Every finding on record at Laredo Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #2) of 5 residents reviewed for resident rights.The facility failed to ensure CNA B did not stand while assisting Resident #2 with Breakfast on 8/28/2026.This failure compromises the residents' right to a dignified existence. Such noncompliance risks causing emotional distress, social isolation, and a diminished quality of life.Findings included:Record review of Resident #2's admission record dated 08/28/26 reflected an [AGE] year-old male with an admit date of 03/03/2025. His relevant diagnoses included Alzheimer's disease (a progressive disorder that causes brain cells to waste away and die, leading to a continuous decline in memory, thinking, and social skills), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), dysphagia, oropharyngeal phase (difficulty moving food or liquid safely from the mouth, through the pharynx, and past the upper esophageal sphincter into the esophagus), and spinal stenosis (a narrowing of the spaces within the spine, which can put pressure on the spinal cord and nerves that travel through it).Record review of Resident #2's significant change MDS assessment dated [DATE] reflected a BIMS score of 2, which indicated his cognition was severely impaired. His functional ability for eating (the ability to use utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal is placed before the resident) was 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 is required for the resident to complete the activity).Record review of Resident's #2 care plan dated 6/17/2026 revealed a focus of Self-Care deficit Limited Physical Functioning r/t stiff or limited joint ROM. RA multiple sites, spinal stenosis LS region. (date initiated 3/27/2025 and revised 3/27/2025) his interventions in part included Eating & Drinking: Set Up Assistance Needed; then usually able to feed self but may require more physical assistance at times x 1 person assistance. Date Initiated: 03/14/2025.During an observation on 8/28/26 at 7:28am, breakfast meal observation was conducted for Resident #2. CNA B was observed standing at the bedside to his left, feeding the resident.During an interview on 8/28/26 at 7:30am, with CNA B, she stated that she was formally taught to sit while feeding residents. She stated sometimes she has fed sitting down but stands as well. CNA B who was feeding Resident #2 could not tell surveyor a negative outcome.During an interview on 8/28/26 at 7:35 a.m., LVN C stated that nurses and management were responsible for supervision over resident care. She said she was the charge nurse over CNA B and said she should have been sitting next to resident during the meal. LVN C stated that a negative outcome would be Resident #2 feeling rushed and could experience weight loss and poor nutrition.During an interview on 8/28/26 at 3:28pm with ADON 1, she stated CNAs should be wearing hair nets and must be sitting down while feeding residents. She said that the clinical reason for sitting was to maintain resident dignity and prevent the resident from feeling rushed, which could lead to adverse outcomes.During an interview on 8/28/2026 at 1:46pm with DON, he stated that during meals, CNAs that were helping residents with feeding, should be sitting at eye level with their residents. DON stated that a negative outcome would be refusing to eat. DON stated they did not have a policy on dignity during mealtimes.

Based on observations, interviews, and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and falls resulting in major injury, were reported immediately, but no later than 2 hours after the suspicion was formed, to the State Survey Agency in accordance with federal and state regulations for 1 (Resident #4) out of 3 residents reviewed for freedom from neglect.The facility failed to immediately, but no later than 2 hours report an unobserved fall for Resident #4 that resulted in a fractured collar bone, and a facial laceration requiring stitches to the State Agency on 05/09/2026.This failure placed the resident population at increased risk for sustained or further potential abuse and neglect due to a complete lack of required external regulatory oversight and administrative monitoring.Findings included: Record review of Resident #4's admission record, dated 08/27/2026, reflected an [AGE] year-old female on hospice who was admitted to the facility on [DATE] with diagnoses including palliative care (specialized medical care focused on providing relief from the symptoms and stress of a serious illness to improve quality of life), Parkinson's disease (a progressive nervous system disorder that affects movement, often causing tremors, stiffness, and slowing of movement), and idiopathic pulmonary fibrosis (a progressive, irreversible disease where the lung tissue becomes thick, scarred, and stiff over time due to an unknown cause, making it increasingly difficult to breathe).Record review of the Resident #4's Discharge MDS assessment on 8/27/2026, dated 05/11/2026, reflected that she was severely cognitively impaired with a staff assessment decision-making code of 3, meaning she never or rarely made daily decisions, and her Brief Interview for Mental Status (BIMS) score was not calculated because the resident was unable to respond properly to questions in the section for calculating the Brief Interview for Mental Status (BIMS). Section GG (Functional Abilities) documented her performance for rolling left and right, lying to sitting, and sitting to lying as 02 (Substantial/maximal assistance-Helper does more than half the effort). Record review of Resident #4's comprehensive care plan on 8/27/2026, completed on 04/17/2026, revealed an active focus area stating: I have memory problems. I am at risk for further decline in my cognition that may affect my ability to communicate my needs/wants and affect my ability in caring for myself/participate in my own care r/t Parkinson's disease. An accompanying intervention initiated on 11/26/2025 mandated that staff: Anticipate my needs if I am unable to tell you what I may want or need.Record review of the Resident #4's nursing progress notes on 8/27/2026, revealed an entry dated 05/09/2026 at 11:35 AM by LVN F, which detailed an unwitnessed fall where the resident was discovered on the floor by staff. The note documented visible blood, a laceration to the right eyebrow, a discoloration to her right forehead, and an abnormal right shoulder with blue/purple discoloration. The resident was transferred via EMS to the acute hospital, where she was diagnosed with a fractured collar bone and a laceration requiring stitches.Record review of the federal iQIES (Internet Quality Improvement and Evaluation System) tracking database on 08/27/2026 at 12:45 PM revealed that the facility did not have an entry submitting an initial incident report regarding Resident #4's fall and subsequent major bone fracture from 5/9/2026.During a telephone interview on 08/28/2026 at 10:42 AM, RN E (Hospice Nurse) said that the resident had a very limited range of motion and was completely unable to move or turn herself independently. He said that during the two weeks prior to her 5/9/2026 fall-wherein she sustained an acute, new fracture-the resident was declining significantly and was entirely unable to move in a manner that could have caused a fall on her own. RN E said that during this period of decline, the resident was completely non-verbal and unable to articulate words.During a telephone interview on 08/29/2026 at 10:18 AM, LVN F said she was the primary floor nurse on duty on the day Resident #4 sustained her unobserved fall and hospital transfer. LVN F claimed that when she directly questioned the resident as to what happened with the fall, Resident #4 stated to her, I leaned over and fell.During an interview on 08/28/2026 at 01:46 PM, the Director of Nursing (DON) confirmed that the resident sustained an unobserved fall resulting in an acute fracture and injury. The DON stated that the internal facility investigation concluded that the resident was capable of carrying on a conversation at that time and stated to staff that she leaned over and fell, and therefore, the facility did not consider it an unknown source fall.During an interview on 08/29/2026 at 12:25 PM, Administrator 1 stated that a fall with a major injury does not automatically need to be reported to the State Agency. He stated that federal and state reporting requirements only mandated an external report if there was an active suspicion of ANE or an injury of unknown source. He said that if the facility's internal review determines how the injury occurred, the incident did not meet criteria for reporting.Record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy, revised January 2024, reflected:Policy: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Policy Explanation and Compliance Guidelines:Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames.

Based on observations, interviews, and record review, the facility failed to comply with federal and state discharge requirements regarding notice and planning for one (Resident #5) of 5 residents reviewed for transfer and discharge.The facility failed to provide a formal 30-day written notice of discharge or a comprehensive transfer plan to the resident and her responsible party and refused readmission following an acute hospital stay on 08/8/2026.This failure placed residents at risk of a lack of treatment and care, decline of condition, emotional distress, and left a vulnerable, long-term resident in an acute care hospital and denied her right to return to her designated home without due regulatory process.Findings included:Record review of Resident #5's admission record, dated 08/29/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her relevant diagnoses included dysarthria following cerebral infarction (difficulty speaking or slurred speech caused by nerve damage from a past stroke), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots), altered mental status, unspecified (a general disruption in brain function causing temporary or chronic confusion and changes in awareness), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis and weakness on the left side of the body resulting from a past stroke), and cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery (a stroke in the back-right section of the brain caused by a blocked or narrowed artery).Record review of the Resident #5's discharge return anticipated MDS on 8/29/2026, dated 8/8/2026, reflected that she was severely cognitively impaired with a staff assessment decision-making code of 3, meaning she never or rarely made daily decisions, and her Brief Interview for Mental Status (BIMS) score was not calculated because the resident was unable to respond properly to questions in the section for calculating the Brief Interview for Mental Status (BIMS). Record review of Resident #5's comprehensive care plan on 08/27/2026, completed on 07/03/2026, revealed an active focus area stating: I wish to remain in the community as LTC. An accompanying intervention initiated on 06/02/2025 mandated that staff: I would like to remain as a resident in the community at this time and not be discharged to an external community.During an interview on 08/28/2026 at 01:38 PM, the resident's family representative (FM 2) stated that the facility was denying readmission to Resident #5, following her treatment for a fall-related left hip fracture. The representative (FM 2) stated that the family had previously signed the facility's bed-hold policy agreement to return to the facility. She said that the facility failed to provide a formal 30-day written notice of discharge, and the acute hospital was now forcing an emergency discharge to a separate, unfamiliar nursing facility because the facility refused to accept the resident back. She stated that facility's administration never notified or met with the family to discuss any clinical inability to meet Resident's #5 needs until the facility learned that a resident's FM placed a complaint to HHSC.During an interview on 08/28/2026 at 01:46 PM, the Director of Nursing (DON) stated that the facility never held a care plan meeting or discussed an inability to meet her needs with the Resident Representative prior to 8/27/2026. The DON further stated that the facility had not issued a formal written 30-day notice of discharge to the family, stating that they instead utilized a generalized, automated text notification system for standard discharges. The DON stated that on the morning of 08/28/2026, the clinical team determined they could meet the resident's medical needs but could not meet the demands of the family to not allow the resident to fall again and to answer the call lights immediately. The DON stated that the Administrator subsequently issued a directive stating that the resident was not to be accepted for readmission.During an interview on 08/29/2026 at 12:25 PM, Administrator 1 stated that he was completely unaware of any specific medical or clinical needs of Resident #5 that the nursing facility team was incapable of meeting. Administrator 1 stated that the reason preventing her readmission was caused strictly by adverse family dynamics that the facility could not accommodate and could not provide what the dynamics were. He further stated that he believed transferring a resident to an acute care hospital created a different set of conditions that bypassed standard notice parameters, stating that a formal 30-day written notice of discharge was only required when a resident was discharged directly to their home from the facility.Record review of the facility's Admission, Transfer, and Discharge policy, revised September 2022, reflected:Policy: The community will not transfer or discharge a resident except when necessary to meet the resident's welfare (and the welfare cannot be met in the community as documented by the physician), the resident's health has improved sufficiently, the safety or health of individuals in the community is endangered, the resident fails to pay after reasonable notice, or the community ceases to operate.Policy Explanation and Compliance Guidelines:Before a resident can be transferred, the community must notify the resident, family member, surrogate, or representative with a written 30-day notice of discharge. A copy of this notice must be kept in the clinical record and a copy sent to the Office of the State Long Term Care Ombudsman. The community is required to provide sufficient preparation and orientation to ensure a safe and orderly discharge, including involving the resident and family in selecting the new residence. Furthermore, the community must notify the resident of its bed-hold and return policies at admission and prior to a hospital transfer, permitting residents to return to their previous room or the first available semi-private room bed if they meet the criteria.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #1) of 3 residents reviewed for quality of care.The facility failed to provide adequate foot care for Resident #1.This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.Findings included:Record review of Resident #1's admission record, dated 08/27/26, reflected a [AGE] year-old female admission date of 5/21/2025. Her relevant diagnoses included dementia (a progressive decline in mental ability severe enough to interfere with daily life), and atherosclerosis (the hardening and narrowing of the arteries due to a buildup of plaque, which can restrict blood flow).Record review of Resident #1's Annual MDS assessment on 8/27/26, dated 05/29/2026, revealed the resident completed the Brief Interview for Mental Status (BIMS) with a summary score of 00, indicating severe cognitive impairment. Resident #1 was coded as substantial/maximal assistance (Helper does more than half the effort. Helper liftsor holds trunk or limbs and provides more than half the effort.) for personal hygiene.Record review of Resident's #1 comprehensive care plan on 08/27/2026, reflected: she had an active care plan structure addressing a self-care deficit related to dementia, impaired vision, and a history of a pelvic fracture The daily care interventions initiated on 05/22/2025 reflected to mandate that staff provide one-person physical assistance for personal hygiene tasks.During an interview and observation on 08/27/2026 at 2:10 PM, FM 1 verbalized significant concern regarding a lack of podiatry care. She stated Resident #1's toenails were overgrown by approximately 1.5 centimeters. FM 1 stated that she has repeatedly requested nail care for more than a month without any intervention from the facility. FM 1 stated that the overgrown nails were causing discomfort, forcing her to continuously readjust her socks at night. During interview, FM 1 removed resident's #1 socks and revealed nails overgrowth of the right big toe protruding upward from nail and the rest of toenails outgrown by 1.5 centimeters long and curved over the front of the toes medially.During an interview on 8/28/2026, CNA A stated that CNAs had a zero role in toenail care, as they were strictly instructed never to perform toenail trimming. He stated that CNAs were only permitted to trim fingernails if the resident was not diabetic, and that residents' toenail care was done by outside specialists.During an interview on 8/28/2026 at 3:28 PM with ADON 1, she stated that CNAs were responsible for performing standard finger and toenail trimming as needed or on specified days like Sundays, unless a resident had an active diagnosis of Diabetes or Peripheral Vascular Disease (PVD), in which case the podiatrist must provide the care. She stated that management monitored nail care during routine rounds. She said she was unaware of any check-off list used to track toenail care.During an interview and observation on 8/28/2026 at 1:46 pm, the DON observed Resident's #1 overgrowth of toenails. The DON stated that a podiatry appointment was arranged three weeks ago but was cancelled because that specific podiatrist no longer performs nail-cutting services. He stated that the facility utilized an external podiatrist who came to the building every 100 days to perform scheduled routine care, and they were currently waiting on a replacement provider as advised by the physician. He added that due to secondary active diagnoses, certain providers cannot see the residents, but the facility policy mandated that all residents with Peripheral Vascular Disease (PVD) or Diabetes Mellitus must be evaluated strictly by a podiatrist. The DON stated that standard, non-risk toenail care should typically be handled by CNAs said that the negative outcome of leaving toenails overgrown can become embedded in the skin and cause severe discomfort. The DON said the facility did not have a policy on foot care.

Based on observations, interviews, and record review, the facility failed to establish and maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) of 5 residents reviewed for infection control.The facility failed to ensure Resident #3's oxygen tubing was maintained in a sanitary manner and kept off the floor on 08/27/2026.This failure could place the residents at risk for cross-contamination and developing healthcare-associated respiratory infections, such as pneumonia.Findings included: Record review of Resident #3's admission record dated 08/27/26 reflected an [AGE] year-old female with an admission date of 08/21/2026. Her relevant diagnoses included acute respiratory failure with hypoxia (a serious clinical condition that occurs when the lungs cannot provide enough oxygen to the blood, leading to dangerously low oxygen levels in tissues and vital organs) and metabolic encephalopathy (a temporary or permanent disorder of the brain caused by underlying metabolic imbalances or disease, resulting in altered mental status and confusion). Record review of Resident #3's comprehensive admission MDS assessment dated [DATE] reflected an incomplete Baseline care plan to address oxygen tubing and care. Record review of Resident #3's physician orders, dated 08/27/2026, reflected active admission orders including: continuous oxygen at 3 liters per nasal cannula to maintain O2 saturation greater than 90% each shift; change oxygen and/or nebulizer tubing weekly. During an observation and interview on 08/27/2026 at 9:32 AM: An interview was conducted with Resident #3. Resident #3 was observed lying in bed with nasal canula on and oxygen tubing touching the floor. Resident # 3 stated she was recently admitted and had to wear oxygen all the time. During an observation and interview on 8/27/2026 at 9:36 am, LVN D was called into the room and observed the oxygen tubing on the floor. LVN D said that oxygen tubing should not be on the floor. LVN D stated that it was the responsibility of all staff members to ensure respiratory tubing was not on the floor. LVN D confirmed that these conditions present a concern because the equipment could easily become contaminated, leading to infections of the resident's respiratory system. During an interview on 8/28/2026 at 1:46pm, the DON said that maintaining and checking oxygen tubing was the mutual responsibility of the floor nurses, Certified Nursing Assistants (CNAs), and unit managers. He stated that the facility utilized a specialized covering sheath to protect the tubing. The DON said that the plastic sheath had not yet been placed to protect the oxygen tube from touching the floor. The DON said that the negative outcome of allowing oxygen tubing to touch the floor was immediate equipment contamination, which could cause bacteria to grow and lead to respiratory infections for the residents. Record review of the facility's Infection Prevention and Control policy, revised April 2024, reflected: 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. Policy Explanation and Compliance Guidelines:9. Prevention of Infection

Based on interview and record review the facility failed to Incorporate the recommendations from the PASARR Level II determination for 1(Resident #1) out of 4 residents reviewed for services received from the PASARR II recommendations. The facility failed to initiate an NFSS within the 20 business days following the date the services were agreed on in the IDT meeting on 12/19/25 for Resident #1. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. The findings included: Record review of Resident#1 face sheet revealed an [AGE] year-old female initially admitted on [DATE], and readmitted on [DATE] with diagnosis of Down Syndrome( a genetic condition caused by an extra full or partial copy of chromosome 21 the extra genetic material alters typical development, causing distinct physical traits, variable degrees of intellectual and developmental delays, and a higher likelihood of specific medical conditions), Muscle Wasting (the thinning or loss of muscle mass), and Myasthenia Gravis is an autoimmune disorder that disrupts nerve-to-muscle communication. Its hallmark is muscle weakness that worsens with activity and improves with rest). Record review of Resident 1#'s Care Plan dated initiated on 05/25/2026 revealed resident is considered PASARR positive and Intellectual disability or development disorder. Interventions included coordinating my plan of care with my Service Coordinator as indicated. Coordinate services and plan of care with the local mental and behavioral health authorities. Provide service coordination with my designated LIDDA. Report any need to re-evaluate specialized services and/or plan of care to service coordinator as well as resident representative or responsible party as indicated. Additional review of the care plan revealed I have a Self-Care deficit related to Downs syndrome; Myasthenia Gravis; Dementia; muscle wasting and atrophy Record review of Resident 1#'s MDS Quarterly dated 05/18/2026 and revealed Resident#1 cognitive skills for daily decision making was severely impaired. The MDS also revealed Resident one was dependent on staff for all ADL Functional abilities for Resident #1 were dependent on helper does not of the effort to complete the activity. Resident #1 walking assessment revealed it was not attempted due to medical condition or safety concerns. The MDS did not have a BIMS score and walking 10 feet was not attempted due to medical conditions. The MDS revealed Resident #1 used a manual wheelchair and was dependent on helper doing all the effort to maneuver wheelchair. No BIMS was available on the MDS. Record review of Resident #1 's progress notes dated 01/13/2026 to 02/13/26 revealed on 01/30/26 in review of Resident #1 Functional Ability it stated Requires assistance with wheelchair mobility for safety. Skilled therapy remains necessary for cueing, strengthening, and improving propulsion techniques to enhance independence and prevent functional decline. Record review of the IDT meeting on dated 12/18/2025 revealed Resident #1 was approved for a customized wheelchair In an interview on 06/16/2026 at 2:49 PM with the claimant stated the facility was contacted by staff in the HHSC PASARR Unit. The Claimant stated the facility was informed of its responsibility of the NFSS PASRR specialized services that were recommended at the IDT meeting on 12/18/2025, but were not initiated within 20 business days following the date the services were agreed to in the IDT meeting, the resident would not receive a PASARR specialized service. The claimant stated the facility was given a specific timeframe to submit the NFSS requests to avoid a regulatory complaint. The claimant stated the facility did not meet this timeframe. According to the claimant, the last request for the wheelchair was resubmitted on 04/23/2026 and was denied and did not provide a follow up submission necessary for approval. In an interview on 06/16/26 at 5:53 PM with the MDS Nurse she stated she was responsible for making sure the PASARR form was filled out correctly and made sure referrals were sent to the correct stated designated authority. The MDS Nurse stated the reason Resident #1 had not gotten services was because on 12/18/25/ the wheelchair was not ordered after the IDT meeting. The MDS Nurse stated it was not until 1/25/26 that she discovered the chair had been approved and had not been ordered for Resident #1. The MDS Nurse stated she the custom wheelchair takes a while and let the party responsible know of the why the chair takes long to receive once the custom wheelchair is ordered. The MDS Nurse stated there was not a person assigned as a back up to her to ensure all PASARR II specialized services were completed and implemented. In an interview on 06/16/2026 at 6:18 PM with the DON he stated he works with the MDS Nurse and at times signed the MDS plans and care plan processes. The DON stated the initial PASARR is completed by the transfer facility and if there is a change in condition with the resident another PASSAR is completed if it was negative before. The DON stated for a significant change in condition with the resident a new PASARR was submitted with a positive finding for ID or MD. The DON stated at admission the MDS Nurse is responsible for making any referrals to the LIDDA. The DON stated MDA Nurse in conjunction with him both make a determination if a resident had an evident or possible MD, ID or related condition for a referral to be sent to the LIDDA. The DON stated the process for referring any new ID or MD identified the appropriate state-designed authority was contacted and sent to the correct entity so services can begin for the resident. The DON stated if a resident does not receive the appropriate service in time or none at all the reason could have been an appropriate screening was not done, but if this occurred, he would immediately advise the physician to make a referral to the LIDDA and a complete PASSAR. In record review of the Comprehensive Assessment policy and procedure dated January 2024 it stated:The PASARR screen lists the specialized services that are required and identifies the services that the state is responsible for providing. The community is responsible for providing the other services needed. The community does not admit new residents with mental illness (MI) or mental retardation (MR) unless approved by the appropriate state mental health or mental retardation agency.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN B accurately assessed and documented Resident #1's newly identified skin impairment including but not limited to characteristics such as measurements, shape, or condition of the surrounding tissue on 02/01/26, in accordance with facility policy. On 02/02/26, record review revealed the wound had progressed and was identified as a Stage IV pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone).This failure could place residents at risk for not receiving the appropriate care and treatment.The findings include:Record review of Resident #1's face sheet dated 04/10/26 reflected a [AGE] year-old-woman with an original admission date of 01/19/26. Diagnoses included displaced intertrochanteric fracture of right femur (break in the upper part of the thigh bone) and orthopedic aftercare.Record review of Resident #1's quarterly MDS dated [DATE], an assessment and formal assessment instrument/tool determined Resident #1 was at risk of developing pressure ulcers/injuries.Record review of Resident #1's SBAR Form Communication Form dated 02/01/26 reflected:LVN B documented: During routine rounds, SN notified by nurse aide (nurse aide unknown) that resident was noted with skin issue to sacrum. Upon assessment, resident noted with redness and dark discoloration to sacrumRecord review of skin assessment dated [DATE], Resident #1's wound went from redness and dark discoloration to a stage 4 on 02/02/26.Record review of Resident #1's progress note dated 02/02/26 reflected: New skin Issue. Location: Sacrum. Laterality / Orientation: Medial (situated in the middle). Issue type: Other skin issue. Progress: New wound. Wound acquired in-house. Wound is new. Painful: No. Length (cm): 7.38 Width (cm): 3.9 Depth (cm): 0 Area (cm2): 19.11Undermining: No. Tunneling: No. Odor after cleansing: None. Surrounding tissue: Erythema.(redness of skin) Edema: No swelling or edema. Periwound (around wound)temperature: Normal. Dressing appearance: Intact. Dressing saturation: None 0%.MD and RP notified.Record review on 04/10/26 of Resident #2's task documentation reflected that the resident was repositioned every two hours in accordance with the established care plan. Documentation entries consistently indicated that staff performed routine repositioning interventions to reduce the risk of skin breakdown and promote skin integrity. Interview attempted via phone on 04/10/26 at 11:23 am and 04/10/26 at 11:57 am, to LVN B, were unsuccessful.A text message was sent to LVN B on 04/10/26 at 1:28 pm, unsuccessful.During an observation on 04/10/26 at 12:15 pm revealed, the WCN and CNA A performed wound care for Resident #2 in accordance with physician orders. No concerns were identified at that time, aside from infection control practices.In an interview on 04/10/26 at 2:07 pm, CNA C stated she frequently assisted Resident #2 with bathing and had not observed any skin concerns. CNA C further stated if any skin concerns were identified, she would have reported it immediately. In an interview on 04/10/26 at 2:12 pm, CNA D stated she frequently assisted Resident #2 with bathing and had not observed any skin discoloration or redness prior to 02/01/26. CNA D stated Resident #2 did not exhibit signs or symptoms of pain. In an interview on 04/10/26 at 4:34 pm the DON stated, nursing staff are expected to assess all new areas of skin concern, including determining size, stage, if applicable. The DON stated that, based on the description of the skin discoloration, LVN B should have assessed and measured the area evaluating whether it was blanchable.The DON indicated that photographing wounds was not consistently completed unless prompted by the documentation system, noting that when a photograph was entered, the system prompts for wound measurements. The DON stated since Resident #1's skin concern was not photographed; the system did not prompt for measurements.In an interview on 04/10/26 at 4:44 pm, the WCN stated all skin concerns are assessed and measured. The WCN further stated that residents should be assessed for pain in relation to skin concerns.Record review of the facilities Skin and Wound Prevention and Management policy dated January 2023 reflected: Guideline Statement:An individual's skin is the largest organ of the body. At times skin failure may occur; however, the community will ensure that a resident admitting into the community will evaluated and identify the associated risks that may result in skin breakdown. The medical provider should consider the resident's current health status, function abilities, comorbidities as well as medications to determine if a pressure ulcer injury should be considered avoidable or unavoidable in etiology. Thus, a plan of care will be developed and implemented based on the identified needs, associated risks, and current skin conditions. Each resident will receive the care and services necessary to retain or regain optimal skin integrity. Skin Prevention Program will: Identify associated risks for alterations in skin integrity or development of pressure ulcers injuries. Identify early onset skin breakdown so that the IDT may implement appropriate interventions as clinically indicated. Guideline:7. A licensed nurse or therapist will measure the wounds as in order of length, width, and depthDocumentation:Exception to normal skin integrity such as abnormal skin conditions should be documented within the E.H.R: Type of skin injury/ulcer Location, shape, ulcer edges, and wound bed: Measurements of wound/skin injury Condition of surrounding tissues; Determine the etiology of the wound.

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 one (Resident #2) of five residents reviewed for infection control practices. 1) The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior and after performing Resident #2's wound care. 2) 1)The facility failed to ensure the WCN performed hand hygiene in between glove changes during Resident #2's wound care.3) The facility failed to ensure CNA A performed hand hygiene in between glove changes while aiding in Resident #2's wound care.These failures could place residents that require wound care at risk for healthcare associated cross-contamination and infections.Findings include:Record review of Resident #2's face sheet dated 04/10/26 reflected an [AGE] year-old-female with an original admission date of 05/30/24. Diagnoses included Parkinson's disease (progressive neurological disorder that primarily affects movement. It is characterized by the degeneration of nerve cells in the brain, chronic (long term) kidney disease, seizures, and high blood pressure. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 6 (severe cognitive impairment). Resident #2 functional abilities revealed dependent for Eating, Oral hygiene, toileting, shower/bathing, dressing, and personal hygiene.Record review of Resident #2's care plan revised on 03/04/26 reflected:Resident #2 had a stage 3 pressure ulcer (issue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible) to the sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis) and was at risk for skin impairment due to co-morbidities, chronic medical conditions that could lead to worsening. Interventions included: Enhanced barrier precautions as clinically indicated Interventions necessary to promote skin healing/resolving of injuriesRecord review of Resident #2's physician orders dated 02/26/26 reflected:Cleanse stage 3 sacrum wound with wound cleanser or normal saline, pat dry only, do not scrub. Apply collagen dressing to wound bed. Secure with dry dressing or bordered dressing. PRN if soiled or dislodged one time a day every Monday, Wednesday, and Friday. Observation of wound care on 04/10/26 at 12:15 pm revealed:-The WCN performed hand hygiene for approximately 10 seconds prior to initiating wound care for Resident #2.-The WCN did not perform hand hygiene between glove changes prior to wound care.-During wound care, CNA A did not perform hand hygiene between glove changes.-After completion of wound care for Resident #2, the WCN performed hand hygiene for approximately 17 seconds.In an interview on 04/10/26 at 12:52 pm, the WCN stated she believed she performed hand hygiene after removing her gloves each time. The WCN stated that proper handwashing should be performed for at least 20 seconds to remove contaminants and help prevent infection. In an interview on 04/10/26 at 12:56 pm, CNA A stated that proper hand hygiene was important to prevent infection. CNA A further stated Resident #2 was bedbound with co-morbidities and that proper handwashing was necessary to prevent cross contamination and possible infections. CNA A stated hands should be washed for 20 to 30 seconds. CNA A stated she had hands on training for handwashing about a month ago.In an interview on 04/10/26 at 1:04 pm, the ICP stated staff should perform hand hygiene for at least 20 seconds, as it was the amount of time needed to remove bacteria and dirt from the hands and wrist. The ICP stated that if a resident's body does not have adequate defense mechanisms to prevent a wound, the wound could become infected or worsen. The ICP further stated the facility provides monthly hands-on in-service training on hand hygiene and infection control. Additionally, the ICP states gloves are not 100% effective in preventing cross-contaminationIn an interview on 04/10/26 at 2:20pm the DON stated handwashing should be performed for 20-30 seconds to ensure hands are thoroughly cleaned and bacteria are effectively removed. The DON stated that if hand hygiene was not performed appropriately, microorganisms could remain on the hands and increase the risk of infection. The DON further stated the ICP conducts monthly hands-on in-service training for all staff on infection control. Additionally, the DON stated staff should perform hand hygiene, including handwashing or hand sanitizing, after each glove removal to prevent cross-contamination and the spread of pathogens.Record review of the facilities Handwashing/Hand Hygiene policy dated January 2023 reflected: GuidelineThis facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation2. 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 the situations such as this )including but not limited to):Between glove changes/After removing gloveswww. cdc.gov guidelines reflected: The CDC provides a clear, five-step process for effective handwashing with soap and water. Here are the steps to follow:1. Wet your hands with clean, running water (warm or cold).2. Apply soap and lather your hands by rubbing them together.3. Scrub your hands for at least 20 seconds, ensuring all areas are covered.4. Rinse your hands well under clean, running water.5. Dry using a clean towel or air dryer.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 4 of 8 residents (Resident #1, Resident #2, Resident #6, and Resident #14) reviewed for medical records.1. The facility failed to ensure RN C did not document a blood sugar of 2 on Resident #1's MAR when she refused finger sticks and insulin on 23 of 23 opportunities from 02/01/26 to 03/05/26.2. The facility failed to ensure LVN B, RN C, LVN D, LVN F, LVN G, and LVN H documented accurate Neuro Check vital signs for Resident #2 after he fell on [DATE].3. The facility failed to ensure RN C documented Resident #6's blood pressure on the MAR when the resident's blood pressure altering medication was not administered because it was outside of the parameters for administration on 17 of 20 opportunities from 02/04/26 to 03/05/26.4a. The facility failed to ensure LVN G documented accurate vital signs on Resident #14's Admission/re-admission assessment when he returned from the hospital on [DATE].4b. The facility failed to ensure RN C did not document a blood sugar of 2 on Resident #14's MAR when he refused finger sticks and insulin on 13 of 13 opportunities from 02/09/26 to 03/05/26.This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.1. Record review of Resident #1's admission record reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), essential (primary) hypertension (high blood pressure), non-traumatic subdural, intracerebral, and subarachnoid hemorrhages (brain bleeds/strokes not caused by trauma), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 00 which indicated severe cognitive impairment.Record review of Resident #1's care plan dated 03/26/25 reflected the focus, I have diabetes and am at risk for complications associated with diabetes. Interventions included, Administer my medications as recommended by my doctor, monitor labs as indicated. Promptly report abnormal lab results and significant clinical findings to my doctor as indicated, initiated on 04/02/25.Record review of Resident #1's physician's order summary on 03/04/26 reflected the following active order: Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector. Inject as per sliding scale: if 180 - 200 = 2 units; 201 - 230 = 3 units; 231 - 260 = 4 units; 261 -290 = 5 units; 291 - 320 = 6 units; 321 - 350 = 7 units; 351 + = 8 units- Administer and notify MD., subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Start date was 04/23/25.Record review of Resident #1's February 2026 MAR reflected RN C documented a blood sugar of 2 and documented code 10 which indicated, resident refused- nurse aware in the space for administered/not administered on:6:00 am on 02/01/26 through 02/04/26 (4 opportunities to check resident #1's blood sugar/administer insulin),6:00am on 02/07/26 through 02/10/26 (4 opportunities),6:00 am on 02/13/26 through 02/16/26 (4 opportunities),6:00 am on 02/19/26 through 02/22/26 (4 opportunities), and6:00 am on 02/25/26 through 02/28/26 (4 opportunities).Further review of Resident #1's February 2026 MAR reflected 6 other instances when another nurse documented Resident #1 refused her fingerstick and documented an X in the space for blood sugar documentation, which indicated a numeric value did not have to be entered in that space.Record review of Resident #1's March 2026 MAR reflected RN C documented a blood sugar of 2 and documented code 10 which indicated, resident refused- nurse aware in the space for administered/not administered on:6:00 am on 03/03/26 through 03/05/26 (3 opportunities).An interview with Resident #1 was attempted on 03/04/26 at 1:45 pm, however she was not able to answer any questions appropriately.2. Record review of Resident #2's admission record reflected a [AGE] year-old female resident originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included congestive heart failure (when the heart does not pump blood as well as it should causing fluid to build up in the lungs), chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), atrial fibrillation (an irregular, often fast heartbeat), presence of cardiac pacemaker (device that is implanted in the chest with wires into the heart that send electrical signals to keep the heart beat regular), essential (primary) hypertension (high blood pressure), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 6 which indicated severe cognitive impairment.Record review of Resident #2's progress note dated 02/21/26 at 11:00 pm, RN C wrote, [Resident #2] was found sitting on the floor next to bed, confused and disoriented, 110/64, 98.2, 64, 97%r a, 20, assessed and assisted back to bed, able to flex and extend all 4 extremities as before, has a approximately 2 superficial skin tear to outer right elbow, cleansed and dressing applied, no c/o pain and in no acute distress.Record review of Resident #2's Neuro Checks form effective 02/21/26 at 11:00 pm reflected the following:RN C documented Resident #2's fall was not witnessed, and she did not have evidence of a possible head injury. RN C documented on neuro checks: 15 minute #'s 1-4, 30 minute #'s 1-4, and 60 minute #'s 1-4 (12 total opportunities from 02/21/26 at 11:00 am through 02/22/26 5:45 am) Resident #2 was alert, pupils were equal and reactive to light, she was able to move all extremities, was unable to follow commands, and had an appropriate response to pain. RN C did not document any vital signs for those 12 checks.LVN B documented on neuro checks 2 hour #'s 1-4 (4 opportunities: 02/22/26 at 7:45 am through 02/22/26 at 1:45pm).LVN G documented on neuro checks 4 hour #'s 1-2 (2 opportunities: 02/22/26 at 5:45 pm and 02/22/26 at 9:45 pm) Resident #2 was alert, pupils were equal and reactive to light, left and right pupils were brisk, hand grasps were equal, she moved all extremities, was able to follow commands, and had an appropriate pain response.Further review of LVN B and LVN G's documentation reflected the most recent pain level: 0, most recent blood pressure: 122/78, most recent temperature: 97.4, most recent pulse: 76, and most recent respiration: 18. All 6 sets of vital signs were dated 02/22/26 at 12:39 am.LVN H documented on neuro check 8 hour #1, Resident #2 was alert, pupils were equal and reactive to light and hand grasps were equal. LVN H documented most recent pain level and most recent vital signs as 02/22/26 at 12:39 am and were all the same as LVN B and LVN G documented.LVN B documented on neuro check 8 hour #2 (02/22/26 at 1:45 pm) Resident #2 was alert, pupils were equal and reactive to light, hand grasps were equal, she moved all extremities and had an appropriate pain response. LVN B documented Resident #2's most recent pain level: 0 on 02/23/25 at 9:10 am, most recent blood pressure: 119/80 on 02/23/26 at 11:51 am, most recent temperature: 97.1 on 02/23/26 at 9:11 am, most recent pulse: 80 on 02/23/26 at 12:43 pm, and most recent respiration: 18 on 02/23/26 at 9:11 am.LVN G documented on 8 hour #3 (02/23/26 at 9:45 pm), Resident #2's most recent vital signs were done on 02/22/26 at 12:39am.LVN H documented on 8 hour #4 (02/24/26 at 5:45 am), Resident #2's most recent vital signs were done on 02/22/26 at 12:39am.LNV D documented on 8 hour #5 (02/24/26 at 1:45 pm), Resident #2's most recent vital signs were done on 02/22/26 at 12:39am.LVN F documented on 8 hour #6 (02/24/26 at 9:45 pm), Resident #2's most recent vital signs were done on 02/22/26 at 12:39 am.In an interview on 03/05/26 at 10:15 am, Resident #'2 RP stated Resident #2 fell because she would forget she could not get out of bed on her own. The RP stated she visited Resident #2 the morning after the fall for at least a couple of hours and did not recall the nurse checking vital signs while she was there.3. Record review of Resident #6's admission record reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included essential (primary) hypertension (high blood pressure), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis on one side of the body after a stroke), unspecified bradycardia (slow heartbeat), presence of a cardiac pacemaker (a small, battery-powered device surgically implanted under the skin to treat slow or irregular heartbeats), end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), aphasia (an impairment in the ability to read, write, and speak), dysphagia (difficulty swallowing), and gastrostomy status (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication).Record review of Resident #6's care plan dated 11/20/25 reflected the focus of heart disease and hypertension created on 12/04/25 and revised on 01/15/26. Interventions included: administer medications as ordered, educate and encourage compliance with medications, and monitor vital signs as indicated and report abnormal findings to provider as indicated, all initiated 12/04/25.Record review of Resident #6's order summary report on 03/05/26 reflected the following order:Hydralazine Hcl Oral tablet 100mg. Give 1 tablet via PEG-tube three times a day related to essential (primary) hypertension. Hold if systolic blood pressure (top number) is less than 110. Start date 02/01/26. Administration times were 6:00 am, 2:00 pm, and 10:00 pm.Record review of Resident #6's February MAR reflected:6:00 am on 02/04/26, (1 of 1 opportunity)6:00 am on 02/08/26 through 02/10/26 (3 opportunities),6:00 am on 02/15/26 and 02/16/26 (2 opportunities),6:00 am on 02/19/26 through 02/22/26 (4 opportunities), and6:00 am on 02/25/26 through 02/28/26 (4 opportunities).Record review of Resident #6's March 2026 MAR reflected:6:00 am on 03/03/26 through 03/05/26 (3 opportunities).Further review reflected on 16 of 19 total opportunities, RN C documented Resident #6's blood pressure as X and documented code 3 which indicated, Held: BP outside parameters in the space for administered/not administered.Record review of Resident #6's February and March 2026 progress notes reflected the following:02/04/26 at 5:11 am by RN C. eMAR- Medication Administration Note. Note text: Hydralazine HCI Oral Tablet 100mg. Give 1 tablet via PEG-Tube three times a day for Hypertension. Hold if systolic pressure is less than 100. (No blood pressure or other information documented.)Further review reflected there were no eMAR Medication Administration notes documented by RN C regarding Resident #6's hydralazine non-administration on 02/08/26 through 02/10/26, 02/15/26 and 02/16/26, 02/19/26 through 02/22/26, 02/25/26 through 02/28/26, or 03/03/26 through 03/05/26.Record review of Resident #6's blood pressure summary from 02/04/26 through 03/05/26 reflected RN C did not document any blood pressures for Resident #6 on the dates that her blood pressure medication was not administered due to other or BP outside parameters.An interview was attempted with Resident #6 on 03/05/26 at 10:45 am but was not possible due to her diagnosis of aphasia.4. Record review of Resident #14's admission record reflected a 96-yeear-old male admitted to the facility on [DATE]. His diagnoses included cerebral ischemia (stroke caused by decreased blood flow and oxygen to the brain due to a clot or narrowed arteries), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), essential (primary) hypertension (high blood pressure), persistent atrial fibrillation (irregular, often fast heartbeat), unspecified heart failure (when the heart does not pump blood as well as it should causing fluid to build up in the lungs), and traumatic subdural hemorrhage with diffuse traumatic brain injury (stroke caused by bleeding in the brain due to trauma such as a fall).Record review of Resident #14's admission MDS dated [DATE] reflected a BIMS score of 8 which indicated moderate cognitive impairment.Record review of Resident #14's care plan dated 12/28/25 reflected a focus of diabetes created on 12/28/25. Interventions included: provide teaching and education regarding my diabetes diagnosis and treatment recommendations to resident and/or care support person as indicated, administer medications as recommended, monitor labs as indicated, and promptly report abnormal lab results and significant clinical findings to the doctor as indicated. Created on 12/29/25.Record review of Resident #14's Nursing Admission/readmission form dated 02/28/26 and signed by LVN G reflected the following:Most recent blood pressure was dated 02/24/26 at 9:06 pm and most recent temperature, pulse, respirations, oxygen saturation, and pain level were dated 02/24/26 at 3:07 pm.Record review of Resident #14's order summary on 03/05/26 reflected the following active order: NovoLog Flex:Pen Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Aspart) Inject as per sliding scale: if 181 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units; 401 + advise MD if above 400, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Start date was 02/07/26.Record review of Resident #14's February MAR reflected the following:6:00 am on 02/09/26 and 02/10/26 (2 opportunities),6:00 am on 02/13/26 through 02/16/26 (4 opportunities), and6:00 am on 02/19/26 through 02/22/26 (4 opportunities).Record review of Resident #14's March 2026 MAR reflected:6:00 am on 03/03/26 through 03/05/26 (3 opportunities).Further review reflected on 13 of 13 total opportunities, RN C documented Resident #14's blood sugar as 2 and documented code 10 which indicated, resident refused-nurse aware in the space for administered/not administered.In an interview on 03/04/26 at 9:40 am, Resident #14 stated he did not like to be woken up to check his blood sugar but if he was already awake he was usually ok with the fingerstick. He stated he needed insulin every once in a while. Resident #14 stated he does not recall having any issues with his blood sugar being too low.In an interview on 03/05/26 at 11:15 am, LVN D stated RN C sometimes told her when he did not give early morning medications to residents. She stated she would not know that a medication was not given unless she went back into the MAR and looked at it. LVN D stated when medications were due during her shift, they would show up as red on the screen when she pulled up the resident's MAR. She stated Resident #1 and Resident #14, had not had any issues with their blood sugars on her shift and she did not have to give them insulin at lunch as their blood sugars were below the limit to give it. LVN D stated when blood sugars were checked, they were documented in the MAR. If a resident refused a fingerstick, in the old system they would leave the space blank for the fingerstick result and document refused. She stated in the new PCC system, she was not sure if there had to be a numerical value in the space or not. LVN D stated if she saw a 2 documented for the blood sugar, she would have thought she needed to go do a fingerstick to see what the sugar was and looked to see if interventions were done to manage hypoglycemia. LVN D stated if a resident refused a medication or the VS were not within parameters to give, the MAR automatically generated a progress note and auto-populated the order, but the nurse had to document the reason for not giving the medication or any other comments either at the beginning or at the end of the order. LVN D stated she was not notified by RN C on 03/05/26 at shift change that Resident #14 did not receive his Novolog, Resident #1 did not receive her Insulin, and Resident #6 did not receive her hydralazine. LVN D stated it was important to tell the oncoming nurse that a medication was not given during the shift so the oncoming nurse could either give the medication or check the resident and/or notify the physician. She stated if a resident refused a mediation because it was too early in the morning on her shift, she would not mark it as not given if it was within 30 minutes to an hour before shift change so the oncoming nurse could try to give it when they were on shift or contact the provider to ask about changing the administration time. LVN D stated when a resident fell, they were assessed, vital signs were checked, and if something was abnormal, they called 911; if things were ok, the nurse notified the provider and RP then completed the Post Fall Review form and initiated the Neuro Checks form in PCC. LVN D stated VS were to be checked at each neuro check interval and documented in the Neuro Check form in PCC. She stated the Neuro Check form auto- populated the most recent documented vital signs and the nurse had to make sure to change them to the VS for that interval. LVN D stated if VS were not done and documented with each neuro check interval, the nurse was not doing a complete assessment and could miss a change in condition. LVN D stated if the resident had a change in condition that was not caught, the resident could decline. She stated they could document VS in the tab for weights/vitals or in the MAR and they would cross over both directions. LVN D stated medication administration was in-serviced once a month, and the last one was a few days ago. She stated fall/post-fall and documentation in general were done about once a month.In an interview on 03/05/26 at 1:25 pm, RN E stated if she had a resident refuse a medication at the end of her shift, she would notify the physician and see if he had any new orders, then notify the family. She stated if the resident complained about the timing of the medication, she would talk to the physician to see if they could change the order time. She stated she would let the next nurse know that the resident refused the medication. RN E stated it was important to let the other nurses know that the resident did not get his medication due to refusal or not VS not in parameters so that they were aware of what was going on with the resident and if their VS or blood sugar was high, it would explain why. RN E stated if a resident refused a fingerstick, the MAR would let you leave the BS blank and it would only accept numbers, not an X. If she saw a BS of 2 with resident refused, she would still do an assessment to ensure that the BS was not too low. RN E stated if a resident had a blood pressure that was outside of parameters she would document the BP in the MAR and in the progress notes. She stated if a medication was not administered because VS or blood sugar were outside of parameters and it was not passed down in report or documented, she would not have a way to know what the resident's blood pressure (or blood sugar) was. RN E stated if a resident fell, she would assess resident and check VS. After notifications and if the resident did not need to go to the hospital she initiated neuro checks. RN E stated when the neuro checks form was started, it automatically put in the most recent vital signs for the first check and those would have to be replaced with the ones she got during the assessment. RN E stated from the 2nd 15 minute check on, it would auto populate the VS she entered on the 1st 15 minute check, so she had to change the VS to the most recent ones. She stated it was important to document everything in the proper places so that everyone would know what was going on with the resident and if things were not documented, things could get missed. RN E stated if things were not documented or passed down, it could cause delays in care or treatment or adverse outcomes.On 03/05/26 at 2:05 pm, an attempt was made to contact RN C by phone. There was no answer and a message that said the mailbox was full, so a text message was sent at 2:07 pm. There was no response from RN C.In an interview on 03/05/26 at 2:35 pm, LVN F stated when she pulled up a new neuro check form, it auto populated the most recent vital signs that were in the system for that resident, and she had to manually go in and change the VS for each check. LVN F stated if a resident had a sliding scale insulin and they refused the fingerstick, the MAR required a number to be put in the space for the blood sugar, or it would not let her continue on. She stated she had tried to put an x or leave it blank, but it would not work. LVN F stated VS were put into the MAR or the vital signs tab. She stated if a resident's BP was outside of parameters to give a medication, she documented it in the space for the BP on the MAR and in the progress notes under the medication order. LVN F stated if a resident refused a medication, she entered it in a progress note and passed it on to the next nurse. She stated it was important so the next nurse knew what was going on and knew whether or not they needed to recheck something.In an interview on 03/05/26 at 2:50 pm, ADON I stated it was important to document the results of VS or blood sugars in the MAR and progress notes so everyone was aware of what was happening with the resident and could recheck or reassess as necessary. ADON I stated if non-administration of medications, and vital signs, and/or blood sugars were not documented it could lead to residents having adverse outcomes. She stated it was important to document accurate VS on neuro checks because resident conditions could change and could be missed leading to bad outcomes.In an interview on 03/05/26 at 3:26 pm, the DON stated it was important to document results (VS, blood sugars) to monitor trends/changes that might require doctor intervention. He stated sometimes the MAR auto populated a progress note if a medication was not given and the nurse was not mandated to enter any further information on that note. The DON stated if a medication was not administered, it was best practice that a progress note was manually entered with what medication was not administered and why it was not administered, and MD notification if necessary. He stated if a medication had a space for vital signs, they needed to be entered, and it was not acceptable to put an x where a vital sign should have been. The DON stated the nurse who did not administer a medication for whatever reason needed to tell the next nurse what was not given and why so they could follow up. He stated it was important to document VS accurately on neuro checks to monitor for any signs of head injury. The DON stated admission/readmission documentation was important because it was the first assessment of the resident and shaped how care would be done. For example, V/S were important to get a baseline of resident status.Record review of the facility's Medication Administration policy dated 03/2019 and revised 01/2024 reflected in part: Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner.5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose (e.g., pulse with digitalis).6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.Record review of the facility's Falls Prevention Guideline dated 03/28/22 and revised 01/2024 reflected in part: Post fall:Document all assessments and actions.Record review of the facility's Professional Standard of Care policy dated 02/2017 and revised 01/2024 reflected in part: Compliance Guidelines:The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified).Compliance with Professional Standard of Care Nursing Practicesa) Licensed nurses should practice within the constraints of applicable state laws and regulations governing their practice and should follow the guidelines contained in the communities' written policies and procedures.e) Nurses should conduct assessments or evaluations and document within the medical record in the following instances:1) admission, re-admission and as clinically indicated.2) at the time of accidents, incidents or change in conditions.3) when exceptions are identified.4) as otherwise directed.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #87) of 3 residents reviewed for respiratory care.The facility failed to ensure Resident # 87's oxygen was administered at the correct setting of 2 liters per minute on 3/03/2026 as ordered by the physician.This deficient practice could place residents at an increased risk of developing respiratory complications and a decreased quality of care.The Findings included:Record review of Resident #87's admission record dated 3/03/26 indicated an [AGE] year-old female with an admission date of 2/19/2026. The resident had a diagnoses which included: Chronic Obstructive Pulmonary Disease (a progressive and irreversible lung disease that makes breathing difficult by damaging airways and air sacs, causing inflammation), Acute Respiratory Failure with Hypoxia (a condition defined by the respiratory system's failure to maintain adequate blood oxygen levels), and Interstitial Pulmonary Diseases (a group of chronic, often progressive, lung conditions causing inflammation and scarring of the lung tissue).Record review of Resident #87's Quarterly MDS assessment, dated 2/26/2026, indicated Resident #87's BIMS score of 4 (indicated severe cognitive impairment). Section O- Special Treatments, Procedures, and Programs. Respiratory Treatments indicated Oxygen therapy was checked off.Record review of Resident #87's active orders as of 3/03/2026 indicated Continuous Oxygen 2 liters per N/C every shift. Order Date:2/19/2026.Record review of Resident # 87's care plan dated 11/28/2026 indicated FOCUS: Oxygen therapy r/t Chronic Lung Disease. GOAL: Will have no s/sx of poor oxygen absorption through the review date. Interventions: .Provide oxygen as ordered/recommended by my physician.During an observation of Resident #87 on 3/03/2026 at 10:56 AM revealed the setting on the portable oxygen tank was at 2.5 Liters Per Minute via Nasal Canula. Observation of Resident # 87 revealed the resident was sitting up in her wheelchair. No signs of respiratory distress noted.In an interview on 3/03/2026 at 11:00 AM with LVN B, she said she was not sure who had placed the resident on the portable oxygen tank with the setting at 2.5 Liters. She said she had checked the oxygen setting at the beginning of her shift and was set at 2 liters on the oxygen concentrator. LVN B checked Resident #87's oxygen saturation and was at 94%. She said the resident had COPD and too much oxygen could cause the residents lungs to expand and cause hyperoxygenation. LVN B said she had an in-service on respiratory services three months ago.In an interview on 3/05/2026 at 1:43 PM with ADON I, she said Resident #87's family possibly increased the oxygen setting. She said the managers were assigned Residents' rooms to check in the residents and ensured the resident's needs were being met. ADON I said oxygen settings were checked during the managers' rounds. She said a negative outcome of not receiving the prescribed dose of oxygen could cause altered mental status due to over oxygenation. ADON I said the oxygen setting should be set at the prescribed rate.In an interview on 3/05/2026 at 2:00 PM with the DON, he said Angel rounds (manager rounds assigned residents' rooms) were performed in the morning to check oxygen settings and the care plan order set which includes interventions. He said nurses made rounds and received alerts from EMR software to check Oxygen settings which they then signed off in the MAR as done. The DON said a negative outcome for a residents that had COPD was SOB and respiratory failure due to too much oxygen. He said in-services on respiratory services were done upon hire, annually, and as needed.Record review of the facility's policy titled Medication Administration dated March 2019 indicated Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner.6. Administer medications as ordered by the physician.Record review of the facility's policy titled Oxygen Administration dated March 14, 2019 indicated Compliance Guidelines: A resident receives oxygen therapy when there is an order by a physician.3. Obtain physician orders for oxygen administration.c. flow rate of delivery.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 medication refrigerators in the medication storage room. The facility failed to ensure medications in the medication room refrigerator were stored at an appropriate temperature. The failure could place residents in the facility at risk of receiving expired medications from staff.Findings included:Record review of the March 2026 medication room refrigerator temperature log revealed the temperature was signed off by ADON J on 03/04/26 stating the temperature was 37 degrees Fahrenheit. Further review revealed the instructions Adjustments To Refrigerator - Record adjustments to correct temperature that is not between 36 to 46 F During an observation of the medication room refrigerator at 4:05 PM on 03/04/26, the refrigerator had two different thermometers placed inside. The refrigerator contained various medications for several residents. One thermometer in the center back area of the top shelf read 24 degrees Fahrenheit. The other thermometer in the back left area of the bottom shelf read 28 degrees Fahrenheit. The DON saw these temperatures and adjusted the refrigerator's setting to increase the temperature. In an interview with ADON J at 10:35 AM on 03/05/26, ADON J stated she checked on the temperature of the medication room refrigerator at around 8:30 AM on 03/04/26. ADON J stated she had never seen the temperature outside of the appropriate range between 36 and 46 degrees Fahrenheit. ADON J stated if the medications were stored outside of the appropriate temperature then some could go bad and become less effective when administered to a resident. In an interview with the PC at 2:23 PM on 03/05/26, the PC stated, per the FDA, refrigerators storing medications should not be below 36 degrees Fahrenheit. The PC stated the refrigerator was audited quarterly and there had been no previous issues noted with the temperature of the refrigerator. The PC stated if the temperature in the refrigerator was below 36 degrees for an extended period of time of at least several hours medications could start to crystalize becoming less effective. The PC stated it was possible for the thermometers to give a false low reading if they were too close to the refrigeration unit. In an interview with the DON at 3:13 PM on 03/05/26, the DON stated he observed the temperature readings in the refrigerator at 4:05 PM on 03/04/26 to be 24 degrees and 28 degrees Fahrenheit from the thermometers in the medication room refrigerator. The DON stated there were various medications stored in the medication room refrigerator for residents in the facility. The DON stated the appropriate temperature range to store medications in the refrigerator was between 36 and 46 degrees Fahrenheit. The DON stated the medications could lose potency and become less effective if left outside of the correct temperature range for too long. The DON stated they did not have a facility policy covering the appropriate storage temperature for medications. In an interview with the DON at 9:25 AM on 03/05/26, the DON was asked for a policy covering the appropriate storage conditions for medications in the refrigerator in the medication room, but none was provided.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #118) of 2 residents observed for contact precautions.SW did not don PPE before entering Resident #118's room on 3/03/2026. Resident #118 was under Contact Precautions as per physician orders.This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.The findings included:Record review of Resident #118's admission record dated 3/03/2026, with an admission date of 2/26/2026, indicated a [AGE] year-old female with diagnoses of Bacteremia (presence of bacteria in the blood stream), Extended Spectrum Beta Lactamase [ESBL] Resistance (bacteria that have developed superbug enzymes capable of breaking down and destroying, last-resort antibiotics like penicillin), and Unspecified Escherichia Coli [E. Coli] as the Cause of Diseases Classified Elsewhere (bacteria commonly found in the intestines of humans and animals).Record review of Resident # 118's MDS assessment dated [DATE], indicated a blank section under C0500 BIMS Summary Score. Section I- Active diagnoses indicated I1700. Multidrug-Resistant Organism (MDRO) and I2000. Pneumonia were checked off. I8000 Additional active diagnoses indicated B. UNSP ESCHRICHIA COLI AS THE CAUSE OF DIEASES ELSWHR C. BACTEREMIA.Record review of Resident #118's care plan dated 2/26/26 indicated FOCUS: At [NAME] for infection or recurrent/chronic infection r/t compromised medical condition.Record review of Resident #118's order summary dated as of 3/03/2026, indicated Isolation: Contact Isolation Precautions: ensure infection site is contained prior to leaving room. If not able to contain infection source, then resident/patient should remain in room for all care/services. Every shift for E coli ESBL in blood and urine until 3/05/2026. Date Ordered: 2/27/2026.In an observation on 3/03/3026 at 9:05 AM, SW was seen in Resident # 118's room without the required PPE (gown). There was a sign at the entrance to the resident's room stating Contact Precautions which listed the type of PPE staff were supposed to don when entering the resident's room. The Contact Precautions sign indicated wearing a gown when entering the resident's room.In an interview on 3/03/2026 at 9:10 AM with SW, she said that she had gone into the room because the resident was under hospice services and was nearing the end and the family had wanted to speak to her. She said she went into the resident's room and afterwards realized the resident was under contact precautions. The SW said a negative outcome to not wearing the appropriate PPE was that the staff can be contaminated and that cross contamination was an infection control problem. She said infection control in-services and reminders were given every week.In an interview on 3/03/2026 at 9:36 AM with RN A, Infection Preventionist, said she held in-services monthly on PPE and handwashing. She said she was going to re-educate the staff on Contact Precautions. RN A said the negative outcome to not wearing the appropriate PPE was that infections could be transmitted to other residents and staff which could create cross contamination. She said the resident was under contact precautions due to positive blood and urine cultures.In an interview on 3/05/3036 at 2:00 PM with the DON, he said Contact Precautions were ordered by the physician and were included in the resident's care plan. He said sign specifying Contact Precautions were placed under the resident's room number which identified the resident under the precautions. The DON said shelving, which included the PPE, was placed outside the resident's room which served as an extra cue to the staff. He said all staff received in-services on TBP upon hire, annually, and as needed. He said the negative outcome of not wearing appropriate PPE was cross contamination between staff, family, and other residents.Record review of policy titled Infection Prevention and Control dated March 13, 2019, indicated .11. Categories: Types of Isolation Precautions: .Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment.d.wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the resident of contaminated surfaces.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a 2-person assist while conducting incontinent and bed mobility care for Resident #1 on 03/18/2025 which led to Resident #1 sustaining a fall. This failure could place residents at risk for falls, injuries and a decline in health.Findings include: Record review of Resident #1's admission record dated 10/04/2025 revealed Resident #1 was a [AGE] year-old female, who initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including: Parkinson's disease (movement disorder) with dyskinesia (involuntary muscle movement), age related osteoporosis (weakening bone) without current pathological fracture (break under normal stress), and arthritis (inflammation of joints). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, Resident #1 had a BIMS score of 6 which meant she was severely cognitively impaired. Additionally, Resident #1 was dependent of staff for all ADLs. Record review of Resident #1's care plan date initiated 05/30/2024 revealed, I have a Self-Care deficit r/t Parkinson's, OA multiple sites. Goal: Resident will experience safe transfers through next review date, and I will maintain or improve my ability to participate in my care with ADLs through my next review date. Interventions: Bed mobility: x2-person assistance. Bathing/Showering Care: x 2-person assistance. Toileting/Incontinent care: x 2-person assistance. Record review of CNA A's 03/18/2025 witness statement revealed description of Incident I [DON] called [CNA A] to get information regarding the incident of a fall from bed (witnessed). CNA A stated I was performing incontinent care prior to wound care. She was extremely soiled, so I was providing partial bed bath x1 person. I knew she was a two person assist and knew that was the case on the KARDEX, but I felt I could do it. I rolled her over and fell as a result of my actions. Signed by DON. Record review of CNA A's 03/18/2025 written witness statement revealed, description of incident I was asked by the wound care nurse to clean resident before she could start wound care. As I checked the resident, I found she was extremely soiled about 3 times her usual.At that moment my CNA coworker was busy with another resident. I was afraid the feces would get into her suprapubic hole and wound, I felt it would be careless and loss of dignity if I left her sitting in her own feces for an additional 30 minutes. I took it upon myself to do the incontinent care myself. (knowing she was a 2 person assist like stated on KARDEX) .After I was done, I logged rolled her to change the sheet she was on an air mattress and the air shifted causing her legs to slide first then her torso ultimately caused the fall. I checked on the resident and then called for help immediately. Signed by CNA A on 03/18/2025. Record review of the ER record dated 03/18/2025 and discharged [DATE] revealed resident did not experience any major injury. No fracture or traumatic malalignment is seen. - no concerns noted. During a phone interview on 10/04/2025 at 3:48PM, 10/05/2025 at 8:03AM and 12:58PM CNA A stated she no longer worked at the facility and would call back when she was available. CNA A did not return call prior to exit conference. During an observation and interview on 10/04/2025 at 10:38AM Resident #1 was assisted by CNA B and CNA C to transfer via bed mobility. Both CNA B and CNA C utilized a draw sheet that was situated under Resident #1. Through the duration of the transfer care, there were no observable concerns. During an interview with Resident #1 while Resident #1's family member was present, both stated the fall on 03/18/2025 was an accident, and stated CNA A was a good CNA. Resident #1 and family member stated the clinical staff are nice and provide good care. Both Resident #1 and family member stated when Resident #1 needs assistance the staff help her and verbalized no concerns regarding any form of care. During an interview on 10/05/2025 at 11:35AM with both CNA B and CNA C, both stated they were not present during Resident #1's fall on 03/18/2025. Both stated as part of their normal shift procedure, they will review the plan of care on their KARDEX, to ensure they provide the necessary safety measures when providing care to each resident. Both stated once they review the plan of care in the beginning of their shift, they would begin providing rounding care. Both stated they work with Resident #1, and when Resident #1 needs incontinent care, transfer care, and bed mobility care, they will always utilize a two-person approach. Both stated, if Resident #1 needed care and no person is readily available, they will look for other clinical staff members to assist with care. Both stated they will never provide care for Resident #1 independently when the plan of care necessitates a two-person assist. Both stated the reason they incorporate a two-person assist with Resident #1 was to minimize Resident#1 falling and also to ensure Resident #1's safety. Both stated if they were to perform care independently without another clinical staff member, the well-being for Resident #1 could be compromised. Both stated they attended the 03/18/2025 in-service regarding transfer care and reviewing the plan of care for every resident. During an interview on 10/04/2025 at 4:12PM, LVN B stated when he was made aware of the incident, he was in the hallway and heard someone scream help. LVN B stated he then rushed into room Resident #1's room to which he found CNA A by herself, with Resident #1 on the floor ensuring her safety. LVN B stated he followed the facility protocol and sent Resident #1 to the emergency room for evaluation and treatment. LVN B stated once Resident #1 was gone, he asked for additional details of what had transpired to which CNA A stated she attempted to turn Resident #1, and while she turned Resident #1 over, the moment of Resident #1 moved further than expected and Resident #1 landed on her face. LVN B stated when he entered Resident #1's room, he immediately conducted a thorough head to toe assessment followed by sending Resident #1 to the emergency room for evaluation and treatment but did not sustain any major injury. LVN B stated he reeducated CNA A that she should have waited for an available person to assist her with Resident #1's care regardless how saturated Resident #1's brief was. LVN B stated CNA A verbalized her awareness of Resident #1's 2-person assist with care, but that she believed it would have compromised her dignity. LVN B stated he reeducated CNA A the reason why Resident #1 was a 2-person assist was to ensure her safety and by not following the plan of care, CNA A could have compromised Resident #1's well-being if Resident #1 had sustained a major injury. LVN B stated by CNA A not following Resident #1's plan of care, Resident #1 could have sustained a neck of facial fracture but fortunately did not. During an interview on 10/05/2025 at 12:09PM ADON, A stated she was not present during the incident on 03/18/2025, however when she was made aware of the situation, the facility commenced a facility wide in-service regarding transfer status and to review the plan of care (KARDEX) upon commencement of shift. ADON A stated CNA A had no professional concerns as CNA A was a good CNA. ADON A stated Resident #1's fall on 03/18/2025 was an accident. ADON A stated CNA A should have utilized a two-person assist with Resident #1 to ensure Resident #1's safety, however there were no major injuries. ADON A stated CNA A could have jeopardized Resident#1's well-being but was fortunate that Resident #1 did not have a major injury. ADON A stated all staff member are expected to review the plan of care for each resident upon commencement of shift. ADON A stated CNA A had no other prior incidents/falls during her employment. During an interview on 10/05/2025 at 12:28PM the DON, stated when he was conducting his phone investigation with CNA A, she stated that she was attempting to provide incontinent care on Resident #1, but that Resident#1 slipped and fell from bed. DON stated that CNA A did not verbalize that she was attempting to log roll resident, and that Resident #1 remained on her back. The DON stated, while CNA A's written statement dated 03/18/2025 was reviewed, CNA A should have waited for another staff member to help her with Resident #1. The DON stated CNA A should have followed the plan of care for Resident #1, which called for a 2-person assist with incontinent care and bathing. The DON stated the reason Resident #1 was a 2-person assist was to ensure Resident #1's safety which may have been compromised when CNA A provided incontinent care independently. The DON stated Resident #1 fortunately did not sustain any major injury on 03/18/2025. The DON stated after Resident #1's 03/18/2025 fall, all staff members were in-serviced to follow the plan of care directive and to follow KARDEX daily. Record reviewed CNA A's Nurse Aid Registry form dated 06/14/2025 no noted concerns. Record reviewed CNA A's background check report completed date 03/28/2024 no concerns noted. Record review of the facility's 03/18/2025-3/20/2025 in-service revealed Topic: ADL assist, KARDEX review, fall prevention, care plan timelines, reviewed on laptop how to access KARDEX, reviewed KARDEX definitions (example: x1, x2 person assist), ADL assistance process, and fall prevention. CNA A was in attendance. Record review of the facility's Routine Resident Care policy and procedure date implemented: 03/14/2019 revealed, resident should receive the necessary assistance to maintain good grooming, person/oral hygiene and safety.Care is taken to maintain resident safety at all times.

Based on observations, interviews and record reviews the facility failed to maintain an infection control and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 3 of 5 residents (Residents #53, #44, and #79) observed for infection control practices. CNA D, E, B, and A failed to properly change gloves, as well as wash or sanitize hands when moving from a dirty area to a clean area when incontinent care was observed for Residents #53, #44, and #79. These failures and deficient practices could place residents at risk for cross contamination and infection. Findings included: During observation of incontinent and peri care on three separate occasions on 1/8/25, on three separate residents (Residents #53, #44, and #79) revealed all CNAs performing the same improper techniques on all three different observations of incontinent and peri care. The CNAs would use a single wipe multiple times, folding over and over until bowel movement could be seen all the way around the inside and the outside of the wipes, to include against the CNAs gloves where the wipes were being held. The dirty gloves that held the dirty wipes were used to reenter the package of wipes to continue to grab clean wipes. The dirty gloves were used to grab the container of barrier cream ointments that were being used for the residents. The dirty gloves were also used to touch the resident's clothing, resident's blankest, as well as open the privacy curtain in the resident's rooms. In an interview with CNA D on 01/08/25 at 9:12 AM, she stated she has worked here 10 -11 months, and this was typical of how she performed incontinent care. She stated she had some training here in the beginning, as well as at a previous employment. According to CNA - D, the process for incontinent care was to do rounds every 2 hours, wash hands, put on gloves, ask resident if it was okay to change them, start wiping the area, and have them roll or turn and clean the other area. Then, once areas were wiped and clean, place a clean brief on. She stated she did not change the gloves if she did not see them dirty, but she did change gloves between patients. In regard to the wipes, they may not have enough in the supply room sometimes, so they tried to conserve the wipes during care. She stated no one ever told them to do this, they just tried to conserve the wipes until it is fully stocked again. CNA - D stated we do have enough wipes to do the job, but sometimes they get low, and we have to wait for someone to get here during the day with the key to restock the supplies. Housekeeping has the key, and she has seen her restock the supplies. In an interview with CNA - E on 01/08/25 at 9:22 AM, CNA - E stated she has worked here a year, and the process she used for incontinent care included to knock on the door, wash her hands, don gloves, get supplies and start peri-care. She stated she uses a pair of gloves for peri care and changed gloves for backside or incontinent care for bowel movements, as well as if they got soiled. If she wiped, and the wipe was soiled, she would throw it away, but only if she could visibly see that it was soiled. She stated it was not okay to keep folding the wipe with it covered in feces. CNA - E also stated it could contaminate the package to stick the soiled glove back into the package to get clean wipes out, as well as transfer feces from resident to resident and room to room when touching packages and other items with dirty gloves. She stated she was not trained to do peri or incontinent care the way it was performed this morning. She was trained by another CNA that was no longer here. CNA - E stated that sometimes they run short on supplies in supply closets, but they have access via housekeeping to get to outside building with extra supplies if needed. Housekeeper and administrator have the key to the shed out back with extra supplies. She has never had to ask them to go get supplies for her because they have never been that low before the closets get restocked. CNA - E stated the lead housekeeper is responsible for keeping the supplies in the supply closets in the building stocked. In an interview with the DON on 01/08/25 at 9:26 AM, the DON stated they have been monitoring and trending if the stock was running low or where it was dispersed. The Director of Education has done in-services on incontinent care. He monitors the in-services, as well as makes recommendations on in-services. In an interview with CNA - B on 01/08/25 at 9:54 AM, CNA - B stated she has worked here since September of this year and the technique she followed was to knock on the door, greet the resident, introduce herself, wash her hands, explain the procedure to the resident, grab supplies, and perform incontinent care. First, she cleaned the front, then after that, she changed gloves and cleaned the backside. She would check to see if she needed to clean any further. She did not change gloves after they get soiled. She stated she did not remember the last in-service or training on incontinent care. She stated she understood why hands should be clean and dirty gloves changed, so that she was not causing a cross contamination between residents. In an interview with CNA - A on 01/08/25 at 2:41 PM, CNA - A stated she had worked here for 2 weeks, but she had been a CNA since May 2024. Her first three days on the job she followed, watched and learned from other CNAs. She did not recall any in-services or trainings on incontinent care. She stated the incontinent care procedure or technique she used was to go in the room, check for gloves and diapers, gathered supplies, and told resident that she was going to change them. She pre-pulled the wipes based on how many she thought she would need, took the brief off and cleansed the front with maybe 3 different wipes, tucked it into the diaper, took off the old diaper and put on new diaper, then wiped the backside. She did not change gloves or clean hands when going from dirty to clean area or brief. She stated she understood that if she did not change out her gloves she could contaminate others and cause infection or sickness. In an interview with the DON on 1/8/2024 at 4:25 PM, he stated improper peri or incontinent care could lead to urinary tract infections, other infections, cross contamination, and, given their age and co-morbidities, could put these residents at a higher risk. In an interview with HK - F on 1/9/24 at 12:25 PM, she stated she had a key to the storage building out back and the supply closets inside. The storage building had incontinent supplies to include gloves, wipes, briefs and pull ups. Housekeeping are the ones who stocked supply closets, and CNAs distributed to other areas. She stated they stocked supply closets every three days by counting what is in the closet and taking an inventory. Maintenance, the Administrator, and housekeeping all have a key to the building or shed with the extra supplies in it. It was rare that it ever got low because she always checked the closets to make sure they were stocked. She stated the CNAs complained about not having supplies, but they also hoard supplies in cabinets and rooms. In an interview with the Administrator on 1/9/24 at 12:30 PM, he stated the CNAs called him at night or on the weekends in the past if their supplies ran low, and he gave them access to his office via the key code where the keys for the building out back are located. He stated they always had access to the storage building if needed, and they knew they could always call if needed. Record review of the facility's Infection Control Policy, Revised 2024, page 1, under Surveillance, revealed the infection preventionist is responsible for gathering and interpreting surveillance data, and the infection preventionist will conduct ongoing surveillance for healthcare associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Prevention of infection include identifying possible infections or potential complication of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring they adhere to proper techniques and procedures. Page 4, under Prevention of Infection, educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation. Page 6, under Glove and Handwashing section, revealed in addition to wearing gloves as outlined under standard precautions, wear gloves during the course of caring for a resident, change gloves after having contact with infective material that may contain high concentration of microorganisms (fecal material and wound drainage). Record review of infection surveillance monitoring for October 2024, November 2024 and December 2024 revealed 45 urinary tract infections. Record review of in-services dated 10/4/24 and 11/21/24 revealed staff were in-serviced over proper showering and peri-care due to residents were found improperly showered, bathed, and peri-care not properly performed. It was also in-serviced that rounding and changing was done every 2 hours, even if residents were continent or have foleys. Peri-care must be done every shift for everyone.

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, consistent with the resident's comprehensive assessment and plan of care for 3 of 4 Residents (Resident's #87, #61 and #26) reviewed for care plans. The facility failed to have quarterly care plan and Interdisciplinary Team Meetings to review Residents #87, #61 and #26's care plans. This failure could place residents at risk for not receiving the required care. The Findings for Resident #87 included: Record review of face sheet revealed Resident #87 as a [AGE] year-old male with an original admitted [DATE], and a current admitted [DATE]. Record review of Resident #87's Quarterly MDS dated [DATE] revealed a BIMS score of 08, which indicated moderately impaired cognition. Record review of Care Plan Conference dated 7/2/24 revealed this as being the most recent care plan meeting for Resident #87. In an interview with the MDS Nurse on 1/8/24 at 3:08 PM, she stated the last care plan meeting was in July, so the care plan had not actually been reviewed or adjusted since July, and Resident #87 should have had another meeting in October or November. In an interview with the Social Worker on 1/8/25 at 3:20 PM, she stated Resident #87 had a lot of back and forth to the hospital, and there was a lot of conversation with the responsible party, but the most recent care plan meeting she could find that was an actual care plan meeting was in July 2024. She stated she typically called the family or sent an email regarding the care plan meeting. Social worker stated that she would call the family right now, and notify the other staff that she was scheduling a care plan meeting for this Resident #87. In an interview with the DON, 1/8/25 at 3:50 PM, he stated the Inter Disciplinary Team included: the social worker, the activities director, different nursing staff, the director of nursing, and sometimes the administrator attends care plan meetings. He stated the social worker is the one who coordinates the meetings, and she typically notifies the responsible party by phone, then lets staff know when the meeting is. The MDS nurse typically updates the care plans. Meetings are held quarterly, or every three months, or with a change in condition. This resident's last care plan meeting was 7/2/24, and he should have had another one in October 2024. The Findings for Resident #61 included: Record review of Resident #61's face sheet revealed an [AGE] year-old-male with initial admission of 3/5/21, and a current admission of 1/1/25. Record review of Resident #61's nursing home discharge MDS dated [DATE] revealed no BIMS score listed for this resident. MDS revealed resident is coded to have a memory problem and cognitive skills for daily decision making is coded as severely impaired. Record review of Resident #61's care plan revealed that prior to 1/6/25, the most recent care plan conference for Resident #61 was in August of 2023. In an interview with the MDS Nurse on 1/9/25 at 9:10 AM, she stated she did not know or understand why the resident was showing the most recent care plan meeting to have been in August of 2023, but she would get with the SW and find out what was going on. She stated she cannot find any other care plan conferences or notices for a care plan meeting, but they did have a meeting with the responsible party yesterday regarding transfer to a rehab for cardio-pulmonary rehab. In an interview with the Human Resources Director, 1/9/25 at 10:15 AM, she stated she is the one who sends out the notices of resident discharges and transfers to the RPs, but regarding notifications about care plan conferences or meetings, those notices are sent by the social worker. The Findings for Resident #26 included: Record review of Resident #26's face sheet revealed a [AGE] year-old male with an original admitted [DATE], and a current admitted [DATE]. Record review of Resident #26's quarterly MDS dated [DATE] revealed resident has a BIMS of 11, which revealed moderately impaired cognition. Record review of Care Plan Conference date 7/19/2021 revealed this was the most recent care plan conference or care plan meeting for this resident. In an interview with the Social Worker, 1/8/25 at 3:20 PM, she stated she typically called the family or sent an email regarding the care plan meetings and is not sure why she cannot find a recent care plan conference or meeting for Resident #26. She stated the meetings should be done quarterly or with a change of condition. In an interview with the DON, 1/8/25 at 3:50 PM, he stated the Inter Disciplinary Team included: the social worker, the activities director, different nursing staff, the director of nursing, and sometimes the administrator attends care plan meetings. He stated the social worker coordinates the meetings, and she typically notifies the RP by phone, then lets staff know when meeting is. The MDS nurse typically updates the care plans. Meetings are held quarterly, or every three months, or with a change in condition. This resident's last care plan meeting was 7/2/24, and he should have had another one in October. In an interview with the MDS Nurse on 1/9/25 at 9:10 AM, she stated she did not know or understand why Resident #26 was showing the most recent care plan meeting to have been in 2021, but she would find out what is going on. She stated she could not find any other care plan conferences or notices for a care plan meeting for this resident since the 2021 meeting.

Based on observations, interviews, and record review, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice, person centered care plans, and resident's goal and preferences for 2 of 2 residents (Resident #13 and #44) reviewed for respiratory care. 1. The facility failed to ensure Resident #44's oxygen was provided continuously. 2. The facility failed to ensure Resident #13's respiratory exercises were consistent with the physician's orders. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of life. Findings included: 1. Record review of Resident #44's face sheet dated 07/18/24 indicated a [AGE] year-old female with an original admitted [DATE]. Diagnoses included heart failure, respiratory failure, mitral valve insufficiency (a weak valve in the heart), atrial fibrillation, a pacemaker, heart disease, high blood pressure, dementia, anxiety, and depression. Record review of Resident #44's quarterly MDS report dated 10/23/24 revealed a BIMS score of 6 indicating severe cognitive impairment. She required moderate assistance with toileting and showering, supervision with lower body dressing, footwear, and personal hygiene, and set-up with upper body dressing, oral hygiene, and eating. She utilized a wheelchair and could self-propel short distances. She was frequently incontinent of bladder and always incontinent of bowel. She required continuous oxygen therapy and was on hospice care. Record review of Resident #44's most recent care plan dated 01/06/25 revealed she was at risk for experiencing shortness of breath, she removed oxygen at times, turned off her oxygen concentrator, and needed reminders to put them back on. Created on 07/18/24 and revised 01/07/25. Interventions included o Alert my nurse for concentrator alarms and/or if my oxygen tank needs to be changed. Date Initiated: 07/18/2024. Provide oxygen as ordered/recommended by my physician. Created on 07/18/24. Record review of Resident #44's active physician orders dated 07/19/24 indicated Continuous Oxygen at 3 liters per nasal cannula every shift. During an interview and observation of Resident #44 on 01/07/25 at 1:49 pm, she said she wore oxygen and had to have it. Resident #44's oxygen concentrator was turned off. She said she did not know why it was off. There was a portable oxygen tank in Resident #44's room at the end of her bed with tubing on it. The oxygen tank registered empty. In an interview with LVN J on 01/07/25 at 1:55 pm, she said Resident #44's family had taken her on a stroll inside the facility. The portable oxygen tank had been left on and was empty. She said she needed to educate the CNAs and the family and monitor Resident #44 whenever she was out of her room. LVN J said she called Resident # 44's family member on 01/07/25 at 2:10 pm and she told her she came for lunch with Resident #44. She said the family member took her from her room without oxygen around noon and was gone for about 30 minutes then returned without reconnecting it. LVN J said Resident # 44 and her family member usually stayed in Resident #44's room to visit. She said she was glad Resident #44 did not suffer any injuries related to not having her oxygen on because she could have gone in to cardiopulmonary arrest. In an interview with the DON on 01/08/25 at 4:28 pm, he said the nurses were responsible for maintaining, providing, and administering oxygen and related therapies such as incentive spirometry and nebulizer treatments. He said Resident #44 was on continuous oxygen for a history of heart failure and chronic respiratory failure, and she will not get better. He said Resident #44's oxygen was sustaining-if she was without it for an hour or so, it could have a bad effect such as she could have an increase in shortness of breath (hypoxia) and ultimately have cardiopulmonary arrest. He said her code status was DNR and she was on hospice. He said it would be a big deal if someone forgot to turn oxygen on. He said the family should notify the nurse if they wanted to move Resident # 44 from her room with portable oxygen. He said the family should be telling the nurses upon her return so the nurse could reconnect her to the oxygen concentrator in her room because the family would not be familiar with the equipment. He said if the family did not tell the nurse, it was not ok. He said it was odd for the nasal cannula to be on the resident and the concentrator to be off. He said it was either nursing error or family error. He said the responsibility fell on the nurses to educate families and for him to educate the nurses. He said in the time he had been working at the facility, (Nov. 1, 2024), he was unaware of any training regarding educating nurses and families on oxygen and equipment for it. He said it was ultimately the responsibility of the bedside nurse. He said portable oxygen tanks were checked daily, but he had not seen a log for refilling or checking the stored oxygen tanks. In a phone interview with the family member on 01/09/25 at 7:10 pm, she said she brought Resident #44 a taco on 01/07/25 for lunch. She said when she arrived at the facility, Resident #44 was sitting in her wheelchair at the entrance of her room, facing the hallway. She said Resident #44 was not wearing oxygen. She said since Resident #44 was already at her doorway, they decided to go to the common area to eat, which they did. She said Resident #44 got tired after she ate and wanted to go back to her room. She said she helped Resident #44 back to bed and put her nasal canula from the concentrator on her but did not realize it was off. She said the nurses usually set up the portable oxygen tank whenever Resident #44 left her room, but this time, they left from the doorway, so she did not think about it. She said she would be more careful next time because she visited Resident #44 nearly daily and never had this issue that she knew of. 2. Record review of Resident #13's face sheet dated 10/16/24 indicated an [AGE] year-old female with an original admitted [DATE]. Diagnoses included pneumonia, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes, kidney disease, Dementia, and high blood pressure. Record review of Resident #13's quarterly MDS report dated 10/24/24 revealed a BIMS score of 8 indicating moderate cognitive impairment. She had verbal behaviors/symptoms directed toward others. She required substantial assistance with lower body dressing, and footwear, moderate assistance with toileting, showering, upper body dressing, and personal hygiene, and supervision with oral hygiene and eating. She utilized a motorized wheelchair. She was always incontinent of bladder and bowel. Respiratory therapy was received daily. Record review of Resident #13's active physician orders dated 12/15/24 indicated change 02 and/or nebulizer tubing every week. Oxygen at 2 Liters per nasal cannula as needed for Shortness of breath . dated 05/04/24. Incentive Spirometer Treatment Order: Steps: Sit up straight as much as possible. Encourage and demonstrate inhaling & exhaling 2-3 times Place device in patient's mouth, instruct to close lips on mouthpiece. Instruct to slowly inhale raising indicator as high as possible as marked goal, then slowly exhale. Repeat respiratory exercises of incentive spirometer deep breathing exercises x 3-5 times reps 2 times daily dated 08/16/24 and 05/04/24. Record review of Resident #13's most recent care plan dated 12/25/24 revealed I am at risk for experiencing shortness of breath. Recent HX of RSV w\residual effects Date Initiated: 10/24/2024 Created on: 01/20/2024 o I will tolerate the use oxygen and treatment without any signs of distress or decline in condition through my next review date. Date Initiated: 10/24/2024 Created on: 01/20/2024 o Administer my respiratory treatments / nebulizers as ordered by my doctor Date Initiated: 01/20/2024 Created on: 01/20/2024 o Alert my nurse for concentrator alarms and/or if my oxygen tank needs to be changed. Date Initiated: 01/20/2024 Created on: 01/20/2024 Revision on: 10/24/2024 o Provide oxygen as ordered/recommended by my physician. Date Initiated: 01/20/2024 Created on: 01/20/2024 o Administer oxygen as recommend by physician. Follow community's protocols for changing tubing and filter cleaning as indicated. Date Initiated: 01/20/2024 Created on: 01/20/2024 o Refer to skilled therapy services for strengthening, mobility as well as oxygen conservation techniques as indicated. Date Initiated: 01/20/2024 Created on: 01/20/2024. Record review of Resident #13's MAR dated 01/01/25-01/08/25 revealed Incentive Spirometer Treatment Order: Steps: Sit up straight as much as possible. Encourage and demonstrate inhaling & exhaling 2-3 times Place device in patient's mouth, instruct to close lips on mouthpiece. Instruct to slowly inhale raising indicator as high as possible as marked goal, then slowly exhale. Repeat respiratory exercises of incentive spirometer deep breathing exercises x 3-5 times reps 2 times daily, two times a day for Therapy Respiratory Exercise -Start Date- 08/16/24. The document indicated the IS treatment was administered as ordered. The same order was repeated with the date of 05/04/24 and with all dates initialed as given. During an interview and observation of Resident #13 on 01/07/25 at 1:17 pm revealed she had no oxygen in her room or an incentive spirometer (a hand-held medical device used to improve the function of the lungs). She said she had not used oxygen or the IS since sometime in June 2024. In an interview with the DON on 01/08/25 at 4:28 pm, he said nursing checked the charts and the physician reviewed their orders monthly. He said the orders for oxygen and incentive spirometry for Resident #13 had been active since 01/01/24; 1 year ago. He had no answer as to why these orders were still in the chart as active. He said the ADONs should have updated the orders. The ADON had worked at the facility since 06/21/22. He said Resident #13's oxygen should have been on because she could have gone in to cardiopulmonary arrest. In an interview and observation with LVN H on 01/09/25 at 3:37 pm, he identified his initials on the MAR and said he administered IS to Resident # 13 this week as ordered. He said the IS was in Resident # 13's bedside cabinet. Observation of Resident # 13's bedside cabinet with LVN H at 3:41 pm revealed no IS in any of the drawers or in the room. He said he had no idea where the incentive spirometer was. He said providing respiratory care would not have been ordered if the resident did not need it to keep them from getting pneumonia. In an interview and observation with LVN I on 01/09/25 at 3:58 pm, she identified her initials on the MAR and said she administered IS this week to Resident #13 as ordered. Observation of Resident #13's room, bedside table, and chest of drawers revealed no IS. She said she did not know why it was not in the room. She said respiratory care for Resident #13 was necessary to keep her lungs working better and prevent pneumonia. Record review of the facility policy revised 01/2023, titled Oxygen Administration revealed under compliance guidelines: A resident receives oxygen therapy when there is an order by a physician.

Based on observations, interviews, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved 1 of 4 residents (Resident #38) reviewed for medication errors. - RN B failed to administer medication as ordered to Resident #38 by preparing only one 25mg tablet of sertraline instead of three 25mg tablets as ordered. - RN B failed to administer medications as ordered to Resident #38 by not preparing a 20mg tablet of isosorbide dinitrate as ordered. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. The findings included: Record review of Resident #38's face sheet dated 01/08/25 revealed a [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included vascular dementia, heart failure, and major depressive disorder. Record review of Resident #38's Comprehensive MDS assessment section C, cognitive patterns, dated 12/27/24 revealed a BIMS score of 15 (cognition intact). Record review of Resident #38's care plan revealed the focus I have heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema initiated on 01/03/25. Interventions listed for the problem included Administer my medications as ordered by my physician initiated on 01/03/25. Further record review revealed the focus I require psychotropic medications and I am at potential risk for side effects r/t my medication regimen initiated on 01/03/25. Interventions listed for the problem included Administer medications as ordered and monitor for potential side effects and notify MD/NP as indicated & ensure that resident/family are educated r/t the potential side effects, and risks associated with psychotropic medications and obtain consent for medication use initiated on 01/03/25. Record review of Resident #38's order summary revealed an active order dated 12/18/24 for Zoloft Oral Tablet 25 MG (Sertraline HCL) Give 3 tablets by mouth one time a day for depression 3 tabs = 75mg. Further record review reflected an active order dated 12/18/24 for Isosorbide Dinitrate Oral Tablet 20 MG (Isosorbide Dinitrate) Give 1 tablet by mouth one time a day for heart failure. During an observation on 01/08/25 at 8:04 AM, RN B prepared medications for Resident #38 during medication pass. RN B only popped one 25mg tablet of sertraline out of the blister package for administration and did not pop any 20mg isosorbide dinitrate tablets out of the blister package. After RN B finished gathering all morning medications for Resident #38, this state surveyor asked RN B if he had all of Resident #70's medication in the cup, to which RN B stated yes. This state surveyor asked RN B to check the sertraline and isosorbide dinitrate orders again and RN B then caught his errors. During an interview with RN B on 01/08/25 at 8:06 AM, RN B stated he had not yet clicked save on his MAR to signify he was completed. RN B stated he remembered answering yes to being asked if he had finished popping all the medication out of the blister packages. RN B stated if a resident did not receive their isosorbide dinitrate tablet they could get elevated blood pressure. RN B stated taking 25mg of sertraline instead of the prescribed 75mg may cause the resident to experience symptoms of depression. During an interview with the DON on 01/08/25 at 4:04 PM, the DON stated it was important for a resident to receive all their prescribed medications to stop the progression of disease, stabilize the disease process, and to prevent bad outcomes. The DON stated if a resident did not receive their full dose of sertraline they could have issues with cognition, mental regression, and mental distress. The DON stated if a resident missed their dose of isosorbide dinitrate they may experience symptoms of heart failure. During an interview with the ADON on 01/09/25 at 3:36 PM, the ADON stated residents should always receive the medications prescribed to them unless they refuse them. The ADON stated antidepressants were important to be taken at a certain time and dose because their serum levels could be thrown off if they did not. The ADON stated medications that lower blood pressure were important to help keep it controlled. The ADON stated if a resident's blood pressure became too elevated, they could have a stroke. Record review revealed the facility policy titled Medication Administration implemented March 2019 and revised January 2023 stated the following: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #70) of 10 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document in the treatment administration record when Resident #70 received their dose of vancomycin (antibiotic) on 01/05/25. This failure could result in residents' records not accurately reflecting the administration of medications and could result in further error and a decline in heath. The findings included: Record review of Resident #70's face sheet dated 01/08/25 revealed a [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnosis included enterocolitis due to Clostridium Difficile not recurrent (Inflammation of the small and large intestine caused by the bacteria Clostridium Difficile). Record review of Resident #70's Discharge MDS assessment section C, cognitive patterns, dated 11/19/24 revealed a BIMS score of 7 (severe impairment). Record review of Resident #70's care plan revealed the focus At risk for infection or recurrent/chronic infection r/t compromised medical condition: Actual infection: C-Diff 1/3/24 [sic]-Vancomycin HCL Oral Capsule 125 MG (Vancomycin HCL). Give 1 capsule by mouth four times a day related to enterocolitis due to clostridium difficile, not specified as recurrent for 10 days initiated on 01/03/25. Interventions listed for the problem included: - Report changes in condition to MD as clinically indicated. - Administer medication and/or antibiotic as per MD orders. - Monitor vital signs as indicated. - Isolation Precautions as clinically indicated. - Coordinate and schedule appointments with physician as indicated. Record review of Resident #70's order summary revealed an active order dated 01/03/25 for Vancomycin HCL Oral Capsule 125 MG (Vancomycin HCL). Give 1 capsule by mouth four times a day related to enterocolitis due to clostridium difficile, not specified as recurrent for 10 days. Record review of Resident #70's MAR on 01/08/25 revealed the order for Vancomycin HCL Oral Capsule 125 MG (Vancomycin HCL) Give 1 capsule by mouth four times a day related to enterocolitis due to clostridium difficile, not specified as recurrent for 10 days was only administered 3 times on 01/05/25 with documentation absent for the 4th dose. An interview with Resident #70 was attempted on 01/07/25 at 4:37 PM, but Resident #70 refused the interview. In an interview with the DON on 01/08/25 at 4:04 PM, the DON stated because the MAR was blank, there could be multiple things that happened including the resident refused the medication, the patient was asleep, or the nurse could have administered the medication but not recorded it. The DON stated if the medication was refused by the resident then it should be documented in the MAR. The DON stated missing a dose of vancomycin during a C. Diff infection could cause the infection to become worse or help create a super bug. The DON stated it was important to document medications in case they needed to reach out to the doctor to change the antibiotic. The DON stated the nurse that administered the medication should sign the MAR. In an interview with the ADON on 01/09/25 at 3:36 PM, the ADON stated it looked like Resident #70 did not receive her 4th dose of vancomycin on 01/05/25 because one of the boxes for that day was blank. The ADON stated if the resident refused the medication, it should be documented. The ADON stated it was important to document medication and treatments so they could know that it was given. The ADON stated the doctor would need to be notified if a dose of medication was missed. The ADON stated the person that administered the medication should sign the MAR. Record review revealed the facility policy titled Medication Administration implemented March 2019 and revised January 2023 stated the following: Record the results of medications administered as necessary. Initial the electronic administration record after the medication is administered to the resident.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Residents #39 and #4) reviewed for abuse. The facility did not take measures to prevent physical abuse between R#4 and R#39; R#39 was bit on the upper thigh and struck with a bed remote and call light by R#4. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The findings were: Resident #39: Record review of Resident #39's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cardiomegaly (an enlarged heart), essential (primary) hypertension (high blood pressure), cerebral ischemia (results from impaired blood flow to the brain), anxiety disorder, unspecified ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #39's MDS assessment, dated 09/29/23, revealed Resident #39 had a BIMS score of 14, indicating intact cognition. Record review of Resident #39's care plan revealed a focus of, I have impaired cognitive function/or impaired though process related to cerebral ischemia. Record review of Resident #39's skin: abrasion/bruise/edema/mole/rash document dated 09/23/23 completed by RNS revealed Resident #39 had dark purple bruise to left and right hand, dark purple bruising to right forearm, a scratch noted to inferior aspect of left eye, redness to right shin and right knee and a bite mark to right lateral thigh and a scratch noted to right inner aspect of thigh/knee area. Record review of Resident #39's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 was being physically and verbally aggressive with Resident #39 with Resident #4 swinging bed remote at Resident #39's bilateral legs. RNS's nursing note stated a Head to toe assessment was performed with noted dark purple bruising to right forearm, dark purple bruise to left and right hand. Redness noted to right shin, right knee and bite mark to right lateral thigh. Scratch noted to inferior aspect of left eye. Scratch noted to right inner aspect of thigh/knee area. Resident #4 At time of the investigation Resident #4 was no longer in the facility, as per record review of Resident #4's face sheet on 10/15/23 Resident #4 was discharged from facility on 09/27/23 Record review of Resident #4's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses that included: Acute diastolic (occurs when left ventricle muscle becomes stiff or thickened) (congestive) heart failure ( the heart does not pump blood as well as it should ), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), current episode depressed, moderate, dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere, moderate, with mood disturbance, pneumonia (infection that affects one or both lungs), unspecified organism and type 2 diabetes mellitus (high blood sugar) with other specified complication. Record review of Resident #4's 5- day MDS assessment, dated 08/17/23, revealed Resident #4 had a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #4's care plan did have specific focuses regarding her anti-depressant and anticonvulsant medication but did not address her history of aggression. Resident #4's care plan had a focus of I use anticonvulsant medication as a mood stabilizer related to Dementia with mood disturbances; Bipolar and I require anti-depressant medication related to diagnosis of Depression which had an intervention to Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, all which had a created date of 08/24/23 and an initiated date of 10/14/23 Record review of Resident #4's hospital paper work submitted as part of her referral revealed a history of present illness from admitted [DATE] stating This lady is a psychiatric patient by all means who requires psychiatric attention. Not too long ago she was admitted for psychiatric treatment after an overdose and several episodes of fights and aggression at home with husband and others who may be there. Last week she was here in the emergency room for the same reason. It also included a hospital progress note for Resident #4 stating there was an open legal case for domestic abuse. Record review of Resident #4's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 swinging bed remote at Resident #39 striking him multiple times. During an interview on 10/11/23 at 5:10pm with the DON and ADM they both stated they were not aware of any APS case or Resident #4's behaviors prior to the incident between Resident #4 and #39 on 9/23/23. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 3:25pm she stated Resident #4 had originally sent over paper work for admission months before her recent admission on 08/10/23 and stated that paperwork did include resident #4's behaviors and aggression towards Resident #39 and stated she was denied admission. The Admissions Coordinator stated when they received referral paper work for Resident #4's recent admission on 08/10/23 the paper work was submitted under a different name, she stated one of Resident #4's last names had been switched around or removed. The Admissions Coordinator could not provide any documentation of the original paperwork submitted for admission before current admission on 08/10/23 and stated because it was a denial that paperwork was not uploaded into any chart. During an interview with the responsible party for both Resident #4 and #39 on 10/11/23 at 4:25pm she stated Resident #4 had a history of aggression towards Resident #39 and had previously hit her as well. The responsible party for both Resident #4 and #39 stated the Medical Director knew Resident #4 was aggressive. The responsible party for both Resident #4 and #39 stated 2 or 3 days after Resident #39 was admitted to the facility she went to speak to the Admissions Coordinator at the facility and thought she had told her that Resident #4 was aggressive and that she was scared that Resident #4 would do something to Resident #39. The responsible party for both Resident #4 and #39 stated the Admissions Coordinator told her that Resident #4 and #39 would be fine and that nothing would happen. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 4:50pm she stated there was nothing on Resident #4's records or referral about aggression. The Admissions Coordinator stated family for Resident #4 had not told her about aggression. The Admissions Coordinator stated she was not in communication with the responsible party for both Resident #4 and Resident #39 until Resident #39 was admitted to the facility and stated the only thing the responsible party for both Resident #4 and Resident #39 told her was that Resident #4 and #39 had a very complicated relationship. The Admissions Coordinator at the facility stated the process for reviewing an admission was, that everything was sent to Central Admissions and from there if there was any identified behavior on the paperwork it would be sent to herself, ADM and DON. The Admissions Coordinator stated there were no behaviors identified on either Resident #4 or #39. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. During an interview with the Centralized Admissions Nurse on 10/12/23 at 12:08 pm he stated when reviewing referrals, he reviewed the documentation the hospital provides such as physician notes, therapy evaluations, medication records, specific skilled services they were requesting. The Centralized Admissions Nurse stated what he reviewed was documented under Resident #4's chart titled, referral. The Centralized Admissions Nurse stated he had reviewed Resident #4's referral documentation and stated he had concerns regarding history of bipolar disorder, mention of aggressive behavior, and dementia. The Centralized Admissions Nurse stated these concerns would have been sent over to the DON, ADM and the Liaison. The Centralized Admissions Nurse stated the Liaison completed an onsite assessment of Resident #4 on 08/08/23 at the hospital. The Centralized Admissions Nurse stated the Liaisons onsite included making sure Resident #4 was not on any chemical or physical restraints, was not a 1:1 supervision, speaking with direct care staff and asking about any concerns. The Centralized Admissions Nurse stated during those interviews conducted by the Liaison there were no concerns, and it was identified she was participating with therapy and at that point that decided to move forwards. During an interview with the Liaison 10/12/23 at 12:44pm she stated referrals who are categorized as yellow would require an onsite evaluation on the patient due to concerns of history of behaviors and elopement. The Liaison stated Resident #4 required an onsite evaluation that included her speaking with nurses, attending staff and therapy, she stated through her evaluation she identified Resident #4 was friendly, alert x4, talkative, kind and as per nurse she did have some episodes of confusion but did not with her. The Liaison stated her report was that there were no behaviors and no elopement. The Liaison stated the email from the Centralized Admissions Nurse regarding having her assess Resident #4 for any active behaviors or elopement had also been carbon copied to the ADM, DON, and Admissions Coordinator and stated they were aware of the behaviors being assessed by her. During an interview with the Medical Director on 10/12/23 at 6:21pm he was asked if he was aware of Resident #4's history of aggression towards Resident #39, he stated he had known Resident #4 and #39 for years and stated, this has been going on for years. The Medical Director stated Resident #4 and #39 previously lived together and stated Resident #4 and #39 wanted to be together and did not want to be kept apart so he said it was okay to put them together. When asked if he notified the facility of Resident #4's history of aggression he stated he thought it was written in his discharge summary for Resident #4 and stated the facility was aware that Resident #4 was bipolar. The Medical Director stated Resident #4 was a psych patient and needed to be admitted somewhere she could be monitored, and medication would be given on time and that had a psychologist and psychiatrist available on call to be there for a crisis. The medical director stated Resident #4 was aggressive to those around her by yelling, and would only hit, Resident #39. LVN P was attempted to be reached for telephone interview on 10/13/23 at 9:03am and 9:57am with no answer, voicemail was left however phone call was not returned. During an interview on 10/13/23 at 9:58am with RNS she stated on 9/23/23 she was called over to Resident #4 and #39's by LVN P. RNS stated she observed Resident #4 swinging the bed remote at Resident #39 hitting him on the legs. RNS stated they separated Resident #4 and #39 and checked on Resident #39 who told her Resident #4 had hit him everywhere with both the call light and the bed remote. RNS stated Resident #39 had redness to lower legs and knees and had a bite mark to upper thigh which she stated Resident #4 admitted to doing and Resident #39 confirmed. RNS stated after she separated Resident #4 and Resident #39 she called the doctor to speak with Resident #4 and notify him that she was being aggressive, RNS stated Resident #4 had tried to hit her and slap the phone out of RNS's hand. RNS state Resident #4 cornered her and was able to hit her and stated she believed Resident #4 turned around and had bit and hit LVN P. RNS stated she was not aware of any aggressive behaviors prior to the incident on 9/23/23. RNS stated she spoke to a family member of Resident #4 who stated that was their relationship at home and an APS (Adult Protective Services) worker who was at the building that day had told her that they had previous cases with Resident #4 and #39 for almost 5 years regarding physical arguing. RNS did not provide a name for APS worker. RNS stated Resident #4 had not exhibited similar behaviors towards Resident #39 before incident on 09/23/23. RNS stated Resident #4 only had her moods with refusing medication but that was the only extent of her behaviors. RNS stated she could not recall if Resident #4 had monitoring for behaviors associated with bipolar disorder. RNS stated if a resident had an antipsychotic or antidepressant or anti-convulsant then they would have a monitoring order for sleeplessness, agitation and stated she did not think it included aggression but more restlessness and insomnia. RNS stated she had done routine checks that included checking on Resident #4 and providing medication. RNS stated she always checked for any behaviors residents demonstrated and would have to notify the appropriate person if any changes were identified. During an interview with the ADM on 10/14/23 at 12:09PM he stated he, and facility staff had been trained over abuse identification and prevention, stating they were trained annually. The ADM stated a fracture, spiral fracture or bruising was considered physical abuse. The ADM stated Resident #4 had struck Resident #39 with the bed remote and had bit Resident #39's thigh. The ADM was asked if he considered the incident between Residents #4 and #39 abuse and he stated it was borderline. The ADM stated Resident #39 had a bite to thigh and bruising to left arm. The ADM stated nobody had made him aware of Resident #4's history of aggressive behaviors before the incident. The ADM stated he was made aware of Resident #4's behaviors after the incident when APS spoke to him and told him stories of incidents in the home setting. The ADM stated he was able to review the resident chart but did not review Resident #4's referral documents in that detail because the Central Admission nurse handled that. The ADM stated he did not think there was an indication that Resident #4 had aggressive behaviors. The ADM stated the Medical Director had worked with Resident #4 and #39 previously and stated he could only speculate he was aware of Resident #4's history of aggressive behaviors but could not speak for him. The ADM stated, the Central Admissions nurse had not notified him of Resident #4 having violent behavior. The ADM stated Resident #39 was not scared of Resident #4. The ADM was not aware of Resident #4's care plan information, stating Resident #4 had no behaviors. The ADM stated nurses monitored Resident #4 stated they were with her every day stating any indication of behaviors they would have flagged. The ADM stated Resident #4 had a history of aggressive behaviors, but he was not aware. The ADM stated to ensure residents are free from abuse while in the facility they completed assessments, reviewed data from the physician and any other sources. The ADM stated the data did not indicate the actual violence that occurred, stating he did not know the extent of the aggression because there was not any indication of actual injury. The ADM stated their abuse policy stated they are to keep residents from abuse, he stated the policy was followed in this situation because Resident #39 did not indicate any fear and wanted to be with Resident #4. The ADM stated not identifying residents with history of aggressive behavior could cause a negative impact to other residents such as injury or death. During an interview with the DON on 10/14/23 at 2:35pm she stated her, and facility staff had been trained over abuse identification and prevention, stating training were completed 2 times a month. The DON stated hitting would be considered physical abuse. The DON stated she was notified that Resident #4 had started hitting Resident #39, the DON stated the incident between Resident #4 and #39 was considered physical abuse . The DON stated Resident #39 had purple discoloration of right forearm, left and right hand with redness noted to shin, and right knee. The DON stated Resident #39 was not scared of Resident #4 and wanted to be with her. The DON stated Resident #4 had no exhibited any aggressive behaviors before this incident on 09/23/23. The DON stated to ensure residents are free from abuse while in the facility she made sure that nobody with current aggressive behaviors were paired with anybody else, the DON stated it was effective in the situation with Resident #4 and #39 stating they moved Resident #4 and #39 . The DON stated not identifying residents with history of aggressive behaviors could impact residents because they could potentially be paired with somebody with behaviors who could potentially hurt their neighbors. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. Record review of facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting with an implemented dated of February 2017 and a review date of 10/2022 stated, Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. And The community conducts the following steps to protect the residents, patients and veterans served . Residents should be screened upon referral to ensure that the current staffing patterns and staff expertise are suitable to provide the necessary care that the prospective resident requires, without the possibility of acts of abuse and neglect towards other residents The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F656 Develop/Implement Comprehensive Plan of Care F600 Freedom from Abuse, Neglect, and Exploitation Immediate Response: Resident #4 was immediately assessed by nursing, medical care provided, and IDT continued to monitored resident to ensure his wellbeing. Resident # 39 was immediately assessed by the nurse and placed on 1:1 for monitoring and discharged for evaluation and treatment. Risk Response: All newly admitted residents who are admitted with historical aggressive behaviors may have been potentially affected. Director of Nursing/Designee will conduct an audit of all recent admissions hospital records to identify any concerns with aggressive behaviors towards others and will review the plan of care to ensure it appropriately reflects potential behavioral risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of aggressive behaviors towards others. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential behavioral risks. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the Abuse and Neglect Preventing, Identifying and Preventing, Admission process to include identifying potential behavioral risks; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-14-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-14-23. System Response: Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the admission process and assessing residents to include identifying potential risks to include but not limited to behavioral risks, such as aggression or aggressive behaviors; thus, ensuring the identified risk is identified on the plan of care to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-15-23. Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-15-23. Education was provided to all staff regarding the process for monitoring, observing, and reporting all behavioral concerns to the licensed nurse in effort to provide needed care, protect the safety and well-being of all residents, to meet the resident's needs, have accurate documentation reflected in clinical record and to ensure appropriate interventions are in place as per facility's expected practices. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing, Administrator Admission Coordinator and Centralized Admissions Nurse regarding facility's updated referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-14-23. Facility has updated its referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-13-2023. Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed: 10-15-2023. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified aggressive behavioral or known physical aggression are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: Record review of facility services revealed the DON, MDS and ADM had been trained over the new referral /admission protocol, RAI (Resident Assessment Instrument) process, identifying and preventing abuse and neglect, the admission process to include identifying potential behavior risks and risks that should be care planned and the importance of monitoring of supportive interventions. Record review of facility services revealed the Central Admissions nurse, Liaison, and the Admissions Coordinator, had been trained over the new referral/admission protocol. Record review of facility in services revealed 23 staff members that included nurses and the IDT (interdisciplinary team) were trained over the RAI process and the admission process to include assessing residents for behavioral risks and care planning the risks and supportive interventions. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Identifying and preventing abuse, neglect and exploitation. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had identified 4 residents with behaviors, none of which were aggression. Record review of impacted 4 residents revealed all care plans were updated appropriately. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. All staff members stated they had recently been trained over behaviors, documentation, facility procedures and abuse and neglect. All staff members interviewed were aware of what to do when identifying behaviors, who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. In addition, nurses and leadership were aware of the admission process and RAI process. During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility had identified residents with behaviors and had updated care plans appropriately. The DON stated they would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24-hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the DON on 10/16/23 at around 9:00AM she stated they had identified 4 residents with behaviors however none of the behaviors identified were aggression. The DON stated care plans had been updated to reflect identified behaviors. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. During an interview on 10/16/23 at 3:50PM with the Central Admissions nurse he stated he had been trained over the new referral/admission protocol and was aware of needing DON and/or ADM approval for approval/denial for new admissions. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. 45737

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Residents #39 and #4) reviewed for abuse. The facility did not take measures to prevent physical abuse between R#4 and R#39; R#39 was bit on the upper thigh and struck with a bed remote and call light by R#4. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The findings were: Resident #39: Record review of Resident #39's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cardiomegaly (an enlarged heart), essential (primary) hypertension (high blood pressure), cerebral ischemia (results from impaired blood flow to the brain), anxiety disorder, unspecified ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #39's MDS assessment, dated 09/29/23, revealed Resident #39 had a BIMS score of 14, indicating intact cognition. Record review of Resident #39's care plan revealed a focus of, I have impaired cognitive function/or impaired though process related to cerebral ischemia. Record review of Resident #39's skin: abrasion/bruise/edema/mole/rash document dated 09/23/23 completed by RNS revealed Resident #39 had dark purple bruise to left and right hand, dark purple bruising to right forearm, a scratch noted to inferior aspect of left eye, redness to right shin and right knee and a bite mark to right lateral thigh and a scratch noted to right inner aspect of thigh/knee area. Record review of Resident #39's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 was being physically and verbally aggressive with Resident #39 with Resident #4 swinging bed remote at Resident #39's bilateral legs. RNS's nursing note stated a Head to toe assessment was performed with noted dark purple bruising to right forearm, dark purple bruise to left and right hand. Redness noted to right shin, right knee and bite mark to right lateral thigh. Scratch noted to inferior aspect of left eye. Scratch noted to right inner aspect of thigh/knee area. Resident #4 Record review of Resident #4's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses that included: Acute diastolic (occurs when left ventricle muscle becomes stiff or thickened) (congestive) heart failure ( the heart does not pump blood as well as it should ), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), current episode depressed, moderate, dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere, moderate, with mood disturbance, pneumonia (infection that affects one or both lungs), unspecified organism and type 2 diabetes mellitus (high blood sugar) with other specified complication. Record review of Resident #4's 5- day MDS assessment, dated 08/17/23, revealed Resident #4 had a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #4's care plan did have specific focuses regarding her anti-depressant and anticonvulsant medication but did not address her history of aggression. Resident #4's care plan had a focus of I use anticonvulsant medication as a mood stabilizer related to Dementia with mood disturbances; Bipolar and I require anti-depressant medication related to diagnosis of Depression which had an intervention to Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, all which had a created date of 08/24/23 and an initiated date of 10/14/23 Record review of Resident #4's hospital paper work submitted as part of her referral revealed a history of present illness from admitted [DATE] stating This lady is a psychiatric patient by all means who requires psychiatric attention. Not too long ago she was admitted for psychiatric treatment after an overdose and several episodes of fights and aggression at home with husband and others who may be there. Last week she was here in the emergency room for the same reason. It also included a hospital progress note for Resident #4 stating there was an open legal case for domestic abuse. Record review of Resident #4's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 swinging bed remote at Resident #39 striking him multiple times. During an interview on 10/11/23 at 5:10pm with the DON and ADM they both stated they were not aware of any APS case or Resident #4's behaviors prior to the incident between Resident #4 and #39 on 9/23/23. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 3:25pm she stated Resident #4 had originally sent over paper work for admission months before her recent admission on 08/10/23 and stated that paperwork did include resident #4's behaviors and aggression towards Resident #39 and stated she was denied admission. The Admissions Coordinator stated when they received referral paper work for Resident #4's recent admission on 08/10/23 the paper work was submitted under a different name, she stated one of Resident #4's last names had been switched around or removed. The Admissions Coordinator could not provide any documentation of the original paperwork submitted for admission before current admission on 08/10/23 and stated because it was a denial that paperwork was not uploaded into any chart. During an interview with the responsible party for both Resident #4 and #39 on 10/11/23 at 4:25pm she stated Resident #4 had a history of aggression towards Resident #39 and had previously hit her as well. The responsible party for both Resident #4 and #39 stated the Medical Director knew Resident #4 was aggressive. The responsible party for both Resident #4 and #39 stated 2 or 3 days after Resident #39 was admitted to the facility she went to speak to the Admissions Coordinator at the facility and thought she had told her that Resident #4 was aggressive and that she was scared that Resident #4 would do something to Resident #39. The responsible party for both Resident #4 and #39 stated the Admissions Coordinator told her that Resident #4 and #39 would be fine and that nothing would happen. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 4:50pm she stated there was nothing on Resident #4's records or referral about aggression. The Admissions Coordinator stated family for Resident #4 had not told her about aggression. The Admissions Coordinator stated she was not in communication with the responsible party for both Resident #4 and Resident #39 until Resident #39 was admitted to the facility and stated the only thing the responsible party for both Resident #4 and Resident #39 told her was that Resident #4 and #39 had a very complicated relationship. The Admissions Coordinator at the facility stated the process for reviewing an admission was, that everything was sent to Central Admissions and from there if there was any identified behavior on the paperwork it would be sent to herself, ADM and DON. The Admissions Coordinator stated there were no behaviors identified on either Resident #4 or #39. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. During an interview with the Centralized Admissions Nurse on 10/12/23 at 12:08 pm he stated when reviewing referrals, he reviewed the documentation the hospital provides such as physician notes, therapy evaluations, medication records, specific skilled services they were requesting. The Centralized Admissions Nurse stated what he reviewed was documented under Resident #4's chart titled, referral. The Centralized Admissions Nurse stated he had reviewed Resident #4's referral documentation and stated he had concerns regarding history of bipolar disorder, mention of aggressive behavior, and dementia. The Centralized Admissions Nurse stated these concerns would have been sent over to the DON, ADM and the Liaison. The Centralized Admissions Nurse stated the Liaison completed an onsite assessment of Resident #4 on 08/08/23 at the hospital. The Centralized Admissions Nurse stated the Liaisons onsite included making sure Resident #4 was not on any chemical or physical restraints, was not a 1:1 supervision, speaking with direct care staff and asking about any concerns. The Centralized Admissions Nurse stated during those interviews conducted by the Liaison there were no concerns, and it was identified she was participating with therapy and at that point that decided to move forwards. During an interview with the Liaison 10/12/23 at 12:44pm she stated referrals who are categorized as yellow would require an onsite evaluation on the patient due to concerns of history of behaviors and elopement. The Liaison stated Resident #4 required an onsite evaluation that included her speaking with nurses, attending staff and therapy, she stated through her evaluation she identified Resident #4 was friendly, alert x4, talkative, kind and as per nurse she did have some episodes of confusion but did not with her. The Liaison stated her report was that there were no behaviors and no elopement. The Liaison stated the email from the Centralized Admissions Nurse regarding having her assess Resident #4 for any active behaviors or elopement had also been carbon copied to the ADM, DON, and Admissions Coordinator and stated they were aware of the behaviors being assessed by her. During an interview with the Medical Director on 10/12/23 at 6:21pm he was asked if he was aware of Resident #4's history of aggression towards Resident #39, he stated he had known Resident #4 and #39 for years and stated, this has been going on for years. The Medical Director stated Resident #4 and #39 previously lived together and stated Resident #4 and #39 wanted to be together and did not want to be kept apart so he said it was okay to put them together. When asked if he notified the facility of Resident #4's history of aggression he stated he thought it was written in his discharge summary for Resident #4 and stated the facility was aware that Resident #4 was bipolar. The Medical Director stated Resident #4 was a psych patient and needed to be admitted somewhere she could be monitored, and medication would be given on time and that had a psychologist and psychiatrist available on call to be there for a crisis. The medical director stated Resident #4 was aggressive to those around her by yelling, and would only hit, Resident #39. LVN P was attempted to be reached for telephone interview on 10/13/23 at 9:03am and 9:57am with no answer, voicemail was left however phone call was not returned. During an interview on 10/13/23 at 9:58am with RNS she stated on 9/23/23 she was called over to Resident #4 and #39's by LVN P. RNS stated she observed Resident #4 swinging the bed remote at Resident #39 hitting him on the legs. RNS stated they separated Resident #4 and #39 and checked on Resident #39 who told her Resident #4 had hit him everywhere with both the call light and the bed remote. RNS stated Resident #39 had redness to lower legs and knees and had a bite mark to upper thigh which she stated Resident #4 admitted to doing and Resident #39 confirmed. RNS stated after she separated Resident #4 and Resident #39 she called the doctor to speak with Resident #4 and notify him that she was being aggressive, RNS stated Resident #4 had tried to hit her and slap the phone out of RNS's hand. RNS state Resident #4 cornered her and was able to hit her and stated she believed Resident #4 turned around and had bit and hit LVN P. RNS stated she was not aware of any aggressive behaviors prior to the incident on 9/23/23. RNS stated she spoke to a family member of Resident #4 who stated that was their relationship at home and an APS (Adult Protective Services) worker who was at the building that day had told her that they had previous cases with Resident #4 and #39 for almost 5 years regarding physical arguing. RNS did not provide a name for APS worker. RNS stated Resident #4 had not exhibited similar behaviors towards Resident #39 before incident on 09/23/23. RNS stated Resident #4 only had her moods with refusing medication but that was the only extent of her behaviors. RNS stated she could not recall if Resident #4 had monitoring for behaviors associated with bipolar disorder. RNS stated if a resident had an antipsychotic or antidepressant or anti-convulsant then they would have a monitoring order for sleeplessness, agitation and stated she did not think it included aggression but more restlessness and insomnia. RNS stated she had done routine checks that included checking on Resident #4 and providing medication. RNS stated she always checked for any behaviors residents demonstrated and would have to notify the appropriate person if any changes were identified. During an interview with the ADM on 10/14/23 at 12:09PM he stated he, and facility staff had been trained over abuse identification and prevention, stating they were trained annually. The ADM stated a fracture, spiral fracture or bruising was considered physical abuse. The ADM stated Resident #4 had struck Resident #39 with the bed remote and had bit Resident #39's thigh. The ADM was asked if he considered the incident between Residents #4 and #39 abuse and he stated it was borderline. The ADM stated Resident #39 had a bite to thigh and bruising to left arm. The ADM stated nobody had made him aware of Resident #4's history of aggressive behaviors before the incident. The ADM stated he was made aware of Resident #4's behaviors after the incident when APS spoke to him and told him stories of incidents in the home setting. The ADM stated he was able to review the resident chart but did not review Resident #4's referral documents in that detail because the Central Admission nurse handled that. The ADM stated he did not think there was an indication that Resident #4 had aggressive behaviors. The ADM stated the Medical Director had worked with Resident #4 and #39 previously and stated he could only speculate he was aware of Resident #4's history of aggressive behaviors but could not speak for him. The ADM stated, the Central Admissions nurse had not notified him of Resident #4 having violent behavior. The ADM stated Resident #39 was not scared of Resident #4. The ADM was not aware of Resident #4's care plan information, stating Resident #4 had no behaviors. The ADM stated nurses monitored Resident #4 stated they were with her every day stating any indication of behaviors they would have flagged. The ADM stated Resident #4 had a history of aggressive behaviors, but he was not aware. The ADM stated to ensure residents are free from abuse while in the facility they completed assessments, reviewed data from the physician and any other sources. The ADM stated the data did not indicate the actual violence that occurred, stating he did not know the extent of the aggression because there was not any indication of actual injury. The ADM stated their abuse policy stated they are to keep residents from abuse, he stated the policy was followed in this situation because Resident #39 did not indicate any fear and wanted to be with Resident #4. The ADM stated not identifying residents with history of aggressive behavior could cause a negative impact to other residents such as injury or death. During an interview with the DON on 10/14/23 at 2:35pm she stated her, and facility staff had been trained over abuse identification and prevention, stating training were completed 2 times a month. The DON stated hitting would be considered physical abuse. The DON stated she was notified that Resident #4 had started hitting Resident #39, the DON stated the incident between Resident #4 and #39 was considered physical abuse . The DON stated Resident #39 had purple discoloration of right forearm, left and right hand with redness noted to shin, and right knee. The DON stated Resident #39 was not scared of Resident #4 and wanted to be with her. The DON stated Resident #4 had no exhibited any aggressive behaviors before this incident on 09/23/23. The DON stated to ensure residents are free from abuse while in the facility she made sure that nobody with current aggressive behaviors were paired with anybody else, the DON stated it was effective in the situation with Resident #4 and #39 stating they moved Resident #4 and #39 . The DON stated not identifying residents with history of aggressive behaviors could impact residents because they could potentially be paired with somebody with behaviors who could potentially hurt their neighbors. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. Record review of facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting with an implemented dated of February 2017 and a review date of 10/2022 stated, Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. And The community conducts the following steps to protect the residents, patients and veterans served . Residents should be screened upon referral to ensure that the current staffing patterns and staff expertise are suitable to provide the necessary care that the prospective resident requires, without the possibility of acts of abuse and neglect towards other residents The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F656 Develop/Implement Comprehensive Plan of Care F600 Freedom from Abuse, Neglect, and Exploitation Immediate Response: Resident #4 was immediately assessed by nursing, medical care provided, and IDT continued to monitored resident to ensure his wellbeing. Resident # 39 was immediately assessed by the nurse and placed on 1:1 for monitoring and discharged for evaluation and treatment. Risk Response: All newly admitted residents who are admitted with historical aggressive behaviors may have been potentially affected. Director of Nursing/Designee will conduct an audit of all recent admissions hospital records to identify any concerns with aggressive behaviors towards others and will review the plan of care to ensure it appropriately reflects potential behavioral risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of aggressive behaviors towards others. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential behavioral risks. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the Abuse and Neglect Preventing, Identifying and Preventing, Admission process to include identifying potential behavioral risks; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-14-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-14-23. System Response: Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the admission process and assessing residents to include identifying potential risks to include but not limited to behavioral risks, such as aggression or aggressive behaviors; thus, ensuring the identified risk is identified on the plan of care to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-15-23. Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-15-23. Education was provided to all staff regarding the process for monitoring, observing, and reporting all behavioral concerns to the licensed nurse in effort to provide needed care, protect the safety and well-being of all residents, to meet the resident's needs, have accurate documentation reflected in clinical record and to ensure appropriate interventions are in place as per facility's expected practices. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing, Administrator Admission Coordinator and Centralized Admissions Nurse regarding facility's updated referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-14-23. Facility has updated its referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-13-2023. Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed: 10-15-2023. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified aggressive behavioral or known physical aggression are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: Record review of facility services revealed the DON, MDS and ADM had been trained over the new referral /admission protocol, RAI (Resident Assessment Instrument) process, identifying and preventing abuse and neglect, the admission process to include identifying potential behavior risks and risks that should be care planned and the importance of monitoring of supportive interventions. Record review of facility services revealed the Central Admissions nurse, Liaison, and the Admissions Coordinator, had been trained over the new referral/admission protocol. Record review of facility in services revealed 23 staff members that included nurses and the IDT (interdisciplinary team) were trained over the RAI process and the admission process to include assessing residents for behavioral risks and care planning the risks and supportive interventions. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Identifying and preventing abuse, neglect and exploitation. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had identified 4 residents with behaviors, none of which were aggression. Record review of impacted 4 residents revealed all care plans were updated appropriately. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. All staff members stated they had recently been trained over behaviors, documentation, facility procedures and abuse and neglect. All staff members interviewed were aware of what to do when identifying behaviors, who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. In addition, nurses and leadership were aware of the admission process and RAI process. During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility had identified residents with behaviors and had updated care plans appropriately. The DON stated they would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24-hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the DON on 10/16/23 at around 9:00AM she stated they had identified 4 residents with behaviors however none of the behaviors identified were aggression. The DON stated care plans had been updated to reflect identified behaviors. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. During an interview on 10/16/23 at 3:50PM with the Central Admissions nurse he stated he had been trained over the new referral/admission protocol and was aware of needing DON and/or ADM approval for approval/denial for new admissions. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #100) reviewed for accidents and hazards: The facility failed to develop and implement interventions to prevent Resident #100's elopement from the facility. Resident #100 eloped from the facility and was found by the road having sustained abrasions, lacerations and a hematoma. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Review of Resident #100's face sheet dated 10/15/23 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including, other specified arthritis (inflammation or swelling of joints), multiple sites, unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning), moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other unspecified depressive episodes ( feeling sad, irritable, empty). cognitive communication deficit (difficulty with thinking and how someone uses language) and unsteadiness on feet. Resident #100 was not identified as her own responsible party. Review of Resident #100's MDS, dated [DATE], reflected a BIMS of 05, indicating severe cognitive impairment. It further reflected that Resident #10 did not require any mobility devices and when walking up to 150 feet required supervision or touching assistance. Resident #100's MDS reflect a 0 when asked is Has the resident wandered?, a 0 indicated wandering behavior had not been exhibited. Resident #100's MDS reflected she used a wander/elopement alarm daily. Record review of Resident #100's comprehensive care plan revealed Resident #100 had impaired cognitive function or impaired though processes related dementia with a created and initiated date of 09/12/23. Resident #100's care plan stated, I am exit seeking, I am at risk for elopement and/or wandering with unsafe boundaries related to dementia 9/30 elopement with a created and initiated date of 09/15/23 and a revision date of 10/05/23. Interventions included, 9/30 out to ER(emergency room ) for check up; room change provided; with an initiation date of 10/05/23 and Assess my continued need for the wander guard use as indicated . Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer the following: . I wear a wander guard device; confirm functioning of device & change device as indicated . Identify pattern of exit seeking: Intervene as appropriate in efforts to minimize behavior . Provide planned and engaging activities as well as activities to meet my needs such as toileting efforts and addressing thirst and hunger needs to prevent/minimize wandering and/or exit seeking attempts because the behavior may be related to a need that cannot be stated. All with an initiation date of 09/15/23. Record review of Resident #100's physician orders revealed an order to check functionality and visualization of wander guard/exit management system through wand or alarmed door QS (every shift) with a start date of 09/14/23 and that was active with no end date noted. Record review of Resident #100 September 2023 licensed nurse administration record revealed order had been completed and documented for every shift in September 2023 as ordered. Record review of Resident #100's exit seeking risk tool dated 09/15/23 completed by the DON revealed Resident #100 exhibited wandering and/or confused behavior, verbalized the need and /or desire to go home or to another location and has the ability to act on that verbalization, has a medical diagnosis associated with confusion which may indicate future likelihood for wandering and was physically able to exit on foot or by wheelchair. Wandering assessment identified Resident #100 did not display exit seeking behavior further stating, NO EXIT SEEKING AT THIS TIME, ONLY WANDERING BEHAVIOR. Record review of Resident #100's nursing notes with an effective date of 09/30/23 and 2:47pm written by RNS revealed she was called to 400 hall by NAIT L due to an activated door alarm. RNS stated her and LVN N went to reset the alarm and looked outside but did not see anyone. RNS stated she completed a resident check and noted Resident #100 was not in her room and went back outside and checked again but did not find the resident. RNS stated she searched inside the facility again and asked other nurses if they had seen Resident #100 but Resident #100 was not located. RNS stated her and LVN N went outside to check again and went down the street when someone was calling out behind her, she turned back and saw what appeared to be a person on the floor with people around and cars on the street. RNS ran to Resident #100 with LVN N and saw Resident #100 sitting on the curb past a vacant lot near offices who when asked where she was going stated she had left to go to the store. RNS identified Resident #100 was actively bleeding from nose and mouth, had a hematoma noted to right side of her forehead above the eyebrow, redness to nose, abrasion to left knee and laceration to the lower lip, Resident #100 was conscious and able to recall a family members phone number. 911 was activated at 3:00pm. Resident #100 was noted with good range of motion to all extremities and denied pain. Record review of Resident #100's hospital records dated 9/30/23 revealed a diagnosis of, contusion to left knee, contusion to right knee, facial abrasion, facial contusion, fall, traumatic hematoma of forehead and wrist sprain. Prescriptions given included acetaminophen 325mg (milligrams) with instructions of 650 MG by mouth every 4 hours as needed for pain for 5 days. Bacitracin/neomycin/polymyxin pramoxine top (triple antibiotics plus topical ointment) for 1 application to be applied topically 2 times for 3 days. Imaging results stated as pending. Record review of Resident #100's nursing noted completed by RNS on 09/30/23 at 6:33pm stated RNS received a call from hospital nurse who stated Resident #100 would be returning to facility and stated Resident #100 had cervical and facial CT scan, x-rays of left knee, left wrist which were all negative. Only finding was soft tissue swelling. New orders to be send for Tylenol 650MG PRN (as needed) and triple antibiotic ointment to be applied to abrasions. Record review of Resident #100's nursing noted completed by RNS on 09/30/23 at 7:37pm stated Resident #100 arrived back to facility after emergency room visit and was able to get out of family members truck and ambulate to her room, RNS completed a head to assessment that noted abrasion to nose, upper lip, left knee, left hand knuckle and right aspect of forehead. A Hematoma was noted to the right aspect of forehead and a laceration to inner lower lip. Resident #100 denied pain and could not recall falling or eloping. Resident #100 was placed on 15-minute monitoring and neuro check (assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.) Record review of Resident #100's document titled Skin: Abrasion/Bruise/Edema/Mole/Rash dated 09/30/23 and signed by RNS on 10/01/23 revealed Resident #100 had abrasion to left hand knuckles, abrasion to left knee and a hematoma to right aspect of forehead, abrasion to nose, upper lip and laceration to inner aspect of lower lip that was first observed on 09/30/23. Record review of Resident #100's document titled Skin & Wound - Total Body Skin Assessment with an effective date of 09/30/23 at 7:37pm and signed by RNS on 10/01/23 revealed a total of 9 new wounds. During an interview an observation with the Maintenance Director on 10/11/23 between 9:52am and 10:15am noted a total of 9 doors, 2 doors identified as the service door and front door were equipped with similar alarm systems that required the alarm to be turned off at the door and at the nurse's station. All other 7 doors were equipment with a different type of alarm. Doors were tested with and without wander guard, all doors opened after a 15 second egress regardless of if using a wander guard or not. During an interview with the ADM on 10/11/23 at 10:12am he stated the front door and service door were equipped with a wander guard alarm while all other doors were equipped with a sound alarm. The ADM stated the service door and the front door were high traffic areas and that was why they were equipped those 2 doors with a wander guard alarm. It was identified through this information that the door Resident #100 eloped from in hall 400 door was equipped with a 15 second delayed egress and a stop alarm (manual annunciator) Record review of maintenance logbook documentation stating Resident Monitoring System: check operation of door monitors and patient wandering system. Marked done on time by (Maintenance supervisor) on September 22, 2023. Revealed 9 doors were tested and alert and alarm system are in working condition. Record Review of TULIP (HHSC online incident reporting application) on 10/10/23 at 5:00PM revealed the facility made a self-reported incident on 10/02/23 at 2:01pm regarding Resident #100's elopement. Record review of facility elopement training/in services completed prior to Resident #100's elopement revealed the facility had a training over elopement on 09/25/23 at 1:40pm. NAIT L was not on identified on attendance record. Record Review of facility elopement training/in services revealed NAIT L had not previously been trained before Resident #100's elopement on 09/30/23. Observation on 10/13/23 at 9:00am of surrounding streets revealed a 2-way street with a turning lane with a speed limit of 30 miles per hour. Observation of Resident #100 on 10/10/23 at 9:32am revealed scab to left knee, bruising under bilateral eyes, bruising to right side of forehead, bubbled skin tear area inside lower lip with scabbing noted on lower lip. Resident #100 was noted with a wander guard in place. During an interview on 10/10/23 at 9:32am with Resident #100 she stated she had a fall when she went alone to cross the street to go to the store. Resident #100 was unable to recall what happened after she was helped up but stated she had pain inside her lip. During an interview on 10/10/23 at 12:17 pm with NAIT L she stated on 09/30/23 she heard the alarm go off in the 400 hall back side door, she stated she went to put in the code to the key pad because normally a resident would click there but not go out. NAIT L stated she attempted to put in the code, but it did not work. NAIT L stated she proceeded to notify RNS and LVN N who both went to the door. NAIT L stated RNS fixed the door alarm, did a head count and checked every room in every hall but did not find Resident #100. NAIT L stated everyone went outside to search for Resident #100. NAIT L stated she did not look outside the door when responding to the door alarm because she is used to residents in the wheelchair just pushing the door. NAIT L stated she had been trained over elopement procedures and should have gone outside to check but stated she forgot and got the nurse instead, NAIT L stated she looked through the window. NAIT L stated everybody including herself was responsible for supervision of Resident #100 on 09/30/23. NAIT L stated Resident #100 had a wander guard in place at the time of elopement and stated everyone was responsible for ensuring it was in place and working. NAIT L stated door alarms were working on 09/30/23. NAIT L stated she was not aware where Resident #100 was found. NAIT L stated residents eloping could negatively impact them because they could get ran over or something even worse than that. During an interview with RNS on 10/10/23 at 1:16pm she stated when a door alarm goes off they need to check surroundings by the door and check if anybody is walking outside and if nobody is found they proceed to do a head count and check in rooms and have other nurses check residents who are elopement risks. RNS stated she went to Resident #100's room and did not see her, RNS stated she ran outside with a nurse and went towards a vacant lot in the back and towards the street and checked the sides and did not find anyone. RNS stated she went back into facility and searched again but stated no one saw Resident #100. RNS stated they began to search outside again and decided to go down the street because Resident #100 always said she wanted to go home and to her family members house who RNS stated lived close by. RNS stated she heard someone behind her saying, over here, over here and stated she saw a car in the middle of the street and a lady in the middle of the street. RNS stated once she got to the location, Resident #100 was sitting at the side the street. RNS stated Resident #100 told her she was just going to the store nearby. RNS stated she assessed Resident #100 and identified an abrasion to left knee, a hematoma to right upper forehead, laceration to inner lower lip, redness to nose and was bleeding from her nose and mouth. RNS stated Resident #100 was able to recall family members phone number which RNS stated she called but stated the call was not picked up. RNS stated she called 911. RNS stated there was 1 car that had pulled over and 1 that was on the side. RNS stated there were 2 ladies who were there with Resident #100 with 1 stating they did not see anything and the other stating she had only seen Resident #100 crawling on the street when she was turning. RNS stated the street where Resident #100 was found was accessible by cars with both coming and going lanes. RNS stated she had been previously trained over elopement and stated when they hear an alarm they had to go right aware and check surroundings and count residents and complete a walk through. RNS stated the alarm was working on 9/30/23 because they did hear the alarm. RNS stated when the alarm went off they had positive COVID (coronavirus disease) residents and had the double doors shut and stated the alarm did not sound as loud, stating she did not hear it right away. RNS stated NAIT L stated she had heard the alarm, but RNS was not sure if NAIT L had went outside. RNS stated once NAIT L called her that's when they went to check. RNS stated she was not too sure on what time Resident #100 exited the facility but stated she started going towards the alarm at 2:47pm and had found Resident #100 at 2:55pm with the ambulance arriving at 3:18pm. RNS stated everyone on the floor including nurses and aides were responsible for supervising Resident #100 on 09/30/23. RNS stated Resident #100 had a wander guard in place at time of elopement on 09/30/23. RNS stated the nurses were responsible for ensuring the wander guard was in place and working, stating nursing would check it per shift and document it on the MAR (Medication Administration Record). RNS stated everyone in general and maintenance were responsible for ensuring the door alarms were working, stating she was not sure how often they were checked but stated they were working that day. RNS stated as per family Resident #100 had a history of this behavior which was why Resident was placed in facility. RNS stated residents eloping could negatively impact the residents due to injury, and death if they are not gotten to on time and on a busy street they could get hit and lost or dehydrated. During an interview with the ADM on 10/14/23 at 11:57AM he stated he did not work on 09/30/23 when Resident #100 eloped from facility. The ADM stated RNS was responsible for supervising Resident #100. The ADM did not have the exact time Resident #100 exited the facility. The ADM stated he had not been told about Resident #100 verbalizing she wanted to leave the facility. The ADM stated Resident #100 had not eloped from the facility before 09/30/23. The ADM stated Resident #100 had a wander guard placed after assessment was completed and stated it had been care planned. The ADM stated nursing was responsible for completing that assessment. The ADM stated Resident #100 was cognitively impaired and had poor safety awareness. The ADM stated Resident #100 was able to ambulate on her own. The ADM stated staff were aware residents who are wandering/elopement risk through an elopement book that was kept at nurses station and included all the demographics of the residents so they could be identified, the ADM stated he believed there was also another system more on the clinical side. The ADM stated staff received elopement in services and drills, and stated they complete them yearly through an online training program and throughout the year as part of their emergency preparedness plan. The ADM stated staff did look outside the door but stated he did not know how far they did, he stated staff had not seen anyone in the parking lot. The ADM stated they should have gone outside to search. The ADM stated Resident #100 was found across the street and had a skin tear to lip and bruising to forehead. The ADM stated if you were to step outside the door and look to where Resident #100 was found your line of sight would have been obscured by the vehicles in the parking lot. The ADM stated Resident #100 was found in under 15 minutes. The ADM stated from what he gathered from staff Resident #100 was going to the store. He stated there was no other injuries identified at the hospital. The ADM stated the facility elopement policy and procedures stated to search the outside, complete an internal head count, check for resident inside facility. The ADM was asked if the facility's policy was followed in this situation, and he stated staff should have gone further out. The ADM was not sure why staff did not follow their policy and stated staff had been trained to do that. The ADM stated it was possible that NAIT L had not been trained. The ADM stated he monitored that staff provided the appropriate level of supervision for residents to prevent elopement by completing drills to ensure staff follow the process and maintain the resident's safety. During an interview with the DON on 10/14/23 at 2:22PM she stated she did not work on 09/30/23 when Resident #100 eloped from facility. The DON stated RNS, NAIT L, LVN N and NAIT O were responsible for supervising Resident #100. The DON stated Resident #100 was out of the facility for about 15 minutes. The DON stated to her knowledge Resident #100 had not verbalized she wanted to leave the facility. The DON stated Resident #100 had not eloped from the facility before 09/30/23. The DON stated Resident #100 would wander into the nurse's station but would not try and get out, the DON stated it had been care planned. The DON stated the nurse that placed the bracelet, herself or sometimes the MDS Coordinator was responsible for completing development assessments. The DON stated Resident #100 was cognitively impaired but was aware, alert but forgetful, stating she had dementia. The DON stated Resident #100 did not have impaired safety awareness. The DON stated Resident #100 was able to ambulate on her own. The DON stated staff were aware of residents who were wandering/elopement risks through a wander guard note book at nurses' station and included resident demographics and a picture of resident. The DON stated NAIT L notified nurse of door alarm and stated NAIT L did open the door and look outside and sated she also looked through the glass windows and then went to notify the nurses. The DON stated NAIT L should have done a done a search of the outside area. The DON stated if NAIT L had stepped outside and looked at the surrounding areas she would have seen Resident #100. The DON stated Resident #100 sustained abrasion to nose, upper lip, left knee, left hand knuckle, hematoma to right aspect of forehead and had some bleeding noted. The DON stated based on what nurses told her there was some cars that saw Resident #100 and assisted when nurses went to get Resident #100. The DON stated Resident #100 stated she was going to the store. The DON stated there were no other injuries identified at the hospital. The DON stated they placed Resident #100 on a 1:1 and did a room change to place her in front of the nurse's station and in front of HR (human resources) office. The DON stated they had a care plan meeting with the family and stated based on Resident #100's risk a secure unit would be beneficial. The DON stated Resident #100's family was going to be taking her home for private care. The DON stated the facility elopement policy and procedures stated staff should go outside, check surrounding areas, if no one was found then an internal head count should be completed to identify who was missing. The DON stated NAIT L had not been trained prior to Resident #100's elopement on 09/30/23. The DON stated their previous elopement drill was on 09/26/23 and stated NAIT L had not worked that day. However, the DON stated staff had been verbally educated that when they hear alarms they are to immediately go and see why the alarm was sounding and which alarm it was, the DON stated NAIT L had received this verbal training from her before Resident #100's elopement. The DON stated she monitored that staff provided the appropriate level of supervision for residents to prevent elopement with wander guards and stated drills and in services over elopement were completed periodically on different shift. The DON stated residents eloping from the facility could negatively impact them because they could fall. Record review of facility policy titled Elopement Response & Exit Seeking Management with an implementation date of 2019 and a reviewed date of January 2023 stated under section, A. Elopement Response: unable to locate resident. 1. If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises. The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F689 Each resident receives adequate supervision and assistance devices to prevent accidents. Immediate Response: Elopement search had commenced, Resident #1 was noted nearby facility and nurse immediately assessed resident and resident #1 was sent to the ER for further evaluation and treatment. Identified team member was re-educated on the elopement concern: 1. Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol-Implementing inside and outside on grounds search when there is a risk of a missing resident or elopement of a resident. Risk Response: There are 8 out of 100 residents who require a wander guard monitoring device and who may be potentially affected. Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exiting seeking assessment in order to identify any concerns with exiting seeking or elopement risks and the IDT will review the plan of care to ensure it appropriately reflects potential elopement/exit seeking risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exiting seeking / elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exiting seeking / elopement risk noted. Date completed: 10-14-23. System Response: Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Inservice conducted on Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol o Identifying and Responding to Triggers to Prevent Elopement and Behaviors o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Director of Nursing / Designee to conduct retraining to all licensed nurses prior to assuming next shift regarding: o Identifying exit seeking / elopement risk for all new admission/re-admissions and utilizing a wander guard device if the person is identified as an elopement risk. o What to do or response to a missing/unaccounted for resident/patient as per community's process. Immediately initiating a search of inside and outside of facility to search for resident as per facility's expected practice, Elopement Response Protocol reviewed. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed:10-15-23. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. Administrator/Director of Nursing/Designee will conduct Elopement / Missing Person Response Drills at least weekly on random shifts to ensure all shifts have had elopement drills in order to identify competency of TMs work all three shifts or to identify additional education needs. Drills will be conducted weekly for the next 3 months. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility identified a total of 6 residents appropriate for wander guards. The DON stated they will be completing elopement drills weekly for the next 3 months and would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24 hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the ADM on 10/15/23 at 1:06pm he stated residents would be monitored by completing rounds, reviewing them during morning meetings, going over 24hour reports, census, admissions and discharges, nursing notes. The ADM stated elopement/missing person drills would be done weekly for the next 3 months. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had previously identified 8 residents who used a wander guard however, Resident #100 had been discharged and Resident #90 had been downgraded and had wander guard removed due to not exhibiting exit seeking behaviors. Resident #90's updated care plan reflected she was a wander risk but not exit seeking. Resident #90's updated exit seeking risk tool reflected she had been seen walking slowly in the hall way but has not been exhibiting exit seeking behaviors. All other 6 residents had updated exit seeking risk tools, and all 6 resident's care plans appropriately reflect exit seeking/wandering risk. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Elopement, specifically Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol, Identifying and Responding to Triggers to Prevent Elopement and Behaviors. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review of in services revealed NAIT L was in serviced on 10/14/23 over Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol. NAIT L was interviewed on 10/16/23 at 9:52 am and was aware of search protocols, missing person/elopement response and procedures, how to identify and respond to triggers and exit seeking behaviors and how to prevent elopement. Who to report to and where to document identified behaviors. NAIT L was able to define abuse and neglect, she gave examples of abuse and neglect, and aware of signs to identify abuse and neglect, NAIT L was aware of what to do when abuse and neglect was suspected and who to report to. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. Al staff member stated they had recently been trained over elopement, behaviors, exit seeking, facility procedures and abuse and neglect. Nurses were aware of identifying exit seeking behaviors and elopement risks and with all new residents and utilizing a wander guard if resident was an elopement risk. Nurses were also aware of how to respond when a resident is missing and search procedures to follow and initiate. All staff members interview were aware of search protocols were aware of missing person and elopement response and procedures, how to identify and respond to triggers and exit seeking behaviors and how to prevent elopement. Who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. 45737

Based on observation, interview, and record review, the facility failed to ensure that 1 (R#1) of 30 residents with diagnoses of diabetes reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. During R #1's admission medication reconciliation process and throughout his stay, the facility failed to attempt to attain an order for blood glucose monitoring, despite his daily administration of three different diabetic oral medications and decreased appetite. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV mediation intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could affect residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the effects of lack of diabetic monitoring and medication administration. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of progress note dated 05/29/2023 documented by GVN A, revealed .Resident noted eating dinner by himself without any difficulty, notified RP and will continue to monitor. Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226 mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [NAME] Medical Center on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the wife and the daughter, over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 3:34PM, CNA A stated on Wednesday 08/23/2023 R#1 was bathed in the morning and did not see anything out of ordinary. CNA A stated she noticed a difference in R#1's demeanor and worked with R#1 from 08/24-08/27. CNA A stated on Wednesday 8/30 upon her return to work, she assisted R#1 to eat but saw a difference in eating and demeanor. CNA A stated R#1 was no longer able to hold cutlery or feed self effectively and notified LVN A on 08/30/2023. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2pm-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on 08/31/23 after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at the local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs), the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what the infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and sugar was over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when there is a high amount of sugar and acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on [DATE]. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization . The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management plan date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and do [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a physician supervised the care of a resident for one (Resident #1) of five residents reviewed for physician services. The facility failed to ensure the physician supervised and monitored Resident #1's blood glucose monitoring since Resident #1 was diagnosed with diabetes and was prescribed and administered three different oral diabetic medications. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without any appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV medication intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There was no blood glucose monitoring included in the reconciliation. Record review of R#1's Blood Sugar Summary dated 05/23/2023 at 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of R#1's progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation and attempted interview on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed (used for severe low blood pressure , shock, or low heart rate) drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview and record review on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's family member, the family member did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait until the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, progress notes were reviewed, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on 08/31/23 after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on [DATE]. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization . The PCP stated the NF should have been monitoring glucose. Record review of the facility's Changes in Resident Condition Policy date implemented 05/2017 and date reviewed/revised January 2023 stated: 1. The resident, attending physician and resident representative or designated family member should be notified when there is: c. a significant change in the resident's physical, mental or psychosocial status. 2. Provide assessment information to physician d. a need to alter treatment significantly (i.e., a need form of treatment due to adverse consequences, or to commence a new for of treatment); e. A decision to transfer the resident from the community, g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders Record review of the facility's Diabetes Management date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date Commenced: 9/4/2023 Date to be completion: 9/5/23 All staff will be in-serviced on ANE- Prevention, Identification, Protecting and Reporting. Date Commenced: 9/4/2023 Date to be completion: 9/5/23 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response: The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine accu-checks monitoring that is prescribed and interview random nurses to review how to identify patients who have diagnosis of diabetes. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. The surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Record review: -Facility staff training on documenting in chart change of condition/observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Audit of facility residents with diabetes type II and confirmation of standing orders -Employee record for completion of training -QAPI record of meeting discussing diabetic management protocol and changes in condition with recommendation to re-educate all licensed nurses in these areas and confirm current orders with physicians. Hospital record documented: R #1's Dx: Hypernatremia, Acute Kidney Injury superimposed on chronic kidney disease, Altered Mental Status, Constipation, hyperkalemia, Sepsis; Septic Shock, Diabetic Ketoacidosis. R #1's H&P: presented with Altered Mental Status, Dry Mucous Membranes, Distended Abdomen V/S @ 8/31/2023 16:09 T 97.3, RR 20, HR 67, B/P 80/39 O2 98% Interviews: -13 interviews were conducted on 9/6/2023 and 9/7/2023 across 3 shifts with LVN A through LVN M to ensure training was completed. Training began after the facility was notified that the plan of corretion was accepted around noon on 9/6/2023, and was finished the same day on 9/6/2023. Responses were consistent facility training and policy. -demonstration of knowledge of documenting in chart change of condition/ observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Interviewed DON on process for monitoring on an ongoing basis on 9/7/2023 at 9:20 AM: Tool for identifying diabetic residents reviewed. Developed by the Director of [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (R #1) of four residents that were diagnosed with diabetes mellitus. 1. Multiple nursing personnel who cared for R#1 did not consult with R#1's Physician, in attempt to retrieve instructions for blood glucose monitoring. 2. LVN A cared for R#1 for multiple days and stated she did not know he was a diabetic. 3. DON assessed R#1 on 8/31/23 and despite of his change in condition of lethargy and altered level of consciousness, the DON did not conclude that R#1's change in condition was urgent enough to require emergent medical treatment. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure to notify and consult with the physician regarding a change of condition, and diabetic management resulted in a delay of appropriate medical treatment and a worsening of R#1's condition. This failure had the potential to affect residents receiving diabetic management who may experience a significant change in condition and or death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of Hospital Attending Physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive (low blood pressure), blood pressure was 80/39. He was severely hyperglycemic (high blood sugar), glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at [NAME] Medical Centerthe local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs) , the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on 08/31/23 after 3:00 PM. During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and blood sugar level over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when sugar is high and there is high amount of acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on [DATE]. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization . The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. Record review of the facility's Professional Standard of Care Policy date implemented 2017 stated, Nursing Practices: a. Licensed nurses must practice within the constraints of applicable state laws and regulations governing their practice and must follow the guidelines contained in the communities' written policies and procedures. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed the [family member] that she could send patient to the ER to which the spouse agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date Commenced: 9/4/2023 Date to be completion: 9/5/23 All staff will be in-serviced on ANE- Prevention, Identification, Protecting and Reporting. Date Commenced: 9/4/2023 D [TR

Based on observation, record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R #1) of 7 residents reviewed for falls and accident hazards. R #1 required 2 persons transfer with a mechanical lift. CNA D transferred R #1 by herself. R #1 fell and sustained a proximal left humeral fracture. The facility did not provide the type and amount of supervision necessary to prevent R #1 from falling and sustaining a fracture. This failure could place residents with high risk for falls at risk for additional falls and injuries. The findings included: Review of R #1's Face sheet dated March 4, 2020 documented an [AGE] year-old male admitted [DATE], with a re-admission date of [DATE], with the [DIAGNOSES REDACTED]. R #1 was discharged [DATE]. Review of R #1's Minimum Data Set ((MDS) dated [DATE] documented he: - had severe cognitive impairment due to rarely/never being understood. -required extensive assistance for all activities of daily living -required two-person assistance with bed mobility and transfers. -was frequently incontinent of urine and bowel -had one fall since admission or prior assessment with no injury Review of R #1's Care Plan dated 6/24/2014 which was revised on 1/21/2019 documented I have an Activity of Daily living self-care performance deficit related to [MEDICAL CONDITIONS] with [MEDICAL CONDITION] and left upper extremity contracture, dementia. Goal I will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, through the review date. Interventions documented . -Toilet use: I am not toileted. I require extensive two staff participation for incontinent care. (date initiated 6/24/14 and date revised 6/14/18) -Transfers: I require two staff participation for transfers with hoyer lift (mechanical lift). (date initiated 6/24/14 and date revised 10/14/18) Review of R#1's Nurse's Note dated 1/31/20 6:20 AM documented Notified by CNA that resident was slipping off shower chair and she assisted him to the floor in order to break the fall. Upon entering resident's room found resident in supine position on the floor between the left side of the bed and shower chair. Resident alert and with no signs and symptoms of distress noted. Resident able to move upper and lower extremities with no complications. Resident with contracture to left arm. With assistance of CNA, resident transferred to bed for further assessment. Vital signs taken: Blood Pressure 157/90, Respirations 20, Pulse 75, Temperature 97.9 degrees Fahrenheit, and Oxygen saturations 99% on Room Air. Description of Initial Action/ Follow up to action: Once in bed, head to toe assessment performed and noted resident with small closed abrasion to right forearm, light purple discoloration to left shoulder area with a small purple (blotch) next to it. As we continued with assessment resident did do facial grimacing as if in pain when left arm was moved. Pain medication administered at this time. Called MD at this time, left voice message pending MD response. ADON aware. Review of R#1's Nurse's Note dated 1/31/20 7:04 AM documented MD returned call and was informed of current situation. Resident resting comfortably in bed with no facial grimace or distress noted at this time. MD gave orders for X-ray of left shoulder to hand. X-rays scheduled STAT, pending to get done. At approximately 7:10AM, Responsible Party was notified and expressed no concerns, just wants call back with results. Review of Radiology Interpretation for R #1 dated 1/31/20, revealed impression: evidence of proximal left humeral fracture. Acute or subacute in nature. During an interview with CNA D on 3/4/2020 at 1:21 PM, CNA D stated she could not find a staff member to help her transfer R #1 back from the shower chair to the bed. CNA D stated, There was no staff on the hall or on the floor, so I took it upon myself to pick up R #1 and transfer him alone. CNA D stated I knew R #1 was a two person transfer with a hoyer (mechanical lift), but I wasn't going to leave him in the chair until I could find someone because I didn't know how long that would take. CNA D stated she placed her arms under R #1's arms and around his body and started to transfer. When she took R #1 off the chair, he immediately began to slip, so she grabbed tighter around his body and assisted him slowly to the floor. CNA D stated, when that occurred, the left arm which was contracted, moved upward. CNA D said she heard a pop to R #1's left arm. She lowered R #1 to the ground and called the nurse immediately. CNA D stated LVN A came into the room and assessed R #1. CNA D stated this was an accident and I was fired because I didn't get assistance to use a hoyer lift (mechanical lift). During an interview on 3/4/2020 at 3:30 PM, LVN A stated she was notified by an unidentified CNA that R #1 had a fall. LVN A stated CNA D told her R #1 had not fallen, but was assisted to the ground because during the transfer, R#1 had slipped from the shower chair. LVN A stated CNA D said she had guided R #1 to the floor and she heard a pop from R #1's left side but did not specify the exact location. LVN A stated R #1 was alert on the floor lying face up and he did not show signs of pain. LVN A said she checked R #1's vital signs which were stable and did a quick assessment. LVN A stated, she and CNA D and another unidentified CNA transferred R #1 with a draw sheet back to bed for further assessment. LVN A stated she was able to examine R #1 while he was in bed more thoroughly and realized that he had a slight grimace when she manipulated his left arm. LVN A said she gave R #1 his PRN (as needed) pain medication. LVN A said she notified R #1's doctor and the doctor ordered an x ray which was carried out. LVN A said she called the DON, ADON, responsible party, and administrator about the incident. LVN A stated R #1 required the assistance of two persons during transferring and also required the use of a mechanical lift. LVN A said she asked CNA D why she transferred R #1 alone and why she did not ask for help, and CNA D told her that she was looking in the hallways for help, but she did not see anyone so, she did it by herself. LVN A stated that CNA D should have asked for help from another staff member or turned on the call light to let other staff members know that help was needed. During an interview on 3/4/2020 at 2:43 PM, the DON stated R #1 required the assistance of two persons with a mechanical lift, but CNA D transferred R #1 from the shower chair to the bed by herself. The DON said CNA D said R #1 slipped during transfer and she assisted R #1 to the floor. CNA D said she heard a pop from one of R #1's arms. The DON stated CNA D should have called another staff member to help her with the transfer. The DON stated, we tell the staff to press the call light or continue to look for someone to assist with the transfer and/or wait for assistance. Review of the facility's undated Total Mechanical Lift Competency checklist which is used as a procedure guide and check off for staff members indicated Mechanical lift operation: a. Ensures two caregivers are present. As of exit date 3/4/20, the facility took the following actions to correct the non-compliance by: -Observations made by the surveyor on 3/4/20 of two other residents in the facility being transferred as indicated on care plan and Kadex with the proper use of a mechanical lift and two nursing staff. -Seven licensed nursing staff interviewed by the surveyor on 3/4/20 stated they had received training from the facility on 1/31/20 about transfers with a mechanical lift and gait belt, proper use of Kardex, abuse and neglect, fall prevention, call lights, and repositioning. These staff represented all shifts. During an interview on 3/4/20 at 2:45 PM, the DON stated some ways the facility attempts to prevent and reduce falls are daily rounds done by managers into designated rooms to check on the residents and make sure that all interventions that are required for that resident are in place. Other ways to prevent falls is by using a fall star program which highlights and identifies the residents that are at risk for falls, so that staff can monitor them more frequently and make sure that any intervention set for that resident in the Kardex are followed. Staff have been in-serviced on 1/31/20 on requiring two persons for all mechanical lift transfers, how to properly use the mechanical lift, and following the Kardex. Facility staff and rehabilitation staff worked together to show a demonstration of how to properly use a mechanical lift for a transfer and a gait belt transfer. They had staff return the demonstration to properly evaluate staff abilities and to make sure staff understood the teaching. The DON stated that an action plan for the fall was included in the QAPI meeting on 2/2/20 and the facility documented that the problem identified was increased falls and major injury. The DON stated the action plan dated 2/2/20 included training CNAs, medication aides, charge nurses on stop and watch declines and SBARs. The action plan had assigned walk through for department managers. Reviewed fall and risk management in morning meetings and completed a fall track and trends, and reviewed interventions carried out in care plans and ensured guardian angel rounds were done daily, which allowed managers to go to assigned rooms and check on each resident in the room.

Based on record review and interview, the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R#13) of 17 residents reviewed for accidents and injuries. Certified Nurse Aide (CNA) P transferred R#13 by herself when the resident needed a two person transfer. R#13 sustained two broken (fractured) knees. This failure could affect 15 residents on hall 100 requiring two person staff assistance. The findings were: R#13's Admission Record dated 07/15/15 indicated was [AGE] years old, R#13 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. R#13's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated, R#13 had clear speech, was understood and could usually understand. R#13 required extensive physical assistance by two persons for bed mobility and transfer. Under Balance During Transitions and Walking, the MDS indicated R#13 was not steady and only able to stabilize with staff assistance for moving from seated to standing position and transferring between bed and chair or wheelchair. Under Functional Limitation in Range of Motion, the MDS indicated R#13 had impairment on one side (lower extremity). R#13 had severely impaired cognition. On 07/16/15 at 6:55 p.m. during a telephone interview, CNA P said I did the transfer by myself, the Cardex did instruct it should have been a two person transfer. CNA P said she was the only CNA on hall 100, but other CNAs were available to assist in the facility. On 07/16/15 at 2:15 p.m., the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) A came to her (the DON) and said R#13 had c/o of pain to the right knee. The DON reported LVN A had done an assessment, R#13's right knee had no redness, R#13's left knee did have some redness. The DON reported CNA P (worked the shift starting at 10:00 p.m. on 07/09/15 to 6:00 a.m. on 07/10/15) had informed her (the DON) that at two or three a.m. R#13 wanted to lie down and she (CNA P) had done the transfer by herself. Surveyor asked the DON if CNA P had checked the Cardex (had information for the residents' activities of daily living including transfers). The DON said, no, CNA P just assumed (R#13) was a one person transfer. The DON said CNA P had written a statement that she had transferred R#13 by herself and R#13 was a two person transfer. R#13's Nurse's Notes dated 07/10/15 at 10:39 a.m. revealed Resident c/o (complained of) pain to Rt (right) lower leg. R#13's Nurse's Notes dated 07/10/15 at 12:30 p.m. revealed . resident is complaining of pain to bilateral lower extremities. Assisted resident at this time and resident noted with redness to left knee .resident got up for breakfast with no c/o of any pain until 10:40 a.m. then resident c/o pain only to right leg. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to MD's (Medical Doctor) office and spoke to Family Nurse Practitioner (FNP), notified of resident's c/o pain to bilateral lower extremities (BLE). Order received for X-rays to BLE. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to Hospice and notified of resident's new onset pain complaining to bilateral lower extremities if we can get a stronger pain med (medication). R#13's Nurse's Notes dated 07/10/15 at 9:19 p.m. revealed RP (Responsible Party) was informed of X-ray results showing bilateral knee fractures. RP also informed that MD was aware and ordered immobilizers and if RP wishes for an orthopedic to assess resident. R#13's Nurse's Notes dated 07/12/15 at 10:30 p.m. revealed as per RP do not transfer resident to wheelchair until orthopedic surgeon assess (sic) resident. The facility's Investigation Report dated 07/16/15 revealed in the Investigation Summary CNA (Certified Nurse Aide) (P) was suspended pending investigation due to not following Resident's (R#13's) plan of care-transfers. Employee (CNA P) was terminated due to not following resident's plan of care -transfers. On 07/16/15 at 11:15 a.m., CNA Q said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall when R#13 had complained of pain. CNAQ stated R#13 had c/o of pain at about 10:30 a.m., first complained of right knee pain and later reported pain in both knees. On 07/16/15 at 11:35 a.m., CNA R said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall with R#13. CNA R reported the nurse (unidentified) had told her R#13 had pain. On 07/16/15 at 2:10 p.m., surveyor did an in-room visit. R#13 had her eyes open and was lying on her back in her bed. Surveyor asked R#13 what had happened to her knees. R#13 did not respond. On 07/16/15 at approximately 2:45 p.m., LVN A reported a housekeeper (unidentified) had informed her R#13 was in pain. LVN A replied initially R#13 had c/o pain to her right knee and later had c/o pain to both knees. LVN A replied she had done an initial assessment and R#13's right knee had no redness or swelling. During a later assessment R#13's left knee had redness. Surveyor asked LVN A if R#13 said what had happened to her knees. LVN A said R#13 was unable to recall. On 07/16/15 at 3:40 p.m., LVN S said R#13 had denied a fall or hurting herself. The facility's undated Resident Abuse Policy revealed Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The DON provided a list on 07/16/15 of the residents on the 100 hall who require a two-person to assist with transfers. There were 15 residents on the list, including R#13.

Based on observation, record review and interview, the facility failed to implement their written policy and procedures to prohibit abuse/neglect for two residents (R#13 and R#3) of 17 residents reviewed for abuse/neglect in that: 1. Certified Nurse Aide (CNA) P transferred R#13 by herself when the resident needed a two person transfer. R#13 sustained two broken (fractured) knees. This failure could affect 15 residents on hall 100 requiring two person staff assistance. 2. The facility did not follow their policy to investigate when R#3 had trauma of unknown origin to his penis. This failure could prevent the facility from providing immediate care to the five residents with catheters. The findings were: 1. The facility's undated Resident Abuse Policy revealed Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#13's Admission Record dated 07/15/15 indicated was [AGE] years old, R#13 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. R#13's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated, R#13 had clear speech, was understood and could usually understand. R#13 required extensive physical assistance by two persons for bed mobility and transfer. Under Balance During Transitions and Walking, the MDS indicated R#13 was not steady and only able to stabilize with staff assistance for moving from seated to standing position and transferring between bed and chair or wheelchair. Under Functional Limitation in Range of Motion, the MDS indicated R#13 had impairment on one side (lower extremity). R#13 had severely impaired cognition. On 07/16/15 at 6:55 p.m. during a telephone interview, CNA P said I did the transfer by myself, the Cardex did instruct it should have been a two person transfer. CNA P said she was the only CNA on hall 100, but other CNAs were available to assist in the facility. On 07/16/15 at 2:15 p.m., the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) A came to her (the DON) and said R#13 had c/o of pain to the right knee. The DON reported LVN A had done an assessment, R#13's right knee had no redness, R#13's left knee did have some redness. The DON reported CNA P (worked the shift starting at 10:00 p.m. on 07/09/15 to 6:00 a.m. on 07/10/15) had informed her (the DON) that at two or three a.m. R#13 wanted to lie down and she (CNA P) had done the transfer by herself. Surveyor asked the DON if CNA P had checked the Cardex (had information for the residents' activities of daily living including transfers). The DON said, no, CNA P just assumed (R#13) was a one person transfer. The DON said CNA P had written a statement that she had transferred R#13 by herself and R#13 was a two person transfer. R#13's Nurse's Notes dated 07/10/15 at 10:39 a.m. revealed Resident c/o (complained of) pain to Rt (right) lower leg. R#13's Nurse's Notes dated 07/10/15 at 12:30 p.m. revealed . resident is complaining of pain to bilateral lower extremities. Assisted resident at this time and resident noted with redness to left knee .resident got up for breakfast with no c/o of any pain until 10:40 a.m. then resident c/o pain only to right leg. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to MD's (Medical Doctor) office and spoke to Family Nurse Practitioner (FNP), notified of resident's c/o pain to bilateral lower extremities (BLE). Order received for X-rays to BLE. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to Hospice and notified of resident's new onset pain complaining to bilateral lower extremities if we can get a stronger pain med (medication). R#13's Nurse's Notes dated 07/10/15 at 9:19 p.m. revealed RP (Responsible Party) was informed of X-ray results showing bilateral knee fractures. RP also informed that MD was aware and ordered immobilizers and if RP wishes for an orthopedic to assess resident. R#13's Nurse's Notes dated 07/12/15 at 10:30 p.m. revealed as per RP do not transfer resident to wheelchair until orthopedic surgeon assess (sic) resident. The facility's Investigation Report dated 07/16/15 revealed in the Investigation Summary CNA (Certified Nurse Aide) (P) was suspended pending investigation due to not following Resident's (R#13's) plan of care-transfers. Employee (CNA P) was terminated due to not following resident's plan of care -transfers. On 07/16/15 at 11:15 a.m., CNA Q said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall when R#13 had complained of pain. CNAQ stated R#13 had c/o of pain at about 10:30 a.m., first complained of right knee pain and later reported pain in both knees. On 07/16/15 at 11:35 a.m., CNA R said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall with R#13. CNA R reported the nurse (unidentified) had told her R#13 had pain. On 07/16/15 at 2:10 p.m., surveyor did an in-room visit. R#13 had her eyes open and was lying on her back in her bed. Surveyor asked R#13 what had happened to her knees. R#13 did not respond. On 07/16/15 at approximately 2:45 p.m., LVN A reported a housekeeper (unidentified) had informed her R#13 was in pain. LVN A replied initially R#13 had c/o pain to her right knee and later had c/o pain to both knees. LVN A replied she had done an initial assessment and R#13's right knee had no redness or swelling. During a later assessment R#13's left knee had redness. Surveyor asked LVN A if R#13 said what had happened to her knees. LVN A said R#13 was unable to recall. On 07/16/15 at 3:40 p.m., LVN S said R#13 had denied a fall or hurting herself. The DON provided a list on 07/16/15 of the residents on the 100 hall who require a two-person to assist with transfers. There were 15 residents on the list, including R#13. 2. The facility's policy, Accidents & Incidents Reporting/Investigation indicated that all accidents and incidents involving residents would be investigated. The reports would be utilized in all incidents, such as bruises, skin tears or abrasions observed on the residents. The policy also stated that the licensed nurse would conduct an investigation of the accident or incident. R#3's Admission Record dated 07/15/15 indicated R#3 was admitted on [DATE], some of the [DIAGNOSES REDACTED]. The Admission Record indicated R#3 was [AGE] years old. R#3's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#3 had clear speech, was understood and could understand others. He was not able to correctly state the year, month or day. R#3, according to the MDS had physical behavior symptoms (hitting, scratching) directed toward others that occurred one to three days. R#3 required extensive assistance by two persons for transfers, dressing and toilet use. R#3's Care Plan revised on 06/18/15 indicated R#3 had a suprapubic catheter and that R#3 would remain free from catheter related trauma. LVN B reported on 07/15/15 at 8:27 a.m., she had worked the night shift on 05/18/15 and she was told during the change of shift report that a small trace of blood was found on R#3's brief, but he would not allow her to assess him. LVN B said the FNP was called on 05/18/15 and the Family Nurse Practitioner (FNP) had seen R#3 on 05/19/15. LVN B stated the FNP told her R#3's penis was split in two. LVN B stated R#3 would allow the certified nurse aides (CNA) to provide care at times, and sometimes he would not. LVN B denied any reports of R#3 having trauma to his penis previous to 05/18/15. LVN B added she thought she had documented the incident. LVN A stated on 07/13/15 at approximately 2:45 p.m., R#3 had anger and agitation that was displayed by hitting staff and being verbally and physically abusive when care was provided. LVN A stated R#3 now had a suprapubic catheter (tube inserted into the bladder through a small hole in the belly) since R#3 had pulled out his indwelling Foley catheter (tube inserted into the bladder to drain urine.) R#3 was in bed sleeping covered up. The Foley bag was observed on the side of the bed. The DON reported on 07/14/15 at 3:55 p.m., she had called LVN B. LVN B stated the incident involving R#3 had been given to her during change of shift report, and that R#3 had not allowed her to assess him, but LVN B had not documented anything. The DON added that she expected the nurse to write an incident report and to do an investigation. Nurse's Note dated 05/19/15 indicated R#3 had an appointment with a urologist on 06/03/15 at 2:00 p.m. No other information was written. The note was written by Licensed Vocational Nurse (LVN) B. Incident/Accident Report logs were reviewed; there was no documentation dated 05/18/15 or 05/19/15 to indicate why R#3 had the urologist appointment. Review of the Family Nurse Practitioner's (FNP) note dated 05/19/15 indicated R#3 had ventral erosion of penis. Encounter Summary by the urologist dated 06/03/15 at 2:00 p.m. indicated R#3 was there for checkup, ventral erosion of penis. Indwelling Foley for retention, failed several voiding trials. Now Foley has eroded most of penile urethra. The Director of Nurses (DON) reported on 07/14/15 at 12:40 p.m., there was no incident report written concerning the incident involving R#3. The facility policy regarding indwelling Catheter Care (Daily Cleansing) dated 1-2011 revealed the following information: Objective: Care and maintenance of indwelling catheters is essential to prevent infection and/or complications. This clinical practice standard is written to clarify methods of daily cleansing care for residents with an indwelling catheter. The wellness CDC (Center for Disease Control) does not endorse routine meatal cleansing; this community does conduct daily and as needed (PRN) indwelling catheter cleansing. Documentation: In the nursing progress notes, document pertinent observation and interventions. According to the Centers for Medicare and Medicaid (CMS ) Form 672 dated 07/13/15 there were 5 residents in the facility with catheters.

Based on observation and interview the facility failed to ensure each resident receives adequate supervision to prevent accidents for one resident (R#13) of 17 residents reviewed for accidents and injuries and failed to ensure the resident environment remains as free of accident hazards as possible for 10 of 15 resident rooms on the hall 300 reviewed for environmental safety. 1. Certified Nurse Aide (CNAP) transferred R#13 by herself when the resident needed a 2 person transfer. R#13 sustained two broken (fractured) knees. This failure could affect 15 residents on hall 100 requiring two person staff assistance. 2. The facility failed to identify risk for safety by allowing stuffed animals, pictures and greeting cards to be displayed on top of the main lighting fixture above the resident's beds. This failure could affect 23 residents on hall 300 by placing them at risk for a fire hazard. The findings were: 1. R#13's Admission Record dated 07/15/15 indicated was [AGE] years old, R#13 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. R#13's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated, R#13 had clear speech, was understood and could usually understand. R#13 required extensive physical assistance by two persons for bed mobility and transfer. Under Balance During Transitions and Walking, the MDS indicated R#13 was not steady and only able to stabilize with staff assistance for moving from seated to standing position and transferring between bed and chair or wheelchair. Under Functional Limitation in Range of Motion, the MDS indicated R#13 had impairment on one side (lower extremity). R#13 had severely impaired cognition. On 07/16/15 at 6:55 p.m. during a telephone interview, CNA P said I did the transfer by myself, the Cardex did instruct it should have been a two person transfer. CNA P said she was the only CNA on hall 100, but other CNAs were available to assist in the facility. On 07/16/15 at 2:15 p.m., the Director of Nurses (DON) said Licensed Vocational Nurse (LVN) A came to her (the DON) and said R#13 had c/o of pain to the right knee. The DON reported LVN A had done an assessment, R#13's right knee had no redness, R#13's left knee did have some redness. The DON reported CNA P (worked the shift starting at 10:00 p.m. on 07/09/15 to 6:00 a.m. on 07/10/15) had informed her (the DON) that at two or three a.m. R#13 wanted to lie down and she (CNA P) had done the transfer by herself. Surveyor asked the DON if CNA P had checked the Cardex (had information for the residents' activities of daily living including transfers). The DON said, no, CNA P just assumed (R#13) was a one person transfer. The DON said CNA P had written a statement that she had transferred R#13 by herself and R#13 was a two person transfer. R#13's Nurse's Notes dated 07/10/15 at 10:39 a.m. revealed Resident c/o (complained of) pain to Rt (right) lower leg. R#13's Nurse's Notes dated 07/10/15 at 12:30 p.m. revealed . resident is complaining of pain to bilateral lower extremities. Assisted resident at this time and resident noted with redness to left knee .resident got up for breakfast with no c/o of any pain until 10:40 a.m. then resident c/o pain only to right leg. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to MD's (Medical Doctor) office and spoke to Family Nurse Practitioner (FNP), notified of resident's c/o pain to bilateral lower extremities (BLE). Order received for X-rays to BLE. R#13's Nurse's Notes dated 07/10/15 at 1:36 p.m. revealed called to Hospice and notified of resident's new onset pain complaining to bilateral lower extremities if we can get a stronger pain med (medication). R#13's Nurse's Notes dated 07/10/15 at 9:19 p.m. revealed RP (Responsible Party) was informed of X-ray results showing bilateral knee fractures. RP also informed that MD was aware and ordered immobilizers and if RP wishes for an orthopedic to assess resident. R#13's Nurse's Notes dated 07/12/15 at 10:30 p.m. revealed as per RP do not transfer resident to wheelchair until orthopedic surgeon assess (sic) resident. The facility's Investigation Report dated 07/16/15 revealed in the Investigation Summary CNA (Certified Nurse Aide) (P) was suspended pending investigation due to not following Resident's (R#13's) plan of care-transfers. Employee (CNA P) was terminated due to not following resident's plan of care -transfers. On 07/16/15 at 11:15 a.m., CNA Q said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall when R#13 had complained of pain. CNAQ stated R#13 had c/o of pain at about 10:30 a.m., first complained of right knee pain and later reported pain in both knees. On 07/16/15 at 11:35 a.m., CNA R said she had worked the 6:00 a.m. to 2:00 p.m. shift on 07/10/15 on the 100 hall with R#13. CNA R reported the nurse (unidentified) had told her R#13 had pain. On 07/16/15 at 2:10 p.m., surveyor did an in-room visit. R#13 had her eyes open and was lying on her back in her bed. Surveyor asked R#13 what had happened to her knees. R#13 did not respond. On 07/16/15 at approximately 2:45 p.m., LVN A reported a housekeeper (unidentified) had informed her R#13 was in pain. LVN A replied initially R#13 had c/o pain to her right knee and later had c/o pain to both knees. LVN A replied she had done an initial assessment and R#13's right knee had no redness or swelling. During a later assessment R#13's left knee had redness. Surveyor asked LVN A if R#13 said what had happened to her knees. LVN A said R#13 was unable to recall. On 07/16/15 at 3:40 p.m., LVN S said R#13 had denied a fall or hurting herself. The facility's undated Resident Abuse Policy revealed Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The DON provided a list on 07/16/15 of the residents on the 100 hall who require a two-person to assist with transfers. There were 15 residents on the list, including R#13. 2. On 07/12/15 starting at 2:00 p.m. during the initial tour of the facility with LVN C, surveyor observed the resident's lighting fixtures over their beds to be used as a shelf where stuffed animals, pictures, and greeting cards were placed. LVN C stated the residents placed their personal belongings on the light fixture. On 07/13/15 at 4:12 p.m., surveyor observed the following occupied resident rooms (RM). The light fixtures which hung over the residents beds were long and held a light contained by a box with an opening on the top and one the bottom of the box. The openings of the light fixtures were covered with an opaque plastic. The plastic was warm to the touch. There was no evidence of melted or burnt plastic on the lighting fixture. The following items on top of the lighting fixtures over the bed on the 300 hall: RM 302 A- a plastic plant 306 A- three stuffed animals and four picture frames 306 B- three stuffed animals 308 B -stuffed animal 309 A-five framed pictures 309 B- five stuffed animals 310 B- six stuffed animals 311 B- four framed pictures 312 A- one hat, two Christmas decorations, and a plastic plant 312 B- framed picture, stuffed doll, and a snowman, 313 A- 10 stuffed animals 314 A- two snowmen 314 B- framed picture, two plastic flowers in two vases 315 A-three stuffed animals Review of the facility roster dated 07/13/15 revealed there were 23 residents who resided on hall 300.