #10 2. a) An admission record dated [DATE] documented Resident #10 was an [AGE] year-old male admitted to the facility on [DATE]. Physician's reports and assessments on [DATE] and [DATE] documented that Resident #10 had [DIAGNOSES REDACTED]. b) A care plan initiated on [DATE] and continued with revision only to insulin dosages on [DATE] included the following: Problem #6: "Potential for complications related to diabetes mellitus. Goal: Will have blood glucose levels ranging within ,[DATE] and absence of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] over the next 90 days." c) Resident #10's care plan for diabetes documented 13 interventions that included the following interventions: Approach: 1) Provide diet as ordered: LCS 2) Monitor for signs of [MEDICAL CONDITION] (increased thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting; hypothermia; [MEDICAL CONDITION]; stupor, muscle weakness. 3) Monitor for signs of [DIAGNOSES REDACTED] (blood glucose <60mg/dl), sweating, cold, clammy skin, numbness of fingers/ toes/ mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination). 4) Monitor/record/report blood glucose per MD order: CBG Q before meals. Notify MD of CBG>400 of <70. d) Monthly medication administration records from [DATE] through [DATE] documented that a CBG be done every AC and the physician should be notified if Resident #10's blood sugar was lower than 70 or higher than 400. e) physician's orders [REDACTED].[REDACTED] f) A physician's telephone order dated [DATE] documented an order to fax CBGs to the physician every three days. g) Nurse's notes and interviews revealed the following: [DATE]: 0535: LVN D documented a reading of "Hi" on the glucometer. She reported to the resident's physician who told her to go ahead with regularly scheduled insulin with no other orders. The resident was alert and responsive. No other assessment of the resident's physical condition was documented. 0800: This was LVN D's first note following the 0535 entry. She documented that the CBG continued to read "Hi." She documented Resident #10 refused breakfast and said he did not feel well. At 0800, LVN D did not document any physical assessment of Resident #10 and did not notify the physician that Resident #10's blood sugar continued to register as "Hi" on the glucometer. The next note regarding Resident #10's condition was not documented until two hours and fifty five minutes later. Physician's telephone orders did not include any telephone orders from the physician dated [DATE]. During an interview on [DATE] at 11:15 a.m., LVN D said that Resident #10 had to be watched closely because of his fluctuating blood sugar. She said, "We never know with him." She said a CBG reading of "Hi" meant the blood sugar was more than 500 and a reading of "Lo" meant the blood sugar was less than 20. She said it had never really been clear to her what the parameters were for notifying the physician, but she was told to notify the physician if the blood sugar was under 50 or over 400. She said it was just clarified this week (following initiation of this investigation) that the parameters were less than 70 or more than 400 to notify the physician. When discussing [DATE] when she documented a "Hi" CBG at 8:00 a.m., but no notification to the physician, LVN D said it was time for her to go home that day as her shift had already ended and that is why she did not call the physician. She said she just told the oncoming shift nurse and left. [DATE]: 12:30 p.m.: LVN E documented that Resident #10 was unresponsive to verbal commands. CBG read "Lo" on two readings. On-call physician ordered [MEDICATION NAME] 1mg. IM x1. LVN E did not document any other assessment of Resident #10's physical condition. 1415 (2:15 p.m.) This was the next entry by LVN E following the above entry regarding the "Lo" CBG reading. LVN E documented, "No complaints of any distress or discomfort." LVN E did not document any other assessment of Resident #10's physical condition and did not document a re-check of the CBG in the progress note. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Lo" readings at 12:30 p.m. (It was noted in a note [DATE] when the resident's blood sugar was 37, the physician ordered a re-check in 15 minutes and to be called if the blood sugar was still below 70). During an interview on [DATE] at 2:00 p.m., LVN E said that he was not sure what the "Lo" reading on the CBG meant (regarding the "Lo" reading on [DATE]). He said "Hi" meant over 500 and "Lo" was very low. He said that he did not re-check Resident #10's blood sugar after administering the [MEDICATION NAME] injection until an hour later when it was time for the routine blood sugar check. LVN E said he should have monitored it every 15 minutes. [DATE]: 1300: RN F documented Resident #10 was slumped in his wheelchair and was not talking with staff. CBG was 31. She gave four cups of juice and Dr. Pepper, two packages of graham crackers and took his vital signs. A re-check of the CBG at 1330 (1:30 p.m.) was 128. RN F did not notify the physician that the CBG was 31 and did not receive any orders to treat with orange juice, Dr. Pepper and graham crackers. LVN A documented she notified the physician of the hypoglycemic episode by sending him the information by fax machine at 1940 (7:40 p.m.) on [DATE], almost seven hours after the hypglycemic episode. During an interview on [DATE] at 9:50 a.m., RN F said she did not call the physician regarding Resident #10's blood sugar of 31 on [DATE]. RN F said, "They told us not to bother Dr. ___ (A)." She said of Resident #10, "He does this pretty often" (referring to low blood sugar). She said, "He bottoms out alot." She said that the nurses only faxed the information to the physician and usually did not call unless their efforts to bring up the resident's blood sugar by giving him juice or snacks was not successful. RN F said that each unit has an RN manager but the RN managers were not held accountable to know what was going on in their units. [DATE]: CBG sheet at 1630 (4:30 p.m.) documented a blood sugar of 404. There was no interventions documented by the nurse. 2100 (9:00 p.m.) LVN C documented that Resident #10 reported his blood sugar was high. A CBG reading was "Hi". LVN C received new orders for a one time dose of two units of Humalog. There was no physical assessment documented regarding the resident. (There was no re-check of the resident's blood sugar documented in nurse's notes, on the CBG sheet, or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2330 (11:30 p.m.) LVN D documented another CBG reading of "Hi". The resident was complaining of thirst. She contacted the physician on call and received new orders for Humalog three units x1 dose and recheck CBG at 0030 (12:30 a.m.). The only assessment of Resident #10 was that the resident said he felt pretty good. 0035 (12:35 a.m.) LVN D documented the CBG continued to read "Hi". The physician gave order to recheck in one hour and obtain a UA the next day. 0135: LVN D documented the CBG continued to read "Hi." She received an order for [REDACTED]. 0500: Resident #10's CBG was 391. (LVN D did not document monitoring or assessment of Resident #10's physical condition from 9:00 p.m. to 5:00 a.m. while his blood sugar was at a level that only read "Hi" on the glucometer, other than documenting that the resident said he felt pretty good at 11:30 p.m.). During interview [DATE] at 11:15 a.m., when discussing that Resident #10's documented blood sugar was above parameters (404) on [DATE] at 1630 (4:30 p.m.) and there was no evidence of physician notification until a reading of "Hi" at 9:00 p.m. that night, LVN D (who was on duty [DATE]) said she did not really remember that night. She said she probably was not aware of the reading at 1630 that was entered by LVN A, stating, "It wouldn't be the first time I was not informed of what had occurred." [DATE] In a nurse's note dated [DATE] at 2240 (10:40 p.m.), LVN D documented, "Res noted having confused conversation. CBG 37 at this time. Skin w/d (warm/dry) to touch. Res given juice with 2 pks sugar, healthshake, et (and) bowl of soup. Consumed 100%. low CBG reported to Dr. ___, on call for Dr. __. Order received for HS CBG check. Will continue to monitor. The next note by LVN D on [DATE] was documented a half hour later, at 2310 (11:10 p.m.). She documented Resident #10's CBG was 78 at that time. During interview on [DATE] at 11:15 a.m., LVN D said she did not take the resident's vital signs when his blood sugar registered 37 because the CNA had taken the resident's vital signs earlier at shift change (10:00 p.m.). She then said that the vital signs she documented later that shift (2:10 a.m.) were also the same vital signs that were taken at shift change, and acknowledged she never took the resident's vital signs after his blood sugar registered 37. She was unable to explain why she did not document the presence or absence of other physical symptoms that can be associated with [DIAGNOSES REDACTED]. h) CBG Sheet for [DATE] documented: [DATE] at 1630: ",[DATE]". There was no entry in nurse's notes to document that the physician was notified of a blood sugar of 42. [DATE] at 1630: CBG was 420. [DATE] at 1630: CBG was 412. [DATE] at 11:30 a.m. CBG was 478. At 1630 CBG was 476. (Later it registered "Hi" at 2:25 a.m.). There was no documentation that the physician was called to report these lab values that were less than 70 and greater than 400. Unknown persons documented that CBGs were faxed to the physician on [DATE], 14, 21, 28, and 31st (per the physician's orders [REDACTED]. i) CBG Sheet for February 2012 documented: [DATE]: CBG of 424. There was no documentation that the physician was called to report the CBG that was greater than 400. An unknown person documented a fax was sent to the physician on [DATE]. j) CBG Sheet for [DATE] documented: [DATE] at 1630: CBG 404. There was no documentation that the physician was notified of a blood sugar over 400. As noted above, later on [DATE] the physician had to be called for a blood sugar that read "Hi". [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 450 An unknown person documented faxes were sent to the physician on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE], but no evidence the physician was contacted with these CBGs that were out of the parameters identified on the medication administration record. There was no acknowledgement from the physician that he was aware of the information sent him. k) Medication Administration Records for [DATE] documented the following: [DATE] at 1:30 p.m.: 498 [DATE] at 6:30: 418 [DATE] at 6:30: 425 [DATE] at 6:30: 449-- Physician notification was documented. l) During an interview on [DATE] at 10:15 a.m., LVN G said he was training another LVN on [DATE] and the other LVN entered the blood sugar of 425. He said the physician was not notified because he did not know the other LVN had obtained a blood sugar of 425. He said the physician should have been called. m) During an interview on [DATE] at 3:00 p.m., LVN C said she would call the physician if the resident's blood sugar was 400 but she did not routinely document anything because, "He always says just to monitor and hydrate." She said she knew it should be documented and that any assessment of the resident's physical condition should also be documented. n) During an interview on [DATE] at 9:15 a.m., Resident #10's physician said that Resident #10 was a "strange case" and his blood sugar went very low, sometimes very unpredictably. He said that he told staff to call his cell phone, day or night, when Resident #10's blood sugar is outside of the parameters of 70 and 400. He said he did not even want them calling an on-call physician who was not familiar with this resident. o) During an interview on [DATE], the DON said she did not know why the nurses were not always keeping the physician informed of blood sugars that were out of parameters. She said she was not aware the nurses had ever been told not to call the doctor in those situations. She said, "That's just basic nursing." 3. The facility protocol on physician notification dated [DATE] documented, in part, "The purpose of this protocol is to clarify the decision of when to call the doctor." Under the column, Events, for Lab Reports, "notify immediately: panic or critical lab values, as soon as received. Glucose <60 milligrams (mg) in a diabetic, <50 mg in a non-diabetic, >300 mg in anyone." Also documented on the protocol, "Use of nursing judgement and observation (for which an order is never required) is encouraged. A nurse should call if, in his/ her judgement an intervention needs to be made by the physician immediately. 4. RN Supervisors on each unit provided a list of residents who received finger stick blood sugar checks. There were 39 residents listed. 5. On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #2 and #10. 6. The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -Medical records print diabetic physician orders [REDACTED]. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 7. Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Reviews of the 24-hour report and reviews of Resident #10 following corrective actions, confirming that the facility followed their corrective action plan to notify the physician when Resident #10's blood sugar was outside the parameters determined by the physician. 8. During a conference on [DATE] at 4:00 p.m., the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of [DATE] when the action plan was fully implemented.

Based on interview and record review the facility failed to ensure that LVN A provided services that met professional standards of quality for one 1 of 9 residents reviewed for diabetes (Resident #2) as evidenced by not notifying/consulting the physician or a supervising RN for medical advice and/or not calling [DATE] when the resident had a hypoglycemic crisis (critical low value of blood sugar) on [DATE]. This failure resulted in Resident #2 not receiving emergency medical treatment for [REDACTED]. This resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of Isolated and Severity of Actual Harm that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. The failure to follow professional standards of practice during a diabetic medical emergency could affect the 39 residents identified as receiving blood sugar monitoring and could result in diabetic complications or death. The findings include: 1) The Texas Administrative Code, Title 22, Examining Boards, Part 11, Texas Board of Nursing, Chapter 217, Licensure, Peer Assistance and Practice, Rule ? 217.11 Standards of Nursing Practice reflected: 1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; ... (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status.... ...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices... ...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care... 2) Review of Texas Administrative Code Title 22, Part 11, Chapter 217, Rule 217.12 entitled Unprofessional Conduct dated [DATE] revealed unprofessional conduct was behaviors which included: Unsafe practice- Actions or conduct which included but was not limited to: Carelessly failing to perform nursing in conformity with the standards of minimum acceptable level of nursing practice as set out in Rule 217.11. 3. a) Review of the record of admission revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __ (A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other resident's of his he wants like every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___(A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." f) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." g) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said the nurses were supposed to call him with critical blood sugar readings. He said that the nurses had his cell phone number and he was not aware they were not always contacting him. He said he had given the facility his protocol for his patients which was to contact him for any blood sugar less than 70 or greater than 400. The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low. He said, "She can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." h) Physician orders [REDACTED]." i) Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 30 times the blood sugar was greater than 300 (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. j) Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 15 times the blood sugar was greater than 300 (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. 3) RN Supervisors on each unit provided a list of residents who received finger stick blood sugar checks. There were 39 residents listed. 4) On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #2 and #10. 5) The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -Medical records print diabetic physician orders [REDACTED]. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 6) Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Reviews of the 24-hour report and reviews of Resident #10 following corrective actions, confirming that the facility followed their corrective action plan to notify the physician when Resident #10's blood sugar was outside the parameters determined by the physician. 7) During a conference on [DATE] at 4:00 p.m. the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of [DATE] when the action plan was fully implemented. The facility had not yet monitored the effectiveness of the action plan.

Based on interview and record review, the facility failed promptly notify the physician of lab results for 2 of 11 (Residents #2 and #10) reviewed for laboratory services as evidenced by: 1) failure to follow their own protocol to notify the physician directly (speak to the physician) for any/ all lab results (blood sugar) outside the parameters of <60 milligrams (mg) or >350 mg. Resident #2 died on [DATE] while experiencing panic values of low blood sugar. Resident #2 was admitted to the facility with orders for a capillary blood glucose (CBG) to be performed before each meal and to fax the results daily to the physician; and 2) failure to follow Resident #10's physician's protocol and care plan to notify the physician directly (speak to the physician) for all lab results (blood sugar results) outside the parameters of less than 70 mg. or greater than 400 mg. Resident #10's physician was not notified of a "Hi" reading (greater than 500) on [DATE], a blood sugar of 31 on [DATE], and multiple blood sugar results over 400 during January, February, March and [DATE]. The failure to promptly notify the physician of panic level blood sugar for Resident #2 resulted in the resident not receiving the medical attention she needed. Resident #2 died approximately 70 minutes after LVN A obtained the critical (Lo) blood sugar reading. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "harm that was not immediate jeopardy" because the facility was monitoring the implementation of the plan of removal. Failure to notify the physician promptly of lab results could result in any of the facility's 150 residents not receiving the medical care needed to treat their condition. This includes the 39 residents in the facility identified as receiving blood sugar monitoring. The findings include: 1. a) Review of the admission face sheet revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) Physician orders [REDACTED]." d) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "Called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __ (A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." e) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "Called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." f) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other resident's of his he wants like every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___ (A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." g) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) she should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." h) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said, "they are suppose to call me with critical reading; they have my cell phone. I changed from a pager to a cell phone for this reason. I will reinforce this with them. I want direct contact. If they don't reach me the first time they need to call right back. I am busy but if I see the second call then I know they really need me and I always call right back. Most of the time staff are good at calling me about any blood sugar problems; I wasn't aware they didn't always though. I have a protocol for my patients; it's anything less than 70 or greater than 400 they are to call me." The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low saying, "she can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." i) Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60 mg. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 30 times the blood sugar was greater than 300 mg (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. j) Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60 mg. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 15 times the blood sugar was greater than 300 mg (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. 2) Resident #10 a) An admission record dated [DATE] documented Resident #10 was an [AGE] year-old male admitted to the facility on [DATE]. Physician's reports and assessments on [DATE] and [DATE] documented that Resident #10 had [DIAGNOSES REDACTED]. b) A care plan initiated on [DATE] and continued with revision only to insulin dosages on [DATE] included the following: Problem #6: "Potential for complications related to diabetes mellitus. Goal: Will have blood glucose levels ranging within ,[DATE] and absence of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] over the next 90 days." Resident #10's care plan for diabetes documented 13 interventions that included the following interventions: Approach: 1) Provide diet as ordered: LCS 2) Monitor for signs of [MEDICAL CONDITION] (increased thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting; hypothermia; [MEDICAL CONDITION]; stupor, muscle weakness. 3) Monitor for signs of [DIAGNOSES REDACTED] (blood glucose <60mg/dl), sweating, cold, clammy skin, numbness of fingers/ toes/ mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination). 4) Monitor/record/report blood glucose per MD order: CBG Q before meals. Notify MD of CBG>400 or <70. c) Monthly medication administration records from [DATE] through [DATE] documented that a CBG be done every AC and the physician should be notified if Resident #10's blood sugar was lower than 70 or higher than 400. d) physician's orders [REDACTED].[REDACTED] e) A physician's telephone order dated [DATE] documented an order to fax CBGs to the physician every three days. f) Nurse's notes and interviews revealed the following: [DATE]: 0535: LVN D documented a reading of "Hi" on the glucometer. She reported to the resident's physician who told her to go ahead with regularly scheduled insulin with no other orders. The resident was alert and responsive. No other assessment of the resident's physical condition was documented. 0800: This was LVN D's first note following the 0535 entry. She documented that the CBG continued to read "Hi." She documented Resident #10 refused breakfast and said he did not feel well. At 0800, LVN D did not document any physical assessment of Resident #10 and did not notify the physician that Resident #10's blood sugar continued to register as "Hi" on the glucometer. The next note regarding Resident #10's condition was not documented until two hours and fifty five minutes later. Physician's telephone orders did not include any telephone orders from the physician dated [DATE]. During an interview on [DATE] at 11:15 a.m., LVN D said that Resident #10 had to be watched closely because of his fluctuating blood sugar. She said, "We never know with him." She said a CBG reading of "Hi" meant the blood sugar was more than 500 and a reading of "Lo" meant the blood sugar was less than 20. She said it had never really been clear to her what the parameters were for notifying the physician, but she was told to notify the physician if the blood sugar was under 50 or over 400. She said it was just clarified this week (following initiation of this investigation) that the parameters were less than 70 or more than 400 to notify the physician. When discussing [DATE] when she documented a "Hi" CBG at 8:00 a.m., but no notification to the physician, LVN D said it was time for her to go home that day as her shift had already ended and that is why she did not call the physician. She said she just told the oncoming shift nurse and left. [DATE]: 1300: RN F documented Resident #10 was slumped in his wheelchair and was not talking with staff. CBG was 31. She gave four cups of juice and Dr. Pepper, two packages of graham crackers and took his vital signs. A re-check of the CBG at 1330 (1:30 p.m.) was 128. RN F did not notify the physician that the CBG was 31 and did not receive any orders to treat with orange juice, Dr. Pepper and graham crackers. LVN A documented she notified the physician of the hypoglycemic episode by sending him the information by fax machine at 1940 (7:40 p.m.) on [DATE], almost seven hours after the hypglycemic episode. During an interview on [DATE] at 9:50 a.m., RN F said she did not call the physician regarding Resident #10's blood sugar of 31 on [DATE]. RN F said, "They told us not to bother Dr. ___." She said of Resident #10, "He does this pretty often" (referring to low blood sugar). She said, "He bottoms out alot." She said that the nurses only faxed the information to the physician and usually did not call unless their efforts to bring up the resident's blood sugar by giving him juice or snacks was not successful. g) CBG Sheet for [DATE] documented: [DATE] at 1630: ",[DATE]". There was no entry in nurse's notes to document that the physician was notified of a blood sugar of 42. [DATE] at 1630: CBG was 420. [DATE] at 1630: CBG was 412. [DATE] at 11:30 a.m. CBG was 478. At 1630 CBG was 476. (Later it registered "Hi" at 2:25 a.m.). There was no documentation that the physician was called to report these lab values that were less than 70 and greater than 400. Unknown persons documented that CBGs were faxed to the physician on [DATE], 14, 21, 28, and 31st (per the physician's orders [REDACTED]. h) CBG Sheet for February 2012 documented: [DATE]: CBG of 424. There was no documentation that the physician was called to report the CBG that was greater than 400. An unknown person documented a fax was sent to the physician on [DATE]. i) CBG Sheet for [DATE] documented: [DATE] at 1630: CBG 404. There was no documentation that the physician was notified of a blood sugar over 400. (See review of nurse's note below). [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 450 Unidentified persons documented faxes were sent to the physician on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE], but no evidence the physician was contacted with these CBGs that were out of the parameters identified on the medication administration record. There was no acknowledgement from the physician that he was aware of the information sent him. j) Nurse's notes for [DATE] revealed Resident #10 was found to have blood sugar that read "Hi" on the glucometer beginning at 9:00 p.m. The physician was notified and had to provide three separate orders for insulin through the night (9:00 p.m., 11:30 p.m., and 1:35 a.m.) to get Resident #10's blood sugar to come down. The resident's blood sugar finally registered below 400 at 5:00 a.m. k) During interview on [DATE] at 11:15 a.m., when discussing that Resident #10's documented blood sugar was above parameters (404) on [DATE] at 1630 (4:30 p.m.) and there was no evidence of physician notification until a reading of "Hi" at 9:00 p.m. that night, LVN D (who was on duty [DATE]) said she probably was not aware of the reading at 1630 that was entered by LVN A, stating, "It wouldn't be the first time I was not informed of what had occurred." l) Medication Administration Records for [DATE] documented the following: [DATE] at 1:30 p.m.: 498 [DATE] at 6:30: 418 [DATE] at 6:30: 425 [DATE] at 6:30: 449-- (Physician notification was documented) m) During an interview on [DATE] at 10:15 a.m., LVN G said he was training another LVN on [DATE] and the other LVN entered the blood sugar of 425. He said the physician was not notified because he did not know the other LVN had obtained a blood sugar of 425. He said the physician should have been called. n) During an interview on [DATE] at 3:00 p.m., LVN C said she would call the physician if the resident's blood sugar was 400 but she did not document anything because, "He always says just to monitor and hydrate." She said she knew it should be documented and that any assessment of the resident's physical condition should also be documented. o) During an interview on [DATE] at 9:15 a.m., Resident #10's physician said that Resident #10 was a "strange case" and his blood sugar went very low, sometimes for unexplainable reasons. He said that he told staff to call his cell phone, day or night, when Resident #10's blood sugar is outside of the parameters of 70 and 400. He said he did not even want them calling an on-call physician who was not familiar with this resident. p) During an interview on [DATE], the DON said she did not know why the nurses were not always keeping the physician informed of blood sugars that were out of parameters. She said she was not aware the nurses had ever been told not to call the doctor in those situations. She said, "That's just basic nursing." 3. Review of the facility protocol on physician notification dated [DATE] documented, in part, "The purpose of this protocol is to clarify the decision of when to call the doctor." Under the column, Events, for Lab Reports, "notify immediately: panic or critical lab values, as soon as received. Glucose <60 milligrams (mg) in a diabetic, <50 mg in a non-diabetic, >300 mg in anyone." Also documented on the protocol, "Use of nursing judgement and observation (for which an order is never required) is encouraged. A nurse should call if, in his/ her judgement an intervention needs to be made by the physician immediately. 4. RN Supervisors on each unit provided a list of residents who received finger stick blood sugar checks. There were 39 residents listed. 5. On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #2 and #10. 6. The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -Medical records print diabetic physician orders [REDACTED]. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 7. Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Reviews of the 24-hour report and reviews of Resident #10 following corrective actions, confirming that the facility followed their corrective action plan to notify the physician when Resident #10's blood sugar was outside the parameters determined by the physician. 8. During a conference on [DATE] at 4:00 p.m., the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of [DATE] when the action plan was fully implemented.

Based on interview and record review, the facility failed to implement their policy and procedure to prohibit neglect by failing to consult with the residents' physicians for two of nine residents reviewed for diabetes (Residents #2 and 10) when there was a significant change in the resident's physical condition as evidenced by: 1 a) failure to coordinate care with the physician on [DATE], when Resident #2 had symptoms of severe [DIAGNOSES REDACTED] (sweating, clammy skin) and her blood sugar registered "Lo" on the glucometer. Nursing staff reported "Lo" meant the blood sugar was probably below 20. The physician was not notified of Resident #2's critical low blood sugar readings. b) failure to obtain emergency medical care for Resident #2 during the critical situation on [DATE]. Resident #2 died during the emergency. LVN A did not notify the supervising RN or the physician. LVN A also did not call 911. Resident #2 died approximately 70 minutes after the nurse first assessed that her blood sugar was critically low; c) failure to investigate the death of unusual circumstances of Resident #2 and report it to the State which resulted in LVN A continuing to work with residents after neglecting Resident #2 on [DATE]. 2) failure to assess, monitor, and coordinate care with the physician for Resident #10 during and following hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) episodes as prescribed in the resident's care plan. Resident #10's physician identified Resident #10 as high risk for medical crises related to his unstable diabetes. These failures resulted in Resident #2's physician not being notified of her medical crisis and medical treatment not prescribed as needed for the resident. Resident #2 was not sent to the hospital and she died on [DATE]. These failures also resulted in Resident #10 experiencing hypo/ hyperglycemic critical situations and his physican was not informed. On [DATE] at 4:20 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of Actual harm that was not immediate jeopardy and a scope of Pattern due to the facility still implementing the Plan of Removal. These failures could affect the 39 residents who received finger stick blood sugar checks from the facility by placing them at risk for not receiving critical care and services during a medical emergency, which could lead to further diabetic complications, and death. Findings included: 1. RESIDENT #2 a) Review of the record of admission revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was an [AGE] year old female. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __(A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other resident's of his he wants like every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___(A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." f) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." g) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said, "they are supposed to call me with critical reading; they have my cell phone. I changed from a pager to a cell phone for this reason. I will reinforce this with them. I want direct contact. If they don't reach me the first time they need to call right back. I am busy but if I see the second call then I know they really need me and I always call right back. Most of the time staff are good at calling me about any blood sugar problems; I wasn't aware they didn't always though. I have a protocol for my patients; it's anything less than 70 or greater than 400 they are to call me." The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low saying, "she can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." h) The monthly physician orders [REDACTED]." i) Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 30 times the blood sugar was greater than 300 (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. j) Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 15 times the blood sugar was greater than 300 (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. 2) Resident #10 a) An admission record dated [DATE] documented Resident #10 was an [AGE] year-old male admitted to the facility on [DATE]. Physician's reports and assessments on [DATE] and [DATE] documented that Resident #10 had [DIAGNOSES REDACTED]. b) A care plan initiated on [DATE] and continued with revision only to insulin dosages on [DATE] included the following: Problem #6: "Potential for complications related to diabetes mellitus. Goal: Will have blood glucose levels ranging within ,[DATE] and absence of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] over the next 90 days." c) Resident #10's care plan for diabetes documented 13 interventions that included the following interventions: Approach: 1) Provide diet as ordered: LCS 2) Monitor for signs of [MEDICAL CONDITION] (increased thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting; hypothermia; [MEDICAL CONDITION]; stupor, muscle weakness. 3) Monitor for signs of [DIAGNOSES REDACTED] (blood glucose <60mg/dl), sweating, cold, clammy skin, numbness of fingers/ toes/ mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination). Monitor/record/report blood glucose per MD order: CBG Q before meals. Notify MD of CBG>400 of <70. d) Monthly medication administration records from [DATE] through [DATE] documented that a CBG be done every AC and the physician should be notified if Resident #10's blood sugar was lower than 70 or higher than 400. e) physician's orders [REDACTED].[REDACTED] f) A physician's telephone order dated [DATE] documented an order to fax CBGs to the physician every three days. g) Nurse's notes and interviews revealed the following: [DATE]: 0535: LVN D documented a reading of "Hi" on the glucometer. She reported to the resident's physician who told her to go ahead with regularly scheduled insulin with no other orders. The resident was alert and responsive. No other assessment of the resident's physical condition was documented. 0800: This was LVN D's first note following the 0535 entry. She documented that the CBG continued to read "Hi." She documented Resident #10 refused breakfast and said he did not feel well. At 0800, LVN D did not document any physical assessment of Resident #10 and did not notify the physician that Resident #10's blood sugar continued to register as "Hi" on the glucometer. The next note regarding Resident #10's condition was not documented until two hours and fifty five minutes later. Physician's telephone orders did not include any telephone orders from the physician dated [DATE]. During an interview on [DATE] at 11:15 a.m., LVN D said that Resident #10 had to be watched closely because of his fluctuating blood sugar. She said, "We never know with him." She said a CBG reading of "Hi" meant the blood sugar was more than 500 and a reading of "Lo" meant the blood sugar was less than 20. She said it had never really been clear to her what the parameters were for notifying the physician, but she was told to notify the physician if the blood sugar was under 50 or over 400. She said it was just clarified this week (following initiation of this investigation) that the parameters were less than 70 or more than 400 to notify the physician. When discussing [DATE] when she documented a "Hi" CBG at 8:00 a.m., but no notification to the physician, LVN D said it was time for her to go home that day as her shift had already ended and that is why she did not call the physician. She said she just told the oncoming shift nurse and left. [DATE]: 12:30 p.m.: LVN E documented that Resident #10 was unresponsive to verbal commands. CBG read "Lo" on two readings. On-call physician ordered [MEDICATION NAME] 1mg. IM x1. LVN E did not document any other assessment of Resident #10's physical condition. 1415 (2:15 p.m.) This was the next entry by LVN E following the above entry regarding the "Lo" CBG reading. LVN E documented, "No complaints of any distress or discomfort." LVN E did not document any other assessment of Resident #10's physical condition and did not document a re-check of the CBG in the progress note. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Lo" readings at 12:30 p.m. (It was noted in a note [DATE] when the resident's blood sugar was 37, the physician ordered a re-check in 15 minutes and to be called if the blood sugar was still below 70). During an interview on [DATE] at 2:00 p.m., LVN E said that he was not sure what the "Lo" reading on the CBG meant (regarding the "Lo" reading on [DATE]). He said "Hi" meant over 500 and "Lo" was very low. He said that he did not re-check Resident #10's blood sugar after administering the [MEDICATION NAME] injection until an hour later when it was time for the routine blood sugar check. LVN E said he should have monitored it every 15 minutes. [DATE]: 1300: RN F documented Resident #10 was slumped in his wheelchair and was not talking with staff. CBG was 31. She gave four cups of juice and Dr. Pepper, two packages of graham crackers and took his vital signs. A re-check of the CBG at 1330 (1:30 p.m.) was 128. RN F did not notify the physician that the CBG was 31 and did not receive any orders to treat with orange juice, Dr. Pepper and graham crackers. LVN A documented she notified the physician of the hypoglycemic episode by sending him the information by fax machine at 1940 (7:40 p.m.) on [DATE], almost seven hours after the hypoglycemic episode. During an interview on [DATE] at 9:50 a.m., RN F said she did not call the physician regarding Resident #10's blood sugar of 31 on [DATE]. RN F said, "They told us not to bother Dr. ___ (A)." She said of Resident #10, "He does this pretty often" (referring to low blood sugar). She said, "He bottoms out alot." She said that the nurses only faxed the information to the physician and usually did not call unless their efforts to bring up the resident's blood sugar by giving him juice or snacks was not successful. RN F said that each unit has an RN manager but the RN managers were not held accountable to know what was going on in their units. [DATE]: CBG sheet at 1630 (4:30 p.m.) documented a blood sugar of 404. There was no interventions documented by the nurse. 2100 (9:00 p.m.) LVN C documented that Resident #10 reported his blood sugar was high. A CBG reading was "Hi". LVN C received new orders for a one time dose of two units of Humalog. There was no physical assessment documented regarding the resident. (There was no re-check of the resident's blood sugar documented in nurse's notes, on the CBG sheet, or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2330 (11:30 p.m.) LVN D documented another CBG reading of "Hi". The resident was complaining of thirst. She contacted the physician on call and received new orders for Humalog three units x1 dose and recheck CBG at 0030 (12:30 a.m.). The only assessment of Resident #10 was that the resident said he felt pretty good. 0035 (12:35 a.m.) LVN D documented the CBG continued to read "Hi". The physician gave an order including a recheck of the blood sugar in one hour. 0135: LVN D documented the CBG continued to read "Hi." She received an order for [REDACTED]. 0500: Resident #10's CBG was 391. (LVN D did not document monitoring or assessment of Resident #10's physical condition from 9:00 p.m. to 5:00 a.m. while his blood sugar was at a level that only read "Hi" on the glucometer, other than documenting that the resident said he felt pretty good at 11:30 p.m.). During interview [DATE] at 11:15 a.m., when discussing that Resident #10's documented blood sugar was above parameters (404) on [DATE] at 1630 (4:30 p.m.) and there was no evidence of physician notification until a reading of "Hi" at 9:00 p.m. that night, LVN D (who was on duty [DATE]) said she did not really remember that night. She said she probably was not aware of the reading at 1630 that was entered by LVN A, stating, "It wouldn't be the first time I was not informed of what had occurred." [DATE] In a nurse's note dated [DATE] at 2240 (10:40 p.m.), LVN D documented, "Res noted having confused conversation. CBG 37 at this time. Skin w/d (warm/dry) to touch. Res given juice with 2 pks sugar, healthshake, et (and) bowl of soup. Consumed 100%. low CBG reported to Dr. ___(B), on call for Dr. __(A). Order received for HS CBG check. Will continue to monitor. The next note by LVN D on [DATE] was documented a half hour later, at 2310 (11:10 p.m.). She documented Resident #10's CBG was 78 at that time. During interview on [DATE] at 11:15 a.m., LVN D said she did not take the resident's vital signs when his blood sugar registered 37 because the CNA had taken the resident's vital signs earlier at shift change (10:00 p.m.). She then said that the vital signs she documented later that shift (2:10 a.m.) were also the same vital signs that were taken at shift change, and acknowledged she never took the resident's vital signs after his blood sugar registered 37. She was unable to explain why she did not document the presence or absence of other physical symptoms that can be associated with [DIAGNOSES REDACTED]. h) CBG Sheet for [DATE] documented: [DATE] at 1630: ",[DATE]". There was no entry in nurse's notes to document that the physician was notified of a blood sugar of 42. [DATE] at 1630: CBG was 420. [DATE] at 1630: CBG was 412. [DATE] at 11:30 a.m. CBG was 478. At 1630 CBG was 476. (Later it registered "Hi" at 2:25 a.m.). There was no documentation that the physician was called to report these lab values that were less than 70 and greater than 400. Unknown persons documented that CBGs were faxed to the physician on [DATE], 14, 21, 28, and 31st (per the physician's orders [REDACTED]. i) CBG Sheet for February 2012 documented: [DATE]: CBG of 424. There was no documentation that the physician was called to report the CBG that was greater than 400. An unknown person documented a fax was sent to the physician on [DATE]. j) CBG Sheet for [DATE] documented: [DATE] at 1630: CBG 404. There was no documentation that the physician was notified of a blood sugar over 400. As noted above, later on [DATE] the physician had to be called for a blood sugar that read "Hi". [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 450 An unknown person documented faxes were sent to the physician on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE], but no evidence the physician was contacted with these CBGs that were out of the parameters identified on the medication administration record. There was no acknowledgement from the physician that he was aware of the information sent him. k) Medication Administration Records for [DATE] documented the following: [DATE] at 1:30 p.m.: 498 [DATE] at 6:30: 418 [DATE] at 6:30: 425 [DATE] at 6:30: 449-- Physician notification was documented l) During an interview on [DATE] at 10:15 a.m., LVN G said he was training another LVN on [DATE] and the other LVN entered the blood sugar of 425. He said the physician was not notified because he did not know the other LVN had obtained a blood sugar of 425. He said the physician should have been called. m) During an interview on [DATE] at 3:00 p.m., LVN C said she would call the physician if the resident's blood sugar was 400 but she did not document anything because, "He always says just to monitor and hydrate." She said she knew it should be documented and that any assessment of the resident's physical condition should also be documented. n) During an interview on [DATE] at 9:15 a.m., Resident #10's physician said that Resident #10 was a "strange case" and his blood sugar went very low, sometimes for unexplainable reasons. He said that he told staff to call his cell phone, day or night, when Resident #10's blood sugar is outside of the parameters of 70 and 400. He said he did not even want them calling an on-call physician who was not familiar with this resident. o) During an interview on [DATE], the DON said she did not know why the nurses were not always keeping the physician informed of blood sugars that were out of parameters. She said she was not aware the nurses had ever been told not to call the doctor in those situations. She said, "That's just basic nursing." 3) A facility policy titled, "Care, Management, and treatment of [REDACTED]. c) "Hypoglycemic reactions: This can be caused by too much insulin, too little food or excessive physical activity. Observe for complaints of headache, light-headedness, confusion, emotional changes, memory lapses, numbness of lips and tongue, slurred speech, incoordination, staggering gait, double vision, drowsiness, convulsions, and eventually coma. Do an accu-check if symptomatic and accu-check is less than 70. If resident is alert and able to swallow, give 4 oz. of juice with ,[DATE] packets of sugar. Continue to monitor and re-check within 15 minutes." Under "Precautions": "Report any excessive itching-may indicate an elevated blood sugar." (This policy did not address when to contact the physician or any other symptoms or interventions for high blood sugar). 4) Review of the facility protocol on physician notification dated [DATE] documented, in part, "The purpose of this protocol is to clarify the decision of when to call the doctor." Under the column, Events, for Lab Reports, "notify immediately: panic or critical lab values, as soon as received. Glucose <60 milligrams (mg) in a diabetic, <50 mg in a non-diabetic, >300 mg in anyone." Also documented on the protocol, "Use of nursing judgement and observation (for which an order is never required) is encouraged. A nurse should call if, in his/ her judgement an intervention needs to be made by the physician immediately. 5) According to the American Diabetes Association, "Standards of Medical Care in Diabetes-2012, at http://care.diabetesjournals.org/content/35/Supplement_1/S11.full, the following was included under, "K. [DIAGNOSES REDACTED]": "Recommendations. Glucose (,[DATE] g) is the preferred treatment for [REDACTED]. If SMBG (blood glucose) 15 min after treatment shows continued [DIAGNOSES REDACTED], the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of [DIAGNOSES REDACTED]."... ...A large cohort study suggested that among older adults with type 2 diabetes, a history of severe [DIAGNOSES REDACTED] was associated with greater risk of dementia."... ...treatment of [REDACTED].<70 mg/dL) requires ingestion of glucose or carbohydrate containing foods." 6. Review of facility abuse and neglect policy dated [DATE] documented, in part, "The resident has the right to be free of abuse, neglect, exploitation and misappropriation of resident property, corporal punishment and involuntary seclusion. All incidents including those of unknown origins will be thoroughly investigated. These include, but are not limited to, resident death under unusual circumstances. Results of the investigation will be reported immediately to the Administrator. A written report, if appropriate, will be sent to the Texas Department of Aging and Disability within 5 days following the verbal report." 7. RN Supervisors on each unit provided a list of residents who received finger stick blood sugar checks. There were 39 residents listed. 8. On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #2 and #10. 9. The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -Medical records print diabetic physician orders [REDACTED]. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 10. Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Reviews of the 24-hour report and reviews of Resident #10 following corrective actions, confirming that the facility followed their corrective action plan to notify the physician when Resident #10's blood sugar was outside the parameters determined by the physician. 11. During a conference on [DATE] at 4:00 p.m., the administrator was notified that the Immediate Jeopardy was lowered to actual harm at a pattern as of [DATE] when the facility fully implemented the corrective action. The facility had yet to monitor and evaluate the effectiveness of the corrective action plan.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being for two of nine residents reviewed for diabetes (Residents #2 and #10) as evidenced by: 1) failure to coordinate care with the physician or obtain emergency medical care when Resident #2 had symptoms of severe [DIAGNOSES REDACTED] (sweating, clammy skin) and her blood sugar registered "Lo" on the glucometer. Nursing staff reported "Lo" meant the blood sugar was probably below 20. Resident #2 died approximately 70 minutes after the nurse first assessed that her blood sugar was critically low; and 2) failure to assess, monitor, and coordinate care with the physician for Resident #10 during and following hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) episodes as prescribed in the resident's care plan. Resident #10's physician identified Resident #10 as at high risk for medical crises related to his unstable diabetes. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical conditions/crises for Residents #2 and #10. Resident #2 died . On [DATE] at 4:20 p.m., an Immediate Jeopardy was identified. On [DATE] the Immediate Jeopardy was lowered to actual harm at a pattern after the facility developed and implemented an action plan to remove the Immediate Jeopardy prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to manage a critical blood sugar for a diabetic could result in further complication or death. The failure to monitor residents during and following hyper/hypoglycemic episodes (or any significant change of condition) could result in a deterioration in their condition that is unknown to staff and not reported to a physician. These failures could affect the 39 residents the facility identified who received fingerstick blood sugar checks. Findings included: 1) RESIDENT #2 a) Review of the record of admission revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __ (A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other resident's of his he wants like every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___ (A)called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." f) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." g) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said, "They are suppose to call me with critical reading; they have my cell phone. I changed from a pager to a cell phone for this reason. I will reinforce this with them. I want direct contact. If they don't reach me the first time they need to call right back. I am busy but if I see the second call then I know they really need me and I always call right back. Most of the time staff are good at calling me about any blood sugar problems; I wasn't aware they didn't always though. I have a protocol for my patients; it's anything less than 70 or greater than 400 they are to call me." The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low saying, "She can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." h) Monthly physician orders [REDACTED]." i) Review of Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 30 times the blood sugar was greater than 300 (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. j) Review of Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 15 times the blood sugar was greater than 300 (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. 2) Resident #10 a) An admission record dated [DATE] documented Resident #10 was an [AGE] year-old male admitted to the facility on [DATE]. Physician's reports and assessments on [DATE] and [DATE] documented that Resident #10 had [DIAGNOSES REDACTED]. b) A care plan initiated on [DATE] and continued with revision only to insulin dosages on [DATE] included the following: Problem #6: "Potential for complications related to diabetes mellitus. Goal: Will have blood glucose levels ranging within ,[DATE] and absence of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] over the next 90 days." c) Resident #10's care plan for diabetes documented 13 interventions that included the following interventions: Approach: 1) Provide diet as ordered: LCS 2) Monitor for signs of [MEDICAL CONDITION] (increased thirst, increased urination, increased appetite followed by lack of appetite, nausea, vomiting; hypothermia; [MEDICAL CONDITION]; stupor, muscle weakness. 3) Monitor for signs of [DIAGNOSES REDACTED] (blood glucose <60mg/dl), sweating, cold, clammy skin, numbness of fingers/ toes/ mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness, headaches, light headedness, slurred speech, confusion, lack of coordination). 4) Monitor/record/report blood glucose per MD order: CBG Q before meals. Notify MD of CBG>400 of <70. d) Monthly medication administration records from [DATE] through [DATE] documented that a CBG be done every AC and the physician should be notified if Resident #10's blood sugar was lower than 70 or higher than 400. e) physician's orders [REDACTED].[REDACTED] f) A physician's telephone order dated [DATE] documented an order to fax CBGs to the physician every three days. g) Nurse's notes and interviews revealed the following: [DATE]: 0535: LVN D documented a reading of "Hi" on the glucometer. She reported to the resident's physician who told her to go ahead with regularly scheduled insulin with no other orders. The resident was alert and responsive. No other assessment of the resident's physical condition was documented. 0800: This was LVN D's first note following the 0535 entry. She documented that the CBG continued to read "Hi." She documented Resident #10 refused breakfast and said he did not feel well. At 0800, LVN D did not document any physical assessment of Resident #10 and did not notify the physician that Resident #10's blood sugar continued to register as "Hi" on the glucometer. The next note regarding Resident #10's condition was not documented until two hours and fifty five minutes later. Physician's telephone orders did not include any telephone orders from the physician dated [DATE]. During an interview on [DATE] at 11:15 a.m., LVN D said that Resident #10 had to be watched closely because of his fluctuating blood sugar. She said, "We never know with him." She said a CBG reading of "Hi" meant the blood sugar was more than 500 and a reading of "Lo" meant the blood sugar was less than 20. She said it had never really been clear to her what the parameters were for notifying the physician, but she was told to notify the physician if the blood sugar was under 50 or over 400. She said it was just clarified this week (following initiation of this investigation) that the parameters were less than 70 or more than 400 to notify the physician. When discussing [DATE] when she documented a "Hi" CBG at 8:00 a.m., but no notification to the physician, LVN D said it was time for her to go home that day as her shift had already ended and that is why she did not call the physician. She said she just told the oncoming shift nurse and left. [DATE]: 12:30 p.m.: LVN E documented that Resident #10 was unresponsive to verbal commands. CBG read "Lo" on two readings. On-call physician ordered [MEDICATION NAME] 1mg. IM x1. LVN E did not document any other assessment of Resident #10's physical condition. 1415 (2:15 p.m.) This was the next entry by LVN E following the above entry regarding the "Lo" CBG reading. LVN E documented, "No complaints of any distress or discomfort." LVN E did not document any other assessment of Resident #10's physical condition and did not document a re-check of the CBG in the progress note. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Lo" readings at 12:30 p.m. (It was noted in a note [DATE] when the resident's blood sugar was 37, the physician ordered a re-check in 15 minutes and to be called if the blood sugar was still below 70). During an interview on [DATE] at 2:00 p.m., LVN E said that he was not sure what the "Lo" reading on the CBG meant (regarding the "Lo" reading on [DATE]). He said "Hi" meant over 500 and "Lo" was very low. He said that he did not re-check Resident #10's blood sugar after administering the [MEDICATION NAME] injection until an hour later when it was time for the routine blood sugar check. LVN E said he should have monitored it every 15 minutes. [DATE]: 1300: RN F documented Resident #10 was slumped in his wheelchair and was not talking with staff. CBG was 31. She gave four cups of juice and Dr. Pepper, two packages of graham crackers and took his vital signs. A re-check of the CBG at 1330 (1:30 p.m.) was 128. RN F did not notify the physician that the CBG was 31 and did not receive any orders to treat with orange juice, Dr. Pepper and graham crackers. LVN A documented she notified the physician of the hypoglycemic episode by sending him the information by fax machine at 1940 (7:40 p.m.) on [DATE], almost seven hours after the hypglycemic episode. During an interview on [DATE] at 9:50 a.m., RN F said she did not call the physician regarding Resident #10's blood sugar of 31 on [DATE]. RN F said, "They told us not to bother Dr. ___(A)." She said of Resident #10, "He does this pretty often" (referring to low blood sugar). She said, "He bottoms out alot." She said that the nurses only faxed the information to the physician and usually did not call unless their efforts to bring up the resident's blood sugar by giving him juice or snacks was not successful. RN F said that each unit has an RN manager but the RN managers were not held accountable to know what was going on in their units. [DATE]: CBG sheet at 1630 (4:30 p.m.) documented a blood sugar of 404. There was no interventions documented by the nurse. 2100 (9:00 p.m.) LVN C documented that Resident #10 reported his blood sugar was high. A CBG reading was "Hi". LVN C received new orders for a one time dose of two units of Humalog. There was no physical assessment documented regarding the resident. (There was no re-check of the resident's blood sugar documented in nurse's notes, on the CBG sheet, or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2330 (11:30 p.m.) LVN D documented another CBG reading of "Hi". The resident was complaining of thirst. She contacted the physician on call and received new orders for Humalog three units x1 dose and recheck CBG at 0030 (12:30 a.m.). The only assessment of Resident #10 was that the resident said he felt pretty good. 0035 (12:35 a.m.) LVN D documented the CBG continued to read "Hi". The physician gave an order to recheck the blood sugar in one hour . 0135: LVN D documented the CBG continued to read "Hi." She received an order for [REDACTED]. 0500: Resident #10's CBG was 391. (LVN D did not document monitoring or assessment of Resident #10's physical condition from 9:00 p.m. to 5:00 a.m. while his blood sugar was at a level that only read "Hi" on the glucometer, other than documenting that the resident said he felt pretty good at 11:30 p.m.). During interview [DATE] at 11:15 a.m., when discussing that Resident #10's documented blood sugar was above parameters (404) on [DATE] at 1630 (4:30 p.m.) and there was no evidence of physician notification until a reading of "Hi" at 9:00 p.m. that night, LVN D (who was on duty [DATE]) said she did not really remember that night. She said she probably was not aware of the reading at 1630 that was entered by LVN A, stating, "It wouldn't be the first time I was not informed of what had occurred." [DATE] In a nurse's note dated [DATE] at 2240 (10:40 p.m.), LVN D documented, "Res noted having confused conversation. CBG 37 at this time. Skin w/d (warm/dry) to touch. Res given juice with 2 pks sugar, healthshake, et (and) bowl of soup. Consumed 100%. low CBG reported to Dr. ___(B), on call for Dr. __(A). Order received for HS CBG check. Will continue to monitor." The next note by LVN D on [DATE] was documented a half hour later, at 2310 (11:10 p.m.). She documented Resident #10's CBG was 78 at that time. During interview on [DATE] at 11:15 a.m., LVN D said she did not take the resident's vital signs when his blood sugar registered 37 because the CNA had taken the resident's vital signs earlier at shift change (10:00 p.m.). She then said that the vital signs she documented later that shift (2:10 a.m.) were also the same vital signs that were taken at shift change, and acknowledged she never took the resident's vital signs after his blood sugar registered 37. She was unable to explain why she did not document the presence or absence of other physical symptoms that can be associated with [DIAGNOSES REDACTED]. h) CBG Sheet for [DATE] documented: [DATE] at 1630: ",[DATE]". There was no entry in nurse's notes to document that the physician was notified of a blood sugar of 42. [DATE] at 1630: CBG was 420. [DATE] at 1630: CBG was 412. [DATE] at 11:30 a.m. CBG was 478. At 1630 CBG was 476. (Later it registered "Hi" at 2:25 a.m.). There was no documentation that the physician was called to report these lab values that were less than 70 and greater than 400. Unknown persons documented that CBGs were faxed to the physician on [DATE], 14, 21, 28, and 31st (per the physician's orders [REDACTED]. i) CBG Sheet for February 2012 documented: [DATE]: CBG of 424. There was no documentation that the physician was called to report the CBG that was greater than 400. An unknown person documented a fax was sent to the physician on [DATE]. j) CBG Sheet for [DATE] documented: [DATE] at 1630: CBG 404. There was no documentation that the physician was notified of a blood sugar over 400. As noted above, later on [DATE] the physician had to be called for a blood sugar that read "Hi". [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 451 [DATE] at 1630: CBG 450 Unidentified persons documented faxes were sent to the physician on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE], but no evidence the physician was contacted with these CBGs that were out of the parameters identified on the medication administration record. There was no acknowledgement from the physician that he was aware of the information sent him. k) Medication Administration Records for [DATE] documented the following: [DATE] at 1:30 p.m.: 498 [DATE] at 6:30: 418 [DATE] at 6:30: 425 [DATE] at 6:30: 449-- Physician notification was documented. l) During an interview on [DATE] at 10:15 a.m., LVN G said he was training another LVN on [DATE] and the other LVN entered the blood sugar of 425. He said the physician was not notified because he did not know the other LVN had obtained a blood sugar of 425. He said the physician should have been called. m) During an interview on [DATE] at 3:00 p.m., LVN C said she would call the physician if the resident's blood sugar was 400 but she did not document anything because, "He always says just to monitor and hydrate." She said she knew it should be documented and that any assessment of the resident's physical condition should also be documented. n) During an interview on [DATE] at 9:15 a.m., Resident #10's physician said that Resident #10 was a "strange case" and his blood sugar went very low, sometimes for unexplainable reasons. He said that he told staff to call his cell phone, day or night, when Resident #10's blood sugar is outside of the parameters of 70 and 400. He said he did not even want them calling an on-call physician who was not familiar with this resident. o) During an interview on [DATE], the DON said she did not know why the nurses were not always keeping the physician informed of blood sugars that were out of parameters. She said she was not aware the nurses had ever been told not to call the doctor in those situations. She said, "That's just basic nursing." 3) RN Supervisors on each unit provided a list of residents who received finger stick blood sugar checks. There were 39 residents listed. 4) A facility policy titled, "Care, Management, and treatment of [REDACTED]. "c) Hypoglycemic reactions: This can be caused by too much insulin, too little food or excessive physical activity. Observe for complaints of headache, light-headedness, confusion, emotional changes, memory lapses, numbness of lips and tongue, slurred speech, incoordination, staggering gait, double vision, drowsiness, convulsions, and eventually coma. Do an accu-check if symptomatic and accu-check is less than 70. If resident is alert and able to swallow, give 4 oz. of juice with ,[DATE] packets of sugar. Continue to monitor and re-check within 15 minutes." Under "Precautions": "Report any excessive itching-may indicate an elevated blood sugar." (This policy did not address when to contact the physician or any other symptoms or interventions for high blood sugar). 5) Review of the facility protocol on physician notification dated [DATE] documented, in part, "The purpose of this protocol is to clarify the decision of when to call the doctor." Under the column, Events, for Lab Reports, "notify immediately: panic or critical lab values, as soon as received. Glucose <60 milligrams (mg) in a diabetic, <50 mg in a non-diabetic, >300 mg in anyone." Also documented on the protocol, "Use of nursing judgement and observation (for which an order is never required) is encouraged. A nurse should call if, in his/ her judgement an intervention needs to be made by the physician immediately. 6) According to the American Diabetes Association, "Standards of Medical Care in Diabetes-2012, at http://care.diabetesjournals.org/content/35/Supplement_1/S11.full, the following was included under, "K. [DIAGNOSES REDACTED]": "Recommendations. Glucose (,[DATE] g) is the preferred treatment for [REDACTED]. If SMBG (blood glucose) 15 min after treatment shows continued [DIAGNOSES REDACTED], the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of [DIAGNOSES REDACTED]."... ...A large cohort study suggested that among older adults with type 2 diabetes, a history of severe [DIAGNOSES REDACTED] was associated with greater risk of dementia."... ...treatment of [REDACTED].<70 mg/dL) requires ingestion of glucose or carbohydrate containing foods." 7) On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #2 and #10. 8) The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -Medical records print diabetic physician orders [REDACTED]. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 9) Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Reviews of the 24-hour report and reviews of Resident #10 following corrective actions, confirming that the facility followed their corrective action plan to notify the physician when Resident #10's blood sugar was outside the parameters determined by the physician. 10) During a conference on [DATE] at 4:00 p.m., the administrator was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of [DATE] when the action plan was fully implemented. The facility had not yet evaluated the effectiveness of the plan. .

Based on interview and record review, the facility failed to thoroughly investigate and report to the State survey agency when 1 of 3 residents reviewed for death in the facility (Resident #2, who was a brittle diabetic) died as a result of neglect during a diabetic (hypoglycemic) medical emergency as evidenced by: 1) failure to investigate the circumstances that resulted in the death of Resident #2. LVN A failed to notify the physician, the in-house Registered Nurse (RN) or call 911 emergency medical service (EMS) and failed to follow the facility's physician notification protocol when Resident #2's blood sugar level was at critical low values (less than 30). Resident #2 died during the medical emergency; and 2) failure to report to the State the death of unusual occurrence of Resident #2. These failures resulted in a lack of investigation into the unusual death of Resident #2 and the alleged perpetrator (LVN A) remaining in the facility providing care to residents from [DATE] to [DATE]. The facility's failure to ensure unusual occurrences were thoroughly investigated, to rule out possible neglect and reported to officials in accordance with State law, resulted in an Immediate Jeapordy (IJ) on [DATE] at 4:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a level of harm the scope identified at isolated. The facility failure to investigate and report incidents of death of unusual circumstances could result in ongoing neglect in the facility. The findings were: a) The record of admission documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __(A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) Review of monthly physician orders [REDACTED]." f) Review of Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60 mg. and the physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 30 times the blood sugar was greater than 300 mg (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. g) Review of Resident #2's CBG flow sheet for [DATE] documented once the blood sugar was less than 60 mg. NOTE: there was no documentation on the flow sheet for [DATE] after the 6:00 a.m. reading. There were two times the resident's blood sugar was greater than 400 mg (the physician's protocol) and there were 15 times the blood sugar was greater than 300 mg (facility protocol). Of the 15 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only one documented time the physician was actually spoken to by telephone. h) Review of Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." i) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other residents of his he wants, like, every three days." LVN A acknowledged she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___ (A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." j) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said the nurses were supposed to call him with critical blood sugar readings and they had his cell phone number. He said he was not aware nurses were not always calling him when they should. He said his protocol for his patients was anything less than 70 or greater than 400 they were to call him. He said he was sure he had provided this protocol to the facility. The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low and stated, "She can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day..." k) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in "that situation, the first thing she would do was recheck the blood sugar immediately, then call 911 if I could not reach the doctor." She added, "any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." RN B acknowledged LVN A "should have called for help immediately so someone else could try to help ____(Resident #2)." l) During a second interview on [DATE] at 3:50 p.m., RN B said she did not ask any questions to find out why LVN A did not call an RN supervisor, the physician, or 911. She said she pronounced the resident, but did not ask any questions about circumstances leading to the resident's death after it happened. When discussing whether she discussed the resident's death with the Director of Nurses, RN B said that she only talked to the administrator. She said that when she talked to the administrator about the death, he did not ask her any questions regarding the circumstances of the death. m) During an interview on [DATE] at 3:00 p.m., LVN C said that she was the nurse that was coming on shift for the evening shift on [DATE]. She said she came in to work early that day, at 1:30 p.m. instead of 2:00 p.m., when her shift actually started. She said that when she arrived, a CNA approached her and told her that LVN A needed her in Resident #2's room. She said that LVN A told her that Resident #2's blood sugar had been 24, but she had gotten it up to "40-something." She said she asked LVN A if she had called the doctor and LVN A said she had not. LVN C said she ran to get her stethescope and page the RN to the room, but by the time she got back to the room, the resident had died . LVN C became tearful regarding the incident. LVN C said she would have gotten assistance from an RN supervisor or called 911. n) During an interview on [DATE] at 2:00 p.m., LVN E (also the facility risk manager) said that he remembered the death being brought up in the morning meeting with all managers. He said, "It wasn't presented as anything unusual, I can't remember what was said, just the passing was reported." o) During an interview on [DATE] at 9:50 a.m., RN F said she was not on duty when Resident #2 died . She said, "That made me so mad!" She said that when Resident #2 "bottomed out" it was very serious and the resident would get sweaty and unresponsive. She said that the nurses usually got an immediate order for [MEDICATION NAME] and re-checked the resident in 15 minutes. She said if the resident did not recover, 911 should have been called. p) During an interview on [DATE] at 10:05 a.m., the DON said she started as interim DON on [DATE] (the day after Resident #2 died ). When discussing why she (or her designee) did not review the death of this resident, she said, "I honestly cannot tell you that." q) During an interview on [DATE] at 4:15 p.m., the administrator said that he was not aware there was any unusual circumstances surrounding the death of Resident #2 until that date ([DATE]), and he had suspended LVN A and would conduct an investigation. He said he did not know there was a need to investigate until RN B spoke with him after her interviews with surveyors. The administrator confirmed that there had been no previous investigation or reporting of the incident. 2. Review of the facility protocol on physician notification dated [DATE] documented, in part, "The purpose of this protocol is to clarify the decision of when to call the doctor." Under the column, Events, for Lab Reports, "notify immediately: panic or critical lab values, as soon as received. Glucose <60 milligrams (mg) in a diabetic, <50 mg in a non-diabetic, >300 mg in anyone." Also documented on the protocol, "Use of nursing judgement and observation (for which an order is never required) is encouraged. A nurse should call if, in his/ her judgement an intervention needs to be made by the physician immediately. 3. On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy. 4. The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 5. Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Review of facility investigation report and confirmation of report to the state authority. 6. During a conference on [DATE] at 4:00 p.m., the Immediate Jeopardy was lowered to actual harm at a pattern as of [DATE] when the corrective action plan was fully implemented as the facility had yet to monitor the effectiveness of the corrective action plan.

Based on interview and record review, the facility failed to implement its written policies that prohibit mistreatment, neglect, and abuse of residents for 1 of 3 residents reviewed for death (Resident #2) as evidenced by: 1) failure of LVN C or RN B to report an allegation of neglect to the facility Administrator. LVN C and RN B were present on [DATE] and had information regarding neglect of Resident #2 by LVN A. LVN A neglected to seek/obtain medical attention for Resident #2 during a hypoglycemic crisis. Resident #2 died during this medical emergency; and 2) failure to thoroughly investigate Resident #2's death and report an allegation of neglect to the State Authority when the facility became aware that Resident #2 died on [DATE]. Resident #2's death was also announced during an administrative/department head meeting on [DATE]. The facility had no method to ensure that deaths in the facility were reviewed to rule out neglect. These failures resulted in a lack of investigation into the unusual death of Resident #2 and the alleged perpetrator (LVN A) remaining in the facility providing care to residents from [DATE] to [DATE]. The facility's failure to ensure unusual occurrences were thoroughly investigated, to rule out possible neglect and reported to officials in accordance with State law, resulted in an Immediate Jeapordy (IJ) on [DATE] at 4:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a level of harm the scope identified at isolated. The facility failure to investigate and report incidents of death of unusual circumstances could result in ongoing neglect in the facility. Findings included: 1) The facility's policy titled, "Resident Abuse/Neglect/Exploitation/Misappropriation of Resident Property/Involuntary Seclusion/Corporal Punishment" dated [DATE] included the following: "3. Any employee having knowledge or suspicions of an alleged violation involving resident abuse, neglect, exploitation, and misappropriation of resident property, involuntary seclusion or corporal punishment is required to report immediately to the Campus Administrator, to the Risk Manager or to the Department Manager without fear of reprisal. 4. All incidents including those of unknown origins will be thoroughly investigated. These include, but are not limited to, resident death under unusual circumstances, missing residents, serious accidental injury. Potential abuse, neglect. exploitation and misappropriation of resident property, involuntary seclusion. and corporal punishment will be prevented during investigation. Results of investigation will be reported immediately to the Campus Administrator or designee and other officials in accordance with Texas law. A written report, if appropriate will be sent to the Texas Department of Aging and Disabilitgy Services within five (5) days following the verbal report, in accordance with applicable laws..." Under "Definitions", "Neglect means failure to provide goods and services to avoid physical harm, mental anguish, or mental illness." 2. a) Review of the record of admission revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to year and month, and her recall was good. b) Resident #2's care plan for Diabetes, dated [DATE] documented the goal as, "Resident will have stable blood sugar and no episodes of hypo/ [MEDICAL CONDITION] for the next 90 days." The approaches were, "monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs and symptoms of hypo/ [MEDICAL CONDITION]. Notify physician of any significant changes. Monitor skin for any open areas and notify MD if occurs. Labs as ordered. Results to physician. 8 ounces OJ with 2 packs sugar." c) A nurse's note by LVN A dated [DATE] at 1:55 p.m. documented: "called to resident room at approximately 12:30 p.m.. Resident was diaphoretic, skin cool and clammy. CBG (capillary blood glucose) checked, monitor read LO. Dr __ (A) called with no answer. Resident given OJ (orange juice) with sugar. CBG rechecked after 15 minutes, meter read 31. Resident given more OJ with sugar, rechecked after 15 minutes, meter read 47. Continued to stay with resident and recheck CBG every 15 minutes. CBG rechecked at 1:20 p.m., resident CBG 64. Resident was moaning, no respiratory distress noted. At approximately 1:30 p.m., resident jaw fell open and when this nurse called her name she did not respond. 2 - 10 shift LVN summoned by staff and LVN summoned RN to resident room. RN note to follow." d) A nurse's note by RN B dated [DATE] at 1:55 p.m. documented, in part: "called to resident's room. Resident laying in bed in supine position. Resident unresponsive to verbal and physical stimuli, no visible respirations noted. Assessed for carotid pulse, none noted. No apical pulse noted, no respirations noted for one minute. Order received for RN to pronounce. Time of death 1:40 p.m." e) In an interview on [DATE] at 10:00 a.m., LVN A said, "On the day she died , I tried to reach him (the physician) but couldn't. I just stayed with the resident. I was worried but I kept giving her OJ and sugar and rechecking her sugars. She was finally kinda coming around somewhat then just died ; just quit breathing. I ran to the door (resident's room door) and hollared at LVN C to get RN B." LVN A also said, "Dr ___'s (A's) protocol for blood sugars is for us to fax the readings every day, other residents of his he wants like every three days." LVN A said she did not attempt to notify an RN in the facility at the time of crisis, attempt to call the physician a second time, nor did she call 911. LVN A said she did "not have the authority to call 911, only an RN could do that." LVN A also said, "later this day Dr ___(A) called to give orders on all of his patients and the first one he named was ____ (Resident #2). I had to tell him she died earlier in the day. He was surprised; he was unaware she died ." f) Review of monthly physician orders [REDACTED]." g) Review of Resident #2's CBG flow sheet for February 2012 documented four times the blood sugar was less than 60. The physician was "faxed" the results. There were six times the resident's blood sugar was greater than 400 (the physician's protocol) and there were 30 times the blood sugar was greater than 300 (facility protocol). Of the 30 times Resident #2's blood sugar was outside the physician's parameters or the facility's parameters, there was only four documented times the physician was actually spoken to by telephone. h) In an interview on [DATE] at 10:40 a.m., RN B said if she had been the nurse caring for Resident #2 in that situation, the first thing she would do was re-check the blood sugar immediately, then call 911 if I could not reach the doctor. She added, "Any critical lab value you must call and speak to the doctor or else call 911. As an LVN, she (LVN A) should have called me at the first low reading. You can't just keep giving OJ and sugar; you have to get the doctor or the RN." i) During a second interview on [DATE] at 3:50 p.m., RN B said she did not ask any questions to find out why LVN A did not call an RN supervisor, the physician, or 911. She said she pronounced the resident, but did not ask any questions about circumstances leading to the resident's death after it happened. When discussing whether she discussed the resident's death with the Director of Nurses, RN B said that she only talked to the administrator. She said that when she talked to the administrator about the death, he did not ask her any questions regarding the circumstances of the death. j) In a telephone interview on [DATE] at 12:40 p.m., Resident #2's physician said the nurses had his cell phone number and were supposed to call critical readings to him. He said he was not aware the nurses were not always calling him regarding blood sugar problems. He said that his protocol was that he wanted to be contacted for a blood sugar less than 70 or greater than 400, and that he was sure he had given these parameters to the facility. The physician said he was unaware LVN A did not get RN B involved when Resident #2's blood sugar was so low saying, "She can't just practice medicine, they have to get me or the on-call physician." The physician added, "I can look at my phone records but she never called me or I would have called her back. I wasn't even aware the resident expired until later in the day. I will reinforce what I expect for my patients." k) During an interview on [DATE] at 3:00 p.m., LVN C said that she was the nurse that was coming on shift for the evening shift on [DATE]. She said she came in to work early that day, at 1:30 p.m. instead of 2:00 p.m., when her shift actually started. She said that when she arrived, a CNA approached her and told her that LVN A needed her in Resident #2's room. She said that LVN A told her that Resident #2's blood sugar had been 24, but she had gotten it up to "40-something." She said she asked LVN A if she had called the doctor and LVN A said she had not. LVN C said she ran to get her stethescope and page the RN to the room, but by the time she got back to the room, the resident had died . LVN C became tearful regarding the incident. LVN C said she would have gotten assistance from an RN supervisor or called 911. l) During an interview on [DATE] at 2:00 p.m., LVN E (also the facility risk manager) said that he remembered the death being brought up in the morning meeting with all managers. He said, "It wasn't presented as anything unusual, I can't remember what was said, just the passing was reported." m) During an interview on [DATE] at 9:50 a.m., RN F said she was not on duty when Resident #2 died . She said, "That made me so mad!" She said that when Resident #2 "bottoms out" it was very serious and the resident gets sweaty and unresponsive. She said that the nurses usually got an immediate order for [MEDICATION NAME] and re-check the resident in 15 minutes. She said if the resident did not recover, 911 should have been called. n) During an interview on [DATE] at 4:15 p.m., the administrator said that he was not aware there was any unusual circumstances surrounding the death of Resident #2 until that date ([DATE]), and he had suspended LVN A and would conduct an investigation. He said he did not know there was a need to investigate until RN B spoke with him after her interviews with surveyors on [DATE]. The administrator confirmed that there had been no previous investigation or reporting of the incident. 3) In response to a request for any policies the facility had regarding deaths in the facility (such as review of deaths), the facility provided a memo from a corporate representative to the facility dated [DATE] that documented, "There is no policy for review of deaths; the process should entail a chart review within 24 hours not only to make sure all documentation is complete and accurate, but also to review for opportunities for improving the quality of life and quality of care for our residents on an ongoing basis." 4) During an interview on [DATE] at 10:05 a.m., the DON said she started as interim DON on [DATE] (the day after Resident #2 died ). When discussing why she (or her designee) did not review the death of this resident, she said, "I honestly cannot tell you that." 5) On [DATE] at 4:20 p.m., the administrator and DON were informed of the Immediate Jeopardy. 6) The facility submitted the following corrective action plan of removal : -Licensed staff were in-serviced and tested for competency on physician notification of critical lab values. Monitoring of compliance by the nursing management team and RN supervisors will continue daily through review of lab reports, 24-hour reports, and incident reports. -Licensed staff in-serviced and tested for competency on appropriate nursing interventions for serious medical condition. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on physician notification protocols. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report, and incident reports. -Licensed staff in-serviced and tested for competency on diabetic management policy. Monitoring of compliance by nursing management team and RN house supervisors through review of lab reports, 24-hour report and incident reports. -Nurse (LVN A) suspended immediately pending investigation, for failure to provide immediate attention or notification on a resident needing immediate intervention. -Nursing Management Team revised the RN supervisors' delegation of duties to include review of 24-hour report and corresponding nurse's notes, including follow-up as needed. Nursing management team will receive a daily report from the RN supervisor on serious medical conditions. -100% chart audit for all diabetics to ensure there were orders for parameters and the parameters were correct (completed on [DATE]). (Physician was notified of all blood sugar outside parameters). -The medical record for a resident that dies will be reviewed by the nurse management team and administrator within 24 hours to determine if there were any unusual circumstances. 7) Plan of removal verification: -Interviews were conducted with licensed nursing staff to verify in-service participation and the participant's understanding of requirements for physician notification. -An interview was conducted with the facility's medical director regarding the Immediate Jeopardy and plan of removal. Confirmed that the medical director (Residents' physician) and facility were in agreement regarding notification. Physician confirmed he had a cell phone and was available to the facility by the cell phone when needed. -Interviews with the RN House Supervisors confirming the 100% diabetic chart audit and Review of the chart audit and actions taken. -Review of facility investigation report and confirmation of report to the state authority. 8) During a conference on [DATE] at 4:00 p.m., the Immediate Jeopardy was lowered to actual harm at a pattern as of [DATE] when the corrective action plan was fully implemented as the facility had yet to monitor the effectiveness of the corrective action plan.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for four of eight residents reviewed for falls (Residents #1, 2, 3, and 4) as evidenced by: a) failure to determine the cause of un-witnessed falls, monitor and evaluate the effectiveness of fall prevention strategies, or modify ineffective fall prevention strategies to prevent falls for Resident #1. Resident #1 had seven falls between 11/19/11 and 1/4/12; b) failure to determine the cause of un-witnessed falls, monitor and evaluate the effectiveness of fall prevention strategies, modify ineffective fall prevention strategies (reminders by staff were ineffective), and implement restorative nursing services to prevent falls for Resident #2. Resident #2 had eleven falls between 10/5/11 and 12/30/11; c) failure to monitor and evaluate the effectiveness of fall prevention strategies and to modify ineffective strategies to prevent falls for Resident #3. The facility continued use of a personal alarm even though the resident said she did not want it and frequently removed the alarm, and did not address the resident's expressed need for toileting assistance to prevent falls. Resident #3 had nine falls between 10/9/11 and 1/2/12; and d) failure to determine the cause of un-witnessed falls, monitor and evaluate the effectiveness of fall prevention strategies, and modify ineffective fall prevention strategies (reminders that were ineffective and a personal alarm that did not sound or was removed) to prevent falls for Resident #4. Resident #4 had thirteen falls between 10/13/11 and 1/8/12. These failures could result in falls and related injuries for any of the 62 residents of the facility that were identified as being at high risk for falls. Findings included: RESIDENT #1 1. A record review of a medical record face sheet for Resident #1 revealed he was an [AGE] year-old male admitted to the facility on [DATE]. A physician's progress note dated 11/21/11 documented Resident #1's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment for Resident #1, dated 12/16/11 documented under the speech section of the assessment that Resident #1 rarely/never understood others and was rarely/never understood. His cognitive skills were assessed as severely impaired. He was independently mobile, required limited assistance with dressing and toilet use, and required extensive assistance with personal hygiene. The MDS documented that Resident #1 had two or more falls with no injury since his admission or prior assessment, and two or more falls with injury since his admission or prior assessment. A review of a fall risk assessment for Resident #1 revealed he received a total score of "17" on assessments dated in August 2011, September 2011, December 2011, and January 2012. A score of 10 or more indicated the resident was at high risk for falls, according to assessment instructions. A record review revealed seven incident reports describing falls for Resident #1 between 11/19/11 and 1/4/12. These incident reports did not include information regarding any facility determinations of how or why Resident #1 had repeated falls, and no information regarding any recommendations to prevent falls. The incident reports included the following information: -11/19/11 at 05:30 a.m.: Resident #1 was found lying on his back in the floor of his bed area. The LVN documented there was no witness to the incident and the resident was unable to state how he fell . On the incident report under "Care prior to fall," the writer had six options from which to choose such as "visually observed", "toileted", etc. All options were marked, "N/A" (not applicable). Preventive measures at the time of fall included eleven options and all were marked "N/A" or "None". Under "Footwear", the options included whether the resident was wearing shoes, socks, slippers, etc. All options were marked "N/A." Under "Staff Interviews" the writer documented, "No staff interviews available." Under "Recommendations" the writer documented, "None Noted." -11/29/11 at 6:00 p.m.: Resident #1 was observed to lose his balance and fall, landing on the left side of his back. He was in the dining room at the time. The incident report documented "None" or "N/A" under the section titled, "Preventive measures at time of fall." Under "Root cause" the writer documented, "Due to resident action or internal risk factors." Under "Recommendations" the writer documented, "None Noted." -12/16/11 at 3:45 a.m.: Resident #1 was found lying on his back on the floor in the activity/television room. Since the resident was indicating pain in his left hip, he was sent to the local emergency room . The incident report documented "N/A" to all choices under "Care prior to fall" and "None", "N/A", or "Not in use" under all choices of preventive measures at the time of fall. Under the section, "Root cause," the writer documented, "Due to resident action or internal risk factors." Under the section, "Staff interviews," the writer documented, "No staff intervews available." Under "Recommendations," the writer documented, "None noted." The conclusion documented that the hospital determined Resident #1 did not sustain a fracture in the fall. -12/21/11 at 5:20 a.m.: Resident #1 was found lying on his back on his bedroom floor. The resident's statement and witness statement were both documented, "N/A." The incident report documented the resident was barefoot and the environment was quiet. All choices under the section, "Care prior to fall" were marked, "N/A." All choices under the section, "Preventive measures at time of fall" were marked, "None", "Not in use", or "N/A." The "Root cause" was documented as, "Due to resident action or internal risk factors." Under the section titled, "Resident Status Prior to Fall", the writer had choices including, Resident state of motion at time of fall, how many staff were in assistance, Fall risk re-assessment completed, plan of care for falls completed, and resident fall review completed. Each of these choices was marked, "N/A." Under the section titled, "Recommendations," the writer documented, "None noted." -12/27/11 at 8:30 p.m.: Resident #1 was found lying on his back with his head propped up on the wall near the doorway to the unit. There were no witnesses and the resident could not tell what happened. "Preventive Measures at time of fall" were all marked "None" or "N/A." The "Root cause" was documented as, "Due to resident action or internal risk factors." Under "Recommendations", the writer documented, "None Noted." -1/3/12 at 9:45 p.m.: Resident #1 was found lying on the floor next to his bed. There were no witnesses to his fall and he could not describe what happened. He had not used his call light. The "Root Cause" was documented as, "Due to resident action or internal risk factors." Under "Recommendations" the writer documented, "None noted." -1/4/12 at 2:30 a.m.: The nurse documented that Resident #1 was walking, and he slipped and fell on his back and hit his head. The incident report documented "N/A" under "Witness statement of what happened." The writer documented a low bed was in place to prevent falls and the resident was wearing slipper-socks. Under "Root cause" the writer documented, "Due to resident action or internal risk factors." Under, "Recommendations", the writer documented, "None noted." The incident report documented that there were no injuries and Resident #1 was sent to out of the facility to a behavioral health center on 1/4/12. Observations of Resident #1 could not be accomplished as he was not present in the facility during this investigation. A record review of Resident #1's care plan dated 3/29/11 and updated 6/28/11, 9/27/11, and 12/27/11 revealed the facility had not revised the care plan to prevent falls for Resident #1 since it was developed on 3/29/11. The care plan had interventions to give the resident verbal reminders not to ambulate or transfer without assistance, provide toileting assistance every two hours, keep the environment free of clutter, keep personal items within the resident's reach, and keep the call light in reach at all times. The facility had added "Acute care plan-falls" to the care plan on 11/19/11, 11/29/11, 12/16/11, 12/21/11, 12/27/11, and 1/4/11. These acute care plans were very similar to the initial care plan. They included interventions to keep the call light in reach, provide toileting assistance, ensure proper footwear, ensure lighting in room, orient resident to room environment, and encourage resident to call for assistance when getting out of bed and transferring to chair. During an interview on 1/11/12 at 1:45 p.m., LVN B said he was the Memory Care Unit 2 Manager (Manager of the Alzheimer's unit where Resident #1 resided). LVN B said that he did not make any attempts to find the causes of Resident #1's falls. He said he could not think of any interventions that the facility put into place or changed to prevent falls for Resident #1. When discussing the incident report conclusions and there being no recommendations on any of the incident reports, he said that he really did not know since he did not complete that part of the incident report. He said, "It's just a check off thing." During an interview on 1/11/12 at 3:00 p.m., the DON said that the facility did not make any efforts to determine what may have been contributing to Resident #1's falls. When discussing the facility's interventions to prevent falls, he said, "Just what's on the forms (incident reports) and care plans." He said that the facility just started a fall committee this week, but there had not been any decisions made about Resident #1's falls. RESIDENT #2 2. A record review of a medical record face sheet revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. According to the face sheet and a history and physical dated 3/8/10, Resident #2's [DIAGNOSES REDACTED]. An MDS dated [DATE] for Resident #2 documented that he required limited assistance of one staff to transfer between surfaces, extensive assistance (resident involved in activity, staff provide weight-bearing support) for dressing, and extensive assistance for toileting. The section titled, "Balance During Transitions and Walking" documented that Resident #2 was not steady when transferring surface to surface and required human assistance to stabilize. The MDS documented that Resident #2 was always continent and not on a toileting program. The MDS documented that Resident #2 had two falls with no injury and two falls with injury since admission or prior assessment (the one more recent). The MDS documented that Resident #2 had not received any restorative programs during the seven day period before assessment. A nursing monthly summary for Resident #2, dated 12/20/11 documented that Resident #2 required assistance to dress "at times", he independently toileted, and only required occasional physical or verbal assistance to transfer to and from his bed, chair, or standing. The current care plan for Resident #2, dated 6/21/11 and updated 9/27/11 and 12/27/11 revealed the care plan stated that Resident #2 required assistance from staff to transfer to the toilet, his wheelchair, and to and from bed. The care plan documented that Resident #2 required assistance for grooming, and personal care and hygeine. Problem #9 included a problem of history of falls, last one resulted in hip fracture. The approaches included reminding him to ask for assistance to ambulate or transfer, provide clutter-free environment, keep call light in reach, ensure resident has eyeglasses, keep wheelchair in reach, observe frequently, occupy with meaningful dstraction (music, TV), provide toileting every 2 hours, remind to lock brakes on his wheelchair, and keep bed in lowest position with brakes locked. On 9/29/11 the care plan added physical therapy, and this was discontinued on 11/4/11. The care plan documented that a personal alarm was discontinued on 8/11/11. The care plan did not say when the personal alarm was implemented. There had been no changes to the care plan for prevention of falls since the discontinuation of physical therapy. The care plan was not changed at the review on 12/27/11. A record review of a fall risk evaluation revealed a score of "17" in November 2011, and four evaluations in December 2011 with scores of "17", "17", "17", "14", and "16." The assessement indicated that any score above "10" indicated the resident was at high risk for falls. A record review of incident reports and nurse's notes revealed eleven (11) falls were recorded for Resident #2 between 10/5/11 and 12/30/11 and included the following information: -10/5/11 at 3:15 p.m.: Resident #2 was found on the floor laying on his right side. Resident #2 said he may have fallen asleep and fell from his wheelchair. The "Root Cause" of the fall was documented as, "Due to resident action or internal risk factors." The section titled, "Recommendations" documented, "None Noted." -10/6/11 at 12:30 p.m.: Resident #2 was found on his back on the floor between the bed and the window. The "Resident statement of what happened" documented "N/A." There was no witness to the fall. The "Root Cause" was documented as, "N/A" The section titled, "Recommendations" documented, "None Noted." -10/15/11 at 7:45 p.m.: Resident #2 "appeared to have fallen asleep and slipped out of chair." The resident's statement was documented as, "I fell out of my chair and the only thing that is hurt is my pride." A witness statement documented, "Resident appeared to be re-situating himself and fell out of chair." The section titled, "Recommendations" revealed the writer documented, "None noted." -10/24/11 at 7:30 p.m.: Resident #2 was found sitting on the floor of the bathroom in the hallway of a wing. The resident said that he fell while trying to get to the toilet. Under the section titled, "Root cause" the writer documented, "Due to resident action or internal risk factors." Under the section, "Recommendations," the writer documented, "None noted." -11/18/11 at 12:38 p.m.: Resident #2 fell from his chair while attempting to toilet. Under the section titled, "Root cause", the writer documented, "Due to resident action or internal risk factors." Under the section titled, "Recommendations," the writer documented, "None noted." -11/24/11 at 7:00 p.m.: Resident #2 slid from his wheelchair as he was attempting to transfer himself, according to a CNA who witnessed the incident. The "Root cause" was documented as on all other incident reports, and there were no recommendations documented. -12/4/11 at 6:40 p.m.: Resident #2 was yelling for help and found sitting on the floor of his room. The "Root cause" was documented as on all other incident reports for Resident #2 and there were no recommendations documented. Corresponding nurse's notes of the same date at 6:40 p.m. and 6:55 p.m. revealed the nurse documented that Resident #2 was found by another resident and the nurse told the resident he should lock his wheelchair and use his call light to ask for assistance. -12/11/11 at 4:15 p.m.: Resident #2 fell when his "feet were tangled up." The incident report documented that a wheelchair was in use at the time. The "Root cause" was documented as on all other incident reports for Resident #2 and there were no recommendations documented. A corresponding nurse's note of the same date documented that Resident #2 was standing behind his wheelchair, pulling it backward when he fell . -12/26/11 at 9:10 a.m.: Resident #2 was found on the floor in the television room. The resident told the staff he sat on the floor because he did not think he was going to make it when moving to sit in his wheelchair. The "Root cause" was documented as on all other incident reports for Resident #2 and there were no recommendations. -12/27/11 at 9:00 p.m.: Resident #2 was found sitting on the floor. The resident said he slipped and fell but did not know how. The "Root cause" was documented as on all other incident reports for Resident #2 and there were no recommendations. -12/30/11 at 11:00 p.m., Resident #2 was found lying on his right side on the floor. Resident #2 told the staff that he rolled out of bed. The incident report documented the resident did not have a low bed at the time. The "Root cause" was documented as on all other incident reports for Resident #2, and there were no recommendations. During review of the above incident reports and corresponding nurse's notes, the nurse documented notification to the physician regarding each fall. There was no physician's response documented on notifications of falls for Resident #2 for the above dates. A record review of physician's orders [REDACTED]. A record review of the most recent physician's progress note, dated 11/28/11 revealed the physician documented a history of present illness, social history, physical examination, and assessment and plan. The assessment and plan documented that Resident #2's hypertension, coronary artery disease, depression, and osteoarthritis were stable and no changes were recommended. The physician did not document any acknowledgement regarding Resident #2's falls. A record review of a Physical Therapy Discharge Summary for Resident #2, dated 11/4/11 documented that Resident #2 had received physical therapy where he had received progressive resistance exercises for his lower extremities to increase independence in mobility tasks; gait training to normalize gait pattern with emphasis on increasing safety and performance in his room; bed mobility activities to increase functional skills; transfer training to increase functional task performance; dynamic balance activities while standing; and dynamic functional activities to increase strength, range of motion, and flexibility in a progressive manner. The physical therapist documented the resident's response as, "Patient has made consistent progress with skilled interventions." The physical therapist documented that the resident's prognosis was "good with consistent staff follow-through." Discharge reason was, "Pt. no longer motivated to engate in rehab and unable to demonstrate progress due to change in desire." The Discharge recommendations included the restorative nursing program to maintain the resident's current level of performance and in order to prevent decline. The Physical therapist documented, "Development of and instruction in the following RNPs (restorative nursing programs) has been completed with the IDT: ambulation, transfers, and ROM (range of motion), active." During an interview on 1/12/12 at 9:30 a.m., LVN C said that Resident #2 had previously fallen and broken his hip. She said she thought it happened last summer. When discussing recent falls and what preventive measures were in place, LVN C said, "We just watch him." She said that he used to have a personal alarm, but he took it off and so it was discontinued. LVN C said that Resident #2 had confusion at times and he would get "shaky" at times. She said that sometimes he could transfer himself from wheelchair to chair (or back) and sometimes he could not. She said he often forgot to lock his wheelchair before transferring himself. She said that he could do "simple" activities of daily living such as dress himself. When discussing whether the resident could stand to pull up his pants, LVN C said she did not know. She said Resident #2 slept in his clothes, so he was dressed when she got to work. When discussing whether Resident #2 was receiving restorative nursing services, LVN C said she did not think so. She then called the restorative nursing department and confirmed that Resident #2 was not receiving restorative nursing services. During an interview on 1/12/12 at 10:00 a.m., RNA F stated she had not served Resident #2 in restorative nursing services. When discussing the physical therapist's recommendation for restorative nursing services when the resident was discharged from physical therapy in November 2011, RNA F said she never received a referral for Resident #2. She looked through her paperwork back to November 2011 and confirmed that Resident #2 had never received her services. She said the unit referred him today after the call from LVN C. During an interview on 1/12/12 at 10:30 a.m., RN J said that she was the unit manager for the unit where Resident #2 resided. She said she was not responsible to determine what happened to cause falls, and that the falls were discussed in a daily meeting. RN J stated that the only intervention in place to prevent falls for Resident #2 was "Trying to remind him. That's all." She could not identify any other interventions the facility had attempted, except a personal alarm that was attempted last summer. RN J said she did not know if Resident #2 did not understand instructions or just did not accept his limitations. During an interview on 1/12/12 at 10:55 a.m., Resident #2 was observed to be sitting in his wheelchair. There was no personal alarm attached to his clothing or his wheelchair. Resident #2 said that he did not call for help from staff because he did not need help to transfer. When discussing a history of eleven falls, Resident #2 said he did not remember any of his falls. During an observation on 1/11/12 at 3:45 p.m., Resident #2's room was observed to have a regular bed (not a low bed). No alarms were attached to the bed. There was no fall matt in the room. RESIDENT #3 3. Review of the current clinical record (admission sheet) for Resident #3 revealed she was originally admitted on [DATE] and current admission was 4/21/2011. Resident #3 was currently [AGE] years of age. The resident's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Diagnosis: [REDACTED]. Observation on 1/11/12 at 11:35 a.m. revealed Resident #3 was in her room, in her wheelchair, clipping her pin alarm onto her dress, then she clipped it onto her shirt sleeve. Resident #3 said " if I fall it will go off and they will come, I don ' t like it, I want to refuse it, I fall sometimes in my room, I call them to help me, they have more than me to take care of, sometimes it takes them too long, they are busy and I have to go to the bathroom." At 12:00 p.m. CNA " I " came down the hallway and said the facility was putting in a new call light system. Surveyor asked CNA " I " to check Resident #3 ' s personal alarm to see if it worked. When CNA " I " tested the personal alarm it did not sound, CNA " I " looked at the alarm and said it was turned off, " see turns it off. " Resident #3 said " I didn ' t turn it off. " A review of the quarterly MDS assessment for Resident #3, dated 12/05/11 documented under the cognitive section of the assessment that Resident #3 was cognitively intact. She required extensive assistance for transfers, dressing and toileting, was not able to walk, required limited assistance with personal hygiene. The MDS documented that Resident #3 was not steady, but able to stabilize without human assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS documented Resident #3 had falls since her admission or prior assessment, but did not document the number of falls or if there were injuries. Record review of Resident #3's care plan dated 6/14/11 and reviewed 9/20/11 and 12/20/11 revealed the facility had not revised the care plan to prevent falls for Resident #3 since it was developed on 6/14/11. The care plan had interventions to encourage the resident to call for assistance for transfers, may apply personal alarm, encourage to use call light if needed, keep the environment free of clutter, maintain appropriate lighting for time of day/activity, encourage the resident not to sit on the edge of the wheelchair, assist in anyway that permits the resident to maintain the highest level of functioning possible for process, monitor for effectiveness of prescribed medication and monitor for safety every two hours. The facility had added "Acute care plan-falls" to the care plan on 10/09/11, 10/22/11 and 11/20/11. These acute care plans were very similar to the initial care plan. They included interventions to keep the call light in reach, provide toileting assistance, ensure proper footwear, ensure lighting in room, orient resident to room environment, and encourage resident to call for assistance when getting out of bed and transferring to chair. The facility had added "Acute Care Plan - Fall At Risk" to the care plan on 11/08/11 and 11/09/11. These acute care plans were similar to the initial care plan, but included to monitor the resident every 30 minutes per shift. There were no 30 minutes checks documented in the record. During an interview on 1/12/12 at 3:20 p.m. LVN "G" verified he had completed the "Acute Care Plan - Fall At Risk" forms for Resident #3. RN Unit Manager "A" was present and said these forms were not the correct ones. RN "A" said LVN "G" should have completed the "Acute care plan-falls" form. RN "A" said Resident #3 was not on 30 minute checks. A review of a fall risk assessment for Resident #3 revealed she received a total score of "24" on assessments dated 10/22/11, 12/05/11, 12/10/11, 12/28/11 and 01/02/12. A score of 10 or more indicated the resident was at high risk for falls, according to assessment instructions. A record review of incident reports for Resident #3 revealed the following: -10/09/11 at 11:15 p.m.: Resident #3 was observed on the floor by CNA, sitting beside her bed, no complaints of pain at this time, denies hitting her head. The resident stated she was unsure of how she ended up on the floor. The LVN documented there was no witness. On the incident report under "Care prior to fall," visually observed was marked, "N/A" (not applicable) and Toileted documented 10/09/11 at 11:45 (30 minutes after the fall). Preventive measures at the time of fall documented alarm-none, call light-off, low bed-yes, hip protectors-N/A. Under "Footwear", socks only was marked. Under "Staff Interviews" the writer documented, "No staff interviews available." Under "Recommendations" the writer documented, "None Noted." -10/22/11 at 1:00 a.m.: Resident #3 observed sitting on her buttocks, on the floor, next to her bed. Resident was only wearing socks at the time of the fall. Resident detached her personal alarm. Full ROM (range of motion) without pain to both upper and lower extremities. No injuries noted. Neuros initiated and within normal limits. Counseled Resident to call for staff assist with transfers and the purpose of personal alarm and leaving it in place, resident verbalized understanding. Resident #3 stated " I was standing up holding onto my recliner and when I let go I fell " . The incident report documented under the section titled, "Preventive measures at time of fall" the alarm was not sounding and call light-off. Under "root cause" the writer documented, "Due to resident action or internal risk factors." Under "Recommendations" the writer documented, "None Noted." -11/08/11 at 2:25 a.m.: Resident #3 was found sitting on the floor in her room in front of her roomates bed. Resident was transferring self from restroom, slipped, slippery socks noted on resident ' s feet. No complaints of pain voiced. Blood sugar 239, respirations even & non-labored. Active ROM x 4, within normal limits. Assisted x2 to bed. Call light in reach. Resident #3 stated she was looking for grandson in the yard. Resident was transferring self from restroom. The incident report documented "N/A" to all choices under "Care prior to fall". Under " Preventive Measures at Time of Fall " - Alarm none and call light-on. Under the section, "Root cause," the writer documented, "Due to resident action or internal risk factors." Under the section, "Staff interviews," the writer documented, "No staff interviews available." Under "Recommendations," the writer documented, "None noted." -11/09/11 at 3:55 p.m.: Resident #3 was found sitting on the floor on her wheelchair pad. Resident was transferring self independently, wheelchair not locked, resident encouraged to continue with personal-alarm, voiced understanding. Resident assisted x2 to bed, call-light in reach, personal-alarm intact. Neuros initiated, notified M.D. due to low blood pressure, received order to send to emergency room for evaluation, 911 dispatched, transferred to hospital via ambulance. Resident stated I slipped when getting on my wheelchair. The incident report documented the resident was visually observed at 3:30 p.m., had slipper-socks, call light was on, but the alarm was not sounding. It was revealed the personal alarm was rolled up and locked in a drawer. The "Root cause" was documented as, "Due to resident action or internal risk factors." Under the section titled, "Recommendations," the writer documented, "None noted." -11/20/11 at 9:35 p.m.: Resident #3 stated that she was moving blankets out of the way and slid out of bed. Head to toe body check, placed in bed, neuro checks initiated, no pain when ROM performed, alarm applied, referred to PT/OT (physical therapy/occupational therapy) and fall risk reassessment completed. There were no witnesses. "Preventive Measures at time of fall" documented the alarm was sounding. The " Root Cause" was documented as, "Due to resident action or internal risk factors." Under "Recommendations", the writer documented, "None Noted." -12/10/11 at 11:00 a.m.: On 12/10/11 at 3:24 p.m. Resident #3 reported at 11:00 a.m. she fell while ambulating to get into her wheelchair, has alarm but takes it off. She stated she fell to her knees and got herself up and back into the wheelchair. There were no witnesses. The "Root Cause" was documented as, "Due to resident action or internal risk factors." Under "Recommendations" the writer documented, "None Noted." -12/10/11 at 8:30 p.m.: The nurse documented that Resident #3 slid out of her wheelchair. The incident report documented "N/A" under "Witness statement of what happened." The nurse documented the resident only had socks on, the call light was off and the alarm was sounding. Under "Root cause" the writer documented, "Due to resident action or internal risk factors." Under, "Recommendations", the writer documented, "None noted." -12/28/11 at 9:45 p.m.: The nurse documented she heard resident #3's roommate calling "help." Resident #3 was found sitting on the floor in the doorway of the room. Resident's personal alarm was taken off. The call light was with-in reach, not used. ROM x4 within normal limits. No complaints of pain or distress voiced. Resident encouraged to call for assist, voiced inderstanding. The incident report documented "N/A" under "Witness statement of what happened." The nurse documented the resident only had socks on, the call light was off and the alarm was not sounding. Under "Root cause" the writer documented, "Due to resident action or internal risk factors." Under, "Recommendations", the writer documented, "None noted." -01/02/12 at 6:00 p.m.: The staff notified the nurse that Resident #3 was visually observed sitting on her buttocks in front of her wheelchair. Full ROM to upper and lower extremities. No injuries noted. Resident had removed and turned off personal alarm. Alarm was put back in place and counseling provided, resident verbalized understanding. Resident #3 stated, "I just slid out of my wheelchair." The incident report documented "N/A" under "Witness statement of what happened." The nurse documented the resident had socks/slippers on, the call light was off and the alarm was not sounding. Under "Root cause" the writer documented, "N/A " . Under, "Recommendations", the writer documente

Based on observation, interview and record review the Administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for each resident's environment to remain as free of accident hazards as is possible. This failure had the potential to effect 25 of 25 residents residing on the locked unit, all of whom were identified as elopement risks by the facility. This failure effected one of two locked units. A. It was determined the facility failed to ensure the doors on the secured unit closed securely in a way that would prevent elopement. B. The administrator failed to ensure their plan of action dated [DATE] was followed related to the prior Immediate Jeopardy about elopement on the locked unit. The facility failed to ensure the only staff with access to the code to unlock the door was limited to the Direct Care staff on the Memory Support Unit. The facility failed to ensure the direct care staff supervised the entrance and egress onto the secured unit. An immediate Jeopardy (IJ) situation was identified on [DATE] at 5:00 p.m. The IJ was removed on [DATE] at 1:05 p.m. Although the IJ was removed, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm at a pattern. The failure could cause any of the 25 residents residing on the unit, identified by the facility as being at risk for elopement by increasing their risk of serious injury or death from eloping from the facility. The findings: During a previous visit (visit ending [DATE], a week prior to the annual survey) a resident was admitted to the locked unit on [DATE], with a known history of wandering. On [DATE] he eloped from the facility without the facility being aware. The local police responded to a 911 report and found a resident in the middle of the highway, with a head injury. The resident told the police he had been hit by a car. The resident later died due to his injuries on [DATE]. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] (CMS 2567 dated [DATE]). Observation on [DATE] at 9:20 a.m. revealed multiple residents up and ambulating up and down the 600 hallways. An unsampled female resident was observed being redirected away from the double doors leading out of the secured unit. Observation on [DATE] at 7:22 a.m. revealed staff redirecting two female unsampled residents away from the secured doors to allow the meal tray cart to come through the doors. Observation on [DATE] at 4:08 p.m. revealed surveyor approached the locked unit doors. Surveyor pushed the door bell, looked through the door window and noticed no staff in the vicinity of the door. At that time it was noted the door was slightly ajar. Surveyor pushed the door and was able to easily enter the locked unit. During an interview on [DATE] at 4:10 p.m. LVN "M" was informed the entry door was not securely closed, LVN "M" said "the doors are broke and needs to be fixed, I don't know what we are going to do." Observation on [DATE] at 4:27 p.m. from the nurses station revealed a Maintenance staff "FF" carrying a ladder to the secured unit doors, pushing the key pad on the wall, opening up the door and struggling to get the ladder through the door. At this time surveyor walked down to the door, the door was not securely closed, surveyor was able to push the door open. There were no staff in sight at the time. Observation on [DATE] at 4:30 p.m. revealed two unidentified female residents go to the secure unit doors, push on the door and look through the window in the door. There were no staff in sight at the time. During an interview on [DATE] at 4:30 p.m. LVN "M" said if someone did not make sure the door to the secured unit was closed it would not latch. She said it had been that way for about a month. During an interview on [DATE] at 4:40 p.m. Unit Manager "N" said if there were windows or something open, the difference in air pressure between the non-secured hall and the secured unit would sometimes prevent the door from completely shutting. He said they had tried to change the weather stripping on the door and everything. During an interview on [DATE] at 4:40 p.m. the Administrator was informed of two observations the doors on the secured unit were not closed securely. At this time the Administrator went to the secured unit doors and checked them. The Administrator said "it's working now." Surveyors informed the Administrator there were two observations the doors were not closed securely which could create a accident hazard for confused wandering residents on the secured unit. At 4:42 p.m. the Administrator posted a staff at the door until the doors could be checked. At 4:45 p.m. the Maintenance Director "F" arrived at the secured unit doors and was informed of the observation by the surveyors of the doors not being securely closed. The Maintenance Director "F" said "if a window is open it can effect the doors." During an interview on [DATE] at 5:00 p.m. the Administrator was informed of the immediate jeopardy situation. The Administrator said he "anticipated" the finding. He said the last Plan of Correction completed on [DATE] outlined that only nursing and direct care staff were to have the codes to the locked unit door and when people went in and out of the unit door they had to be supervised. He said the maintenance tech signed an inservice less than a week ago acknowledging he understood this was how it had to happen. In an interview on [DATE] at 8:33 a.m. the Administrator said he was not having a good day yesterday. The Administrator said "the Maintenance staff that went out the door should not have had the code and he is no longer working here." The Administrator said "the plan of correction was that only the staff on the unit was to have the code. I knew it was coming, apparently it takes two staff to do anything." Record review of the Lamun Lusk Sanchez Texas State Veteran's Homes Plan of action dated [DATE] revealed the following: 1. No corrective action was necessary as no resident was involved. 2. All residents in the memory support unit have the potential to be affected by the same alleged deficient practice. 3. The door codes were changed at 5:30 PM on [DATE] and access will be limited to direct care staff in memory support, social workers the administrator, the DON and the RN supervisors (for emergent situations). On [DATE] at 11:00 AM door alarms were installed on the secure unit doors that will alarm until the door is closed. There will be direct supervision of entrance and exit to the secure unit with the exception of the DON, the administrator and the RN supervisors. The code will be changed every two weeks to ensure security is maintained. A bulletin board was placed at the entrance to each unit welcoming our new admissions, with their pictures posted. This will assist in identification of new residents. These pictures will initially be maintained for a minimum of one month. Q 30 minute checks will be established on all new residents in memory support for the initial 48 hours after admission to assure that resident is appropriate for the level of care and supervision. A count will be completed at the start of each shift change to ensure all residents are accounted for 4. A QA meeting will be held no less than 5 times weekly for the next 30 days to ensure the effectiveness of this corrective action. An RN supervisor will be on site 24 hours a day 7 days a week for the next 2 weeks to monitor this program and ensure compliance. During an interview on [DATE] at 5:45 p.m. the Corporate RN VP said the facility would be putting in an alarm system on [DATE] that would not stop beeping until the door was sealed. Observation made on [DATE] at 11:50 a.m. revealed the alarm system was attached to the Memory Support Unit #1's magnetic door and it sounded when the door was open. The Administrator was informed the IJ was removed on [DATE] at 1:05 p.m. Although the IJ was removed, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm at a pattern. Record review of the Room Roster provided by the facility on [DATE] documented the facility identified 25 residents living on the first memory support unit who were at risk for elopement.

Based on record review and interview the facility failed to ensure 1 resident (Resident #3) of 10 sampled residents maintained acceptable parameters of nutritional status. Over a period of nine months (February 2010 through November 2010), Resident #3 experienced a significant weight loss. The facility failed to ensure the doctor responded to the recommendations of the dietician in a timely manner. The facility failed to: 1. assess Resident #3 for calorie needs; 2. initiate new interventions to address Resident #3's significant weight loss (34.5 pound weight loss (17%) in nine months); These facility failures created the potential risk of increasing [MEDICAL CONDITION] with associated medical complications [REDACTED]. The facility census was 146. Findings include: RESIDENT #3 1) During initial tour on 11/15/10 Registered Nurse (RN) "E" said Resident #3 had weight loss. She said he was diabetic and not aware of any change in diet texture. 2) Record review of Resident #3's clinical record documented: - Admission Record: Resident #3's most recent admission was on 3/15/10. He was [AGE] years old. - November 2010 Physician order [REDACTED]. He was on the memory loss unit. He had an order for [REDACTED]. - Nurse's Notes dated 10/31/10 documented at 7:00 p.m. Resident #3 was "noted to have difficulty eating - has decreased cognitive functions - Dx (Diagnosis) Alzheimer's - noted to hold food in his mouth - consumed bits of PM meal - refused most - offered supplement, accepted. Notified Doctor." - Nurse's Notes dated 11/11/10 documented - new orders to change diet to LCS (Low concentrated sweets) - puree d/t (due to) change in resident not eating food, holding in mouth or refusing meals. - Nutrition Progress notes documented Resident #3 was assessed on 8/28/09. He was 176.5 pounds. That dietician documented Resident #3's ideal body weight was 178 plus or minus 18 pounds ( 160 - 196 lbs) - Nutrition Progress notes dated 2/17/10 documented Resident #3 weighted 172 pounds and was stable. Resident #3 needed cuing/ encouragement to complete meals. - Nutrition Progress notes dated 5/13/10 documented Resident #3 weighed 167 pounds. She recommended no change in approach. (Approximately 3% weight loss in 90 days) - Nutrition Progress notes dated 8/13/10 documented Resident #3 weighed 156 pounds and Resident #3 was now at 88% of his ideal body weight. (this was a 16 pound weight loss, approximately 9% in six months.) Her recommended approach was to discontinue the fortified meal program and put Resident #3 on diabetic supplements at 10 a.m., 2 p.m., and before bed (he received supplements since 5/28/08 which means it is not a new approach to prevent weight loss.) - Nutrition progress notes dated 11/11/10 documented Resident #3 now weighed 142 pounds. The dietician recommended a pureed diet with large portions. (This was a 17% weight loss in 9 months, or 15% weight loss in 6 months.) - Record review of Resident #3's meal consumption documented of the 30 days prior to 10/31/10 (when the nurse documented Resident #3 had difficulty eating), Resident #3 had difficulty eating at least one meal for 22 days. - Record review of Resident #3's meal consumption from 11/1/10 (after Resident #3 was identified as having difficulty eating) through 11/10/10 Resident #3 had difficulty eating at least 7 days of the documented meals (with one meal left completely blank.) - Record review of Resident #3's meal consumption from 11/11/10 through 11/16/10 documented Resident #3 refused one meal. He consumed between 75% and 100% of all the other meals. - Record review of Resident #3's weights by month documented: May 2010 166.2 pounds. June 2010 (no dates) 162; 161.3, 159.4 pounds July 2010 (no dates) 153, 152.5 8/1/10 - 159; 8/8/10 - 152; 8/15/10 - 154; 8/22/10 - 154; 8/29/10 - 151 9/5/10 - 156; 9/12/10 - 152; 9/19/10 - 151 9/29/10 - blank 10/3/10 - 153; 10/10/10 - 131; 10/17/10 - 148; 10/24/10 - 146; 10/31/10 - 142 11/07/10 - 142; 11/14/10 - 146 (four pound weight gain after Resident #3 was placed on a puree diet) - Record review of Resident #3's care plan documented on 3/23/10 Resident #3's current weight was 172; the goal was Resident #3 would remain between 162 and 182 over the next 90 days. The care plan was updated 6/22/10; the facility documented Resident #3 was 162 and to continue with the current care plan. The care plan was again updated on 9/21/10; the facility documented Resident #3 was 156 pounds: the new goal was Resident #3's weight would remain between 151 and 161 pounds over the next 90 days. - There were no speech therapy notes in the clinical records. 3) During an interview on 11/16/10 at 2:00 p.m. RN "E" said she did not know why it took 11 days for Resident #3 to be assessed for a texture change. 4) During an interview on 11/17/10 at 9:40 a.m. RN "E" said Resident #3's diet was changes from regular diet to puree. When asked why there was an 11 day delay from when it was noticed Resident #3 was pocketing food to changing the texture RN "E" called the Charge Nurse, LVN (Licensed Vocational Nurse) "F" in. LVN "F" said the nurses monitored Resident #3 for a few days prior to asking for a change to puree because it was such a drastic change in care. 5) During an interview on 11/18/10 at 12:20 p.m. RN "E" said there was no change in Resident #3's diet beyond discontinuing the Fortified Meal Program (FMP). She said the FMP was discontinued because it was not working. RN "E" said she and the dietician decided if his blood sugar checks were stable they would change him to the house supplement instead of the diabetic supplement because it had more calories. 6) During an interview on 11/19/10 at 11:50 a.m. RN "E" said the speech therapist would evaluate the residents if they qualified. She said it took approximately two days for the speech therapist to be able to evaluate the residents. RN "E" said if the resident did not qualify the nurses would contact the doctor and get an order. She said the dietician came to the facility monthly but only evaluated the resents quarterly. 7) During an interview on 11/22/10 at 10:55 a.m. RN "E" said she was aware Resident #3 lost as much weight as he did, she said it was a result of the disease process (the dementia.) She said the facility tried supplements and assisting him with eating. RN "E" said the process when the facility identified a resident had a weight change was to first reweigh the residents, then they looked at the diet and the medications. She said they would try a texture change. She said they notified the doctor and the family. She said they would have the dietician review the resident when that came in and the girls (staff) would call the dietician if the resident lost 6 - 7 pounds in a week, but she tried to encourage them to call when the resident lost five pounds. 8) During an interview on 11/22/10 the Director of Nurses (DON) said the protocol for weight was that each resident was weighed weekly when possible. She said they now had specific aides doing the weights because there was such a variance in the numbers before. She said now that the facility was doing weekly weights they were catching the weight loss quicker because they could catch when someone lost two or three pounds. She said once the facility got the results they notified the dietician and got her recommendations and called the doctor to ok it. The DON said the facility called the dietician came as soon as they realized there was an issue, but the dietician only came once a month. She said a reasonable amount of time to monitor someone for a diet change was three days. Surveyor showed her the clinical record that documented an 11 day period between identifying Resident #3 as pocketing food in his cheek and changing him to a puree diet. Surveyor also showed her that the month prior to the nurse documenting Resident #3 pocketing food he had 22 of 31 days of eating 50% or less of his meals but once Resident #3's diet was changed to puree he began eating 100% of his meals. The DON said she could not say the weight loss was unavoidable if the diet change was what he needed. 9) During an interview on 11/22/10 at 3:20 p.m. LVN "D" said there were some people Resident #3 would eat for and some he would not eat for. 10) During an interview on 11/22/10 at 5:15 p.m. the Dietician said the facility was very good about adding supplements, changes in texture, and utilizing speech therapy. She said if the nurse felt it necessary the facility would get it done. She said Resident #3 had one of those declines due to disease progression, that sometimes residents with late stage Alzheimer's would not let the staff feed them. She said she did not do supplements with meals because residents would do one or the other. She informed surveyor there would be an equation in the chart indicating how many calories Resident #3 needed. Surveyor read to the dietician the entire dietary noted dating back from 8/28/09. The dietician acknowledged she did not do the equation assessing what Resident #3's calorie needs were. She said she felt the facility aggressively addressed Resident #3's weight loss. She said pocketing would trigger a consistency change evaluation. 11) Record review of the facility's June 2005 Policy and Procedure on Weight Monitoring and Nutrition Assessments documented , in part: "a. The dietician will review the weights when all weights are in the weight log. Unplanned weight loss at 30 days 5 (5%), at 90 days (7.5%), and at 180 days (10 %) will be calculated and a list formulated. Individuals will be assessed and appropriate dietary intervention will be recommended. b. Based on individual resident's needs, the dietary consultant will conduct nutritional assessment and re-assessment and document accordingly. The dietician will participate quarterly in the interdisciplinary team to develop nutritional plan of care." " The Charge nurse will notify the physician and the responsible party of the significant weight loss stats and what dietary/ nursing interventions are planned." "If weight loss/ gain continues after two weeks of intervention, revised interventions are indicated." "Based on acuity and clinical needs, the dietician or dietician consultant will be available to assure each resident a daily diet that meets their daily nutritional and special dietary needs. Record review of the form CMS 672 Resident Census and Condition completed on 11/15/10 by the DON documented there were 146 residents in the building. The facility documented there were 17 residents who experienced unplanned significant weight loss/gain.