Every finding on record at Longwood Community Living Center

Based on staff interviews, record review, and facility policy review, the facility failed to maintain complete, accurately documented clinical records for one (1) of eight (8) residents reviewed for clinical record accuracy. (Resident #1).Findings Include:Record review of facility policy titled Charting and Documentation Policy and Procedure revealed, The purpose of Charting and Documentation is to provide the following; A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care .Record review of Neurological Checks revealed neurological assessments documented for Resident #1 as obtained on 8/2/2026 at 8:15 AM, 12:15 PM, and 4:15 PM. The assessments included documentation of the resident's level of consciousness, pupil response, motor function, pain response, blood pressure, temperature, pulse, respirations, and observations. The neurological assessments were electronically signed by the Minimum Data Set (MDS) Coordinator on 8/12/2026.Record review of Employee Timecards revealed the MDS Coordinator's documented start time on 8/2/2026 was 6:57 PM, with a stop time of 7:29 PM.During an interview on 8/25/2026 at 2:00 PM, the MDS Coordinator stated that she personally performed neurological checks on Resident #1 on 8/2/2026 at 8:15 AM, 12:15 PM, and 4:15 PM. When questioned regarding her employee timecard, which documented a start time of 6:57 PM and a stop time of 7:29 PM on 8/2/2026, the MDS Coordinator stated that she had come to the facility that morning because she anticipated she would have to work the 2:00 PM to 10:00 PM shift again. She stated that she performed the neurological checks while working off the clock.During an interview on 8/25/2026 at 1:55 PM, Registered Nurse (RN) #1 stated the MDS Coordinator was not present when she arrived at work on the morning of 8/2/2026 and was not at the facility at any time during the day. She stated the MDS Coordinator came to the facility later that evening following an incident involving a disgruntled employee who was sent home.During an interview on 8/25/2026 at 2:07 PM, the Administrator stated he arrived at the facility at approximately 5:30 PM on 8/2/2026 to counsel an employee. He stated the MDS Coordinator was not present at the facility when he arrived. The Administrator stated he called the MDS Coordinator and asked her to come to the facility to cover the medication cart after the employee was sent home. He stated the MDS Coordinator arrived later that evening and covered the medication cart for approximately 30 minutes until the night-shift nurse arrived early and relieved her. When informed that the MDS Coordinator stated she had been at the facility earlier that day and had performed the neurological checks while working off the clock, the Administrator stated that, to his knowledge, the MDS Coordinator had not been at the facility during the day. He stated staff should not work off the clock. When the MDS Coordinator's timecard and the documented times of the neurological checks were reviewed with him, the Administrator acknowledged the importance of ensuring resident clinical documentation is accurate.Record review of admission Record revealed Resident #1 was admitted to facility on 7/6/2026 with diagnoses that included Volvulus and Dementia in Other Diseases Classified Elsewhere, Severe, with Mood Disturbance.

Based on observation, staff interviews, and record review, the facility failed to ensure adequate supervision for (1) one of (3) three residents reviewed for behaviors. Resident #1. Findings include:Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, bipolar disorder, and Alzheimer's disease.Record review of the Brief Interview for Mental Status (BIMS) dated 10/29/25 revealed a score of 11, indicating Resident #1 was moderately cognitively impaired.Record review of progress notes for Resident #1 dated 11/5/25 through 12/11/25 revealed six documented episodes of inappropriate behaviors.Record review of Resident #1's Order Recap Report revealed on 12/4/25 oxcarbazepine 150 mg (milligrams) one tablet twice daily for mood was increased to 300 mg twice daily due to continued inappropriate behaviors.Record review of the December 2025 Medication Administration Record for Resident #1 revealed no documentation of monitoring or supervision related to the resident's increased behaviors.Record review of an incident report dated 12/11/25 at 5:02 PM revealed Resident #1 was observed attempting to rub Resident #2's leg while stating, Gimme some of that right there. The Business Office Manager (BOM) and Activity Certified Nurse Assistant (CNA) #1 immediately intervened. Resident #1 was taken to his room and monitored until he was transferred by ambulance to behavioral health for evaluation.Record review of the admission Record revealed Resident #2 was admitted on [DATE] with a diagnosis of unspecified dementia.Record review of the BIMS dated 10/22/25 revealed a score of 3, indicating Resident #2 was severely cognitively impaired and unable to protect herself from unsafe interactions.Review of records and staff interviews revealed the facility failed to implement increased supervision or monitoring for Resident #1 despite documented escalating behaviors, placing Resident #2 at risk for avoidable harm.An interview with CNA #2 on 12/23/25 at 10:00 AM revealed she observed Resident #1 touch Resident #2's upper leg but did not hear him say anything. She stated Resident #1 has a history of making vulgar comments to staff.An interview with the BOM on 12/23/25 at 10:15 AM revealed she observed Resident #1 sitting next to Resident #2, leaning toward her and talking, but did not see him do anything inappropriate. An interview with Activity CNA #1 on 12/23/25 at 10:20 AM revealed she observed Resident #1 attempt to move his hand upward while touching Resident #2's upper leg and heard him say, Gimme some of that right there. She stated staff immediately intervened and Resident #1 was moved away by the Director of Nursing (DON).An interview with Licensed Practical Nurse (LPN) #1 on 12/23/25 at 11:00 AM revealed Resident #1 is known to make sexual comments to staff and visitors and has been sent out previously for psychiatric services. She confirmed that they had monitored the resident for medication changes and he had been evaluated by psychiatric services but confirmed that they should have had increased monitoring in place for Resident #1's behaviors.An interview with CNA #3 on 12/23/25 at 11:35 AM revealed she had heard Resident #1 make sexual comments. She stated she was unaware of any increased monitoring in place related to those behaviors.An interview with the DON on 12/23/25 at 11:45 AM revealed after review of Resident #1's record she was unable to find documentation indicating increased supervision and monitoring for the resident's sexual behaviors. She also confirmed that they had implemented medication changes and he had been evaluated by psychiatric services but confirmed that they should have had increased supervision and monitoring in place for Resident #1's behaviors.An interview with the Administrator on 12/23/25 at 11:50 AM revealed Resident #1 had previously been sent out for psychiatric services related to inappropriate comments and had multiple medication changes. She confirmed that the facility did not have a policy for supervision but that with the documented increase in behaviors the facility should have implemented increased monitoring to reduce the risk of an incident.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 3rd Quarter 2025. Findings Include: Record review of the facility policy titled, Staffing Hours-Monitoring of Policy and Procedure undated, revealed, Purpose: To assure the facility staffing meet federal and state guidelines. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 3 2025 (April 1-June 30), revealed the facility triggered on this report for excessively low weekend staffing.During an interview on 12/11/25 at 9:53 AM, the Administrator (ADM) revealed the data that was submitted to PBJ was not accurate because they did not include the termed employees worked hours during this 3rd quarter, therefore the data showed low weekend staffing when actually the staffing was adequate. This was a data entry error. They were supposed to capture current and termed employees who had worked during that pay period, but they failed to capture those employees who actually worked. She revealed the Corporate Office submits the PBJ information and the facility was unaware that they had triggered for low weekend staffing.

Based on observation, resident interview, and staff interviews, the facility failed to ensure a homelike environment by maintaining resident equipment in a clean condition, as evidenced by a visibly soiled wheelchair for one (1) of 38 wheelchairs observed at the facility. (Resident #48) Findings Include: On 12/09/25 at 11:30 AM, observation and interview revealed Resident #48's wheelchair was visibly dirty. The bottom frame of the wheelchair had a caked, dried brown substance present. The resident stated he did not realize his wheelchair was so dirty until it was brought to his attention and stated, Oh, I didn't notice it was that dirty. It does need to be cleaned. On 12/09/25 at 11:45 AM, Licensed Practical Nurse (LPN) #3 observed the wheelchair and stated it should have been cleaned on the night shift. During an interview with the Administrator and observation of Resident #48's wheelchair on 12/09/25 at approximately 2:05 PM, she stated the resident spills food and liquids onto the chair often. The Administrator confirmed the wheelchair was dirty and had not been cleaned in a while, she stated she expected the wheelchairs to be cleaned on the night shift.Review of facility documentation on facility letterhead dated 12/10/25 and signed by the Administrator revealed the facility did not have a policy or procedure addressing the routine cleaning, monitoring, or maintenance of resident wheelchairs to ensure a homelike environment.Record review of the admission Record revealed the facility admitted Resident #48 on 7/23/2025 with a medical diagnosis that included Dementia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/2025 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 08, indicating the resident was moderately cognitively impaired.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure the resident's right to participate in healthcare decision-making regarding advance directives and code status for (1) one of 18 sampled residents. (Resident #6)Findings Include: Review of the facility policy titled Advance Directives Policy and Procedure with no revision date revealed, .3. The resident's advance directives will be recorded in the resident clinical record . Record review on [DATE] at 2:00 PM revealed Resident #6's medical record indicated a code status of Do Not Resuscitate (DNR). The signed document located in the chart was a Cardiopulmonary Resuscitation (CPR) form, not a signed DNR order. Record review on [DATE] revealed the resident's DNR status was displayed on the patient profile in the electronic medical record (EMR). When the hyperlink was selected to review supporting documentation, a signed CPR form dated [DATE], signed by the resident representative, was present. A physician's order for DNR dated [DATE] was also located in the chart; however, a signed DNR form was not available. During an interview with Registered Nurse (RN) #1 on [DATE] at 3:10 PM, stated Resident #6 was a DNR based on the information listed on the resident's profile and in the chart. She stated she was unaware that there was no signed DNR form on file. During an interview with the Director of Nursing (DON) on [DATE] at 4:15 PM, she stated that Resident #6's son signed paperwork when the resident went on hospice services. The DON reviewed documents scanned into the resident's medical record and confirmed CPR form dated [DATE], along with a physician's order dated [DATE]. The DON stated the family had signed a DNR when the resident went on hospice; however, the signed DNR document could not be located. Record review of the admission Record revealed the facility admitted Resident #6 on [DATE] with a medical diagnosis that included Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, under section C, a Brief Interview for Mental Status (BIMS) Summary score of 01, indicating the resident was cognitively impaired.

Based on observations, resident and staff interviews, record reviews, and facility policy reviews, the facility failed to implement care plans related to Activity of Daily Living (ADL) needs, such as personal hygiene, to include shaving, for four (4) of the eighteen sampled residents. Resident #7, #8, #27, and #40. Findings Include: Review of the facility policy titled, Care Plan Policy and Procedure, undated, revealed under Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Under Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. Resident #7 Record review of Resident #7's Care Plan Focus .The resident has an ADL self-care performance deficit related to primary lateral sclerosis, chronic weakness and decreased mobility .Interventions .Self Care Personal hygiene: Usually requires substantial/maximal to dependent assist to maintain personal hygiene, including combing hair, shaving. On 12/08/2025 at 11:03 AM an observation and interview revealed Resident #7, a female resident, with sporadic facial hair on the chin measuring approximately one-half (1/2) inch in length. Resident #7 revealed she did not like the hair on her chin. On 12/09/2025 at 9:00 AM an observation revealed that Resident #7's facial hair in the chin area was unchanged from the previous day. On 12/09/2025 at 11:05 AM, during an interview and observation Certified Nurse Aide (CNA) #2 revealed it is the CNA's responsibility to ensure facial hair is removed, particularly during a resident's shower. CNA #2 confirmed Resident #7 had a shower this morning and continued to have long facial hair on her chin. CNA #2 stated, Yes, she should have been shaved. On 12/09/2025 at 11:15 AM,during an observation and interview Licensed Practical Nurse (LPN) #2 confirmed that Resident #7 had 1/2 inch sporadic long chin hairs. LPN #2 revealed the resident should not have long facial hair, especially since she just had her morning shower. LPN #2 stated, That's part of daily grooming, to ensure the resident is shaved and presentable. During an interview on 12/09/2025 at 11:25 AM, the Director of Nurses (DON) revealed it is the facility's expectation that female residents have no visible facial hair and that shaving is considered part of their routine personal hygiene. The DON stated, If the resident was not adequately groomed, including being appropriately shaven, then the resident's plan of care was not being followed. Record review of the admission Record revealed Resident #7 was admitted to the facility on [DATE] with medical diagnoses that included Primary Lateral Sclerosis, lack of coordination, and need for assistance with personal care. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #7 is cognitively intact. Resident #8 Record review of Resident #8's ADL Care Plan with review date, 10/20/2025, revealed, I have an ADL self-care performance deficit .Interventions .Bathing/Showering (times 1 Assist) .Personal Hygiene Routine: The resident prefers shower 3 times weekly .) On 12/08/2025 at 10:24 AM, during an observation of Resident #8 it was noted that the resident had approximately three-fourths of an inch-long whiskers on his cheeks, chin, and upper lip. On 12/08/2025 at 1:50 PM an additional observation and interview revealed that Resident #8 still had facial hair on his cheeks, chin, and upper lip. He stated that he would prefer to be clean-shaven. On 12/09/2025 at 11:20 AM, during an observation and interview CNA #1, she confirmed that Resident #8 did not receive a shower or shave on Saturday, 12/06/2025. She stated that she worked on 12/06/2025 but was not assigned to Resident #8. Record review of the admission Record revealed the facility admitted Resident #8 on 9/26/25 with diagnoses including need for assistance with personal care. Record review of Resident #8's MDS with an ARD of 10/3/25 revealed a BIMS score of 12 indicating moderate cognitive impairment. Resident #27 Review of Resident #27's ADL care plan with review date, 1/23/2025, revealed, I have an ADL self-care performance deficit r/t Alzheimer's .Interventions Self Care Personal hygiene: Requires (usually requires partial/moderate assist times 1) to maintain personal hygiene, including combing hair, shaving, . On 12/08/2025 at 10:27 AM and again at 12:19 PM, during observations of Resident #27 it was noted that Resident #27 had facial hair on his cheeks, upper lip, and chin, approximately one-half inch in length. On 12/08/2025 at 2:19 PM, during an interview Resident #27 expressed that he would like to be clean-shaven. On 12/09/2025 at 11:16 AM, during an observation and interview CNA #1, confirmed that Resident #27 did not receive a shower or shave on Saturday, 12/06/2025. She stated that she worked on 12/06/2025 but was not assigned to Resident #27. Record review of Resident #27's admission Record revealed the facility admitted him on 1/16/25 with diagnoses including Alzheimer's Disease and need for assistance with personal care. Record review of the MDS with ARD of 10/22/25 revealed a BIMS score of 10 indicating moderate cognitive impairment. Resident #40 Review of Resident #40's ADL care plan with review date, 11/03/2025, revealed, I have an ADL self-care performance deficit .Interventions . Self Care Personal hygiene: (usually requires dependent assist to maintain personal hygiene, including combing hair, shaving, . During observation and interview of Resident #40 on 12/08/2025 at 10:24 AM, it was noted that Resident #40, a female resident, had full facial hair on her cheeks, upper lip, and chin. Resident #40 expressed that she would like to be clean-shaven. On 12/09/2025 at 11:25 AM, during an interview with CNA #4, confirmed that Resident #40 did not receive a shower or shave on Saturday, 12/06/2025. Record review of the admission Record revealed Resident #40 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Record review of the MDS with an ARD of 11/03/25, revealed under section C, a BIMS summary score of 15, indicating Resident #40 is cognitively intact. During an interview on 12/09/2025 at 2:14 PM, the Minimum Data Set (MDS) Coordinator revealed she is responsible, in collaboration with nursing staff, for developing each resident's individualized care plan. She explained that under the ADL care plan, specifically in the self-care/personal hygiene section, grooming needs such as shaving are addressed. The MDS Coordinator confirmed that if Resident #7, Resident #8, Resident #27 and Resident #40 was not shaved as indicated, it would indicate the resident's care plan addressing personal hygiene were not being followed.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for four (4) of 51 residents reviewed for Activities of Daily Living (ADL) care. Resident #7, #8, #27 and #40. Findings Include: Review of the facility policy titled, ADL Care of a Resident Policy and Procedure, undated, revealed Policy: Resident ADL care will be provided to the resident according to the individualized resident needs . Resident #7 An observation and interview on 12/08/2025 at 11:03 AM revealed Resident #7, a female resident, with sporadic facial hair on the chin measuring approximately one-half (1/2) inch in length. Resident #7 revealed she did not like the hair on her chin. An observation on 12/09/2025 at 9:00 AM revealed that Resident #7's facial hair in the chin area was unchanged from the previous day. During an interview and observation on 12/09/2025 at 11:05 AM, Certified Nurse Aide (CNA) #2 revealed it is the CNA's responsibility to ensure facial hair is removed, particularly during a resident's shower. CNA #2 confirmed Resident #7 had a shower this morning and continued to have long facial hair on her chin. CNA #2 stated, Yes, she should have been shaved. During this interaction, Resident #7 nodded affirmatively when asked if she would like her chin hair removed. During an observation and interview on 12/09/2025 at 11:15 AM, Licensed Practical Nurse (LPN) #2 confirmed that Resident #7 had 1/2 inch sporadic long chin hairs. LPN #2 revealed the resident should not have long facial hair, especially since she just had her morning shower. LPN #2 stated, That's part of daily grooming, to ensure the resident is shaved and presentable. In an interview on 12/09/2025 at 11:25 AM, the Director of Nurses (DON) revealed it is the facility's expectation that female residents have no visible facial hair, and shaving is considered part of their personal hygiene and is completed on shower days. Record review of the admission Record revealed Resident #7 was admitted to the facility on [DATE] with medical diagnoses that included Primary Lateral Sclerosis, lack of coordination, and need for assistance with personal care. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #7 is cognitively intact. Resident #8 During an observation of Resident #8 on 12/08/2025 at 10:24 AM, it was noted that the resident had approximately three-fourths of an inch-long whiskers on his cheeks, chin, and upper lip. An additional observation and interview on 12/08/2025 at 1:50 PM revealed that Resident #8 still had facial hair on his cheeks, chin, and upper lip and stated that he would prefer to be clean-shaven. During an observation and interview on 12/09/2025 at 11:20 AM, CNA #1 confirmed that Resident #8 did not receive a shower or shave on Saturday, 12/06/2025. She stated that she worked on 12/06/2025 but was not assigned to Resident #8. She further explained that if a resident refused to take a shower or be shaved, the CNA was to notify the nurse, who would then follow up to see if she could persuade the resident to shower or shave. The CNA accessed the computer charting for Saturday, 12/06/2025, which documented N/A for shower/bath. She noted that there is an option for refused, but it seems that the shower aide for that day did not mark it. In an observation and interview on 12/09/2025 at 11:30 AM, LPN #1, she stated that when a resident refuses to take a shower or bath on their scheduled day, the CNA is supposed to inform the nurse so that the nurse can attempt to persuade the resident to shower. If the resident still refuses, the reason must be documented. She confirmed that she worked this hall on Saturday, 12/06/2025, and no one made her aware that Resident #8 had refused his shower. She also confirmed that Resident #8 did not usually have this much facial hair, so she knew he had not been shaved in a while. During an interview on 12/09/2025 at 11:42 AM with the Administrator, it was confirmed that when a resident refuses to take a shower or shave on their assigned shower day, the CNA is to inform the nurse, who will then follow up. The Administrator further stated that she checks the daily alerts on her computer to see if a resident has gone more than three days without a shower. She reviewed the CNA task documentation and confirmed the residents should be showered and shaved on their scheduled days and as needed. Record review of the admission Record revealed the facility admitted Resident #8 on 9/26/25 with diagnoses including need for assistance with personal care. Record review of Resident #8's MDS with an ARD of 10/3/25 revealed a BIMS score of 12 indicating moderate cognitive impairment. Resident #27 During observations of Resident #27 on 12/08/2025 at 10:27 AM and again at 12:19 PM, it was noted that Resident #27 had facial hair on his cheeks, upper lip, and chin, approximately one-half inch in length. During an interview on 12/08/2025 at 2:19 PM, Resident #27 expressed that he would like to be clean-shaven. During an observation and interview on 12/09/2025 at 11:16 AM, CNA#1, confirmed that Resident #27 did not receive a shower or shave on Saturday, 12/06/2025. She stated that she worked on 12/06/2025 but was not assigned to Resident #27. She further explained that generally, if a resident refused to take a shower or be shaved, the CNA was to notify the nurse, who would then follow up to see if she could persuade the resident to shower or shave. The CNA accessed the computer charting for Saturday, 12/06/2025, which documented N/A for shower/bath. She noted that there is an option for refused, but evidently, the shower aide for that day did not mark it. During an observation and interview on 12/09/2025 at 11:27 AM, LPN #1 stated that when a resident refuses to take a shower or bath on their scheduled day, the CNA is supposed to inform the nurse so that the nurse can attempt to persuade the resident to shower. If the resident still refuses, the reason must be documented. She confirmed that she worked this hall on Saturday, 12/06/2025, and no one made her aware that Resident #27 had refused his shower. She also confirmed that his facial hair was long and that, based on his appearance, Resident #27 had not been showered or shaved on Saturday. During an interview on 12/09/2025 at 11:42 AM with the Administrator, it was confirmed that when a resident refuses to take a shower or shave on their assigned shower day, the CNA is to inform the nurse, who will then follow up. The Administrator further stated that she monitors daily alerts on her computer to check if a resident has gone more than three days without a shower. She reviewed the CNA task documentation and confirmed the residents should be showered and shaved on their scheduled days and as needed. Record review of Resident #27's admission Record revealed the facility admitted him on 1/16/25 with diagnoses including Alzheimer's Disease and need for assistance with personal care. Record review of the MDS with ARD of 10/22/25 revealed a BIMS score of 10 indicating moderate cognitive impairment. Resident #40 An observation and interview on 12/08/2025 at 10:24 AM revealed Resident #40, a female resident, with full facial hair covering her cheeks, chin, upper lip. Resident #40 revealed she did not get a shower and shave over the weekend, and she did not like the hair on her face. During an interview with CNA #4 on 12/09/25 at 11:25 AM she stated that she had showered Resident #40 and shaved her this morning. She stated, Resident told me that she did not get a shower and shave over the weekend. An interview conducted with the DON on 12/09/2025 at 11:25 AM, confirmed that she had full facial hair on 12/08/25. She stated it is the facility's expectation that female residents have no visible facial hair, and shaving is considered part of their personal hygiene and is completed on shower days. Record review of the admission Record revealed Resident #40 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Record review of the MDS with an ARD of November 3, 2025, revealed under section C, a BIMS summary score of 15, indicating Resident #40 is cognitively intact.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure oxygen tubing was properly stored when not in use, resulting in the potential for contamination and compromised resident safety for two (2) of 10 residents reviewed for respiratory. (Resident #19 and #27) Findings included:Review of facility policy titled, Oxygen Concentrator Cleaning Policy and Procedure with no date revealed, .Store Oxygen tubing, cannula, and mask in plastic bag when not in use .Resident #19During an observation on 12/08/2025 at 3:20 PM, it was noted that Resident #19's oxygen tubing was not stored properly in a bag; instead, it was wrapped around the top of the portable oxygen tank.During an observation and interview on 12/09/2025 at 1:35 PM with Certified Licensed Practical Nurse (CLPN) #1, she confirmed that Resident #19's oxygen tank had open tubing wrapped around the top of the tank, rather than being stored in a bag.Review of the admission Record indicated that the facility admitted Resident #19 on 4/7/2025 with a medical diagnosis that included Chronic Obstructive Pulmonary Disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated Resident #19 was cognitively intact.Resident #27During an observation on 12/08/2025 at 10:27 AM, it was noted that Resident #27's oxygen tubing was not stored properly in a bag; instead, it was wrapped around the top of the portable oxygen tank.During an interview on 12/09/2025 at 1:45 PM with the Director of Nursing, she confirmed that oxygen tubing should always be stored in a bag when not in use. She further explained that the purpose of this practice is to ensure that the tubing remains clean.Review of the admission Record indicated that the facility admitted Resident #27 on 1/16/2025 with a medical diagnosis that included Other Specified Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Need for Assistance with Personal Care. A review of the MDS with an ARD of 10/22/25 revealed under section C, a BIMS summary score of 10 which indicated Resident #27 had moderate cognitive impairment.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure medications were stored in a properly secured refrigerator for one (1) of two (2) medication storage rooms. Findings Include: Review of the facility's policy titled Medications Storage Policy and Procedure with no revision date revealed, Purpose: To properly secure medications and biologicals according to CMS guidelines . An observation on 12/10/25 at 8:28 AM revealed the medication storage room on C Hall contained a narcotic lock box located inside the refrigerator, locked, but not secured/affixed to the refrigerator. The lock box was easily removable and contained a bottle of Lorazepam. An interview conducted on 12/10/25 at 8:30 AM with Licensed Practicing Nurse (LPN) #2, she stated she thought the lock box was secured properly. During an interview conducted on 12/10/25 at 8:35 AM with the Director of Nursing (DON), she confirmed the narcotic lock box was not secured, explained that it had been secured in the past, and she was unaware that the lock box was not secured/affixed to the refrigerator.

Based on observation, interviews, facility policy review, and record review, the facility failed to ensure a resident had a call system in her room for one (1) of 18 resident rooms reviewed. Resident #6 Findings Include: Review of the facility policy titled CALL LIGHTS USE OF POLICY AND PROCEDURE with no revision date revealed, Purpose: To provide the resident with a call light to notify staff to meet the need of the resident . On 12/08/25 at 10:50 AM, observation revealed Resident #6 was in her room without a call light within reach and no alternative method available to request assistance. A second observation on 12/09/25 at 2:18 PM, at the resident's bedside revealed no call light present within reach and no alternative method available for the resident to request assistance. At the time of the observation, Housekeeper #1 was present in the resident's room and stated, She doesn't have a call light. An interview on 12/09/25 at 2:40 PM, was conducted at the bedside with Licensed Practicing Nurse (LPN) #3, who stated there was no call light at the bedside and she did not know if it had been borrowed and put in another resident's room, stating there was one present previously. During an interview on 12/09/25 at 3:30 PM with the Director of Nursing (DON) revealed all residents are expected to have call lights at their bedside so they can request assistance as needed. The DON stated the resident did have a call light, but she did not know what had happened to it. Record review of the admission Record revealed the facility admitted Resident #6 on 6/04/2025 with a medical diagnosis that included Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2025 revealed, under section C, a Brief Interview for Mental Status (BIMS) Summary score of 01, indicating the resident was severely cognitively impaired.

Based on observation of a social media post, staff and resident interviews, record review, and facility policy review, the facility failed to provide care for a resident in a manner that maintained the resident's dignity. A picture of Resident #1 was posted to the facility's social media account which portrayed the resident in an undignified manner for one (1) of four (4) residents sampled. Resident #1 Findings include: Record review of facility policy titled, Resident Rights dated 7/24/23, revealed, Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state aws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . Record review of facility policy titled, Dignity dated 7/24/23, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Residents are treated with dignity and respect at all times. Observation and review of the social media page for the nursing facility with the date posted as 1/10/25, revealed Resident #1 sitting in her wheelchair holding a cup of ice cream. She was dressed in a blue, long-sleeved shirt and peach colored pants. The resident was wet between her mid thighs and on her right leg. The resident's lower abdominal and groin area appeared to be wet with clear fluid and the wetness extended to her knees and appeared dark in color. During an interview with the resident on 3/19/25 at 12:30 PM, Resident #1 stated she did not use the toilet often, had accidents, and wore briefs that were changed by the staff frequently. During an interview on 3/19/25 at 12:45 PM, the Administrator stated the Activity Director had taken the pictures during activities and other events and had posted these on the facility's social media page. She stated it was the facility's responsibility to ensure each resident's rights, including being treated with dignity and respect, were honored. During our interview, she reviewed the social media post dated 1/10/25 of Resident #1 and confirmed that the picture of Resident #1 was a resident rights concern and should have been monitored more closely prior to being posted. During the interview with the Administrator, the Director of Nursing (DON) came into the Administrator's office at 12:48 PM on 3/19/25 and confirmed that the picture on social media of the resident violated the resident's rights. She confirmed the facility failed to ensure that the rights of Resident #1 were not violated before the picture was posted to social media. Review of Resident #1's Admission Record revealed the facility admitted Resident #1 on 3/24/23 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment.

Based on staff interview, record review, and facility policy review, the facility failed to ensure accuracy of a code status based on the Power of Attorney for one (1) of 14 residents sampled. Resident #19 Findings include: Record review of facility policy titled, Advanced Directives reviewed ,d+[DATE], revealed, Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .If the Resident has an Advance Directive: 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DON) or designee notifies the attending physician of advance directive (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care . Record review of Resident #19's Durable Power of Attorney for Health Care signed and dated by the resident on [DATE], revealed, Special Instructions: Do not resuscitate after one (1) hour of trying. No life support machine(s) in any town city, or state. Record review of electronic physician's order dated [DATE], revealed an order for DNR (Do Not Resuscitate). Record review of Order Details dated ,d+[DATE] revealed a physician's telephone order for a DNR, which was signed by the physician. Record review of Code Status form for Resident #19 signed by a family member and not the Resident's Representative on admission [DATE], revealed Do Not Attempt Resuscitation (DNR). During an interview on [DATE] at 9:15 AM, the Administrator revealed the special instructions on Resident #19's Power of Attorney document for Do not resuscitate after one (1) hour of trying. No life support machine(s) in any town city, or state would indicate the Cardio-Pulmonary Resuscitation (CPR) should be initiated. She confirmed the physician's orders and code status form did not reflect the wishes conveyed in Resident #19's Durable Power of Attorney for Health Care document concerning his end-of-life care. She acknowledged this could lead to a resident not receiving the end-of-life care desired. She confirmed that record accuracy of end-of-life care was necessary to ensure the information concerning end of life care was reflective of the resident's wishes and the facility failed to accurately indicate Resident #19's choice for end-of-life care. Record review of Resident #19's Admission Record, revealed the facility admitted the resident on [DATE]. Diagnoses included Dysphagia following cerebral infarction and Chronic kidney disease. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated the resident was moderately impaired cognitively.

Based on observation, resident and staff interview, and facility policy review, the facility failed to provide a safe environment as evidenced by an overbed table with exposed jagged edges for one (1) of 44 resident's observed. Resident #37 Findings Included: Record review of the facility policy titled, Maintenance Service with revision date of December 2009, revealed, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . On 08/21/24 at 9:10 AM, an observation and interview revealed Resident #37 lying in bed with her over bed table positioned beside her on the right side of the bed. The plastic protective border was missing from all four sides of the over bed table and there were rough, jagged areas exposed. Resident #37 revealed that the rough edges on her over bed table could scratch her and if she rubbed up against the edges, she stated, It might bruise me. Resident #37 also revealed that her skin was thin and would easily tear. On 08/21/24 at 2:00 PM, an interview with Director of Nursing (DON) confirmed that Resident #37's over bed table had rough outer edges exposed and that the protective border was missing from all four sides. She revealed that the rough edges on the over bed table could cause skin tears or bruising. She revealed that this should have already been noticed and replaced. Record review of Resident #37's Admission Record revealed that she admitted on [DATE] and had diagnoses that included Unspecified Dementia, Anxiety, and Muscle Weakness. Record review of Resident #37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/09/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated that she had moderate cognitive deficits.

Based on staff interviews, record review, and facility policy review, the facility failed to develop a person-centered care plan for residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for two (2) of the 14 resident care plans reviewed. Resident #11 and Resident #37. Findings included: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered undated revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. Resident #11 Record review of Resident #11's care plans revealed the resident did not have a care plan regarding PTSD. During an interview on 8/20/24 at 1:16 PM, Resident #11 revealed she does have PTSD because she had a traumatic event happen to her as a child. An interview on 8/21/24 at 3:01 PM, Registered Nurse (RN)/ Minimum Data Set (MDS) Coordinator, confirmed Resident #11 does have a diagnosis of PTSD. However, she does not have a comprehensive care plan addressing this diagnosis. She revealed it was not developed because it was missed in error. She revealed that the care plan is developed so the staff knows how to care for each resident and Resident #11 should already have a care plan already in place for her PTSD. During an interview on 8/22/24 at 11:25 AM, the Director of Nurses (DON) confirmed Resident #11 has a diagnosis of PTSD. However, a trauma-informed care plan was not developed and was missed. She revealed it is very important that anyone with a PTSD diagnosis has a care plan addressing it. Record review of Resident #11's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and a PTSD diagnosis which was added with an onset date of 10/27/2023. Record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date of 07/10/24, revealed in Section I that the resident had a diagnosis of PTSD and in Section C a Brief Interview Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #37 Record review of Resident #37's Care Plans revealed there was not a care plan in place to address PTSD that included triggers or interventions. On 08/21/24 at 11:05 AM, an observation and interview with Resident #37 revealed she was sitting up in her wheelchair in her room. Resident #37 revealed that she had a three month old baby to die many years ago and also had an adult son who had passed away in his sleep about [AGE] years ago and this still bothered her. Resident #37 revealed that she often had nightmares, cried out in her sleep and had done this for a long time and didn't know what caused it. She also revealed that she worried about all of her kids and grandkids because she had lost her own children. On 08/21/24 at 3:05 PM, an interview with RN/MDS Coordinator confirmed the resident had a diagnosis of PTSD and did not have a comprehensive care plan addressing this diagnosis. She revealed that the care plan was developed so the staff knew how to take care of the individualized needs of the resident. The RN/MDS Coordinator confirmed that Resident #37's care plan for her PTSD had not been developed and that it should have been. On 08/22/24 at 11:45 AM, an interview with the DON revealed that the RN/MDS Coordinator was responsible for care planning the needs of each resident and that Resident #37's Trauma Informed Care Assessment should have been completed to help identify any possible triggers and these triggers should be included in her care plan. Record review of Resident #37's Psych Eval (Evaluation)dated June 20, 2024, revealed Recommendations: Add .Post traumatic stress disorder, chronic to diagnoses. Record review Resident #37's Admission Record revealed that she was admitted on [DATE] with diagnoses that included Unspecified Dementia with other behavioral disturbance, Anxiety Disorder and Hallucinations. The diagnosis of Post-Traumatic Stress Disorder, Chronic was added on 06/24/24. Record review of Resident #37's MDS with ARD of 05/09/24 under Section C revealed a BIMS score of 10 which indicated that she had moderate cognitive deficits. 45598

Based on resident and staff interviews, record review, and facility policy review the facility failed to complete a Trauma Informed Care Assessment for a resident with Post Traumatic Stress Disorder (PTSD) diagnosis for one (1) of two (2) residents reviewed for PTSD. Resident #37. Findings Included: Record review of the undated facility policy titled Trauma Informed Care undated, revealed It is the policy of this facility to provide culturally competent, trauma-informed care to residents who are trauma survivors in accordance with professional standard of practice. On [DATE] at 11:05 AM, an observation and interview with Resident #37 revealed her sitting up in her wheelchair in her room. Resident #37 revealed that she had a three-month- old baby who died many years ago and also had an adult son who was found dead in his bed about [AGE] years ago and this caused her to worry a lot about her kids and grandkids. Resident #37 revealed that she often had nightmares and cried out in her sleep at night but didn't know what caused it. On [DATE] PM at 3:10 PM, an interview with Social Services revealed that she was responsible for completing the Trauma Informed Care Assessment on admission and any time there was a change in condition or a new diagnosis of PTSD. She revealed that she was not aware of Resident #37's PTSD diagnosis and confirmed that with this new diagnosis, she should have completed a Trauma Informed Care Assessment. Social Services revealed that they had a Care Plan Meeting with Resident #37 and her family and they reported that she yelled out at night during her sleep, that nothing seemed to trigger it, and that she had been doing it for a long time. She revealed that the family also denied any past traumatic events other than the death of two children that happened many years ago. Social Services revealed that Resident #37 was diagnosed with PTSD on [DATE] and it should have triggered them to do another Trauma Informed Care Assessment but they had missed it somehow. On [DATE] at 11:45 AM, an interview with Director of Nursing (DON) revealed that Resident #37 admitted to the facility on [DATE] for therapy services and was told by her family on [DATE] that she had to remain long-term in the facility and could not return to her home. The DON revealed that Resident #37 was upset and very tearful about having to stay long term. The DON revealed that they had not reported any other traumatic events in Resident #37's past other than her losing two of her children. The DON confirmed that they had discussed with the family about her crying out in her sleep and her family brushed it off and said that she cried out in her sleep all the time at home. She revealed that a psychiatric Nurse Practitioner evaluated Resident #37 and the new diagnosis of PTSD was added on [DATE]. The DON revealed that a Trauma Informed Care Assessment should have been completed with this new diagnosis and she didn't know why it wasn't done. Record review of Resident #37's Psych Eval (Evaluation)dated [DATE], revealed Recommendations: Add .Post traumatic stress disorder, chronic to diagnoses. Record review Resident #37's Admission Record revealed an admitted [DATE] with diagnoses that included Unspecified Dementia with other behavioral disturbance, Anxiety Disorder and Hallucinations. The diagnosis of Post-Traumatic Stress Disorder, Chronic was added on [DATE]. Record review of Resident #37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 10 which indicated that she had moderate cognitive deficits.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, dry storage room and on metal shelves were dated, labeled and discarded by the expiration date for one (1) of two (2) kitchen tours. Findings include: Review of the facility policy titled, Food Storage dated August 18, 2011, revealed, It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner . 8. All foods stored in refrigerators and freezers that have been opened, will be covered, and labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame. 9. All leftover foods are to be stored in covered containers, dated, & labeled .If not used by the (3rd) day, they are to be discarded .Cold leftovers not used by the third (3rd) day are to be discarded. An observation and interview on the initial tour of the kitchen on 07/05/23 at 10:05 AM, revealed: Refrigerator #1: A round plastic container with a date of 7/1/23 and no label. Dietary Worker #1 revealed these are great northern beans and they should have been thrown away. There was a round plastic container with a label of meatballs and a date of 6/30/23, a rectangular plastic container with no label or date. Dietary Worker #1 revealed its tuna fish, but I don't know when it was put in here nor how long it's been in here. There was a peeled onion wrapped in aluminum foil, with no date or label which was identified by Dietary Worker #1. Observed a pack of opened pack of celery with no date. Dietary Worker #1 revealed I'm not sure of the date, I'm going to throw this stuff out. She confirmed we are supposed to keep the refrigerators cleaned out and confirmed the food is supposed to have a label with the name of the food item on it and the date it is put in the refrigerator, and it is supposed to be thrown away within three (3) days. Refrigerator #2: Observed a container with a manufactured label of sour cream with an open date of 6/27/23. Dietary Worker #2 revealed this was supposed to be thrown away. A white round container with two labels on the top of the lid, one label with an opened date of 6/28/23 and another label with an opened date of 6/29/23 was observed. Dietary Worker #2 revealed, I think it was opened on 6/29/23 but I'm not sure because there's another label for 6/28/23. He identified the food as Pimento and Cheese and revealed regardless, it should have been thrown away. Dietary Worker #2 revealed I usually clean out the refrigerator every week but confirmed it had not been cleaned out. Supply Room: Observed three (3) bags of opened cereal in original bags. Dietary Worker #2 identified one package of Rice Krispies, one package of Corn Flakes, and the other package as Toasted Oats. Dietary Worker #2 confirmed these are supposed to be labeled and dated and in a plastic bag because they have been opened. He revealed I'm not sure who opened these and not sure how long they had been opened. He stated they could get stale. Metal Cart: Observed a three-tier metal cart with a large clear container with plastic bowls on the bottom shelf. Dietary Worker #2 identified the items in the bowls as cereal. A plastic lid was on each bowl which was too small for the bowl leaving the cereal exposed. Dietary Worker #2 revealed the Dietary Manager (DM) is supposed to be ordering the right size lids. She ordered these but they are too small. Dietary Worker #2 revealed he should have wrapped them with plastic wrap so they wouldn't be exposed. He confirmed there was no date or label on the lids and it should be and stated with the cereal not being properly covered it leaves the food exposed and something could get on the food. An interview on 07/06/23 at 8:45 AM, the DM revealed everyone is responsible for making sure the foods are labeled and dated. She revealed staff is being careless and not labeling, dating, and discarding out-of-date foods. She confirmed that foods that are not dated and discarded properly could possibly cause someone to get sick. The DM confirmed that the cups of cereal on the three-tier metal container should have been covered by plastic wrap being exposed like that could the food to become stale or allow something to get on the cereal. During an interview on 07/06/23 at 8:50 AM, the Registered Dietician confirmed the food items that were not dated, labeled, and exposed could cause cross-contamination and a possible food-borne illness.

Based on observations, staff and resident interviews and facility policy review the facility failed to provide furniture in the resident's room that was not broken and failed to provide warm water in resident's rooms for four (4) of 47 residents reviewed during initial tour. Resident #1 for furniture and Residents #18, Resident #25 and Resident #42 for water. Findings include: Record review of the facility policy titled, Resident Rights with a revision date of 11/28/16 revealed under section (i), Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment Also revealed under, (2) Housekeeping and maintenance services necessary to maintain sanitary, orderly, and comfortable interior; . (6) Comfortable and safe temperature levels Record review of the typed statement on facility letterhead July 6, 2023 and signed by the Administrator revealed the facility does not have a policy regarding replacing broken furniture. Record review of the policy titled, Weekly Water Temperature Checklist-Notes with no revision date revealed Resident room temperatures should be no less than 100 degrees and no more than 115 degrees. Resident #1 An observation and interview on 07/05/23 at 11:28 AM, revealed Resident #1 had a side table with a missing top drawer and a small chest of drawers with 3 out of six (6) that were missing handles and a bottom drawer that could not be opened all the way. Resident #1 revealed the missing top drawer had been that way since she moved in that room about 3 weeks prior and she just sits stuff around because she doesn't always have room with only two drawers in her nightstand. She stated the chest of drawers in the closet cannot be opened all the way because it sits in the corner and it hits the inside edge of the closet when you try to open the drawers. An observation on 7/5/23 at 4:30 PM, revealed the resident had personal belongings lying on the bed and on the overbed table. An interview and observation on 07/06/23 9:23 AM, with the Administrator confirmed that Resident #1's nightstand had a top drawer missing and needed to be replaced. She revealed that the bottom drawer of the chest of drawers in the resident's closet would not open all the way because it got stuck on the edge of the inside of the closet and needed to be moved so that all drawers could open. An interview on 7/6/23 at 3:00 PM, with the Director of Nurses (DON) revealed that when a resident is admitted or moved to another room, then the staff will review the room to make sure everything is in order and nothing needs to be replaced. She revealed that if the resident's nightstand had a missing drawer, then it should have been replaced. 47874 Resident #25: An interview with Resident # 25 during initial tour on 7/5/23 at 10:30 AM, revealed the facility staff have to come into his room to get hot water for the other residents on this hall (C hall) and stated that his room had plenty of warm water. An observation during initial tour on 7/05/23 at 10:40 AM, of the bathroom water in Resident #25's bathroom revealed that the water was cold and had no warmth after running the faucet for 3-5 minutes. An interview on 7/05/23 at 11:02 AM, with Certified Nurse Aide (CNA) #2 revealed none of the water on C hall gets real warm. She stated a couple of the rooms get warmer water because they have individual hot water heaters going to those rooms. An interview with the Maintenance Director on 7/05/23 at 11:10 AM, revealed he had not been told anything about the water on C hall being cold. He revealed the warmness of the water temperature depended on how close the resident's room was to the water heater. The State Agent (SA) requested temperature check on the hot water in Resident #42's and Resident 18's bathrooms. The SA observed the temperature in Resident #42's bathroom to be 75 degrees Fahrenheit and in Resident #18's bathroom the water temperature was 80.2 degrees Fahrenheit. An interview with the Administrator (ADM) on 7/5/23 at 11:45 AM, revealed that she had not been told by any of the residents that the hot water was not working on C hall. She revealed that they have had issues in the past with the mixing valve on the hot water tank. Resident #18 An interview with Resident # 18 on 7/5/23 at 11:52 AM, revealed he has not had warm water in his bathroom since Christmas time. He stated he has told the maintenance man about the water in the past, but that particular maintenance man was no longer employed at the facility. Resident #18 stated, The pilot light has gone out several times and they have replaced the tank.He stated, I would like to have warm water to at least wash my face. He revealed he goes down the hall to get his shower and the water is always warm there. Resident #42 An interview with Resident # 42 on 7/5/23 at 12:01PM, revealed she has not had warm water in her bathroom for months. She stated, I like to wash my hair in the bathroom, and I would like warm water to do that. She revealed she has not had any issues with hot water in the shower room just in her bathroom in her room. An interview with the Maintenance Director on 7/05/23 at 12:35 PM, revealed when he started to work here 2 weeks ago the hot water was on his list of things to check. He stated that he had many other electrical issues on his list to fix first, as he felt that took top priority. He stated that he had not been doing any monitoring of the water in the facility to see if it was warm enough. An interview with the ADM on 7/05/23 at 1:00PM, revealed that the facility does not do any water temperature monitoring. An observation and interview with the ADM on 7/06/23 at 4:06 PM of the hot water Resident #18's bathroom confirmed the water was only tepid. She stated that they had replaced the water heater before and recently had issues with the pilot light going out. She stated, I'm not going to have the residents without hot water. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/8/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident has moderate cognitive impairment. Record review of the MDS with an ARD of 5/10/23 revealed under section C a BIMS score of 15, which indicated Resident #25 is cognitively intact. Record review of the MDS with an ARD of 6/21/23 revealed under section C a BIMS score of 15, which indicated Resident #18 is cognitively intact. Record review of the MDS with an ARD of 05/12/23 revealed under section C a BIMS score of 15, which indicated Resident #42 is cognitively intact.

Based on observation, resident and staff interviews, and facility policy review the facility failed to ensure that a resident who was unclothed had privacy and was free from view to maintain personal privacy for one (1) of 47 residents reviewed during initial tour. Resident #38 Findings include: Record review of the undated facility policy entitled, Dignity and Respect, undated, revealed, Policy Statement It is the policy of this facility to treat each resident with respect and dignity .Procedure .3. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by . On 07/05/23 at 11:00 AM an observation was made of Resident #38 lying in bed with no shirt on and was covered with a blanket from his waist down. His door was not closed, and the resident was visible to anyone passing down the hallway. Resident #38 was lying in the first bed at the doorway just inside the room. On 07/05/23 at 12:00 PM, an observation was made of Resident #38 lying in bed with a brief on and with no top sheet or blanket covering him and he had no shirt or pants on. The door to the hallway was open and there was no curtain pulled to prevent exposure of resident from those ambulating in the hallway. Resident was lying flat in bed and was visible to those outside the room. On 07/05/23 at 2:00 PM, an observation of Resident #38 from the hallway, revealed the door to his room was open, and he was lying in bed with only a brief on and there was not a top sheet or blanket covering him. On 07/06/23 at 8:02 AM, an interview with Resident #38 revealed that he had trouble breathing and didn't like to wear shirts or pants. Resident stated, I don't want to put a shirt on. Resident revealed that he tried to keep the cover over him; but he sometimes got hot and felt like he was smothering and would kick the cover off. Resident #38 revealed that he would rather not be seen by other's when he was uncovered. Resident #38 stated, I don't want people to see my legs. On 07/06/23 at 9:20 AM, an interview with Director of Nursing (DON), revealed that Resident #38 constantly kicked his covers off, would not wear clothes, and the staff had to constantly watch him. She revealed that they had tried gowns, more comfortable shirts, and shorts; but he just took them off. She stated that the staff usually monitor him and when he was uncovered, they would go in and cover him back up. On 07/06/23 at 9:50 AM, an interview with DON, revealed that she agreed one hundred percent that the resident lying in bed uncovered with only a brief on was a personal privacy issue, especially because he didn't want anyone to see his legs. On 07/06/23 at 10:00 AM, an interview with the Administrator (ADM), revealed that she was made aware of the concern with Resident #38 today. The ADM confirmed that this resident lying in his bed unclothed and uncovered with the door to his room left open was a privacy issue. Record review of Resident's Admission Record revealed an admitted [DATE] with the following diagnoses to include Heart Failure, Chronic Obstructive Pulmonary Disease, Morbid Obesity, Restlessness and Agitation, and Weakness. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/08/23, documented under Section C a Brief Interview for Mental Status (BIMS) Score of 08 which indicated that resident had moderate cognitive deficits.

Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide personal hygiene as evidenced by long, jagged fingernails with a brown substance underneath the nails for one (1) of 12 sampled residents. Resident #40 Findings include: Record review of the facility policy titled, Fingernails/Toenails, Care of with a revised date of February 2018, revealed, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . An observation and interview on 07/05/23 at 3:15 PM, revealed Resident #40's fingernails on both hands were approximately one-half (1/2) inch long and jagged past the tip of the fingers and had a brown substance underneath the nails. The resident revealed he wasn't sure when the last time they were cut and he would like for them to be cut. An interview on 07/05/23 at 3:20 PM, Certified Nurse Aide (CNA) #1 revealed we are responsible for making sure the resident's nails are cleaned each time they are bathed but the nurses trim their nails on the weekends. She revealed she is assigned to Resident #40 but just came in to work and wasn't sure what was done today. An observation and interview on 07/05/23 at 03:25 PM, the Director of Nurses (DON) revealed according to Resident #40's physician orders the resident is supposed to get routine nail care weekly on Saturday. She revealed the residents are supposed to have their nails cleaned every day when they are bathed or cleaned up. She confirmed that Resident #40's nails were long and jagged and needed to be cleaned. She revealed with his nails long and dirty he could cut his skin and could also possibly spread infection. She stated I will make sure they get cleaned and cut right now. Record review of Resident #40's Order Summary report revealed an order dated 9/1/2021 for Routine nail care every Saturday . Record review of Resident #40's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Depressive episodes, Chronic Respiratory failure, and Tachycardia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of April 12, 2023, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.

Based on staff interviews, record review, and facility policy review the facility failed to implement a comprehensive care plan for a resident who required assistance with Activities Daily Living (ADL) nail care for one (1) of 12 residents sampled. Resident #40 Findings include: Record review of the facility's Using the Care Plan policy (undated) revealed It is the policy of this facility that the care plan be used in developing the resident's daily care routines .4. Daily care and documentation should be consistent with the resident's care plan. Record review of Resident #40's care plan revealed I have an ADL self-care performance deficit date initiated 09/09/2021 . Interventions/Tasks . Routine nail care weekly on Saturday, Bathing/Showering: Check nail length and trim and clean on bath day as necessary. Report any changes to the nurse . During an observation and interview on 07/05/23 at 3:15 PM, revealed Resident #40's fingernails on both hands was approximately one-half (1/2) inch long and jagged past the tip of the fingers, and had a brown substance underneath the nails. The resident revealed he wasn't sure when the last time they were cut, and he would like for them to be cut. The Director of Nurses (DON) reported during an observation and interview on 07/05/23 at 3:25 PM that according to Resident #40's physician orders the resident is supposed to get routine nail care weekly on Saturday. She revealed the residents are supposed to have their nails cleaned every day when they are bathed or cleaned up. She confirmed that Resident #40's nails were long and jagged and needed to be cleaned. She revealed with his nails long and dirty he could cut his skin and could also possibly spread infection. She stated I will make sure they get cleaned and cut right now. An interview on 07/06/23 at 2:40 PM, the DON confirmed Resident #40's ADL care plan was not being followed when she observed his long and dirty nails yesterday. An interview on 07/06/23 at 3:54 PM with the Minimum Data Set (MDS) Coordinator revealed she along with the interdisciplinary team is responsible for developing the residents' care plan. She revealed the care plan guides us on how to care for them and is individualized for each resident. A record review of Resident #40's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Depressive episodes, Chronic Respiratory failure, and Tachycardia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/23 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.

Based on observation, record review, facility policy review, and resident interview and staff interview, the facility failed to maintain accurate medical records as evidenced by insulin was falsely documented twice on the Medication Administration Record [REDACTED]. Resident #1 had 15 units of routine insulin ordered for 8:00 PM on 10/18/18, and LPN #3 failed to administer the insulin, but documented that it was administered on the Medication Administration Record [REDACTED]#1, but documented that it was administered on the MAR. Resident #1's blood sugar elevated to over 600 mg/dL at 7:30 AM on 10/19/18, which required additional insulin, and was transferred to the hospital around 11:30 AM for continued elevation of her blood sugar. The facility's failure to ensure accurate medical records, with false documentation of Insulin medication administration, placed Resident #1 and other residents who received insulin and/or other medications, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was identified to be an Immediate Jeopardy (IJ) that began on 10/18/18, when the facility staff falsely documented the administration of Insulin medication on the MAR indicated [REDACTED]. On 10/26/18 at 3:30 PM, the Administrator was notified of the IJ. The facility provided corrective measures to remove the IJ on 10/27/18, in which the facility alleged all corrective measures were completed as of 10/22/18, and the removal of the IJ on 10/23/18. The SA validated the corrective measures, and determined the Immediate Jeopardy Past Non-compliance (IJPNC) was removed on 10/23/18, prior to the SA entrance on 10/24/18. Findings include: A review of the Facility Policy entitled, Charting and Documentation Guidelines, dated (MONTH) 13, 2005, revealed: 16. Medication Administration g: Document on the Medication Administration Record [REDACTED] Review of the facility's investigative report revealed an investigation was initiated by the Director of Nursing (DON) on 10/19/18, related to Resident #1's consistent elevated blood glucose above 600 mg/dL for three (3) consecutive checks and transfer to the emergency room for evaluation and treatment. The investigation determined LPN #1 (11-7 shift) and LPN #3 (3-11 shift) did not give insulin to Resident #1 as ordered. The report noted that both nurses stated they knew the resident's blood glucose was elevated, but forgot to give the scheduled insulin; however they recorded insulin as given on the Medication Administration Record [REDACTED]. A review of Resident #1's October, (YEAR), physician's orders revealed orders dated 10/18/18, for Humalog solution 100 unit/milliliter-inject as per sliding scale: if 0-150=zero (0) units of insulin; 151-200=three (3) units; 201-250=five (5) units; 251-300=six (6) units; 301-350=10 units; 351-400=15 units; 401-450=18 units; 451-500=21 units; 501-999=zero (0) units Notify MD, subcutaneously every four (4) hours. Orders also included to administer Insulin [MEDICATION NAME] ([MEDICATION NAME]) Solution 100 unit/ml inject 15 units subcutaneously one time daily (The MAR indicated [REDACTED] Review of the face sheet revealed the facility admitted Resident #1 on 5/14/18, with a re-admission on 10/18/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #1 on 10/25/18 at 4:45 PM, revealed she did not receive her routine bedtime insulin as ordered on [DATE], and her sliding scale during the early morning on 10/19/18. She stated she was sent out to the hospital with a high blood sugar on 10/19/18, due to not getting her insulin. She stated she felt like she needed the insulin. Review of the Nurse's Notes, dated 10/19/18 at 9:30 AM revealed Resident #1's blood sugar was 600 milligrams per deciliter (mg/dL) and she received two (2) different injections of insulin from 9:30 AM until she was sent to the hospital around 11:30 AM, for her consistent blood sugar of 600 mg/dL. The 11:30 AM Nurse's Note, prior to transfer, documented the Resident's symptoms of shortness of breath, decreased breath sound, low oxygen saturation and pale/ashy skin color. A review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. On 10/29/18 at 12:45 PM, a telephone interview with LPN #1 confirmed she did not give the 8:00 PM [MEDICATION NAME] to Resident #1 because it did not come up on the computer for her to give. Then, she stated she did document on the MAR indicated [REDACTED] A review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. On 10/26/18 at 12:38 PM, a telephone interview with LPN #3 confirmed she documented that she administered the 21 units of Humalog to Resident #1 on 10/19/18 at 4:00 AM, but she forgot to give it. She stated she got busy and just forgot. Review of termination action forms for LPN #1 and LPN #3, dated 10/22/18, revealed both nurses were terminated for falsification of records and poor performance. Interview with the Director of Nursing (DON) on 10/24/18 at 5:45 PM, revealed both LPN #1 and LPN #3 signed the MAR indicated [REDACTED]. She confirmed the false documentation. The DON stated both nurses were suspended and terminated on 10/22/18, and education to other staff for false documentation, neglect, following the care plans, and medication errors. The facility provided corrective measures to remove the IJ on 10/27/18: Brief Summary of Event: At 3:30 PM on Friday, 10/26/2018, the state complaint surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #1, who is a known diabetic with a history of noncompliance with diet, not receiving insulin as ordered by the Physician. Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) at 3:40 PM, with orders for [MEDICATION NAME] 15 units subcutaneously (subq) at bedtime, Humalog 5 units subq three (3) times daily before meals. Humalog sliding scale subq every four (4) hours as follows: <151 give zero (0) units, < 70 use hypoglycemic protocol, 151-200 give three (3) units, 201-250 give five (5) units, 251-300 give six (6) units, 301-350 give 10 units, 351-400 give 15 units, 401-450 give 18 units, 451-500 give 21 units, >500 give zero (0) units and contact the Medical Doctor (MD). 1. On (MONTH) 19, (YEAR) at 8:00 AM, LPN #2 administered routine insulin to Resident #1. Resident #1 stated to LPN #2 that her blood sugar may be high because she had not gotten any insulin since she had returned to the facility the previous day. LPN #2 notified the DON on (MONTH) 19, (YEAR) at approximately 9:30 AM about Resident #1's statement regarding not receiving insulin. The DON initiated an investigation at this time. 2. On (MONTH) 19, (YEAR) at 9:30 AM and 10:30 AM, Resident #1's glucose readings were noted to be 600+ by Registered Nurse #1 (RN). RN #1 contacted Physician #1, who is also the facility Medical Director (MD), each time with new orders given each time to administer Humalog 15 units subq now and recheck glucose in one (1) hour. 3. On (MONTH) 19, (YEAR) at 11:30 AM, RN #1 rechecked glucose with a reading noted of 600+. RN #1 assessed Resident #1, who had become symptomatic with Shortness of Breath, Oxygen Saturation of 80 percent and pale skin color. RN #1 contacted the MD at 11:33 AM, and received an order to transfer Resident #1 to the emergency room (ER) for further evaluation and treatment of [REDACTED].#1 left the facility by ambulance at 11:45 AM. 4. On (MONTH) 19, (YEAR), Resident #1 was noted to have a glucose of 296 and a Sodium level of 125 millimoles per liter (mmol/l) per ER records. Resident #1 did not receive any treatment for [REDACTED]. The ER could not get any intravenous (IV) access on Resident #1 to treat the [MEDICAL CONDITION]. Resident #1 was then transferred at 3:18 p.m. to another hospital for treatment and was admitted with a [DIAGNOSES REDACTED]. 5. On (MONTH) 19, (YEAR) at approximately 2:45 PM, the DON discovered through her interviews with LPNs #1 and #3, that Resident #1 had not received the routine order of [MEDICATION NAME] 15 units due at 8:00 PM on (MONTH) 18, (YEAR), by LPN #3, and Resident #1 had not received Humalog 21 units at 4:00 AM on (MONTH) 19, (YEAR), by LPN #1, for a blood glucose reading of 500. Facility Actions: 1) On (MONTH) 19, (YEAR) at 3:30 PM, both LPN #1 and LPN #3 were suspended by the DON and the Facility Administrator pending investigation regarding significant medication errors with insulin administration. 2) On (MONTH) 19, (YEAR) at 4:12 PM, a message was left on the Mississippi Department of Health hotline by the Facility Administrator regarding a significant medication error with insulin administration. 3) On (MONTH) 19, (YEAR) at 4:30 PM, a 100 percent (%) audit of all residents with insulin orders, for a total of 10 residents, was completed by the DON to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) On (MONTH) 19, (YEAR) at 5:00 PM, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON. In-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistants (CNAs)- 11 of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1) and Social Services - one (1) of one (1). * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistant - 16 of 20, Social Services - one (1) of one (1), Administrator - one (1) of one (1), Medical Records - one (1) of one (1). * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. The following staff were present at the in-service: RNs - three (3) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistant - eight (8) of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1). No clinical staff will be allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which includes new hires: this will be monitored by the facility Administrator. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. The following staff were present at the in-service initiated on (MONTH) 19, (YEAR) at 5:00 PM by the DON: RNs - six (6) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistants - 17 of 20, Administrator - one (1) of one (1), Housekeeping - three (3) of six (6), Dietary - four (4) of seven (7), Business Office Manager - zero (0) of one (1), Social Services - one (1) of one (1), Life Connections - zero (0) of one (1), Therapy - zero (0) of 18, Medical Records - one (1) of one (1). No staff will be allowed to work until in-serviced on abuse and neglect policy and procedure, which includes new hires; this will be monitored by facility Administrator. 5) On (MONTH) 19, (YEAR) at 3:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON on (MONTH) 19, (YEAR) was discussed. In-services initiated by the DON were discussed. 6) On (MONTH) 22, (YEAR) at 1:51 PM, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) On (MONTH) 22, (YEAR) at 3:30 PM, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1, and false documentation. 8) On (MONTH) 22, (YEAR) at 10:00 AM, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin and to note if the residents had any concerns with getting their insulin or blood sugar checks. No concerns were noted with the interviews. 9) On (MONTH) 22, (YEAR), The Attorney General's Office online report was submitted at 3:32 PM, by the Facility Administrator, regarding significant medication errors with insulin administration and false documentation. 10) LPN #1 and LPN #3 were both terminated from the facility on (MONTH) 22, (YEAR), by the Facility Administrator, for failure to administer insulin as ordered and false documentation. 11) The facility alleges that all corrective measures have been completed as of (MONTH) 22, (YEAR) and the jeopardy removed as of (MONTH) 23, (YEAR). The State Agency (SA) validated the facility's corrective measures to remove the current IJ through interviews, record reviews, policy reviews, facility documentation, and review of in-service and QAPI sign-in sheets. 1) The SA validated through interview with the DON and review of personnel records that both LPN #1 and LPN #3 were suspended on 10/19/19. 2) The SA validated through documentation from the Mississippi Department of Health, a report was made on 10/19/18, regarding a significant medication error with insulin administration. 3) The SA validated through interview with the DON and facility documentation, that on 10/19/18, a 100 % audit of all residents with insulin orders, for a total of 10 residents, was completed to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) The SA validated through interview with staff and review of in-service sign in sheets that on 10/19/18, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON and that the staff documented were in attendance. The SA validated that the in-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. No clinical staff was allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which included new hires. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. No staff was allowed to work until in-serviced on abuse and neglect policy and procedure, which included new hires 5) The SA validated through random interviews with participating staff and review of the sign-in sheet that on 10/19/18, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON and in-services initiated by the DON were discussed. 6) The SA validated through random interviews with attendees and review of the sign-in sheet that on 10/22/18, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) The SA validated through interview with the DON, that on 10/22/18, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1 and false documentation. 8) The SA validated through interview with staff, Social Services documentation, and random interview with residents who received insulin, that on 10/22/18, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin, with no concerns of receiving their insulin or blood sugar checks. 9) The SA validated through review of documentation and interview with the Administrator, that on 10/22/18, the Attorney General's Office online report was submitted, regarding significant medication errors with insulin administration and false documentation. 10) The SA validated through interview with the Administrator, and review of termination reports, that LPN #1 and LPN #3 were both terminated from the facility on 10/22/18, for failure to administer insulin as ordered and false documentation. 11) The SA validated that all corrective measures to remove the IJ were completed as of 10/22/18, and the IJ removed 10/23/18, prior to state entrance on 10/24/18. Based on the facility's corrective measures, that were completed on 10/22/18, prior to the SA entrance on 10/24/18, the IJ will be PNC, however the facility will remain out of compliance, related to the re-certification survey, with an exit date of 10/11/18, with deficiencies at F842.

Based on observation, record review, facility policy review, and staff and resident interviews, the facility failed to prevent a significant medication error for Resident #1, as evidenced by 15 units of insulin was not given as ordered for routine administration on 10/18/18 at 8:00 PM, by LPN #1, and 21 units of sliding scale insulin was not administered as ordered, at 4:00 AM by LPN #3, for a blood sugar of 500 milligram per deciliter (mg/dL). This affected one (1) of five (5) diabetic residents reviewed, Resident #1. Resident #1 was transferred to the emergency room (ER) with blood sugar readings of over 600 mg/dL and symptoms of shortness of breath, decreased lung sounds, low oxygen saturation and pallor of skin. The facility's failure to prevent significant medication errors by not providing Insulin as ordered, resulted in Resident #1's Blood Glucose level increasing to over 600 mg/dL, which required additional insulin, and the resident's transfer to the emergency room (ER). This placed Resident #1, and other residents who received insulin, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was identified to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/18/18, when a significant medication error occurred in the omission of the routine 15 units of insulin at 8:00 PM, and on 10/19/18 at 4:00 AM, 21 units of sliding scale insulin was not administered for Resident #1 for a blood sugar over 600 mg/dL, resulting in symptoms of shortness of breath, low oxygen saturation, pallor of skin, and decreased lung sounds. Resident #1 was transferred to the ER for further treatment. On 10/26/18 at 3:30 PM, the Administrator was notified of the IJ and SQC. The facility provided the SA with corrective measures to remove the IJ on 10/27/18, in which the facility alleged all corrective measures were completed as of 10/22/18, and the removal of the IJ on 10/23/18. The SA validated the corrective measures provided by the facility, and determined the IJ Past Non-compliance and was removed on 10/23/18, prior to the SA entrance on 10/24/18. Findings include: A review of the Facility Policy entitled Medication Administration - General Guidelines, dated (MONTH) 1, 2008, revealed: Medications are administered in accordance with written orders of the attending physician. Review of the face sheet revealed the facility admitted Resident #1 on 5/14/18, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of a facility self-reported investigation, revealed the investigation was initiated by the Director of Nursing (DON) on 10/19/18, related to Resident #1's elevated blood glucose above 600 mg/dL for three (3) consecutive checks. Resident #1 was transferred to the hospital after the third check and continued elevation of blood sugar of 600+, even with treatment of [REDACTED].#1 did not give sliding scale insulin (11-7 shift) and LPN #3 did not give routine insulin (3-11 shift) to Resident #1 as ordered. The investigation noted that both nurses stated they knew the resident's blood glucose was elevated, but forgot to give the scheduled insulin; even though they recorded insulin as given on the Medication Administration Record [REDACTED]. An observation and interview on 10/25/18 at 4:20 PM, revealed Resident #1 sitting in her room in her wheelchair, awake, alert, and oriented to person, place, time, and situation. Interview on 10/25/18 at 4:45 PM, revealed Resident #1 stated that she was sent out to the hospital for high blood sugar recently, but couldn't recall the exact date. Resident #1 stated she did not receive her insulin the night before she was sent to the hospital. She stated that was the only time she hasn't received her insulin while at the facility. Resident #1 stated that her blood sugar would go up and down. During an interview on 10/26/18 at 3:35 PM, Resident #1 stated she didn't really feel that sick when she was sent to the hospital for her high blood sugar; she just felt like she needed her insulin. A review of Resident #1's (MONTH) (YEAR) physician's orders, revealed orders dated 10/18/18, for Humalog solution 100 unit/ (per) ml (milliliter)-inject five (5) units subcutaneously (SQ) before meals; Humalog solution 100 unit/ml-inject as per sliding scale: if 0-150=zero (0) units of insulin. For blood glucose less than 70, notify MD (physician); 151-200=three (3) units; 201-250=five (5) units; 251-300=six (6) units; 301-350=10 units; 351-400=15 units; 401-450=18 units; 451-500=21 units; 501-999=zero (0) units Notify MD, inject subcutaneously every four (4) hours. Orders also included: Insulin [MEDICATION NAME] ([MEDICATION NAME]) Solution 100 unit/ml-inject 15 units subcutaneously once daily (listed at 8:00 PM on the Medication Administration Record) for Diabetes. Review of the Weights and Vitals Summary, for Resident #1's Blood Sugar checks, revealed the following documented results: 10/18/18 at 6:37 PM - Blood Sugar 386 milligrams per deciliter (mg/dL). (for the 4:00 PM check). 10/18/18 at 10:19 PM -Blood Sugar 303 mg/dL (for the 8:00 PM check) 10/19/18 at 1:13 AM -Blood Sugar 187 mg/dL (for the 12 Midnight check) 10/19/18 at 6:51 AM -Blood Sugar 500 mg/dL (for the 4:00 AM check) Review of the Nurse's Notes dated 10/19/18 at 9:30 AM, revealed Resident #1's Blood Sugar was 600 plus (+) mg/dL. The Physician was notified and new orders for insulin were obtained (15 units of Humalog insulin). Review of the Nurse's Notes, dated 10/19/18 at 11:30 AM, revealed Resident #1's Blood Sugar remained at 600 mg/dL. Resident #1 reports shortness of breath, decreased breath sounds in lower lung, oxygen saturation in the 80s, and color pale and ashy. The physician was notified and new orders received to transfer the resident to the emergency room (ER) for evaluation. Review of the hospital ER records, dated 10/19/18 at 12:06 PM, revealed Resident #1 presented with [MEDICAL CONDITION]. Her blood sugar at the facility was 600 mg/dL and after administration of 15 units of [MEDICATION NAME], the blood sugars decreased to 475 mg/dL, and then 371 mg/dL once at the ER. The resident presented with fatigue and weakness. The clinical impression: [MEDICAL CONDITION] (low sodium) and [MEDICAL CONDITION] (high blood sugar). Resident #1 was transferred to another hospital on [DATE] for treatment of [REDACTED]. A telephone interview with LPN #2 on 10/30/18 at 4:30 PM, revealed she was assigned to Resident #1 on 10/19/18, for the 7:00 AM-3:00 PM shift. LPN #2 stated when she went to check Resident #1's blood sugar that morning, Resident #1 informed her that it was going to be high because she had not received any of her insulin since she had returned to the facility the day before, 10/18/18 at approximately 2:45 PM. LPN #2 stated Resident #1's blood sugar was 600 mg/dL at 7:30 AM. She stated she notified her Charge Nurse (RN #1) and the resident's MD was called. She stated an order was received to administer 15 units of Humalog insulin and recheck blood sugar in an hour. LPN #1 stated Resident #1's blood sugar was checked again after an hour and was 600 mg/dL. She stated the MD was notified and another order was received to administer 15 units of Humalog insulin and recheck in an hour. LPN #1 stated Resident #1 was sent to the hospital emergency room when the recheck of the blood sugar remained at 600 mg/dL. In an interview on 10/26/18 at 1:00 PM, Registered Nurse (RN) #1 (Charge Nurse), stated that on 10/19/18 at approximately 8:30 AM, she was notified by LPN #2 that Resident #1's blood sugar was 600 mg/dL. She stated she notified Resident #1's MD and received orders to administer 15 units of Humalog insulin and recheck the blood sugar in an hour. She stated on recheck, Resident #1's blood sugar remained 600 mg/dL and the MD gave orders to administer another 15 units of Humalog insulin, and recheck the blood sugar in an hour. She stated an hour later at around 11:30 AM, the resident's blood sugar remained at 600 mg/dL and the resident had become symptomatic; she had Shortness of breath, decreased breath sounds in her lower lungs, oxygen saturation was in the 80s, and her color was pale and ashy. RN #1 stated she notified the MD and received the order to send Resident #1 to the emergency room (ER). She stated Resident #1 was transported to the ER shortly thereafter. In a telephone interview on 10/26/18 at 12:38 PM, LPN #3 confirmed that on the night of 10/18/18, she worked the 11:00 PM-7:00 AM shift and was assigned to Resident #1. She stated at midnight she checked Resident #1's blood sugar and gave her three (3) units of insulin. She stated she checked Resident #1's blood sugar at 5:00 AM for the 4:00 AM check, and the glucometer read high. She stated high means over 500 mg/dL. LPN #3 stated Resident #1 should have received 21 units of sliding scale insulin, but she did not administer it because she got busy with other residents and forgot to give the insulin to Resident #1. She stated she did not notify the MD of the high reading. She stated protocol would be to give the 21 units of insulin if high. She confirmed she forgot to give the insulin. LPN #3 confirmed the medication error and stated she could see how it might be neglect, not to give the medication as ordered. In a telephone interview on 10/29/18 at 12:45 PM, LPN #1 stated she worked the 3:00 PM-11:00 PM shift on 10/18/18, when Resident #1 returned to the facility from the Behavioral Health Unit (BHU). She stated she was made aware that Resident #1's blood sugars were to be checked every four (4) hours according to the hospital return orders. She stated between 4:30 PM and 4:45 PM, she checked Resident #1's blood sugar which was 386 mg/dL, which would require 10 units of sliding scale insulin. She stated the resident also received five (5) units of insulin at supper. She stated she administered a total of 15 units of Humalog insulin to Resident #1 at supper. She stated she did not give the bedtime [MEDICATION NAME] (15 units) at 8:00 PM, because it did not come up on the computer Medication Administration Record [REDACTED]. She was aware of Resident's non-compliance to her diet. During an interview on 10/24/18 at 5:45 PM, the Director of Nursing (DON) stated she was made aware of Resident #1's statement of not receiving her insulin by RN #1 on the morning of 10/19/18. The DON stated she began an investigation and determined from interviews with LPN #1 and LPN #3, that Resident #1 had not received her insulin on the 3:00 PM-11:00 PM shift at bedtime from LPN #1, and the sliding scale insulin on the 11:00 PM-7:00 AM shift at 4:00 AM, from LPN #3, as ordered. The DON stated Resident #1 was sent to the hospital due to a Blood Sugar over 600 mg/dL that would not respond to the insulin that morning; the two (2) now orders that had been received from the Physician. She acknowledged the medication error for the insulin and stated that it is a medication error when a medication is not administered as ordered. The DON stated both nurses were suspended and terminated on 10/22/18, for the medication error and false documentation, and education was provided to other staff for false documentation, neglect, following the care plans, and medication errors. The facility provided corrective measures to remove the IJ on 10/27/18: Brief Summary of Event: At 3:30 PM on Friday, 10/26/2018, the state complaint surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #1, who is a known diabetic with a history of noncompliance with diet, not receiving insulin as ordered by the Physician. Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) at 3:40 PM, with orders for [MEDICATION NAME] 15 units subcutaneously (subq) at bedtime, Humalog 5 units subq three (3) times daily before meals. Humalog sliding scale subq every four (4) hours as follows: <151 give zero (0) units, < 70 use hypoglycemic protocol, 151-200 give three (3) units, 201-250 give five (5) units, 251-300 give six (6) units, 301-350 give 10 units, 351-400 give 15 units, 401-450 give 18 units, 451-500 give 21 units, >500 give zero (0) units and contact the Medical Doctor (MD). 1. On (MONTH) 19, (YEAR) at 8:00 AM, LPN #2 administered routine insulin to Resident #1. Resident #1 stated to LPN #2 that her blood sugar may be high because she had not gotten any insulin since she had returned to the facility the previous day. LPN #2 notified the DON on (MONTH) 19, (YEAR) at approximately 9:30 AM about Resident #1's statement regarding not receiving insulin. The DON initiated an investigation at this time. 2. On (MONTH) 19, (YEAR) at 9:30 AM and 10:30 AM, Resident #1's glucose readings were noted to be 600+ by Registered Nurse #1 (RN). RN #1 contacted Physician #1, who is also the facility Medical Director (MD), each time with new orders given each time to administer Humalog 15 units subq now and recheck glucose in one (1) hour. 3. On (MONTH) 19, (YEAR) at 11:30 AM, RN #1 rechecked glucose with a reading noted of 600+. RN #1 assessed Resident #1, who had become symptomatic with Shortness of Breath, Oxygen Saturation of 80 percent and pale skin color. RN #1 contacted the MD at 11:33 AM, and received an order to transfer Resident #1 to the emergency room (ER) for further evaluation and treatment of [REDACTED].#1 left the facility by ambulance at 11:45 AM. 4. On (MONTH) 19, (YEAR), Resident #1 was noted to have a glucose of 296 and a Sodium level of 125 millimoles per liter (mmol/l) per ER records. Resident #1 did not receive any treatment for [REDACTED]. The ER could not get any intravenous (IV) access on Resident #1 to treat the [MEDICAL CONDITION]. Resident #1 was then transferred at 3:18 p.m. to another hospital for treatment and was admitted with a [DIAGNOSES REDACTED]. 5. On (MONTH) 19, (YEAR) at approximately 2:45 PM, the DON discovered through her interviews with LPNs #1 and #3, that Resident #1 had not received the routine order of [MEDICATION NAME] 15 units due at 8:00 PM on (MONTH) 18, (YEAR), by LPN #3, and Resident #1 had not received Humalog 21 units at 4:00 AM on (MONTH) 19, (YEAR), by LPN #1, for a blood glucose reading of 500. Facility Actions: 1) On (MONTH) 19, (YEAR) at 3:30 PM, both LPN #1 and LPN #3 were suspended by the DON and the Facility Administrator pending investigation regarding significant medication errors with insulin administration. 2) On (MONTH) 19, (YEAR) at 4:12 PM, a message was left on the Mississippi Department of Health hotline by the Facility Administrator regarding a significant medication error with insulin administration. 3) On (MONTH) 19, (YEAR) at 4:30 PM, a 100 percent (%) audit of all residents with insulin orders, for a total of 10 residents, was completed by the DON to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) On (MONTH) 19, (YEAR) at 5:00 PM, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON. In-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistants (CNAs)- 11 of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1) and Social Services - one (1) of one (1). * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistant - 16 of 20, Social Services - one (1) of one (1), Administrator - one (1) of one (1), Medical Records - one (1) of one (1). * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. The following staff were present at the in-service: RNs - three (3) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistant - eight (8) of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1). No clinical staff will be allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which includes new hires: this will be monitored by the facility Administrator. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. The following staff were present at the in-service initiated on (MONTH) 19, (YEAR) at 5:00 PM by the DON: RNs - six (6) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistants - 17 of 20, Administrator - one (1) of one (1), Housekeeping - three (3) of six (6), Dietary - four (4) of seven (7), Business Office Manager - zero (0) of one (1), Social Services - one (1) of one (1), Life Connections - zero (0) of one (1), Therapy - zero (0) of 18, Medical Records - one (1) of one (1). No staff will be allowed to work until in-serviced on abuse and neglect policy and procedure, which includes new hires; this will be monitored by facility Administrator. 5) On (MONTH) 19, (YEAR) at 3:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON on (MONTH) 19, (YEAR) was discussed. In-services initiated by the DON were discussed. 6) On (MONTH) 22, (YEAR) at 1:51 PM, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) On (MONTH) 22, (YEAR) at 3:30 PM, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1, and false documentation. 8) On (MONTH) 22, (YEAR) at 10:00 AM, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin and to note if the residents had any concerns with getting their insulin or blood sugar checks. No concerns were noted with the interviews. 9) On (MONTH) 22, (YEAR), The Attorney General's Office online report was submitted at 3:32 PM, by the Facility Administrator, regarding significant medication errors with insulin administration and false documentation. 10) LPN #1 and LPN #3 were both terminated from the facility on (MONTH) 22, (YEAR), by the Facility Administrator, for failure to administer insulin as ordered and false documentation. 11) The facility alleges that all corrective measures have been completed as of (MONTH) 22, (YEAR) and the jeopardy removed as of (MONTH) 23, (YEAR). The State Agency (SA) validated the facility's corrective measures through interviews, record reviews, policy reviews, facility documentation, and review of in-service and QAPI sign-in sheets. 1) The SA validated through interview with the DON and review of personnel records that both LPN #1 and LPN #3 were suspended on 10/19/19. 2) The SA validated through documentation from the Mississippi Department of Health, a report was made on 10/19/18, regarding a significant medication error with insulin administration. 3) The SA validated through interview with the DON and facility documentation, that on 10/19/18, a 100 % audit of all residents with insulin orders, for a total of 10 residents, was completed to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) The SA validated through interview with staff and review of in-service sign in sheets that on 10/19/18, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON and that the staff documented were in attendance. The SA validated that the in-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. No clinical staff was allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which included new hires. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. No staff was allowed to work until in-serviced on abuse and neglect policy and procedure, which included new hires 5) The SA validated through random interviews with participating staff and review of the sign-in sheet that on 10/19/18, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON and in-services initiated by the DON were discussed. 6) The SA validated through random interviews with attendees and review of the sign-in sheet that on 10/22/18, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) The SA validated through interview with the DON, that on 10/22/18, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1 and false documentation. 8) The SA validated through interview with staff, Social Services documentation, and random interview with residents who received insulin, that on 10/22/18, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin, with no concerns of receiving their insulin or blood sugar checks. 9) The SA validated through review of documentation and interview with the Administrator, that on 10/22/18, the Attorney General's Office online report was submitted, regarding significant medication errors with insulin administration and false documentation. 10) The SA validated through interview with the Administrator, and review of termination reports, that LPN #1 and LPN #3 were both terminated from the facility on 10/22/18, for failure to administer insulin as ordered and false documentation. 11) The SA validated that all corrective measures to remove the IJ were completed as of 10/22/18, and the IJ removed 10/23/18, prior to state entrance on 10/24/18. Based on the facility's corrective measures, that were completed on 10/22/18, prior to the SA entrance on 10/24/18, the IJ will be PNC.

Based on observation, record review, facility policy review, and staff and resident interviews, the facility failed to follow a resident's Diabetes Care Plan to administer medication as ordered for a known diabetic who was non-compliant with a diabetic diet. The resident did not receive routine and sliding scale insulin as ordered/care planned. This affected one (1) of five (5) Residents reviewed for care plans, Resident #1. The facility's failure to follow the care plan to provide Insulin as ordered, resulted in Resident #1's Blood Glucose level increasing to over 600 milligrams per deciliter (mg/dL). Addition insulin was ordered/administered, and the resident was transferred to the emergency room for further treatment. This placed Resident #1, and other residents who received insulin, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was identified to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/18/18, when the facility failed to ensure Resident #1 received routine and sliding scale Insulin per care plan, resulting in further treatment and transfer to the ER for further evaluation and treatment. On 10/26/18 at 3:30 PM, the Administrator was notified of the IJ and SQC. The facility provided the SA with corrective measures to remove the IJ on 10/27/18, in which the facility alleged all corrective measures were completed as of 10/22/18, and the removal of the IJ on 10/23/18. Based on the completion of corrective measures on 10/22/18, prior to the SA entrance on 10/24/18, the SA validated the facility's corrective measures and determined the IJ to be Past Non-compliance and removed on 10/23/18. Findings include: A review of the Facility Policy entitled, Using the Care Plan, dated (MONTH) 1, 2000, revealed: It is the policy of this facility that the care plan be used in developing the resident's daily care routines. 5. Daily care and documentation must be consistent with the resident's care plan. Review of the Care Plans-Comprehensive policy, dated (MONTH) 1, 2000, revealed the policy to develop and maintain a comprehensive care plan for each resident and the care plan is designed to prevent declines and enhance optimal functioning of the resident. A review of Resident #1's Care Plan, initiated 5/16/18, revealed, I have Diabetes Mellitus. Interventions included: Diabetes medication as ordered by the doctor, Monitor/document for side effects and effectiveness, and Fasting Serum Blood Sugar/ accuchecks as ordered by the doctor. Resident #1's care plan, initiated 9/5/18, and revised 9/20/18, revealed she was non-compliant with her diet. Review of a facility report revealed an investigation was initiated on 10/19/18, related to Resident #1's elevated blood glucose above 600 mg/dL, and determined LPN #1 and LPN #3 did not give insulin to Resident #1 as ordered. Both nurses stated they knew blood glucose was elevated but forgot to give the scheduled insulin, even though they recorded insulin as given on the Medication Administration Record [REDACTED]. A review of Resident #1's physician's orders for (MONTH) (YEAR), revealed orders dated 10/18/18, for Humalog solution 100 unit/milliliter (ml)- inject as per sliding scale: if 0-150=zero (0) units of insulin; 151-200=3 units; 201-250=5 units; 251-300=6 units; 301-350=10 units; 351-400=15 units; 401-450=18 units; 451-500=21 units; 501-999=zero (0) units Notify MD, administer subcutaneously every four (4) hours. Orders included Insulin [MEDICATION NAME] ([MEDICATION NAME]) Solution 100 unit/ml-inject 15 units subcutaneously once daily (The Medication Administration Record [REDACTED] Review of the face sheet revealed the facility admitted Resident #1 on 5/14/18, with a re-admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. In an interview on 10/25/18 at 4:20 PM, LPN #4 stated Resident #1's Blood Sugar would probably be high because the resident went to the dollar store today and came back with a bag of snacks. She stated Resident #1's blood sugars are up and down and never stable. She confirmed the non-adherence to a diabetic diet. Observation and interview with Resident #1 on 10/25/18 at 4:45 PM, revealed she didn't receive any insulin the day she returned to the facility from the hospital (10/18/18), until the morning of 10/19/18. She stated the reason she went to the hospital on [DATE], was because she didn't get her insulin like she was supposed to. Observation, prior to the arrival of supper trays, around 5:00 PM, revealed Resident #1 getting snacks from the vending machine. Interview with LPN #2 on 10/30/18 at 4:30 PM, revealed she obtained Resident #1's blood sugar on 10/19/18 at 7:30 AM, and the resident told her that the blood sugar was going to be high because she had not received any of her insulin since she had returned to the facility, the day before. LPN #2 stated Resident #1's Blood Sugar was 600 mg/dL at 7:30 AM. She stated she notified the Charge Nurse. LPN #2 stated the Physician ordered 15 units of Humalog insulin, and when the Blood Sugar was re-checked in one (1) hour, it remained at 600 mg/dL. She stated a second order of 15 units of Humalog was obtained and administered. She stated the third blood sugar check around 11:30 AM, remained at 600 mg/dL and the resident was sent to the ER for further treatment. Interview with RN #1, Charge Nurse, on 10/26/18 at 1:00 PM, revealed when Resident #1's blood sugar was checked for the third time on 10/19/18 around 11:30 AM, and it remained at 600 mg/dL, she was symptomatic with shortness of breath, decreased breath sounds in the lower lungs, oxygen saturation in the 80s, and her color was pale and ashy. RN #1 stated orders were received to send Resident #1 to the ER for further evaluation and treatment. RN #1 stated she notified the Director of Nursing (DON) of what Resident #1 said about not getting her insulin. Interview with the Director of Nursing (DON) on 10/24/18 at 5:45 PM, revealed she investigated the resident's statement of not receiving the insulin, as ordered/care planned, and determined LPN #1 didn't give Resident #1's 8:00 PM routine insulin on 10/18/18, and LPN #3 didn't give sliding scale insulin on 10/19/18 at 4:00 AM, when the blood sugar was 500 mg/dL. The DON confirmed Resident #1's care plan was not followed as she didn't receive the medication as ordered. On 10/26/18 at 12:38 PM, a telephone interview with LPN #3 revealed she did not administer the sliding scale insulin on 10/19/18 at 4:00 AM, according to Resident #1's orders and care plan. LPN #3 stated she got busy and forgot to give the insulin. On 10/29/18 at 12:45 PM, LPN #1 confirmed during a telephone interview, that administering insulin is a part of Resident #1's care plan. She stated she didn't administer the 8:00 PM routine insulin on 10/18/18, for Resident #1. LPN #1 confirmed Resident #1 had eaten an oatmeal cream pie shortly before 11:00 PM on 10/18/18, and had asked for another one, acknowledging the non-compliance to her diet. Per the investigative report, LPN #1's statement to the DON on 10/19/18 at 2:00 PM, revealed that she told Resident #1 she didn't need the oatmeal cream pie because her blood sugar was already elevated. The statement revealed LPN #1 did not give Resident #1's routine [MEDICATION NAME] on 10/18/18 at 8:00 PM, per orders and care plan. The facility provided the following corrective measures to remove the IJ, on 10/27/18: Brief Summary of Event: At 3:30 PM on Friday, 10/26/2018, the state complaint surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #1, who is a known diabetic with a history of noncompliance with diet, not receiving insulin as ordered by the Physician. Resident #1 was readmitted to the facility on (MONTH) 18, (YEAR) at 3:40 PM, with orders for [MEDICATION NAME] 15 units subcutaneously (subq) at bedtime, Humalog 5 units subq three (3) times daily before meals. Humalog sliding scale subq every four (4) hours as follows: <151 give zero (0) units, < 70 use hypoglycemic protocol, 151-200 give three (3) units, 201-250 give five (5) units, 251-300 give six (6) units, 301-350 give 10 units, 351-400 give 15 units, 401-450 give 18 units, 451-500 give 21 units, >500 give zero (0) units and contact the Medical Doctor (MD). 1. On (MONTH) 19, (YEAR) at 8:00 AM, LPN #2 administered routine insulin to Resident #1. Resident #1 stated to LPN #2 that her blood sugar may be high because she had not gotten any insulin since she had returned to the facility the previous day. LPN #2 notified the DON on (MONTH) 19, (YEAR) at approximately 9:30 AM about Resident #1's statement regarding not receiving insulin. The DON initiated an investigation at this time. 2. On (MONTH) 19, (YEAR) at 9:30 AM and 10:30 AM, Resident #1's glucose readings were noted to be 600+ by Registered Nurse #1 (RN). RN #1 contacted Physician #1, who is also the facility Medical Director (MD), each time with new orders given each time to administer Humalog 15 units subq now and recheck glucose in one (1) hour. 3. On (MONTH) 19, (YEAR) at 11:30 AM, RN #1 rechecked glucose with a reading noted of 600+. RN #1 assessed Resident #1, who had become symptomatic with Shortness of Breath, Oxygen Saturation of 80 percent and pale skin color. RN #1 contacted the MD at 11:33 AM, and received an order to transfer Resident #1 to the emergency room (ER) for further evaluation and treatment of [REDACTED].#1 left the facility by ambulance at 11:45 AM. 4. On (MONTH) 19, (YEAR), Resident #1 was noted to have a glucose of 296 and a Sodium level of 125 millimoles per liter (mmol/l) per ER records. Resident #1 did not receive any treatment for [REDACTED]. The ER could not get any intravenous (IV) access on Resident #1 to treat the [MEDICAL CONDITION]. Resident #1 was then transferred at 3:18 p.m. to another hospital for treatment and was admitted with a [DIAGNOSES REDACTED]. 5. On (MONTH) 19, (YEAR) at approximately 2:45 PM, the DON discovered through her interviews with LPNs #1 and #3, that Resident #1 had not received the routine order of [MEDICATION NAME] 15 units due at 8:00 PM on (MONTH) 18, (YEAR), by LPN #3, and Resident #1 had not received Humalog 21 units at 4:00 AM on (MONTH) 19, (YEAR), by LPN #1, for a blood glucose reading of 500. Facility Actions: 1) On (MONTH) 19, (YEAR) at 3:30 PM, both LPN #1 and LPN #3 were suspended by the DON and the Facility Administrator pending investigation regarding significant medication errors with insulin administration. 2) On (MONTH) 19, (YEAR) at 4:12 PM, a message was left on the Mississippi Department of Health hotline by the Facility Administrator regarding a significant medication error with insulin administration. 3) On (MONTH) 19, (YEAR) at 4:30 PM, a 100 percent (%) audit of all residents with insulin orders, for a total of 10 residents, was completed by the DON to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) On (MONTH) 19, (YEAR) at 5:00 PM, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON. In-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistants (CNAs)- 11 of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1) and Social Services - one (1) of one (1). * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. The following staff were present at the in-service: RNs - six (6) of seven (7), LPNs - seven (7) of seven (7), Certified Nursing Assistant - 16 of 20, Social Services - one (1) of one (1), Administrator - one (1) of one (1), Medical Records - one (1) of one (1). * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. The following staff were present at the in-service: RNs - three (3) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistant - eight (8) of 20, Administrator - one (1) of one (1), Medical Records - one (1) of one (1). No clinical staff will be allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which includes new hires: this will be monitored by the facility Administrator. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. The following staff were present at the in-service initiated on (MONTH) 19, (YEAR) at 5:00 PM by the DON: RNs - six (6) of seven (7), LPNs - six (6) of seven (7), Certified Nursing Assistants - 17 of 20, Administrator - one (1) of one (1), Housekeeping - three (3) of six (6), Dietary - four (4) of seven (7), Business Office Manager - zero (0) of one (1), Social Services - one (1) of one (1), Life Connections - zero (0) of one (1), Therapy - zero (0) of 18, Medical Records - one (1) of one (1). No staff will be allowed to work until in-serviced on abuse and neglect policy and procedure, which includes new hires; this will be monitored by facility Administrator. 5) On (MONTH) 19, (YEAR) at 3:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON on (MONTH) 19, (YEAR) was discussed. In-services initiated by the DON were discussed. 6) On (MONTH) 22, (YEAR) at 1:51 PM, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) On (MONTH) 22, (YEAR) at 3:30 PM, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1, and false documentation. 8) On (MONTH) 22, (YEAR) at 10:00 AM, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin and to note if the residents had any concerns with getting their insulin or blood sugar checks. No concerns were noted with the interviews. 9) On (MONTH) 22, (YEAR), The Attorney General's Office online report was submitted at 3:32 PM, by the Facility Administrator, regarding significant medication errors with insulin administration and false documentation. 10) LPN #1 and LPN #3 were both terminated from the facility on (MONTH) 22, (YEAR), by the Facility Administrator, for failure to administer insulin as ordered and false documentation. 11) The facility alleges that all corrective measures have been completed as of (MONTH) 22, (YEAR) and the jeopardy removed as of (MONTH) 23, (YEAR). The State Agency (SA) validated the facility's corrective measures through interviews, record reviews, policy reviews, facility documentation, and review of in-service and QAPI sign-in sheets. 1) The SA validated through interview with the DON and review of personnel records that both LPN #1 and LPN #3 were suspended on 10/19/19. 2) The SA validated through documentation from the Mississippi Department of Health, a report was made on 10/19/18, regarding a significant medication error with insulin administration. 3) The SA validated through interview with the DON and facility documentation, that on 10/19/18, a 100 % audit of all residents with insulin orders, for a total of 10 residents, was completed to ensure there were no discrepancies noted with the MAR indicated [REDACTED]. No concerns were noted. 4) The SA validated through interview with staff and review of in-service sign in sheets that on 10/19/18, in-services regarding medication errors/following MD orders, false documentation, and care plans for all clinical staff members, and abuse/neglect for all staff members were initiated by the DON and that the staff documented were in attendance. The SA validated that the in-service content included: * Medication errors- All medications are to be administered as ordered by the physician. If a medication error occurs, a medication error report should be completed with physician and family notification. * False Documentation - All medications administered should be documented after administration to the resident. No medication should be documented if not given to the resident. You should not document any care that was not performed or provided to the resident. * Care plans - All care plans are to be followed at all times. Care plans must be updated with any changes with the residents. No clinical staff was allowed to work until in-serviced on Medication errors, False documentation, and Care Plans, which included new hires. * Abuse/neglect - Types of abuse/neglect. Not administering medications to a resident when ordered is considered neglect. No staff was allowed to work until in-serviced on abuse and neglect policy and procedure, which included new hires 5) The SA validated through random interviews with participating staff and review of the sign-in sheet that on 10/19/18, an emergency Quality Assurance Improvement Meeting (QAPI) was held per phone with the Medical Director and QAPI members, including the Medical Director, DON, and Facility Administrator. The Medical Director was notified of the investigation of insulin not being administered as ordered. Possible termination of LPN #1 and LPN #3 was discussed. An audit performed by the DON and in-services initiated by the DON were discussed. 6) The SA validated through random interviews with attendees and review of the sign-in sheet that on 10/22/18, an emergency QAPI meeting was held with the Medical Director, DON, Facility Administrator, Regional Nurse Consultant, Minimum Data Set (MDS) Nurse #1, and Social Service Director in attendance. Facility policies including medication administration, abuse/neglect, initiating and following care plans, and documentation were reviewed with no changes made. Recommendations at that time included the DON to monitor glucose checks and insulin administration and refer to QAPI for any discrepancies. 7) The SA validated through interview with the DON, that on 10/22/18, complaints were filed by the DON with the Mississippi Board of Nursing for LPN #1 and LPN #3, regarding not administering insulin as ordered to Resident #1 and false documentation. 8) The SA validated through interview with staff, Social Services documentation, and random interview with residents who received insulin, that on 10/22/18, the Social Service Director interviewed six (6) residents that receive insulin to ensure that they had received insulin, with no concerns of receiving their insulin or blood sugar checks. 9) The SA validated through review of documentation and interview with the Administrator, that on 10/22/18, the Attorney General's Office online report was submitted, regarding significant medication errors with insulin administration and false documentation. 10) The SA validated through interview with the Administrator, and review of termination reports, that LPN #1 and LPN #3 were both terminated from the facility on 10/22/18, for failure to administer insulin as ordered and false documentation. 11) The SA validated that all corrective measures to remove the IJ were completed as of 10/22/18, and the IJ removed 10/23/18, prior to state entrance on 10/24/18. Based on the facility's corrective measures, that were completed on 10/22/18, prior to the SA entrance on 10/24/18, the IJ will be PNC.

Based on observation, staff interview, record interview, and policy review the facility failed to provide adequate supervision to prevent falls with injuries for one (1) of three (3) residents reviewed for falls. (Resident #2) Findings include: Resident #2 Review of the facility's policy entitled, "Fall Risk Management", dated February 22, 2012, documented, "Residents will be assessed for fall risk potential. Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness during care planning and as needed". Review of Resident #2's Accident Reports documented resident had ten (10) falls between 12/19/13-06/30/14. Resident #2 had 3-falls in December 2013, 3-fall in May 2014, 1-fall in April 2014, 2-falls in May 2014 with one (1) resulting in raised area to left forehead about a dime size, and 1-fall in June 2014 resulting in a skin tear to the left forearm measuring 7 cm by 5 cm and a skin tear to the right forearm measuring 1.2 cm by 0.5 cm. Review of Resident #2 "Incident Report" dated 05/08/14 at 7:20 AM documented when the staff assisted Resident #2 to bed, the resident had a reddened, raised area to the left forehead, tender to touch, with complaint of headache. It was documented that Resident #2 also had complaints of right wrist, knees and bilateral hip pain. Staff notified the Physician, and the physician ordered to send the resident to the hospital for evaluation. Immediately after this incident, the facility documented the resident's RP (Responsible Party) requested that the resident to be up and dressed for breakfast at 6 AM daily. Review of Resident #2 "Incident Report," dated 06/30/14 at 5:10 AM, documented "resident lying on back in floor beside bed on floor mat, alarm not sounding, noted 2 skin tears one to left arm and one to right arm, resident confused and agitated. Skin tear left forearm 7 cm x 0.5 cm, skin tear to right forearm 1.2 cm x 0.5 cm". The facility failed to document any post incident actions or interventions for Resident #2's fall. Review of Resident #2's EMAR (Electronic Medication Administration Record) documented every hour visual checks while in bed due to history of falls. The facility failed to document if Resident #2's bed or chair alarms were checked daily. During an interview with the Director of Nursing (DON) on 07/09/14 at 5:00 PM, the DON acknowledged Resident #2's falls and said, "We have a bed and chair alarm. I know when it sounds, she is already up. Her falls have been her rolling out of bed. She has long legs and she kind of throws them out of the bed. The alarm that was not working was replaced. I think it was the battery. The alarms are checked daily". Interview with the DON on 07/09/14 at 5:30 PM confirmed the facility had no documentation of bed or chair alarm checks. The DON said the resident got checked every hour, but the EMAR did not show the alarm check. Interview with the Administrator, on 07/10/14 at 3:00 PM, revealed Resident #2 had a history of [REDACTED].#2 had not suffered a fall since she was placed on a scoop mattress. The DON contradicted the Administrator and stated the resident had a fall in June (2014) (after implementation of the scoop mattress).