Every finding on record at Mary Gran Nursing Center

Based on record review and staff, Medical Director #1, Cardiologist, LifeVest Resident Representative and LifeVest Technician interviews, the facility failed to consult with Medical Director #1 when Resident #119's LifeVest (an external defibrillator designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) delivered treatment shocks to her multiple times in the early morning hours on [DATE]. The LifeVest Resident Representative contacted Resident #119's Cardiologist on [DATE] about Resident #119's severe episodes of ventricular tachycardia, a life-threatening rapid heart rate. The Cardiologist called the facility and requested to talk to the Medical Director. The Cardiologist recommended that the resident be sent to the hospital for evaluation. The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Other significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for notification of change (Resident #119).Immediate jeopardy began on [DATE] when Resident #119 received multiple treatment shocks from the external defibrillator device and the facility failed to consult the physician immediately. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings included:Review of the manufacturer's information and the instructional videos for the LifeVest external defibrillator revealed that the device is prescribed for residents at risk for sudden cardiac death, a condition that occurs without warning with no signs that something is about to happen due to an electrical malfunction of the heart causing a dangerously fast heartbeat with no signs or symptoms. The LifeVest uses electrodes to continuously monitor the heart's electrical activity and detect dangerous heart rhythms, such as ventricular tachycardia and ventricular fibrillation. The device is designed to deliver an electrical shock to the heart when an abnormal rhythm is detected to restore a normal heart rhythm. The manufacturer's instructions indicated that if a treatment shock is delivered, the physician is to be called immediately, and an announcement is made by the device with this instruction. If the vest discharges, it means either the person has an unstable arrythmia (heartbeat) requiring immediate physician attention, or the device is malfunctioning. Both require medical evaluation as soon as possible.An interview with the LifeVest Technician on [DATE] at 5:00 PM revealed that the device does not provide continuous real time monitoring by a medical professional. The LifeVest Technician stated that the device was set with parameters and if the heart rate was above the set parameter, the device alarmed. The information from the device went into a server which could be reviewed by the physician. The technician stated that if a shock was delivered, it was recorded on the downloaded information. The technician stated that the information from the device was downloaded into the system every 24 hours, however there were sometimes issues with connectivity. The technician indicated that the blue gel was released prior to a shock being delivered. A button can be pressed to delay the shock from being delivered. 5 shocks are administered, then if more shocks are indicated they will be delivered based on the heart rhythm. The technician stated that if an abnormal heart rhythm was detected, the device emitted a siren alarm which was loud and identifiable. If the device administered a shock, the blue gel was released onto the skin. The technician stated that if the device continuously sounded, the physician and the device manufacturer should have been notified right away to check the equipment. A technician is available 24 hours per day 7 days per week to walk through issues with the device and if the technician is unable to resolve the issue via phone, a technician will come out within 24 hours to fix it or replace the device. Resident #119 was admitted on [DATE] with diagnosis which included ischemic cardiomyopathy (a condition that occurs when the heart muscle is damaged by lack of blood supply making it difficult for the heart to pump) requiring a LifeVest external defibrillator device, hypertensive heart disease, atrial fibrillation, coronary artery disease, chronic kidney disease with heart failure, acute on chronic systolic heart failure, and diabetes. Review of Resident #119's electronic record revealed a physician order dated [DATE] which indicated LifeVest was to be worn at all times every shift. Resident #119 was discharged from the nursing home to the hospital on [DATE] with a diagnosis of gastrointestinal hemorrhage and was readmitted on [DATE].A physician order revealed an order dated [DATE] indicated the LifeVest was to be worn at all times every shift. The order did not contain directives for when to notify the provider.An interview conducted with Nurse Aide (NA) #2 on [DATE] at 10:06 AM revealed that she was assigned to Resident #119 on [DATE] from 11:00 PM to 7:00 AM. NA #2 stated that Resident #119 had a device that she thought was to kick start the heart. NA #2 stated that she recalled on the night of [DATE] Resident #119's LifeVest device from 11:00 PM to 7:00 AM was going off all night. NA #2 could not recall if the device was beeping or if it was another sound. NA #2 stated that she let Nurse #1 know that the device was sounding and she did not know what the nurse did about it or if the nurse went in to assess the resident. Attempts were made to interview Nurse #1 were unsuccessful with text messages sent on [DATE] at 2:16 PM and [DATE] at 12:31 PM with no return call received. Nurse #1 was an agency nurse that worked as needed at the facility and was assigned to Resident #119 on [DATE] from 7:00 PM to 7:00 PM. Nurse #1 no longer worked at the facility. A health status note dated [DATE] at 8:32 PM written by Nurse #5 revealed that the off going nurse from the 7:00 PM to 7:00 AM shift (Nurse #1) reported that Resident #119's LifeVest was shocking Resident #119 all through the night. The note indicated that Nurse #1 stated that she changed the battery for the LifeVest, and Resident #119 was fine. The note indicated that Nurse #5 immediately went to check Resident #119 and observed the resident was lying in bed with brown dried emesis on her gown and around her mouth. The note did not indicate that the physician was notified and there were no vital signs recorded. The note stated that Nurse #5 observed that the pads of the electrodes for the LifeVest had leaked gel onto Resident #119's skin and her upper body was covered in gel. Resident #119 was cleaned, and the electrode pads were replaced. LifeVest was placed back on the resident. Resident #119 was alert and responsive but grunting. Nurse #5 notified Support Nurse #1 of the situation. Resident #119 vomited again and did not eat during the shift. The oncoming nurse (Nurse #7) was informed of concerns with the LifeVest and that Resident #119 had vomited. An interview was conducted with Nurse #5 on [DATE] at 1:15 PM. Nurse #5 was assigned to Resident #119 frequently and was assigned to her on [DATE] from 7:00 AM to 7:00 PM. Nurse #5 indicated that Resident #119 had a LifeVest cardiac defibrillator device. Nurse #5 stated that on the morning of [DATE], she received in report from the off going night shift nurse (Nurse #1) that Resident #119's LifeVest device was shocking the resident all night and that the device was sounding all night. Nurse #5 stated she asked the off going nurse (Nurse #1) if she had notified the provider or assessed Resident #119 and was told no, she had not. Nurse #5 stated that Nurse #1 did not indicate why she had not notified the provider or assessed the resident when the shocks occurred. Nurse #5 stated she immediately went to the room and observed Resident #119 was soaked with the blue conducting gel on her chest and upper body from the LifeVest device. Nurse #5 stated she and the Nurse Aide cleaned the resident, obtained vital signs and reapplied the electrodes and the LifeVest device. Nurse #5 indicated she informed Support Nurse #1 what was reported to her regarding Resident #119's condition and being shocked by the LifeVest. A follow up interview with Nurse #5 on [DATE] at 2:30 PM revealed that she did not notify the physician on [DATE] that Resident #119 was shocked by the LifeVest during the night shift. Nurse #5 stated that she thought Support Nurse #1 was going to notify the provider, and that she did not follow up to ensure that the physician was notified. Voice mail messages and text messages were sent to Nurse #7 on [DATE] at 11:25 AM, [DATE] at 12:24 PM, and [DATE] at 12:35 PM. Nurse #7 was assigned to Resident #119 on [DATE] from 7:00 PM to 7:00 AM. Nurse #7 was an agency nurse that was no longer employed at the facility. An interview with Support Nurse #1 on [DATE] at 12:05 PM revealed she recalled that Resident #119 had a LifeVest device. Support Nurse #1 stated that if the blue gel was released, a shock was administered. Support Nurse#1 stated that on the morning of [DATE], Resident #119 had blue gel on her chest which indicated that she received a shock. Support Nurse #1 stated the provider should have been notified that the LifeVest was sounding and a shock was administered. Support Nurse #1 stated the resident should have been assessed including vital signs and the provider should have been notified immediately when the shock occurred or as soon as possible after it was discovered that it occurred. Support Nurse #1 stated she did not notify a provider on [DATE] that Resident #119 received a shock from the LifeVest during the early morning hours and explained that she thought Nurse #5 would have done this. Support Nurse #1 stated she should have followed up with Nurse #5 to be sure that she had notified the provider of the shock from the LifeVest. Support Nurse #1 stated she was responsible for managing the residents on 3 halls, so she thought that the floor nurses were responsible for notifying the provider of changes in condition. An interview conducted with Nurse #8 on [DATE] at 11:41 AM indicated that she was assigned to Resident #119 on [DATE] from 7:00 AM to 7:00 PM and was assigned to the resident frequently. Nurse #8 stated that she did not recall any significant changes in Resident #119's condition on [DATE] from 7:00 AM to 7:00 PM. Nurse #8 stated that she did not think that Resident #119 being slow to respond to verbal stimuli, not eating and not showing interest could have been symptoms of a change in condition that required notifying the provider. An interview with the LifeVest Resident Representative on [DATE] at 4:30 PM revealed she had access to her patients' device information and shared alerts and other information with the doctors and cardiologists. She indicated that she called Resident #119's Cardiologist on [DATE] and informed him that the resident had a run of ventricular tachycardia (v tach), a dangerous rapid heart rhythm. The Representative stated that if a resident had a run of v tach greater than 1 minute, a shock was delivered. The device can deliver up to 5 shocks. The Representative stated that the data recorded from Resident #119's LifeVest on [DATE] just after midnight indicated that v tach was detected. The representative stated that there were multiple episodes of v tach on the night of [DATE] and when she received that information, she reached out to the Cardiologist. An interview with the Cardiologist on [DATE] at 3:36 PM revealed that the LifeVest device is designed to detect dangerous arrhythmia including ventricular tachycardia and ventricular fibrillation and deliver an electrical shock to restore the heart to a normal rhythm. The Cardiologist stated that the physician should be notified when the device delivered a shock and if unable to contact the physician, the resident should immediately be sent to the hospital for evaluation. The Cardiologist stated that he received a call on [DATE] from the LifeVest Resident Representative who stated that Resident #119 was shocked by the device during the early morning hours on [DATE] when the abnormal heart rhythm ventricular tachycardia, a dangerous rapid heart rate, was detected. The Cardiologist stated he immediately called the facility on [DATE] and recommended that Resident #119 be sent to the hospital for evaluation. A health status note dated [DATE] at 5:00 PM written by Support Nurse #1 indicated that the facility received a call from the Cardiologist who stated that a remotely acquired EKG (electrocardiogram) strip received from the LifeVest manufacturing company showed severe episode of ventricular tachycardia (a dangerous rapid heart rhythm). The Cardiologist spoke with Medical Director #1. Upon the Cardiologist's recommendation due to the resident not being stable, Medical Director #1 gave an order to send Resident #119 to the emergency department for further evaluation. Emergency Medical Services was contacted, and Resident #119 was transported to the hospital. Support Nurse #1 was interviewed on [DATE] at 12:05 PM. Support Nurse #1 stated the Cardiologist called the facility on [DATE] and was adamant that he spoke with Medical Director #1 regarding Resident #119. Support Nurse #1 stated she immediately went and informed Medical Director #1, who was in the building at the time, that the Cardiologist was on the phone and requested to speak with him. After speaking with the Cardiologist, Medical Director #1 gave the order to send Resident #119 to the hospital due to a dangerous heart arrhythmia. An interview with Medical Director #1 on [DATE] at 3:52 PM revealed that he had just started in the position at the facility in early February 2025 when the incident with Resident #119 occurred. Medical Director #1 stated he was not notified that Resident #119's LifeVest had alarmed or shocked her due to arrhythmia on [DATE]. Medical Director #1 stated when the LifeVest alarm sounded due to an arrhythmia, the resident should have been sent to the emergency room, and the provider should have been notified. Medical Director #1 stated that when the device shocked Resident #119, the nurse should have immediately assessed the resident, sent her to the hospital for evaluation and notified the provider. When the LifeVest discharges an electrical shock to the resident, it means the person had an unstable arrythmia requiring immediate physician attention, or the device malfunctioned and administered a shock when it was not required. Both require evaluation. Review of an Emergency Department (ED) report for hospital #1 dated [DATE] indicated that Resident #119 presented to the hospital with a LifeVest device on. Resident #119 presented after the LifeVest detected a cardiac arrhythmia and the cardiologist requested evaluation at the nearest emergency room. Resident #119 was somnolent, difficult to understand with closed eyes and was unresponsive on presentation to the ED. Resident #119 was noted to have 4+ pitting edema (a type of swelling where when pressure is applied on the area a temporary indentation or pit remains for a short time after the pressure is released) from toes to abdomen. The impression indicated that Resident #119 was evaluated due to a cardiac arrhythmia and was significantly fluid overloaded with severe congestive heart failure. Resident #119 was transferred to hospital #2 for further evaluation and monitoring. Review of the discharge summary for hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Resident #119's discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. Review of Resident #119's certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Other significant condition contributing to death was cardiogenic shock, a life-threatening condition in which the heart suddenly can't pump enough blood characterized by sudden, rapid heartbeat (tachycardia). An interview was conducted on [DATE] at 2:20 PM with the Director of Nursing (DON) and the Clinical Services Director. The DON and Clinical Services Director stated that they expected that if something occurred such as the LifeVest delivered a shock, the provider would be notified immediately for further instructions. The DON and Clinical Services Director stated the physician should have been notified immediately when the LifeVest alarmed. The DON was unable to state why the physician was not notified other than that the nurse that worked on the night of [DATE] was an agency nurse who no longer worked at the facility. The DON stated that she expected that the nurses recognized and reported changes in condition to the medical provider. The Administrator was notified of immediate jeopardy on [DATE] at 12:10 PM.The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.The facility failed to ensure the physician was notified of a significant change for Resident #119.Resident #119's LifeVest shocked her multiple times in the early morning hours (beginning shortly after midnight) of [DATE]. Nurse #1 observed the device deliver shocks to the resident and did not notify the physician. The physician was not notified until [DATE] when Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia.Resident #119 did not return to the facility after discharge on [DATE]. Facility has not been able to contact Nurse #1, and she is no longer working in the facility. The Administrator and Director of Nursing attempted to contact Nurse #1 on [DATE], but the number was not operational.On [DATE], the facility initiated a comprehensive response to address the identified noncompliance related to failure to notify provider of an acute change in Resident # 119's condition. The Direct care nurses conducted an immediate assessment of 100% of current residents to identify any acute changes in condition that had not been communicated to the appropriate medical provider. This included symptoms or signs that were:- Acute or sudden in onset - Markedly more severe than usual - Unrelieved by previously prescribed measures - Indicative of respiratory distress (e.g., difficulty breathing, low oxygen saturation, new onset cough or congestion, decreased appetite)During the above audit, it is noted that no residents were found to be using wearable cardiac devices.The audit was completed on [DATE]. There were 5 residents identified with acute changes in condition. For each of these residents, the provider was notified, and appropriate medical orders were implemented by the direct care staff on [DATE].Additionally, on [DATE], the Director of Nursing (DON) reviewed the progress notes to include the E -interact transfer and change in condition assessments for all resident transfers to an acute care hospital within the past 30 days to ensure provider notification had occurred for any acute change in condition. The audit confirmed that provider notification was completed timely for 14 out of 14 residents.Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. To prevent recurrence, the DON began in-servicing all licensed nurses (Registered Nurses and Licensed Practical Nurses) and certified Nurse Aides (CNAs), including full-time, part-time, PRN (as needed), and agency staff, on [DATE]. The training emphasized the importance of timely provider notification for any acute change in condition. This included symptoms or signs that were:- Acute or sudden in onset - Markedly more severe than usual - Unrelieved by previously prescribed measures - Indicative of respiratory distress (e.g., difficulty breathing, low oxygen saturation, new onset cough or congestion, decreased appetite) Specific training for a resident with a LifeVest was if a person's LifeVest discharges, it means the person may have an unstable arrythmia or that the device is malfunctioning or both, and both of these would require immediate physician notification. Training for licensed nursing staff began on [DATE] and includes viewing the 26-minute LifeVest instructional video designed for both patients and caregivers. Following the video, the Director of Staff Education utilized a competency checklist to validate staff understanding. This competency checklist includes verbalization of understanding of the knowledge of the LifeVest purpose and function, application and maintenance, emergency response, communication and education as well as the location and contents of the quick reference guide for LifeVest. This training initiative was coordinated by the Director of Nursing. All current staff must complete this training by [DATE] to care for residents with wearable cardiac devices. Staff who do not complete the training by [DATE] will not be permitted to work until the training is completed.The Director of Nursing and the Director of Staff Development will do a daily reconciliation of the schedule to ensure all licensed staff and CNAs have completed the training as indicated above.This in-service training has been incorporated into the orientation program for all new facility and agency staff.No staff shall work without this training after [DATE]. Alleged date of Immediate Jeopardy removal: [DATE]The immediate jeopardy removal plan was validated on [DATE]. A sample of staff including the Administrator, Director of Nursing, Staff Development Director, nurses, nurse aides and medication aides were interviewed regarding in-services they received related to the deficient practice. All staff interviewed stated they had received in-service training regarding the LifeVest purpose and function, application and maintenance and emergency response. Validation indicated that licensed nurses had completed a competency checklist regarding the LifeVest device and the indications for when to notify the physician. The nurses that were interviewed indicated that they had received training regarding timely provider notification of acute changes in condition. The immediate jeopardy was removed on [DATE].

Based on record review and staff, Medical Director #1, Cardiologist, LifeVest technician and LifeVest patient representative interviews, the facility failed to obtain physician directives for staff about what to do when the LifeVest delivered a shock, identify the seriousness of Resident #119's cardiac status and the need for a comprehensive medical evaluation when a LifeVest (an external defibrillator device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) shocked the resident multiple times in the early morning hours (beginning shortly after midnight) of 2/11/25. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. From 2/11/25 through 2/13/25 the facility failed to consult with the physician regarding the LifeVest having delivered treatment shocks to the resident and provide ongoing nursing assessment. According to the manufacturer's instructions, a resident with a LifeVest is to be evaluated by a physician for potential arrhythmia once the vest delivers a treatment shock. On 2/13/25, Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate). The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated 2/27/25 indicated that Resident #119 was admitted to the critical care unit on 2/13/25 and was deceased on 2/27/25. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated 2/27/25 at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Another significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for professional standards (#119).Immediate jeopardy began on 2/11/25 when Resident #119 received multiple treatment shocks from the external defibrillator device which meant the resident possibly had an unstable arrythmia (irregular heart rhythm that means the heart is not effectively pumping enough blood to the body's vital organs increasing the risk of complications like heart failure, stroke, or even sudden cardiac arrest) and staff failed to identify the seriousness of Resident #119's cardiac status which required immediate evaluation by a medical provider. Immediate jeopardy was removed on 8/12/25 when the facility implemented an acceptable plan of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings included:Review of the manufacturer's information and the instructional videos for the LifeVest external defibrillator revealed that the device is prescribed for residents at risk for sudden cardiac death, a condition that occurs without warning with no signs that something is about to happen due to an electrical malfunction of the heart causing a dangerously fast heartbeat with no signs or symptoms. The LifeVest uses electrodes to continuously monitor the heart's electrical activity and detect dangerous heart rhythms, such as ventricular tachycardia and ventricular fibrillation. The device is designed to deliver an electrical shock to the heart when an abnormal rhythm is detected to restore a normal heart rhythm. The manufacturer's instructions indicated that if a treatment shock is delivered, the physician is to be called immediately, and an announcement is made by the device with this instruction. If the vest discharges, it means either the person has an unstable arrythmia (heartbeat) requiring immediate physician attention, or the device is malfunctioning. Both must have medical evaluations as soon as possible. The LifeVest device should be removed to bathe, shower or change the garment. The device comes with 2 batteries, and 1 battery is always to be charged while using the other. Changing and charging the batteries was to occur at the same time each day. The monitor, electrode belt or charger is not to be put in water and should not get wet. The data from the device is to be downloaded as directed by the device or at least weekly. If data is not sent in for greater than 7 days, a prompt appears on the monitor which states time to send data.An interview with the LifeVest Manufacturer Technician on 8/6/25 at 5:00 PM revealed that the device does not provide continuous monitoring. The LifeVest Manufacturer Technician stated that the device was set with parameters and if the heart rate was above the set parameter, the device alarms. The information from the device goes into a server which can be reviewed by the physician. The technician stated that if a shock was delivered, it was recorded on the downloaded information. The technician stated that the information from the device was downloaded into the system every 24 hours, however there are sometimes issues with connectivity. The technician indicated that the gel was released prior to a shock being delivered. A button can be pressed to delay the shock from being delivered. Five shocks are administered, then if more shocks are indicated they will be delivered based on the heart rhythm. The technician stated that if an abnormal heart rhythm was detected, the device emits a siren alarm which was loud and identifiable. If the device administered a shock, the blue gel was released onto the skin. The technician stated that if the device continuously sounded, the physician and the device manufacturer should be notified to check the equipment. A technician was available 24 hours per day 7 days per week to walk through issues with the device and if the technician was unable to resolve the issue via phone, a technician will come out within 24 hours to fix it or replace the device. Resident #119 was admitted on [DATE] with diagnosis which included ischemic cardiomyopathy (a condition that occurs when the heart muscle is damaged by lack of blood supply making it difficult for the heart to pump) requiring a LifeVest external defibrillator device, hypertensive heart disease, atrial fibrillation, coronary artery disease, chronic kidney disease with heart failure, acute on chronic systolic heart failure, and diabetes. Resident #119's electronic record revealed a physician order dated 10/17/24 which indicated LifeVest was to be worn at all times every shift. Resident #119's care plan dated 10/18/24 indicated that the resident had altered cardiovascular status related to cardiomyopathy and coronary artery disease and wore a LifeVest. The goal indicated that Resident #119 would be free from signs or symptoms of complications of cardiac problems through the next review date. Interventions included assess for chest pain every shift, enforce the need to call for assistance if pain starts, assess for shortness of breath and cyanosis every shift, monitor/document/report to MD changes in lung sounds, edema (swelling) and changes in weight, monitor/document/report to the physician as needed any signs or symptoms of coronary artery disease: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color or warmth of extremities. An additional care plan problem indicated that Resident #119 had a problem of atrial fibrillation (abnormal heart rhythm) with increased risk of stroke and or heart failure. Interventions stated that Resident #119 was to be assessed for chest pain or discomfort every shift and vital signs were to be obtained weekly per protocol. There were no interventions listed in the care plan for management of the LifeVest device, indications when the resident required medical attention or what to do after a treatment shock was delivered. Resident #119 was discharged from the nursing home to the hospital on 1/4/25. Resident #119 was diagnosed with lower gastrointestinal bleed and was readmitted on [DATE].Resident #119's physician order revealed an order dated 1/20/25 that indicated the LifeVest was to be worn at all times every shift. Resident #119's January and February 2025 Medication Administration Records (MAR) revealed the entry for the LifeVest to be worn at all times every shift was electronically signed for each shift. The MAR lacked directives for the LifeVest, including instructions to call the provider if the alarm sounded, remove the LifeVest for showers or baths, change and charge the battery every 24 hours, change and wash the garment every 1-2 days, manage post-treatment shocks, and download data weekly.Resident #119's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact, had no behavior, and the presence of a heart assistive device. Resident #119 was dependent on staff for toileting, transfers and wheelchair mobility, required moderate assistance with bed mobility and was non ambulatory. A physician progress note dated 1/27/25 by Medical Director #3 indicated Resident #119 was recently readmitted to the facility following hospitalization due to gastrointestinal bleed. The progress note indicated Resident #119 was full code status, had a LifeVest in place, was to be monitored closely and facility staff were to alert the medical staff with changes in condition. Vital signs were recorded in Resident #119's record on 2/10/25 at 3:36 PM as blood pressure 108/65, pulse 87 beats per minute, respirations 18 breaths per minute, and temperature 97.0.An interview was conducted with Nurse Aide (NA) #2 on 8/6/25 at 10:06 AM. It revealed that she was assigned to Resident #119 on 2/10/25 from 11:00 PM to 7:00 AM. NA #2 stated that Resident #119 had a device that she thought was to kick start the heart. NA #2 stated that she recalled on the night of 2/10/25 Resident #119's LifeVest device from 11:00 PM to 7:00 AM was going off all night. NA #2 could not recall if the device was beeping or if it was another sound. NA #2 stated that she let Nurse #1 know that the device was sounding and she did not know what the nurse did about it or if the nurse went in to assess the resident. Attempts were made to interview Nurse #1 were unsuccessful with text messages sent on 8/7/25 at 2:16 PM and 8/8/25 at 12:31 PM with no return call received. Nurse #1 was an agency nurse who worked as needed at the facility and was assigned to Resident #119 on 2/10/25 from 7:00 PM to 7:00 PM. Nurse #1 no longer worked at the facility. An interview conducted with NA #4 on 8/6/25 at 2:45 PM revealed that she was assigned to Resident #119 on 2/11/25 from 7:00 AM to 3:00 PM. NA #4 stated that Nurse #5 asked her to assist with cleaning Resident #119 on the morning of 2/11/25. NA #4 stated she observed blue gel from the LifeVest all over Resident #119's upper body. NA #4 stated she and Nurse #5 cleaned Resident #119 and reapplied the LifeVest. A health status note dated 2/11/25 at 8:32 PM written by Nurse #5 was a summary note that described the events during the 7:00 AM to 7:00 PM shift. Nurse #5 stated in morning report that day, the off going nurse from the 7:00 PM to 7:00 AM shift (Nurse #1) reported that Resident #119's LifeVest was shocking Resident #119 all through the night. The note indicated that Nurse #1 stated that she changed the battery for the LifeVest, and Resident #119 was fine. The note indicated that Nurse #5 immediately went to check Resident #119 and observed the resident was lying in bed with brown dried emesis on her gown and around her mouth. The note did not indicate that the physician was notified and there were no vital signs recorded. The note stated that Nurse #5 observed that the pads of the electrodes for the LifeVest had leaked gel onto Resident #119's skin and her upper body was covered in gel. Resident #119 was cleaned, and the electrode pads were replaced. LifeVest was placed back on the resident. Resident #119 was alert, responsive but grunting. The note indicated that the LifeVest monitor was beeping with a message which stated to replenish the gel. Nurse #5 notified Support Nurse #1 of the situation. The note stated that the LifeVest support technician was notified of the issues with the LifeVest and the technician attempted to do a system check without success because of internet connection issues. The technician informed Nurse #5 that a technician would come to the facility to check the LifeVest equipment later that day or the next day. Resident #119 vomited again and did not eat during the shift. The oncoming nurse (Nurse #7) was informed of concerns with the LifeVest and that Resident #119 had vomited. On 2/11/25 at 12:29 PM Resident #119's vital signs were, blood pressure 123/78, pulse 94 beats per minute, respirations 18 breaths per minute, and temperature 97.0.An interview was conducted with Nurse #5 on 8/6/25 at 1:15 PM. Nurse #5 was assigned to Resident #119 frequently and was assigned to her on 2/11/25 from 7:00 AM to 7:00 PM. Nurse #5 indicated that Resident #119 had a LifeVest cardiac defibrillator device. Nurse #5 stated that she was familiar with the LifeVest device as she had worked with one at another facility in the past. Nurse #5 indicated that the LifeVest device provided an alert if an irregular heart rate was detected and the screen on the device indicated what to do. Nurse #5 stated that electrodes are applied and attached to the vest that the resident wears at all times. Nurse #5 stated that on the morning of 2/11/25, she received in report from the off going night shift nurse (Nurse #1) that Resident #119's LifeVest device was shocking the resident all night and that the device was sounding all night. Nurse #5 stated she asked the off going nurse (Nurse #1) if she had notified the provider or assessed Resident #119 and was told no, she had not. Nurse #5 stated she immediately went to the room and observed Resident #119 was soaked, her LifeVest device was soaked with the blue conducting gel that was released when a shock was received. Nurse #5 stated she and the Nurse Aide cleaned the resident, obtained vital signs and reapplied the electrodes and the LifeVest device. Nurse #5 stated that there was a message on the device that indicated that shocks were delivered. Nurse #5 indicated she informed Support Nurse #1 what was reported to her regarding Resident #119's condition and being shocked by the LifeVest. Nurse #5 indicated that the gel was all over the resident and that the gel released when the device delivered a shock. A follow up interview with Nurse #5 on 8/7/25 at 2:30 PM revealed that she did not notify the physician on 2/11/25 that Resident #119 was shocked by the LifeVest during the night shift. Nurse #5 stated that she reported to Support Nurse #1 that the off going nurse (Nurse #1) stated Resident #119 was shocked by the device, and she thought Support Nurse #1 was going to notify the physician. Nurse #5 stated that she did follow up with Support Nurse #1 to ensure that the physician was notified that Resident #119 was shocked. An interview with Nurse Aide (NA) #7 on 8/8/25 at 1:20 PM revealed that she was assigned to Resident #119 regularly on the 3:00 PM to 11:00 PM shift and that she was assigned to her (Resident #119) on 2/11/25, 2/12/25 and 2/13/25. NA #7 indicated that Resident #119 was alert at first when she was admitted but she had become increasingly weak. NA #7 stated that Resident #119 had stopped feeding herself, required 2-person assistance with bed mobility, and was bed bound. NA #7 stated Resident #119 was unable to manage the LifeVest device. NA #7 indicated that she did not know anything about the LifeVest or what it did until the night of 2/11/25 when the technician came to the facility to change out the equipment. NA #7 stated that the technician informed her on 2/11/25, that the LifeVest device was a defibrillator that shocked the resident's heart if an abnormal heart rate was detected. NA #7 stated she was surprised when she found out this information as she had no idea about the seriousness of this device. Until 2/11/25, NA stated she just knew that Resident #119 was to always wear the LifeVest. An interview with the Staff Development Director (SDD) on 8/7/25 at 3:00 PM revealed that she was informed on 2/11/25 that Resident #119 was noted with blue gel on her LifeVest indicating that a shock was delivered. The SDD stated that she was present on the evening of 2/11/25 when the representative from the manufacturer arrived. The SDD indicated that she did not conduct any orientation or any training regarding the LifeVest device with Nurse #1 who was an agency nurse who worked at the facility as needed. The SDD stated she was not aware of the directives for managing the LifeVest and was unable to explain why she had not provided education to the staff regarding the device. Voice mail messages and text messages were sent to Nurse #7 on 8/6/25 at 11:25 AM, 8/7/25 at 12:24 PM, 8/8/25 at 12:35 PM. Nurse #7 was assigned to Resident #119 on 2/11/25 from 7:00 PM to 7:00 AM. Nurse #7 was an agency nurse who was no longer employed at the facility. A review of the facility staffing assignment sheet revealed that the on-call nurse, an administrative nurse designated to be called for any emergency situations for 2/10/25-2/11/25, was Support Nurse #1. An alert note (a note designation in a resident chart that includes important information and is used to notify care team members about the need for follow up) dated 2/12/25 at 8:16 AM written by the Support Nurse #1 indicated that Resident #119 refused meal. The note did not indicate a comprehensive assessment was completed, did not indicate that the physician was notified and did not include vital signs. An interview with Support Nurse #1 on 8/6/25 at 12:05 PM revealed she recalled that Resident #119 had a LifeVest device. Support Nurse #1 stated that the LifeVest device had a transmitter box that sounded a gong noise if it detected an abnormal rhythm. If a button was not pressed, a shock was administered. Support Nurse #1 stated that she talked to the technician at the manufacturer regarding the device on 2/11/25 and was informed that if the gel was released, a shock was administered. Support Nurse #1 stated that on 2/11/25, Resident #119 had gel on her chest which indicated that she received a shock. Support Nurse #1 stated the provider should have been notified that the LifeVest was sounding and a shock was administered. Support Nurse #1 stated that Resident #119 should have been assessed immediately including vital signs and monitored closely and stated that she thought that the floor nurse (Nurse #5 would have done this. Support Nurse #1 stated she did not notify a provider on 2/11/25 that Resident #119 received a shock from the LifeVest and explained that she thought Nurse #5 would have done this. Support Nurse #1 stated she should have followed up with Nurse #5 to be sure that she had assessed Resident #5 and notified the provider of the shock from the LifeVest. Support Nurse #1 stated the Cardiologist called the facility on 2/13/25 and was adamant that he speak with Medical Director #1 regarding Resident #119. A health status note dated 2/12/25 at 7:07 PM written by Nurse #8 indicated Resident #119 had been in bed resting with eyes closed most of the shift. The note indicated that Resident #119 had difficulty feeding herself, showed no interest in food when staff attempted to assist with feeding and was slow to respond to verbal stimuli. Staff attempted to keep Resident #119 engaged, but she showed no interest. Resident #119's urinary catheter was patent draining yellow urine with sediment. Resident #119 showed a lack of interest in any activities. The note did not indicate a comprehensive assessment was completed, did not indicate that the physician was notified and did not include vital signs. Review of Resident #119's medical record revealed no documentation of vital signs on 2/12/25.An interview conducted with Nurse #8 on 8/7/25 at 11:41 AM indicated that she was assigned to Resident #119 on 2/12/25 from 7:00 AM to 7:00 PM and was assigned to the resident frequently. Nurse #8 stated that she was familiar with the LifeVest device as she had personal experience with it. Nurse #8 stated she did not recall receiving in service education at the facility regarding the device. Nurse #8 stated that Resident #119 was unable to manage the device herself and that there were no directives for how to manage the device. Nurse #8 stated that she did not recall whether Resident #119 had any significant changes on 2/12/25 from 7:00 AM to 7:00 PM and stated that the resident had been demonstrating a gradual, slow decline. Nurse #8 was unable to explain why she did not complete a full assessment of Resident #119. An interview was conducted on 8/6/25 at 1:45 PM with the Nurse Aide (NA) #6 who stated she was assigned to Resident #119 on 2/11/25 and 2/12/25 from 11:00 PM to 7:00 AM. NA #6 stated Resident #119 had some type of LifeVest that she wore and she did not recall any issues with it. NA #6 stated she did not know much about the device but knew that it had something to do with resident's heart and if it beeped, she notified the nurse. NA #6 stated she had not received any instructions about the device. An interview with Nurse #6 on 8/7/25 at 2:20 PM indicated that she was assigned to Resident #119 on 2/12/25 from 7:00 PM to 7:00 AM. Nurse #6 stated she was familiar with the LifeVest device from working with residents at other facilities with this device. Nurse #6 stated there were no issues with Resident #119 on the night of 2/12/25. If the device had alarmed, she would have called for assistance, called Emergency Medical Services, the provider and the responsible party. An interview with the Resident Representative for the LifeVest manufacturer on 8/7/25 at 4:30 PM revealed she worked with the physician and shared information with the doctors and cardiologists. She indicated that she called the Cardiologist on 2/13/25 and informed him that Resident #119 had a sustained run of ventricular tachycardia (v tach) on 2/11/25. The representative indicated that if a resident had a run of v tach greater than 1 minute, a shock was delivered. The device can deliver up to five shocks. The representative stated that the LifeVest device does not provide continuous real time monitoring of the resident's heart rhythm meaning that there was not a medical professional viewing the information for each resident wearing a LifeVest, therefore if an alarm sounds on the device, it was imperative to respond to that alarm and inform the medical provider. If the monitor was not plugged in, then the information was stored and was downloaded when it was plugged in again. The representative stated that when the technician for the manufacturer came to the facility on 2/11/25 and serviced the equipment, then the monitor generated the stored information from the device. The representative stated that the strip from 2/11/25 just after midnight indicated that v tach was detected. The representative stated that there were multiple episodes of v tach from the night of 2/11/25 and when she received that information, she reached out to the Cardiologist. An interview with the Cardiologist on 8/6/25 at 3:36 PM revealed that the LifeVest device is designed to detect dangerous arrhythmias including ventricular tachycardia and ventricular fibrillation. The Cardiologist stated that the device can be disarmed to prevent a shock from being administered. If the resident is unable to disarm the device, a shock is delivered. The Cardiologist stated that the physician should be notified when the device delivered a shock and if unable to contact the physician, the resident should be sent to the hospital for evaluation. Following an electrical shock from the LifeVest device, evaluation is required to determine if the heart has returned to a regular rate and rhythm. The cardiologist stated that he received a call on 2/13/25 from the representative for the LifeVest manufacturer who stated that Resident #119 was shocked by the device due to the abnormal heart rhythm ventricular tachycardia. The Cardiologist stated he called the facility and recommended that Resident #119 be sent to the hospital for evaluation. A health status note dated 2/13/25 at 5:00 PM written by Support Nurse #1 indicated that the facility received a call from the cardiologist who stated that a remotely acquired EKG (electrocardiogram) strip received from the LifeVest manufacturing company showed severe episode of ventricular tachycardia (a dangerous rapid heart rhythm). The Cardiologist spoke with Medical Director #1 and upon cardiologist's recommendation due to the resident not being stable, an order was received to send Resident #119 to the emergency department for further evaluation. Emergency Medical Services was contacted, and Resident #119 was transported to the hospital. An interview was conducted with Support Nurse #1 on 8/6/25 at 12:05 PM. She said the Cardiologist was on the phone and requested to speak with the Medical Director. She immediately went and informed Medical Director #1, who was in the building at the time. After speaking with the Cardiologist, Medical Director #1 gave the order to send Resident #119 to the hospital due to a dangerous heart arrhythmia.An interview with Medical Director #1 on 8/6/25 at 3:52 PM revealed that he had started in the facility in early February 2025. Medical Director #1 stated he was not notified that Resident #119's LifeVest had alarmed or shocked her due to arrhythmia. Medical Director #1 stated if the LifeVest alarm sounded due to arrhythmia, the resident should be sent to the emergency room and then the provider should be notified. Medical Director #1 stated that if the device shocked the resident, the nurse should have immediately assessed the resident and sent her to the hospital for evaluation. When the LifeVest discharges an electrical shock to the resident, it means the person had an unstable arrythmia requiring immediate physician attention, or the device malfunctioned and administered a shock when it was not required. Both require evaluation. An Emergency Department (ED) report from hospital #1 dated 2/13/25 indicated that Resident #119 presented to the hospital with a LifeVest device on. Resident #119 presented after the LifeVest detected a cardiac arrhythmia and the cardiologist requested evaluation at the nearest emergency room. Resident #119 was somnolent, difficult to understand with closed eyes and was unresponsive on presentation to the ED. Resident #119 was noted to have 4+ pitting edema from toes to abdomen. The impression indicated that Resident #119 was evaluated due to a cardiac arrhythmia and was significantly fluid overloaded with severe congestive heart failure. Due to her severe and acute condition, Resident #119 was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated 2/27/25 indicated that Resident #119 was admitted to the critical care unit on 2/13/25 and was deceased on 2/27/25. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated 2/27/25 at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Other significant condition contributing to death was cardiogenic shock. An interview was conducted on 8/6/25 at 2:20 PM with the Director of Nursing (DON) and the Clinical Services Director. The DON stated that the facility had residents with a LifeVest in the past, and they usually came in with a booklet that provided instructions about the device and managed their own device. The DON did not recall if Resident #119 came in with a booklet about her device or if she was able to manage her own LifeVest when she was admitted . The DON and Clinical Services Director stated that they expected that if something occurred such as the LifeVest delivered a shock, the provider would be notified immediately for further instructions. The DON and Clinical Services Director stated that Resident #119 should have had a full assessment completed including vital signs and the physician should have been notified immediately for further instructions when the LifeVest alarmed during the night on 2/11/25. The DON stated that when the alarm on the device sounded, it indicated an abnormal heart rate was detected and this required notification of the physician. The DON was unable to state why the physician was not notified other than that the nurse who worked on the night of 2/10/25 was an agency nurse who is no longer working at the facility. The DON further stated that when Resident #119 had a change in condition with emesis twice and lack of appetite the resident should have been assessed, and the provider should have been notified. The DON stated that the manufacturer provided an in-service to the administrative nursing staff following this incident, but it was not part of a plan of correction. The DON did not provide a plan of correction and stated a plan of correction was not implemented nor was an investigation of the incident completed. An interview with the Administrator on 8/7/25 at 4:00 PM revealed that when the facility admitted Resident #119 with the LifeVest device, the facility was responsible for managing the device. The Administrator stated that the facility staff as well as agency staff that were assigned to Resident #119 should have been aware of the seriousness of the LifeVest device and the directives for managing it. The Administrator was notified of immediate jeopardy on 8/11/25 at 12:10 PM.The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.Resident #119 was placed at serious risk due to the facility's failure to recognize and respond appropriately to a critical change in condition. The resident wore a LifeVest, an external defibrillator prescribed due to a severely reduced left ventricular ejection fraction. This device is intended to detect and treat life-threatening arrhythmias.This failure in clinical judgment and timely notification to the physician, so that a comprehensive medical evaluation necessity determination could be made, created a high likelihood of serious harm or death, as the LifeVest's discharge indicates either an unstable arrhythmia or device malfunction, both requiring immediate medical evaluation.On 2/11/25, the LifeVest delivered multiple shocks beginning shortly after midnight. Nurse #1 witnessed these events but failed to assess the resident and to notify a physician, instead only informing the incoming shift nurse. No physician directives were in place regarding staff response to LifeVest discharges. The Cardiologist was only informed on 2/13/25 after the LifeVest manufacturer reported a severe episode of ventricular tachycardia, at which point the resident was sent to the hospital and did not return to the facility.The facility has not been able to contact Nurse #1, and she is no longer working in the facility. The Administrator and Director of Nursing attempted to contact Nurse #1 on 8/6/25, but the number was not operational.On 8/6/25, the facility initiated a comprehensive response to address the facility's failure to recognize and respond appropriately to a critical change in condition for Resident #119.The Director of Staff

Based on record review and staff, Medical Director #1, Cardiologist, Resident Representative, LifeVest technician, and LifeVest patient representative interviews, the facility failed to ensure staff were trained and competent to care for a resident who wore a LifeVest (a device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). Resident #119 received a treatment shock multiple times by the LifeVest she was wearing in the early morning hours (beginning shortly after midnight) on [DATE]. Nurse #1, an agency nurse assigned to Resident #119, observed the device deliver the treatment shocks to Resident #119 and took no action with the exception of notifying the oncoming first shift nurse (Nurse #5) that the LifeVest was shocking the resident all through the night. The 7 of 7 staff members that cared for Resident #119 from [DATE] through [DATE] that included Nurse #1, Nurse #5, Nurse #6, Nurse #8, Nurse Aide (NA) #2, NA #6, and NA #7 had not been trained on how to respond if the LifeVest alarmed or sounded or how to respond if the LifeVest delivered a treatment shock. Per the manufacturer instructions, if a treatment shock was delivered, the physician was to be called immediately, and an announcement was made by the device with this instruction. Resident #119's Cardiologist contacted the facility on [DATE] and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate). The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Another significant condition contributing to death was cardiogenic shock (medical emergency resulting from inadequate blood flow to the body's organ due to dysfunction of the heart). Immediate Jeopardy began for Resident #119 on [DATE] when Resident #119 received a treatment shock from LifeVest and the staff did not demonstrate competency for delivering care according to the manufacturer's instructions. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings:This tag is cross referred to:F580: Based on record review and staff, Medical Director #1, Cardiologist, LifeVest Resident Representative and LifeVest Technician interviews, the facility failed to consult with Medical Director #1 when Resident #119's LifeVest (an external defibrillator designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) delivered treatment shocks to her multiple times in the early morning hours on [DATE]. The LifeVest Resident Representative contacted Resident #119's Cardiologist on [DATE] about Resident #119's severe episodes of ventricular tachycardia, a life-threatening rapid heart rate. The Cardiologist called the facility and requested to talk to the Medical Director. The Cardiologist recommended that the resident be sent to the hospital for evaluation. The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Other significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for notification of change (Resident #119). F684: Based on record review and staff, Medical Director #1, Cardiologist, LifeVest technician and LifeVest patient representative interviews, the facility failed to obtain physician directives for staff about what to do when the LifeVest delivered a shock, identify the seriousness of Resident #119's cardiac status and the need for a comprehensive medical evaluation when a LifeVest (an external defibrillator device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) shocked the resident multiple times in the early morning hours (beginning shortly after midnight) of [DATE]. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. From [DATE] through [DATE] the facility failed to consult with the physician regarding the LifeVest having delivered treatment shocks to the resident and provide ongoing nursing assessment. According to the manufacturer's instructions, a resident with a LifeVest is to be evaluated by a physician for potential arrhythmia once the vest delivers a treatment shock. On [DATE], Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate). The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Another significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for professional standards (#119). An interview with Resident #119's Resident Representative on [DATE] at 9:02 AM revealed that Resident #119 was not cognitively intact, was unable to manage the LifeVest device and was dependent on staff for all care. Resident Representative stated that when she visited Resident #119, she was unable to recall the exact dates, she observed that the extra battery for the LifeVest device was in a drawer or in a bag and was not charged and the transmitter (router) device was not plugged in. Resident Representative stated that when she asked the staff assigned to Resident #119 questions, she was unable to recall which staff members specifically, about the Life Vest device, the staff stated they did not know about it and to ask someone else. An interview was conducted with staff nurse Nurse #5 on [DATE] at 1:15 PM. Nurse #5 was assigned to Resident #119 frequently and was assigned to her on [DATE] from 7:00 AM to 7:00 PM. Nurse #5 indicated that Resident #119 had a LifeVest cardiac defibrillator device. Nurse #5 stated she had not received any training regarding the LifeVest device and there were no instructions for management or when to notify the provider regarding the device on Resident #119's Medication Administration Record (MAR). Nurse #5 stated that she had some knowledge of the LifeVest and how it functioned from working with one at another facility. Nurse #5 indicated she had not asked for training regarding the LifeVest device. Attempts were made to interview Nurse #1 were unsuccessful with text messages sent on [DATE] at 2:16 PM and [DATE] at 12:31 PM with no return call received. Nurse #1 was an agency nurse that worked as needed at the facility and was assigned to Resident #119 on [DATE] from 7:00 PM to 7:00 PM. Nurse #1 no longer worked at the facility. An interview with Support Nurse #1 (who was assigned as the on-call administrative nurse designated to be called for emergencies on [DATE]-[DATE]) on [DATE] at 12:05 PM revealed she did not know anything about the device prior to Resident #119 being admitted with a LifeVest device and had received no training regarding the device. Support Nurse #1 indicated that she had not asked for training or information regarding the LifeVest. Support Nurse #1 stated that the facility had admitted residents with LifeVest devices in the past, but the residents had managed the device themselves, so she had not learned about the device or the management of it. Support Nurse #1 stated Nurse #5 informed her on [DATE] that Resident #119's LifeVest device had a message on the monitor that stated the gel was depleted. Nurse #5 requested that Support Nurse #1 call the LifeVest support help line. Support Nurse #1 stated that after speaking with the LifeVest technician on [DATE], she learned that the blue gel observed on Resident #119's chest and upper body indicated that an electrical shock was administered due to an abnormal heart rhythm. An interview conducted with Nurse Aide (NA) #2 on [DATE] at 10:06 AM revealed that she was assigned to Resident #119 on [DATE] from 11:00 PM to 7:00 AM. NA #2 stated she had not received any training regarding the LifeVest device. An interview with Nurse #6, an agency nurse that worked at the facility as needed, was conducted on [DATE] at 2:20 PM. Nurse #6 indicated that she was assigned to Resident #119 on [DATE] from 7:00 PM to 7:00 AM. Nurse #6 stated she knew what a LifeVest device was from working with residents at other facilities with this device. Nurse #6 stated that she did not receive any training regarding the LifeVest device or how to manage it. Nurse #6 stated that she did not ask for training regarding the device since she only worked at the facility as needed and she worked the 7:00 PM to 7:00 AM shift when there was no administrative staff available. An interview with the Staff Development Director (SDD) on [DATE] at 12:25 PM revealed that she did not know much about the LifeVest Device when Resident #119 was admitted with the device in [DATE]. The SDD stated that she researched the device to find out more about it. The SDD stated she briefly reviewed some of the things to know about the device with a few of the nurses and nursing assistants, she could not recall which ones. The SDD stated that information regarding managing the device should have been entered on the Medication Administration Record (MAR) by the admitting nurse so that all nurses were aware of the management of the device. The SDD stated she did not know how an agency nurse or facility nurse would know how to manage the LifeVest device or the response to an alarm. The SDD stated she did not complete any training on the LifeVest or orientation to the facility or procedures with agency Nurse #1 that was assigned to Resident #119 on the night of [DATE]. The SDD was unable to explain why she had not conducted any training regarding the LifeVest device with the staff. The SDD stated she had not consulted with the physician regarding management of the LifeVest device. An interview with Medical Director #1 on [DATE] at 3:52 PM revealed that he had just started in the position at the facility in early February 2025 and prior to the incident with Resident #119's LifeVest on [DATE], he was not aware that the facility had an external defibrillator device in the facility. Medical Director #1 stated that the nursing staff should have been trained in the management of the LifeVest device due to the seriousness of the device and the potential for complications. An interview was conducted on [DATE] at 2:20 PM with the Director of Nursing (DON) and the Clinical Services Director. The DON stated that the facility had residents with a LifeVest in the past, and they usually had a booklet about the device and managed their own device. The DON did not recall if Resident #119 had a booklet or if she was able to manage her own LifeVest when she was admitted . The DON revealed that staff training about the LifeVest was not completed prior to Resident #119's admission in [DATE] with the physician order for the LifeVest device nor was staff training completed upon Resident #119's readmission in [DATE]. The DON stated that training regarding the LifeVest was not provided at any time during Resident #119's stay at the facility. The DON did not provide a plan of correction and stated a plan of correction was not implemented nor was an investigation of the incident completed. The DON indicated that the staff should have been trained in management of the LifeVest and emergency procedures. There were no other residents at this time that had LifeVest in the facility.An interview with the Administrator on [DATE] at 4:00 PM revealed that when the facility admitted Resident #119 with the LifeVest device, the facility was responsible for managing the device. The Administrator stated that the facility staff as well as agency staff that were assigned to Resident #119 should have been trained regarding the seriousness of the LifeVest device and the directives for managing it. The Administrator did not recall if she was aware that Resident #119 had the LifeVest device prior to the incident on [DATE]. The Administrator revealed that the DON and SDD were responsible for ensuring that staff were trained on medical devices or equipment prior to the resident's admission. The Administrator was notified of Immediate Jeopardy on [DATE] at 12:10 PM.The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #119 was admitted on [DATE] with a physician-prescribed LifeVest. The clinical staff did not receive adequate training or demonstrate competency in the operation, monitoring, and emergency response procedures associated with the device. This lack of preparedness created a significant risk for serious adverse outcomes for Resident #119. Resident #119 was shocked by her LifeVest multiple times in the early morning hours (beginning shortly after midnight) of [DATE]. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. On [DATE] Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest' s manufacturer that the resident had a severe episode of ventricular tachycardia.Nurse #1 no longer works for the facility. The Administrator and the Director of Nursing attempted to contact Nurse #1 on [DATE], but the number was not operational.Resident #119 did not return to the facility after discharge on [DATE].As of [DATE], a review conducted by the Director of Nursing confirmed that there have been no residents with a LifeVest residing in the facility since [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. To prevent recurrence, a new protocol has been established requiring documented training and competency validation for any wearable cardiac device (e.g., cardioverter defibrillator) prior to resident admission.On [DATE], the Director of Admissions was instructed by the Administrator that any prospective resident with a wearable cardiac device must undergo a clinical review to ensure staff competency before acceptance. On [DATE], a LifeVest manufacturer representative came to the facility to complete a hands-on review of the care and function of the LifeVest, utilizing a demo vest, with the Director of Nursing and the Director of Staff Education. Instruction manual with several resource documents were provided. On [DATE], the Director of Nursing created a LifeVest quick reference guide for each nursing station. Contents of the manual included a patient checklist, a quick reference guide for trouble shooting, an educational overview for patients and families on use of the LifeVest, and the manufacturers manual for the LifeVest. The 24- hour help line number is also located on the outside and inside of the manual. Beginning [DATE], all Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) are required to complete education and competency validation prior to providing care to any resident with a wearable cardiac device.All licensed nurse new hires, including agency staff, must complete mandatory training and competency checks before being assigned to residents using these devices.Training for licensed nursing staff began on [DATE] and includes viewing the 26-minute LifeVest instructional video designed for both patients and caregivers. Following the video, the Director of Staff Education utilized a competency checklist to validate staff understanding. This competency checklist includes verbalization of understanding of the knowledge of the LifeVest purpose and function, application and maintenance, emergency response, communication and education as well as the location and contents of the quick reference guide for LifeVest. On [DATE], all Certified Nursing Assistants received education from the Director of Nurses, Director of Staff Education, and the Minimum Data Set Nurse Coordinator on the need to immediately report to the staff nurse when a resident utilizing a LifeVest receives a shock treatment or expresses any other concerns. Staff who do not complete the training by [DATE] will not be permitted to work until the training is completed. The Director of Nursing and the Director of Staff Development will do a daily reconciliation of the schedule to ensure all licensed staff have completed the training and competency validation and all Certified Nursing Assistants received education as indicated above. This in-service training indicated above in addition to the competency validation for licensed staff has been incorporated into the orientation program for all new facility and agency staff. The in-service training indicated above for the Certified Nursing Assistants has been incorporated into the orientation program for all new facility and agency staff.No staff shall work without this training after [DATE]. Alleged date of Immediate Jeopardy removal: [DATE]The removal plan of the Immediate Jeopardy was validated on [DATE]. A sample of staff including the Administrator, the DON, Support Nurse #1, SDD, nurses, and nurse aides were interviewed regarding in-services they received related to the deficient practice. All staff interviewed stated they received in-service training regarding the LifeVest purpose and function, application, maintenance and emergency response. Validation indicated that licensed nurses had completed a competency checklist regarding the LifeVest device and the indications to notify the physician. A LifeVest reference manual was created and was observed at the nurses' station. The immediate jeopardy removal date of [DATE] was validated.

Based on record review and staff, LifeVest Technician, LifeVest Resident Representative, Medical Director #1 and Cardiologist interviews, the facility failed to protect Resident #119's right to be free from neglect. Resident #119 was admitted on [DATE] with a LifeVest (a wearable device designed to detect life-threatening rapid heart rhythm and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). The nurses and nurse aides had no training on how to care for and manage a resident who required a LifeVest and staff neglected to provide necessary care and services after the LifeVest delivered several treatment shocks. Nurse #1 observed the device deliver treatment shocks to the resident in the early morning hours of [DATE] and took no action with the exception of notifying the oncoming first shift nurse that the Life Vest was shocking the resident all through the night. The Physician was not contacted to evaluate Resident #119 after the treatment shocks were delivered as specified in the manufacturer's instructions. Due to ineffective staff communication and lack of comprehensive assessments Resident #119's significant change from her baseline was not recognized or acknowledged by the staff. On [DATE], Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate) on [DATE]. The emergency department (ED) at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and noted Resident #119 was somnolent, difficult to understand with closed eyes and was unresponsive on presentation to the ED. Resident #119 was transferred to another hospital for further evaluation and monitoring. These failures had a high likelihood of resulting in serious harm or death for Resident #119. Immediate jeopardy began on [DATE] when Resident #119 received multiple treatment shocks from the LifeVest and the facility neglected to provide the necessary care and services and consult with the physician about an evaluation for a potential arrhythmia. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable plan of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. The findings included:This is cross-referred to:F580: Based on record review and staff, Medical Director #1, Cardiologist, LifeVest Resident Representative and LifeVest Technician interviews, the facility failed to consult with Medical Director #1 when Resident #119's LifeVest (an external defibrillator designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) delivered treatment shocks to her multiple times in the early morning hours on [DATE]. The LifeVest Resident Representative contacted Resident #119's Cardiologist on [DATE] about Resident #119's severe episodes of ventricular tachycardia, a life-threatening rapid heart rate. The Cardiologist called the facility and requested to talk to the Medical Director. The Cardiologist recommended that the resident be sent to the hospital for evaluation. The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Other significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for notification of change (Resident #119). F684: Based on record review and staff, Medical Director #1, Cardiologist, LifeVest technician and LifeVest patient representative interviews, the facility failed to obtain physician directives for staff about what to do when the LifeVest delivered a shock, identify the seriousness of Resident #119's cardiac status and the need for a comprehensive medical evaluation when a LifeVest (an external defibrillator device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm) shocked the resident multiple times in the early morning hours (beginning shortly after midnight) of [DATE]. Nurse #1 observed the device deliver shocks to the resident and took no action with the exception of notifying the oncoming first shift nurse that the LifeVest was shocking the resident all through the night. From [DATE] through [DATE] the facility failed to consult with the physician regarding the LifeVest having delivered treatment shocks to the resident and provide ongoing nursing assessment. According to the manufacturer's instructions, a resident with a LifeVest is to be evaluated by a physician for potential arrhythmia once the vest delivers a treatment shock. On [DATE], Resident #119's Cardiologist contacted the facility and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate). The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Another significant condition contributing to death was cardiogenic shock. This deficient practice occurred for 1 of 1 resident reviewed for professional standards (#119). F726: Based on record review and staff, Medical Director #1, Cardiologist, Resident Representative, LifeVest technician, and LifeVest patient representative interviews the facility failed to ensure staff were trained and competent to care for a resident who wore a LifeVest (a device designed to detect certain life-threatening rapid heart rhythms and, if needed, automatically deliver a treatment shock to restore normal heart rhythm). Resident #119 received a treatment shock multiple times by the LifeVest she was wearing in the early morning hours (beginning shortly after midnight) on [DATE]. Nurse #1, an agency nurse assigned to Resident #119, observed the device deliver the treatment shocks to Resident #119 and took no action with the exception of notifying the oncoming first shift nurse (Nurse #5) that the LifeVest was shocking the resident all through the night. The 7 of 7 staff members that cared for Resident #119 from [DATE] through [DATE] that included Nurse #1, Nurse #5, Nurse #6, Nurse #8, Nurse Aide (NA) #2, NA #6, and NA #7 had not been trained on how to respond if the LifeVest alarmed or sounded or how to respond if the LifeVest delivered a treatment shock. Per the manufacture instructions, if a treatment shock was delivered, the physician was to be called immediately, and an announcement was made by the device with this instruction. Resident #119's Cardiologist contacted the facility on [DATE] and recommended the resident be sent to the hospital for evaluation after being notified by the LifeVest's manufacturer that the resident had a severe episode of ventricular tachycardia (a life-threatening rapid heart rate). The emergency department at hospital #1 determined Resident #119 had significant fluid overload with severe congestive heart failure and she was transferred to another hospital for further evaluation and monitoring. The discharge summary from hospital #2 dated [DATE] indicated that Resident #119 was admitted to the critical care unit on [DATE] and was deceased on [DATE]. Discharge diagnoses included acute heart failure, cardiogenic shock, cardiac arrhythmia, acute hypoxic respiratory failure, acute kidney failure, and sustained ventricular tachycardia. The certificate of death dated [DATE] at 10:41 AM indicated the immediate cause of death was acute hypoxic respiratory failure and acute on chronic congestive heart failure with the approximate interval of onset to death for the immediate causes was 2 weeks. Another significant condition contributing to death was cardiogenic shock (medical emergency resulting from inadequate blood flow to the body's organ due to dysfunction of the heart). The Administrator was notified of immediate jeopardy on [DATE] at 12:10 PM.The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Failure to protect Resident #119 from neglect, with cross-references to F580, F684, and F726. On [DATE] the facility failed to adhere to its abuse/neglect policy and failed to protect Resident #119 from neglect by not recognizing and responding to a resident's change in condition. Specifically, staff did not notify the Medical Director; did not identify the seriousness of resident's condition and need for a comprehensive medical evaluation; and did not ensure staff were trained and competent to care for a resident who wore a Life Vest, resulting in a failure to provide timely medical intervention.Upon learning of the allegation of neglect on [DATE], the Administrator submitted an initial report to the Department of Health and Human Services and report to Adult Protective Services. Resident #119 discharged from the facility on [DATE]. Nurse #1 no longer works for the facility. The Administrator and the Director of Nursing attempted to contact Nurse #1 on [DATE], but the number was not operational.As of [DATE], a review conducted by the Director of Nursing confirmed that there have been no residents with a Life Vest residing in the facility since [DATE]. On [DATE] all current residents were assessed for changes in condition to ensure appropriate care and services were provided. The nurse management team consisting of the Director of Staff Education, Minimum Data Set Nurse Coordinator, and 3 Licensed Practical Nurse Support Staff conducted comprehensive head-to-toe assessments of all residents with a Brief Interview for Mental Status (BIMS) score of 12 or less to identify any signs of distress or neglect. No concerns were identified. On [DATE], residents with a BIMS score of 13 or higher were interviewed by the nurse management team regarding any concerns related to abuse, neglect, or care. All residents denied any such concerns.Additionally, on [DATE], the nurse management team completed immediate assessments of 100% of current residents to identify any unreported acute changes in condition. This included symptoms that were:- Acute or sudden in onset- Markedly more severe than usual- Unrelieved by previously prescribed measures- Indicative of respiratory distress (e.g., difficulty breathing, low oxygen saturation, new onset cough or congestion, decreased appetite)On [DATE], corrective actions were completed for 5 out of 116 residents who were identified as having a change in condition. Providers were notified, and orders were carried out by direct care staff.On [DATE], the Director of Nursing audited all hospital transfers from the past 30 days to ensure provider notification occurred for any acute changes in condition. The audit confirmed that provider notification was completed for all 14 residents reviewed. No corrective action was required.Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed.On [DATE], the Administrator and Director of Nursing conducted in-service training for all staff (full-time, part-time, as needed, and agency) on the abuse/neglect policy, including procedures for identifying, reporting, and preventing abuse and neglect. This training was delivered in person and by phone. Staff who did not complete the training by [DATE] were restricted from working until completion.On [DATE], the Director of Nursing began targeted education for all licensed nurses (Registered Nurses, Licensed Practical Nurses), and certified nursing assistants on the importance of notifying providers of any acute change in condition. Training included emphasis on timely care and services, and the definition of neglect as failure to act during a medical emergency. The training also included:- Recognizing types of changes in condition- Appropriate response protocols- Notification procedures- When to initiate Emergency Medical ServicesAdditionally, beginning [DATE], all Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) are required to complete education and competency validation prior to providing care to any resident with a wearable cardiac device. This will be completed by the Director of Nursing, Minimum Data Set Nurse and Director of Staff Education. Specific training for a resident with a Life Vest was if a person's Life Vest discharges, it means the person may have an unstable arrythmia or that the device is malfunctioning or both, and both of these would require immediate physician notification. Nurses received training to complete a comprehensive assessment and notify the medical provider of findings and concerns. On [DATE] Nurses were trained on the emergency response to include areas of: if the Life Vest delivers a shock, when to notify the physician and document the event and understanding of when to remove the Life Vest. On [DATE] the Administrative nursing team to include the Director of Nursing, the Director of Staff Education, the 3 licensed practical nurse support nurses and the Minimum Data Set nurses were educated by the Regional Nurse Consultant to ensure that orders directing care for residents with Life Vests are obtained from the physician and entered into the medical record to include: maintenance and emergency response. On [DATE] the Minimum Data Set Nurse was educated by Regional Nurse Consultant to ensure that all residents with a Life Vest have a care plan moving forward that will include directives of what to do in the event the vest delivers a shock. On [DATE], the Director of Admissions was instructed by the Administrator that any prospective resident with a wearable cardiac device must undergo a clinical review to ensure staff competency before acceptance. On [DATE], a Life Vest manufacturer representative came to the facility to complete a hands-on review of the care and function of the Life Vest, utilizing a demo vest, with the Director of Nursing and the Director of Staff Education. Instruction manual with several resource documents were provided. On [DATE], the Director of Nursing created a life-vest quick reference guide for each nursing station. Contents of the manual included a patient checklist, a quick reference guide for trouble shooting, an educational overview for patients and families on use of the Life Vest, and the manufacturers manual for the Life Vest. The 24- hour help line number is also located on the outside and inside of the manual. Training for licensed nursing staff began on [DATE] and includes viewing the 26-minute Life Vest instructional video designed for both patients and caregivers. Following the video, the Director of Staff Education utilized a competency checklist to validate staff understanding. This competency checklist includes verbalization of understanding of the knowledge of the Life Vest purpose and function, application and maintenance, emergency response, communication and education as well as the location and contents of the quick reference guide for Life Vest. On [DATE], all Certified Nursing Assistants received education from the Director of Nurses, Director of Staff Education, and the Minimum Data Set Nurse Coordinator on the need to immediately report to the staff nurse when a resident utilizing a Life Vest receives a shock treatment or expresses any other concerns.The Interdisciplinary Team-including the Administrator, Director of Nursing, Nurse Managers, Minimum Data Set Coordinators, Unit Manager, Support Nurse, Therapy, Health Information Management, Dietary Manager, Medical Director, and Pharmacist-was informed of the neglect allegation on [DATE] and actively participated in the removal plan. The Director of Nursing and the Director of Staff Education along with the individual department managers will do a daily reconciliation of the schedule to ensure all staff have completed the training and education as indicated above. This training has been incorporated into the orientation process for all new employees and agency staff. All licensed nurse new hires, including agency staff, must complete mandatory training and competency checks before being assigned to residents using these devices. The Administrator and Director of Nursing will ensure that any staff member who did not complete the required training by [DATE] will not be able to work until training is completed.The Administrator is responsible for ensuring full implementation of the removal plan. Alleged date of Immediate Jeopardy removal: [DATE] The removal plan of the Immediate Jeopardy was validated on [DATE]. A sample of staff including the Administrator, Director of Nursing, Support Nurse #1, nurses, nurse aides and medication aides were interviewed regarding in-service training received related to the deficient practice. All staff interviewed stated they had been in serviced regarding the importance of staff understanding that all residents have a right to be free of neglect and they indicated that they understood that failing to provide the necessary care and services to residents constituted neglect. The staff interviewed indicated that the in-service training they received stated that failure to notify the physician of significant changes including receiving shocks from a wearable defibrillator device constituted neglect. The removal date of [DATE] was validated.

Based on record review, and resident, staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to lock the left brake on Resident #3's wheelchair during a one person stand-pivot transfer on 3/14/25. The left wheelchair brake mechanism was worn and did not engage with the rubber on the tire. The resident could not stand independently or stop the wheelchair when it started to roll. Nurse Aide (NA) #1 lowered Resident #3 to the floor. Both Resident #3 and NA#1 heard a pop. Nurse #3 assessed Resident #3 who denied pain and wanted to go to a scheduled dialysis appointment. During the dialysis appointment, Resident #3 experienced left knee pain. A portable x-ray taken at the facility was negative. Resident #3 continued to have pain and was sent to an orthopedic clinic where he had another x-ray with a negative result. He was treated with a left knee steroid injection for pain. Pain continued after the injection. On 3/28/25 Resident #3 was sent to the hospital for further evaluation. Resident #3 was diagnosed with a left femoral fracture and had an open reduction and internal fixation (ORIF) surgery to repair a bone fracture of his left femur. This deficient practice occurred for 1 of 5 residents (Resident #3) sampled for supervision to prevent accidents.The findings included:Resident #3 was admitted to the facility on [DATE]. His diagnosis included end stage renal disease stage 4 with dialysis, history of falls, anxiety, weakness, osteopenia, and peripheral vascular disease. A review of Resident #3's annual Minimum Data Set, dated [DATE] indicated Resident #3 had no cognitive impairment and required supervision to one-person assistance for activities for daily living (ADL) and one-person extensive assistance with transfers.The care plan last reviewed on 01/08/25 showed Resident #3 was care planned for falls and required assistance with activities of daily living due to chronic health conditions and weakness in extremities. The intervention included the use of a manual wheelchair for mobility, and extensive assistance with transfers using stand pivot method. The January 2025 physician orders showed that Resident #3 was not on any blood thinner medications and had scheduled dialysis on Mondays, Wednesday and Fridays. Nurse #3 completed an incident report dated Friday, 03/14/25 at 5:00 AM. The nurse stated Resident #3 reported pain upon return from dialysis at 8:30 AM. A report from dialysis of resident signing off machine early due to pain described from fall at the facility prior to transport to dialysis. Resident #3 stated, The Nursing Aide (NA #1) who had me went to get me up into the wheelchair and when she went to put me down in the wheelchair, it started to roll away, so I told her to sit me down on the floor. When she did, I heard something go ‘pop'. I didn't think anything of it until I was at dialysis, and they wanted to move me, and it hurt like you know what. Facility's immediate action: Nurse #3 assessed resident with noted generalized edema to the left knee. Resident #3 described pain as 8 out of 10 and voiced inability to move due to pain. The Nurse Practitioner (NP) was notified of concern with orders given for x-ray of left knee and orthopedic consultation. No injuries were observed at the time of incident. Resident #3's wheelchair rolled away with break levers in place to lock. Resident's family members and physicians were notified on the morning of 03/14/25. Root cause of fall was determined by facility to be wheelchair malfunction, with intervention for maintenance to repair the wheelchair for safety, care plan reviewed and updated, with physician and Responsible Party (RP) aware and agreed with intervention.An interview and observation were conducted on 08/04/25 at 11:10 AM with Resident #3 revealed the resident sitting up in bed, fully dressed, alert and oriented, TV on, room clean, had bilateral bed rails for positioning, his wheelchair was next to the bed on right side. Resident stated he had dialysis that morning and was just resting up in bed. His wheelchair was checked. It had bald, worn wheels with rubber peeling off. The right brake functioned well and locked. The left wheel brake was not functioning and did not lock. Resident #3 stated on the morning of 03/14/25, Nurse Aide #1 was helping him transfer from the side of his bed, with assist to stand, and pivot to his wheelchair. The wheelchair started to slide back on the left side, when NA #1 started to lower him onto the wheelchair seat. Resident #3 stated he told NA not to lift him up, but to lower him to the floor, which she did. When he was on the floor, they both heard a pop from his left knee. He said a nurse looked at his knee, which did not hurt at all until the dialysis staff used a mechanical lift, and straightened his leg to put him into their dialysis lift, and it was then that he said his knee started to hurt. He stated he had two knee x-rays, which were negative for knee injury, and had doctor visits and an orthopedic visit and they thought his knee was the issue and the reason for his pain, which the facility was medicating him for. During a follow-up orthopedic visit, the orthopedic nurse observed that his left foot was turned inward, and they sent him to the hospital for further testing and evaluation on 03/27/25. It was at that time that the x-rays revealed a fractured femur, not a dislocated hip or injured left knee. Resident #3 said he then had surgery and was doing fine now. He said when NA #1 lowered him to the floor on 3/14/25 his left leg must have bent at a strange angle. An interview was conducted on 08/05/25 at 8:15 AM with NA #1. She said on 03/14/25 around 5:00 AM she was helping Resident #3 pivot from his bed to the wheelchair for his dialysis appointment and when she was lowering him onto his wheelchair, she noted his wheelchair started to slide back some on the left side, even though she thought he had both wheels locked. She said she was going to lift him back onto his bed, but the resident said he did not want to see her hurt her back, and asked that she lower him to the floor, which she did without incident. She said she heard resident's knee pop, but he denied any injury or pain, and wanted to go to his dialysis appointment, which he did. The NA stated she told Nurse #3 about the incident, and the nurse immediately assessed Resident #3's left knee, which was not painful or swollen, so the resident stated he still wanted to go on to his dialysis appointment, which he did. A nursing note written by Nurse #3, dated 03/14/25 at 7:10 AM for Resident #3 revealed the resident returned to facility from dialysis in wheelchair. The resident was alert and oriented upon return and answered writer's questions appropriately. The resident said, When the girl got me up this morning around 5:00 AM to put me in my chair, the chair kept moving back, and instead of her struggling, I told her to sit me down on the floor and I guess my leg twisted and I heard a pop in my knee and I was fine it didn't hurt, but when I got to dialysis and they put me in the mechanical lift I was very uncomfortable and it took everything in me to not scream because my knee hurt so bad and I just could not take it so I had to come back. The resident's vital signs were obtained and documented. The resident requested and received as needed pain medication. The resident stated he was unable to straighten his leg without pain. Nurse Practitioner #1 was notified and stated she had already spoken to Nurse #3 and given orders for Resident #3 to obtain a left knee x-ray. This writer has put in order with portable x-ray and notified resident and resident's Responsible Party (RP) via voicemail.An interview was conducted on 08/05/25 at 1:20 PM with Nurse #3 who stated Resident #3 returned from dialysis around 8:30 AM on 03/14/25 and told her that his left knee started to hurt at dialysis. The resident told her that earlier when NA #1 was helping him into his wheelchair to go to dialysis, the wheelchair moved, so the NA #1 lowered him to the floor, and he heard his left knee pop. Resident #3 stated his knee did not hurt at that time, so he went to his dialysis appointment, where his left knee started to hurt. Nurse #3 stated she went and got NP #1 to come and assess the resident's knee and she ordered a portable x-ray and set up an orthopedic consult visit. They also asked for maintenance to change out resident's wheelchair. The nurse said if Resident #3's wheelchair had locked properly and did not slide backwards on the left side during his pivot transfer, NA #1 would not have had to lower the resident to the floor, and Resident #3's left knee would not have popped, resulting in further pain and treatment.A written statement from the Maintenance Director revealed, On 03/14/25 he received a request to check Resident #3's wheelchair for brakes locking properly. When checked it was noticed that the rubber piece on the wheelchair had worn down and the brake was not engaging properly. Resident #3 was in bed at the time, and the wheelchair was replaced. I removed the chair with the wheel issue from the room and took it to the storage area. An interview was conducted on 08/05/25 at 1:30 PM with the Maintenance Director. He stated he checked Resident #3's wheelchair on 03/14/25, after returning from dialysis. He observed the wheelchair tire rubber did not contact the brake on the left side and could easily slide back on the left side. He stated he removed the wheelchair from the room and brought in another one. He stated he and his assistant did monthly wheelchair checks on all facility wheelchairs. He said he might have missed checking Resident #3's if he was out of facility. The Maintenance Director did not know how Resident #3's old wheelchair got back into his room. An interview was conducted on 08/07/25 at 3:45 PM with Nurse Practitioner (NP) #1. The NP stated on 03/14/25 she assessed Resident #3 after his fall and return from dialysis. She said after his dialysis appointment, he was complaining of left knee pain, so she ordered an x-ray. The NP stated when she assessed his left knee, there was no swelling, no hip pain, or injury of any kind observed. She said his left knee x-ray was negative, and still he was complaining of left knee pain, so she obtained an order to send him to orthopedics for a second x-ray, evaluation and treatment. NA #1 said the second left knee x-ray from orthopedics was also negative for fracture, so they gave him a cortisone steroid injection to see if that would stop his left knee from pain. NP stated after the steroid injection, Resident #3 was still complaining of left knee pain. Orthopedics thought he might then have a dislocated left hip, so they ordered him to go to the hospital for further work-up and treatment. She stated the hospital's hip x-rays revealed the resident had a femur fracture. The NP #1 stated throughout time Resident #3 only complained of left knee pain. NP said nursing staff did what they were trained to do, step by step. She voiced no staffing concerns. A nursing note dated 03/20/25 at 05:10 PM for Resident #3 revealed the resident was out of facility for orthopedic appointment. The resident returned to facility with paperwork stating left knee pain with decreased range of motion and decreased strength. The resident was given cortisone injection in left knee at appointment, for left knee pain to rule out left knee ligament tear, with additional knee x-rays ordered to be obtained at orthopedics and resident to follow up with orthopedics after x-rays obtained. A physician note dated 03/27/25 by the Medical Director #1 for Resident #3 revealed resident complaints about his left hip and knee pain for the past 6 days. He was transitioning into his wheelchair and inadvertently placed weight on that left knee which caused him to lose balance and then the wheelchair moved away from him, and he was lowered to the floor. He complains of pain in the lateral left hip radiating down the lateral thigh to the left knee. He was unable to sustain any weight on his left lower extremity or turn or move the left hip without pain. His left lower extremity is internally rotated with trace lower extremity edema specifically in ankles, unable to place weight upon the left lower extremity due to pain, left hip with significant decreased range of motion due to pain, left lower extremity internally rotated and foreshortened consistent with a dislocation. Emergency Medical Services (EMS) transported Resident #3 to the hospital for possible left hip dislocation or fracture. He was taken to orthopedics where he was evaluated. He was treated with a left knee injection of lidocaine and triamcinolone (a common medical procedure used to treat various conditions involving inflammation and pain). He was subsequently diagnosed with left femoral fracture and underwent surgery of left femur on 03/28/25, with a closed fracture of shaft of left femur. An interview was conducted on 08/07/25 at 3:30 PM with the Medical Director #1. The Medical Director stated when Resident #3 was lowered onto the floor on 03/14/25, he initially had no pain or swelling and went on to dialysis and there he first complained of left knee pain. Upon his return from dialysis the facility obtained a portable x-ray of his left knee, which was negative for fracture. The Medical Director stated the resident was still complaining of pain after the initial x-ray, so a second x-ray was taken, and it also was negative for left knee fracture. The Medical Director stated Resident #3's fall on 03/14/25 initially had no pain from being lowered to the floor and later complained of left knee pain, which was possibly nerve pain that radiated to his left knee, due to a hairline fracture in his left femur that completed the non-displaced fracture days later. The Medical Director stated after the second negative knee x-ray orthopedics gave him a steroid knee injection, which helped some, but his left knee was still hurting after the injection, so they sent him to the hospital for further evaluation and treatment for possible hip dislocation. The hospital's hip x-ray did not show a dislocated hip, but a non-displaced femur fracture, which was treated with ORIF surgery. Medical Director #1 stated all of this might have been prevented if the facility had thrown out the resident's worn-out wheelchair in the first place and provided him with a new one with good wheel tread. The Administrator presented a timeline of Resident #3's fall dated 03/14/25. It revealed during a one-person stand-pivot transfer, Resident #3 requested for the staff member (NA#1) to lower him to the floor when the wheelchair moved backward during the transfer. The resident denied immediate pain, refused assessment and proceeded to dialysis as scheduled. The resident returned from dialysis with complaints of left knee pain, with the resident being immediately assessed by Nurse #3 with notification to the medical provider, with order received for left knee x-ray, and pain management given per regimen and effective. The resident's wheelchair was removed by maintenance with replacement chair provided. The Nurse Practitioner (NP #1) assessed the resident with orders to include x-ray and orthopedic referral. Mobile x-ray on 03/14/25 of resident's left knee revealed knee without fractures or dislocations identified. On 03/17/25 the NP follow-up assessment noted positive bursa effusion (accumulation of fluid in the sacs that cushion joints), and updated resident that the knee x-ray results were without fracture with recommendation to continue with orthopedic consult. On 03/20/25 Resident #3 was sent to orthopedics, with treatment regimen of steroid injection to the left knee, with order to repeat x-ray at local diagnostic center. On 03/20/25 Resident #3 was assessed by the facility medical director with further review of the 03/15/25 x-ray results with notation of results to include: no fracture or dislocation. On 03/21/25 the NP follow-up with notation resident moves all extremities, left knee flexed position and complains of pain at whole knee, with no discoloration and minimum swelling. On 03/24/25 NP #1 evaluated resident with continuation in current plan of treatment. On 03/25/25 the resident was sent out to outpatient diagnostic center for left knee -ray with results to include no fracture or dislocation noted. On 03/27/25 Resident #3 complained of pain to left hip area, not previously identified by resident during prior assessments. Nurse #3 notified NP #1 with new orders of two view x-ray of left hip. On 03/27/25 Medical Director #1 completed a physical assessment on Resident #3 with new orders given to send Resident #3 to local emergency department for further evaluation and treatment. On 03/27/25 hospital records indicated Resident #3 had a left hip fracture of the proximal femoral shaft. On 03/28/25 Resident #3 underwent open reduction internal fixation (ORIF) of his left femur. An observation was conducted on 08/05/25 at 12:20 PM of Resident #3's wheelchair located next to his bed. Resident #3 confirmed the wheelchair next to his bed was his. The wheelchair's two large back tires were worn flat and peeling black rubber tread. The right brake worked well, but the left tire brake did not lock on tire allowing the tire to slide backwards when in the locked position. The resident stated he could not remember if they gave him a different one or not after the 03/27/25 fall. An interview was conducted on 08/04/25 at 3:00 PM with the Director of Nursing (DON). The DON stated that the root cause for Resident #3's fall on 03/14/25 was a faulty wheelchair where the left brake didn't lock due to the worn tire tread, causing the wheelchair to slide back resulting in NA #1 having to lower the resident to the floor. An interview and follow-up wheelchair observation with the Administrator and Director of Nursing were conducted on 08/05/25 at 12:45 PM. They confirmed that on 03/14/25 Resident #3 was lowered to the floor because his wheelchair slid back, due to worn tires, and the left brake lock did not grab the bald tire, which was a wheelchair equipment failure. The DON stated Resident #3's old wheelchair should not have been in his room to use on 08/05/25, and should have been discarded, and a properly functioning wheelchair put in its place. The DON and Administrator expected Resident #3's wheelchair to have been replaced, and all wheelchairs in facility checked monthly and for brakes and tires to function properly, which in Resident #3's case, they missed. The Administrator and DON said they immediately removed Resident #3's wheelchair from his room after the 03/14/25 fall and replaced it with a new one. They both stated they had no idea how Resident #3's old wheelchair showed up in his room on 08/05/25.

Based on observations and staff interviews, the facility failed to: a) label and date opened packages of food for 1 of 1 walk in freezers, b) label and date items in the large walk-in refrigerator and a smaller refrigerator for 2 of 2 refrigerators in the kitchen and c) discard expired items in 2 of 2 refrigerators in 2 of 2 nutrition rooms. This deficient practice had the potential to affect the food served to the residents. Findings included:An initial tour of the kitchen was conducted on 8/4/25 at 11:00 AM in the presence of the Dietary Manager.a) Observation of the walk-in freezer revealed the following:An open cardboard box containing an opened plastic bag of hamburger meat with no opened date, an opened plastic bag of tater tots with no opened dated and an opened plastic bag of diced potatoes with no opened date. The following were also observed in the walk-in freezer:An opened bag of chicken tenders with no opened date.An opened bag of frozen cookie dough with no opened date.An opened bag of garlic bread with no opened date. An interview with the Dietary Manager was completed on 8/4/25 at 11:05 AM. The Dietary Manager stated that all opened foods stored in the walk-in freezer should be labeled and dated with the date it was opened and the expiration date. b) Observation of the large walk-in refrigerator in the kitchen revealed the following: A tray with 7 individual salads with no prepared date and 1 of the salads had brown lettuce.An opened package of sliced deli ham with no opened date Observation of the small refrigerator in the kitchen revealed the following: An opened box of thawed sausage patties with an opened date of 7/2/25. The outside of the box stated the product was to be kept frozen.An opened box of thawed sausage links with an opened date of 7/2/25. The outside of the box stated the product was to be kept frozen.An opened box of thawed bacon with no opened date. A list of Use By Dates for Refrigerator Items taped to the refrigerator stated thawed meats can be stored for 3 days. An interview was completed with the Dietary Manager on 8/4/25 at 11:30 AM. The Dietary Manager stated there was not supposed to be any expired food in the freezer or refrigerators. The Dietary Manager indicated there was not a consistent system to ensure that all foods were labeled, dated and discarded when the items expired. c-1) An observation of the refrigerator in the nutrition room on 700 and 800 Hall was conducted with the Dietary Manager on 8/5/25 at 3:00 PM. The following items were observed:An opened container of nectar thick sweet tea with an opened date of 4/3.An opened container of nectar thick water with an opened date of 3/3.The label on the containers of nectar thick liquids stated that after opening, the items may be kept up to 7 days under refrigeration.An opened bottle of prune juice with a date of 3/24.An opened carton of orange juice with no opened date.A plastic bag of fast food fried chicken with no name or date.An opened carton of apple juice with no opened date. A notice taped to the front of the refrigerator indicated juice in a carton was expired 7 days after being opened. c-2) An observation of the refrigerator in the nutrition room that is utilized for 100, 200, 300, 400, 500 and 600 halls was conducted with the Dietary Manager present on 8/5/25 at 3:10 PM and revealed the following:An opened bottle of prune juice dated 1/18.An opened bottle of prune juice dated 3/29.An unopened half gallon bottle of milk with a sell by date of 7/19/25.An opened carton of medication pass supplement with a date of 7/19/25. The label on the medication pass supplement stated consume within 4 days of opening. An opened carton of nectar thick tea dated 4/3.An opened carton of nectar thick apple juice dated 4/16.A disposable take-out container of food with a resident name and no date. An interview with the Dietary Manager on 8/5/25 at 3:15 PM revealed that she expected that all refrigerated foods, liquids and supplements would be labeled and dated properly and that expired items would be discarded. An interview with the Administrator on 8/7/25 at 4:45 PM revealed she expected all foods, liquids, and supplements would be labeled and dated and that expired items would be discarded. The Administrator further stated she expected the kitchen staff would check the dates on foods, liquids, and supplements in the freezer and the refrigerators in the kitchen and nourishment rooms and discard expired items.

Based on observations, record review, and staff interviews the facility failed to maintain a residents dignity when Nurse Aide #3 placed a meal tray at the bedside of a cognitively impaired resident (Resident #52) who was dependent on staff for feeding assistance and walked away. Nurse Aide #3 did not return to feed Resident #52 for 40 minutes. Nurse Aide #3 then attempted to feed Resident #52 the cold food on the meal tray. This occurred for 1 of 3 residents reviewed for dignity. A reasonable person may feel helpless, forgotten, and become frustrated at not being able to get assistance to eat their meal. Findings included.Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and dysphagia. A care plan dated 6/13/25 revealed Resident #52 required staff assistance with eating. The goal of care was to receive necessary staff assistance with eating to promote adequate nutrition. Interventions included to provide assistance with meals and promote dignity. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #52 was severely cognitively impaired. She required extensive one-person assistance with eating. During dining observations on 8/04/25 at 12:55 PM Resident #52 was observed sitting up in her bed. She was awake, alert, and the head of the bed was elevated in an upright position. Resident #52 was hard of hearing and non-verbal. Nurse Aide #3 entered the room and placed the lunch meal tray on Resident #52's bedside table located on the left side of Resident #52 and within her sight and the bedside table was out of her reach. Nurse Aide #3 did not set up the meal tray and turned and walked away. Resident #52 looked at the meal tray and watched Nurse Aide #3 walk out of the room. A continuous observation was conducted on 8/4/25 from 12:55 PM until 1:35 PM of room [ROOM NUMBER] where Resident #52 resided. No staff member entered the room during that time to feed Resident #52. At 1:35 PM Nurse Aide #3 returned to the room to feed Resident #52. Nurse Aide #3 set up the meal tray, sat down at the bedside and attempted to start feeding Resident#52 her meal. The surveyor intervened and asked if the food which consisted of meatballs, green beans, potato salad and bread was cold. Nurse Aide #3 stated the food was cold due to the meal tray sitting in the room for 40 minutes. Nurse Aide #4 who was in the hallway, was asked to go get a fresh hot meal tray from the kitchen. Resident #52 was pointing at the meal tray while Nurse Aide #3 was sitting there. Nurse Aide #3 went ahead and started feeding her the potato salad which is to be served cold while waiting on another meal tray to come from the kitchen. Nurse Aide #3 returned within 5 minutes with a hot tray. Nurse Aide #3 began feeding Resident #52 at 1:45 PM. During an interview on 8/4/25 at 1:40 PM Nurse Aide #3 stated she had three residents on her assignment that needed to be fed by staff. She stated she delivered the meal tray to Resident #52's room then left to go feed the resident in room [ROOM NUMBER]A while Nurse Aide #4 fed the resident in 415 B. She stated it took a while to feed the residents in 415 then she went down to feed Resident #52. She reported that her and Nurse Aide #4 knew who needed to be fed by staff but today they had Nurse Aide #5 on the unit who was agency staff and would not have known to come and assist with feeding the residents. Nurse Aide #3 stated she should have informed the agency nurse aide (Nurse Aide #5) to assist with feeding Resident #52, but she did not think to do that. During an interview on 8/4/25 at 2:10 PM Nurse Aide #4 stated there were three residents on the hall that needed to be fed by staff. She stated typically three nurse aides would feed the three residents during meals but today they had an agency nurse aide that probably was not told to assist with feeding residents their meals. During an interview on 8/4/25 at 2:20 PM Nurse Aide #5 stated she was an agency nurse aide. She stated she was not informed that there were three residents on the hall that needed to be fed by staff or to assist them with their meals. She indicated she was not assigned to Resident #52. She stated she assisted with feeding residents their breakfast this morning without being told to do so, but she was not told to assist with feeding residents their lunch meal.During an interview on 8/4/25 at 2:30 PM the Director of Nursing (DON) stated waiting 40 minutes to feed Resident #52 was too long. The DON stated that Nurse Aide #3 should have informed the agency nurse aide (Nurse Aide #5) to assist her with feeding the residents. She stated Nurse Aide #3 should not have placed the meal tray in front of Resident #52 and not return for 40 minutes to feed her and then attempt to feed her cold food.

Based on manufacturer directions, observations, and staff interviews, the facility failed to remove 1 opened multi-dose insulin injector pen that was expired in 1 of 3 medication carts (200-hall medication cart), reviewed for medication storage and labeling.The findings included: The manufacturer's directions for insulin glargine injector pen stated once opened, the product is good for 28-days. Discard after 28 days: Even if there's insulin left in the pen after 28-days, discard it. The insulin may have lost potency after this time.An observation of the 200-hall medication cart and interview with Nurse #5 were conducted on [DATE] at 8:45 AM. An opened insulin glargine injector pen dated [DATE] was found in the cart. The insulin glargine pen had a label on it which stated the insulin pen was to be discarded 28 days after opening. Nurse #5 stated the expired insulin glargine pen dated [DATE] should have been removed after 28-days by the night nurse on the 200-hall medication cart and was not.An interview was conducted with the Interview with the Director of Nursing (DON) after the medication storage observation on [DATE] at 3:30 PM. The DON stated the insulin glargine pen that was opened and dated [DATE] should have been discarded by the night nursing staff after 28-days from [DATE] and was not.An interview was conducted with the Administrator on [DATE] at 4:00 PM. She stated the nursing staff were responsible for dating the insulin pen injector when it was opened and discarding it 28 days after opening. The Administrator further stated the nursing staff were responsible for checking and removing any expired medication from the medication carts.

Based on record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.) hold Humulin Regular (short acting) insulin when Resident #7's the blood glucose was less than 150 mg/dl (milligrams per deciliter) at 7:30 AM and less than 120 mg/dl at 11:00 AM and 5:00 PM. 2.) hold Resident #8's Humalog (insulin lispro) short acting insulin 5 units before meals for a blood glucose less than 100 mg/dl. 3.) give Resident #9 Humalog insulin 5 units before meals for premeal blood glucose over 150 mg/dl. 4.) give Resident #10 an additional 4 units of Humalog insulin for premeal blood glucose over 200 mg/dl. 5.) hold Humalog insulin according to the physician's order for Resident #11 and Resident#12 when the blood glucose was less than 120 mg/dl. 6.) administer the antihypertensive medication Clonidine prescribed as needed for increased blood pressure to Resident #3 and Resident#13 when the systolic blood pressure was greater than 160 and 170 millimeters of mercury (mmHg). The residents experienced no significant outcome. This occurred for 8 of 8 residents reviewed for medication administration. Findings included: 1.) Resident #7 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus and long term use of insulin. Review of the medical records for November 2024, December 2024, January 2025, February 2025 and March 2025 revealed Resident #7 had the following active orders: At 7:30 AM Humulin R Injection Solution 100 UNIT/ML (Units per Milliliter) (Insulin Regular (Human)) Inject 7 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus without complications. Hold for blood glucose less than 150 mg/dl. At 11:00 AM & 5:00 PM Humulin R Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 4 unit subcutaneously two times a day related to Type 2 Diabetes Mellitus without complications. Hold for blood glucose less than 120 mg/dl. Review of the Medication Administration Records revealed Resident #7 received 7 units of insulin at 7:30 AM with a blood glucose result of less than 150 mg/dl: 11/05/24 at 7:30 AM blood glucose 136 mg/dl, 7 units of insulin was administered by Nurse #11 11/23/24 at 7:30 AM blood glucose 131 mg/dl, 7 units of insulin was administered by Nurse #22 11/24/24 at 7:30 AM blood glucose 132 mg/dl, 7 units of insulin was administered by Nurse #22 11/26/24 at 7:30 AM blood glucose 143 mg/dl, 7 units of insulin was administered by Nurse #11 11/28/24 at 7:30 AM blood glucose 131 mg/dl, 7 units of insulin was administered by Nurse #22 11/29/24 at 7:30 AM blood glucose 148 mg/dl, 7 units of insulin was administered by Nurse #11 12/03/24 at 7:30 AM blood glucose 127 mg/dl, 7 units of insulin was administered by Nurse #22 12/06/24 at 7:30 AM blood glucose 110 mg/dl, 7 units of insulin was administered by Nurse #22 12/07/24 at 7:30 AM blood glucose 125 mg/dl, 7 units of insulin was administered by Nurse #22 12/08/24 at 7:30 AM blood glucose 115 mg/dl, 7 units of insulin was administered by Nurse #22 12/09/24 at 7:30 AM blood glucose 148 mg/dl, 7 units of insulin was administered by Nurse #13 12/10/24 at 7:30 AM blood glucose 147 mg/dl, 7 units of insulin was administered by Nurse #22 12/11/24 at 7:30 AM blood glucose 137 mg/dl, 7 units of insulin was administered by Nurse #22 12/16/24 at 7:30 AM blood glucose 148 mg/dl, 7 units of insulin was administered by Nurse #13 12/31/24 at 7:30 AM blood glucose 137 mg/dl, 7 units of insulin was administered by Nurse #22 01/15/25 at 7:30 AM blood glucose 133 mg/dl, 7 units of insulin was administered by Nurse #11 01/16/25 at 7:30 AM blood glucose 129 mg/dl, 7 units of insulin was administered by Nurse #11 01/20/25 at 7:30 AM blood glucose 144 mg/dl, 7 units of insulin was administered by Nurse #11 01/29/25 at 7:30 AM blood glucose 121 mg/dl, 7 units of insulin was administered by Nurse #11 01/30/25 at 7:30 AM blood glucose 130 mg/dl, 7 units of insulin was administered by Nurse #11 02/06/25 at 7:30 AM blood glucose 114 mg/dl, 7 units of insulin was administered by Nurse #12 02/09/25 at 7:30 AM blood glucose 123 mg/dl, 7 units of insulin was administered by Nurse #11 02/17/25 at 7:30 AM blood glucose 148 mg/dl, 7 units of insulin was administered by Nurse #11 02/18/25 at 7:30 AM blood glucose 122 mg/dl, 7 units of insulin was administered by Nurse #11 02/19/25 at 7:30 AM blood glucose 127 mg/dl, 7 units of insulin was administered by Nurse #22 03/12/25 at 7:30 AM blood glucose 138 mg/dl, 7 units of insulin was administered by Nurse #11 Review of Medication Administration Records revealed Resident #7 received 4 units of insulin at 11:00 AM and 5:00 PM with a blood glucose result of less than 120 mg/dl: 11/14/24 at 11:00 AM blood glucose 113 mg/dl, 4 units of insulin was administered by Nurse #22 11/27/24 at 5:00 PM blood glucose 116 mg/dl, 4 units of insulin was administered by Nurse #22 11/28/24 at 11:00 AM blood glucose 107 mg/dl , 4 units of insulin was administered by Nurse #22 12/08/24 at 11:00 AM blood glucose 101 mg/dl, 4 units of insulin was administered by Nurse #22 12/10/24 at 5:00 PM blood glucose 118 mg/dl, 4 units of insulin was administered by Nurse #14 12/11/24 at 11:00 AM blood glucose 103 mg/dl, 4 units of insulin was administered by Nurse #22 12/11/24 at 5:00 PM blood glucose 103 mg/dl, 4 units of insulin was administered by Nurse #22 12/14/24 at 5:00 PM blood glucose 100 mg/dl, 4 units of insulin was administered by Nurse #11 12/24/24 at 11:00 AM blood glucose 118 mg/dl, 4 units of insulin was administered by Nurse #11 01/01/25 at 5:00 PM blood glucose 109 mg/dl, 4 units of insulin was administered by Nurse #11 02/06/25 at 11:00 AM blood glucose 102 mg/dl, 4 units of insulin was administered by Nurse #12 02/27/25 at 11:00 AM blood glucose was 104 mg/dl, 4 units of insulin was administered by Nurse #5 02/27/45 at 5:00 PM blood glucose was 104 mg/dl, 4 units of insulin was administered by Nurse #5 Review of the progress notes from 11/05/24 through 03/12/25 for Resident #7 revealed no documentation that the insulin was held on the dates listed. An interview was conducted with Nurse #11 on 03/13/25 at 4:26 PM. She stated that she thought the parameter of 120 mg/dl applied to the insulin order at 7:30 AM as well as before meals for Resident #7. She concluded that she had given insulin in error because she had not paid close attention to the order parameters. A telephone interview was conducted with Nurse #12 on 03/14/25 at 11:00 AM. She stated that she was used to working at the hospital where sliding scales are used and not a lot of different parameters like at the nursing home. She explained that any instructions for medications are written really small on the bottom of the screen, so she probably missed the parameters and administered Resident #7 the wrong dose of insulin. She concluded she needed to pay closer attention to the small print. A telephone interview was conducted with Nurse #5 on 03/14/25 at 12:31 PM. She stated that she did not think she had given any insulin outside of the ordered parameters. She explained that she had immediate family members who had brittle diabetes and that she always looked for parameters on insulin orders. She stated that she thought she had clicked on the wrong box when documenting and had not administered any insulin in error. A telephone interview was conducted with Nurse #14 on 03/14/25 at 12:57 PM. She stated she knew to click on more to see the full order but could not remember seeing parameters set for insulin orders and that to give insulin before breakfast was rare. She stated she did not remember administering insulin to Resident #7 that had parameters. A telephone interview was conducted with Nurse #13 on 03/14/25 at 3:50 PM. She stated that some insulin orders had parameters and some did not. She thought she might have missed the parameters for the insulin orders because she had to click an additional box to open the order instructions and see the parameters. She believed she did not click on the box to open the order instructions and had not realized that any insulin orders had parameters when she administered the medication to Resident #7 in error. A telephone interview was conducted with Nurse #22 on 03/17/25 a 12:27 PM. She stated she had just learned that when she clicked on the order on the computer screen she then had to click on more to see the parameters. She did not realize the insulin orders included parameters and had given the insulin to Resident #7 in error. A telephone interview was conducted with Nurse Practitioner #1 on 03/14/25 at 12:40 PM. She stated that nothing had been reported to her that Resident #7 had experienced a change in condition. She explained that possible outcomes as a result of the medication errors could have been hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) both of which could cause confusion, lethargy, seizures, coma, or death. She reported that Resident #7's blood glucose levels were under control according to the latest laboratory tests and that Resident #7 had not suffered any poor outcome because of the medication errors. A telephone interview was conducted with the Medical Director on 03/17/25 at 3:36 PM. He stated he was new at the facility and had only been there six weeks. He stated nothing had been reported to him regarding Resident #7 related to a change in condition related to insulin administration. He noted the purpose of setting parameters for insulin administration was to regulate the blood glucose using both fast acting and long acting insulins in combination. The parameters for insulin were specifically intended to prevent blood glucoses from being too low or too high which could lead to impaired vision, stroke, mental status change, coronary artery disease, or death. He was not aware of any resident at the facility who had experienced a negative outcome related to insulin that was held or given in error. A telephone interview was conducted with the Pharmacist Consultant on 03/17/25 at 3:15 PM. She stated that she had been notifying the facility that staff were not following parameters when administering insulin. She noted every month she sent pharmacy recommendations via fax to both Unit Managers for follow up. She also attended the Quality Improvement meetings at the facility each month and stated that medication errors caused by not following insulin parameter orders was specifically discussed each month. She stated she knew the facility had been re-educating staff regarding insulin parameters because it had been discussed in the meetings. A telephone interview was conducted with Unit Manager #1 on 03/17/25 at 4:34 PM. She stated she received nursing recommendations monthly from the pharmacist and was aware of the errors caused by nurses not following parameters related to insulin orders. She explained training was provided to individual nurses and beginning in February 2025 to all nursing staff including agency nurses. She educated all the nurses on how to check insulin orders for parameters and how to chart code an order with a 5 or an 11 to indicate the medication had not been administered. She concluded that since the re-education had started there had been a sharp decrease in the number of medication errors related to insulin. 2.) Resident #8 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy and long term use of insulin. Review of the medical records for January 2025 and February 2025 revealed Resident #8 had the following active order: Humalog Solution 100 UNIT/ML (Insulin Lispro (Human)) Inject 5 units subcutaneously before meals for diabetes. Hold for BS (blood glucose) less than 100. Review of Medication Administration Records revealed Resident #8 received 5 units of insulin at 8:00 AM with a blood glucose result of less than 100 mg/dl and was not given insulin with a blood glucose over 100: 01/23/25 at 11:00 AM blood glucose 98 mg/dl, 5 units of insulin was administered by Nurse #7 02/01/25 at 8:00 AM blood glucose 108 mg/dl, 5 units of insulin was held by Nurse #7 indicated by a chart code of 11 (no insulin required per order). 02/07/25 at 8:00 AM blood glucose 98 mg/dl, 5 units of insulin was administered by Nurse #3 02/08/25 at 8:00 AM blood glucose 98 mg/dl, 5 units of insulin was administered by Nurse #3 Review of the progress notes from 01/23/25 through 02/08/25 for Resident #8 revealed no documentation that the insulin was held on the dates listed or given on 02/01/25. A telephone interview was conducted with Nurse #7 on 03/14/25 at 1:34 PM. She stated that she did not recall insulin orders with parameters. She explained she had been confused regarding the insulin orders because she had to click on two different tabs plus she had sliding scale orders for insulin that she gave. She stated she did not recall that Resident #8 had parameters in the insulin order. A telephone interview was conducted with Nurse #3 on 03/14/25 at 7:30 PM. She stated that she clicked on the medication to be administered prior to going into a resident's room and did not go back to the tab afterwards to document that she had held the insulin. Because of this she thought she documented in error but had not given the wrong dose of insulin. In addition, she explained her nursing judgement would tell her not to administer fast acting insulin for a blood glucose less than 100. She noted even if the blood glucose was 100 or 101 she would have called the physician for guidance. A telephone interview was conducted with Nurse Practitioner #2 on 03/17/24 at 12:28 PM. She stated she had been working at the facility since February 17, 2025. She explained she was still getting to know the residents. She noted that the insulin parameters were in place in an attempt to control blood glucose levels. She stated insulin administered in error was concerning because it could lead to either hyperglycemia and hypoglycemia either of which could lead to unconsciousness and in extreme cases death. She reported she had not been notified of any change in condition regarding Resident #8. A telephone interview was conducted with the Medical Director on 03/17/25 at 3:36 PM. He stated he was new at the facility and had only been there six weeks. He stated nothing had been reported to him regarding Residents #8 related to a change in condition related to insulin administration. He noted the purpose of setting parameters for insulin administration was to regulate the blood glucose using both fast acting and long acting insulins in combination. The parameters for insulin were specifically intended to prevent blood glucoses from being too low or too high which could lead to impaired vision, stroke, mental status change, coronary artery disease, or death. He was not aware of any resident at the facility who had experienced a negative outcome related to insulin that was held or given in error. A telephone interview was conducted with the Pharmacist Consultant on 03/17/25 at 3:15 PM. She stated that she had been notifying the facility that staff were not following parameters when administering insulin. She noted every month she sent pharmacy recommendations via fax to both Unit Managers for follow up. She also attended the Quality Improvement meetings at the facility each month and stated that medication errors caused by not following insulin parameter orders was specifically discussed each month. She stated she knew the facility had been re-educating staff regarding insulin parameters because it had been discussed in the meetings. A telephone interview was conducted with Unit Manager #1 on 03/17/25 at 4:34 PM. She stated she received nursing recommendations monthly from the pharmacist and was aware of the errors caused by nurses not following parameters related to insulin orders. She explained training was provided to individual nurses and beginning in February 2025 to all nursing staff including agency nurses. She educated all the nurses on how to check insulin orders for parameters and how to chart code an order with a 5 or an 11 to indicate the medication had not been administered. She concluded that since the re-education had started there had been a sharp decrease in the number of medication errors related to insulin. 3.) Resident #9 was admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus with chronic kidney disease Stage 3 and long term use of insulin. Review of the medical records for January 2025 and February 2025 revealed Resident #9 had the following active order: Humalog Solution 100 UNIT/ML (Insulin Lispro (Human)) Inject 5 units subcutaneously before meals for diabetes for premeal glucose over 150. Review of Medication Administration Records revealed Resident #9 received 5 units of insulin with a blood glucose result of less than 150 mg/dl: 01/01/25 at 6:00 AM blood glucose 102 mg/dl, 5 units of insulin was administered by Nurse #15 01/08/25 at 6:00 AM blood glucose 134 ml/dl, 5 units of insulin was administered by Nurse #13 01/12/25 at 11:00 AM blood glucose 146 ml/dl, 5 units of insulin was administered by Nurse #11 01/13/25 at 6:00 AM blood glucose 134 ml/dl, 5 units of insulin was administered by the MDS Nurse 01/22/25 at 6:00 AM blood glucose 126 ml/dl, 5 units of insulin was administered by Nurse #16 01/25/25 at 6:00 AM blood glucose 101 ml/dl, 5 units of insulin was administered by Nurse #7 01/30/25 at 6:00 AM blood glucose 115 ml/dl, 5 units of insulin was administered by Nurse #17 02/05/25 at 6:00 AM blood glucose 119 ml/dl, 5 units of insulin was administered by Nurse #7 02/06/25 at 6:00 AM blood glucose 115 ml/dl, 5 units of insulin was administered by Nurse #14 02/08/25 at 6:00 AM blood glucose 108 ml/dl, 5 units of insulin was administered by Nurse #7 02/12/25 at 6:00 AM blood glucose 98 ml/dl, 5 units of insulin was administered by Nurse #14 02/14/25 at 6:00 AM blood glucose 101 ml/dl, 5 units of insulin was administered by Nurse #18 02/18/25 at 6:00 AM blood glucose 148 ml/dl, 5 units of insulin was administered by Nurse #13 02/20/25 at 6:00 AM blood glucose 132 ml/dl, 5 units of insulin was administered by Nurse #14 02/21/25 at 5:00 PM blood glucose 141 ml/dl, 5 units of insulin was administered by Nurse #6 02/22/25 at 6:00 AM blood glucose 147 ml/dl, 5 units of insulin was administered by Nurse #7 Review of the progress notes from 10/01/25 through 02/22/25 for Resident #9 revealed no documentation that the insulin was held on the dates listed. An interview was conducted with Nurse #11 on 03/13/25 at 4:26 PM. She stated that she thought the parameter of 120 mg/dl applied to the insulin order for Resident #9 not 150 mg/dl. She concluded that she had given insulin in error because she had not paid close attention to the order parameters. An interview was conducted with the MDS Nurse on 03/13/25 at 4:48 PM. She stated she had not understood the way the order was written when she administered insulin to Resident #9. She explained that because most parameters were related to holding insulin if the blood glucose was under a certain number not to give insulin if the blood glucose level was above a certain number. She stated she had made a basic human error and had given the insulin when it should have been held. A telephone interview was conducted with Nurse #14 on 03/14/25 at 12:57 PM. She stated she knew to click on more to see the full order but could not remember seeing parameters set for insulin orders and also that giving insulin before breakfast was rare. She stated she did not remember giving insulin that had parameters to Resident #9. A telephone interview was conducted with Nurse #15 on 03/14/25 at 1:11 PM. She stated she had no memory of the resident or that she had administered insulin that had set parameters. A telephone interview was conducted with Nurse #16 on 03/14/25 at 1:15 PM. She stated that she always checked for parameters when administering insulin. She explained that some of the keys on the computer keyboards stuck and that she had found wrong numbers documented in the past that she corrected. She stated she felt the blood glucose that was recorded was not accurate and that she gave the insulin within the set parameters as ordered. A telephone interview was conducted with Nurse #7 on 03/14/25 at 1:34 PM. She stated that she did not recall insulin orders with parameters. She explained she had been confused regarding the insulin orders because she had to click on two different tabs plus a sliding scale order for insulin that she gave. She stated she did not recall that Resident #9 had parameters in the insulin order. A telephone interview was conducted with Nurse #13 on 03/14/25 at 3:50 PM. She stated that some insulin orders had parameters and some did not. She thought she might have missed the parameters for the insulin orders because she had to click an additional box to open the order instructions and see the parameters. She believed she did not click on the box to open the order instructions and had not realized that any insulin orders had parameters when she administered the medication to Resident #9. A telephone interview was conducted with Nurse #6 on 03/17/25 at 12:15 PM when she returned the call. She stated she worked at several different places and could not remember giving insulin at the facility to Resident #9. She explained she could not remember what she had given or why from memory. An interview was not conducted with Nurse #18. Attempts to contact her on 03/14/25 at 1:40 PM vial phone and text message and again on 03/17/25 at 11:59 AM were not successful. An interview was not conducted with Agency Nurse #17. She was out of the country and not available for interview. A telephone interview was conducted with Nurse Practitioner #2 on 03/17/24 at 12:28 PM. She stated she had been working at the facility since February 17, 2025. She explained she was still getting to know the residents. She noted that the insulin parameters were in place in an attempt to control blood glucose levels. She stated insulin administered in error was concerning because it could lead to either hyperglycemia and hypoglycemia either of which could lead to unconsciousness and in extreme cases death. She reported she had not been notified of any change in condition regarding Resident #9. A telephone interview was conducted with the Medical Director on 03/17/25 at 3:36 PM. He stated he was new at the facility and had only been there six weeks. He stated nothing had been reported to him regarding Residents #9 regarding a change in condition related to insulin administration. He noted the purpose of setting parameters for insulin administration was to regulate the blood glucose using both fast acting and long acting insulins in combination. The parameters for insulin were specifically intended to prevent blood glucoses from being too low or too high which could lead to impaired vision, stroke, mental status change, coronary artery disease, or death. He was not aware of any resident at the facility who had experienced a negative outcome related to insulin that was held or given in error. A telephone interview was conducted with the Pharmacist Consultant on 03/17/25 at 3:15 PM. She stated that she had been notifying the facility that staff were not following parameters when administering insulin. She noted every month she sent pharmacy recommendations via fax to both Unit Managers for follow up. She also attended the Quality Improvement meetings at the facility each month and stated that medication errors caused by not following insulin parameter orders was specifically discussed each month. She stated she knew the facility had been re-educating staff regarding insulin parameters because it had been discussed in the meetings. A telephone interview was conducted with Unit Manager #1 on 03/17/25 at 4:34 PM. She stated she received nursing recommendations monthly from the pharmacist and was aware of the errors caused by nurses not following parameters related to insulin orders. She explained training was provided to individual nurses and beginning in February 2025 to all nursing staff including agency nurses. She educated all the nurses on how to check insulin orders for parameters and how to chart code an order with a 5 or an 11 to indicate the medication had not been administered. She concluded that since the re-education had started there had been a sharp decrease in the number of medication errors related to insulin. 4.) Resident #10 was admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus without complications and long term use of insulin. Review of the medical records for December 2025 and January 2025 revealed Resident #10 had the following active order: Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. For premeal glucoses over 200 give additional 4 units. Do not call provider unless blood glucose greater than 450 mg/dL. Review of Medication Administration Records revealed Resident #10 had not received an additional 4 units of insulin with a blood glucose result greater than 200 mg/dl: 12/04/24 at 11:00 AM blood glucose 261 ml/dl, Nurse #7 signed that she gave a total of 10 units of insulin 12/15/24 at 11:00 AM blood glucose 217 ml/dl, Nurse #24 signed that she gave a total of 10 units of insulin 12/26/24 at 4:00 PM blood glucose 237 ml/dl, Nurse #19 signed that she gave a total of 10 units of insulin 12/30/24 at 8:00 AM blood glucose 253 ml/dl, Nurse #13 signed that she gave a total of 10 units of insulin 01/01/25 at 11:00 AM blood glucose 252 ml/dl, Nurse #7 signed that she gave a total of 10 units of insulin 01/01/25 at 4:00 PM blood glucose 207 ml/dl, Nurse #19 signed that she gave a total of 10 units of insulin 01/03/25 at 11:00 AM blood glucose 230 ml/dl, Nurse #7 signed that she gave a total of 10 units of insulin Review of the progress notes from 12/04/24 through 01/03/25 for Resident #10 revealed no documentation that 4 additional units of insulin was given on the dates listed. A telephone interview was conducted with Nurse #7 on 03/14/25 at 1:34 PM. She stated that she did not recall insulin orders with parameters. She explained she had been confused regarding the insulin orders because she had to click on two different tabs plus she had sliding scale orders for insulin that she gave. She stated she did not recall that Resident #10 had parameters in the insulin order. A telephone interview was conducted with Nurse #13 on 03/14/25 at 3:50 PM. She stated that some insulin orders had parameters and some did not. She thought she might have missed the parameters for the insulin orders because she had to click an additional box to open the order instructions and see the parameters. She believed she did not click on the box to open the order instructions and had not realized that any insulin orders had parameters when she administered the medication to Resident #10. A telephone interview was conducted with Nurse #19 on 03/14/25 at 4:10 PM. She stated she knew that she had to click on the word more to see the full order. She did not recall giving insulin that had parameters to Resident #10 and would have to see the order to know what had happened because she could not remember. A telephone interview was conducted with Nurse #24 on 03/17/25 at 4:33 PM. She stated she knew the residents and knew which residents had insulin order parameters. She concluded that she always followed the parameters when administering insulin and must have documented incorrectly that she administered 10 units of insulin to Resident #10 when she knew she gave 14 units as ordered. A telephone interview was conducted with Nurse Practitioner #1 on 03/14/25 at 12:40 PM. She stated that nothing had been reported to her that Residents #10 had experienced a change in condition. She explained that possible outcomes as a result of the medication errors could have been hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) both of which could cause confusion, lethargy, seizures, coma, or death. She reported that residents #10's blood glucoses were under control according to the latest laboratory tests and that Resident #10 had not suffered any poor outcome because of the medication errors. A telephone interview was conducted with the Medical Director on 03/17/25 at 3:36 PM. He stated he was new at the facility and had only been there six weeks. He stated nothing had been reported to him regarding Residents #10 having had a change in condition related to insulin administration. He noted the purpose of setting parameters for insulin administration was to regulate the blood glucose using both fast acting and long acting insulins in combination. The parameters for insulin were specifically intended to prevent blood glucoses from being too low or too high which could lead to impaired vision, stroke, mental status change, coronary artery disease, or death. He was not aware of any resident at the facility who had experienced a negative outcome related to insulin that was held or given in error. A telephone interview was conducted with the Pharmacist Consultant on 03/17/25 at 3:15 PM. She stated that she had been notifying the facility that staff were not following parameters when administering insulin. She noted every month she sent pharmacy recommendations via fax to both Unit Managers for follow up. She also attended the Quality Improvement meetings at the facility each month and stated that medication errors caused by not following insulin parameter orders was specifically discussed each month. She stated she knew the facility had been re-educating staff regarding insulin parameters because it had been discussed in the meetings. A telephone interview was conducted with Unit Manager #1 on 03/17/25 at 4:34 PM. She stated she received nursing recommendations monthly from the pharmacist and was aware of the errors caused by nurses not following parameters related to insulin orders. She explained training was provided to individual nurses and beginning in February 2025 to all nursing staff including agency nurses. She educated all the nurses on how to check insulin orders for parameters and how to chart code an order with a 5 or an 11 to indicate the medication had not been administered. She concluded that since the re-education had started there had been a sharp decrease in the number of medication errors related to insulin. 40044 5a.) Resident #11 was admitted to the facility on [DATE] with diagnoses including diabetes, and long-term use of insulin. A physician's order dated 6/24/24 for Resident #11 revealed Insulin Lispro (Humalog) 100 units per milliliter. Inject 6 units once a day and 10 units before dinner. Hold for blood glucose less than 120 mg/dl. Review of the Medication Administration Record (MAR) dated October 2024 for Resident #11 revealed Insulin Lispro (Humalog) 100 units per milliliter. Inject 6 units once a day and 10 units before dinner. Hold for blood glucose less than 120 mg/dl and scheduled for administration at 11:30 AM and 4:00 PM. Humalog was administered outside of the ordered parameters on the following dates and times: 10/16/24 at 11:30 AM blood glucose 93mg/dl, 6 units of insulin was administered by Nurse #3 10/29/24 at 4:00 PM blood glucose 102 mg/dl, 10 units of insulin was administered by Nurse #3 Review of the progress notes from 10/16/24 through 10/29/24 for Resident #11 revealed no documentation that the insulin was held on the dates listed. Review of the Medication Administration Record (MAR) dated November 2024 for Resident #11 revealed Insulin Lispro (Humalog) 100 units per milliliter. Inject 6 units once a day and 10 units before dinner. Hold for blood glucose less than 120 mg/dl and scheduled for administration at 11:30 AM and 4:00 PM. Humalog was administered outside of[TRUNCATED]

Based on observation and staff interviews the facility failed to maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and failed to repair peeling paint hanging from the ceiling above 2 of 2 food preparation tables. These practices had the potential to affect 90 of 91 residents' food quality and kitchen sanitation safety. Findings included: 1) The initial tour of the kitchen conducted on 08/05/24 at 11:35 AM the Dietary Manager (DM) said the staff used the solution in the red bucket to wipe down the main food preparation table area after food preparation and prior to manning the tray line. DM said their stainless-steel food preparation tables were wiped down before breakfast and again just before lunch tray line set-up using the sanitizing solution kept in the only red sanitizing bucket kept under the kitchen's food preparation tables. At 11:45 AM on 08/05/24 strips were used to check the sanitizing solution in the kitchen's only red sanitizing bucket. The solution in the bucket registered 0-parts per million (PPM) of quaternary sanitizer. DM reported she or her staff did not check the strength of the sanitizing solution in the bucket when it was filled that morning, prior to wiping down all [NAME]. preparation table services. She said her dietary kitchen aide was new and did not know how to add sanitizing solution to the red bucket or how to test strip the solution's strength throughout the day, to keep it between 200 - 300 PPM. The DM then demonstrated with the help of the new dietary kitchen aide how to properly fill the red sanitizing bucket, by first filling the bucket with clean tap water, then she added the proper amount of sanitizing solution to the bucket, and finally she tested the red bucket's solution with a test strip that read 200 - 300 PPM, which the DM said was acceptable for disinfecting food preparation services. DM was interviewed on 08/05/24 at 11:50 AM said she preferred the quaternary solution in the red sanitizer bucket to register 200 - 300 PPM when checked with the appropriate strips. She reported when the strength was less than this there was a chance that the surfaces being wiped down were not properly disinfected. She commented the strength of the solution in the bucket should be checked when the bucket was made up and should not have registered 0-PPM. 2) A follow-up interview and observation were conducted of the kitchen on 08/05/24 at 12:00 PM revealed the ceiling above 2 of the food preparation tables and tray line table had chipped and peeling paint hanging from the ceiling above the tables. An interview was conducted on 08/06/24 at 9:00 AM with the Maintenance Director. He stated he was not aware of the kitchen's peeling ceiling paint. He stated the Dietary Manager had recently spoken to him about the need to repair the peeling ceiling paint area above the food preparation area. When the Maintenance Director observed the peeling paint on the kitchen's ceiling, he stated it needed to be repaired and he would see to it. An interview was conducted on 08/06/24 at 9:15 AM with the Administrator. She reported it was her expectation for the facility's kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety by testing disinfectant solution and keeping painted areas repaired per kitchen sanitation guidelines. She said the peeling ceiling in the kitchen needed to be repaired and will instruct the Maintenance Director to begin the process of repairing the ceiling. An interview was conducted on 08/06/24 at 12:15 PM with the Dietary Manager. She stated the Maintenance Director was notified of the kitchen's peeling ceiling paint and the need to be repaired. She said the peeling ceiling paint could be a food or sanitation hazard, if it fell on to the preparation tables or into residents' food.

Based on observations, record review, resident, staff, and the Nurse Practitioner's interviews the facility failed to implement an order for Metoprolol 50 milligrams daily (a beta blocker indicated for the treatment of hypertension and heart failure) that was prescribed for atrial fibrillation (irregular heart rhythm) following a cardiology appointment. The medication error resulted in 25 missed doses. This occurred for 1 of 1 resident (Resident #55) reviewed for medication administration. Findings included. Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation and chronic systolic congestive heart failure. Review of a cardiology consult report dated 07/11/24 revealed Resident #55 had permanent atrial fibrillation. The electrocardiogram (ECG) showed atrial fibrillation with mildly increased ventricular rate at 114 beats per minute. The recommended best medical therapy was to add Metoprolol Succinate 50 milligrams (mgs) daily to help with ventricular rate control. Medication changes included: to add Metoprolol Succinate 50 mgs take one tablet by mouth daily with a start date of 07/11/24 and end date 07/11/25. Review of the Medication Administration Record (MAR) dated July 2024 for Resident #55 revealed no order for Metoprolol Succinate 50 mgs daily. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #55 was cognitively intact. He experienced no shortness of breath. During an interview on 08/05/24 at 11:34 AM Resident #55 was observed lying in bed. He was alert and oriented to person, place, and time. He stated he felt okay today but had not been up yet. He stated he did not have difficulty breathing, chest pain or dizziness at this time. During an interview on 08/06/24 at 01:58 PM Nurse #1 indicated Resident #55 did not have Metoprolol 50 mgs ordered for administration. She stated he was not on blood pressure medications. She stated she assessed Resident #55 today and his lungs were clear, his oxygen saturation was within normal limits, and he had no shortness of breath or complaints of chest pain. She stated Nurse Practitioner #1 also evaluated Resident #55 today and reported no shortness of breath or chest pain. She indicated she was not aware of an order for Metoprolol 50 mgs for Resident #55. During a phone interview on 08/07/24 at 9:55 AM the Director of Nursing (DON) stated the Nurse Practitioner evaluated Resident #55 yesterday on 08/06/24 and reviewed the cardiology report and that was when it was realized that Metoprolol 50 mgs daily had not been implemented for Resident #55 following the cardiology visit on 07/11/24. She stated when residents returned from an appointment the consult reports with any new orders were placed into the physician or Nurse Practitioners box. She stated that the delay in getting the medication ordered was because the order was placed in the box of a temporary physician who no longer worked for the facility. She stated the order was overlooked and not followed up on which was done in error. She stated the order for Metoprolol 50 mgs was entered yesterday on 08/06/24 for Resident #55 and acknowledged that the Metoprolol order should have been initiated on 07/11/24 following the cardiology appointment. During a phone interview on 08/07/24 at 11:15 AM Nurse Practitioner #1 stated she saw the cardiology notes just yesterday on 08/06/24 to order Metoprolol 50 mgs daily for Resident #55. She stated once she read the cardiology consult and saw that Resident #55 was not on Metoprolol she wrote the order. She reported the cardiologist ordered Metoprolol for Resident #55 for the treatment of atrial fibrillation. She stated there had been no significant outcome from not receiving the medication and Resident #55's heart rate was never elevated enough to cause concern. She indicated his heart rate and blood pressure were within normal limits. She stated she was not aware of the facility process regarding getting physician consultation orders to her but expected the physician consultation notes would get to her for review within a reasonable timeframe. She indicated the order should have been implemented following the cardiology appointment on 07/11/24.

Based on observations, record review, staff, and resident interviews the facility failed to provide an adaptive handled cup for 1 of 1 resident (Resident #27) reviewed for accommodation of needs. Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses of osteoarthritis with stiffness of right and left hand. Resident #27's 1/28/23 quarterly Minimum Data Set (MDS) assessment revealed resident was cognitively intact and required set up assist and supervision with eating. Resident #27 had functional limitation of range of motion of upper extremity on both sides. Resident #27's care plan indicated a focus entered on 6/17/20 and revised on 1/28/23 of required set up assistance with eating meals and handled cups for all meals. Interventions included a handled cup with all meals, set up meal tray and report if increased assistance was needed with eating and drinking. Observation on 3/20/23 at 12:56 PM revealed Resident #27sitting in wheelchair with meal tray on the tray table in front of her. Resident #27's drinks were not served in handled cups. Observation on 3/21/23 at 8:56 AM of breakfast meal revealed Resident #27 did not have handled cups on her meal tray for her drinks. Observation of the meal ticket on her tray revealed a diet order of regular diet and did not list handled cup for meals. Observation and interview with Resident #27 on 3/22/23 at 8:56 AM revealed resident sitting in wheelchair with breakfast tray on the table in front of her and resident feeding herself. Resident #27's meal tray was observed with coffee in a plastic handled cup and juice in a plastic cup with no handles and a straw in it. Resident #27was observed putting her thumb inside the cup of juice and lifting with her thumb and the side of her hand unsteadily to her mouth to drink, Resident #27 stated it was difficult and sometimes she spilled but she tried to do the best she could and did not want to bother anyone. Resident #27 stated if the drink was served in a cup with a lid and a straw, as it sometimes was, she could not lift the cup and instead had to move her head down to the cup to drink. Resident #27 stated a cup with handles would be easier to drink from, but she had not had one for a long time. Interview on 3/22/23 at 9:45 AM with the Occupational Therapist indicated Resident #27 received occupational therapy in June 2020 and recommendation was made for handled cups for all meals. Occupational Therapist stated that handled cups for all meals should still be in place. Interview on 3/23/23 at 1:15 PM with the Dietary Manager revealed she had been in the position since June 2022. The Dietary Manager revealed that the dietary department did not provide a handled cup for Resident #27 for meals. Dietary Manager revealed that the dietary department used to provide assistive devices for eating for residents, but it had been a long time since they had done that. Dietary Manager stated she thought nursing provided assistive devices for eating for the residents. Interview with the Director of Nursing on 3/23/23 at 4:20 PM revealed the dietary department should provide assistive devices including handled cups for residents. DON stated she was not aware that Resident #27 was to have a handled cup and was not getting one for meals. DON stated that she expected residents would be provided with assistive devices for eating and drinking.

Based on record review, staff and Consultant Pharmacist interviews, the facility failed to address drug irregularities noted by the Consultant Pharmacist on two consecutive monthly Medication Regimen Reviews for 2 of 5 residents (Resident #43 and Resident #5) reviewed for unnecessary medications. Findings included: 1). Resident #43 was admitted to the facility on [DATE] with readmissions on 12/19/22 and 12/26/22. Resident #43's medical diagnoses included epilepsy, and anxiety. The 12/19/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 milligrams (mg.) give 0.5 tablet three times per day as needed anxiety, agitation, seizure. The 12/26/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 mg. give 0.5 tablet three times per day as needed anxiety, agitation, seizure. A physician order dated 12/19/22 was entered by Support Nurse #1 for lorazepam 0.5 mg. give 0.5 tablet by mouth three times per day. Review of Resident #43's December 2022 Medication Administration Report (MAR) revealed resident received lorazepam 0.5 mg. 0.5 tablet three times per day scheduled starting on 12/19/22 at 2:00 PM. Resident #43's 12/26/22 quarterly Minimum Data Set (MDS) revealed resident was severely cognitively impaired and received an antianxiety medication 6 of the 7 days in the review period. Consultant Pharmacist's Medication Regimen Review (MRR) on 1/20/23 stated: Please note the following transcription error: Lorazepam was ordered prn (as needed) on 12/19/22 and 12/26/22 readmission orders. Nurse entered as 0.25 mg three times per day scheduled. There is not a current order for this. Please obtain this order if it was clarified on readmission. Must always upload clarification orders. Review of the January 2023 MAR for Resident #43 revealed resident received lorazepam 0.5 mg. give 0.5 tablet three times per day daily for anxiety. Consultant Pharmacist's Medication Regimen Review 2/22/23 revealed a second notice which stated: Please note the following transcription error: Lorazepam ordered prn (as needed) on 12/19/22 and 12/26/22 readmit orders. Nurse entered as 0.25mg tid (three times per day) scheduled. There is not a current order for this. Please obtain this order if it was clarified on readmission. Must always upload clarification orders. Review of the February 2023 MAR for Resident #43 revealed resident received lorazepam 0.5 mg. give 0.5 tablet three times per day daily for anxiety. Review of the March 2023 MAR for Resident #43 revealed resident received lorazepam 0.5 mg. give 0.5 tablet three times per day daily for anxiety. Interview with Support Nurse #1 on 3/23/23 at 1:00 PM revealed the pharmacy recommendations were divided by hall between herself and Support Nurse #2. Support Nurse #1 stated she was responsible for Resident #43's pharmacy recommendations as he was on one of her halls. Support Nurse #1 did not recall what happened with the pharmacy recommendations for January and February for Resident #43 which indicated a transcription error was made and the order for lorazepam required clarification. Support Nurse #1 revealed she received the pharmacy recommendations, printed them, and gave them to the provider in the facility or faxed them. It may be a while, she stated, before the recommendations were returned from the doctor. Support Nurse #1 stated she tried to have the pharmacy recommendations addressed by the time the pharmacist returned for the next visit but if not, the Pharmacy Consultant wrote a second notice. Interview on 3/21/23 at 4:45 PM with the Director of Nursing (DON) revealed Support Nurses #1 and #2 were responsible for printing the pharmacy recommendations upon receiving via email from the Consultant Pharmacist. DON further stated Support Nurses #1 and #2 were expected to review, provide copies to the medical providers, and follow up on all recommendations. DON indicated she had recommendations from January and February on her desk that she meant to follow up on. DON further indicated there was not a system for tracking the recommendations but would be implementing one. Interview with Consultant Pharmacist on 3/22/23 at 3:36 PM revealed she sent the recommendations via email to the Support Nurses, Director of Nursing and Administrator and expected the recommendations were addressed by the next monthly visit at the least, but hopefully sooner than that. The Consultant Pharmacist revealed clarification of the order was not received following the medication regimen reviews on 1/20/23 or 2/22/23. Consultant Pharmacist stated this type of order was one that would be a priority to have clarified but there was a breakdown in communication. Consultant Pharmacist revealed there had been change over in the position of Support Nurse and this may have resulted in some things falling through the cracks. Interview on 3/22/23 at 5:15 PM with Resident #43's physician revealed he signed and responded to pharmacy recommendations timely, usually within 24 hours of receiving them. If he had received the pharmacist note regarding clarification of the lorazepam order, the Physician stated he would have responded promptly. The Physician could not recall if he received the pharmacy recommendations for January and February for Resident #43. 2). Resident #5 was admitted to the facility on [DATE] with diagnoses which included in diabetes and long term use of insulin. Resident #5's 2/15/23 quarterly Minimum Data Set (MDS) assessment revealed resident with moderate cognitive impairment and received injections and insulin 7 days during the lookback period. Assessment indicated Resident #5 had orders for insulin changed once in the look back period. Review of December Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units before lunch and dinner. Hold for blood sugar less than 120. 12/1/22 at 5 PM blood sugar 119. Insulin administered. 12/10/22 at 11 AM blood sugar 106. Insulin administered. 12/16/22 at 5 PM blood sugar 111. Insulin administered. 12/26/22 at 5 PM blood sugar 114. Insulin administered. Review of January Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units subcutaneous before dinner and lunch. Hold for blood sugar less than 120. 1/1/23 at 5 PM blood sugar 114. Insulin administered. 1/2/23 at 5PM blood sugar 116. Insulin administered. 1/4/23 at 5 PM blood sugar 100. Insulin administered. Novolog Solution 100 units/milliliter Inject 8 units subcutaneously one time a day every morning. Hold if blood sugar less than 100. 1/2/23 blood sugar 93. Insulin administered. Consultant Pharmacist Medication Regimen Review on 1/20/23 indicated: Please note the following errors and write up-Novolog should have been held on the following days due to hold parameters but was given January 1, 2,4 at 5:00 PM. Review of February Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units twice per day before lunch and dinner. Hold if blood sugar less than 120. 2/5/23 at 11 AM blood sugar 110. Insulin administered. 2/7/23 at 5 PM blood sugar 97. Insulin administered. 2/8/23 at 11 AM blood sugar 107. Insulin administered. Novolog 100 units/milliliter Inject 8 units twice per day before lunch and dinner. Hold if blood sugar less than 120. 2/13/23 at 5 PM blood sugar 110. Insulin administered. 2/24/23 at 5 PM blood sugar 12. Insulin administered. Novolog 100 units/milliliter. Inject 4 units every morning. Hold for blood sugar less than 120. 2/15/23 at 8AM blood sugar 101. Insulin administered. Consultant Pharmacist Medication Regimen Review on 2/22/23 indicated: Staff continues to administer Novolog when doses should be held-New parameters are to hold for Blood Sugar less than 120. This must be discussed with staff. Review of March Medication Administration Record revealed: Novolog Insulin 4 units subcutaneous every morning. Hold for blood sugar less than 120. 3/4/23 blood sugar 111. Insulin administered. 3/14/23 blood sugar 104. Insulin administered. Interview on 3/21/23 at 4:45 PM with the Director of Nursing (DON) revealed Support Nurses #1 and #2 were responsible for printing the pharmacy recommendations upon receiving via email from the Consultant Pharmacist. DON further stated Support Nurses #1 and #2 were expected to review, provide copies to the medical providers, and follow up on all recommendations. DON indicated she had recommendations from January and February on her desk that she meant to follow up on. DON further indicated there was not a system for tracking the recommendations but would be implementing one. Interview on 3/22/23 at 12:38 PM with the Nurse Practitioner (NP) revealed that insulin administered below the parameter could result in hypoglycemia. NP stated she had not been notified of Resident #5 receiving insulin outside of the parameters, had not been made aware of the Consultant Pharmacist Medication Regimen Reviews for January and February and had not been involved in any follow up regarding this. Interview on 3/22/23 at 3:50 PM with the Consultant Pharmacist revealed she had reviewed Resident #5's medications and noted the issue with the insulin, blood sugars and not following parameters. Consultant Pharmacist stated the risk would be that resident would experience hypoglycemia (low blood sugar) if insulin was administered outside the parameter. Resident #5's blood sugars were labile and required adjustments, so it was especially important that the nurses followed the orders as written. Consultant Pharmacist stated there had been changes in the Support Nurse position and that may be why the pharmacy recommendations were not addressed. Interview on 3/23/23 at 1:00 PM with Support Nurse #1 revealed she did not recall addressing the pharmacy recommendation regarding the insulin being given outside of the parameters and did not complete any education or follow up regarding insulin and following parameters. Interview with the Director of Nursing (DON) on 3/23/23 at 4:41 PM revealed she did not know why the Consultant Pharmacist's Medication Regimen Reviews for Resident #5 for January and February were not addressed but she would begin tracking the recommendations more closely.

Based on record review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to 1). accurately transcribe and administer a medication used to treat anxiety resulting in resident was administered antianxiety medication on a scheduled basis instead of as needed per the physician order, and 2) accurately transcribe and administer a medication used to treat depression and insomnia resulting in resident received 22 doses of the medication at a higher dose than ordered for 2 of 5 residents (Resident #43 and Resident #5 ) reviewed for psychotropic medication (a medication used to treat behavior, mood, thoughts, or perception). Findings included: 1). Resident #43 was admitted to the facility on [DATE] with readmissions on 12/19/22 and 12/26/22. Resident #43's medical diagnoses included in part intellectual disability, epilepsy, and anxiety. Resident #43's care plan revealed a focus initiated on 7/24/20 and reviewed on 1/15/23 of received anti-anxiety medication with risk for adverse side effects. The goal indicated Resident #43 would be free from discomfort or adverse reactions related to antianxiety therapy. Interventions included Consultant Pharmacist to review psychotropic medications quarterly and as needed for possible changes or reductions and give anti-anxiety medication as ordered by the physician. The 12/19/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 milligrams (mg.) give 0.5 tablet three times per day as needed. The 12/26/22 discharge summary medication list for Resident #43 included an order for lorazepam 0.5 mg. give 0.5 tablet three times per day as needed. A physician order dated 12/19/22 was entered by Support Nurse #1 for lorazepam 0.5 mg. give 0.5 tablet by mouth three times per day. Review of Resident #43's December 2022 Medication Administration Report (MAR) revealed resident received lorazepam 0.5 mg. 0.5 tablet three times per day scheduled starting on 12/19/22 at 2:00 PM. Resident #43's 12/26/22 quarterly Minimum Data Set (MDS) revealed resident was severely cognitively impaired and received an antianxiety medication 6 of the 7 days in the review period. Consultant Pharmacist's Medication Regimen Review (MRR) on 1/20/23 stated: Please note the following transcription error: Lorazepam was ordered prn (as needed) on 12/19/22 and 12/26/22 readmission orders. Nurse entered as 0.25 mg three times per day scheduled. There is not a current order for this. Please obtain this order if it was clarified on readmission. Must always upload clarification orders. Review of the January 2023 MAR for Resident #43 revealed resident received lorazepam 0.5 mg. give 0.5 tablet three times per day daily. Consultant Pharmacist's Medication Regimen Review 2/22/23 revealed: Please note the following transcription error: Lorazepam ordered prn (as needed) on 12/19/22 and 12/26/22 readmit orders. Nurse entered as 0.25mg tid (three times per day) scheduled. There is not a current order for this. Please obtain this order if it was clarified on readmission. Must always upload clarification orders. Review of the February 2023 MAR for Resident #43 revealed resident received lorazepam 0.5 mg. give 0.5 tablet three times per day daily. Interview on 3/21/23 at 4:45 PM with the Director of Nursing revealed when a resident was admitted or readmitted from the hospital the Support Nurse, if available entered the orders in the computer from the discharge summary. The floor nurse was to complete the second check comparing the discharge paperwork with the physician orders entered in the computer. DON stated there was supposed to be a QA system in place for a 3rd check of the physician orders. The Support Nurse was to notify the provider when the resident was admitted or readmitted , verified the orders and made any changes. DON stated she was not aware of the discrepancy with the lorazepam order that was entered until this week and did not know how it occurred. DON stated she did not know how the order was entered incorrectly if the checks were completed as they were supposed to be. Follow up interview with the DON on 3/22/23 at 10:00 revealed clarification was received via phone on 3/22/23 from the provider regarding the scheduled order for lorazepam for Resident #43. Interview with Consultant Pharmacist on 3/22/23 at 3:36 PM revealed she sent the recommendations via e mail to the Unit Managers, Director of Nursing and Administrator and expected the recommendations were addressed by the next monthly visit at the least, but hopefully sooner than that. The Consultant Pharmacist stated the order for Resident #43 for lorazepam dose as needed was entered and administered scheduled which was a medication error. The Consultant Pharmacist revealed clarification of the order was not received following the medication regimen reviews on 1/20/23 or 2/22/23. Consultant Pharmacist stated this type of order was one that would be a priority to have clarified but there was a breakdown in communication. Interview on 3/22/23 at 5:15 PM with Resident #43's physician revealed he signed and responded to pharmacy recommendations timely, usually within 24 hours of receiving them. If he had received the pharmacist note regarding clarification of the lorazepam order, the Physician stated he would have responded promptly. The Physician could not recall if he was notified of clarification needed of lorazepam dose. The Physician stated the dose of lorazepam given would not have caused harm, but it was a medication error in that the facility did not follow the orders as written from the hospital. Interview with Support Nurse #1 on 3/23/23 at 1:00 PM revealed she entered the orders for Resident #43 when he returned from the hospital on 12/19/22. Support Nurse # 1 stated she did not recall having made a transcription error when she entered the order for Resident #43 for lorazepam 0.25 mg. three times per day scheduled instead of as needed. Support Nurse #1 indicated she had not verified the orders or received clarification changing the dose from as needed to scheduled when Resident #43 was readmitted to the facility. Support Nurse #1 stated she did not rec what happened with the pharmacy recommendation that indicated a transcription error was made and the dose of lorazepam 0.25 milligrams for Resident #43 required clarification. Support Nurse #1 revealed she received the Consultant Pharmacy recommendation printed them and gave them to the provider in the facility or faxed them. It may be a while, she stated before the recommendations were returned from the doctor. Support Nurse #1 stated she tried to have the pharmacy recommendations addressed by the time the pharmacist returned for the next visit but if not, the Consultant Pharmacist wrote a second notice. Follow up interview with the DON on 3/23/23 at 4:35 PM revealed she did not know why this order for lorazepam was transcribed incorrectly and was not addressed. DON stated she was not sure how the order was transcribed incorrectly as there was a system that required another nurse to confirm the orders to make sure the medication was transcribed to include right patient, right medication, right dose, right frequency, right route, and the right time to ensure all orders were transcribed correctly. DON stated she was not aware until this week that there had been a medication error made with Resident #43's medication. 2). Resident #5 was admitted to the facility on [DATE] with diagnoses which included in part depression, schizophrenia, and dementia. Consultant Pharmacist Medication Regimen Review on 12/21/22 indicated: Continues on Trazodone 100 mg. qhs (at bedtime) Please consider a small reduction of the Trazodone to 75 mg. to help establish the lowest, effect dose to reduce risks of developing side effects. Consultant Pharmacist Medication Regimen Review with recommendation to reduce Resident #5's trazodone to 75 mg. at bedtime was signed on 12/23/22. A physician order dated 12/26/22 was entered by Support Nurse #1 for trazodone 75 mg. at bedtime. Review of Resident #5's December 2022 MAR revealed resident received: trazodone 75 mg. at bedtime nightly from 12/27/22 through 12/31/22. trazodone 100 mg. at bedtime nightly from 12/1/22 through 12/31/22. Resident #5's care plan indicated a focus reviewed on 1/4/23 of received antidepressant medication with increased risk for adverse side effects. Interventions included Consulting Pharmacist to review my psychotropic medications quarterly and as needed for possible changes or reductions and give antidepressant medications ordered by physician. Review of Resident #5's January 2023 MAR revealed resident received: trazodone 75 mg. at bedtime nightly from 1/1/23 through 1/31/23. trazodone 100 mg. at bedtime nightly from 1/1/23 through 1/17/23 with discontinuation date listed as 1/18/23. Consultant Pharmacist Medication Regimen Review on 1/20/23 indicated: Please note the following error needs to be written up. Trazodone reduced to 75 mg. q hs (at bedtime) on 12/26/22 and order entered however staff did not d/c (discontinue) the old order for 100 mg. Cannot tell what resident had been receiving Pharmacist indicated she will d/c the 100 mg. today. Resident #5's 2/15/23 quarterly Minimum Data Set (MDS) revealed resident with moderate cognitive impairment and received an antidepressant 7 days during the lookback period. Interview on 3/22/23 at 12:38 PM with the Nurse Practitioner (NP) revealed she was not made aware of the medication error in which Resident #5 received an increased dose of trazodone or the Consultant Pharmacist Medication Regimen Review regarding the error. NP stated that an increased dose of trazodone would result in increased sleepiness. NP stated that the order written for 75 mg. trazodone should have been entered and administered as ordered with the previous order for 100 mg. trazadone discontinued. Interview on 3/22/23 at 2:02 PM with the Director of Nursing (DON) revealed the nurses were responsible for transcribing and entering orders correctly into the computer. Interview on 3/22/23 at 3:50 PM with the Consultant Pharmacist revealed over sedation and increased risk of falls would be the risk associated with an increased dose of trazodone. Consultant Pharmacist indicated this was an error that should have been addressed and the facility should have investigated the process of how the error occurred. Interview with Support Nurse #1 on 3/23/23 at 1:00 PM revealed she entered the order for trazodone 75 milligrams at bedtime but did not recall an error with not discontinuing the previous dose. When the physician or provider wrote an order to decrease or change a dose, Support Nurse #1 stated, the previous dose was to be discontinued. Support Nurse #1 stated Resident #5's previous dose of trazodone should have been discontinued when the new dose was started. Interview with the Director of Nursing (DON) on 3/23/23 at 4:45 PM revealed that when the physician wrote an order for a dose reduction the prior dose should be discontinued. DON indicated she was not aware there had been a medication error with Resident#5's trazadone orders.

Based on record review, staff, Nurse Practitioner and Consultant Pharmacist interviews, the facility failed to follow parameters for administration of a medication used to treat hyperglycemia resulting in 16 doses administered in error for 1 of 1 resident (Resident #5) reviewed for medication error. Findings included: Resident #5 was admitted to the facility on [DATE] with diagnosis which included in part diabetes and long term use of insulin. Resident #5's 2/15/23 quarterly Minimum Data Set (MDS) assessment revealed resident with moderate cognitive impairment and received injections and insulin 7 days during the lookback period. Assessment indicated Resident #5 had orders for insulin changed once in the look back period. Resident #5's care plan indicated a 6/6/19 focus of Diabetes Mellitus with risk for complications. The focus was reviewed on 1/4/23. The goal indicated diabetes would be adequately managed in order to minimize risk for complications. Interventions included Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Follow facility protocol for episodes of hypoglycemia (low blood sugar), follow physician orders for episodes of hyperglycemia (high blood sugar). Review of December Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units before lunch and dinner. Hold for blood sugar less than 120. 12/1/22 at 5 PM blood sugar 119. Insulin administered. 12/10/22 at 11 AM blood sugar 106. Insulin administered. 12/16/22 at 5 PM blood sugar 111. Insulin administered. 12/26/22 at 5 PM blood sugar 114. Insulin administered. Review of January Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units subcutaneous before dinner and lunch. Hold for blood sugar less than 120. 1/1/23 at 5 PM blood sugar 114. Insulin administered. 1/2/23 at 5PM blood sugar 116. Insulin administered. 1/4/23 at 5 PM blood sugar 100. Insulin administered. Novolog Solution 100 units/milliliter Inject 8 units subcutaneously one time a day. Hold if blood sugar less than 100. 1/2/23 blood sugar 93. Insulin administered. Consultant Pharmacist Medication Regimen Review on 1/20/23 indicated: Please note the following errors and write up-Novolog should have been held on the following days due to hold parameters but was given January 1, 2,4 at 5:00 PM. Review of February Medication Administration Record revealed: Novolog 100 units/milliliter Inject 16 units twice per day before lunch and dinner. Hold if blood sugar less than 120. 2/5/23 at 11 AM blood sugar 110. Insulin administered. 2/7/23 at 5 PM blood sugar 97. Insulin administered. 2/8/23 at 11 AM blood sugar 107. Insulin administered. Novolog 100 units/milliliter Inject 8 units twice per day before lunch and dinner. Hold if blood sugar less than 120. 2/13/23 at 5 PM blood sugar 110. Insulin administered. 2/24/23 at 5 PM blood sugar 12. Insulin administered. Novolog 100 units/milliliter. Inject 4 units every morning. Hold for blood sugar less than 120. 2/15/23 at 8AM blood sugar 101. Insulin administered. Consultant Pharmacist Medication Regimen Review on 2/22/23 indicated: Staff continues to administer Novolog when doses should be held-New parameters are to hold for Blood Sugar less than 120. This must be discussed with staff. Review of March Medication Administration Record revealed: Novolog Insulin 4 units subcutaneous every morning. Hold for blood sugar less than 120. 3/4/23 blood sugar 111. Insulin administered. 3/14/23 blood sugar 104. Insulin administered. Interview on 3/22/23 at 12:38 PM with the Nurse Practitioner (NP) revealed that Resident #5 received long and short acting insulin. Insulin administered below the parameter could result in hypoglycemia. NP stated she had not been notified of resident receiving insulin outside of the parameters and had not been made aware of the pharmacy notation regarding the doses of insulin given outside of the parameters. Interview on 3/22/23 at 3:50 PM with Consultant Pharmacist revealed she had reviewed Resident #5's medications and noted the issue with the insulin, the blood sugar and not following parameters. Consultant Pharmacist stated the risk would be that resident would experience hypoglycemia (low blood sugar) if insulin was administered outside the parameter. Resident #5's blood sugars are labile and have required adjustments, so it was especially important that the nurses followed the orders as written. Interview on 3/22/23 at 4:24 PM with Nursing Supervisor revealed she had been in this role since November 2022. Nursing Supervisor revealed that she was assigned to check the blood sugar and administer insulin some days when a Medication Aide was assigned to Resident #5. Nursing Supervisor indicated a check mark with the initials on the MAR indicated the dose was administered. MARs were reviewed with the Nursing Supervisor who stated she administered the insulin in error when it should have been held when below the specified parameter according to the physician order. Nursing Supervisor stated if Resident #5 had not eaten and the blood sugar was below the parameter, she still administered the insulin according to her nursing judgement. Interview with Nurse #1 on 3/22/23 at 4:50 PM revealed that a check mark with the initials on the MAR indicated that the dose was administered. Review of the MARs with Nurse #1 indicated she had checked Resident #5's blood sugar and administered the insulin in error. Nurse #1 indicated that when she obtained the blood sugar outside of the parameter, she should have held the insulin dose according to the parameter designated in the physician order. Nurse #1 did not recall having had an in service regarding insulin administration and parameters recently. Nurse #1 stated she must have missed looking at the parameter as part of the order for insulin administration for Resident #5. Interview with Resident #5 on 3/23/23 at 9:06 AM revealed she is diabetic, and her sugar is up and down. Resident #5 stated she gets dizzy sometimes and doesn't feel well when her sugar is low. Resident #5 stated she had history of falls and that she had fallen due to being dizzy. Interview on 3/23/23 at 1:00 PM with Support Nurse #1 revealed she was not aware Resident #5 received insulin outside of the parameters. Support Nurse #1 stated she did not recall addressing the pharmacy recommendation regarding the insulin being given outside of the parameters and did not complete any education or follow up regarding insulin and following parameters. Interview with the Director of Nursing (DON) on 3/23/23 at 4:41 PM revealed she was not aware of the issue with Resident #5's insulin being given outside of parameter. DON stated she had not in serviced the staff regarding administration of insulin and following parameters. DON stated nurses should be following the parameters and should contact the provider and document if they had a question about a parameter for a medication.

Based on observations and staff interviews the facility failed to maintain potentially hazardous food items within safe temperature range for cold food items, at or below 41 degrees Fahrenheit (F) during the lunch meal service. The findings include: An observation of the lunch meal tray line on 03/20/232 at 11: 30 AM. Temperature monitoring, with the Dietary Manager on 11/07/22 at 12:20 PM revealed the following temperatures: garden salads 48 degrees F. The four garden salads were observed not on ice, kept on a food tray on top of an empty food cart next to the food tray line, ready to be placed on residents' food trays. The garden salads contained lettuce, shredded carrots, tomatoes, and cheese. During an interview with the Dietary Manager on 03/20/23 at 12:45 PM, she stated that she expected dietary staff to serve cold foods 41 degrees F or below and if cold foods were higher than 41 degrees F the food items should be discarded prior to serving. She also stated the salads should have been kept cool below 41 degrees F just prior to serving and was not. During an interview with the Director of Dietary Services on 03/22/23 at 8:45 AM, she revealed cold food temperatures were required to be below 41 degrees F when served from the tray line. During an interview with the Administrator on 03/23/23 at 7:00 PM it was revealed it was her expectation the facility's kitchen would follow all regulatory guidelines for food and kitchen sanitation safety.

Based on record review and staff and resident interviews, the facility failed to provide an ongoing resident centered activities program based on residents' individual interests for 2 of 7 residents reviewed for activities (Resident #27 and Resident #50). Findings included: a). Resident #27 was admitted to the facility on [DATE] with diagnoses of osteoarthritis with stiffness of right and left hand and glaucoma. Resident #27's 10/28/22 Annual Minimum Data Set (MDS) assessment revealed resident was cognitively intact. Resident #27's activity preferences included keeping up with the news, activities with groups of people, favorite activities, going outside and religious activities were very important. Books and music were not important to Resident #27. Resident #27's care plan revealed an activities focus was added on 5/24/21 and reviewed on 1/28/23. The activities care plan focus stated Resident #27 enjoyed attending and participating in most activities at the facility. Resident #27's goal indicated resident will attend and participate in activities daily. Interventions included: assist to and from activities as needed, place activity calendar in room, provide praise for participating in and attending activities, and remind me about upcoming activities. Interview on 3/20/23 at 11:22 AM with Resident #27 revealed there was nothing to do on the weekends. Resident #27 indicated the facility used to have more activities, but they hadn't for a while. Resident #27 further revealed she used a wheelchair for mobility and was not able to propel her wheelchair due to arthritis in her hands and knee. If staff did not assist her, which they sometimes didn't, she was not able to attend activities. b). Resident #50 was admitted to the facility on [DATE] with diagnosis which included in part stroke with hemiparesis, blindness in left eye and depression. Resident #50's 4/24/22 annual MDS assessment indicated resident was cognitively intact and had impaired vision. Resident #50 indicated books, newspapers, pets and keeping up with the news were not very important, music was somewhat important and doing things with groups of people, doing favorite activities, religious activities and going outside were very important. Resident #50's care plan indicated an activities focus was added on 10/19/22 and reviewed on 1/9/23. The goal indicated Resident #50 would attend and participate in activities daily. Interventions included assist to and from activities, provide monthly activity calendar and remind about upcoming activities for the day. Interview on 3/20/23 at 1:22 PM with Resident #50 revealed she usually stayed in bed on the weekends because there was nothing to do. Resident #50 stated there were no activities available on weekends, so staff did not get her up out of bed. Interview on 3/21/23 at 1:10 PM with the Activity Director revealed she had been in the position since December 2022. Activity Director indicated she worked Monday through Friday and provided activities when she was in the facility. On the weekends, the Activity Director indicated she sometimes had volunteers that came in but right now it was usually only one Saturday during the month that volunteers came in the afternoon for an activity and some Sunday mornings she had a church that did a service. Activity Director did not know what to do for activities for residents on the weekends. A resident council meeting on 3/21/23 at 2:49 PM with a group of cognitively intact residents revealed there were no activities on the weekends. The residents indicated sometimes there was a church service but not every weekend. The residents stated they used to have a lot more activities but now there is nothing to do here on the weekends. The residents stated we have not had many activities here for a while and it can be boring on the weekends with nothing to do. Interview on 3/23/23 at 12:50 PM with Nursing Assistant (NA) #1 revealed there were no activities available on weekends. NA #1 stated sometimes they had church services on Sunday. NA #1 stated residents asked about activities on the weekends and complained they had nothing to do. NA#1 stated she did not have time on the weekends to provide activities for her residents. Interview on 3/23/23 at 2:50 PM with the Administrator revealed she thought the facility tried to have some activities on the weekend, but she couldn't recall what they did. The Administrator stated the facility sometimes had activities with outside groups of volunteers on the weekends but did not know how often or of any other activities on the weekends. The Administrator indicated the activity director was here during the week so that was when activities were provided. The activity calendar was reviewed with the administrator who stated she guessed there should be more activities provided for the residents on the weekends.

Based on record review, observation and staff interview, the facility failed to shave a resident who was dependent on the staff for activities of daily living (ADL) care for 1 of 1 sampled resident reviewed for ADLs (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with multiple diagnoses including metabolic encephalopathy, dementia, anxiety, and affective mood disorder. A Psychiatric follow-up evaluation dated 12/20/22 for Resident #65 revealed resident's cognition noted to decline indicating severe cognitive impairment, with mood stable and no increase in paranoia or anxiety per staff. Resident with history of severe aggression toward staff, behaviors controlled on current medications. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #65 had severe cognitive impairment and needed total assistance with personal hygiene. Resident #65 was coded for physical and verbal behavioral symptoms directed toward others and rejection of care on 0 to 0 days out of 7 days. Review of the Nurse's Aide (NA) behavior documentation revealed that Resident #65 exhibited behaviors with rejection of care for 6 out of the last 22 days, from 03/01/23 through 03/22/23. An observation on 03/20/23 at 11:05 AM was conducted with Resident #65. Resident was sitting up in bed with a patch of white facial chin hair approximately 3 to 4 inches long. An observation on 03/20/23 at 1:30 PM was conducted with Resident #65. The resident's facial hair on her chin remained unchanged. Review of Resident #65's care plan dated 03/21/23 was conducted. The care plan problems were I have an Activities of Daily Living (ADL) self-care performance deficit related to dementia. I am resistive to care such as bathing, turning, repositioning, and grooming related to dementia. Interventions included, in part, if the resident had an episode of inappropriate behaviors of yelling out for no apparent reason, cursing, or striking at staff, the staff member should leave the resident for a time, and come back later to complete the task. An observation on 03/21/23 at 8:45 AM was conducted with Resident #65. The resident's facial hair on her chin remained unchanged. An interview on 03/22/23 at 11:40 AM was conducted with Nursing Aide (NA) #2. She said Resident #65 refused her bath and oral care today. NA #2 said Resident #65 had facial chin hair, which needed to be shaved off. NA #2 said the reason the facial hair was not removed was because the resident would often become combative and would refuse ADL care. NA #2 said staff were supposed to shave residents after their daily bath, and if the resident was resistive to care, they were taught to walk away and come back later and try again. NA #2 said she could not remember the last time Resident #65 was shaved, but it had been a while. She said when she tried to shave the resident in the past the resident became combative, so she left as she was taught to do. She said she was too busy with other residents' morning care that she never went back to try again. An interview on 03/22/23 at 11:45 AM was conducted with Nursing Aide (NA) #4. She said Resident #65 had a lot of facial chin hair, which the resident had had for a while, and needed to be shaved. NA #4 said the reason the resident was not shaved was because she could become combative and nursing staff did not want to deal with the resident becoming combative when you tried to touch her face. NA #4 said she could not remember the last time Resident #65 was shaved. She said staff usually shaved their residents after their morning bath. NA #4 said she could not remember the last time she attempted to shave the resident. She said if a resident became combative or abusive in any way they were instructed to walk away and come back later to try again. An interview and observation on 03/22/23 at 2:40 PM were conducted with Resident #65. The resident was observed to be alert, calm, and her facial hair had been shaved. When asked about her chin facial hair being gone, she said the facial hair on her chin was shaved off that morning by a nurse (Nurse #1). She said she had asked before for her facial hair to be removed, but no one removed it. She said she was not upset or angry that it took so long, but was glad the hair on her chin was removed. An interview on 03/22/23 at 5:00 PM was conducted with Nurse #1. She said she shaved Resident #65's facial hair with shaving cream and a wet warm washcloth that morning around 9:00 AM after she completed her 8:00 AM medication pass. She said the resident was not combative, was not in any pain, and seemed pleased to have the facial hair removed. The nurse said the resident had refused ADL care in the past and the NAs documented resident's refusals in the NA electronic charting system. The nurse said she had no answer as to why it had taken so long for the resident to be shaven. The nurse said NAs should have been more persistent, or asked one of the nurses for assistance, but did not. An interview on 03/22/23 at 4:00 PM was conducted with the Administrator. She stated Resident #65's facial hair should have been removed timely. The Administrator stated the resident had a known history of being combative with care; however, she still expected her nursing staff to be persistent, wait a couple of hours and try again, or ask for additional nursing assistance. The Director of Nursing (DON) was interviewed on 3/23/23 at 11:20 AM. The Director of Nursing expected the staff to provide complete ADL care and if the resident was combative to leave and to try later.

Based on record review, staff and Nurse Practitioner interviews the facility failed to obtain physician ordered laboratory tests for 1 of 3 residents reviewed for antibiotic use (Resident # 44). Findings included. Resident #44 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection of the bone), urinary tract infection, and stage IV sacral ulcer. A physician's order dated 02/24/23 for Resident #44 revealed ertapenem sodium solution (antibiotic). Use 1 gram intravenously every 24 hours for infection to wounds for 28 Days via PICC line (peripherally inserted central catheter). A physician's order dated 02/24/23 for Resident #44 revealed weekly CBC (complete blood cell count), BMP (basic metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) (these labs are used to make treatment decisions) for 28 days while continuing intravenous antibiotics. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #44 received antibiotics and had no rejection of care. Review of Resident #44's electronic medical record on 03/23/23 revealed the laboratory (lab) tests for CBC, BMP, ESR, and CRP were drawn on 02/27/23 and on 03/07/23. There were no further laboratory tests drawn after 03/07/23. Resident #44 began antibiotics on 02/24/23 and remained on antibiotics as of 03/23/23. An interview on 03/23/23 at 04:36 PM with Nurse #1, revealed she was routinely the assigned nurse for Resident #44 and stated lab orders were entered into the resident's electronic medical record and would show on the residents Medication Administration Record (MAR). She stated labs were drawn nightly by an outside vendor when they were due. She stated the nurse records the labs to be drawn in the vendors notebook located at the nurse's station on the day the labs were due. The vendor looks in the notebook to determine who needs labs, then draws the labs and leaves a requisition form in the notebook to notify the facility of the date, time, and what labs were drawn. The labs were typically faxed back to the facility the next day and the physician is notified accordingly. She stated they had only used this vendor for a few months and were still getting used to recording the ordered labs in the vendor notebook. She stated the miscommunication for Resident #44's lab work not getting done was due to the nurse's failure to record the lab work that was ordered in the vendor notebook. She stated it was an oversight. An interview on 03/23/23 at 05:01 PM with the Director of Nursing (DON) revealed Resident #44 was to receive weekly monitoring of labs while receiving the course of IV (intravenous) antibiotics for osteomyelitis. She stated lab orders were entered in the resident's electronic medical record, and the nurse had a process to follow, then the support nurse was to follow up to ensure the labs were done and the physician was notified as needed. She stated the process had not been followed which led to Resident #44 not getting the labs drawn. An interview on 03/23/23 at 5:27 PM with Support Nurse #1 revealed she was responsible for following up to ensure labs were drawn. She stated it was an oversight that she had not followed up on Resident 44's labs. She stated she notified the physician earlier when it was brought to her attention and the physician ordered her to draw Resident #44's labs tonight for review tomorrow. She indicated Resident #44's vital signs were stable, and she was asymptomatic. An interview on 03/23/23 at 05:59 PM with Nurse Practitioner #2 revealed the importance of the labs was to monitor Resident #44's white blood cell count, kidney function, sedimentation rate, and CRP and if the labs were abnormal, they would have referred back to the infectious disease physician. She indicated staff had not reported any change in Resident #44's condition and stated she was not in the facility and could not view the residents medical record but stated staff should be following the orders and drawing the labs.

Based on observation, record review, staff, and Physician interviews the facility failed to notify the physician when a resident was noted to have redness and bleeding along the gumline for 1 of 1 resident reviewed for dental care (Resident #65). The findings included: Resident #65 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #65 had severe cognitive impairment and needed total assistance with personal hygiene. Resident #65 was coded for no issues with his teeth and no pain. A nursing note dated 02/16/23 at 2:31 PM by Nurse #7 revealed Resident #65 has strong foul odor coming from mouth, redness and bleeding noted on gum line and teeth. Resident has verbalized that there is pain in her mouth on several occasions. There was not any documentation of a physician being notified. A nursing note dated 02/23/23 at 7:08 PM by Nurse #1 revealed Resident #65 remains in bed today, denies any pain. Resident continues to have dry mouth/lips and a foul, strong odor coming from her mouth. There was not any documentation of a physician being notified. A nursing note dated 03/22/23 at 12:04 PM by Nurse #1 revealed Resident #65 continues to have dried lips and a very foul odor coming from mouth. The resident was offered oral care and refused. The medication aide stated resident began grabbing her hand along with another staff members hands and refused oral care. A nursing note dated 03/22/23 at 4:35 PM for Resident #65 revealed Director of Nursing (DON) evaluated resident gums and mouth. The resident was pleasant and agreed to let her look inside her mouth. Resident's gums were red and inflamed, with no active bleeding noted. An interview was conducted with Nurse #1 on 03/22/23 at 5:00 PM. Nurse #1 said she was the nurse who wrote the 02/23/23 nursing note about Resident #65 having a strong mouth odor, dry lips, and no pain. She said she thought she faxed a note to MD #2 office informing him of what she observed. Nurse #1 said she did not follow-up with the MD's office to see if they received her information and should have. Nurse #1 said they could not find any documentation supporting she sent the fax to MD #10's office. The facility physician (MD) was interviewed by phone on 03/23/23 at 10:25 AM. The MD reported the first time he had been notified of Resident #65's mouth pain was on 12/2022, which the resident was treated with Peridex mouth swabs, and was later discontinued due to resident's non-compliance. MD said since 12/2022 he had no contact from the facility regarding resident's recent gum issues until yesterday (03/22/23). The MD reported he expected the NP or MD to be notified if a resident experienced mouth pain. An interview was conducted on 03/23/23 at 3:20 PM with the Administrator and DON. They both stated that they would expect their nurses to notify a resident's physician if a resident was assessed for mouth or gum odor, swelling, redness or strong odor.

Based on observation, record review, staff, hospice staff, and Nurse Practitioner interviews, the facility failed to provide supervision to prevent a severely cognitively impaired resident (Resident #71) who displayed wandering behaviors and was known by some staff to require supervision while outside from being outside the facility unsupervised for 1 of 4 residents reviewed for accidents. Immediate Jeopardy began on 9/26/18 when Resident #71 was left outside the facility unsupervised by staff and developed blisters to her right forearm. The resident was brought back inside by a concerned visitor. On 10/2/18 Resident #71 was let outside the facility without supervision in her wheelchair in the facility parking lot where she sustained a fall without injury. The resident was assessed and retrieved by Hospice Nurse #1 and returned to the facility with no physical injuries. Immediate jeopardy was removed on 10/11/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #71 was admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #71's most recent minimum data set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. Resident #71 had no moods or behaviors. She required extensive assistance with bed mobility, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. She was totally dependent on staff for transfers. Resident #71 was always incontinent of bowel and bladder. No restraints or alarms of any kind were used. Review of Resident #71's care plan dated 8/14/18 revealed she was care planned to be at risk for falls. The interventions included to anticipate and meet her needs as much as possible, criss cross grip strips on floor in her room, educate Resident #71, family, and caregivers about safety reminders and what to do if a fall occurs, encourage her to wear non-skid socks when she was not wearing shoes, observe for possible side effects from medications that may affect balance and gait and report to nurse if Resident #71 had changes in gait or balance, review information on past falls and attempt to determine the cause of falls, record possible root causes, and alter or remove any potential causes if possible. Review of Resident #71's nurse's notes revealed there were no nursing notes on 9/26/18. Review of a hospice nurse's note dated 9/27/18 at 1:28 PM revealed Resident #71 was alert and active with no distress noted and no complaints of pain. Blisters were noted on her lower right arm and it was reported to Hospice Nurse #1 that Resident #71 was outside on 9/26/18 and became overheated. Review of a hospice fall report dated 10/2/18 revealed at 10:00 AM Resident #71 sustained a witnessed fall from her wheelchair in the facility parking lot. The contributing factors were noted to be confusion and disorientation. Resident #71 had no apparent injuries and the facility staff were informed that Resident #71 was not allowed outside the facility alone. The responsible party was called and informed of the fall. Review of a hospice nurse's note dated 10/2/18 at 10:44 AM revealed Resident #71 sustained a fall out of her wheelchair in the parking lot which was witnessed by a nursing student. Resident #71 denied pain and no obvious injuries were noted. Resident #71 was brought back to her room where she had a complaint of being thirsty and ice water was given to her. Resident #71 responsible party was called but there was no answer. Resident #71 complained of arm itching and cream was applied to areas on arms and hands. Review of a health status note dated 10/2/18 at 1:14 PM revealed an interdisciplinary team meeting was held to discuss Resident #71 beginning to exhibit exit seeking behaviors. A group decision was made to apply a wander guard to the resident. Resident #71 responsible party was in the facility and was made aware and agreed with the plan. It was documented she was also aware of the fall the morning of 10/2/18. The Nurse Practitioner as well as Resident #71's physician were notified of the fall and wander guard placement. Review of a nurse's note dated 10/2/18 at 5:00 PM revealed Nurse #2 documented she was informed by a hospice nurse that Resident #71 had fallen while outside. The hospice nurse and a nursing student got the resident off the ground and brought her back inside. Review of a fall review and follow up dated 10/2/18 at 5:14 PM revealed Resident #71 fell outside of the building attempting to reach over the side of her wheelchair to get something. Resident #71 had no complaints of pain and a neurological check was performed which was negative. Review of Resident #71's care plan dated 10/4/18 revealed she was care planned to be an elopement risk and wanderer. The interventions included to assess Resident #71 for fall risk, monitor for fatigue and weight loss. Provide structured activities with toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes. She was care planned to have a wander guard in place. Review of a fall review and follow up dated 10/4/18 at 3:05 AM revealed Resident #71 had no changes in condition following her fall and her neuro checks were negative. Review of weather.com for Mount Olive revealed the high temperature was 88 degrees Fahrenheit and it was cloudy on 9/26/18. On 10/2/18 the high temperature was 85 degrees Fahrenheit and it was sunny. During an interview on 10/8/18 at 12:23 PM Hospice Nurse #2 stated she admitted Resident #71 to hospice care. She further stated Hospice Nurse #1 was her primary hospice nurse. Hospice Nurse #2 stated Hospice Nurse #1 had told her someone had pushed Resident #71 outside the facility and the resident had fallen into some ants. She further stated Resident #71's level of functioning was not good when she admitted Resident #71 and she was surprised she had been outside unsupervised and would not have been comfortable with Resident #71 being outside unattended. During observation on 10/9/18 at 8:39 AM Resident #71 was observed in bed. Her right forearm was wrapped in bandages as ordered and no broken skin was visible. During an interview on 10/9/18 at 9:58 AM Hospice Nurse #1 who was the nurse that responded to Resident #71 fall stated she had gone to Resident #71's room to find Resident #71 and she went to all the halls and could not find her. She further stated she asked Resident #71's nurse and nurse aide where Resident #71 was, and they did not know. She then stated the Activities Director heard her asking for Resident #71 and told Hospice Nurse #1 Resident #71 was outside which was odd because she was not supposed to go outside unattended. Hospice Nurse #1 stated the responsible party had requested the resident not go outside without supervision because of an incident the week before the fall where she stayed outside too long and got overheated. Hospice Nurse #1 stated she noted blisters to Resident #71's forearms and she had Hospice Nurse Aide #1 place cream on Resident #71's arms and wrap them. She stated she asked staff who said it might have been related to her being outside in the sun too long and overheating. She further stated other staff in the facility knew not to let Resident #71 outside unattended but the staff member who took Resident #71 outside did not know because she had left Resident #71 outside. Hospice Nurse #1 stated she then was going outside and heard someone saying, I need a nurse outside. When she went to the front of the building she saw Resident #71 laying against the curb in the handicapped parking spot across the parking lot drive through and a Nursing Student was with Resident #71 and was brushing ants off her. She stated the Nursing Student was in his car in the parking lot and observed Resident #71 sustain a fall in the parking lot. She further stated the nursing student told her she was trying to pick something up off the parking lot and had tumbled out of the chair and he responded to her immediately. She stated Resident #71 did not hit her head. Hospice Nurse #1 stated she assessed Resident #71 and there were no signs of injuries, but ants were crawling on her which she and the nursing student brushed off Resident #71. She further stated the reason Resident #71 was not to be left outside unattended was because she would not know to come back in and had poor safety awareness. She further stated Nurse #2 who had Resident #71 on 10/2/18 knew Resident #71 was not to be outside alone. Hospice Nurse #1 concluded Resident #71 was able to self-propel herself in her wheelchair and must have wheeled herself to the other side of the parking lot near the curb where she sustained her fall. During an interview on 10/9/18 at 11:06 AM Nurse #2 stated she was familiar with Resident #71's care. She further stated Resident #71 would think she could do what she used to be able to do. Resident #71 used to come and go in the facility as she pleased when she was in assisted living, but now needed more help and did not understand that. She further stated Resident #71 needed one on one supervision when outside. Nurse #2 stated Resident #71 was to be on one on one supervision since (MONTH) of (YEAR). She further stated on 10/2/18 one of the nursing students found Resident #71 in the parking lot. Resident #71 had eaten her breakfast, got up in her chair, and was out in the hall. Nurse #2 further stated she did not take Resident #71 outside and instead, Resident #71 scooted to the locked door where the Activities Director opened the door for her while she was heading to stand up meeting. Nurse #2 stated Resident #71 then must have proceeded to go out the front door. She further stated the Activities director did not know she was not allowed to go outside on her own and needed another person to sit with her. Nurse #2 stated Resident #71 needed to be repositioned in her chair often through the day because she would slump in her chair and was at risk for falls. She further stated she spoken with the Activities Director and educated her. She further stated the Administrator had also educated staff to not allow Resident #71 outside unattended since her return in (MONTH) (YEAR). She further stated there was a wandering poster board next to the time clock as well as near the nurse ' s station. She further stated they had not placed her on that list prior to the fall on 10/2/18 but did not know why she had not been placed on the list. During an interview on 10/9/18 at 11:29 AM the Activities Director stated she was on her way to the standup meeting which started at 9:15 AM and Resident #71 was right behind her as she went through the door and she held the door for Resident #71 to go out of the locked area of the facility. The Activities Director stated she then went to the conference room door on that hall and went in as Resident #71 was heading to the front door. The Activities Director further stated at that time she was not aware Resident #71 was not to leave the facility unattended by staff. She stated after Resident #71 had her fall in the parking lot, Nurse #2 came and informed her Resident #71 was not to leave the locked area unattended by staff. She further stated sometimes the staff send an email to all staff informing them of who could not be outside the locked area unattended and other times the staff verbally inform her of who cannot leave the locked area unattended. She further stated the only reason she held the door open for Resident #71 on 10/2/18 was because she was unaware Resident #71 was to be under supervision when outside the locked area of the facility. She stated either no one told her, she missed the email, or no email was sent. During an interview on 10/9/18 at 11:47 AM Hospice Nurse Aide #1 stated she had cared for Resident #71 since (MONTH) (YEAR) when she was placed on hospice care. She further stated Resident #71 was able to self-propel herself with her feet. She further stated she helped a nursing student get Resident #71 bathed and up for the day on 10/2/18 when she had her fall. She further stated once she was clean and positioned in her chair she went to her next hospice resident and did not see Resident #71 for the rest of the day. Hospice Nurse #1 further stated she was told about Resident #71's fall the next day on 10/3/18. The Hospice Nurse Aide further stated ever since Resident #71 had been placed on hospice care she was supposed to have supervision when exiting the locked area of the facility. She further stated the supervision was needed because Resident #71 tended to slump in her chair and was at risk to falling from her chair, so she needed to be repositioned in her chair often. She further stated the Hospice Nurse #1 would inform her which residents required supervision when outside the facility and Resident #71 had always been one who needed supervision when outside. During an interview on 10/9/18 at 1:56 PM the Director of Nursing stated she had not been aware Resident #71 had been outside the previous week on 9/26/18 and overheated until after Resident #71's fall on 10/2/18. She further stated no staff members brought the concern to her attention that Resident #71 had been outside and gotten over heated or had a decline safety awareness. She further stated sitting outside was not anything unusual for Resident #71 and she had not implemented any one on one care and no concerns had been brought to her by staff prior to the fall that Resident #71's Responsible Party and hospice did not want Resident #71 outside unsupervised until they had a meeting after the fall. During the meeting following Resident #71's fall on 10/2/18 staff then did inform the Director of Nursing about the concern of the family and Nurse #2 informed the Director of Nursing that Resident #71's responsible party had wanted Resident #71 to not be outside unattended. She further stated if a family member shared a concern with a staff member it was her expectation that the staff member brings that concern to the administrative staff to follow up on. She further stated Nurse #2 did not bring the concern to the administrative staff and should have. The Director of Nursing concluded to her knowledge, Resident #71 had been in the facility for a long time in assisted living and had recently been placed in the skilled nursing unit following her hospitalization , but she had always been let outside unsupervised. During an interview on 10/9/18 at 2:16 PM the Administrator stated Resident #71 had been having some changes recently and he felt it would be best for the wander guard to be placed following the fall on 10/2/18. He further stated the week before the fall Resident #71 had been outside for an extended period and a guest was concerned she was too warm. He further stated he was not aware of the blisters to the resident's right arm until after the fall on 10/2/18 but Resident #71 was very lethargic when she came inside on the day someone was concerned she overheated. He further stated from that point he spoke with staff to be sure they were aware of her location for safety precautions. He further stated Resident #71 had been outside every day since she had been in the facility for years and because her cognition was decreasing he wanted staff to be aware of where she was. He further stated no staff had brought to his attention that Resident #71's responsible party had requested Resident #71 not be left outside unsupervised. The Administrator also stated he was not aware that front line nurses and nurse aides had not been allowing Resident #71 to go outside unsupervised and thought it had always been her routine to go outside. He further stated if a family member brought a request such as supervision while outside to their attention, it was his expectation that the staff member bring this concern to the administration's attention to be addressed in the interdisciplinary team meetings. He further stated he had provided education verbally to staff to ensure they were aware of where Resident #71 was and if she was outside following the incident where the visitor was concerned about her overheating. He further stated it was his expectation Resident #71's nurse and nurse aide would have known Resident #71's location on 10/2/18 when the hospice nurse was asking where her location was. He further stated following the fall on 10/2/18 he met with the responsible party and she shared with him she had spoken to an unnamed staff member that she wanted Resident #71 to have supervision while outside. He further stated this was the first time he had heard this concern and the conclusion was to place a wander guard on Resident #71 following the fall on 10/2/18. During an interview on 10/9/18 Nurse Aide #1 stated Resident #71 moved fast since she came to the 300 hall and if she did not keep up with Resident #71 she would disappear. She further stated staff were to keep up with where Resident #71 was. The nurse aide stated Resident #71 used to go outside by herself when she was on the assisted living side of the facility. She further stated since she came to the skilled unit at some point in (MONTH) (YEAR) Resident #71 was not to go outside the facility unsupervised by staff. If Resident #71 wanted to go outside a staff member would need to go outside with her. She further stated she was made aware of this by word of mouth that Resident #71 was not to go outside the facility unsupervised. She further stated she did not know anything about her being outside for an extended period of time or getting overheated. She concluded she did know, however, Resident #71 was not supposed to be outside on her own since sometime in (MONTH) and sometimes visitors would let her outside and staff would have to bring her back in and educate the visitors. During an interview on 10/9/18 at 3:50 PM Nurse #3 stated she was familiar with Resident #71's care. She further stated Resident #71 was not to be left outside unsupervised during her shifts. She further stated this was due to her cognitive decline when she moved to the skilled nursing side in (MONTH) on (YEAR). She further stated she did not know what other did on their shifts, and she stated she did not report her concern for Resident #71 being outside unsupervised except to ask visitors or staff to not let her be unsupervised outside. During an interview on 10/9/18 at 4:24 PM the Administrator stated he did not have any documentation regarding the incident on 9/26/18 when the resident was brought in by a visitor and was lethargic and there was a concern she was warm. During observation on 10/9/18 at 5:35 PM the distance Resident #71 traveled from the entrance to the area she sustained a witnessed fall was measured with the Plant Operations Supervisor to be 68 feet. During an interview on 10/10/18 at 8:08 AM Nurse #2 stated some time prior to Resident #71's fall on 10/2/18, Unit Manager #1 had brought Resident #71 in the facility from outside because she had overheated, and her arms were very warm. Unit Manager #1 placed Resident #71 by the nurse station and told Nurse #2 that Resident #71 had gotten over heated. She stated Resident #71's Nurse Practitioner and Nurse #2 did an assessment of Resident #71. She further stated Resident #71 sat in her chair for a while and then had placed her in her room. Resident #71 was lethargic and not as active as she had been in the morning. Nurse #2 further stated she had told other nurse aides and nurses that Resident #71 was not to go outside unsupervised but had never brought this to the attention of her managers. During an interview on 10/10/18 at 8:18 AM Resident #71's Nurse Practitioner stated Resident #71 was in the facility in the assisted living section of the facility for a long time. The Nurse Practitioner stated she saw Resident #71 much more than the physician and was very familiar with Resident #71. The Nurse Practitioner stated Resident #71 had sustained a gradual decline in status with a huge bump in deterioration of her kidney function. Resident #71 then went to the hospital and came back in (MONTH) (YEAR) very debilitated due to her kidney function decline. The Nurse Practitioner spoke with the family and the decision was made to make the resident a hospice resident. She further stated when Resident #71 was in assisted living she was able to make safety decisions, however, once she returned from the hospital in (MONTH) (YEAR) she had a very noticeable cognitive decline. She further stated one day Resident #71 went outside in the sun and fell asleep and had gotten a sunburn with some blistering to both forearms, possibly related to kidney failure as well. She stated she did not document this assessment anywhere because hospice usually documented on Resident #71. She further stated following this incident she believed the facility staff supervised Resident #71 more closely when she was outside. She further stated she then visited Resident #71 on 10/1/18 and her blisters had opened and were itchy. She further stated she had ordered [MEDICATION NAME] for the itching. The Nurse Practitioner concluded Resident #71 had declined in safety awareness since her hospitalization and she agreed with the placement of the wander guard for safety and for staff to be more cognizant of where she was. During an interview on 10/10/18 at 8:51 AM MDS Nurse #1 stated if there was a change in condition for a resident it would be brought to MDS Nurse #2's attention by the floor nurse and then discussed in the interdisciplinary team meeting and updated on the care plan. She further stated if a resident began to have a cognitive or functional decline it was the expectation that the frontline staff would notify the interdisciplinary team to address the decline in documentation and the care plan. She further stated Resident #71 had sustained a severe decline when she came back to the facility from the hospital in (MONTH) (YEAR). She further stated Resident #71's safety and cognitive awareness drastically declined following her hospitalization and she was then placed on hospice in (MONTH) (YEAR). She further stated if Resident #71 went outside it was supposed to be with family who would supervise her outside and Resident #71 was not to be outside by herself. If it was noticed she was going outside by herself the staff would stop her and bring her back on the unit. She further stated Resident #71 would always sit by the locked door and if a visitor came she would ask them to hold the door for her and would attempt to go out to the front of the facility. She further stated she cared for Resident #71 when she first came back from the hospital on the 100 hall and Resident #71 hardly got out of bed during that time. She further stated once she moved to the 300 hall Resident #71 began getting up and out of bed. She stated it was around the beginning of (MONTH) (YEAR) when Resident #71 became more active and at that time MDS Nurse #1 did not have Resident #71 on her unit and did not know if Nurse #2 had reported the concern of her waiting by the door. MDS Nurse #1 stated it was a general understanding among the frontline nurses and nurse aides Resident #71 was not to be outside unsupervised and she did not know why it was not known by the Director of Nursing, Administrator, or other members of the interdisciplinary team. She stated she did not have Resident #71 once she moved to the 300 hall so she would ask Nurse #2 if Resident #71 was okay to go outside before opening the door and Nurse #2 would tell her no, Resident #71 had to be supervised outside the facility. She further stated Resident #71 was to be supervised outside the facility since her return from the hospital in (MONTH) (YEAR). MDS Nurse #1 further stated it was the expectation that Nurse #2 bring the concern of Resident #71's change in condition, waiting by the door, and decreased safety awareness to the charge nurse, MDS Nurse for care planning, and flagged the chart for the physician. During an interview on 10/10/18 at 12:40 PM Unit Manager #1 stated approximately two weeks ago she was returning to the facility from her lunch break with Unit Manager #2 who was Resident #71's unit manager. She further stated they were coming into the front of the building around 1 PM and a visitor was bringing Resident #71 inside from outside and said that Resident #71 didn't seem like herself and asked them to help her get Resident #71 inside. Unit Manager #1 stated they took her to unit 2 where Nurse #2 and Resident #71's Nurse Practitioner were. Unit Manager #1 stated she took Resident #71's vital signs, oxygen blood levels, and blood sugars because Resident #71 was diabetic. Unit Manager #1 stated she did not recall any vital signs being abnormal at that time or her blood sugar being abnormal. She further stated she did not do a skin assessment on Resident #71 at that time. She stated if anyone had ever told her Resident #71 was not supposed to be outside or needed to be supervised it would have been alarming because she thought Resident #71 could go outside unsupervised. She further stated a staff member was not outside with Resident #71 on the day she was brought in by a concerned visitor, however other residents and visitors were outside with Resident #71. She further stated Resident #71 would sit at the locked door and wait for someone to open the door and let her go outside. She further stated after her fall outside on 10/2/18 she was aware Resident #71 needed supervision, however prior to 10/2/18 no staff, family members, or hospice staff had informed her they did not want Resident #71 outside unsupervised. During an interview on 10/2/18 at 2:02 PM Hospice Nurse Aide #1 stated when Hospice Nurse #1 told her about the blisters to Resident #71's arms Hospice Nurse #1 asked her to place cream to Resident #71's blisters and wrap them. She further stated this happened about two weeks ago but did not remember the date. She stated when she first observed Resident #71's forearms it looked like a sun burn because her skin was peeling, and Resident #71 was scratching at it. She stated she placed the cream on Resident #71's forearms and wrapped them. She further stated now the left arm had appeared to heal and they were currently only wrapping the right forearm. During an interview on 10/10/18 at 2:14 PM Unit Manager #2 stated she was coming back from lunch around 1 PM with Unit Manager #1 and when she came into the building she was stopped by a family member as Unit Manager #1 continued. Someone stopped Unit Manager #1 and mentioned something to her about Resident #71 and Unit Manager #1 took Resident #71 back in to the facility. Unit Manager #2 stated Unit Manager #1 pushed Resident #71 to Nurse #2 and reported to Nurse #2 she had been stopped and that there was a concern about Resident #71's health. She further stated Unit Manager #1 and Nurse #2 did an assessment on Resident #71 and everything seemed okay. Unit Manager #2 further stated at that time to her knowledge no skin assessment was done. She further stated she did not know when the blisters to Resident #71 were first identified but they were brought to her attention on 10/4/18. Unit Manager #2 stated it was brought to her attention because on 9/29/18 Resident #71's nurse had documented a new skin issue in their documentation. She further stated she was not aware of any blisters to Resident #71's left arm that Hospice Nurse #1 and Hospice Nurse Aide #1 wrapped on 9/27/18. She further stated when Resident #71 was on the assisted living side she was able to self-propel. Resident #71 then returned from the hospital to the skilled unit on 100 hall but was not as active. Unit Manager #2 further since Resident #71 went to the 300 hall on 9/1/18 she began to self-propel herself in her chair again. She further stated Resident #71 had always had a routine of going outside and sitting under the car port when she was in assisted living. She further stated prior to 10/2/18 she would have opened the door and let the resident go outside unsupervised. Unit Manager #2 stated no staff, family members, or hospice staff had brought to her attention their concerns with Resident #71 going outside unsupervised by staff. She further stated it was her expectation that if any staff had such concerns they would report to her and she could begin the process of implementing a plan and updating the care plan. During an interview on 10/10/18 at 5:25 PM the Director of Nursing stated Resident #71 had no new formal risk assessment or elopement risk assessment since her admission on 8/10/18 when she was on the 100 hall. During an interview on 10/11/18 at 10:30 AM Nurse Aide #1 stated Resident #71 came to the 300 hall in (MONTH) of (YEAR). She further stated since that time Resident #71 was not to go outside the locked area of the facility unsupervised by staff per her nurses. The Administrator and DON were notified of the immediate jeopardy on 10/9/18 at 4:35 PM. On 10/10/18 at 4:30 AM the facility provided the following credible allegation of compliance for immediate jeopardy removal: Credible Allegation for Supervision to prevent accidents Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 09/26/2018 the resident had been sitting outside on the front porch when a visitor assisted her in the front door and alerted the Unit Manager. This occurred around 1PM. The resident was assisted back to her unit by the Unit Manager and an assessment performed revealing vital signs, SPO2, and blood sugar were within normal limits for this resident. The Unit Manager stated that the resident ' s skin was warm and dry. No blisters or redness were observed to the residents upper extremities at this time. A report was immediately given to the FNP who then assessed the resident. The FNP stated that the Unit Manager reported to her that the resident had been brought in from outside due to appearing sleepy and was sitting out doors. The Unit Manger took the residents vital signs and reported them to her and they were well within her normal limits and the resident did not appear to be in any distress. The FNP states that she was aware of the resident sitting outside alone as she has seen the resident sitting on the front porch frequently and no concerns were seen with this activity. No medical interventions were required due to this event. On 09/27/2018 the Hospice nurse was in the facility to assess the resident and noted blisters on the resident ' s right arm. The resident was complaining of itching in this area. The hospice nurse directed the hospice aide to apply cream to the area and apply sleeves to prevent the resident from scratching the area and to trim her nails. The hospice nurse states this was completed on 09/27/2018. On 10/02/2018, the Director of Nursing and the Administrator met and discussed the incident regarding the fall outside and determined the root cause of the incident was that the resident now required supervision while outside. · Corrective action for the affected resident: On 10/02/2018 the resident was assigned a wander guard bracelet to prevent her from going outside unsupervised due to her safety risk. On 10/02/2018 the Director of nursing interviewed and assessed the resident for the need of wander guard placement and initiated orders for wander guard placement and monitoring. On 10/02/2018 at approximately 9:15AM the resident was assisted through the double doors onto the front hall way by the activities assistant. The resident proceeded to go out the front doors to sit on the front porch as per her normal routine. Per the staff interviews conducted including the FNP this was her normal routine up until 10/02/2018. The activity assistant observed the resident still sitting on the front porch at approximately 9:45AM. At approximately 10:15AM the resident was observed leaning over in her wheel chair as to pick something up off the ground and fell out of her wheel chair. The resident did not sustain an injury as a result of this fall. The fall

Based on record review, observation, Physician and staff interviews the facility failed to follow the care plan for use of a medium pad and 2 people while transferring a resident with a use of a lift, resulting in a subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) for 1 of 1 sampled resident. (Resident # 125) The findings included: Resident # 125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #125's care plan dated 5/24/2017 indicated the resident has an Activities of Daily Living (ADLs) self-care performance deficit. The care plan indicated the goal as I will maintain current level of function in bed mobility and transfer through the next 90 days. The care plan interventions included use of full mechanical lift for all transfers using a medium pad and assist with use of 2 persons. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #125 was severely cognitively impaired. The MDS also indicated the resident required extensive assistance of one person for bed mobility and extensive assistance of two person for transfer from bed to wheel chair. The MDS also indicated the resident was totally dependent on staff for all Activities of Daily Living (ADLs). The resident was not coded for falls and walking did not occur during the look back period. The resident's Kardex dated August/July 2017 (a care guide for direct staff identifying resident care needs at the facility) under transfer headline indicated the resident required a full mechanical lift for transfers using 2 persons and the use of medium pad size. A nurse note dated 7/24/2017 at 12:57 PM revealed the nurse was called to the resident's room around 11:40 am due to the resident's fall. When the nurse entered the room she noted the resident lying on the floor next to bed lying on her left side. NA # 1 stated the resident fell on her back with head being bumped noted alert and verbal with sitter and staff NA#1 was with the resident. A raised area to back of the head was noted and no bleeding was noted. NA# 1 stated that the resident was being transferred from bed to wheel chair when a fall occurred. The doctor was called and the responsible party was notified. The patient was then sent out to an emergency room for an evaluation. A nurse note dated 7/24/2017 at 5:00 PM revealed the resident was admitted back to the facility from the emergency room with no new medication but with an order for [REDACTED]. Review of the emergency room report dated 7/24/2017 indicated the resident was diagnosed with [REDACTED]. The resident was subsequently transported back to the nursing home facility on 07/24/2017. Review of the facility's investigation report dated 7/24/2017 revealed Resident, # 125 was being transferred by Nurse Aide (NA) # 1 using the Maxi-move lift (full mechanical lift) with a XL (Extra Large) lift pad. During the transfer NA# 1 reported lift pad became unhooked on 1 corner. Initially, the resident sustained [REDACTED]. The resident was immediately assessed by Nurse # 1. The doctor was notified and orders were obtained to send the patient for evaluation. Under the investigation headline the report indicated, The resident was assessed to use a medium lift pad for transfers. The resident's care guide listed the correct lift pad to be used. NA # 1 was aware of the process of reviewing the care guide before giving care and transfers. The NA # 1 failed to check the care guide as a result, the NA#1 failed to use the correct lift pad for transfer, resulting in an improper transfer. The NA#1 reenacted the lift transfer by demonstrating to the Administrator the following: NA demonstrated by re-enactment of lifting the resident using the XL lift pad with the Maxi-move (total lift device). She demonstrated incorrectly criss-crossing the leg straps to the lift bar reporting that she and the private sitter were present at time of transfer. The NA # 1 was asked at the time of interview by Administrator why she did not have another staff member present during lift use and NA#1 stated, That she normally does, but the sitter was in the room. Administrator informed her this was not acceptable as the sitter was not a trained employee. NA#1 had received recent lift training regarding having 2 staff members with mechanical lifts on 10/25/16 and 5/29/17. During the interview with NA #1 on 8/16/2017 at 12:30 PM, she verified she did not use the correct pad size while transferring the resident and she did not have another staff with her in the room while transferring the resident. NA #1 further reported on 7/24/2017 while in the process of transferring the resident from bed to wheelchair, she (Resident # 125) fell on the floor. NA # 1 also reported she was aware of where the Kardex was located which indicated the resident was to be transferred using medium size pad and use of 2 people. NA #1 also reported she always used 2 persons while transferring a resident but she was in a hurry and used one person for the transfer. During the interview with Nurse # 1 on 8/16/2017 at 1:00 PM, she reported that on 7/24/2017 she was called to resident #125's room by NA #1 who stated she transferred the resident alone and the resident fell on the floor. Nurse #1 also reported she assessed the resident and she found the resident had a bump by the side of the head. She (Nurse # 1) then notified the Physician who ordered the patient to be sent to the emergency room . Nurse # 1 further added the resident came back to the facility the same day with the [DIAGNOSES REDACTED]. During the interview with the Physician on 8/17/2017 at 11:00 AM, the Physician reported he evaluated the resident immediately after the fall and the resident was doing remarkably well. He indicated since the resident's fall on 7/24/2017, the facility staff were continuing to monitor the resident closely for any changes in cognition or her health. The doctor also reported the resident was not a candidate for surgery due to age. He further mentioned the resident will continue to be evaluated by the neurosurgeon and an appointment had been set up by the facility staff. On 8/17/2017 at 1:30 PM, observation of Resident #125 in her wheel chair revealed no grimacing or behaviors to indicate she was in pain and no bump on the head. The NA # 2 and NA # 3 were also observed transferring the resident from the wheel chair to bed. The staff used assigned pad size (medium) and lift belt securement the proper procedure while transferring the resident. No concerns were identified During the interview with the facility Administrator on 8/18/2017 at 10:50 am, she stated she had investigated the circumstances of Resident # 125's fall on 7/24/2017 and determined that NA #1 had not followed the care plan interventions for the use of 2 staff members while transferring the resident and had not used the right pad size. The Administrator stated his expectation was for the NA# 1 to have followed the care plan while transferring a resident. The Administrator also added that NA # 1 was aware the resident needed 2 persons and the use of correct pad size while transferring a resident because she had been in serviced on 10/25/2016 and 5/29/2017. Facility provided corrective action plan on 8/16/2017 Description of event: Resident # 125 was being transferred by NA#1 using the Maxi-move lift with a XL lift pad. During the transfer NA #1 reports lift pad became unhooked on 1 corner. Initially, the resident sustained [REDACTED]. The resident was immediately assessed by Nurse # 1. The Physician was notified and orders were obtained to send to ER for evaluation. This was completed on 07/24/2017. The resident was assessed to use a medium lift pad for transfers. The Kardex listed the correct lift pad to be used. NA # 1 was aware of the process of reviewing the Kardex before giving care and transfers. The NA # 1 failed to check the Kardex as a result, the NA # 1 failed to use the correct lift pad for transfer, resulting in an improper transfer. The NA # 1reenacted the lift transfer by demonstrating to the Administrator the following: NA # 1 demonstrated by re-enactment of lifting the resident using the XL lift pad with the Maxi-move (total lift device). She demonstrated incorrectly criss- crossing the leg straps to the lift bar reporting that she and the private sitter were present at time of transfer. The NA # 1 was asked at time of interview by Administrator why she did not have another staff member present during lift use and NA # 1 stated, That she normally does, but the sitter was in the room. Administrator informed her this was not acceptable as the sitter was not a trained employee. NA # 1 had received recent lift training regarding having 2 staff members with mechanical lifts on 10/25/16 and 5/29/17. After review of the investigation of the event, it is identified, the root causes to be as follows: -NA# 1 failed to review Kardex prior to transfer -NA # 1used incorrect lift sling -NA# 1 attached leg straps to the cradle incorrectly - NA# 1 failed to have second trained staff member present during lift transfer Corrective Action for Affected Residents The resident was immediately assessed and the provider was notified by Nurse # 1 at 11:50 AM. Pain was also assessed. Responsible Party was notified by Nurse # 1 on 7/24/17 at approximately. 11:55 AM. The resident was transferred to the hospital at 12:05 PM. Corrective Action for Potentially Affected Residents All lift slings on 7/24/2017 were inspected with all/any issues corrected or equipment removed from service immediately. All nursing staff received in-service education with return demonstration for accessing the Kardex & executing proper transfers using all types of facility lifts. Education will be provided to all clinical staff on the following: -Using the Kardex to identify the correct lift and sling size -Appropriate processes of lift usage, including number of staff required All nurses and CNA's will perform return demonstration for lift usage. Systematic Changes Education provided to all Nurses and Nurse Assistants on the utilization of resident Kardexes and using the correct lift for safe resident transfers. Education will be provided by the Staff Development coordinator (SDC). This education will be included in new hire orientation for nurses and CNAs. Return demonstration to validate competency of the staff showing correct usage of the lift pads with the lifts will be performed. Any education not completed on 8/7/17 will result in staff being removed from the schedule until education is complete. All nursing staff including: LPNs, RNs, Nursing Managers, CNAs and Med. Aides/Techs Were in serviced on the importance of checking resident Kardex prior to initiating any transfers in order to ensure that the safest transfer technique is used. This education was initiated on 7/24/17 by the Staff Development Coordinator. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees and will be reviewed by the Quality Assurance Process to verify that the change has been sustained. The education completion date on 8/7/2017. HOW THE FACILITY PLANS TO MONITOR CHANGES IMPLEMENTED The Staff nurses or licensed nurse will complete a Safe Transfer/Lift Quality Assurance (QA) Audit weekly x 4 and then monthly x 2 making sure the correct lift pad is being used with correct lift on the correct resident. The Director of Nursing will present findings to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Unit Managers, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Health Information Management and meets weekly. As part of the validation on 8/17/2017 at 3:30 PM, the entire plan of correction was reviewed including the interviews with staff related to the use of the lift. Interview with the Nurses' Aides revealed they had knowledge in checking the residents' Kardex and following the interventions before using a lift to transfer a resident. The staff were reeducated on a safe transfer with use of a lift and making sure the correct lift pad is used with correct lift on the correct resident. 2 staff were observed during a transfer of Resident # 125. The 2 staff appropriately transferred the resident by making sure the correct lift pad (medium size) was used with correct lift. Review of the facility's Audit of appropriate use of lift revealed a nurse supervisor on each unit observed 5 random residents who required a use of mechanical lift while being transferred by 2 nurses' aides. The audit revealed no concerns were identified for the last 4 weeks. Quality Assurance committee report revealed the facility met daily to discuss the appropriate use of lift audit beginning 7/25/2017 until 8/11/2017. Review of the monitoring tools revealed that the facility had completed the 100% in-service on 8/7/2017.

Based on record review, observations, and staff interviews the facility failed to use designated pad size (medium) and use 2 people while transferring a resident using a full mechanical lift, resulting in a subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) for 1 of 1 sampled resident who was care planned for use of a lift. (Resident # 125) The findings included: The user manual instruction manual for use of the mechanical lift dated January 2015 was reviewed. The instruction indicated the following: - Do not use a sling unless it is recommended for use with the lift. - Always check the sling is suitable for the particular patient and is of the correct size and capacity. Resident # 125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #125's care plan dated 5/24/2017 indicated the resident has an Activities of Daily Living (ADLs) self-care performance deficit. The care plan indicated the goal as I will maintain current level of function in bed mobility and transfer through the next 90 days. The care plan interventions included use of full mechanical lift for all transfers using a medium pad and assist with use of 2 persons. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #125 was severely cognitively impaired. The MDS also indicated the resident required extensive assistance of one person for bed mobility and extensive assistance of two person for transfer from bed to wheel chair. The MDS also indicated the resident was totally dependent on staff for all Activities of Daily Living (ADLs). The resident was not coded for falls and walking did not occur during the look back period. The resident's Kardex dated August/July 2017 (a care guide for direct staff identifying resident care needs at the facility) under transfer headline indicated the resident required a full mechanical lift for transfers using 2 persons and the use of medium pad size. A nurse note dated 7/24/2017 at 12:57 PM revealed the nurse was called to the resident's room around 11:40 am due to the resident's fall. When the nurse entered the room she noted the resident lying on the floor next to bed lying on her left side. NA # 1 stated the resident fell on her back with head being bumped noted alert and verbal with sitter and staff NA#1 was with the resident. A raised area to back of the head was noted and no bleeding was noted. NA# 1 stated that the resident was being transferred from bed to wheel chair when a fall occurred. The doctor was called and the responsible party was notified. The patient was then sent out to an emergency room for an evaluation. A nurse note dated 7/24/2017 at 5:00 PM revealed the resident was admitted back to the facility from the emergency room with no new medication but with an order for [REDACTED]. Review of the emergency room report dated 7/24/2017 indicated the resident was diagnosed with [REDACTED]. The resident was subsequently transported back to the nursing home facility on 7/24/2017. Review of the facility's investigation report dated 7/24/2017 revealed Resident, # 125 was being transferred by Nurse Aide (NA) # 1 using the Maxi-move lift (full mechanical lift) with a XL (Extra Large) lift pad. During the transfer NA# 1 reported lift pad became unhooked on 1 corner. Initially, the resident sustained [REDACTED]. The resident was immediately assessed by Nurse # 1. The doctor was notified and orders were obtained to send the patient for evaluation. Under the investigation headline the report indicated, The resident was assessed to use a medium lift pad for transfers. The resident's care guide listed the correct lift pad to be used. NA # 1 was aware of the process of reviewing the care guide before giving care and transfers. The NA # 1 failed to check the care guide as a result, the NA#1 failed to use the correct lift pad for transfer, resulting in an improper transfer. The NA#1 reenacted the lift transfer by demonstrating to the Administrator the following: NA demonstrated by re-enactment of lifting the resident using the XL lift pad with the Maxi-move (total lift device). She demonstrated incorrectly criss-crossing the leg straps to the lift bar reporting that she and the private sitter were present at time of transfer. The NA # 1 was asked at the time of interview by Administrator why she did not have another staff member present during lift use and NA#1 stated, That she normally does, but the sitter was in the room. Administrator informed her this was not acceptable as the sitter was not a trained employee. NA#1 had received recent lift training regarding having 2 staff members with mechanical lifts on 10/25/16 and 5/29/17. During the interview with NA #1 on 8/16/2017 at 12:30 PM, she verified she did not use the correct pad size while transferring the resident and she did not have another staff with her in the room while transferring the resident. NA #1 further reported on 7/24/2017 while in the process of transferring the resident from bed to wheelchair, she (Resident # 125) fell on the floor. NA # 1 also reported she was aware of where the Kardex was located which indicated the resident was to be transferred using medium size pad and use of 2 people. NA #1 also reported she always used 2 persons while transferring a resident but she was in a hurry and used one person for the transfer. During the interview with Nurse # 1 on 8/16/2017 at 1:00 PM, she reported that on 7/24/2017 she was called to resident #125's room by NA #1 who stated she transferred the resident alone and the resident fell on the floor. Nurse #1 also reported she assessed the resident and she found the resident had a bump by the side of the head. She (Nurse # 1) then notified the Physician who ordered the patient to be sent to the emergency room . Nurse # 1 further added the resident came back to the facility the same day with the [DIAGNOSES REDACTED]. During the interview with the Physician on 8/17/2017 at 11:00 AM, the Physician reported he evaluated the resident immediately after the fall and the resident was doing remarkably well. He indicated since the resident's fall on 7/24/2017, the facility staff were continuing to monitor the resident closely for any changes in cognition or her health. The doctor also reported the resident was not a candidate for surgery due to age. He further mentioned the resident will continue to be evaluated by the neurosurgeon and an appointment had been set up by the facility staff. On 8/17/2017 at 1:30 PM, observation of Resident #125 in her wheel chair revealed no grimacing or behaviors to indicate she was in pain and no bump on the head. The NA # 2 and NA # 3 were also observed transferring the resident from the wheel chair to bed. The staff used assigned pad size (medium) and lift belt securement the proper procedure while transferring the resident. No concerns were identified During the interview with the facility Administrator on 8/18/2017 at 10:50 am, she stated she had investigated the circumstances of Resident # 125's fall on 7/24/2017 and determined that NA #1 had not followed the care plan interventions for the use of 2 staff members while transferring the resident and had not used the right pad size. The Administrator stated his expectation was for the NA# 1 to have followed the care plan while transferring a resident. The Administrator also added that NA # 1 was aware the resident needed 2 persons and the use of correct pad size while transferring a resident because she had been in serviced on 10/25/2016 and 5/29/2017. Facility provided corrective action plan on 8/16/2017 Description of event: Resident # 125 was being transferred by NA#1 using the Maxi-move lift with a XL lift pad. During the transfer NA #1 reports lift pad became unhooked on 1 corner. Initially, the resident sustained [REDACTED]. The resident was immediately assessed by Nurse # 1. The Physician was notified and orders were obtained to send to ER for evaluation. This was completed on 07/24/2017. The resident was assessed to use a medium lift pad for transfers. The Kardex listed the correct lift pad to be used. NA # 1 was aware of the process of reviewing the Kardex before giving care and transfers. The NA # 1 failed to check the Kardex as a result, the NA # 1 failed to use the correct lift pad for transfer, resulting in an improper transfer. The NA # 1reenacted the lift transfer by demonstrating to the Administrator the following: NA # 1 demonstrated by re-enactment of lifting the resident using the XL lift pad with the Maxi-move (total lift device). She demonstrated incorrectly criss- crossing the leg straps to the lift bar reporting that she and the private sitter were present at time of transfer. The NA # 1 was asked at time of interview by Administrator why she did not have another staff member present during lift use and NA # 1 stated, That she normally does, but the sitter was in the room. Administrator informed her this was not acceptable as the sitter was not a trained employee. NA # 1 had received recent lift training regarding having 2 staff members with mechanical lifts on 10/25/16 and 5/29/17. After review of the investigation of the event, it is identified, the root causes to be as follows: -NA# 1 failed to review Kardex prior to transfer -NA # 1used incorrect lift sling -NA# 1 attached leg straps to the cradle incorrectly - NA# 1 failed to have second trained staff member present during lift transfer Corrective Action for Affected Residents The resident was immediately assessed and the provider was notified by Nurse # 1 at 11:50 AM. Pain was also assessed. Responsible Party was notified by Nurse # 1 on 7/24/17 at approximately. 11:55 AM. The resident was transferred to the hospital at 12:05 PM. Corrective Action for Potentially Affected Residents All lift slings on 7/24/2017 were inspected with all/any issues corrected or equipment removed from service immediately. All nursing staff received in-service education with return demonstration for accessing the Kardex & executing proper transfers using all types of facility lifts. Education will be provided to all clinical staff on the following: -Using the Kardex to identify the correct lift and sling size -Appropriate processes of lift usage, including number of staff required All nurses and CNA's will perform return demonstration for lift usage. Systematic Changes Education provided to all Nurses and Nurse Assistants on the utilization of resident Kardexes and using the correct lift for safe resident transfers. Education will be provided by the Staff Development coordinator (SDC). This education will be included in new hire orientation for nurses and CNAs. Return demonstration to validate competency of the staff showing correct usage of the lift pads with the lifts will be performed. Any education not completed on 8/7/17 will result in staff being removed from the schedule until education is complete. All nursing staff including: LPNs, RNs, Nursing Managers, CNAs and Med. Aides/Techs Were in serviced on the importance of checking resident Kardex prior to initiating any transfers in order to ensure that the safest transfer technique is used. This education was initiated on 7/24/17 by the Staff Development Coordinator. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees and will be reviewed by the Quality Assurance Process to verify that the change has been sustained. The education completion date on 8/7/2017. HOW THE FACILITY PLANS TO MONITOR CHANGES IMPLEMENTED The Staff nurses or licensed nurse will complete a Safe Transfer/Lift Quality Assurance (QA) Audit weekly x 4 and then monthly x 2 making sure the correct lift pad is being used with correct lift on the correct resident. The Director of Nursing will present findings to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Unit Managers, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Health Information Management and meets weekly. As part of the validation on 8/17/2017 at 3:30 PM, the entire plan of correction was reviewed including the interviews with staff related to the use of the lift. The staff were reeducated on a safe transfer with use of a lift and making sure the correct lift pad is used with correct lift on the correct resident. 2 staff were observed during a transfer of Resident # 125. The 2 staff appropriately transferred the resident by making sure the correct lift pad (medium size) was used with correct lift. Review of the facility's Audit of appropriate use of lift revealed a nurse supervisor on each unit observed 5 random residents who required a use of mechanical lift while being transferred by 2 nurses' aides. The audit revealed no concerns were identified for the last 4 weeks. Quality Assurance committee report revealed the facility met daily to discuss the appropriate use of lift audit beginning 7/25/2017 until 8/11/2017. Review of the monitoring tools revealed that the facility had completed the 100% in-service on 8/7/2017.

Based on observations, staff interviews, and record review, the facility failed to safely transfer a resident with a sit to stand lift by failing to use the assistance of two persons, the correct sling size and leg strap which resulted in 1 of 1 resident (Resident #1) falling from a sit to stand lift during transfer and sustaining a hip fracture. The findings include: Resident #1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1's cognition was intact based on a Brief Interview for Mental Status (BIMS) of 15. In the area of activities of daily living, she required extensive to total assistance in most areas of activities of daily living except she required supervision during meals. Resident #1 required two person assistance with transfers. In the area of locomotion on and off the unit, Resident #1 required one person physical assistance. Review of Resident #1's care plan which was updated on 8/4/16 addressed the resident's increased risk for falls related to confusion, deconditioning and history of falls. The interventions did not address transfers. The care plan also addressed activities of daily living self-care performance deficit related to dementia, fatigue and pain. Review of the interventions revealed Resident #1 required total assistance with transfers, however the interventions did not mention Resident #1 required two person assistance with transfers. Review of a Staff Nursing note dated 8/4/16 at 12:26 PM, written by Staff Nurse # 1, read in part, Nursing Assistant reports pt. (patient) fell on floor during transfer. Patient complains of pain to rt. (right) hip, right leg, ems (emergency medical services) called and in route for transport to hospital, report to charge nurse and supervisor, monitoring continued. Review of a Staff Nursing note dated 8/4/16 at 3:02 PM, written by Staff Nurse # 1, read in part, Nursing Assistant reports pt.(patient) slide from lift, pt. noted in bed upon, assessment, transferred via ems (emergency medical services) for x-ray, report given to oncoming nurse. Review of a Staff Nursing Note dated 8/4/16 at 11:57 PM, written by Staff Nurse # 2, read in part, Resident #1 admitted on [DATE]. Currently the pain assessment revealed acute pain verbalized. New rt. (right) Hip fx. (fracture) hurts a whole lot. Additional Documentation: Resident returned to facility at 8:50 PM. New orders noted. Prn (as needed) pain-medication given. Review of the facility's fall incident report dated 8/4/16 at 2:30 PM, written by Staff Nurse #1 revealed Nursing Assistant (NA#1) reported that Resident #1 slid to the floor during transfer and the resident was in bed when the Staff Nurse entered the room. During Staff Nurse #1's assessment Resident #1 complained of pain to her right hip and right leg. Resident #1 was assessed for injuries, and no injuries were observed. Resident #1's level of pain was a 2 (on a scale of 0 to 10 with 0 no pain and 10 is the most pain that the patient experienced). The resident was alert and oriented to person. The doctor was notified and the doctor gave orders to send Resident #1 to the hospital emergency room . Review of the facility fall incident investigative report dated 8/15/16 revealed NA#1 was transferring Resident #1 using the sit to stand lift, when during transfer, the lift sling began slipping up her torso. According to the report Nursing Assistant 1 tried to maneuver the wheelchair under Resident #1 but was unable to do so and was forced to assist Resident #1 to the floor. On 8/8/16, Nursing Assistant #1 demonstrated the lift procedure used at the time of incident. Through NA#1's demonstration it was determined that the cause of the incident was due to failure to use 2 staff member's assistance with the transfer by the lift, failure to use appropriate sling size and failure to secure leg strap. Review of a hospital emergency room report and radiology report dated 8/4/16, revealed Resident #1 was seen at the hospital emergency room for a fall, injury and severe pain to her right hip. According to a radiology report Resident #1 had a prior right hip arthroplasty (surgical reconstruction or replacement of a joint) based on a 10/31/11 examination. The radiology report noted a trochanteric fracture right hip (upper part of the thigh bone). During an interview on 8/23/16 at 10:08 AM, Nursing Assistant (NA#2) recalled when she went into Resident #1's room they already had the sling lift pad under Resident #1 to get her off the floor. She stated NA# 1 and NA#3 were in the room. NA#2 said she just hooked one of the sling hooks to the lift. She stated they said they had it under control after that. NA#2 said NA#1 & NA# 3 started lifting Resident # 1 from the floor using a full body lift. NA#2 commented she guessed they were going to put her back in the bed. She revealed Resident #1 was fine and she did not see her hurt or anything. NA# 2 said no one said what happened or anything. NA #2 stated she had worked with Resident #1 before, but it had been a while back. She recalled she used the sit to stand lift when she worked with Resident #1 and she controlled the sit to stand lift by herself. NA#2 stated she could not recall how long ago she worked with Resident #1. During an interview on 8/23/16 at 10:22 AM, Staff Nurse #1 revealed NA#1 came to her and she was on the telephone talking to a doctor's office. She said NA#1 told her Resident #1 couldn't hold on to the lift and Resident #1 fell down. Staff Nurse # 1 revealed she told the aide to leave the resident there and to get a set of vitals and she would be there after she got off the phone. Staff Nurse #1 said it was an important call, it was a short call, a couple of minutes. She stated after the phone call she went to Resident #1's room and a Nurse Supervisor went with her to the room. Staff Nurse #1 stated the Nursing Assistant had other nursing assistants in the room when she got there. She stated she did not know all their names. She stated Resident #1 was on the bed. Staff Nurse # 1 said the Nursing Assistant did not tell her why she moved Resident #1 from the floor to her bed. She revealed she started the assessment, and the resident complained of pain. Staff Nurse # 1 stated she thought Resident # 1 got something for pain. She said everything happened so fast. Staff Nurse # 1 said initially Resident # 1 was not complaining of pain until after she touched her leg. She recalled Resident # 1 frowned up and barely wanted to admit she had pain. Staff Nurse #1 stated she kept checking Resident #1. Staff Nurse # 1 said she assessed Resident #1's right hip and right leg and Resident #1 grimaced a little, but she did not show extreme pain. She revealed Resident #1 did not want to go to the hospital. She stated she sent Resident #1 out to the hospital after the assessment and emergency medical services transported Resident #1 to the hospital. During an interview on 8/23/16 at 10:34 AM, the Unit Manager stated when she got called to Resident #1's room, Resident #1 was lying in bed complaining of pain to her right hip. She stated she assisted the charge nurse with sending Resident #1 to the emergency room to have the right hip area assessed further. The Unit Manager reported that based on her observation with the resident, it was best for Resident #1 to go to the emergency room to have it checked further. She revealed they could not be sure if there was a problem without x-rays or scans. She stated she told Resident #1 that they were going to send her to the emergency room . The Unit Manager said Resident #1 was talking and was not crying or anything. She stated she called the doctor who gave an order to send Resident #1 to the hospital. The Unit Manager revealed she gave a report to emergency medical services that Resident #1 had a fall from a lift and she did not witness it. She also reported that Resident #1 used oxygen and was alert and oriented. The Unit Manager revealed after she gave the report, emergency medical services left with Resident #1. The Unit Manager stated she was surprised Resident #1 came back with a fracture because the resident did not initially complain of pain, except when she touched it. During an interview on 8/24/16 at 11:09 AM, NA #3 stated she was called to help NA #1 assist Resident #1 from the floor and to put her in bed. She stated she did not know exactly what happened. NA# 3 stressed her main reason for being there was to get Resident #1 from the floor to the bed. She stated they used the full lift to transfer Resident #1 from the floor to the bed. NA# 3 said when she came in the room, Resident #1 was sitting on the floor, she was talking and she did not complain of pain. During an interview on 8/24/16 at 11:28 AM, NA #1 revealed the day of the incident she was pulled from the 800 hall to the 300 hall with two other nursing assistants to work. She stated she received a verbal communication report about Resident #1's care. She revealed Resident #1 required the sit to stand lift for transfer. She stated during the morning she gave Resident #1's bath first and after her bath she transferred Resident #1 to her wheelchair using the sit to stand lift. NA# 1 stated when she did her last rounds at 2:00 PM Resident # 1 was in her wheelchair and she needed to be changed. She revealed she planned to transfer Resident #1 from her wheelchair to her bed to change her. NA #1 explained she hooked Resident #1's sling up to the lift and put a buckle around the resident's waist and lifted her up in the sling with the lift. NA #1 revealed that she tried to move the resident's wheelchair and oxygen out of the way because there was not enough room to maneuver the sit to stand lift. She revealed that she tried to direct the lift toward the resident's bed and she saw Resident #1 going down, slipping through the left side of the sling. She stated as she was trying to lower Resident #1 to her wheelchair, Resident #1 got to the edge of the wheelchair and she was still sliding and the wheelchair started moving. NA# 1 recalled when Resident #1's knees started to buckle, she pulled the lift out so she could straighten the resident's legs and when Resident # 1 finished sliding she was on the floor and the seat cushion from the wheelchair was pushed up against the night stand. NA #1 recalled that she got behind Resident #1 to try to support her back until someone else came to assist her. She stated Resident #1 did not bear weight on her legs, she said Resident #1's knees buckled and she did not hit the floor hard. NA#1 stressed that she called for assistance when Resident #1 slid to the floor. She stated she waited until Resident #1 was out of harm and she ran to the door and looked for help. NA#1 revealed Resident #1 said she was not hurting, but Resident #1 said she could not breathe right. NA#1 stated she shouted in the hall for the Nurse, but the nurse said she could not get there right away. NA#1 revealed two other Nursing Assistants came in to help her get the resident up from the floor. She revealed she thought the nurse asked the nursing assistants to come help her get Resident #1 off the floor. NA#1 stated the nursing assistants came in with a full lift and she recalled they used the pad from the full lift to lift Resident #1 up and put her in bed. NA #1 stated Staff Nurse #1 and the Unit Manager came and they checked Resident #1 out. She stated they proceeded to change Resident #1 until emergency services arrived. NA#1 said NA#3 helped her change Resident #1 in bed. She revealed she did not know Resident #1 was supposed to have two staff to transfer her. She stated she could not recall who gave her the report on how to care for Resident #1. During an observation on 8/24/16 at 4:25 PM, the Administrator and two Nursing Assistants NA #4 and NA# 5 demonstrated how residents should be transferred with a sit to stand lift. The two Nursing Assistants lifted the Administrator in the sit to stand lift. The Nursing Assistants revealed they looked at a chart with different colors noting the size of the slings, which was based on a resident's weight. The Nursing Assistants revealed they made sure they had the right size sling and going by the chart they used a medium sling to lift the Administrator. The medium sling pad was placed in the wheelchair. A velcro buckle from the sling was placed around the Administrator's waist. Velcro straps were also placed around the Administrator's legs. An apparatus from the lift was placed against the Administrators knees and legs for support. The sit to stand lift was locked into place. The Administrator held onto hand rails and NA#5 pressed the button on the lift and the lift caused the Administrator to go from a sitting position to a standing position. After the demonstration was over the Nursing Assistants removed the velcro buckles from the Administrator's waist and legs. The Nursing Assistants revealed they looked at the chart to determine what size sling to use and revealed staff could also ask the Nurse on the hall about the correct size of sling to use. During an interview on 8/24/16 at 12:19 PM, the Administrator revealed he had NA#1 come in to demonstrate for them what happened during the transfer with the lift. He stated the Nurse Consultant was also present. The Administrator reported that NA#1 hooked him up in the sling to the lift. He stated he asked NA#1 what kind of sling she was using and she said she could eye ball it. The Administrator explained his arms were up as NA#1 stated Resident #1's arms were up while in the sling and she stated Resident #1 slipped through the sling and said she was going down. The Administrator stated NA#1 said it was like Resident #1 gave out. He stated he let his legs go too and he did not go anywhere. The Administrator revealed NA#1 was not able to show them how Resident #1 fell . He stated NA# 1 said she flagged a Nursing Assistant to help her get Resident #1 up from the floor. The Administrator revealed NA#1 did not give the nurse time to assess Resident #1 and she put the resident back in bed. He stated NA#1 could not recreate what happened. The Administrator suspected that NA#1 either did not hook up the resident properly in the sling or she did not use the right sling size.

Based on record review, observations, staff and family interviews the facility failed to assess residents for hazardous side rails for a resident that was observed by a family member attempting to get out of bed resulting in a fall with her arm stuck in the side rail and by failing to implement the side rail padding to prevent it from happening again (Resident #160) and for a resident observed attempting to get over the side rail with one leg through and one leg over the side rail and a second observation of the same resident with one leg wedged between the high-low mattress and side rail (Resident #78) for 2 of 2 residents (Resident #160 and Resident #78) with hazardous side rails. The facility also failed to provide supervision while she was left alone in a Geri chair resulting in a fall and femur fracture for 1 of 1 resident (Resident #78) reviewed for falls with a fracture. Immediate jeopardy (IJ) began on 8/21/15 at 11:10 AM for example #1(Resident #160). Immediate jeopardy began on 8/31/15 at 2:30 PM for example #2 (Resident #78). Immediate jeopardy was removed on 9/4/15 at 11:39 AM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of level G (isolated deficiency that constitutes actual harm that is not immediate jeopardy). The facility was in the process of full implementation and monitoring their corrective action. The findings included: Example #1 Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #160 ' s only side rail assessment was completed on 5/8/15. Resident #160 was unable to state preference about her side rails. She was assessed to have ½ length side rail on both sides. She was assessed as having a history of falls and was mobile while in bed. She did have enough mobility to turn from side to side but had not attempted to get out of bed. She was assessed as having a decreased safety awareness due to confusion or judgment problems. Staff decision was for her to continue current side rail usage. A review of the Progress Notes dated 5/8/15 revealed Resident #160 had a fall from her bed and was observed sitting on the floor. The nurse documented she was alerted to the resident ' s room by her personal alarm and Resident #160 was found on the floor. The facility ' s interventions included an order for [REDACTED]. A review of the Progress Notes dated 5/10/15 revealed Resident #160 had a fall from her bed and was observed lying on her back on the floor beside her roommate ' s bed. The personal alarm was attached to the bed. Resident #160 was assessed as having a bruise measuring 2 centimeters (cm) by 2 cm on her left hip. The resident could not give a reason why she had gotten up unassisted. The facility ' s new intervention included the use of a bed alarm and therapy was initiated. A review of her care plan last revised on 5/11/15 revealed Resident #160 was at risk for falls related to her being unaware of safety needs. She had poor communication and comprehension with gait and balance problems. The facility had interventions in place that included she needed a safe environment with her bed in low position and to monitor, document and report to the physician any signs and symptoms of bruising 72 hours after a fall. All interventions were started on 5/11/15 and there were no updates concerning the personal, floor, bed alarms or padding to the side rails. A review of the Physical Therapy notes dated 5/12/15 revealed Resident #160 received therapy beginning 5/12/15 and ended on 6/2/15 because she was at her maximum potential. Resident #160 was documented as able to ambulate with assistance and could transfer to and from the bed to the wheelchair with minimal assistance. She was inconsistent and had cognition impairment and could not remember from day to day. She always required some assistance. A review of Resident #160 ' s admission Minimum Data Set ((MDS) dated [DATE] and her most recent quarterly MDS dated [DATE] revealed Resident #160 had short and long term memory problems. Resident #160 was coded as having verbal behavioral symptoms directed toward others and she rejected care. She required one person extensive assistance for transfer and bed mobility. She was not steady moving from a seated to standing position and moving from surface-to-surface. She had impairment on both sides of her lower extremities. Bed rails, trunk restraint, limb restraint or chair that prevented rising were coded as not being used. A review of Resident #160 ' s Care Area Assessment (CAA) dated 5/21/15 revealed she triggered for behaviors and falls. Resident #160 had short and long term memory problems and a few episodes of refusing medications over the last week and yelling at a nurse (The assessment date was 5/15/15.) She was admitted from the hospital to the facility after a fall from home for rehabilitation, strengthening and endurance. The facility proceeded to care plan due to behavioral symptoms and a history of falls. A review of the Progress Notes dated 6/14/15 revealed Resident # 160 was sitting at the Nurse ' s station in a Broda chair and was found on the floor in a sitting position. When staff asked the resident what happened she stated she tripped. For the intervention, staff placed Resident # 160 at the Nurse ' s station for close monitoring. A review of the Progress Notes dated 7/25/15 at 11:38 AM revealed Resident #160 ' s alarm was sounding and she was observed at her bedside on the floor in a sitting position. She was assessed for injuries and assisted back to a chair. For an intervention after her fall a therapy screening was initiated. On 9/2/15 at 8:41 AM the Rehab Manager stated Resident #160 was admitted to the facility for therapy and she started Physical Therapy on 5/12/15. Her therapy ended on 6/2/15 because she was at her maximum potential. Resident #160 was able to ambulate with assistance. She could transfer to and from the bed to the wheelchair with minimal assistance. She was inconsistent and had cognition impairment and could not remember from day to day. She was assessed as being able to stand 2 minutes with contact guard assistance, but could not stand by herself. She always required some assistance. The Rehab Department did receive a referral in July 2015 and made attempts to pick her up for therapy but she was very aggressive and had cognitive impairment. The Rehab Department did not evaluate her regarding the side rails. A review of the Progress Notes dated 8/21/15 at 11:10 AM Nurse #6 was called to Resident #160's room by her roommate's family member. Documentation revealed the resident was found sitting on the floor beside her bed with her left arm caught in the side rail. The nurse documented that the family member stated that she and another visitor observed the resident moving about in her bed and squirmed until she had her feet off the side of the bed, and when her feet touched the floor, she slid because she did not have on her non-skid socks. The nurse further documented the family member stated Resident #160 was holding onto the side rail and when she slid to the floor her arm got caught in the side rail. The nurse assessed her for injuries and the resident was helped back into bed with her arm only being red and no break in the skin. On 9/1/15 at 5:12 PM the roommate's family member stated she was in Resident #160's room on the day she saw Resident #160 have her arm stuck in the side rail (8/21/15). She stated she visited every day and Resident #160 usually stuck her arm through the side rail. She stated on the day of the incident (8/21/15) the resident had her body wrapped up in a sheet. Resident #160 was squirming and slid out of bed and she fell down on her knees. The family member stated as Resident #160 was observed falling out of bed she got her left arm stuck in the side rail. The family member stated the resident stated her knees were hurting and she went and got someone to help her. She stated she observed staff lifting her up and saying for them to be careful getting her arm out of the rail. She stated the facility just put the cushion over the side rail yesterday (8/31/15). On 9/1/15 at 3:25 PM Nurse #6 stated that she assessed Resident #160 on 8/21/15. Nurse #6 stated she was called into the resident's room by the roommate's family member and found Resident #160 sitting on the floor beside her bed with her left arm caught in the side rail. Nurse #6 stated the roommate's family member told her that Resident #160 had been moving around in her bed and had slipped out of the bed onto the floor. Nurse #6 further stated the roommate's family member told her that Resident #160 was holding onto the bed rail and she slid down onto the floor and her left arm slid into the side rail. Nurse #6 stated as staff were getting her off the floor they got her arm out of the side rail. Nurse #6 stated she assessed the resident and her left upper arm was a little red but she had no skin tears. A review of the incident report dated 8/21/15 revealed the facility ordered side rail pads. Non-skid socks were already in place. A review of the Progress Notes dated 8/31/15 at 11:49 AM revealed that half rail padding was added to Resident #160's side rails in the morning (8/31/15). During an interview on 9/2/15 at 9:41 AM, the MDS Coordinator stated she had been involved with the Unit Manager, the Director of Nursing (DON), and the Administrator after the fall on 8/21/15. She stated they had decided to put a cushion over the side rail but there were no cushions available and they had to order a cushion that came in on 8/31/15. She stated they had nothing else in place to prevent her from getting her arm stuck through the side rails again. The MDS Coordinator further stated that she did not think the side rails were hazardous. During an observation on 8/31/15 at 2:33 PM Resident #160 was observed in her bed with padded side rails. The padding was observed with the ends of the padding extending 2 to 3 inches over the side rails. During an interview on 9/03/15 at 2:04 PM Resident #160's responsible party (RP) stated that the facility had called her about 2 weeks ago and told her that her roommate's family member had reported that Resident #160 had gotten tangled up in the covers, slid off the bed and got her left arm caught in the side rail. She stated staff had told her that she did not have any bruising. While talking the RP was observed lifting the sleeve from Resident #160's left arm and there was no bruising observed. The RP was then observed lifting the sleeve of her right arm. Resident #160's arm was observed with a dark purple bruise approximately 2 inches long and 1 inch wide. The RP stated her arm looked like it was bruised by the side rail. The RP asked Resident #160 how she got the bruise and she stated she got her arm caught in the side rail. During an interview on 9/3/15 at 2:06 PM Nurse #7 stated she was not aware of the resident having a bruise and asked Resident #160 how she had gotten the bruise and she stated she got her arm caught in the side rail. On 9/3/15 at 2:23 PM, with Nurse #7 and NA #12 present, NA #12 stated that she was assigned to be Resident #160's NA on 9/3/15 and saw the bruise while she was bathing her at 7:30 AM. NA #12 stated she asked the resident how she thought it happened and Resident #160 told her she hurt it in the side rail. Nurse #7 stated the area looked like an older bruise that happened several days ago. She stated it did look like the bruise was from the side rail on her upper right arm. During an interview on 9/4/15 at 11:56 AM the Director of Nursing (DON) stated that she had been a part of the clinical meeting concerning Resident #160 ' s 8/21/15 fall. The DON stated she met with the Administrator, the Unit Manager and the MDS Coordinator. They discussed that the resident's arm did get caught in the side rail and they ordered padding to go over the rail. The DON stated that the roommate's family member told her that Resident #160 slid out of the bed using the side rail to hold on to and when her feet touched the floor she did not have on non-skid socks and slid getting her arm caught through the side rail. The DON stated she did not have any witness statements from the investigation and the incident report was what they used to discuss the fall. When the DON was asked if she was aware that when a resident got their arm caught through a side rail while exiting her bed, she was at risk for injury, the DON stated that side rails can be hazardous but she had assessed Resident #160 ' s side rails as an enabler to help her move in her bed. The DON stated she was still investigating why Resident #160 had the bruise on her right upper arm. The DON stated they did order the side rail cover to avoid her getting her arm stuck in the side rail again. She stated she was not aware that the padding did not come until 8/31/15 and would have expected her staff to let her know if the padding was not available for that long. 2. Resident #78 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) of 9). Resident #78 had no behaviors. She required extensive two person assistance with bed mobility and transferring. She did not walk in room or hallways. Balance during transitions and walking was coded as 8 - as activity did not occur. She had no range of motion limitations. She did not use a cane/crutch/walker or wheelchair for mobility. She received an anti-anxiety and anti-depressant medications seven days a week. Restraints (bed rails, trunk restraints, limb restraints or chair that prevents rising) were not coded as being used. Review of the medical record revealed Resident #78 was 61 inches tall and weighed 92 pounds on 8/20/15. Review of most recent care plan dated 10/29/14, with a revised goal target date of 11/14/15, for use of side rails identified the Focus area as: ½ (half) side rails to both sides of the bed to enable the resident to maintain as much independence with bed mobility as possible, with increased risk for complications. Interventions in meeting the goal of minimizing the risks for complications related to the use of side rails included, in part: periodically (at least quarterly) reassess for continued need for use of side rail and report to the nurse immediately if resident was noted between the rail and the bed. During an interview with the MDS Nurse on 09/01/15 4:08 PM she stated Resident #78 does move around in bed and roll side to side. She did not roll on command but will move in the bed. She had a pressure alarm and fall mat alarm because of her history of falls. During an interview with the MDS Nurse on 9/2/15 at 9:00 AM she stated that the care plan for side rails read to notify the nurse if the resident was between the rail and bed because the old beds use to have a gap between the rails and the bed and residents could get stuck. She stated now that note remains on the care plan as a precaution. She further stated the alarms are evaluated but Resident #78 still moves a lot so it is better if she has alarms. She stated Resident #78 will roll in bed and move from side to side. She also stated that while in the Geri chair she would throw her legs over the arms and this made her think Resident #78 could throw legs over the bed rail. The MDS Coordinator stated that Resident #78 would not know where to get up if she decided to get up, whether it be the top, middle or bottom of bed. Review of the Side Rail assessment dated [DATE] read the resident was unable to state her preference about the side rails. The side rails were ½ (half) in length on both sides of the bed. The resident has a history of falls. She had no history of falls from bed or attempts to get out of bed climbing over or around rails. She was mobile in the bed and did not turn side to side. She had difficulty with balance/trunk control and had a decreased safety awareness. The side rail decision was to continue with the current side rails. Review of the Physician Communication note dated 6/19/15 listed a concern that Resident #78 was discontinued off Zoloft (anti-depressant medication) on 5/10/15. Resident #78 was now real agitated and thought she could walk again and was having spells of yelling at staff and crying out for no reason and had increased nervousness. During an interview with Nurse #3 on 9/2/15 at 9:25 AM she stated that on 6/19/15 the resident was fighting and attempting to get out of bed so she notified the Physician. She stated Resident #78 was trying to get out of bed by scooting to bottom of the bed to exit. During an observation on 8/31/15 at 2:30 PM Resident #78 was noted to be in her bed with ½ (half) side rails in the up position on both sides of the bed. The rails had a top and bottom rail with an approximate 4 inch gap between the bottom and top rail. There was approximately 16 from top of bed to the start of side rail which was then approximately 2 foot long. The mattress was a high-low mattress with the upper and lower portion of the mattress high and a portion in the middle of the mattress lower. The side rail was observed to be placed next to the low area of the hi-low mattress. There was an alarming fall mat on the floor next to the bed. The resident was observed to have her left leg over the side rail and her right leg through the top portion of the side rail lying horizontal in her bed with her head in the direction of the wall. The bed was pushed against the wall. She was alert but not oriented. During an observation on 8/31/15 at 5:12 PM Resident #78 was asleep in her bed with legs observed in bed. The half side rails were in the up position on both sides and an alarming fall mat was on floor. During an interview with Nurse #5 on 9/1/15 at 3:48 PM she stated that Resident #78 could turn from side to side in bed, was not supposed to get up on her own and had an alarming fall mat. She continued by stating that once in a while Resident #78 would hang her legs over the bed but there were alarms if she got up. During an interview on 09/01/2015 3:51 PM with Nursing Assistant #4 she stated that the resident can move around in the bed and turn side to side. She had alarms on the bed and a fall mat because of a previous fall and fractured hip. She stated Resident #78 had no range of motion limitations. She stated she thought the facility left the alarms on because Resident #78 used to get out of bed unassisted. During an observation on 9/1/15 at 4:52 PM Resident #78 was observed with her right leg out of the bed wedged between the hi-low mattress and the side rail with her foot dangling towards the fall mat. Nurse #5 was made aware and entered the resident ' s room. During an interview on 9/1/15 at 4:55 PM with Nurse #5, upon entering Resident #78s room, she stated This is why we keep the alarms because she tries to get out of bed. Nurse #5 then took the resident ' s leg and stated to the resident, let ' s get your leg up here and turn you back in bed. Resident #78 was observed on 9/3/15 at 2:00 PM. She had a low bed, high-low mattress and bed and fall mat alarms in place. The side rails had been removed. During an interview with the DON on 9/4/15 at 11:56 AM she stated that behaviors such as putting legs or arm through side rails are hazardous; but she was unaware of these residents having these behaviors or she would have acted on the issue immediately. The Administrator was notified of the Immediate Jeopardy on 9/2/15 at 3:06 PM. The Immediate Jeopardy was removed on 9/4/15 at 3:30 PM based on the Credible Action Plan. Interventions listed on the plan included: The Administrator was notified of the Immediate Jeopardy on 9/2/15 at 3:06 PM. The Immediate Jeopardy was removed on 9/4/15 at 3:30 PM. Interventions listed on the plan included: What measures the facility put into place for the resident affected: For Resident #160 on 8/31/15 the padding was placed on the side rails. On 9/3/15 the side rails were removed from the bed as a results of the side rail assessment completed on 9/3/15 by the care plan team. For Resident #78 on 9/3/15 the care plan team evaluated the use of the hi-low mattress. The team decided to continue the use of the hi-low mattress and reevaluate weekly for a maximum of 30 days since the side rail reduction has also occurred. The care plan team also completed a device evaluation related to the side rail and discontinued its use on 9/3/15 as a result of the evaluation. WHAT MEASURES WERE PUT IN PLACE FOR RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED? All residents have the potential to be affected by this alleged deficient practice. On 9/2-3/15 the nurse reviewed all current patients who have had a fall in the last 12 months. To accomplish this the nurse managers printed a list of patients that had a fall incident report. The incident report was then reviewed by the nurse manager to identify the reason and/or contributing factors for the fall. This included reviewing falls for any indication that the bed rail contributed to the accident. Interventions for the falls was then reviewed by the nurse manager to ensure that the interventions were appropriate. Interventions may include alarms but also included medication evaluations, pharmacy evaluations, therapy evaluations for alternative positioning/strengthening exercises, increased supervision, one on one supervision, and other specifically related to the individual resident. Any incident involving a bed rail was also reviewed to ensure that the bed rail had been discontinued if no longer required by the patient. Any resident who was identified that did not have a falls prevention intervention or whose fall prevention intervention was not related to the specific fall was reviewed by the care planning team (nursing, social, activities and therapy) on 9/3/15 and interventions were identified and implemented as appropriate. Interventions may include alarms but also included medication evaluations, pharmacy evaluations, therapy evaluations for alternative positioning/strengthening exercises, increased supervision, one on one supervision, and other specifically related to the individual resident. WHAT SYSTEMS WERE PUT IN PLACE TO PREVENT THE DEFICIENT PRACTICE FROM REOCCURRING? On 9/3/15 the QA Nurse Consultant, in serviced all nurse ' s managers (unit managers, MDS, SDC and DON) on restraints. · Daily during clinical meeting all incident reports will be reviewed by the nurse managers. This review will include identifying any devices that could have been involved in the fall to ensure that they are appropriate for the patients care. These devices include but are not limited to bedrails, hi low mattresses or Geri chairs. Devices should be reviewed to determine if the device was a hazard that could have contributed to the fall. A device/side rail evaluation should be completed to ensure that if the device is a restraint that a restraint reduction plan is developed and implemented. This investigation should be document in the electronic health record and should include details regarding any resident, staff, family interviews that have been completed. Once the root cause of the fall is identified the clinical team will identify the appropriate prevention interventions for the patient and will implement such interventions. · Witness statements should also be obtained and documented in the Quality Assurance Review. · Upon completion of this review, interventions should be identified. Interventions may include alarms, medication evaluations, pharmacy evaluations, therapy evaluations for alternative positioning/strengthening exercises, increased supervision, one on one supervision, and other specifically related to the individual resident. Alarms should never be substituted for staff supervision or monitoring. · Always implement 1:1 supervision for resident who are actively trying to get up unassisted. Also consider the devices that are being utilized for these patients. This is especially true if a patient is trying to get up unassisted out of a Geri chair or over a bedrail or high-low mattress. · If 1:1 supervision is initiated by a nurse/nursing assistant review the patient during daily clinical meeting to determine if 1:1 should continue and what other interventions may be initiated to minimize the risk. This review should also include the completion of a device/side rail evaluation form to ensure that restraints are identified. · If a restraint is identified then the committee should create a restraint reduction plan. The restraint reduction plan should include reduction strategies and a time frame for the re-evaluation and completion of the process. On 9/3/15 the nurse managers began in-servicing all current nursing staff (RN, LPN, NA both full time and part time regarding the use of devices and side rails. The Director of Nursing will ensure that any employee who has not received this training by 9/3/15 will not be allowed to work until the training is completed. As of 9/3/15 approximately 50% of employees have received this training. This in-service included the following topics: Patients who are restless or trying to get out of bed should not be left unattended as this could result in a fall. In general when dealing with a patient who is agitated there are some basic steps you can follow to try and reduce the agitation. They include: listening, providing reassurance, involve resident in activities, modify the environment, find outlets for the person ' s energy, and check yourself to ensure your communication is calming and reassuring. Each patient is unique and interventions to minimize the risk of falling may range from offering favorite foods to playing music or a TV program that they may like. The patient ' s care plan will include interventions that should be used to try to calm the patient. The physician should also be notified so that medical interventions can be explored if the care plan interventions do not work or if the agitation is more severe than usual. If interventions listed in the care plan do not work and the physician cannot provide additional directions, then notify the DON or nurse manager on call. Anytime a patient is actively trying to get up unassisted or if they are trying to get out of a Geri chair unassisted or throwing their legs over a side rail, one on one supervision must be implemented. Staffing should be reallocated to cover all patients until additional assistance can be called in to cover the one on one supervision. Your charge nurse should contact the administrator and DON immediately if a patient meets this criteria and to get assistance in coordinating the staffing needs. The administrators and DON phone numbers are listed at the nursing station. One on one supervision should be continued until the patient is reviewed by the Quality Assurance team and alternative safety interventions are identified and implemented. The QA team should ensure that the complete a device evaluation or a side rail evaluation is completed. Also make sure to document the restlessness and any fall in the electronic health record. To assist in fall prevention make sure to include any devices (Geri chair, bedrail. hi-low mattress or restraint) that was in use. The Credible Allegation was verified by: 1. Record review of In-Service Education content and sign in sheets. 2. Interviews on 9/4/15 at 1:20 PM through 9/4/15 at 3:30 PM with Nurses, Unit Managers and Nursing Assistants on all halls for both first and second shift confirming recent in-service. 3. For Resident #160, the side rails were removed from the bed as a results of the side rail assessment completed on 9/3/15 by the care plan team. Resident #160 was observed without her side rails 4. For Resident #78 on 9/3/15 the care plan team evaluated the use of the hi-low mattress. The team decided to continue the use of the hi-low mattress and reevaluate weekly for a maximum of 30 days since the side rail reduction has also occurred. The care plan team also completed a device evaluation related to the side rail and discontinued its use on 9/3/15 as a result of the evaluation. 5. A review of the list of residents with side rail evaluation and that the evaluation was implemented. 3. This example was cited at a G (isolated deficiency that constitutes actual harm that is not immediate jeopardy). Resident #78 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 as being cognitively impaired (BIMS of 4). Resident #78 had no behaviors. She required the assistance of two persons with bed mobility and transferring. She did not walk in her room or corridor. Resident #78 had no range of motion limitations. She used no mobility devices (cane/crutch/walker or wheelchair). She was not steady, only able to stabilize with staff assistance while moving from seated to standing position and surface-to-surface transferring (between bed and chair or wheelchair) and balance during walking, turning around and moving on and off the toilet -this activity did not occur. Resident #78 had had one fall with no injury. She weighed 106 pounds. She received an anti-anxiety and anti-depressant medications seven days a week. Restraints (bed rails, trunk restraints, limb restraints or chair that prevents rising) were coded as not being used. Review of the Care Area Assessment (CAAs) Summary dated 10/1/14 triggered in the areas of Cognitive Loss/Dementia, Delirium, Falls and Psychotropic Drug Use. Review of the CAA revealed falls was triggered related to balance problems during transitioning, having at least one fall since admission and she received antidepressants and antianxiety medications seven days per week. Care plan considerations included: (Resident #78) remains at an increased risk for falls due to frequent attempts to get out of bed unassisted, along with increased confusion at times. The staff were to monitor resident for any attempts to get up unassisted or any other factors that may have contributed to a fall and intervene as needed to prevent falls from occurring. Review of the revised care plan dated 10/6/14 for falls identified the Focus area as Resident #78 being at risk for falls related to Confusion, Psychoactive drug use, history of falls and frequent attempts to get up unassisted. Interventions in meeting the goal of minimizing the risk of falls included, in part: repeated interventions of keeping the resident at the nursing station for supervision, re-educating staff on fall precautions and the need for the resident to be in view of staff while up in Geri chair, educating staff to keep resident at nurses station when in Geri chair and to putting Resident #78 in bed if in her room, keeping the bed in the lowest position, having the personal alarm in place, the chair alarm in place, the floor mat alarm in place and the bed alarm in place while in bed. During an interview with the Rehabilitation Manager on 9/3/15 at 10:00 AM she stated that Resident #78 was screened on 9/25/14 because the resident appeared agitated and was trying to get up out of her Geri chair. She stated the recommendation was that Resident #78 would be supervised while in her Geri chair. She further stated that Resident #78 was seen on 10/6/14 for Geri chai

Based on medical record review and facility staff, nurse practitioner and physician interviews, the facility failed to notify the resident ' s physician of recurrent low blood sugars (BS); and failed to immediately notify the resident ' s physician of an acute episode of unresponsiveness associated with low blood sugars for 1 of 4 sampled residents diagnosed with [REDACTED]. Immediate jeopardy began on 6/8/14. On 6/8/14, Resident #1 was found to be unresponsive and identified as having a low blood sugar. The resident ' s physician was not immediately notified of the hypoglycemic (low blood sugar) event in accordance with the facility ' s Diabetic Protocols in the Standing Orders. The evidence revealed that the acute hypoglycemic episode of 6/8/14 had been preceded by 4 of the last 35 days where the resident experienced low blood sugars and the physician was not notified per the facility ' s Diabetic Protocols in the Standing Orders or as indicated by the physician's order [REDACTED]. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: A review of the facility ' s " Episodic Charting Policy " dated 10/2001 and revised on 6/2010 read, in part: " If an incident (Ex., fall, resident becomes ill, elevated temperature, on antibiotics, UTI ' s (urinary tract infections), emotional/behavioral problems, newly combative resident, resident wanders out of Facility, etc.) occurs on your shift you are responsible for: #2 (of 9): Calling MD (Medical Doctor) of an emergency, at the time of event, or #3 (of 9): Fax info to MD next day if problem not urgent and/or after hours. #5 (of 9): If MD is called, it shall be noted in Electronic Nurses Notes by the nurse making the call, as well as response received from MD. #6 (of 9): If info is faxed, it shall be noted in Electronic Nurses Notes by the nurse who sent the fax, as well as response received from MD. " A review of the facility ' s Admitting and Standing Orders included a section entitled, " Diabetic Protocols. " The Diabetic Protocols read as follows: " BS < (less than) 40 Responsive Resident: Give 120 cc (cubic centimeter, a measure of liquid equivalent to a milliliter) of Resource. Hold Insulin or hypoglycemic and notify MD (Medical Doctor) and recheck in one hour. Monitor closely. BS < 40 Unresponsive Resident: Administer 1 unit dose of [MEDICATION NAME] (an injectable antidote for [DIAGNOSES REDACTED] or low blood sugar) IM (intramuscularly). Hold insulin or hypoglycemic. Notify MD immediately. Recheck BS in 1 hour and monitor closely. BS < 80 > (greater than) 40: Hold insulin or hypoglycemic. Offer 120 cc Resource. Recheck in 1 hour. If BS remains < 80, call MD. If BS >80, give medications and continue to monitor. BS > 400: call MD immediately. Monitor closely. " Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #1 ' s May 2014 Physician order [REDACTED]. SSI coverage indicated that the dose of insulin administered was dependent on the resident's BS result. Blood sugars were checked twice daily at 9 AM and 5 PM. A review of the Nursing Progress Notes revealed that on the morning of 5/3/14, Resident #1 ' s BS was 46 and she was described as, " unresponsive and wet with sweat. " The resident was administered one dose of [MEDICATION NAME], the physician was contacted, and the resident was sent to the hospital. Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. A review of Resident #1 ' s medical record revealed that on 5/5/14, the Nurse Practitioner (NP) wrote new orders for the resident at the facility. The orders included: " Decrease [MEDICATION NAME] to 2.5 mg po (by mouth) qd (every day); Change C/S (an abbreviation for [MEDICATION NAME], which referred to the BS checks) to TID (three times daily) 6AM-no SSI; 9AM with SSI and 5PM with SSI (same scale, no changes-flag to reevaluate if BS <70 or >150); staff to assist with meals. " An interview conducted with the Director of Nursing (DON) on 6/17/14 at 9:47 AM clarified that a " flag " was an indication to the nursing staff that a resident ' s chart should be set aside at the nursing station as a means to call the NP ' s attention to it. The system was designed so that the NP would be alerted of a situation or resident needing to be reviewed. The DON reported the NP came in every weekday, Monday through Friday. A review of the resident ' s May 2014 Medication Administration Record (MAR) revealed her BS were checked at 6AM, 9AM and 5PM beginning on 5/6/14. A note on the MAR was handwritten and read in part, " flag to re-eval if BS<70 or >150. " A review of Resident #1 ' s quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. She required extensive assist with bed mobility, locomotion on/off unit; dressing; toilet use; and personal hygiene. The resident required supervision with eating. The MDS assessment indicated Resident #1 received insulin injections on 4/7 days during the assessment period. No care plan was included in the resident ' s medical record. On 5/22/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR revealed that on 5/22/14 the resident ' s BS at 5 PM was 58 with a rechecked BS (no time noted) of 63. There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. A telephone interview was conducted with Nurse #1 on 6/18/14 at 3:28 PM. Nurse #1 was the 2nd shift nurse assigned to care for Resident #1 on 5/22/14. During the interview, Nurse #1 reported that she could not recall this particular situation. When asked if she would have notified the physician of the low blood sugar, Nurse #1 stated that if the resident had not responded or her blood sugars had not come up, " then yes. " The nurse reported that if she did notify the physician, this would have been noted in the Nurse ' s notes or on the MAR. On 5/23/14, Resident #1 was noted to have a low BS on three occasions. A review of Resident #1 ' s May 2014 MAR revealed that on 5/23/14 the resident ' s BS at 6 AM was 57; on 5/23/14 at 9 AM BS was 61; and on 5/23/14 at 5 PM BS was 67. There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. A telephone interview was conducted with Nurse #2 on 6/18/14 at 4:26 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on 5/23/14. During the interview, Nurse #2 reported that she could not recall this particular situation. Upon inquiry, Nurse #2 reported that she did not report any of Resident #1 ' s low blood sugars to the physician or NP at any point in time. A telephone interview was conducted with Nurse #1 on 6/18/14 at 3:28 PM. Nurse #1 was the 2nd shift nurse assigned to care for Resident #1 on 5/23/14. During the interview, Nurse #1 reported that she could not recall this particular situation. The nurse reported that if the resident had not been responding under these circumstances, she would have contacted the physician. On 5/31/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR revealed that on 5/31/14 the resident ' s BS at 6 AM was 68; on 5/31/14 at 9 AM no BS result was documented; and on 5/31/14 at 5 PM her BS was 71. There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. A telephone interview was conducted with Nurse #2 on 6/18/14 at 4:26 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on 5/23/14. When asked if she could recall this particular situation, Nurse #2 stated, " not really. " Upon inquiry, Nurse #2 reported that she did not report any of Resident #1 ' s low blood sugars to the physician or NP at any point in time. A review of the June 2014 MAR revealed the resident ' s BS were checked at 6AM, 9AM and 5PM. A note on the MAR was handwritten and read in part, " flag to re-eval if BS<70 or >150. " On 6/1/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/1/14 the resident ' s BS at 6 AM was 62 (on 6/1/14 at 9 AM her BS was 86; and on 6/1/14 at 5 PM BS was 185). There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. A telephone interview was conducted with Nurse #3 on 6/18/14 at 3:57 PM. Nurse #3 was the 3rd shift nurse assigned to care for Resident #1 on 6/1/14. During the interview, Nurse #3 recalled the situation encountered with Resident #1 at 6 AM on that date. The nurse indicated that the resident was alert, oriented and responded to her at that time. Upon inquiry, Nurse #3 indicated she did not notify the resident ' s physician of the low BS. She stated there was, " no reason because her BS came up and she was alert and oriented and responded to me. " On 6/8/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/8/14 the resident refused a BS check at 6 AM; on 6/8/14 at 9 AM her BS was 60. There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. An interview was conducted with Nurse #4 on 6/16/14 at 2:51 PM. Nurse #4 was the 1st shift nurse assigned to care for Resident #1 on 6/8/14. During the interview, Nurse #4 recalled that the outgoing 3rd shift nurse reported the resident ' s refusal to have her BS checked at 6 AM and that the resident was alert and verbal. At 9 AM on 6/8/14, Resident #1 ' s BS was 60. Nurse #4 reported that she gave the resident 120cc Med Pass and that the resident was fine. The nurse stated that she rechecked the BS after the Med Pass was consumed and her breakfast was served. She was not sure how much breakfast the resident ate. Nurse #4 stated she did not document the result of the resident ' s BS recheck, but thought it was in the 90 ' s. The nurse reported that the resident appeared, " fine " the rest of the morning but noted she did talk with herself that morning. She noted this was a usual behavior for the resident. Nurse #4 indicated that she did not report the low BS results to the resident ' s physician or NP. The nurse stated she did make a report of the 9 AM BS result to the oncoming nurse but that there was nothing else out of the ordinary to share. On 6/8/14, Resident #1 was noted to have a second low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/8/14 the resident ' s BS at 5 PM was 42. A Nursing Progress note dated 6/8/14 at 5:00 PM read: " Pt (patient) unresponsive bs (blood sugar) 42 VS (Vital Signs) 96.4 (temperature); 64 (heart rate); 18 (respiration rate); 120/74 (blood pressure); [MEDICATION NAME] given bs (blood sugar) came up to 71 pt alert responsive sweating pt drank glucerna refused supper will monitor. " A notation was made on the back of the resident ' s MAR dated 6/8/14 at 5:00 PM which indicated the resident ' s BS was 42; she was unresponsive; [MEDICATION NAME] was given; and the results of a BS recheck (no time provided) was 71. There were no notations made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. An interview was conducted with Nurse #5 on 6/16/14 at 3:19 PM. Nurse #5 was the 2nd shift nurse assigned to care for Resident #1 on 6/8/14. During the interview, the nurse reported the resident was asleep that day when they made rounds at 3PM. She indicated that was not unusual for Resident #1. The nurse stated that when she went to check the resident around 4:30 PM (to do the 5PM BS check), the resident would not wake up. The resident ' s BS at that time was 42. The nurse stated that she had the NA take the resident ' s vital signs while she went to get a [MEDICATION NAME] shot for her. After the [MEDICATION NAME] shot was given, the nurse had the NA stay with the resident. The resident woke up after about 20 minutes and was reported to be alert but confused at that time. The nurse indicated the resident was usually disoriented. When the resident was awake, the nurse rechecked her BS again and found that it had come up to 71. Nurse #5 stated that she gave the resident some Glucerna at that time (around 5:00 PM). The nurse reported that the resident seemed her " normal self " after consuming this Glucerna. Nurse #5 stated that she did check the resident ' s BS again after the supper trays came out, but didn ' t document the result. The nurse thought that BS result when rechecked was, " either 100 or 148. " Nurse #5 stated that Resident #1 wouldn ' t eat her supper that evening, which was not unusual for her. The nurse also reported that at around 8:30PM the resident drank another can of Glucerna. The nurse reported that she checked on her 2-3 more times that shift. She stated that her checks, " just involved verbal stimuli " and that the resident would wake up and talk with her. At the end of the shift, the nurse reported that Resident #1 was sleeping (like she usually would have at that time of night). Nurse #5 stated that she faxed the resident ' s physician the evening of 6/8/14 to inform him that Resident #1 ' s BS had been low and that [MEDICATION NAME] was given. Upon inquiry, the nurse indicated that she would have called the physician if the resident would have remained unresponsive. The nurse noted that she told the oncoming nurse in report that she had given [MEDICATION NAME] to the resident, Resident #1 was refusing her meals, and to watch her BS. On 6/9/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/9/14 the resident ' s BS at 6 AM was 41. A notation dated 6/9/14 at 6 AM was made on the back of the June 2014 MAR. The notation reported Resident #1 ' s BS was 41; 2 packs of sugar were given under her tongue; and BS recheck at 7 AM was 57. A telephone interview was conducted with Nurse #2 on 6/16/14 at 4:35 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on the evening of 6/8/14 to the morning of 6/9/14. During this interview, the nurse recalled there was nothing unusual noted for Resident #1 that night. The nurse reported that Resident #1 would sometimes wake up around 3 AM - 4 AM, but did not recall whether or not she woke up that night. The nurse reported that when she took the resident ' s BS between 6AM and 6:30AM, she found it was low and the resident was unresponsive. The nurse stated that she went to the Stat Box (referring to the Stat Medication Box, an emergency supply of medications kept in the Medication Room), " to see if we had [MEDICATION NAME], " but there wasn ' t any. Nurse #2 reported she then went to a second unit ' s medication room and there wasn ' t ' any [MEDICATION NAME] there either. At that time, the nurse reported she went and got sugar (2-3 packets) and put it under the resident ' s tongue. After that, she called to the 3rd and final unit in the facility to see if they had any [MEDICATION NAME] and found that they did not. Nurse #2 stated that she rechecked the resident ' s sugar more than once but only documented the results of the last recheck when her BS had gone up to around 57. She recalled that the resident was moaning at about that time (approximately 7:00 AM). Nurse #2 stated that it was also about 7:00 AM when she gave report to the on-coming nurse. When asked why she did not initiate any further interventions or call the resident ' s physician, Nurse #4 stated, " I thought her sugar was coming up and the situation was resolving. " A telephone interview was conducted with NA #1 on 6/16/14 at 6:31 PM. NA #1 was the 3rd shift NA assigned to care for Resident #1 on the evening of 6/8/14 to the morning of 6/9/14. The NA recalled that around 2:00 AM she told the nurse that the resident was in deep sleep and snoring. She recalled that at about 4:00 AM she reported the same to the hall nurse. NA #1 stated that at 6:00 AM (on her last round) she couldn ' t wake the resident up. She told Nurse #2 (the hall nurse), and the nurse said she was aware of it and was trying to find the [MEDICATION NAME] to bring her sugar up. The NA stated the nurse wasn ' t able to find any [MEDICATION NAME]. She recalled that the nurse then gave the resident some sugar under her tongue. The NA stated that the resident did not respond while she was in the room. A Nursing Progress note written for 6/9/14 at 7:15 AM (created as a late entry on 6/16/14 at 11:40 AM) read: " In rsdt (resident ' s) room this shift. Rsdt noted unresponsive, BS checked 51. [MEDICATION NAME] shot given at 7:15 AM. Back in rsdt room at 7:45 am. BS increase to 113 rsdt remained unresponsive. Sat (oxygen saturation) 93% ra (on room air). V/S (Vital Signs) 97.5 (temperature), 130/60 (blood pressure), 18 (respiration rate); 80 (heart rate). White foam substance noted coming from mouth. Called (name of hospital) to get MD on call for (name of resident ' s physician), (name of on-call physician) called right back, informed him of status change. Order given to send to (name of hospital) for eval. 911 called for transport of rsdt to (name of hospital). RP (family member) called informed of status change and order to send to (name of hospital), was appreciative. " An interview was conducted with Nurse #6 on 6/16/14 at 2:33 PM. Nurse #6 was the 1st shift nurse who came on duty at 7:00 AM on 6/9/14. Nurse #6 stated that when she got to the facility that morning, the resident was unresponsive and she was told the resident ' s sugar was low. Nurse #6 stated, " I think I was told (her BS was) 51. " Nurse #6 reported the BS was rechecked and it was still low (no value was given). The nurse reported she went and got a [MEDICATION NAME] shot from the neighboring facility and administered it to the resident at 7:15 AM. The nurse indicated that she waited 15-30 minutes to see if the resident would respond. When the nurse went back at 7:45 AM, her BS was 113 but she wasn ' t responding. Nurse #6 stated she did a sternal rub and the resident was still nonresponsive. She obtained the vital signs, phoned the on-call physician, and received orders to send her out to the Emergency Department. The nurse reported that was her second time having to give the resident a shot of [MEDICATION NAME]---the first was in the beginning of May. The nurse stated that back in May the resident did become responsive once her sugar went up. " That ' s why this time I knew it was different. " A review of Resident #1 ' s medical record revealed a Physician ' s Telephone Order was received on 6/9/14 at 8:25 AM to send the resident to (name of hospital) to be evaluated. A review of the Emergency Department records revealed Resident #1 was transported by air to another hospital on [DATE] at 1:07 PM for specialty care/treatment. The [DIAGNOSES REDACTED]. Interviews were conducted with the Director of Nursing (DON) on 6/16/14 at 4:05 PM and 6/17/14 at 9:47 AM. During the interviews, the DON was asked what she would have expected to be done as follow-up on 5/22/14, 5/23/14, 5/31/14, and 6/1/14 when Resident ' s #1 ' s blood sugars were noted to be less than 70. The DON indicated that the resident ' s chart should have been flagged for the NP to review when she came in. When asked what the DON ' s expectations would have been after the [MEDICATION NAME] injection was given to Resident #1 on the evening of 6/8/14, the DON stated that the protocol was to notify the physician. However, she indicated that the timing of the physician notification would have depended on the BS result and the resident ' s response to the [MEDICATION NAME]. The DON stated that the resident ' s response would have been " key " in regards to MD notification. She reported that if [MEDICATION NAME] was given and the resident got back to her baseline, the nursing staff may not have called the physician. Instead, the nurse may have told the NP of the situation the next day when she came into the facility. An interview was conducted on 6/17/14 at 11:33 AM with the NP. During this interview, the order written on 5/5/14 for Resident #1 was discussed. This order included the phrase, "flag to reevaluate if BS <70 or >150. " The NP stated that the facility would sometimes " flag " a chart, which meant the nurses would pull a resident ' s chart at the Nurses ' Station to let her know that she needed to review the resident. The NP described the procedure as, " a tickler system. " After reviewing the May 2014 and June 2014 MAR for Resident #1, the NP stated she had not been made aware of any of the resident ' s low BS results from May 2014 or June 2014. The NP indicated she would have wanted to know about each of the low BS results that were less than 70. The NP reported that if the resident ' s BS were outside of the parameters and the resident was symptomatic, then she would have wanted to be notified of the situation by telephone. If the resident was not symptomatic, flagging the chart for her to see the resident the next day would have been acceptable. The NP noted that she was in the facility every weekday, Monday through Friday. Additionally, she had been on call the weekends of 5/31/14 -6/1/14 and 6/7/14-6/8/14 from 7 AM until 7 PM. Upon review of the resident ' s low blood sugar results from May 2014 and June 2014, the NP stated, " This could have been taken care of. " An interview was conducted on 6/17/14 at 12:50 PM with Resident #1 ' s physician. Resident #1 ' s May 2014 and June 2014 MARs were reviewed (noting the low BS results of 5/22/14, 5/23/14, 5/31/14, and 6/1/14) along with the 5/5/14 order written to "flag to reevaluate if BS <70 or >150 " for Resident #1. Upon inquiry, the physician stated that he " would have expected someone to be contacted...a provider, on-call physician or NP, especially if parameters were written. " The physician indicated he had not been notified. Upon review of the situation encountered on the evening of 6/8/14, the physician stated, " The physician has got to be notified in that situation ...there are always different ways to manage a patient with [DIAGNOSES REDACTED]. A fax is not immediate notification. I would expect if you have an unresponsive resident, even if the resident becomes responsive that provider should be notified. I think that ' s a standard. A physician needs to help guide them. " He stated, " The problem is the MD was not contacted ....They should have contacted the physician from the get-go. " The facility ' s Administrator was notified of the Immediate Jeopardy on 6/17/14 at 6:45 PM. A credible allegation of compliance was received on 6/18/14 at 8:45 PM as follows: Physician Notification 157 Corrective Action for affected patient Resident #1was discharged from the facility on 6/9/2014. Corrective Action for Potentially Affected Patients All residents with physician orders [REDACTED]. On 6/18/2014 the nurse consultant checked orders for all patients to identify those on insulin and /or oral medications. Those patients were then checked to ensure that all patients on these medications had orders for glucometer checks. One patient was identified who did not have a routine blood glucose checked order. On 6/18/2014 the MD for this patient was contacted by the Unit Manager and an order for [REDACTED]. All patients who have physician orders [REDACTED]. All current patients who have physician orders [REDACTED]. For these patients the blood glucose results documented on the medication administration record for the past 30 days were reviewed. 0 patients were identified with results less than or equal to 40 over the past 30 days. 6 patients were identified with results greater than or equal to 41 and less than 80 in the last 30 days. The physicians were notified of the low blood sugar results for 6 patients who were identified as having a blood glucose of less than 80 in the last 30 days. This notification was completed by the unit manager and director of nursing on 6/18/2014 and this notification was documented in the medical record for that patient by the unit manager and director of nursing on 6/18/14. MD ' s were notified of the BS and current diabetic medication was listed. Systematic Changes See below diabetic protocol. All current nurses (registered nurses and licensed practical nurses) who are currently employed on a full time, part time or as needed basis will receive education on the proper notification of physicians/physician extenders when a patient experiences low blood sugars provided by the Staff Development Coordinator. There are two agency nurses that may provide staffing coverage if needed. On 6/18/2014, the director of nursing contacted both of these nurses and provided them with the education. This included the following details: 1. The current hypoglycemic protocol includes: Diabetic Protocols All diabetic patients should have blood glucose monitoring orders based on their individual needs. If orders are not received on admission then the charge nurse should contact the MD for orders or reason why orders for blood sugar checks are not required. Blood sugar less than 40 Responsive Resident: Give 120cc of Med Pass PO (by mouth). Hold Insulin or hypoglycemic and notify MD immediately. Re-check blood glucose in 15 minutes and every 30 minutes until blood glucose is above 80. Blood sugar less than 40 Unresponsive Resident: Administer 1 unit dose of [MEDICATION NAME] IM. Hold insulin or hypoglycemic. Notify MD immediately. Someone should stay with the patient until the blood sugar is above 80. Recheck blood glucose every 15 minutes x 2 until blood glucose is above 80 and the patient is responsive, or if remains below 80 notify MD or order to send to ER for evaluation. 911 should be called if the patient does not respond to treatment and has been unresponsive for more than 30 minutes. Blood sugar less than 80 but greater than or equal to 41: hold insulin or hypoglycemic. Offer 120cc Med Pass. Recheck in 30 minutes. If blood sugar remains less than 80 or if the patient is symptomatic, call MD immediately. If blood sugar is greater than 80, give medications and either call physician or fax physician if after normal business hours. Resident assessment will be performed and documented. If you cannot reach the attending physician the patient ' s blood sugar is not responding to the actions or if the patient is unresponsive then call 911 and initiate transfer to the emergency room . If the patient ' s blood sugar is improving and the signs and symptoms of [DIAGNOSES REDACTED] are improving then contact the on call administrative nurse who will call the medical director. Some patients may have more specific parameters for contacting the physicians. This will be documented in a physician order [REDACTED]. You must contact the physician anytime the patient ' s condition meets the criteria identified in the order. 2. The physician must be notified any time the protocol is implemented. 3. Some patients may have more specific parameters for contacting the physicians. This will be documented in a physician order [REDACTED]. You must contact the physician anytime the patient ' s condition meets the criteria identified in the order. 4. Document all communication with the physician in the nursing notes. Include times of calls/pages and time when the physician responded to the call. Initiate telephone orders for any new orders received. As of 6/18/14 employees who have not received this training will not be on the schedule to work and will not be allowed to work until the in-services are completed. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that is completed started 6/18/14. Completion Date 6/18/14. On 6/18/14 at 9:40 PM, the credible allegation of compliance was validated. The surveyor confirmed that the facility implemented the following: Nursing staff interviews confirmed each nurse had been in-serviced on the current hypoglycemic protocol (revised on 6/18/14), including documentation and communication with the physician.

Based on medical record review and staff interviews, the facility failed to develop a care plan based on the results of the Minimum Data Set Assessments for 1 of 3 sampled residents (Resident #1). Immediate jeopardy began on 6/8/14. On 6/8/14, Resident #1 was found to be unresponsive and identified as having a low blood sugar, preceded by 4 of the last 35 days where the resident experienced low blood sugar(s). Resident #1 did not have an individualized plan of care in place which addressed the management of diabetes and risk of complications from it. Immediate Jeopardy was removed on 6/18/14 at 9:40 PM. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm. The facility was in the process of full implementation and monitoring of their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. A review of the Nursing Progress Notes revealed that on the morning of 5/3/14, Resident #1 ' s BS was 46 and she was described as, " unresponsive and wet with sweat. " The resident was administered one dose of [MEDICATION NAME], the physician was contacted, and the resident was sent to the hospital. Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. A review of Resident #1 ' s quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. She required extensive assist with bed mobility, locomotion on/off unit; dressing; toilet use; and personal hygiene. The resident required supervision with eating. The MDS assessment also indicated the resident received pain medications (scheduled and as needed) for almost constant pain (rated as a 7 on a pain rating scale of 0-10). Resident #1 received a therapeutic diet. Her medications included insulin injections (on 4 out of the 7 days during the assessment period), an antipsychotic medication (on 7 out of the 7 days), an antibiotic (on 7 out of the 7 days), and a diuretic (on 7 out of the 7 days). A review of Resident #1 ' s medical record revealed there was no care plan included in either the resident ' s paper chart or electronic chart. On 5/22/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR indicated [REDACTED]. On 5/23/14, Resident #1 was noted to have a low BS on three occasions. A review of Resident #1 ' s May 2014 MAR indicated [REDACTED]. On 5/31/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR indicated [REDACTED]. On 6/1/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. On 6/8/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. On 6/8/14, Resident #1 was noted to have a second low BS. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. A notation was made on the back of the resident ' s MAR indicated [REDACTED]. On 6/9/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. A notation dated 6/9/14 at 6 AM was made on the back of the June 2014 MAR. The notation reported Resident #1 ' s BS was 41; 2 packs of sugar were given under her tongue; and BS recheck at 7 AM was 57. A Nursing Progress note written for 6/9/14 at 7:15 AM (created as a late entry on 6/16/14 at 11:40 AM) read: " In rsdt (resident ' s) room this shift. Rsdt noted unresponsive, BS checked 51. [MEDICATION NAME] shot given at 7:15 AM. Back in rsdt room at 7:45 am. BS increase to 113 rsdt remained unresponsive. Sat (oxygen saturation) 93% ra (on room air). V/S (Vital Signs) 97.5 (temperature), 130/60 (blood pressure), 18 (respiration rate); 80 (heart rate). White foam substance noted coming from mouth. Called (name of hospital) to get MD on call for (name of resident ' s physician), (name of on-call physician) called right back, informed him of status change. Order given to send to (name of hospital) for eval. 911 called for transport of rsdt to (name of hospital). RP (family member) called informed of status change and order to send to (name of hospital), was appreciative. " A review of Resident #1 ' s medical record revealed a Physician ' s Telephone Order was received on 6/9/14 at 8:25 AM to send the resident to (name of hospital) to be evaluated. A review of the Emergency Department records revealed Resident #1 was transported by air to another hospital on [DATE] at 1:07 PM for specialty care/treatment. The [DIAGNOSES REDACTED]. On 6/16/14 at 12:20 PM, an interview was conducted with the facility ' s Administrator (upon his request). The Administrator reported that no care plan had been developed for Resident #1 since her admission to the facility on [DATE]. He reported a care plan was put into the resident ' s electronic chart on this date (6/16/14) by Nurse #7 after the facility realized she did not have an existing care plan on record. An interview was conducted with Nurse #8 on 6/16/14 at 1:44 PM. Nurse #8 reported that she assumed responsibility for assisting with MDS assessments and putting the data into the computer. The nurse indicated that Nurse #7 assumed responsibility for creating the care plans for each of the facility ' s residents. A telephone interview was conducted with Nurse #7 on 6/16/14 at 4:00 PM. Nurse #7 confirmed that she assumed responsibility for developing a care plan for each of the facility ' s residents. In regards to Resident #1, the nurse stated, " There was no care plan. It just got missed. " An interview was conducted with the Director of Nursing (DON) on 6/16/14 at 4:05 PM. Upon inquiry, the DON stated " My expectation is for the care plan to be done on admission and updated per MDS schedule. " The facility ' s Administrator was notified of the Immediate Jeopardy for F279 on 6/26/14 at 6:47 PM. The facility provided the following credible allegation of compliance on 6/27/14 at 12:29 PM. F 279--Care Plan Tag Corrective Action for Affected Patient For the affected resident a comprehensive care plan was developed by the interdisciplinary team including the MDS Coordinator, Dietary, Social Services, and Activities. The care plan included a focus on Diabetes, Communication, Pain, Pressure ulcer risk, Dehydration risk, Falls risk and ADL performance. This was completed on 06/16/14 by the MDS Nurse. Potentially Affected Patients All residents could be potentially affected. On 6/17/2014 an audit was conducted by the MDS Nurse Consultant of all current residents to ensure a comprehensive care plan was in place. The audit revealed 1 out of 136 residents did not have a comprehensive care plan in place. The affected resident was discharged on [DATE] at 14:20. Systematic Changes The MDS Coordinator was educated on 06/17/14 by the MDS Nurse Consultant for failure to complete a comprehensive care plan for the residents identified. Topics included completing an interim care plane that includes individual risks, needs or problems in a resident centered format on admission. Interim care plans should be completed within 48 hours of admission. The interim care plan should also be updated after the admission comprehensive MDS assessment is completed. All care plans will be reviewed and updated at a minimum of quarterly and annual basis. In addition to this, care plans will be reviewed by the interdisciplinary team with any significant change in condition to ensure that the care plan currently reflects any individualized approaches in order to provide the highest practical level of well-being for each resident. Daily Monday thru Friday in the Daily QOL meeting, attended by the Director of Nursing, Administrator, Unit Managers, Support Nurse, and MDS Nurse, (unless they are off from work that day), all new admissions will be reviewed by this committee to ensure interim care plans are developed within 48 hours of admission. The care plans will be check to ensure that they include individual risks, needs or problems in a resident centered format. This review began on 06/18/14. This training was incorporated into the general orientation program for all newly hired MDS Nurses starting 6/18/2014. Completion Date 6/18/14 On 6/18/14 at 9:40 PM, verification of the credible allegation of compliance was evidenced by record review. The surveyor confirmed that the facility implemented the following: A care plan was developed for Resident #1 on 6/16/14, which included a focus area related to the management of diabetes and risk for complications related to the diabetes; Care plans had been developed for sample residents diagnosed with [REDACTED].

Based on medical record review, facility staff and pharmacy staff interviews, the facility failed to maintain a supply of glucagon (an injectable medication used to treat severe [DIAGNOSES REDACTED]) in the emergency medication box for 1 of 1 sampled residents (Resident #1) presenting with an acute episode of unresponsiveness associated with low blood sugars. Immediate jeopardy began on 6/8/14. On 6/8/14, the facility used their last dose of glucagon and did not have any more doses available within the facility for use in an emergency. Immediate Jeopardy was removed on 6/18/14 at 9:40 PM. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: A review of the facility ' s Admitting and Standing Orders included a section entitled, " Diabetic Protocols. " The Diabetic Protocols included indications for the use of glucagon. The Diabetic Protocols read in part: BS < (less than) 40 Unresponsive Resident: Administer 1 unit dose of Glucagon IM (intramuscularly). Hold insulin or hypoglycemic. Notify MD (Medical Doctor) immediately. Recheck BS (blood sugar) in 1 hour and monitor closely. A review of the Emergency Drug Box Contents List for each of the facility ' s three Emergency Drug Kits (Stat Med Boxes) included the following: Drug: Glucagon Emergency 1 mg (milligram) Injection Quantity: 2 Location: Top Compartment A review of the facility ' s " Emergency Drug Kit, General Guidelines " policy dated 10/2001, read in part: " Purpose: 1. To obtain drugs on a prompt and timely basis. 2. Immediate availability of emergency drugs. Procedure: 8. (of 12) The pharmacy will be notified that the emergency supply has been used via the faxing of the Emergency Usage Form at the time of usage and prior to the next scheduled delivery, but at least within 24 hours after the drug has been removed. The pharmacy will deliver a replacement. " A review of the facility ' s contract pharmacy Long Term Care Policy & Procedures included information titled, " Using the Emergency Kit " which read: " When a drug is used from the Emergency Drug Kit, an Emergency Drug Kit Usage Form should be filled out and faxed to (name of contract pharmacy) along with the new order. This will insure proper billing and proper restocking of the emergency drug kit. Failure to provide this form will result in the facility being charged for a medication when the Emergency Drug Kit becomes short of medications. " Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. A notation was made on the back of the resident ' s MAR indicated [REDACTED]. An interview was conducted with Nurse #5 on 6/16/14 at 3:19 PM. Nurse #5 was the 2nd shift nurse assigned to care for Resident #1 on 6/8/14. Nurse #5 reported that after using glucagon for Resident #1 on 6/8/14, she faxed the pharmacy to request replenishment of glucagon in the Stat Med Boxes. A review of the fax sent to the pharmacy revealed the following notation was written on the fax dated 6/8/14 at 10:29PM: " No Glucagon in any stat box. Please send for Unit 1, Unit 4, Unit 3. " During an interview conducted with the Director of Nursing (DON) on 6/17/14 at 10:15 AM, the DON reported that the pharmacy routinely delivered medications for the facility in the evenings (sometimes as late as 11 PM). The glucagon requested on the evening of 6/8/14 would have been scheduled for delivery on the evening of 6/9/14. A review of Resident #1 ' s June 2014 MAR indicated [REDACTED]. A notation dated 6/9/14 at 6 AM was made on the back of the June 2014 MAR. The notation reported Resident #1 ' s BS was 41; 2 packs of sugar were given under her tongue; and BS recheck at 7 AM was 57. A telephone interview was conducted with Nurse #2 on 6/16/14 at 4:35 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on the evening of 6/8/14 to the morning of 6/9/14. The nurse reported that when she went to check the resident ' s BS between 6AM and 6:30AM on 6/9/14, the resident was unresponsive and her BS was low. The nurse stated that she went to the Stat Box (referring to the Stat Medication Box, an emergency supply of medications kept in the Medication Room), " to see if we had glucagon, " but there wasn ' t any. Nurse #2 reported she then went to a second unit ' s medication room and there wasn ' t ' any glucagon there either. At that time, the nurse reported she went and got sugar (2-3 packets) and put it under the resident ' s tongue. After that, she called to the 3rd and final unit in the facility to see if they had any glucagon and found that they did not. Nurse #2 stated that it was about 7:00 AM when she gave report to the on-coming nurse. An interview was conducted with Nurse #6 on 6/16/14 at 2:33 PM. Nurse #6 was the 1st shift nurse who came on duty at 7:00 AM on 6/9/14. Nurse #6 stated that when she got to the facility that morning, the resident was unresponsive and she was told the resident ' s sugar was low. Nurse #6 stated, " I think I was told (her BS was) 51. " Nurse #6 reported the BS was rechecked and it was still low (no value was given). The nurse reported she went and got a glucagon shot from the neighboring facility and administered it to the resident at 7:15 AM. The nurse indicated that she waited 15-30 minutes to see if the resident would respond. When the nurse went back at 7:45 AM, her BS was 113 but she wasn ' t responding. Nurse #6 stated she did a sternal rub and the resident was still nonresponsive. She obtained the vital signs, telephoned the on-call physician, and received orders to send her out to the Emergency Department for evaluation. A review of Resident #1 ' s medical record revealed a Physician ' s Telephone Order was received on 6/9/14 at 8:25 AM to send the resident to (name of hospital) to be evaluated. A review of the Emergency Department records revealed Resident #1 was transported by air to another hospital on [DATE] at 1:07 PM for specialty care/treatment. The [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON) on 6/17/14 at 9:47 AM. During the interview, the DON was asked to outline the facility ' s process of replenishing medications, specifically glucagon, in the three Stat Med Boxes kept at the facility. The DON stated that when a medication from the Stat Med Box was used, the nurse was supposed to send a fax to the contract pharmacy informing the pharmacy of this. The DON then stated that the pharmacy would send that medication out the next night with its regularly scheduled delivery. The DON noted that Nurse #5 did send a fax to the pharmacy on 6/8/14 at 10 PM which indicated the glucagon stock needed to be replenished. However, based on a review of the Emergency Drug Box Contents List, each of the facility ' s three Emergency Drug Kits (Stat Med Boxes) should have contained two doses of glucagon (for a total of six doses of glucagon kept in the facility at any one time). Upon inquiry, the DON stated that, " Obviously, the process wasn ' t effective. " She indicated that even with that obvious system problem, there was glucagon " on campus " (referring to the supply of glucagon at the sister facility located in a separate building approximately 200 feet away from her facility). During the interview, the DON acknowledged that her facility did not have control over the sister facility ' s system to ensure that glucagon would always be available there as a backup. An interview was conducted with the Staff Development Coordinator (SDC) on 6/17/14 at 10:45 AM. The SDC assumed responsibility for training the nursing staff. The SDC reported there were three Stat Med Boxes in the facility: Unit 1 and Unit 2 shared one box; Unit 3 had a box; and Unit 4 had a box. During this interview, the SDC outlined the process involved in ensuring the Stat Med Boxes were fully stocked. The SDC stated that if a nurse received an order for [REDACTED]. This form included information on the nurse opening the Stat Med Box, the resident receiving the medication, the name of the medication, dosage units used, and the facility ' s Unit borrowing the medication. The completed form would be faxed to the pharmacy to let them know the medication needed to be replaced. Depending on the time of day borrowed (noting that the cut-off time for same day delivery was around 4PM), the medication would be sent out to the facility with the next pharmacy delivery. The SDC stated that each time glucagon was used, the Emergency Drug Kit Usage Form should have been filled out and sent to the pharmacy. She speculated that if there were not two doses of glucagon in each of the facility ' s three Stat Med Boxes, then one of two things happened. Either the Emergency Drug Kit Usage Form didn ' t get faxed or the pharmacy didn ' t replace the medication after receiving the fax. The SDC reported that one of the two pieces would have failed if the glucagon was not in the Stat Med Boxes. An interview was conducted with the Nurse Practitioner (NP) on 6/17/14 at 11:33 AM. The course of events surrounding Resident #1 on the morning of 6/9/14 was discussed. With regard to glucagon not being available within the facility on 6/9/14 when needed for Resident #1, the NP stated, " That needs to be corrected immediately and there needs to be a system where its checked and to ensure it is available at all times. " An interview was conducted with Resident #1 ' s physician on 6/17/14 at 12:50 PM. During the interview, the physician was asked if he felt that glucagon needed to be kept in stock at the facility at all times. The physician stated, " Absolutely glucagon needs to be in the building. " A telephone interview was conducted with the pharmacy manager for the facility ' s contract pharmacy on 6/17/14 at 1:25 PM. During this interview, the pharmacy manager reported that the facility ' s Stat Med Boxes were periodically replaced by the pharmacy to ensure all medications contained in the boxes were kept within their expiration dates. Upon inquiry, the pharmacy manager indicated that records were not kept of the date(s) the boxes were replaced. He reported that an inventory sheet was kept by the Stat Med Box to identify the contents of the box, including the name/dose of the medications and number of dosage units of each. The pharmacy manager stated that when a medication was taken out of a Stat Med Box, the nursing staff needed to fill out a usage sheet and fax it to the pharmacy. The Usage sheet provided information used for the billing purposes and for the replenishment of medications used from the Stat Med Box. A follow-up interview was conducted with the DON (in the presence of the facility ' s Nurse Consultant) on 6/17/14 at 5:15 PM. Inquiry was made as to who was responsible to check the facility ' s Stat Med Boxes and how often this was done to ensure they were fully stocked. The DON indicated that up until today (6/17/14), there was not a process for this. The DON stated that the process in place up to this point included a re-ordering/replenishment procedure via use of the Stat Medication Usage forms. In addition, she noted that the Stat Med Box did have an expiration date on the top of the box which indicated when the first medication in the box would expire. The DON reported that the consultant pharmacist was responsible to check/monitor this expiration date. When the box was nearing the expiration date, the DON stated that the pharmacy would pick up the Stat Med Box and send out a completely new box with a new expiration date. During this interview, the facility ' s Nurse Consultant reported that as of 6/17/14, a process had been developed to be sure the facility ' s Stat Med Boxes were stocked appropriately. A telephone interview was conducted with the facility ' s Consultant Pharmacist on 6/18/14 at 11:55 AM. The Consultant Pharmacist stated that she assumed responsibility to monitor the expiration date of the Stat Med Boxes and to initiate replacement of each box based on the earliest expiration date of the medications in the box. The Consultant Pharmacist confirmed that she was not assigned the responsibility to review the contents of the Stat Med Boxes or to ensure the boxes were fully stocked at all times. The facility ' s Administrator was notified of the Immediate Jeopardy on 6/17/14 at 6:45 PM. A credible allegation of compliance was received on 6/18/14 at 8:45 PM as follows: Medications not available F425 Corrective Action for Affected Patient Resident #1 was discharged from the facility on 6/9/2014. Corrective Action for Potentially Affected Patients Any patient who requires glucagon administration has the potential to be affected by the alleged deficient practice. On 6/17/2014 the Director of Nursing contacted the Director of Pharmacy services and requested that two doses of glucagon be included in each of the three emergency medication boxes. These doses were sent on 6/17/2014 and were verified as being in the emergency boxes by the Director of Nursing on 6/18/2014. Systematic Changes All current nurses (registered nurses and licensed practical nurses) who are currently employed on a full time, part time or as needed basis will receive education on the [DIAGNOSES REDACTED] protocol provided by the Staff Development Coordinator. There are two agency nurses that may provide staffing coverage if needed. On 6/18/2014, the director of nursing contacted both of these nurses and provided them with the education. This included: 1. When glucagon is used from the emergency stat box the nurse must complete an " Emergency Kit Usage Form " and fax to (fax number of pharmacy). The charge nurse should keep the form with the 24 hour report and should report off to the next shift that the medication has been ordered. 2. The glucagon should be received from the pharmacy that night in the delivery totes. When the medication is checked in the charge nurse should put the medication in the emergency box and put the order form in the Director of Nursing box. 3. If the glucagon is not received, the Director of Nursing must be notified by leaving a note under her door. 4. If you utilize glucagon and there is not another dose in the emergency box contact the on-call pharmacy (name and phone number of pharmacy) to obtain the dose from the back up pharmacy. If the pharmacy says that the dose cannot be obtained contact the Director of Nursing (phone number). 5. If glucagon is not available and resident meets the diabetic protocol to receive it, the MD will be called for an order to send to the ER (emergency room ) for evaluation. When the order is obtained, 911 will be initiated. Unit Managers & MDS Nurse will check the stat box Monday through Friday and document. If items are identified as used and not re-stocked, they will initiate a form to pharmacy. As of 6/18/2014 employees who have not received this training will not be on the schedule to work and will not be allowed to work until the in-services are completed. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that are completed ????????6/18/2014. Completion Date 6/18/14. On 6/18/14 at 9:40 PM, the credible allegation of compliance was validated. The surveyor confirmed that the facility implemented the following: Nursing staff interviews confirmed each nurse had been in-serviced on the facility ' s procedures for obtaining glucagon when indicated per the Diabetic Protocol and the procedures to be followed after using glucagon from the emergency medication box.

Based on medical record review, hospital record review, and facility staff, nurse practitioner and physician interviews, the facility failed to provide immediate assessment, intervention, and monitoring for 1 of 4 sampled residents diagnosed with [REDACTED]. Immediate jeopardy began on 6/8/14. Resident #1 was found to be unresponsive and identified as having a low blood sugar on 6/8/14, preceded by 4 of the last 35 days where the resident experienced low blood sugar(s). The evidence revealed the facility did not follow their Diabetic Protocols in the Standing Orders to ensure corrective interventions were put into place, follow-up monitoring was provided, and physician guidance was obtained when needed. Immediate Jeopardy was removed on 6/18/14 at 9:40 PM. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: A review of the facility ' s Admitting and Standing Orders included a section entitled, " Diabetic Protocols. " The Diabetic Protocols read as follows: " BS < (less than) 40 Responsive Resident: Give 120 cc (cubic centimeter, a measure of liquid equivalent to a milliliter) of Resource (a liquid nutritional supplement high in calories and protein). Hold Insulin or hypoglycemic (a medication that lowers blood sugar) and notify MD (Medical Doctor) and recheck in one hour. Monitor closely. BS < 40 Unresponsive Resident: Administer 1 unit dose of [MEDICATION NAME] (an injectable antidote for [DIAGNOSES REDACTED] or low blood sugar) IM (intramuscularly). Hold insulin or hypoglycemic. Notify MD immediately. Recheck BS in 1 hour and monitor closely. BS < 80 > (greater than) 40: Hold insulin or hypoglycemic. Offer 120 cc Resource. Recheck in 1 hour. If BS remains < 80, call MD. If BS >80, give medications and continue to monitor. BS > 400: call MD immediately. Monitor closely. " According to LexiComp, a comprehensive medication database, the appropriate indication for [MEDICATION NAME] is insulin or sulfonylurea overdose. Additionally, under the heading of " Other warnings/ precautions, " LexiComp includes a notation that patients with [DIAGNOSES REDACTED] should immediately be treated with [MEDICATION NAME] (sugar). If IV (intravenous) access cannot be established or if [MEDICATION NAME] is not available, [MEDICATION NAME] may be considered as alternative acute treatment until [MEDICATION NAME] can be administered. Other precautions include: Monitor blood glucose levels closely. Supplemental carbohydrates should be given to patients who respond to [MEDICATION NAME] for severe [DIAGNOSES REDACTED] to prevent secondary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #1 ' s May 2014 Physician order [REDACTED]. SSI coverage indicated that the dose of insulin administered was dependent on the resident's BS result. Blood sugars were checked twice daily at 9 AM and 5 PM. The SSI ordered utilized the following parameters: If BS 150-200, give 2 units insulin; If BS 201-250, give 3 units insulin; If BS 251-300, give 4 units insulin; If BS 301-350, give 5 units insulin; If BS 351-400, give 6 units insulin; If BS 401 or greater, give 7 units insulin. A review of the Nursing Progress notes for Resident #1 revealed the following notation was made on 5/3/14 at 8:45 AM: " In rsdt (resident ' s) room to check bs (blood sugar) and bs (blood sugar) 46 and resident was unresponsive and wet with sweat. [MEDICATION NAME] shot given IM at 8:15 AM. Called (name of hospital) to get MD on call for (name of resident ' s physician). (Name of resident ' s physician) called right back. Informed him of bs (blood sugar) and rsdt (resident) unresponsive. Ordered given to send to (name of hospital). Called to arrange transport. 911 in at 8:45 am to transport rsdt (resident) to ER (emergency room ). Called rp (Responsible Party) in r/t (relation to) being sent to (name of hospital), called all three no (numbers). No answer. " A review of the hospital ' s Discharge Summary dated 5/4/14 revealed Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The discharge [DIAGNOSES REDACTED]. The Discharge Summary included information titled, " Hospital Course " , which read, in part: " This (age of resident) woman was hospitalized after she was found unresponsive at the Mary Gran Nursing Home with [DIAGNOSES REDACTED]. Her initial blood sugar was as low as 44. She also had recently been diagnosed with [REDACTED]. Following admission, the patient was treated with IV [MEDICATION NAME] (sugar) infusions, until her sugar stabilized. When the infusion was stopped, her BS remained stable in the low 100s ... " A review of Resident #1 ' s medical record revealed that on 5/5/14, the Nurse Practitioner wrote new orders for the resident at the facility. The orders included: " Decrease [MEDICATION NAME] to 2.5 mg po (by mouth) qd (every day); Change C/S (an abbreviation for [MEDICATION NAME], which referred to the BS checks) to TID (three times daily) 6AM-no SSI; 9AM with SSI and 5PM with SSI (same scale, no changes-flag to reevaluate if BS <70 or >150); staff to assist with meals. " A review of the resident ' s May 2014 Medication Administration Record (MAR) revealed her BS were checked at 6AM, 9AM and 5PM beginning on 5/6/14. A note on the MAR was handwritten and read in part, " flag to re-eval if BS<70 or >150. " A review of Resident #1 ' s quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. She required extensive assist with bed mobility, locomotion on/off unit; dressing; toilet use; and personal hygiene. The resident required supervision with eating. The MDS assessment indicated Resident #1 received insulin injections on 4/7 days during the assessment period. No care plan was included in the resident ' s medical record. On 5/22/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR revealed that on 5/22/14 the resident ' s BS at 5 PM was 58 with a rechecked BS (no time noted) of 63. There was no record of a Nursing Progress note written on this date; no notations were made regarding interventions initiated in response to the resident ' s low BS per the Diabetic Protocols in the Standing Orders; no notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. The May 2014 MAR noted the resident ' s [MEDICATION NAME] (antidiabetic medication) had been given as scheduled at 9 AM on 5/22/14; no insulin was given to the resident on this date. A review of Resident #1 ' s Meal Intake records from 5/22/14 indicated she had consumed 51-75% of her breakfast meal; and 51-75% of her mid-day meal. No intake record was available for the evening meal. No intake record was available to document the resident ' s acceptance of a bedtime snack on 5/22/14. A telephone interview was conducted with Nurse #1 on 6/18/14 at 3:28 PM. Nurse #1 was the 2nd shift nurse assigned to care for Resident #1 on 5/22/14. During the interview, Nurse #1 reported that she could not recall this particular situation. However, she stated that in this type of circumstance she would have typically given the resident Med Pass (a liquid nutritional supplement high in calories, protein, and fat) and gone back in 1 hour to recheck her blood sugar. When asked what she would typically have done next, Nurse #1 reported that if the resident was acting fine, eating and responding appropriately, she would, " just let it be. " However, she noted that if the resident was sluggish or not responding, she would notify the physician. When asked if she would have notified the physician of the low blood sugar, Nurse #1 stated that if the resident had not responded or her blood sugars had not come up, " then yes. " The nurse reported that if she did notify the physician, this would have been noted in the Nurse ' s notes or on the MAR. On 5/23/14, Resident #1 was noted to have a low BS on three occasions. A review of Resident #1 ' s May 2014 MAR revealed that on 5/23/14 the resident ' s BS at 6 AM was 57; on 5/23/14 at 9 AM BS was 61; and on 5/23/14 at 5 PM BS was 67. The May 2014 MAR noted the resident ' s [MEDICATION NAME] (antidiabetic medication) was given as scheduled on 5/23/14 at 9 AM. There was no record of a Nursing Progress note on this date; no notations were made regarding interventions initiated in response to the resident ' s low BS per the Diabetic Protocols in the Standing Orders; no notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. No insulin was given to the resident on 5/23/14. A review of Resident #1 ' s Meal Intake records from 5/23/14 revealed there were no intake records available for the breakfast or mid-day meals; the records indicated Resident #1 had consumed 0-25% of her evening meal. A notation, " Not Applicable, " was made on the resident ' s bedtime snack intake record for 5/23/14. A telephone interview was conducted with Nurse #2 on 6/18/14 at 4:26 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on 5/23/14. During the interview, Nurse #2 reported that she could not recall this particular situation. When asked what she would have typically done under similar circumstances, Nurse #2 reported she would have given the resident 120 cc of Med Pass for the low BS. When asked if she would have rechecked the resident ' s BS, Nurse #2 stated, " I know I ' m supposed to recheck it, but sometimes I haven ' t. " The nurse indicated that if she did recheck the resident ' s BS it should be noted on the back of the MAR. She acknowledged that if the results of a BS recheck were not on the back of the MAR, the BS was not re-checked. Nurse #2 added that if the BS was not rechecked and it was less than 1 hour before she went off of her shift, she would, " probably report it to the oncoming nurse. " Upon inquiry, Nurse #2 reported that she did not report any of Resident #1 ' s low blood sugars to the physician or NP at any point in time. A telephone interview was conducted with Nurse #1 on 6/18/14 at 3:28 PM. Nurse #1 was the 2nd shift nurse assigned to care for Resident #1 on 5/23/14. During the interview, Nurse #1 reported that she could not recall this particular situation. When asked what she would have typically done for Resident #1 when her BS result was 67, the nurse stated that if she was not responding she would have called the physician. However, Nurse #1 also stated that if the resident was, " acting her norm, " she would have kept a check on her and given her Med Pass. Nurse #1 stated that if she didn ' t do a re-check, she probably didn ' t give her Med Pass. But, she added that was hard to say and depended on the situation. Nurse #1 stated, " I try really hard to document BS lows and Med Pass given at such and such a time (in the Nurses ' Notes or on the back of the MAR). " On 5/28/14, an order was initiated for Resident #1 to receive Glucerna (a liquid nutritional product designed for people with diabetes) three times daily based on the facility ' s consultant Dietitian ' s recommendation due to a low oral intake. Each serving of Glucerna, if consumed, provided 190 calories, 23 grams of carbohydrate, 10 grams of protein and 7 grams of fat. Resident #1 received Glucerna between meals at 10 AM, 3 PM, and at HS (bedtime). The meal and bedtime snack intake records from 5/30/14 were reviewed. There was no record of Resident #1 ' s intake available for either her meals or snack. A review of Resident #1 ' s May 2014 MAR revealed that on 5/30/14 Resident #1 ' s 10 AM Glucerna was refused; the 3 PM Glucerna was refused; and, there was no documentation of the resident ' s acceptance of the 8 PM Glucerna. Resident #1 received 4 units of insulin in accordance with her SSI regimen on 5/30/14 at 5 PM for a BS of 251. On 5/31/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s May 2014 MAR revealed that on 5/31/14 the resident ' s BS at 6 AM was 68; on 5/31/14 at 9 AM no BS result was documented; and on 5/31/14 at 5 PM her BS was 71. The May 2014 MAR noted the resident ' s [MEDICATION NAME] (antidiabetic medication) was given as scheduled on 5/31/14 at 9 AM. There was no record of a Nursing Progress note written on this date; no notations were made regarding interventions initiated in response to the resident ' s low BS at 6 AM per the Diabetic Protocols in the Standing Orders; no notations were made documenting the reason why no BS result was recorded at 9 AM; and no notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. No insulin was documented to have been given on 5/31/14. A review of Resident #1 ' s Meal Intake records from 5/31/14 revealed there were no intake records available for the resident ' s breakfast or mid-day meals. The records indicated Resident #1 consumed 51-75% of her evening meal. The May 2014 MAR revealed Resident #1 ' s acceptance of the Glucerna was not recorded at 10AM, and noted as 0% at 3PM and 0% at bedtime. A notation, " Accepted, " was made on the resident ' s bedtime snack intake record for 5/31/14. A telephone interview was conducted with Nurse #2 on 6/18/14 at 4:26 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on 5/23/14. When asked if she could recall this particular situation, Nurse #2 stated, " not really. " Upon inquiry, Nurse #2 reported that she typically would have given the resident Med Pass with the resident ' s [MEDICATION NAME] (a medication indicated for the treatment of [REDACTED]. When asked if she would have rechecked the resident ' s BS, Nurse #2 stated, " probably not ...I just report it to the oncoming nurse. " Upon inquiry, Nurse #2 reported that she did not report any of Resident #1 ' s low blood sugars to the physician or NP at any point in time. A review of the June 2014 MAR revealed the resident ' s BS were checked at 6AM, 9AM and 5PM. A note on the MAR was handwritten and read in part, " flag to re-eval if BS<70 or >150. " On 6/1/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/1/14 the resident ' s BS at 6 AM was 62 (on 6/1/14 at 9 AM her BS was 86; and on 6/1/14 at 5 PM BS was 185). The June 2014 MAR noted the resident ' s [MEDICATION NAME] (antidiabetic medication) was given as scheduled on 6/1/14 at 9 AM. There was no record of a Nursing Progress note on this date; a notation was made on the back of the resident ' s MAR dated 6/1/14 at 6:00 AM which indicated 120 cc of Med Pass were given to the resident in response to the resident ' s low BS at 6 AM, along with the results of a BS recheck of 74 (the time of the re-check was not noted). No notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that either the physician or NP was notified of a low BS as indicated by the physician orders [REDACTED]. A review of Resident #1 ' s Meal Intake records from 6/1/14 revealed there was no documentation available for the resident ' s breakfast or mid-day meals. The records indicated Resident #1 consumed 76-100% of the evening meal on 6/1/14. The June 2014 MAR noted that two units of insulin were given to the resident at 5 PM on 6/1/14 in accordance with the SSI regimen (for a BS of 185). The June 2014 MAR also revealed Resident #1 accepted 25% of the Glucerna at 10 AM, none of the Glucerna at 3PM; and 50% of the Glucerna at bedtime. A notation, " Accepted, " was made on the resident ' s bedtime snack intake record for 6/1/14. A telephone interview was conducted with Nurse #3 on 6/18/14 at 3:57 PM. Nurse #3 was the 3rd shift nurse assigned to care for Resident #1 on 6/1/14. During the interview, Nurse #3 recalled the situation encountered with Resident #1 at 6 AM on that date. The nurse indicated that the resident was alert, oriented and responded to her at that time. Nurse #3 stated that she gave the resident 120cc Med Pass and then rechecked her BS approximately 30-45 minutes later. She recalled that the BS had come up and that she reported this to the oncoming nurse. The nurse reported that she recorded the BS recheck results on the back of the MAR. Upon inquiry, Nurse #3 indicated she did not notify the resident ' s physician of the low BS. She stated there was, " no reason because her BS came up and she was alert and oriented and responded to me. " A review of the June 2014 MAR revealed the resident refused her 8 AM and 9 AM medications on 6/3/14 and 6/4/14. The refused medications included [MEDICATION NAME] scheduled for 9 AM administration on each of these dates. No notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of the medication refusal on 6/3/14 and 6/4/14. On 6/8/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/8/14 the resident refused a BS check at 6 AM; on 6/8/14 at 9 AM her BS was 60. The June 2014 MAR noted the resident ' s [MEDICATION NAME] (antidiabetic medication) was given as scheduled on 6/8/14 at 9 AM. There was no record of a Nursing Progress note having been written on 6/8/14 in reference to the 9 AM low blood sugar; no notations were made regarding interventions initiated in response to the resident ' s low BS at 9 AM per the Diabetic Protocols in the Standing Orders; no notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. No insulin was given to the resident on 6/8/14. A review of Resident #1 ' s Meal Intake records from 6/8/14 revealed there was no documentation available for the resident ' s breakfast or mid-day meals. The June 2014 MAR revealed Resident #1 accepted 0% of the Glucerna at 10 AM; no documentation was made regarding her acceptance of the Glucerna at 3PM. A telephone interview was conducted with Nurse #2 on 6/16/14 at 4:35 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on the evening of 6/7/14 to the morning of 6/8/14. Upon inquiry, the nurse indicated the resident was very agitated the morning of 6/8/14 and she would not allow the BS to be checked. The nurse also reported that sometimes the resident would get agitated and refuse the BS checks. Nurse #2 reported that she was, " yelling out and wouldn ' t let me stick her finger. " A telephone interview was conducted with Nursing Assistant (NA) #1 on 6/16/14 at 6:31 PM. NA #1 was the 3rd shift NA assigned to care for Resident #1 on the evening of 6/7/14 to the morning of 6/8/14. The NA reported the resident slept all night that evening. NA #1 stated that she would go into the resident ' s room every 2-3 hours during rounds to check on her. The NA reported she would check to be sure the resident was breathing, if she was wet, or had other needs. NA #1 indicated the resident liked to ring her call bell if she needed help. Upon inquiry, NA recalled that Resident #1 was very agitated the morning of 6/8/14 and noted, " at times she would be like that. " An interview was conducted with Nurse #4 on 6/16/14 at 2:51 PM. Nurse #4 was the 1st shift nurse assigned to care for Resident #1 on 6/8/14. During the interview, Nurse #4 recalled that the outgoing 3rd shift nurse reported the resident ' s refusal to have her BS checked at 6 AM and that the resident was alert and verbal. At 9 AM on 6/8/14, Resident #1 ' s BS was 60. Nurse #4 reported that she gave the resident 120cc Med Pass and that the resident was fine. The nurse stated that she rechecked the BS after the Med Pass was consumed and her breakfast was served. She was not sure how much breakfast the resident ate. Nurse #4 stated she did not document what the result of the resident ' s BS recheck was, but thought it was in the 90 ' s. The nurse reported that the resident appeared, " fine " the rest of the morning but noted she did talk with herself that morning. She noted this was a usual behavior for the resident. Nurse #4 indicated that she did not report the low BS results to the resident ' s physician or NP. The nurse stated she did make a report of the 9 AM BS result to the oncoming nurse but that there was nothing else out of the ordinary to share. A telephone interview was conducted with Nursing Assistant (NA) #2 on 6/16/14 at 3:43 PM. NA #2 was the 1st shift NA assigned to care for Resident #1 on 6/8/14. The NA recalled that the resident was, " talking a little off for a while " that morning, but that this wasn ' t unusual for her. NA #2 reported the resident drank a little of her juice but would not eat her breakfast that morning. Upon inquiry, NA #2 stated that she set up the meal for the resident and then she ate it on her own. She recalled that the resident drank her sweet tea at lunchtime and kept something off of her tray to eat at a later time, but the NA was not sure what that item was or whether or not the resident actually consumed it later that day. On 6/8/14, Resident #1 was noted to have a second low BS result. A review of Resident #1 ' s June 2014 MAR revealed that on 6/8/14 the resident ' s BS at 5 PM was 42. A Nursing Progress note dated 6/8/14 at 5:00 PM read: " Pt (patient) unresponsive bs (blood sugar) 42 VS (Vital Signs) 96.4 (temperature); 64 (heart rate); 18 (respiration rate); 120/74 (blood pressure); [MEDICATION NAME] given bs (blood sugar) came up to 71 pt alert responsive sweating pt drank glucerna refused supper will monitor. " A notation was made on the back of the resident ' s MAR dated 6/8/14 at 5:00 PM which indicated the resident ' s BS was 42; she was unresponsive; [MEDICATION NAME] was given; and the results of a BS recheck (no time provided) was 71. No notations were made in the resident ' s medical record (including the Nurse ' s Notes and MAR) to indicate that the NP or physician was notified of a low BS per the Diabetic Protocols in the Standing Orders or as indicated by the physician orders [REDACTED]. A review of Resident #1 ' s Meal Intake records from 6/8/14 indicated Resident #1 consumed 26-50% of the evening meal on 6/8/14. No documentation of the resident ' s acceptance of Glucerna at bedtime was recorded on the MAR. A notation, " Accepted, " was made on the resident ' s bedtime snack intake record for 6/8/14. An interview was conducted with Nurse #5 on 6/16/14 at 3:19 PM. Nurse #5 was the 2nd shift nurse assigned to care for Resident #1 on 6/8/14. During the interview, the nurse reported the resident was asleep that day when they made rounds at 3PM. She indicated that was not unusual for Resident #1. The nurse stated that when she went to check the resident around 4:30 PM (to do the 5PM BS check), the resident would not wake up. The resident ' s BS at that time was 42. The nurse stated that she had the NA take the resident ' s vital signs while she went to get a [MEDICATION NAME] shot for her. After the [MEDICATION NAME] shot was given, the nurse had the NA stay with the resident. The resident woke up after about 20 minutes and was reported to be alert but confused at that time. The nurse indicated the resident was usually disoriented. When the resident was awake, the nurse rechecked her BS again and found that it had come up to 71. Nurse #5 stated that she gave the resident some Glucerna at that time (around 5:00 PM). The nurse reported that the resident seemed her " normal self " after consuming this Glucerna. Nurse #5 stated that she did check the resident ' s BS again after the supper trays came out, but didn ' t document the result. The nurse thought that BS result when rechecked was, " either 100 or 148. " Nurse #5 stated that Resident #1 wouldn ' t eat her supper that evening, which was not unusual for her. The nurse also reported that at around 8:30PM the resident drank another can of Glucerna. The nurse reported that she checked on her 2-3 more times that shift. She stated that her checks, " just involved verbal stimuli " and that the resident would wake up and talk with her. At the end of the shift, the nurse reported that Resident #1 was sleeping (like she usually would have at that time of night). Nurse #5 stated that she faxed the resident ' s physician the evening of 6/8/14 to inform him that Resident #1 ' s BS had been low and that [MEDICATION NAME] was given. Upon inquiry, the nurse indicated that she would have called the physician if the resident would have remained unresponsive. The nurse noted that she told the oncoming nurse in report that she had given [MEDICATION NAME] to the resident, Resident #1 was refusing her meals, and to watch her BS. An interview was conducted with NA #3 on 6/16/14 at 3:08 PM. NA #3 worked the 2nd shift on 6/8/14 and recalled the situation with Resident #1 on that date. NA #3 reported that when Nurse #5 told her she couldn ' t get Resident #1 awake, she went into the room and also tried to awaken her without success. The NA reported the nurse checked her BS, left to get the [MEDICATION NAME], then returned and administered it to her. NA #3 reported that she and a co-worker (another NA) stayed with the resident " the entire time " until she woke up. Upon awakening, the resident was described as disoriented and very sweaty. The NA stated that the resident drank a whole can of Glucerna but wouldn ' t eat her supper. An interview was conducted with NA #4 on 6/17/14 at 9:26 AM. NA #4 worked as a NA during the 2nd shift on 6/8/14 and recalled the events that occurred with Resident #1 on that date. NA #4 recalled that she was working with another resident when the resident ' s sugar had dropped. The NA reported that she assisted the resident with drinking a can of Glucerna at around 5PM. The NA reported that the resident was, " talking and everything and seemed like she was getting okay ...she said she was cold. " The NA indicated she went in and checked on the resident about every 30 minutes and noted that she was, " sleeping sometimes and sometimes awake. " NA #4 reported that around 8:00 PM or so she assisted the resident with drinking another can of Glucerna, which she finished. The NA stated, " I just did it because I knew she didn ' t eat her food. " Upon inquiry, the NA stated that the last time she checked on the resident was probably around 10:30 PM on 6/8/14. The resident was noted to be sleeping at that time. On 6/9/14, Resident #1 was noted to have a low BS. A review of Resident #1 ' s June 2014 MAR revealed that on 6/9/14 the resident ' s BS at 6 AM was 41. A notation dated 6/9/14 at 6 AM was made on the back of the June 2014 MAR. The notation reported Resident #1 ' s BS was 41; 2 packs of sugar were given under her tongue; and BS recheck at 7 AM was 57. A telephone interview was conducted with Nurse #2 on 6/16/14 at 4:35 PM. Nurse #2 was the 3rd shift nurse assigned to care for Resident #1 on the evening of 6/8/14 to the morning of 6/9/14. During this interview, the nurse recalled there was nothing unusual noted for Resident #1 that night. The nurse reported that Resident #1 would sometimes wake up around 3 AM - 4 AM, but did not recall whether or not she woke up that night. The nurse reported that when she took the resident ' s BS between 6AM and 6:30AM, she found it was low and the resident was unresponsive. The nurse stated that she went to the Stat Box (referring to the Stat Medication Box, an emergency supply of medications kept in the Medication Room), " to see if we had [MEDICATION NAME], " but there wasn ' t any. Nurse #2 reported she then went to a second unit ' s medication room and there wasn ' t ' any [MEDICATION NAME] there either. At that time, the nurse reported she went and got sugar (2-3 packets) and put it under the resident ' s tongue. After that, she called to the 3rd and final unit in the facility to see if they had any [MEDICATION NAME] and found that they did not. Nurse #2 stated that she rechecked the resident ' s sugar more than once but only documented the results of the last recheck when her BS had gone up to around 57. She recalled that the resident was moaning at about that time (approximately 7:00 AM). Nurse #2 stated that it was also about 7:00 AM when she gave report to the on-coming nurse. When asked why she did not initiate any further interventions or call the resident ' s physician, Nurse #4 stated, " I thought her sugar was coming up and the situation was resolving. " A telephone interview was conducted with NA #1 on 6/16/14 at 6:31 PM. NA #1 was the 3rd shift NA assigned to care for Resident #1 on the evening of 6/8/14 to the morning of 6/9/14. The NA recalled that around 2:00 AM she told the nurse that the resident was in deep sleep and snoring. She recalled that at about 4:00 AM she reported the same to the hall nurse. NA #1 stated that at 6:00 AM (on her last round) she couldn ' t wake the resident up. She told Nurse #2 (the hall nurse), and the nurse said she was aware of it and was trying to find the [MEDICATION NAME] to bring her sugar up. The NA stated the nurse wasn ' t able to find any [MEDICATION NAME]. She recalled that the nurse then gave the resident some sugar under her tongue. The NA stated that the resident did not respond while she was in the room. A Nursing Progress note written for 6/9/14 at 7:15 AM (created as a late entry on 6/16/14 at 11:40 AM) read: " In rsdt (resident ' s) room this shift. Rsdt noted unresponsive, BS checked 51. [MEDICATION NAME] shot given at 7:15 AM. Back in rsdt room at 7:45 am. BS increase to 113 rsdt remained unresponsive. Sat (oxygen saturation) 93% ra (on room air). V/S (Vital Signs) 97.5 (temperature), 130/60 (blood pressure), 18 (respiration rate); 80 (heart rate). White foam substance noted coming from mouth. Called (name of hospital) to get MD on call for (name of resident ' s physician), (name of on-call physician) called right back, informed him of status change. Order given to send to (name of hospital) for eval. 911 called for transport of rsdt to (name of hospital). RP (family member) called informed of status change and order to send to (name of hospital), was appreciative. " An interview was conducted with Nurse #6 on 6/16/14 at 2:33 PM. Nurse #6 was the 1st shift nurse who came on duty at 7:00 AM on 6/9/14. Nurse #6 stated that when she got to the facility that morning, the resident was unresponsive and she was told the resident ' s sugar was low. Nurse #6 stated, " I think I was told (her BS was) 51. " Nurse #6 reported the BS was rechecked a

Based on record reviews, observations and staff interviews, the facility failed to supervise one of four residents reviewed with exit seeking and wandering behavior, which resulted in the resident's elopement from the facility. (Resident #5) The Immediate Jeopardy began on 2/13/11 at 1:15AM and was identified on 3/10/11 at 2:00PM. The Immediate Jeopardy was removed on 3/11/11 at 3:45PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (with more than minimal potential for harm that is not immediate jeopardy). The facility remained out of compliance to complete additional care plan audits, in-service nursing staff who had not received training on frequent monitoring and supervision to ensure resident safety and notifying nurse management when residents exhibit exit seeking behaviors. The facility also planned to inservice nursing staff on redirecting residents that exhibit exit seeking behavior, notifying Director of Nursing immediately when residents cannot be redirected and nurse rosters maintained at nurse's station that include care plan interventions on how to intervene to prevent elopement. The findings are: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set ((MDS) dated [DATE], Resident #5 was unable to complete the cognitive portion of the MDS. In the area of "Wandering, - Presence & Frequency," Resident #5 was coded on the MDS as behavior of this type occurred 4 to 6 days, but less than daily. In the area of "Wandering-Impact," the MDS revealed Resident #5's wandering significantly intruded on the privacy or activities of others. In the area of bed mobility, the MDS revealed Resident #5 required limited assistance, which indicated that the resident was highly involved in the activity with one person physical assistance. In the area of transfer, Resident #5 required limited assistance of one person to move between surfaces, (self sufficient once in wheelchair) from bed to wheelchair to standing position. Resident #5 was independent in moving from her room (using wheelchair) to the adjacent corridor with no physical help from the staff. Resident #5 was also independent (using wheelchair) in moving to and returning from off-unit locations, such as dining or other activities. Wander guard (Bracelet) A device worn by wandering residents that sound an alarm when residents wearing the device travel close to a door equipped to detect wander guards. Review of the facility's Nursing Assessment on 3/10/10 revealed Resident #5 had an elopement risk of 13. A score of 10 or greater, was considered at risk for elopement. A Care Plan and a list of elopement prevention measures were to be initiated, to prevent elopement. On 4/2/10, Resident #5's elopement risk was 16. On 7/5/10, the resident's elopement risk was 15. There was no Care Plan, elopement prevention measures, or interventions to prevent elopement initiated for either dates. Review of the facility's Nursing Assessments on 10/18/10, 12/31/10 and 1/17/11 revealed Resident #5's elopement risk was 14. There was no Care Plan or elopement prevention measures initiated for the dates. However, a wander guard was used as an intervention. Resident #5's Care Plan which was reviewed and revised on 1/7/11, revealed the resident's wandering behavior and risk for elopement was not addressed. Review of the facility's "Resident Incident Report" dated 2/13/11 at 1:51AM revealed Resident #5 eloped from the facility. There was no apparent injury and the location was the 600 hall. The property involved was a wheelchair and the activity at the time was propelling the wheelchair independently. The narrative of the incident and description of injuries, read, "CNA (Nursing Assistant) reports that she could not locate resident on the hall, facility wide search was indicated, resident was located on facility grounds." The immediate action taken was the resident was placed with one-on-one care. The resident's mental condition at the time of the incident was confused. The medical risk factors possibly related to the incident was confusion/disorientation. An additional narrative description of the incident, read, "1:30AM, staff unable to locate resident - search initiated at 1:50AM - states pt. (patient) was found on facility grounds does not say where. Pt. (patient) was given Ativan 0.25 milliliters IM." Review of Resident #5's Care Plan, updated on 2/14/11, under "Problem Onset," read, "Patient has had an elopement and is at risk for recurrent elopements (due to) dx (diagnosis) of dementia and poor safety awareness." Under "Approaches," read, in part, "Wander guard in use at all times. Redirect patient when she is wandering. Provide diversional activities for her. Place patient's picture in wander guard notebook for all staff to recognize as wanderers. Staff to monitor her whereabouts at all times and offer an activity as diversion." Review of a facility document dated 2/14/11 titled, "QA (Quality Assurance) Elopement Review," revealed a written statement by NA#1, and read, "I, (NA#1) was working the night of (2/13/11) (with) the patient, (Resident #5) when the incident occurred. At approximately 1:15AM I noticed (Resident #5) had traveled further than her usual wandering spots, and I notified neighboring Nurse & other (NAs) that she was missing (& the Supervisor) and we all began the search for her at about 1:30AM." During an interview on 3/10/11 at 9:20PM, NA#1, revealed prior to Resident #5's elopement on 2/13/11, she saw the resident a little after 1:00AM. She stated that Resident #5 was at the end of the 500 hall rolling around in her wheelchair, NA#1 revealed Resident #5 was not agitated and she acted normal. She stated when she did not see Resident #5 after she completed her rounds, she went down the 500 hall to the 400 hall. NA #1 revealed after she did not see the resident, she alerted everyone. She stated they started the initial search and she then asked others for help. NA#1 stated she completed her rounds in the last room on the 600 hall and she did not hear any alarms sounding. She stated when Resident #1 was roaming, she usually did not let the resident get too far out of sight. She stated she usually checked for her whereabouts every 15 to 30 minutes. NA#1 revealed that Resident #5 would usually stay on her unit if someone was talking to her. NA#1 explained that Resident #5 would sometimes sit up half the night or all night. She revealed the resident became agitated if someone tried to assist her in going to bed and that Resident #5 could walk with assistance. She stated if any double doors were closed the resident would open them. She stated that Resident #5 would try to open the doors at the end of the 500 and 600 hall, but she did not push on them very hard. On the night Resident #5 eloped from the facility after 1:00AM, the Monthly Weather Forecast for the named city on Sunday, 2/13/11, the lowest temperature was 27 degrees (Fahrenheit). During another review, the "QA (Quality Assurance) Elopement Review, dated 2/14/11, revealed a written statement by Staff Nurse #1, and read, "After all rooms were checked inside the facility we started an outside search. Staff Nurse #2 and I started searched the grounds in front of the building & toward (Nursing facility next door). I walked around the pavement which goes around (Nursing facility next door). I noticed something moving to the left of me. When I shined my flashlight in the direction of the movement I noticed resident sitting between (Nursing facility next door) and the storage building in the back of the facility. Resident #5 had gotten off the pavement, into the grass and could not move. I said "(Resident #5), what are you doing." She said "I'm freezing honey, I need to get in the car." Writer then took her coat off and draped it around resident. Writer yelled. "I found her." Writer was met by other staff members with blankets & helped to get (her) back into facility. We entered through the employee entrance. Resident was wearing a wander guard but no alarm sounded." During an interview on 3/8/11 at 10:45AM, Staff Nurse #1 stated she saw Resident #5 at 11:00PM.(start of night shift). She revealed the resident was sitting at the corner in front of the Nurse's station, (300 and 400 hall). Staff Nurse #1 stated she was getting ready to start medication pass between 11:00PM and 12:00AM. She revealed she took Resident #5 back to the 600 hall nurse's station. Thereafter, she indicated she did not know where the resident went. Staff Nurse #1 stated that NA#1 walked through and asked if they had seen Resident #5. Staff Nurse #1 stated that they checked doors that opened and they walked from the end of the 400 hall to the (front door) entrance. Staff Nurse #1 indicated facility staff got flashlights and went outside. Staff Nurse #1 stated that Staff Nurse #2 walked around one end of the facility next door and she walked around the other end of the facility next door. Staff Nurse #1 revealed that she found Resident #5 located in the back of the Nursing facility next door between the building and a storage building. Staff Nurse #1 explained the resident was found between the middle of another nursing facility (facility where the resident did not reside) and the storage building. She stated Resident #5 had on a pink light short sleeve house coat and a t-shirt with a night gown underneath. Staff Nurse #1 stated the resident was found sitting up in her wheelchair. She revealed that Resident #5 seemed to be okay when they looked at her. Staff Nurse #1 stated staff assisted the resident through the employee entrance upon return to the facility, where Resident #5 resided. She indicated Resident #5 had on her wander guard. She revealed that they had to put in a code to get in or out of the building. Staff Nurse #1 stated when the resident was assisted back into the facility where she resided, no alarm sounded on the door, upon entry. (The employee entrance door was not equipped with the wander guard detector. Therefore, no alarm would have sounded). Staff Nurse #1 stated she had worked with Resident #5 before and indicated the resident traveled throughout the facility. Staff Nurse #1 stated that Nursing Assistants were supposed to check on Resident #5. She stated in the past she had called the unit, (600 nurse's station) and told staff where the resident was located. Staff Nurse #1 revealed Resident #5 would look out the door of the smoking area, but did not attempt to get out of the building. Staff Nurse #1 stated she did not hear any alarms the night the resident eloped from the facility. During an interview on 3/8/11 at 12:10AM, Staff Nurse#2, who worked the night Resident #5 eloped from the facility, indicated the resident was found behind another nursing facility, where the resident did not reside. He stated it was 20 degrees that night and Resident #5 looked like she was cold. Staff Nurse #2 stated Resident #5 seemed to be okay and his coworker put her jacket on the resident to try to keep her warm. He stated that Resident #5 roamed throughout the building anywhere there was an open area. On 3/8/11 at 12:45AM, with the assistance of Staff Nurse #2, an observation was made of the area where Resident #5 was found. The area was located in the back of another nursing facility, where Resifdent #5 did not reside, behind a storage building on the left side in a grassy area. Staff Nurse#2 stated the area observed was where he saw her when he arrived at the location. During an interview on 3/8/11 at 10:55AM, Staff Nurse #3 stated Resident #5 was up at the Nurse's station (500 and 600 hall) in her wheelchair prior to her elopement. She stated that the resident went down the hallway wandering around in her wheelchair. She stated that she watched Resident #5 while she was on the unit. She stated that Resident #5 normally stayed on the 600 hall, and if the resident went of the unit (600 hall) someone would return her to the unit or her Nursing Assistant brought the resident back the unit. Staff Nurse #3 indicated prior to Resident #5's elopement the resident's Nursing Assistant could not locate the resident and they searched for her on different halls. She stated when staff was not able to locate the resident after twenty minutes, they started to search for her. Staff Nurse #3 stated that Resident #5 was returned to the Nurse's station two times the night of the elopement. She stated both times the Nursing Assistant on the 600 hall that night, returned the resident to her unit. She stated Resident #5 wandered off again after redirected. Staff Nurse #3 stated she helped to search for the resident. She stated she notified the Nursing Supervisor Resident #5 could not be located. Staff Nurse #3 revealed staff searched different rooms for Resident #5 and then proceeded to search outside. She stated one nurse remained at the Nurse's station. During an interview on 3/8/11 at 4:35PM, Staff Nurse #4 revealed she saw Resident #5 go around the nurse's station (100 and 200 hall) and it was hour or so before she was notified the resident had eloped from the facility. She indicated she thought the resident was on the 200 hall that night. She stated Resident #5 would usually circle around unit 1 (100 and 200 hall) and unit 2 (300 and 400 hall). She stated occasionally the resident would go to unit 4 (700 and 800) hall. Staff Nurse #4 revealed everyone knew how Resident #5 roamed throughout the building. She stated that she was sitting at the 200 hall nurse's station charting when she saw Resident #5 heading back toward her unit. Staff Nurse #4 stated she spoke to Resident #5 as the resident went around the corner, toward unit 2 (300 and 400 hall). Staff Nurse #4 revealed one of the nurse aides informed her the resident was missing, and she asked the aide if she had checked her unit. Staff Nurse #4 stated staff immediately searched the building. She revealed she did not think Resident #5 left the building because she thought she would have heard an alarm once the resident got close to the door. (If a door with a wander guard detector was open and if Resident #5 who was wearing her wander guard came close to the door, an alarm would sound.) Staff Nurse #4 revealed all doors were supposed to alarm. (The front door alarm was supposed to sound when the front door was open and a resident wearing a wander guard came close to the door. If the front door was closed the door would lock when a resident with a wander guard got close to it.) Staff Nurse #4 stated she did not know which door staff brought Resident #5 through when they returned her to the building. She revealed after the staff returned Resident #5 to the building, she checked all doors to ensure all doors latched properly. She stated the door at the end of the 500 hall would not latch properly. She revealed when someone pushed against the door, the bottom of the door would open, but it would not open all the way, because the door was locked at the top with a mag lock. On 3/10/11 at 6:00PM, accompanied by the Maintenance Director, the distance was measured from the facility where Resident #5 eloped, to where the resident was found in a grassy area in the back of another nursing facility. The measurements were taken on the left side of the facility. The distance was measured from a facility door, referred to as the laundry door, which was between the corridor of the 400 and 500 hall. (facility where the resident resided). The passage from the laundry door led to a sidewalk, which led to a gravel lot which joined a paved road (one of the access roads to both facilities.) From the facility to where the resident was found was an estimated 272 feet. The storage building behind the nursing facility where Resident #5 was found was 20 feet long and 12 feet wide. There was a wooded area along the access road and a creek was beyond the wooded area. The facility access road extended to stop a sign at the main road and there were ditches, which dropped below the road surface on both sides of the road, which intersected the main road. The distance from the facility to the main road was 990 feet. The speed limit for the main road in front of the facility was 35 miles per hour. During an interview on 3/7/11 at 5:45PM, the Director of Nursing (DON) stated they never determined which door Resident #5 went out through when she eloped from the facility. She indicated the door at the end of the 500 hall had a mag lock (locked from the top) on it. The DON revealed Resident #5 had one-on-one staff with her after the incident. She stated they checked the resident's wander guard to determine if it was working and they discovered the wander guard had a weak signal. The DON revealed the wander guard with the weak signal was thrown away and replaced with a new one. She stated the maintenance man made sure the mag locks were working when he came in on Sunday. The DON revealed staff checked the facility to verify all residents were in the building on the night Resident #5 eloped from the facility. The DON revealed the 7:00AM to 3:00PM supervisor checked every wander guard bracelet and changed out all bands that morning. During an observation on 3/7/11 at 3:30PM, Resident #5 was awake in bed. The head of her bed was elevated with both side rails up. During an observation on 3/8/11 at 10:30AM, Resident #5 was awake in bed with both side rails up. During an interview on 3/9/11 at 12:10PM, the Nursing Secretary revealed she tested wander guards weekly. She indicated she took residents up to the front door to test wander guards. The Nursing Secretary indicated the front door would lock if a resident with a wander guard approached the front door. She revealed even if the wander guard was weak, the front door still would lock when a resident approached it. She stated that when a wander guard was weak, she would order another one. The Nursing Secretary further stated if there was a problem with the wander guard, she would document the wander guard was weak. She revealed the last time Resident #5's wander guard was tested was on 2/8/11. She stated even if a wander guard was weak, the front door would still lock when a resident with a wander guard approached it. The Nursing Secretary stated a door alarm would sound even if a wander guard was weak. She stated the other doors in the facility were always locked. The Nursing Secretary explained if the front door was open as a resident approached with a wander guard, an alarm would sound, and if the front door was closed when a resident approached with a wander guard, the front door would lock down. The Nursing Secretary revealed the wander guards were good for one year and two or three months. She stated the wander guard might not start getting weak until after twelve or thirteen months. The Nursing Secretary stated she could not remember the last time she changed out Resident #5's wander guard. She stated if she had to change a wander guard for another one, she would try to have another one within a week or two. The Nursing Secretary stated she did not know how long a wander guard lasted before it stopped working, because they changed the wander guard before that happened. During an interview on 3/7/11 at 3:30PM, NA#2 stated she had been working in the facility for 2 ? years. She revealed Resident #5 rolled around in her wheelchair and the resident could walk with assistance to and from the bathroom. NA#2 stated Resident #5 could get around in her wheelchair very well. She revealed the resident would go up and down the 600 hall, through the great room (dining room ) to unit 2 (300 and 400) hall. She stated the resident would make a circle, going from the 300 and 400 hall to the 100 and 200 hall and back to 500 and 600 hall. NA#2 stated everyone knew Resident #5 and the location of her unit. She revealed she would check Resident #5 for toileting every two hours. NA#2 stated she did not have to constantly check on Resident #5. She indicated Resident #5 stayed on her unit most of the time. NA#2 revealed Resident #5 had a wander guard and an alarm on her wheelchair. She stated if Resident #5 tried to stand up, the alarm (on her wheelchair) would sound. NA#2 revealed Resident #5 had the wander guard since she was admitted to the facility. NA#2 explained there was a sheet at the Nurse's station that staff reviewed which listed residents that had to be lifted or if the residents had alarms on their bed or wheelchair. During an interview on 3/8/11 at 12:15AM, NA#3, stated Resident #5 wore a wander guard at all times. She stated the resident used to be up out of bed before she got sick. She revealed Resident #5 would roam throughout the unit and call for her husband. NA#3 stated she tried to make sure Resident #5 stayed on the unit. She stated the resident would travel up to unit 2, (300 and 400 hall) and unit 1 (100 and 200 hall). Na#3 stated she tried to keep an eye on Resident #5 if she (resident) was off the unit. NA#3 stated if Resident #5 was off the unit for more than 15 to 20 minutes, she would check on her. NA#3 revealed she did not work the night of the elopement. During an interview on 3/9/11 at 12:30PM, Staff Nurse #5 revealed Resident #5 was able to propel herself in her wheelchair independently. She stated the resident would propel her wheelchair to other units, and she seemed to be confused while propelling herself through the halls. Staff Nurse #5 stated she had to redirect Resident #5 back to her unit. She stated that she was sure that she had to redirect the resident from the front lobby back to her unit. During an interview on 3/9/11 at 12:45PM, NA #4 stated that prior to Resident #5 being sick, Resident #5 was able to move from her bed to her (room) door unassisted and would come to the door and say hello. She indicated the resident could walk by herself. NA #4 revealed that Resident #5 would roam throughout the entire facility, and would say she was looking for her (named) husband. She stated every other day, Resident #5 would sometimes state that she wanted to go home. NA #4 revealed Resident #5 liked to look out of the exit doors and she liked the 500 and 600 hall exit doors at the end of each hall. During an interview on 3/9/11 at 2:30PM, the Rehab. NA#5 stated Resident #5 was confused at times. She revealed the resident looked for her husband throughout the facility. Rehab. NA#5 stated Resident #5 could walk to and from her bed with one arm assistance. She revealed she had seen the resident once or twice at the smoke area waving at staff. During another interview on 3/10/11 at 11:45AM, NA #3, revealed Resident #5 would be at the doors every night, pushing on the handle of the exit door. She revealed Resident #5 would shake the handle back and forth and state, "Let's go home (named) husband. We have to go or we will miss the train." NA#3 stated Resident #5 would sit at the exit door from a few seconds to thirty minutes at night. She revealed the resident liked a certain room on the 600 hall and would go into that room a lot. NA#3 stated the room was next to the exit door on the 600 hall. During an interview on 3/10/11 at 12:20AM, NA #6 stated she saw Resident #5 a couple of hours before the resident was reported missing. She revealed Resident #5 was sitting in the large dining room near unit 3 (500-600 hall). NA #6 stated she was in the last room on the 800 hall when she was told that Resident #5 was missing. She stated she was told to check all of the rooms and start searching for the resident. NA#6 indicated Resident #5 would usually travel from one hall to another. She revealed most of the time the resident was in the unit 3 dining room watching television. During an interview on 3/10/11 at 12:15AM, NA #7 revealed the night of Resident #5's elopement she saw the resident at the beginning of the shift 11:15PM - 11:30PM. She stated Resident #5 was between the 300 hall (bottom portion of the hall) propelling herself around in her wheelchair. NA#7 stated she met the resident's primary Nursing Assistant at the end of the hallway, and the Nursing Assistant redirected Resident #5 to turn around in her wheelchair to go with her. NA #7 revealed she did not see Resident #5 any other time during that night. She stated she was in a resident's room between 12:00AM-1:00AM and she did not hear any alarms throughout the night. NA #7 revealed at other times, every now and then (not often) she would see Resident #5 in her area, down the 300-400 hall and the resident would sometimes sit at the nurse's station. During an interview on 3/10/11 at 12:30AM, NA #8 revealed she was working on the 500 hall the night Resident #5 was reported missing. She stated on the night Resident #5 was reported missing, she saw the resident roaming around going into different rooms. NA #8 revealed Resident #5 went into a resident's room on unit 2 (300-400 hall) and another aide asked her to assist her in getting Resident #5 out of the resident's room. She stated the last time she saw Resident #5, she was still roaming throughout the facility. NA #8 stated she could not remember which area she last saw the resident, and she further stated she did not hear any alarms sounding. During an interview on 3/9/11 at 1:15PM, the Unit Manager stated Resident #5 was confused. She stated Resident #5 could propel herself in her wheelchair throughout the facility. The Unit Manager revealed that at times Resident #5 would state that she was going home to a named country. She stated Resident #5 liked the exit doors and she would sit up front at the exit doors. The Unit Manager revealed she had not observed the resident trying to leave the facility. She stated prior to Resident #5's elopement the resident was capable maybe of getting out of bed and walking to the doorway of her room, although she was unsteady on her feet. The Administrator was notified of the Immediate Jeopardy on 3/10/11 at 2:00PM. The Immediate Jeopardy was removed on 3/11/11 at 3:45PM, when the facility provided a credible allegation of compliance. The allegation of compliance indicated: Resident # 1 was noted missing by night shift staff on 2/13/2011. An immediate search began and she was located behind Southwood Nursing Center near the utility shed by a staff nurse and was brought back into the facility. The resident was assessed by the staff nurse on 2/13/2011 and no injuries were noted. A nursing assistant was assigned to provide direct one-on-one supervision with this resident until it was determined that all elopement prevention systems (doors, alarms and locks) were properly functioning as described below on 2/13/2011 at 3 PM. The exits were checked on 2/13/2011 by the maintenance supervisor and nurse supervisor on duty. They verified that all (15 out of 15) doors latched and locked. They also verified that doors with alarms (4 out of 4), alarmed when the door is open and the transmitter is within range. The front entrance door was checked by bringing the transmitter bracelet within range and verified that it did not open. They also verified that the door would open and alarm when transmitter was not in range. And that the door opened when the code was keyed into the keypad and transmitter was not in range. No problems were identified. The transmitter bracelet for resident # 1 was also checked by the nursing supervisor on 2/13/2011 and was identified as being " weak " according to manufacturer ' s guidelines. The transmitter was replaced by nursing staff on 2/13/2011. Resident # 1 care plan was reviewed on 2/14/2011 by the care plan nurse and was updated. The updated care plan included elopement, elopement risk, goals, and intervention for elopement risk and wandering. Interventions on 2/14/2011 included wander guard transmitter in use at all times, Notifying nurse of mental status changes, redirecting resident when she is wandering, providing diversional activities, engage her in conversation, give anti-anxiety medications, consult with physician, check transmitter bracelet weekly for proper functioning, place picture in wander guard book for all staff, staff to monitor her whereabouts at all times and offer activity as a diversion. On 2/13/2011, the nursing supervisor checked all residents who currently utilized wander guard transmitters and ensured that the transmitters were on the 17 residents. The transmitters were tested using the manufacturer testing device and there were three transmitter bracelets that were determined to be weak according to the manufacturer ' s guidelines. These three transmitters were replaced with new transmitter on 2/13/2011 by the nursing supervisor. All residents with a wander guard bracelet were reviewed on 2/14/2011 by the quality assurance team to ensure that anyone who was identified at risk for elopement by scoring a 10 or higher on the most recent elopement risk assessment were on the wander guard list. This wander guard list is kept current because the transmitter bracelets are obtained by the nursing staff from the nursing secretary. The nursing secretary then records the resident name and room number on the wander guard testing list. The wander guard list is a list used by the nursing secretary to ensure that the weekly transmitters test is completed. There was no resident identified as being at risk for elopement that was not on the list or not currently using a transmitter. An additional audit of all care plans was conducted on 3/10/2011 by the care plan nurses to verify that all residents who are identified at risk for elopement have a care plan that addresses elopement risk and exit seeking tendencies. Care plan interventions on how to intervene to prevent elopement were added to the nursing rosters on 3/10/2011 by the support nurses. This nurse aide roster will be copied and kept at the nurses ' station. Copies will be available so that every nurse and nursing assistant can have a copy each shift for the hall they are assigned. See below for staff in-service on this intervention. These rosters are updated by the support nurse for that unit and by the MDS nurses. They are updated daily (Monday-Friday) with new admissions, changes in conditions and care plan updates. This includes risk of elopement and how to intervene to prevent elopements. When updated the support nurse will then make copies, place them at the nurses station and remove the outdated copies On 3/10/2011, the RN nurse managers in-services RNs, LPNs and nursing assistants. All RNs, LPNs and nursing assistants that worked evening and night shift on 3/10/2011 were in-serviced on 3/10/2011. All day shift RNs, LPNs, and NAs that were scheduled to work on 3/11/2011 were in-serviced prior to start of the shift at 7AM on 3/11/2011. Telephone in-services were completed on 3/11/2011 by the RN nurse managers for any RNs, LPNs and NAs that had not received the training. Currently there are 18% nursing staff who have not received training. The staff development coordinator will ensure that these employees do not work until training has been completed. This training included the following: 1. Do not forget that frequent monitoring and supervision are needed in order to ensure resident safety. This means that you should be aware of the at risk resident ' s location. Do not accept the wander guard system as a substitution for resident supervision. 2. If a resident begins to exhibit exit seeking behaviors then make sure that nurse management is aware of this and make sure to provide frequent monitoring. Examples of exit seeking behavior include sitting for long periods of time at the doors, verbalizing a desire to leave the facility, trying to open the doors and other activities that involve trying to leave the facility 3. Try to redirect residents who are exit seeking by encouraging them to participate in activities that they enjoy or meeting physical needs such as toileting or hunger/thirst. The care plan or nurse roster is a good resource for additional interventions. 4. If the exit seeking behavior cannot be redirected then call Director of nursing immediately and initiate one-on- one supervision. Resident is not to be left unsupervised at any time. 5. The nurse rosters will be maintained at the nurses station for you to use during your shift. They will include care plan interventions on how to intervene to prevent elopement. On February 22 and 23 2011, in-services wer