Every finding on record at Mesa Springs Healthcare Center

Based on observation, interview and record review the facility failed to ensure a resident, who needed respiratory care, was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1's respiratory status was assessed before and after administering a nebulized breathing treatment on 07/01/2026, per physician's order. 2. The facility failed to ensure CNA-A notified LVN B of Resident #1's racing breathing on 07/02/2026. These failures could place residents at risk for respiratory distress and not having their respiratory needs met. Record review of Resident #1's electronic face sheet, accessed 07/15/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with traumatic brain bleed, heart disease, and dementia. There was no evidence of respiratory diagnosis documented. Record review of Resident #1's admission MDS Assessment, dated 06/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The admission MDS Assessment indicated the resident was on oxygen therapy. There was no evidence of respiratory diagnosis documented. Record review of Resident #1's electronic Physician's Order, accessed 07/15/2026, reflected Before PRN nebulizer treatment, obtain and record pulse, O2 SAT, pre-med lung sounds after PRN nebulizer treatment, obtain and record pulse, O2 SAT, TX minutes, post-med lung sounds, dated 06/22/2026, check & record O2 saturation as needed for SOB, dated 06/02/2026, oxygen at 2 liters via NC, dated 06/04/2026, and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB, dated 06/02/2026. Record review of Resident #1's Comprehensive Care Plan, initiated on 05/28/2026, reflected no evidence of oxygen therapy or breathing treatments. Record review of Resident #1's July 2026 MAR from 07/01/2026-07/02/2026 revealed no evidence of breathing treatment being administered. Record review of Resident #1's progress notes, from 07/01/2026 9:00 PM to 07/02/2026 reflected no evidence of the resident being short of breath, no documentation of assessment, vital signs, or administration of breathing treatment. Observation of video footage, dated 07/01/2026 at 10:15 PM, revealed LVN-B checked oxygen level and stated, Sats 90%. LVN-B checked oxygen tubing and looked at the level on the concentrator and stated, I need to go see what you're supposed to be set at. No lung assessment or any other vital signs were completed, and LVN-B left the room. Observation of video footage, dated 07/01/2026 at 10:18 PM, revealed LVN-B entered the room and started the breathing treatment. No lung assessment was completed, and LVN-B left the room. Observation of video footage, dated 07/01/2026 at 11:05 PM, revealed LVN-B removed the nebulizer mask and put the oxygen nasal cannula back on Resident #1. No lung assessment or vital signs was completed. Observation of video footage, dated 07/02/2026 at 1:28 AM, revealed Resident #1 banging on the wall. CNA-A entered the room. Resident #1 was breathing rapidly and grabbing his chest. He stated, I am breathing like a racehorse. and removed his nasal cannula. CNA-A told him to keep his oxygen on to help him breathe and replaced the nasal cannula. CNA-A left the room. During an Interview on 07/15/2026 at 10:30 AM, the DON stated resident rounds should be done at a minimum of every 2 hours, but she suggested and preferred every hour alternating between nurse and CNA. Rounding consisted of laying eyes on the residents. Rounding was to check for any signs of respiratory distress and falls. She stated any signs of difficulty breathing, or SOB should be reported to the nurse immediately. She stated the nurse should perform a complete assessment including vital signs and listening to the lungs. She stated with any abnormal assessment and unexplained respiratory distress, the physician should be notified immediately, especially if this was a change in the resident's condition. She stated when administering a breathing treatment, vital sign and lung assessment should be completed prior to and after the treatment. She stated it was her expectation that physician's orders be followed. During an Interview on 07/15/2026 at 6:35 PM, CNA-A stated she rounded on Resident #1 every 2 hours on the night of 07/01/2026 to the morning of 07/02/2026. She stated she put him in bed around 9:00 PM. She started to make rounds 1-2 hours after he was having difficulty breathing. She stated she went to get LVN-B. She stated LVN-B then came in and assessed Resident #1. She stated she rounded on him sometime during the night and he was banging on the wall and confused. He was having difficulty breathing and his respirations were shallow. She stated he was complaining about not being able to breathe. She stated she placed his oxygen cannula back in his nose. She stated she did not report this to the nurse because she thought it was just because he did not have his oxygen on. She stated she checked on him again after and he was asleep. CNA-A stated 2-hour rounds consisted of looking for any signs of breathing concerns which would be SOB and shallow breathing. During an Interview on 07/15/2026 at 10:55 PM, LVN-B stated she could not recall Resident #1 having any issues the night of 07/01/2026. She stated she did not know of any SOB or difficulty breathing. She stated she could not remember giving him breathing treatment. She stated when administering a breathing treatment, vital signs and lung assessment should be completed before and after the treatment. She stated the CNAs were expected to round every 2 hours and to notify the nurse of any concerns. She stated when a CNA told her a resident was having difficulty breathing, she would immediately assess the resident and notify the physician if his oxygen sats were low. During an interview on 07/16/2026 at 10:40 AM, the NP stated her expectation was a resident complaining of shortness of breath and a fast heart rate should be assessed. She stated the CNA should have notified the nurse, and the nurse should have performed a complete assessment. During an interview on 07/16/2026 at 4:00 PM, after watching the video footage from 07/01/2026 and 07/02/2026, the DON stated Resident #1 was obviously in respiratory distress, and it should have been reported to the nurse. She stated he needed an assessment, and the doctor should have been notified. During an interview on 07/16/2026 at 5:45 PM, after watching the video footage from 07/01/2026 and 07/02/2026, LVN-B stated she did remember going in to check his oxygen machine to see how much oxygen he was getting, and she checked his O2 sats (saturation- how much oxygen is in the blood) and decided to give him a breathing treatment. She stated she was aware there was a physician's order for the breathing treatment and the pre and post assessment and physicians' orders should be followed. She stated his O2 sats were 90%, so she did not feel the need to notify the doctor. She stated she should have performed a lung assessment and completed a set of vital signs prior to and after the treatment. She stated she must have just gotten busy and forgot to document the breathing treatment. She stated she was not notified of his respiratory distress on 07/02/2026 at 1:30 AM and it was obvious in the video that he was in distress and needed to be assessed. During an interview on 07/17/2026 at 9:25 AM, the MD stated anytime a resident complained of shortness of breath, a nurse should be notified, and an assessment should be completed. He stated once the CNA put the oxygen back on Resident #1 he should have been assessed again within 15 minutes. He stated since the resident was known for removing his oxygen, he should have been more closely monitored throughout the night. He stated there was concern that the CNA did not report to the nurse. Record review of the facility's policy titled, Aerosol Drug Delivery, revised 04/2025, reflected in part . Procedure 1.b- obtain a baseline assessment of the residence heart rate, respiratory rate, oxygen saturation, and lung sounds prior to the procedure .15. Obtain a post treatment assessment of the resident's heart rate, respiratory rate, oxygen saturation, and lung sounds following the procedure 16. record treatment in the medical record which may include medication used, residents' respiratory rate and effort. Record review of the facility's policy titled, Change in Condition, revised 04/2025, reflected in part .Procedure: 1. If, at any time, it is recognized by anyone of the team members that the condition or care needs of the resident of change, the licensed nurse or nurse supervisor should be made aware. Examples would be the following but not limited to: change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation. Change in ability or decline in physical function. Change in mental status.

Based on interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse/neglect for one (Resident #1) of seven residents reviewed for abuse/neglect. The facility did not report an incident of neglect to the state agency within the given time frame. These failures could place all residents that access the facility van. The findings included:Record review of Resident #1's Face Sheet, dated April 14, 2026, revealed a [AGE] year-old female with the latest admission date of 08/24/2025. Her diagnoses included Hemiplegia, unspecified affecting right dominant side (a type of paralysis that affects one side of the body, often resulting from brain damage due to conditions such as a stroke or injury); and ataxic gate (an unsteady, irregular walking pattern caused by cerebellar dysfunction, leading to poor coordination and balance); and cognitive communication deficit (difficulty in communications that arise from impaired cognitive functions). Record review of Resident #1 Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 99 (unable to access cognitive impairment). Section GG revealed Resident #1 required the use of a wheelchair for ambulation. Record review of nursing progress note, dated 3/27/26 at 1515 revealed facility van driver reported that resident fell out from her wheelchair and rolled over near driver's seat. Resident did not have seat belt on at the time van stopped suddenly.In an interview on 04/14/2026 at 12:54 pm, Nurse A said she assessed Resident #1 when she returned to the facility. She was not injured but complained of generalized body pain and was given pain medication which was effective. Post-fall interventions were put into place with no reports of any further effects from the incident. Record review of Resident #1's Medication Administration Record revealed she received Acetaminophen-Codeine Tablet on 3/27/26 at 1510. In an interview on 04/14/2026 at 1:00 pm, Resident #1 stated she was on her way back from a dental appointment and was not buckled in. The van driver was not driving fast but had to stop suddenly and she fell out of her wheelchair and onto the floor of the van. There were no other residents in the van. She said the van driver accessed her and helped her back into her wheelchair and strapped her in. She said she was not injured just some general body pain and was assessed and given pain medication when she returned to the facility. She said, it was just an accident. She said she had always been buckled in before. In interviews with the sampled residents on 4/14/26 the following were revealed: Resident #2 said she rides on the facility van for appointments and outings and has always been buckled in. Resident #3 said she goes to activities and appointments in the van and was always buckled in. Resident #4 said she goes to appointments in the van and was always buckled in. Resident #5 said she goes to doctor's appointments and outings such as going to Wal-Mart was always buckled in. Resident #6 said she goes to outings in the van and was always buckled in. Resident #7 said she rides in the van for appointments and outings and was always buckled in. In an interview on 04/14/26 at 1:15 pm, the Maintenance Director said he is the current van driver for the facility. He had received training on transporting residents and how to secure a resident in the van. He said he recently completed an in-service training with demonstration on how to secure a resident in the van. In an interview on 04/15/26 at 9:35 am, the Administrator said after the incident, an investigation was completed by the facility. She said the van driver admitted he failed to buckle the resident in. When the incident happened, the van driver immediately assessed the resident with no injury, buckled her in her wheelchair, and called and notified the facility of the incident. He was placed on suspended leave, received a final written warning, and he resigned on 03/31/26. In-services with the van drivers were completed with demonstration. She said the Maintenance Manager was currently the van driver for the facility. The Administrator said she did not report the event outside of the facility to the state because she felt like at the time of incident it was not a reportable event as she did not consider the incident as resident neglect. A record review of the van driver employee file on 4/15/26 revealed the van driver received a counseling note on 3/27/26 concerning the failure to buckle in the resident with a final written warning. He resigned on 03/31/26. A record review on 04/15/26 of the investigation and training/in-service titled Annual Fleet Safety Re-Evaluation with a checklist with demonstration that was completed on 3/27/26 for residents to be bucked in at all times. Record review of the facility policy Abuse: Prevention of and Prohibition Against, dated as revised 12.2023, revealed the following [in part]: Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment.The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy.Definitions:*Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifferent or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress.Procedure:H. Reporting/Response2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. The facility provided the policy Transportation to Diagnostic Appointment, not dated, did not address the need to buckle/secure residents while they are using the van for transportation.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 (FY Quarter 4 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 4 2025 (October 1- December 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's Staffing Data Report for FY Quarter 4 2025 (October 1- December 31) reflected the facility triggered for Failed to Submit Data for the Quarter. Review of the facility's PBJ nurse staffing levels for October 1 - December 31, 2025 reflected there were 3 hours and 28 minutes HRD on all days for total nurse hours; there were 34 minutes HRD on all days for RN hours; there were 52 minutes HRD on all days for LVN hours; there were 2 hours and 3 minutes HRD on all days for nurse aide hours; there were 13 minutes HRD on all days for PT hours; there were 2 hours and 59 minutes HRD on weekend for total nurse hours; there were 30 minutes HRD on weekend for RN hours. During an interview on 03/19/2026 at 8:22 a.m., the ADMN stated her expectation was for the facility to follow CMS guidelines for submitting PBJ. She stated the facility had upgraded the facility's payroll vendor system in January and February of 2026, and there was an unanticipated increased length of time for the Facility to review and validate the information to be submitted. She stated the PBJ was submitted on February 13th after 5:00 p.m. by that payroll vendor system, but there was an error code that was not identified by the contracted service submission on the PBJ file. She stated the contracted service did not discover the issue until the submission error occurred, and extensive investigation identified the coding error several days past the submission deadline preventing resubmission. She stated she would provide the facility's data that would make the facility in compliance with sufficient staff guidelines. She stated she felt the facility followed the requirement and there was no negative impact to the residents from the data not being accepted on February 13th, 2026.Record review of facility document titled Process Improvement Plan: F851 - Payroll-Based Journal (PBJ) Staffing Data Submission, no date, reflected: Problem Statement CMS PBJ audits and CASPER reports have indicated opportunities for improvement related to one or more of the following: The Facility's PBJ file failed to submit successfully before the submission deadline due to an inadvertent coding error following a system upgrade, causing CMS to reject the entire file. This issue places the facility at risk for noncompliance with F851, resulting in deficiency citations, public reporting impacts, and potential enforcement consequences.Interventions: Standardize PBJ Submission Workflow 1. Contracted service provider will provide preliminary PBJ report to Facility to review and validate within 14 days prior to CMS submission deadline. 2. Facility will review and validate preliminary report. 3. Contracted service provider will submit PBJ report 10 days prior to submission deadline to allow for unforeseen errors and provide opportunity for Facility to correct and resubmit. 4. Contracted service will provide the validation of successful submission receipt to the facility.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #19, Resident#24 and Resident#31) of 12 residents reviewed for quality of care.The facility failed to ensure Resident #19 and #24's nasal canula was properly stored while oxygen was not in use on 03/17/2026.The facility failed to ensure Resident #31's nebulizer mask was properly stored while not in use on 03/17/2026. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.The findings include:1. Record review of Resident #19's admission Record dated 03/18/2026 revealed a [AGE] year-old female admitted on [DATE].Record review of Resident #19's History and Physical dated 11/25/2025 revealed resident had a diagnosis of hypoxic respiratory failure (a life threating condition where the lungs cannot adequately transfer oxygen to the blood, resulting in low blood oxygen levels). requiring supplemental oxygen via nasal canula.Record review of Resident # 19's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognitive function. Section O indicated the use of respiratory treatments to include oxygen therapy.Record review of Resident #19's physician orders revealed an order for oxygen 2-4 liters per minute via nasal canula to keep oxygen greater than 90 percent. The order had a start date of 11/12/2025.Record review of Resident #19's care plan revised on 01/14/2026 revealed Resident #19 had oxygen therapy related to ineffective gas exchange (the lungs cannot properly swap oxygen for carbon dioxide), hypoxemia( low levels of oxygen in the blood) and pleural effusion (excessive accumulation of fluid in the lungs). Interventions included providing an extension tubing or portable oxygen apparatus and administering continuous oxygen at 2-4 liters per minute.Record review of Resident #24's admission Record dated 03/18/2026 revealed an [AGE] year-old female with admission date 04/18/2025, and initial admission date 07/10/2023.Record review of Resident #19's History and Physical dated 03/17/2026 revealed a medical history of Chronic Obstructive Pulmonary Disease (COPD) a progressive lung disease making it difficult to breathe).Record review of Resident #24's Quarterly MDS dated [DATE] revealed there was no BIMS completed. Section I-Active Diagnosis noted Asthma and COPD for Resident #24. Section O-Special Treatments, Procedures, and Programs noted Resident #24 was receiving oxygen therapy as a resident in the Nursing Facility. Record review of Resident #24's care plan revised on 12/14/2025 revealed Resident #24 had altered respiratory status/difficulty breathing related to diagnosis of COPD and Asthma. The interventions for staff included to provide oxygen to Resident #24 per Physician order.Record review of Resident #24's Order Summary Report dated 03/18/2026 revealed the physician order of oxygen administration at 2 Liters per minute via nasal cannula, continuous.2. Record review of Resident #31's admission Record dated 03/18/2026 revealed an [AGE] year-old female with admission date 10/06/2025 and initial admission date 06/15/2023.Record review of Resident #31's Quarterly MDS revealed the BIMS was not completed. Section I- Active Diagnoses noted Resident #24 with Asthma or COPD, and Respiratory Failure .Record review of Resident #31's History and Physical dated 03/18/2026 revealed a medical history of Asthma and COPD.Record review of Resident #31's Care plan revised on 03/11/2025 revealed Resident #31 had altered respiratory status/difficulty breathing related to Asthma. The staff interventions included to administer Budesonide (a steroid medication used to prevent Asthma symptoms and making it easier to breathe) per physician's order.Record review of Resident #31's Order Summary Report dated 03/18/2026 revealed Physician order: Budesonide Inhalation Suspension 0.5 MG/2 ML Inhale 2 ML by mouth two times a day for Asthma and COPD.An observation on 03/17/2026 at 09:08 AM in Resident #24's room revealed an empty room with a nasal cannula that was left open to air and on the floor.An observation and interview on 03/17/2026 at 09:12 AM of Resident #31's nebulizer mask on her nightstand revealed it was open to air and uncovered. Resident #31 stated she had Asthma and had nebulizer treatments every morning and night. She stated that the staff administered her medication with the nebulizer mask that morning. She stated that it was usually stored in the plastic bag. An observation on 03/17/2026 at 11:15am in Resident #19's room revealed an empty room with a nasal canula left on the bed.An interview on 03/19/2026 at 10:57 a.m., with CNA H revealed nasal cannulas and nebulizer masks should be stored in plastic bags when not in use to prevent contamination. She stated that it was all staff's responsibility to ensure the nasal cannulas and nebulizer masks were stored properly when not in use. She stated the risk of not storing oxygen supplies properly would be the possibility of infection. She stated she could not recall the last in-service over nasal canula and nebulizer mask storage.An interview on 3/19/2026 at 11:35 a.m., with RN I revealed nasal cannulas and nebulizer masks needed to be stored in a bag, when not in use, to prevent contamination. He stated nasal cannulas and nebulizer masks were to be discarded if not stored properly, and there was always a potential risk to the resident if they were to use a contaminated nasal canula or nebulizer mask due to their age and co-morbidities. An interview on 03/19/2026 at 1:29 p.m., with the DON revealed oxygen tubing and masks were to be stored in a bag when not in use. She stated not storing them in bags was an infection control issue that could potentially pose a risk to the resident's health. She stated all staff were responsible for ensuring nasal cannulas and nebulizer masks were stored properly when not in use.Review of the facility's undated policy titled Oxygen Administration did not address storage of oxygen tubing or nebulizer masks when not in use.

Based on observations, interviews, and record reviews, the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 3 of 5 residents (Resident #2, Resident #3, and Resident #6) reviewed for bed rail consents. 1. The facility failed to obtain informed consent, or maintain evidence that, Resident #2 and Resident #3 or their representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails.2. The facility failed to obtain informed consent from Resident #6 when bed rails were installed on his bed. Informed consent was obtained 17 days after bed rail safety evaluation was performed and 23 days after physician order was obtained. This failure could place residents at risk of not being able to make an informed decision due to not having sufficient information on the risks of bed rail usage.Findings included:1. Record review of Resident #2's electronic face sheet, dated 03/18/2026, reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness or immobility following a stroke), and muscle weakness, Record review of Resident #2's quarterly MDS assessment, dated 03/04/2026, reflected a BIMS score of 14 indicating she was cognitively intact. Further review reflected Resident #2 required a helper to do more than half of the effort for bed mobility and transferring from the bed to a chair. And bed rail was not used as a physical restraint.Record review of Resident #2's comprehensive care plan reviewed on 03/17/2026 reflected no evidence that Resident #3 utilized a bed rail.Record review of Resident #2's electronic physician orders on 03/17/2026 reflected no evidence the physician had ordered the bed rail.Record review of Resident #2's electronic medical record reflected a Bed Rail Safety Evaluation, dated 03/11/2026, for bed side rails that reflected IDT Recommendation: Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail. During an observation and interview on 03/17/2026 at 11:04 a.m., Resident #2 was lying in her bed in her room. The bed had quarter rails to both sides. Resident #2 stated she used the rails to help with turning in the bed. She stated she wanted to continue to have the rails on her bed. She could not state the risks of having the rails on the bed. During an interview on 03/18/2026 at 4:25 p.m., RN C stated she worked in the facility since August of 2025. She stated she was not sure when Resident #2 had bed rails placed on her bed, but thought that they had been present since she had been taking care of Resident #2. She stated it was the nurse's responsibility to obtain orders for bed rails and to obtain a consent for bed rails prior to bed rails being placed on the beds. She stated she did not know who would be responsible for obtaining the consent or order for Resident #2 because she did not initiate the bed rails being placed. She stated Resident #2 used the rails to help with turning in the bed and the rails were not to restrict Resident #2 in anyway. During an interview on 03/18/2026 at 4:28 p.m., CNA D stated Resident #2 required two people to help with bed mobility. She stated she did not know how long Resident #2 had bed rails on her bed. She stated the rails were used when the resident was turning in the bed and were not to restrict Resident #2's mobility in any way. During an interview on 03/18/2026 at 4:40 p.m., LVN E stated she had done an audit for residents with bed rails on 03/11/2026 and had performed the bed rail safety evaluation for Resident #2. She stated there should be a physician order for the bed rails and a consent for the bed rails. She stated she was unsure why there was no physician order for the bed rails or no consent for the bed rails. She stated those must have been missed during the audit. Record review of Resident #3's electronic face sheet, dated 03/18/2026, reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses including dementia (loss of memory, thinking, and reasoning skills), muscle weakness, need for assistance with personal care, and unsteadiness on feet.Record review of Resident #3's quarterly MDS assessment, dated 01/26/2026, reflected a BIMS score of 0 indicating severe cognitive impairment. Further review reflected Resident #3 required helper to do less than half the effort for bed mobility and was dependent on helper for transferring from bed to chair. And bed rail was not used as a physical restraint.Record review of Resident #3's comprehensive care plan reviewed on 03/17/2026 reflected no evidence that Resident #3 utilized a bed rail.Record review of Resident #3's electronic physician orders on 03/17/2026 reflected no evidence the physician had ordered the bed rail.Record review of Resident #3's electronic medical record reflected a Bed Rail Safety Evaluation, dated 03/12/2026, for bed side rails that reflected IDT Recommendation: Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail.During an observation on 03/17/2026 at 10:08 a.m., Resident #3 was lying in her bed with her eyes closed. There was a quarter rail on the right side of the bed. During a telephone interview on 03/18/2026 at 9:58 a.m., Resident #3's representative stated he had no concerns about the care she received at the facility. He did not know when she had bed rails placed on her bed. He could not remember if he had signed a consent for the rail to be put on her bed.2. Record review of Resident #6's electronic face sheet, dated 03/18/2026, reflected a [AGE] year-old male who was admitted on [DATE] with diagnosis including acquired absence of right leg below knee (right leg amputation below the knee).Record review of Resident #6's admission MDS assessment, dated 02/21/2026, reflected a BIMS score of 15 indicating his cognition was intact. Further review reflected Resident #6 required helper to do less than half the effort for bed mobility and required helper to do more than half of the effort for transferring from bed to chair. And bed rail was not used as a physical restraint.Record review of Resident #6's comprehensive care plan, dated 02/23/2026, Resident #6 had ADL self-care performance deficit r/t recent hospitalization, right BKA (below the knee amputation), and neuropathy (disorder of the nerves affecting feeling in extremities) with intervention SIDE RAILS: Mobility rails per MD order.Record review of Resident #6's electronic physician orders on 03/18/2026 reflected order, dated 02/19/2026, Resident #6 May use mobility bars to aide in easy turning and repositioning while in bed.Record review of Resident #6's electronic medical record reflected a Bed Rail Safety Evaluation, dated 02/24/2026, for assist bars that reflected IDT Recommendation: Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail. Further review of medical record reflected a bed side rail consent was obtained and signed by Resident #6 on 03/14/2026 with the following possible dangers Suffocation.Bed side rail land in bed entrapment.Bed side rail and off bed entrapment.Increased potential of injury due to fall from crawling over the top of bed side rails or out the end of bed over the footboard.Each of these situations sited above have been known to cause injury or even death.During an observation and interview on 03/17/2026 at 2:30 p.m., Resident #6 was sitting in a wheelchair in his room. He had a side rail on the right side of his bed. Resident #6 stated that he used the rail to help him get out of the bed and to help him move while in the bed. During an interview on 03/19/2026 at 9:42 a.m., LVN A stated Resident #6 used the bed rail for mobility. She stated he used to help him in the bed and transfer out of the bed. She stated there should be a consent obtained when bed rail was placed on the bed, and the admissions nurse was responsible for getting informed consent. She stated the ADON monitored that the consent was obtained. During an interview on 03/19/2026 at 10:30 a.m., the DON stated the consent for mobility bars on the bed should not be obtained prior to installation. She stated the bars needed to be installed so that an assessment could be performed then the consent would be obtained if it was determined by the IDT that the bars were appropriate. She stated the nurse manager LVN E had done a bed rail sweep a week ago, and performed the safety assessments at that time, but did not look for consents or orders. She stated she was responsible for making sure consents were obtained and would pull a report on physicians' orders to do so. She stated, since some of the residents who utilized mobility bars did not have a physician order for them, she did not catch that the consent was not in their chart. She stated she believed the residents and their representatives had been informed of the risks, but did not have the consent for Resident #2 or Resident #3 prior to 03/18/2026. She stated the consent should have been obtained sooner for Resident #6. She did not know when Resident #2 or Resident #3's mobility bars had been installed on their beds, but stated she did not believe they had them very long. She stated the nurses were responsible for obtaining the consent and she did not know why the consents were not obtained. She stated the facility did not use the rails to decrease mobility and they were to help residents move more.Record review of the facility's policy titled Bed Rail, no date, reflected Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized patient assessment using an interdisciplinary team with input from the Resident and/or the Residents representative. PROCEDURES: Resident Assessment 1. Residents will be assessed for the use of bed side rails upon admission, quarterly, annually and with a change of condition that may warrant the use of bed rails. 2. The Interdisciplinary Team (IDT) will review the resident's individualized patient assessment and will make recommendations for the use or to discontinue the use of bed rails. 3. Bed Rails are to be placed on bed for completion of assessment. 4. The Risk and benefits will be explained to the resident and/or their representative and informed consent will be obtained when assessment has been completed and the need for bed rails has been deemed appropriate. 5. When bed rail use has been deemed appropriate following assessment for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan.

Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for reviewed food and nutrition services.The facility failed to adhere to their policy for acceptable serving temperatures on 03/17/26.This failure could place residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.Findings included:In an observation on 03/17/26 at 12:10 PM, the Meal Cart for the 100-hall left the kitchen into the 100-hall. The last tray was observed to be served by staff into their room at 12:23 PM. All sample trays were tested for temperature and all meal entrees were under the serving temperature per facility policy. All trays were in transported in a meal cart with the plate covering on. On 03/17/26 at 12:25 PM, the Food Sample Trays tested at the following: Mechanical diet- 114 F Steak Fritters, 118 F [NAME] Beans, and 111 F Red Potatoes; Regular diet- 130 F Steak Fritters, 115 F [NAME] Beans, and 117 F Red Potatoes; Puree diet- 117 F Steak Fritters, 114 F Mashed Potatoes, and 113 F [NAME] Beans.In a confidential resident group meeting on 03/18/26 at 9:30 AM, 6 of 12 residents reported they were not satisfied with the meals provided by the facility. They stated the meals would be cold when received in their rooms, and the appearance was not appealing. They stated these concerns had been reported to staff before.In an interview on 03/19/26 at 9:11 AM with Dietary Aide G, she stated the [NAME] was responsible for the meal temperatures and she monitored all meal entrees twice before serving. She stated cold food and low food temperatures could cause the residents to be upset. She stated other risks of low food temperatures would include potential for illness.In an interview on 03/19/26 at 10:27 AM with the Assistant Dietary Manager, she stated she was also the [NAME] on the weekdays and as needed. She stated she was responsible for the food serving temperatures and monitored them before serving for each meal service. She stated the meal serving temperatures were to be at least 145 F. The Dietary Assistant Manager stated the risks of below serving temperatures for residents included not wanting to eat since it could be unpleasant to eat, stomach aches, or foodborne illnesses.In an interview on 03/19/26 at 10:40 AM with the Dietary Manager, she stated meal serving temperatures were to be 145F or above. She stated none of the test trays met the temperature of 145F or above for hot foods. She stated the cook was responsible for ensuring the food temperatures were 145F and above. She stated the cook monitored the temperatures before serving every meal. She stated the risks of the meal tray temperatures being below 145F included the residents being upset and complaints of their food. She stated other risks to residents included illness and bacteria, depending on the meal entrees such as meat.Record review of facility's Infection Control Policy/Procedure with no date, titled Dietary Department, read in part under Food Preparation and Serving . 3. hot foods must be kept at 140F or above.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in the facility.1.The facility failed to date a tray of covered cups of milk and fruit cups on 03/17/26.2. The facility failed to keep 2 boxes of Vanilla pudding cups off the floor in the walk-in pantry on 03/17/26.3. The facility failed to ensure the steam table was clean and free from food particles on 03/17/26.4. The facility failed to ensure cookware was properly rinsed and sanitized in adherence to professional standards for food service safety on 03/17/26.These failures could place residents at risk of food-borne illnesses.Findings include:During the brief initial kitchen interview on 03/17/26 at 8:55 AM, the following observations were made: a serving tray with multiple cups of milk covered with plastic wrapping, 3 small bowls of served fruit covered with plastic wrapping, and a cup of gelatin, located in the walk-in refrigerator, was not dated; 2 boxes of Vanilla puddings on the floor in the walk-in pantry. On 03/17/26 at 10:55 AM, the steam table was observed with food particles and brown debris in the metal compartments in the water of the steamtable.In an interview on 03/19/26 at 8:57 AM with Dietary Aide G, she stated that the [NAME] was responsible for cleaning and maintaining the cleanliness of the steamtable. She stated the Dietary Manager was responsible for monitoring the kitchen cleanliness which was done daily. She stated that the Vanilla pudding cups observed on the pantry floor on 03/17/26, was for medical, as the nursing staff used the pudding cups as needed when passing crushed medications. She stated that all staff were responsible for ensuring no food items were on the floor. She stated that the risks of food items being on the floor included contamination and possible risk of illness to residents. Dietary Aide G stated that all staff were responsible for ensuring all food items were labeled. She stated the kitchen staff preparing the tray would be responsible for ensuring it had the date its was served. She stated the Dietary Manager walked through and monitored the kitchen every morning. She stated the risk of not dating served drinks or food included the risk of mold or bacteria, causing illness. She stated dietary aides were responsible for ensuring the sanitation levels were per policy, or the cook if they were washing their cooking utensils, pots, or pans. She stated that if the sanitation levels were below policy, that would mean the dishes were not being cleaned or sanitized correctly. She stated that could place residents at risk for bacteria and illness.In an interview on 03/19/26 at 10:16 AM with the Assistant Dietary Manager, she stated the dietary aides were responsible for dating serving trays with cups and food. She stated it should have the 3-day date meaning the food and drinks on the tray were to be discarded after 3 days of being served. She stated the vanilla pudding cups were not to be on the floor. She stated the pudding cups were for the medical staff as they used the pudding cups for medication administration. She stated that all staff were responsible for ensuring and removing food items off the floor. She stated possible risks of food items on the floor included contamination such as chemical leaks, or rodents, which can cause the residents to become sick. The Assistant Dietary Manager stated the steam table was to be clean, before and after serving meals. She stated that the heat and water cause corrosion (process of gradual deteriotion of metal) causing a brown debris to be observed. She stated she did not think there was a risk to the residents of staff using the steamtable with the observed food particles as the serving trays cover the compartments. She stated that the dishwasher and the [NAME] were responsible for monitoring and confirming the sanitation levels before washing any dishes when cooking. She stated the dishwasher was not monitored for sanitation levels but was reported for issues or concerns. She stated she was not aware of any issues with the dishwasher before 03/17/26, which resulted being a leak in a hose which was repaired by Maintenance that day. She stated the risk of the dishwasher not being at the sanitation levels to residents included illness as the dishes or utensils were not sanitized correctly.In an interview on 03/19/26 at 10:31 AM with the Dietary Manager, she stated the dietary aides who prepped the trays with drinks and food were responsible for dating them. She stated a 3-day date of the date it was prepped was also notated on the tray, meaning after 3 days of the drinks and food was to be discarded after it was prepared. She stated she monitored the kitchen daily including trays ensuring they were dated. She stated the potential risks of not dating trays of food and drinks included spoilage and illness. The Dietary Manager stated the boxes of Vanilla puddings on the floor was not acceptable and all kitchen staff were responsible for ensuring all food items were stored off the floor and on the shelves. She said the potential risk of food items on the floor included rodents or roaches getting in the food, causing contamination. She stated the steam table was to be cleaned by the Cooks. She stated if the water from the steam table was observed with food particles or dirty, it was to be cleaned and changed. She stated the potential risk of serving food with the dirty steam table included possible contamination. She stated all staff were responsible for monitoring the dishwasher chemical levels. She stated it was checked daily before use. She stated the potential risk of the dishwasher not meeting the sanitation level was infection control since the plates and utensils were not being sanitized properly.Record review of the facility's Infection Control Policy/Procedure, with no date, read in part: Food Preparation and Serving: 1. All equipment must be cleaned and sanitized before use. It continued Storage of Food: 2. Store food above floor level and away from wall. It continued to read Equipment Care and Storage: 1. Keep all work areas, the floor and dietary equipment as clean as possible throughout the work day.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Resident #2 and Resident #3) reviewed for care plans. The facility failed to ensure Resident #2, and Resident #3 had a care plan in place for bed rails. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Findings included:1. Record review of Resident #2's electronic face sheet, dated 03/18/2026, reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness or immobility following a stroke), and muscle weakness, Record review of Resident #2's quarterly MDS assessment, dated 03/04/2026, reflected a BIMS score of 14 indicating her cognition was intact. Further review reflected Resident #2 required a helper to do more than half of the effort for bed mobility and transferring from the bed to a chair. Bed rails were not identified as being used as a physical restraint.Record review of Resident #2's comprehensive care plan reviewed on 03/17/2026 reflected no evidence that Resident #3 utilized a bed rail.Record review of Resident #2's electronic physician orders on 03/17/2026 reflected no evidence the physician had ordered the bed rail.Record review of Resident #2's electronic medical record reflected a Bed Rail Safety Evaluation, dated 03/11/2026, for bed side rails that reflected IDT Recommendation: Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail. During an observation and interview on 03/17/2026 at 11:04 a.m., Resident #2 was lying in her bed in her room. The bed had quarter rails to both sides. Resident #2 stated she used the rails to help with turning in the bed. She stated she wanted to continue to have the rails on her bed.2. Record review of Resident #3's electronic face sheet, dated 03/18/2026, reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses including dementia (loss of memory, thinking, and reasoning skills), muscle weakness, need for assistance with personal care, and unsteadiness on feet.Record review of Resident #3's quarterly MDS assessment, dated 01/26/2026, reflected a BIMS score of 0 indicating severe cognitive impairment. Further review reflected Resident #3 required helper to do less than half the effort for bed mobility and was dependent on helper for transferring from bed to chair. And bed rail was not used as a physical restraint.Record review of Resident #3's comprehensive care plan reviewed on 03/17/2026 reflected no evidence that Resident #3 utilized a bed rail.Record review of Resident #3's electronic physician orders on 03/17/2026 reflected no evidence the physician had ordered the bed rail.Record review of Resident #3's electronic medical record reflected a Bed Rail Safety Evaluation, dated 03/12/2026, for bed side rails that reflected IDT Recommendation: Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail.During an observation on 03/17/2026 at 10:08 a.m., Resident #3 was lying in her bed with her eyes closed. There was a quarter rail on the right side of the bed. During a telephone interview on 03/18/2026 at 9:58 a.m., Resident #3's representative stated he had no concerns about the care she received at the facility.During an interview on 03/18/2026 at 4:25 p.m., RN C stated she had worked in the facility since August of 2025. She stated she was not sure when Resident #2 had bed rails placed on her bed but thought that they had been present since she had been taking care of Resident #2. She stated she did look at care plans, but did not update the care plan. She stated she did not know for sure but thought the ADON and the DON updated the care plans. She stated not having an intervention in the care plan may cause direct care staff, including herself, from knowing the resident utilized bed rails, but she mostly looked in physician orders to see what care was needed. During an interview on 03/19/2026 at 9:42 a.m., LVN A stated Resident #6 used the bed rail for mobility. She stated he used to help him in the bed and transfer out of the bed. She stated bed rails should be on the care plan, but she mainly looked at physician orders to see what care the resident needed. She stated the ADON and the DON were responsible for updating care plans. During an interview on 03/19/2026 at 10:30 a.m., the DON stated bed rails should be included on residents' care plans. She stated care plans were updated by the IDT members during the morning management meetings for new orders and the weekly management meetings for existing orders. She stated the management would pull physician orders to review the needs of the residents, and not having a physician order may have been how the bed rails were not added to the care plans. She stated care plans should reflect the care for residents, and the nursing staff could review to see the residents care needs. She did not state a negative effect for the residents from the mobility bed bars not being listed on the care plan. She stated the bars were used to increase mobility and that was why they were not coded as a restraint on the MDS assessment. Record review of the facility's undated policy titled Bed Rail, reflected When bed rail use has been deemed appropriate following assessment for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan. Record review of the facility's policy titled Comprehensive Person-Centered Care Planning, dated December 2023, reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. 7. The facility IDT includes, but is not limited to the following professionals: A. Attending Physician or Non-Physician Practitioner (NPP) designee involved in resident's care; B. Registered Nurse with responsibility for the resident; C. Nurse Aide with responsibility for the resident; D. Member of the Food and Nutrition services staff; E. To the extent practicable, resident and/or resident representative; d F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

Based on interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on dementia management for all new and existing staff for 1 of 18 (CNA F) staff reviewed for dementia management. The facility failed to ensure CNA F was educated on dementia management upon hire. This failure could place residents with dementia diagnosis at risk of being inappropriately cared for by uninformed staff. Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by HR reflected CNA F had no evidence she had completed the dementia management training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to have appropriate training per regulations. She stated the facility did not have a training policy and went by regulations for staff orientation and annual training. She stated she was sure she had done an in-service on the training but could not find one with CNA F's signature on it. She stated the facility utilized CBT program for training as well and that showed no evidence that CNA F had completed training for dementia management. She stated staff should have all appropriate training and did not know why CNA F had not completed the CBT. She stated she was responsible for making sure all staff were trained and stated training was to inform staff about dementia management. She confirmed that HR monitored staff training as well but she was ultimately responsible for staff being trained. She stated she had no concerns with how CNA F provided resident care since her hire date.During an interview on 03/19/2026 at 2:10 p.m., HR stated she was responsible for making sure facility staff were trained on the CBT program. She stated she was new to her position and that may have led to her not noticing CNA F did not complete the dementia care training. She stated that at the end of the year, the program would drop all of the trainings that had not been completed and that could be why she missed the training. She confirmed she had no evidence that CNA F had training on dementia care. She stated there was no evidence CNA F had completed the training before her hire date of 12/30/2025 because she had quit and was rehired, so CNA F had the training in the past. She stated she was learning how to ensure staff had all required training. Record review of facility's Facility Assessment, dated 2025, reflected Resident Population Profile.Common Diagnoses and Conditions.Alzheimer's disease (a type of dementia that causes memory, thinking, and behavioral issues).Staff training/ education and competencies Our facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for our resident population.Our facility has identified the following training topics that may be utilized by our staff including.direct care staff.Abuse, neglect, and exploitation: training that, at a minimum, educates staff regarding: Care/management for persons with dementia and resident abuse prevention.Required in-service training for nurse aides. In-service training must: Include dementia management training and resident abuse prevention training.A list of training and competency resources are available in the [CBT program] to provide just-in-time training for various care and assessment activities as well as competency validation.

Based on interviews and record review, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 1 of 18 (CNA F) staff reviewed for training on QAPI. The facility failed to ensure CNA F was educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by the HR reflected CNA F had no evidence she had completed QAPI training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to have appropriate training per regulations. She stated the facility did not have a training policy and went by regulations for staff orientation and annual training. She stated she was sure she had done an in-service on the training but could not find one with CNA F's signature on it. She stated the facility utilized CBT program for training as well and that showed no evidence that CNA F had completed training for QAPI. She stated staff should have all appropriate training and did not know why CNA F had not completed the CBT. She stated she was responsible for making sure all staff were trained and stated training was to inform staff about the QAPI program. She confirmed that HR monitored staff training as well but she was ultimately responsible for staff being trained. She stated she had no concerns with how CNA F provided resident care since her hire date.During an interview on 03/19/2026 at 2:10 p.m., the HR stated she was responsible for making sure facility staff were trained on the CBT program. She stated she was new to her position and that may have led to her not noticing CNA F did not complete the QAPI training. She stated that at the end of the year, the program would drop all of the trainings that had not been completed and that could be why she missed the training. She confirmed she had no evidence that CNA F had training on QAPI. She stated there was no evidence CNA F had completed the training before her hire date of 12/30/2025 due to she had quit and was rehired, so CNA F had the training in the past. She stated she was learning how to ensure staff had all required training. Record review of facility's Facility Assessment, dated 2025, reflected Our facility has identified the following training topics that may be utilized by our staff including.direct care staff.Quality Assurance Performance Improvement (QAPI).A list of training and competency resources are available in the [CBT program] to provide just-in-time training for various care and assessment activities as well as competency validation.

Based on interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 1 of 18 (CNA F) reviewed for training on compliance and ethics.The facility failed to ensure that CNA F was educated on compliance and ethics upon hire.This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by the HR reflected CNA F had no evidence she had completed compliance and ethics training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to have appropriate training per regulations. She stated the facility did not have a training policy and went by regulations for staff orientation and annual training. She stated she was sure she had done an in-service on the training but could not find one with CNA F's signature on it. She stated the facility utilized CBT program for training as well and that showed no evidence that CNA F had completed training for compliance and ethics. She stated staff should have all appropriate training and did not know why CNA F had not completed the CBT. She stated she was responsible for making sure all staff were trained and stated training was to inform staff about compliance and ethics for organizations who operate five or more facilities. She stated her organization operated more than five facilities and that compliance and ethics was appropriate for the facility's staff. She confirmed that HR monitored staff training as well but she was ultimately responsible for staff being trained.During an interview on 03/19/2026 at 2:10 p.m., the HR stated she was responsible for making sure facility staff were trained on the CBT program. She stated she was new to her position and that may have led to her not noticing CNA F did not complete the compliance and ethics training. She stated that at the end of the year, the program would drop all of the trainings that had not been completed and that could be why she missed the training. She confirmed she had no evidence that CNA F had training on compliance and ethics. She stated she was learning how to ensure staff had all required training. Record review of facility's Facility Assessment, dated 2025, reflected Our facility has identified the following training topics that may be utilized by our staff including.direct care staff. There was no mention of compliance and ethics training.

Based on interviews, and record reviews, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 5 residents (Resident #312) reviewed for grievances. The facility failed to ensure a grievance was completed for Resident #312's complaint of LVN A. This failure could place residents at risk for not having their grievances resolved. The findings included: Record review of Resident #312's electronic face sheet indicated a [AGE] year-old female, who was initially admitted to the facility on [DATE] with a current admission date of 05/31/25. Resident #312's medical diagnoses included dementia, asthma, weakness, chronic kidney disease, stage 4 severe, pressure ulcer on left buttock, difficulty swallowing, type 2 diabetes mellitus, Parkinson's disease, heart failure, anemia, high blood cholesterol, high blood pressure, gout, cognitive communication deficit, and nausea with vomiting. Record review of Resident #312's quarterly MDS assessment, dated 05/18/25, Section C - Cognitive Patterns, subsection C0500. BIMS Summary Score was not completed. Subsection C0600 - Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted? 1. Yes (resident was unable to complete Brief Interview of Mental Status) - Continue to C0700 Short-Term Memory OK was entered. Subsection 0700. Short-term Memory OK 1. Memory problem was entered. Subsection C0800. Long-term Memory OK 1. Memory problem was entered. Subsection C0900. Memory/Recall Ability B. Location of own room and D. That they are in a nursing home/hospital swing bed were entered. Subsection C1000. Cognitive Skills for Daily Decision Making 2. Modified independence - some difficulty in new situations only was entered. Record review of Resident #312's care plan revised on 05/08/25 indicated Resident #312 had an actual impairment to her skin integrity to the unstageable of Left Gluteal Fold/Interior Ischial Tuberosity (a large bone commonly referred to as sit bone protected by the gluteus maximus or buttock). Interventions included Cleanse wound with wound cleanser, pat dry, apply [medical honey], cover with border dressing 3x (times) weekly and PRN, Record review of Resident #312's physician's orders dated 05/08/25, indicated, Cleanse wound on Left interior ischial tuberosity with wound cleanser, pat dry then skin prep, apply [medical honey], cover with Border foam. 3 times weekly and as needed. Record review of Resident #312's electronic treatment record for May 2025 revealed the dressing change was performed every Monday, Wednesday, and Friday as ordered. During an interview on 05/31/2025 at 06:30 PM, the Administrator stated she was not sure what the grievance policy was and if it was different from the previous state she had come from. She stated after a conversation with Resident #312's family member on Friday (05/30/25) she did not complete a grievance form or begin investigating staff because the family member stated she was going to call State. The DON stated she did not remember the family member saying she did not want LVN A to work with her family. She remembered the family member making comments such as she did not like LVN A and was disappointed in the care, but the DON did not think that warranted an investigation. The DON stated the Administrator was responsible for monitoring the grievance procedure. During an interview on 06/03/25 at 10:43 AM, the Marketer stated the family member told the Marketer that her family members residing in the facility were being neglected by LVN A. The Marketer stated the family member and LVN A did not get along. The family member told the Marketer on 05/29/25 that she met with the DON and requested LVN A not provide care to her family members anymore. The Marketer could not recall the DON stating when the meeting was or the DON's response to the family member's request. The Marketer stated the family member did not state any other staff member names during the conversation. The Marketer stated she reported the family member's concern to the Administrator. During an interview on 06/03/25 at 12:18 PM, the family member stated she blamed LVN A for the Resident #312's wound and decline. The family member did not explain why she blamed LVN A. The family member reported her grievance verbally to the Marketer who then reported to the Administrator. During a follow-up interview on 06/05/25 at 02:23 PM, the Marketer clarified the date and time she reported the allegation of neglect to the Administrator. She explained during the visit to the hospital Resident #312's family member stated [the facility] neglected my [Resident #312]and continues to neglect my [Resident #312]. The Marketer stated she called the Administrator right away. Review of a screenshot of the call revealed the call was made at 05/07/25 at 04:17 PM. During a follow-up interview on 06/06/25 at 09:16 AM, the family member confirmed the date, approximate time, and conversation she had with the Marketer at the hospital. She stated she was angry about the situation. The family member stated she did not feel LVN A performed dressing changes on her family member's pressure ulcer as ordered causing the wound to worsen. During an interview on 06/06/25 at 09:43 AM, the Administrator stated she would have started the grievance process immediately if the grievance was about alleged abuse or neglect. During an interview on 06/06/25 at 10:08 AM, the DON stated she did not recall knowing about the Administrator being notified of the family member's concerns on 05/27/25. She stated the timeframe to report a grievance was immediately and it was the Administrator's responsibility to report to State if necessary. Review of facility policy titled Grievances, revised 11/23/2016 revealed under Procedures: 1. The facility's grievance official is responsible for overseeing the grievance process, receiving, and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. 2. Resident and/or Resident Representatives have the right to file grievances orally or in writing, the right to file grievances anonymously, and obtain a written decision regarding his or her grievance as requested. Copies of the Grievance Resolution Forms are available from the Social Services Designee or Grievance official and at the nursing stations. These forms are to be initiated when concerns are made. 4. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated.

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 5 residents (Resident #312) reviewed for developing and implementing neglect policies. The facility failed to follow its policy to investigate and report to the Texas Health and Human Services Commission (HHSC) when Resident #312's family member alleged that LVN A neglected Resident #312. This failure could place residents at risk of not having allegations thoroughly investigated per policy. Findings included: Record review of Resident #312's electronic face sheet indicated a [AGE] year-old female, who was initially admitted to the facility on [DATE] with a current admission date of 05/31/25. Resident #312's medical diagnoses included dementia, asthma, weakness, chronic kidney disease, stage 4 severe, pressure ulcer on left buttock, difficulty swallowing, type 2 diabetes mellitus, Parkinson's disease, heart failure, anemia, high blood cholesterol, high blood pressure, gout, cognitive communication deficit, and nausea with vomiting. Record review of Resident #312's quarterly MDS assessment, dated 05/18/25, section C - Cognitive Patterns, subsection C0500. BIMS Summary Score was not completed. Subsection C0600 - Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted? 1. Yes (resident was unable to complete Brief Interview of Mental Status) - Continue to C0700 Short-Term Memory OK was entered. Subsection 0700. Short-term Memory OK 1. Memory problem was entered. Subsection C0800. Long-term Memory OK 1. Memory problem was entered. Subsection C0900. Memory/Recall Ability B. Location of own room and D. That they are in a nursing home/hospital swing bed were entered. Subsection C1000. Cognitive Skills for Daily Decision Making 2. Modified independence - some difficulty in new situations only was entered. Record review of Resident #312's care plan revised on 05/08/25 indicated Resident #312 had an actual impairment to her skin integrity to the unstageable of Left Gluteal Fold/Interior Ischial Tuberosity (a large bone commonly referred to as sit bone protected by the gluteus maximus or buttock). Interventions included Cleanse wound with wound cleanser, pat dry, apply [medical honey], cover with border dressing 3x (times) weekly and PRN, Record review of Resident #312's physician's orders dated 05/08/25, indicated, Cleanse wound on Left interior ischial tuberosity with wound cleanser, pat dry then skin prep, apply [medical honey], cover with Border foam. 3times weekly and as needed. Record review of Resident #312's electronic treatment record for May 2025 revealed the dressing change was performed every Monday, Wednesday, and Friday as ordered. During a phone interview on 06/03/25 at 01:03 PM, Resident #12's primary physician stated the resident had a fall and hit her head in April which he attributed to the resident's decline. He stated when the wound developed, he wanted to send the resident to the local wound care clinic. The physician stated the family declined due to the resident's status. He stated the family told him the wound care could be done in the facility. The physician stated his assessment revealed a necrotic wound (a wound containing dead tissue), no evidence of infection, no tunneling (formation of channels or tunnels under the skin extending from the main wound to deeper tissues), no abscesses. He stated he did not feel the resident had been neglected. During an interview on 06/03/25 at 10:43 AM, the Marketer stated the family member told the Marketer that her family members residing in the facility were being neglected by LVN A. The Marketer stated the family member and LVN A did not get along. The family member told the Marketer she met with the DON and requested LVN A not provide care to her family members anymore. The Marketer could not recall the DON stating when the meeting was or the DON's response to the family member's request. The Marketer stated the family member did not state any other staff member names during the conversation. The Marketer stated she reported the family member's concern to the Administrator via phone call. During a phone interview on 06/03/25 at 12:38 PM, the wound care specialist stated services began on 04/22/25. He stated on 05/13/25 the wound was looking better, necrotic tissue had improved, and the surface area of the wound had decreased. He stated LVN A, the facility treatment nurse, was very involved in resident's care. He stated he had every confidence in her ability to manage the wounds in the facility. During an interview on 06/03/25 at 12:18 PM, the Resident #312's family member stated she was still angry about the wound. She stated she blamed LVN A for Resident #312's wound and decline. The family member did not explain why she blamed LVN A. During a follow-up interview on 06/05/25 at 02:23 PM, the Marketer clarified the date and time she reported the allegation of neglect to the Administrator. She explained during the visit to the hospital Resident #312's family member stated [the facility] neglected my [Resident #312]and continues to neglect my [Resident 312]. The Marketer stated she called the Administrator right away. Review of a screenshot of the call revealed the call was made at 05/07/25 at 04:17 PM. During a follow-up interview on 06/06/25 at 09:16 AM, the family member confirmed the date, approximate time, and conversation she had with the Marketer at the hospital. She stated she was angry about the situation. The family member stated she did not feel LVN A performed dressing changes on her family member's pressure ulcer as ordered causing the wound to worsen. During an interview on 06/06/25 at 09:43 AM, the Administrator stated she was the Abuse Coordinator. She stated her expectations of staff reporting abuse, neglect or exploitation was for staff to report any suspected or witnessed ANE immediately. She explained, once reported, her first action was to ensure resident safety, then report to State and begin an investigation. She stated the timeline to report to State was within 2 hours of being aware of the situation. The Administrator stated the failure to report could be due to staff making a judgement call and deciding to not report to her. She explained she did not feel in this instance that an error was made due to the report made to her on 05/27/25 only stated that family member was angry. She stated she remembered being told the family member was upset, especially at LVN A. She stated she felt that she would have started the investigation and reporting process per the facility policy immediately if the report stated abuse or neglect was alleged. The Administrator stated consequences to a resident or residents of staff failing to report, or administration failing to report and investigate an allegation, would be based on the situation. The Administrator stated ANE training was done at least annually for all staff members, in-services were conducted after an incident involving ANE, and ANE was discussed at all staff meetings. She stated she was ultimately the person responsible for monitoring that staff was in compliance with training requirements. During an interview on 06/06/25 at 10:08 AM, the DON stated she did not recall knowing about the Administrator being notified of the family member's concerns on 05/27/25. She stated her expectations of reporting suspected or witnessed ANE was for a report be made to herself and the Administrator/Abuse Coordinator. She stated if report was made to her, she would tell the reporter to contact the Administrator then follow up to make sure the Administrator was notified. The DON explained failure by the facility to report an allegation of ANE was because it was her understanding that the complaint involved a family member blaming LVN A for her family member's wound and subsequent admission to the hospital. She stated the words abuse and/or neglect were not used. She stated the family member was upset about the whole situation. The DON stated she was notified that the family member was going to report to State. She stated the timeframe to report an incident was immediately and it was the Administrator's responsibility to report to State. The DON explained the consequences to a resident or residents of failing to report would be a problem because staff was frequently trained on reporting. She stated training consisted of reviewing the policy during every staff meeting, reminders of who the Abuse Coordinator was, routine face-to-face and written in-services and online training. She stated training compliance was monitored by corporate. The DON stated a report was sent by corporate to HR twice a month listing training modules due. She stated nursing staff out of compliance was taken off the schedule until training was up to date. Review of facility policy titled Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, reviewed/revised 12/2023 revealed under Definitions: Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) required but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Under Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately but: . Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. 2. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. b. The State Survey Agency. 6. Guidelines for Facility Compliance: In order to comply with the Facility's obligations as set forth in 42 CFR 483.12, it will: e. Conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of the residents for 1 of 1 medication room and 1 of 3 (treatment cart) medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure 1 vancomycin IV bag (antibiotic medication in bag for IV) had been removed from the medication room when it had expired on December 2024. 2. The facility failed to ensure 6 boxes of lancets (needles used to obtain small blood samples) were removed from the medication room when they had expired on or after 08/27/2020. 3. The facility failed to ensure 12 IV start kits (used to start IVs) were removed from the medication room when they had expired on 12/10/2024. 4. The facility failed to ensure 8 packages of lubricating jelly (used for lubrication) were removed from the medication room when they had expired on 12/02/2024. 5. The facility failed to ensure 1 tube of Anasept gel (topical solution that fights bacteria and treats or prevents infections) were removed from the treatment cart when they had expired on 11/01/2024. 6. The facility failed to ensure 1 container of packing iodoform strip (medical dressings made of gauze impregnated with iodoform with antibacterial properties) were removed from the treatment cart when they had expired on 06/2024. These failures could place residents at risk of not receiving the therapeutic benefit of medications and biologicals used for testing and treatment of residents. Findings included: During an observation of the treatment cart on 01/15/2025 at 7:07 a.m. revealed: 1. 1 container of expired Anasept gel (topical solution that fights bacteria and treats or prevents infections) expired on 11/01/2024. 2. 1 container of expired packing iodoform strip (medical dressings made of gauze impregnated with iodoform with antibacterial properties) expired on 06/2024. During an interview on 01/15/2025 at 7:07 a.m., LVN H stated both the Anasept gel (topical solution that fights bacteria and treats or prevents infections) and packing iodoform strip (medical dressings made of gauze impregnated with iodoform with antibacterial properties) should have been removed from the treatment cart when they expired. She stated she was not aware prior to today that those items were expired because she did not use them to treat any residents at this time. She stated those items not being used during treatments may have led to no one noticing those items needed to be removed. LVN H stated nurses were responsible for removing expired items from treatment cart. During an observation of the medication room on 01/15/2025 at 7:37 a.m. revealed: 1. 1 expired bag of vancomycin IV bag expired on December 2024. 2. 6 boxes of expired lancets expired on or after 08/27/2020. 3. 12 containers of expired IV start kits expired on 12/10/2024. 4. 8 packages of expired lubricating jelly expired on 12/02/2024. During an interview on 01/15/2025 at 8:42 a.m., LVN F stated expired vancomycin (an antibiotic medication) should have been removed from the medication room. She stated using medications after expiration could cause skin or body reaction to the medication. LVN F stated the lancets were used to poke fingers and should be disposed of after they expired. She stated she was unsure of what effect it could cause when using expired lancets but could potentially cause them to become dull. LVN F stated the IV started kits were expired and should have been discarded. She stated she was not sure of the risk to residents if the IV start kits had been used but residents should not be exposed to expired goods. LVN F stated that the lubricating jelly was expired and should have been disposed of. She was unsure of any risk using expired lubricating jelly could have on residents. During an interview on 01/16/2025 at 9:20 a.m., MA E stated she checked the medication room daily and did not know how an expired vancomycin IV bag was found in the medication room. She stated she was responsible for making sure that medications including OTC medications were stocked and not expired. She stated expired IV start kits, lubricating jelly, and lancets should have been discarded. She stated she had been responsible for the medication room for approximately five months and did not know she should look for expired supplies in the medication room. She stated not disposing of medication and supplies could hurt the residents if nurses did not notice the items were expired and used them on residents. During an interview on 01/15/2025 at 9:04 a.m., the ADON stated her expectation would be that expired goods be destroyed and not stored in medication room or on medication carts. She stated MA E was responsible for items stored in medication room and nurses were responsible for treatment carts. She stated she did not know why expired goods were found in the medication room and on treatment cart. During an interview on 01/16/2025 at 12:16 p.m., the DON stated her expectation would be that expired medications and supplies were removed from the treatment cart and medication room. She stated the lead MA was responsible for checking the medication room weekly and nurses and MAs should check the carts daily for expired products. The DON stated the effect of using expired medications or biologicals would be symptoms not being managed or treated by products not being as effective. The DON stated both herself and the ADON performed random audits in the medication room and medication carts and the failure occurred due to oversite. Record review of the facility's policy titled Disposal of Drugs and Supplies with no date revealed: Disposal and or disposition of medications and other drugs is defined as any process by which a substance leaves or is removed from the facility, except for the authorized administration to a patient .Procedures: Ointments, creams, and similar substances are placed in trash receptacles in the medication room. Tablets, capsules, and liquids are washed down the toilet or hopper sink or disposed of in another acceptable manner. The consultant pharmacist is contacted if the facility is unsure of proper disposal methods for a medication. Record review of the facility's policy titled Storage of Medications with no date revealed: Medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.

Based on observations, interviews, and record review the facility failed to ensure the quality of laboratory services in the facility for 1 of 1 medication room reviewed for drugs and biologicals. The facility failed to ensure 2 boxes of COVID testing kits (used for COVID testing) were removed from the medication room when they had expired on 12/15/2023. The facility failed to ensure 1 box and 4 packages of influenza A & B Tests (used for Flu testing) were removed from the medication room when they had expired on 11/30/2024. These failures could place residents at risk of inaccurate testing results. Findings included: During an observation of the medication room on 01/15/2025 at 7:37 a.m. revealed: 1. 2 boxes of expired COVID testing kits expired on 12/15/2023. 2. 1 box and 4 packages of expired influenza A & B testing kits expired on 11/30/2024. During an interview on 01/15/2025 at 8:42 a.m., LVN F stated COVID and influenza tests should be disposed of after they were expired. She stated she did not know why expired test kits were in the medication room. LVN F stated COVID and influenza tests that were expired could cause results to not be accurate. During an interview on 01/16/2025 at 9:20 a.m., MA E stated expired COVID tests and influenza tests should have been discarded. She stated she had been responsible for the medication room for approximately five months and did not know she should look for expired supplies in the medication room. She stated not disposing of supplies could hurt the residents if nurses did not notice the items were expired and used them on residents. During an interview on 01/15/2025 at 9:04 a.m., the ADON stated her expectation would be that expired goods be destroyed and not stored in medication room or on medication carts. She stated MA E was responsible for items stored in medication room. She stated she did not know why expired goods were found in the medication room During an interview on 01/16/2025 at 12:16 p.m., the DON stated her expectation would be that expired supplies were removed from the medication room. She stated the lead MA was responsible for checking the medication room weekly. The DON stated the effect of using expired medications or biologicals would be symptoms not being managed or treated by products not being as effective. The DON stated both herself and the ADON performed random audits in the medication carts and the failure occurred due to oversite. Record review of the facility's policy titled Storage of Medications with no date revealed: Medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. The facility failed to ensure foods in Refrigerator #1, Refrigerator #2, and the freezer were not sealed and/or labeled properly. The facility failed to ensure food that left the kitchen was covered. This failure could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on [DATE] at 10:15 AM of facility kitchen revealed the following: Refrigerator #1: 1 bin of Celery was unlabeled and with no in date and was open to air, and 1 box of Muffins was unsealed and open to air. Refrigerator #2: 1 box of sausage was unsealed and open to air, in refrigerator. Freezer: 1 box of Cannoli was unsealed and open to air. During an observation and interview on [DATE] at 9:07 AM with the DM observed in the refrigerators the open to air product (cannoli's, celery and muffins), as well as the open box and open to air box of sausage. The DM stated the open to air products should be in placed in sealed containers or packages. She stated the possible negative impact for residents could have been cross contamination with residents becoming sick. She stated her expectations were for all products, once received, to have an in date, as well as labeled if needed. The DM stated that she had continuous trainings with her staff on this subject. During observation on [DATE] at 12:24 PM, the hall carts which contained resident trays was observed being transported from the kitchen to the hallways with the cakes being uncovered. During an interview on [DATE] at 12:44 AM the DM stated the desert should have been covered prior to being transported to the hallways. She stated the possibility of cross contamination could have been possible. She stated she monitored the proper transporting of food prior to leaving the kitchen to resident's room. The DM stated her expectations were that all food be covered prior to leaving the kitchen. She stated the failure was with the Dietary staff being in a hurry, as well and thinking since the whole cart was covered, they were in compliance. The DM stated it should have never happened and should have been covered. During an interview on [DATE] at 5:12 PM the Interim ADMN stated the staff should have followed the policies and procedures for dating and labeling all food product where needed. He stated there was a possibility of a negative impact to residents with the potential of getting and consuming expired food which could have been a potential for contamination. The Interim ADMN stated the failure likely occurred from the time of food being delivered and stored. He stated the DM monitored all food coming into the facility. During an interview on [DATE] at 5:30 PM the SW stated, all but 1 resident ate from the kitchen. Record Review of facility's Dietary Services, Food Storage, undated revealed; Policy: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. Procedures:.10. Food products must be labeled and dated. Review of FDA Food Code 2022: Full Document accessed on [DATE] in annex 7 page 37, 38 revealed: Applicable Code Sections: ,d+[DATE].16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done.

Based on observation, interview, and record review, the facility failed implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 (Resident #23, Resident #36, and Resident #65) of 18 residents reviewed for food and nutrition services. 1. The facility failed to ensure that Resident #36's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperature after [DATE]. 2. The facility failed to ensure that Resident #65's personal refrigerator did not have expired goods stored and failed to have a thermometer inside to check temperature. 3. The facility failed to ensure that Resident #23's personal refrigerator had a thermometer inside to check temperature and failed to keep temperature log during the month of [DATE]. These failures could place residents at risk for foodborne illnesses. The findings were: 1.During an observation and interview on [DATE] at 10:21 a.m., Resident # 36 personal refrigerator had temperature log outside of the door. Temperature 42 written on [DATE] a.m. with initials WR. No other temperatures logged during [DATE]. Observed container of whip cream inside of the refrigerator with best when used by 07 [DATE] written on container. Observed container of Ranch dressing inside of the refrigerator with best if used by date which read 14 JUN 24 written on the label. Resident #36 stated she was unaware the items had used by dates that had been exceeded. She stated it was hard for her to read small numbers on food labels and asked that the food items be disposed of in the restroom trash receptacle. 2.During an observation and interview on [DATE] at 11:15 a.m., Resident #65 was lying in her bed and a visitor brought in supplemental drinks to place in refrigerator. The outside of the refrigerator had a log with no date or year on it. It was filled in with 14 different numbers with initials MS by each number. There was no thermometer inside of the refrigerator. The refrigerator had cultured buttermilk with a best by date of 09 [DATE] on the container. Resident #65 stated she was unaware of the cultured buttermilk's date and stated she was not able to get items out of the refrigerator without assistance of staff or visitors. She did not know how often the refrigerator was checked. Resident #65's visitor stated she would remove expired buttermilk so that Resident #65 would not accidentally drink it. 3.During an observation and interview on [DATE] at 10:35 a.m., Resident #23 was sitting in her wheelchair inside of her room and was sipping on a soda that she had removed from her personal refrigerator. The refrigerator did not have any temperatures logged during the month of [DATE]. Inside the refrigerator, observed drinks and some food that appeared to be cake stored in Styrofoam container. There was no thermometer inside of the refrigerator. She stated she did not know how often the facility looked at the refrigerator or items inside of it. During an interview on [DATE] at 9:40 a.m., CNA C stated she did not know who was responsible for checking the resident's personal refrigerators. She stated she had gone and checked some of the refrigerators on [DATE] when the residents would let her. She verified that Resident # 36 did not have temperatures on her refrigerator since [DATE]. She verified that Resident # 65 did not have a thermometer in her personal refrigerator. She stated the refrigerators should have thermometers and should be checked to help prevent sickness. During an interview on [DATE] at 9:44 a.m. LVN D stated housekeeping was responsible for monitoring the refrigerators in resident's rooms. She stated nursing staff were responsible for monitoring refrigerators in nutrition and medication room. During an interview on [DATE] at 9:48 a.m., HK B stated housekeeping was responsible for monitoring residents' personal refrigerators including temperatures. He stated temperatures should be taken weekly and then written on logs. He stated if the logs were not filled in then the temperature was not taken. HK B stated the HK supervisor had gone home sick on [DATE] and that may have led to the failure of not checking refrigerators. He stated he used to carry a thermometer that he would use to obtain temperatures in refrigerators that did not have one inside of them but that had been recently broken. During an interview and observation on [DATE] at 11:56 a.m., the Director of Maintenance had personal refrigerators in sealed packages at the nurses' station. He stated that he had gone to several local stores and purchased the thermometers that morning. He stated he had taken over the HK supervisor role 2 weeks ago and was not aware that personal refrigerator thermometers were needed and were part of his role to provide. During a follow up interview on [DATE] at 8:47 p.m., the Director of Maintenance stated HK was responsible for cleaning out the residents' personal refrigerators and that included removing expired foods. He stated not removing expired foods could cause residents to become sick if they ate those items. Record review of the facility policy titled Resident Personal Food Storage revised on ,d+[DATE] revealed Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or persona/resident room refrigeration units will be monitored by designated facility staff for food safety .Facility staff will assist resident with accessing and consuming food if resident is not able to do so on his/her own. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Staff will monitor and document unit refrigerator temperatures. Resident and individuals bringing food in from outside sources will be educated on safe food handling and storage techniques by designated facility staff as needed. Record review of the facility policy titled Food Storage not dated revealed Cold foods shall be maintained at temperatures of 40 F or below.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CMA J and CMA K) of 6 staff observed for infection control practices. The facility failed to ensure CMA J wore the required PPE in a Resident #17's room while providing medication and eye drops for Resident #17. The facility failed to ensure CMA K sanitized face shield per infection control protocols and procedures. These failures place residents at risk for cross contamination and spreading of infections while in facility. Finding included: Record review of facility provided document for Covid testing of residents revealed: Resident #12 tested positive for COVID on 1/11/2025; Resident #17 tested positive for COVID on 01/10/2025; and Resident #41 tested positive of Covid on 1/11/2025. During an observation on 1/14/2025 between 10:30 AM and 10:40 AM Resident #17 and Resident # 12's had signs on door that stated, STOP Airborne Precautions Everyone must: Put on a fit-tested N-95 or higher-level respirator before room entry. There were only surgical masks available at both doors, no N-95 masks were available with the PPE. During an observation on 1/14/2025 at 11:20 PM staff were observed taking the surgical mask out of the PPE bins and placing N-95 masks in its place. During an observation and interview on 1/14/2025 at 12:15 PM CMA K left Resident #47's room with face shield and walked down hallway to shower room to clean shield with bleach wipes and then walked back down hall to place shield in bin PPE bin outside of Resident #47's room. CMA K stated she had been trained on PPE, but there were no wipes on the hall at the Resident room, so she had to go to shower room to get wipes to clean the shield. She stated she was told that the wipes were not left on the hall because they were afraid residents would get the wipes. CMA K stated she did not think it made sense to go down the hall to get wipes to clean the shield and stated the wipes should have been at the door. CMA stated she should not have carried the shield down the hall. During an observation and interview on 01/15/2025 at 10:00 AM CMA J had set a tray covered in a clear bag with medications, gloves and tissues to take into Resident #17's room. CMA J had put on a gown, gloves, and a N95 mask. CMA J failed to put on a face shield before she entered Resident # 17's room. After CMA J entered Resident #17's room she stated she forgot to put on the face shield, CMA J failed to stop and put on a face shield. CMA J continued to place eye drops in Resident #17' s eyes. CMA J gave the last eye drop and dropped a clean glove on the floor, CMA J stated, I never drop gloves and I did not bring, extra gloves. CMA J continued to hand Resident # 17 her medication with gloved hand and assisted Resident # 17 drinking water with her ungloved hand. Before exiting the room CMA J discarded supplies off the tray but did not take the bag off the tray and laid the tray wrapped in the contaminated bag on her mediation cart in hallway. CMA J stated she should have stopped and put on a shield, and she should have gotten another glove. During an interview on 01/16/2025 at 12:16 PM the DON stated staff have been trained on how to provide care for COVID positive residents and the requirements of wearing PPE. The DON stated staff should be wearing all the PPE listed on the door which was a gown, gloves, N95 mask and face shield. The face shield should have not been carried down the hall to be cleaned, it should have been cleaned or disposed of prior to exiting the room. The DON stated the residents could have been affected by exposing residents to COVID. The DON stated what led to failure was staff not following policy or their training. Record review of facility policy titled, COVID Related Processes not dated revealed The facility will follow recommendations made by local health department related to masking, testing and other COVID related precautions. Donning a PPE (healthcare professionals and visitors); Mandatory when working with COVID positive resistant (mask, eye protection and gloves). Review of the CDC https://www.cdc.gov/infection-control/media/pdfs/Toolkits-PPE-Sequence-P.pdf revealed: The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE. GOWN o Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back o Fasten in back of neck and waist 2. MASK OR RESPIRATOR o Secure ties or elastic bands at middle of head and neck o Fit flexible band to nose bridge o Fit snug to face and below chin o Fit-check respirator 3. GOGGLES OR FACE SHIELD o Place over face and eyes and adjust to fit 4. GLOVES o Extend to cover wrist of isolation gown.

Based on interviews, and record review, the facility failed to ensure residents had the right to voice grievances to the facility with respect to care and treatment which had been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 18 residents (Resident #171) reviewed for grievances. The facility failed to investigate and respond to a grievance made by Resident #171's representative who made a grievance to RN A. This failure could place residents and their representatives at risk of not having their grievances heard and or resolved. The findings included: Record review of Resident #171's electronic face sheet dated 01/15/2025 revealed she was a female admitted to the facility on [DATE] and most recently on 07/14/2023 with diagnoses to include: unspecified dementia, muscle weakness, anxiety disorder, and major depressive disorder. Record review of Resident #171's quarterly MDS dated [DATE] revealed no BIMS score because the resident was rarely or never understood. Further review of the MDS Section E behavior revealed Resident #171 did not have hallucinations, delusions, rejection of care, or wandering. Record review of Resident #171's progress notes dated 12/27/2024 by the SW revealed the SW contacted Resident #171's representative via telephone on 12/24/2024 about her concerns with Resident #171 being not compatible with her roommate that had been reported by another staff member. Further review of the progress note revealed that a tour of available rooms was offered and the representative verbalized understanding. The representative stated they would discuss with other representatives and would follow up with SW if interested in room change on 12/31/2024. During a telephone interview on 01/15/2025 at 9:37 a.m., Resident #171's representative stated they had made a verbal grievance around 12/20/2024 to RN A. Resident #171's representative stated the grievance had been written down and placed on the DON's desk by RN A per their request not to give to the grievance coordinator. Resident #171's representative stated she never heard back from the facility about her grievance. Resident #171's representative stated they were upset the facility never responded to the grievance especially since the facility was open 24 hours a day. Resident #171's representative stated they would look through their notes and supply copies of notes. During a record review of notes provided by Resident #171's representative on 01/15/2025 at 5:40 p.m. revealed on 12/21/2024 a grievance regarding Resident #171's roommate had been written and RN A placed the grievance on the DON's desk. Further review of Resident #171's representative notes revealed on 12/24/2024 the grievance coordinator called Resident #171's representative and stated since Resident #171's representative had concern with the roommate then Resident # 171 would need to move if the representative chose to have Resident #171 be moved. A room close to the exit door was offered as available. During a telephone interview on 01/16/2025 at 2:36 p.m., RN A stated she had helped Resident #171's family fill out a grievance form but could not remember exactly what date that had occurred. RN A stated she could not remember exactly what Resident #171's representative had been concerned about. She stated she had placed the grievance on the DON's desk due to it being the weekend and she did not know exactly where to put the grievance form. She stated no-one else but herself had access to the DON's office on the weekends. She stated the grievance coordinator was a different ADMN at the time that no longer worked at the facility. She stated she did not know what happened to the grievance after she left it on the DON's desk. During an interview on 01/16/2025 at 2:49 p.m., the DON stated she had never received a grievance or saw a grievance form on her desk after December 21, 2024, about Resident #171. She stated she had no knowledge of the verbal grievance given to RN A. During an interview on 01/16/2025 at 5:13 p.m., the SW stated she was not aware of a grievance filed by Resident #171's representative later in December. She stated that she had been made aware of concern from Resident #171's representative about a roommate not being compatible with Resident #171. She stated she had called the family on the phone and had written a progress note in the electronic chart about offering room change for Resident #171 due to representative's concerns. She stated she did not remember a formal grievance but would look to see if she had a paper copy of a formal grievance. During an interview on 01/16/2025 at 5:22 p.m., the ADMN stated he was unsure of the grievance process if a family had requested grievance be turned into someone other than the grievance coordinator. The ADMN stated that he was not the administrator over this facility on December 21, 2024. During a follow-up interview on 01/16/2025 at 5:33 p.m., the ADMN stated his expectation would be if a grievance had been reported over the weekend, the SW would have logged the grievance and followed up on the grievance as she was the grievance coordinator. He stated typically if there had been issues with roommate compatibility, the resident or representative who brought up the concerns would be offered a room change. He stated he would look for a policy about roommate compatibility. During a follow-up interview on 01/16/2025at 5:33 p.m., the SW stated she did remember meeting with the representatives of Resident #171's roommate. She stated she remembered a discussion during an IDT morning meeting after December 21, 2024, but could not remember who [NAME] up the discussion about Resident #171's representative's complaint and that another room was offered but Resident #171's representative decided not to have Resident #171 change rooms. The SW stated she never received a formal grievance about the complaint, and she did not log the complaint on the grievance log due to not a formal grievance. The SW stated Resident #171's representative was offered a room change in regard to complaint and she had documented discussion in Resident #171's medical record under progress notes. She denied any change in outcome of issue and stated she had followed up on it but had not documented it as a grievance. During a follow-up interview on 01/16/2025 at 6:14 p.m., the ADMN stated the grievance log had all the grievances in December of 2024. He stated he had not been able to locate any IDT meeting notes from the facility's morning meetings around December 21, 2024. The ADMN stated he had heard from several staff members the discussion had occurred, but he was not present during those meetings. He stated his expectation would be for all grievances to be logged and the SW was responsible for keeping the grievance log up to date. He stated the outcome would not have changed if the grievance had been logged or the formal form had been present. He stated the ADMN monitored that the SW kept the grievance log and forms up to date. The ADMN stated the ADMN during the time of December 21, 2024, was no longer employed by the company. He stated he could not find any facility policy for grievances filed to someone other than the grievance coordinator per resident or resident representative's request. During a record review of facility's grievance log titled complaint tracking and trending log dated December 2024 revealed no documented grievance from Resident #171 or her representative during the month of December. The last grievance listed on the complaint tacking and trending log was dated December 17, 2024. During a record review of facility's policy titled Grievances revised on 12/2023 revealed: Procedure: 1. The facility's grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decision to the resident, if requested; and coordinating with state and federal agencies, as necessary. Information is made available to the resident and/or representative and posted in designated locations throughout the facility .3. General concerns may be voiced at Resident and/or Family Council meetings. 4. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. 5. The Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the Administrator; and as required by State law. 6. The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. 7. The Grievance official/designee completed the Grievance Resolution Forms, takes appropriate corrective action in accordance with State law if the alleged violation of resident's rights is confirmed by the facility or an outside entity having authority or jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency within its area of responsibility. The Grievance Official or designee will contact all parties with the outcome. 8. The grievance log is maintained by the Grievance official and reviewed by the Quality Assessment & Assurance Committee and shall not become part of the medical record. Results of grievance will be maintained no less than 3 years from issuance of the grievance decision.

48883 Based on interviews and record review, the facility failed to refer residents with newly evident or possible serious mental illness or a related condition for PASSR evaluation for 2 of 18 residents (Resident #27, and Resident #29) reviewed for PASRR. The facility failed to refer Resident #27 & Resident #29 for a PASSR evaluation after diagnoses reflected serious mental disorders. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Resident #27 Record review of Resident #27's electronic face sheet dated 01/16/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #27 had a diagnosis of major depressive disorder with onset date of 03/08/2024. Resident #27 had a diagnosis of post-traumatic stress disorder with onset date on 03/08/2024. Record review of Resident #27's quarterly MDS dated [DATE] revealed Resident #27 had a BIMS score of 15 meaning cognition was intact. Further review revealed active diagnosis of depression and post-traumatic stress disorder. Record review of Resident #27's care plan initiated on date 03/09/2024 revealed Resident #27 had risk for impaired cognitive function with goal to maintain current level of cognitive function and interventions included social services to provide psychosocial support as needed. Record review of Resident #27's medical record revealed no evidence a PASRR evaluation had been performed. Resident #29 Record review of Resident #29's electronic face sheet dated 01/16/2025 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and most recently on 10/12/2024. Resident #29 had a diagnosis of schizoaffective disorder bipolar type with onset date of 09/15/2023. Resident #29 had a diagnosis of bipolar disorder with onset date of 09/15/2023. Resident #29 had a diagnosis of major depressive disorder with onset date of 09/15/2023. Record review of Resident #29's quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 00 meaning severe cognitive impairment. Further review revealed active diagnosis of depression, bipolar disorder, and schizophrenia. Record review of Resident #29's care plan initiated on date 09/03/2023 revealed Resident #29 had risk for impaired cognitive function because of diagnoses of bipolar and schizoaffective disorder with goal to maintain current level of cognitive function. Interventions included social services to provide psychosocial support as needed. Record review of Resident #29's medical record revealed no evidence a PASRR evaluation had been performed. During an interview on 01/16/2024 at 4:32 p.m., the SW stated residents who had mental illness diagnoses would not be positive for PASSR services per local mental health authority if a resident had not had law enforcement involvement or an inpatient psych stay in the past two years. During an interview on 01/16/2025 at 8:03 p.m., the MDS coordinator stated post-traumatic stress disorder, major depressive disorder, schizoaffective disorder, and bipolar disorder were all diagnoses that were considered mental illness. She stated if the facility had a suspicion of a mental illness after a resident had been admitted than a PASSR evaluation should have been performed. She stated there was no MDS coordinator on site at the facility at this time and she had been responsible for multiple facilities' resident assessments. She stated she did not know why Resident #27 and Resident #29 had not had a PASSR evaluation performed but could have been because of staff turnover. The MDS coordinator stated the facility had been actively attempting to hire a MDS coordinator for the facility, but she was performing duties until a MDS coordinator was hired. She stated she was responsible for setting up PASSR evaluations after a diagnosis triggered a positive PASSR. She stated both her and the SW monitored that PASSR evaluations were performed. She stated not setting up for local mental health authorities to perform PASSR evaluations could cause residents to be placed in inappropriate living arrangements or not receive services that PASSR positive residents needed. The MDS coordinator stated there were no policies that included what occurred when mental illness was suspected after the resident had been admitted into the facility. Review of the facility policy titled PASRR with no date revealed: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State .Procedures: 1. A PASRR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR.

Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 (Resident #6) of 3 residents reviewed for care plans. The care plan for Resident #6 did not adequately address his interventions to describe how to meet his needs when transferring resulting in a fracture to right arm. This deficient practice placed residents at risk of not having care needs met, which could cause a decline in physical and psychosocial health and serious injury. Findings include: Record review of Resident #6's Face Sheet, dated 10/04/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6's diagnoses included Unspecified displaced fracture (pieces of the bone moved so much that a gap formed around the fracture) of the surgical neck (a bony narrowing at the proximal or nearer to the center end of the shaft of the upper arm or forelimb) of the right humorous subsequent encounter (receiving routine care) for fracture with routine healing, Urinary Tract Infection (infection when bacteria enter the urethra and infect the urinary tract), repeated falls, and Type II Diabetes (problem in the way the body regulates and uses sugar as a fuel). The Face Sheet revealed Resident #6's most recent hospital stay was 04/22/2023 through 04/27/2023. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Section G, Function Status, revealed Resident #6 required extensive assistance (resident involved in activity, staff provided weight-bearing support) with 2-persons or more with physical assist in transfers. Record review of Resident #6's Care Plan, dated 07/24/2023, revealed Resident #6 had a focus of on ADL Self Care Performance Deficit due to recent surgical repair of right humerus fracture due to fall from recliner at home on 02/19/2023. Resident #6's goal was to improve current level of transfers and the interventions included Resident #6 required 1-person staff participation with transfers. Record review of Resident #6's Progress Note, dated 07/19/2023 at 10:28 a.m., documented by LVN N revealed Resident #6 had x-rays that determined an impression of acute fractures of the proximal right humerus per the PCP, who ordered an immobilizer and referral to orthopedic doctor. Record review of the progress notes dated on/or about 7/19/2023 revealed there was no documentation in the record of who Resident #6 reported pain in his right shoulder to or who reported the injury or complaint of pain to the nurse or who contacted the doctor. There was no documentation in the clinical progress notes that documented why x-rays were orders or what precursor occurred to warrant the need for x-rays. Record review of Resident #6's Progress Note, dated 07/19/2023 at 7:14 p.m., documented by LVN N, revealed Resident #6 had new orders from the orthopedic doctor to wear a sling on right arm due to new right Humeral shaft fracture. Record review of the progress notes dated on/or about 7/19/2023 revealed there was no documentation in the record of details of how the fracture occurred or what event preceded prior to Resident #6's injury up to the x-ray results and the orthopedic doctor's orders. Record review revealed the was no incident report completed. During an interview on 10/04/2023 at 11:45 a.m., Resident #6 said he broke his arm in two places when CNA H picked him up under his arms. Resident #6 said CNA H helped him transfer from his wheelchair to his bed and CNA H grabbed him under his arms and picked him up in a bear hug. Resident #6 said he heard two pops, and his arm was broken. Resident #6 said staff would use the gait belt sometimes during transfers and Resident #6 said he used the gait belt in therapy. Resident #6 said CNA H had transferred him using the bear hug in the past and he was comfortable with him using it because CNA H was strong. Resident #6 said two staff would assist him to move from his wheelchair to his bed when he felt like he needed support because his legs would get weak. Resident #6 said since he broke his arm in two places, there was supposed to be two staff in his room, but one staff could transfer him. During an interview on 10/03/2023 at 4:34 p.m., CNA O said she did not have access to residents' care plans. During an interview on 10/05/2023 at 4:42 p.m., CNA F said Resident #6 was able to pivot and transfer with the assistance of one staff for several weeks prior to the new fractures of his right arm that occurred in July 2023. CNA F said Resident #6 was now a 2-person transfer due to the fractures of his arm that occurred in July. CNA F said she was verbally instructed by the DON that Resident #6 was a 2-person transfer. During an interview on 10/05/2023 at 6:09 p.m., CNA H said he had worked at the facility for two years and had always transferred Resident #6 using a bear hug. CNA H said he had never been told to not use the bear hug to transfer Resident #6 or that the bear hug was an inappropriate way to transfer Resident #6 or any of the other residents. CNA H said on the day of the incident when Resident #6 suffered two fractures to his right arm, CNA H said that he used the bear hug technique to attempt to transfer Resident #6. CNA H said he picked Resident #6 up chest to chest and with Resident #6's hands on his arms. CNA H said he heard Resident #6 say ouch when Resident #6 was picked up about a foot off his wheelchair, and CNA H said he immediately sat Resident #6 back down. CNA H said he then retrieved a gait belt and assisted Resident #6 to a sitting position on his bed with a pivot transfer. CNA H said Resident #6 did not immediately complain of pain and responded he was ok when CNA H asked. CNA H said he did not report the incident to the nurse on duty because Resident #6 said he was ok and was not in pain. CNA H said he left Resident #6 in bed and went off shift a short time later. CNA H said he was told by another staff member that Resident #6 complained of pain in his arm a couple of hours after CNA H was off shift, but CNA H did not know who Resident #6 told or what time Resident #6 reported the pain. CNA H said he had been trained on how to use a gait belt but did not remember being instructed to use a belt when transferring Resident #6. CNA H said Resident #6's care plan did not have details on how to transfer Resident #6 and only reflected Resident #6 required 1 staff assistance with transfers. During an interview on 10/06/2023 at 10:51 p.m., the MDS Coordinator said she was notified of Resident #6's injury in the morning meeting the day after the fracture occurred. The MDS Coordinator said Resident #6's arm fracture alone would not cause an update to the MDS assessment and/or care plan. The MDS Coordinator said the IDT would discuss the injury to determine if there was a change in Resident #6's ability to complete daily living activities. The MDS Coordinator said the interventions in the care plan were determined by the therapy department. The MDS Coordinator said an updated care plan with the accurate interventions would be beneficial to the resident and staff to ensure the resident's safety during a transfer. During an interview on 10/10/2023 at 9:11 a.m., the PT said he was familiar with Resident #6 and completed his physical therapy progress reports and certifications. The PT said functionally the bear hug should not have been used with Resident #6 because Resident #6 could bear weight and transfer. The PT said the bear hug technique could cause additional injury to Resident #6's arm because Resident #6's arm had previously been fractured upon admission into the facility. The PT said the use of a gait belt should be in Resident #6's care plan because Resident #6's Plan of Treatment in therapy included gait training therapy to address safe transfers. Record review of Resident #6's Physical Therapy PT Evaluation & Plan of Treatment, dated 4/28/2023, revealed Resident #6 had treatment approaches that included gait training therapy. Review revealed Resident #6's #3.0 Goal was, Patient will improve ability to safely and efficiently transfer to and from a bed to a chair (or wheelchair) with Partial/Moderate Assistance. The evaluation revealed Resident #6 could bear weight as tolerated. During an interview on 10/10/2023 at 9:35 a.m., the OT said he did not reevaluated Resident #6 after he had suffered the new fractures on or around 7/19/2023. The OT said when Resident #6 was admitted to the facility because Resident #6 fell out of his recliner at home and fractured his right shoulder, Resident #6 was very sensitive during transfers and a gait belt was always used. The OT said Resident #6 had chronic anxiety issues. The OT said when Resident #6 broke his arm the second time, Resident #6 went back to the status of non-weight bearing in the right arm and a sling was added. The OT said Resident #6 continued to do stand-to-pivot transfers with the use of a gait belt and clarified with 1 to 2 staff assist as documented in the MDS Assessment. The OT said the facility used an encrypted message system and if a change in condition occurred, the OT said he would have been notified by the message system either through the facility's electronic platform that stored residents' clinical records or text message on his phone with an application that was linked to the electronic platform. The OT said the care plan was updated when he provided residents' OT evaluations to the MDS Coordinator, and the information was entered into the electronic platform used for therapy clinical records. During an interview on 10/11/2023 at 10:10 a.m., the Director of Rehab said Resident #6 was very anxious with transfers and may have been more comfortable when staff used a bear hug, which was an acceptable way to transfer Resident #6. The Director of Rehab said she made the determination to make Resident #6 non-weight bearing on the right-side torso when the encrypted messaging system informed her, the charge nurse, the DON, and all administration staff attached to the message regarding Resident #6 that he was a 2-person assist transfer with a gait belt after Resident #6's right arm was established to be fractured. The Director of Rehab said the nurse would be responsible for letting the CNAs know verbally that there was a change in the way Resident #6 was transferred. The Director of Rehab said she did not consider Resident #6's fracture a change in condition because Resident #6's fracture occurred in the same arm as the dislocated shoulder Resident #6 was originally admitted for . The Director of Rehab said the same interventions were in place in his care plan from the original injury. The Director of Rehab said the therapy assessment information that was completed for Resident #6 that included goals and recommendations was entered into the MDS assessment and care plan by the MDS Coordinator, who had access to therapy's electronic record-keeping platform. The Director of Rehab said Resident #6's care plan intervention was correct that he needed a 1-person assist with transfer and provided enough information for the CNAs to properly transfer Resident #6. During an interview on 10/11/2023 at 10:45 a.m., the DON said that Resident #6 was non-weight bearing in his right upper body after his arm fracture that occurred in the facility. The DON said the CNAs would have been informed verbally by the charge nurse or therapy that Resident #6 required 1 to 2 staff with gait belt to transfer. The DON said from that point, the information would be communicated when staff did walking rounds at shift change. The DON said the information should be in Resident #6's care plan that he needed 1 or 2 staff assist but the specific steps on how to carry out the 1 to 2 staff transfer would be verbally communicated to staff. The DON said the CNAs did not have time to read a 23- to 24- page care plan. The DON said she was aware the facility policy on transfers included the use of gait belt in the steps that described the Sit-to-Stand-to-Chair transfer and the Bed-to-chair (to Bed) transfer. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said Resident #6's injury should have been documented on an incident report. The Administrator said the information on the incident report would have been entered into the electronic clinical records that would notify the MDS Coordinator to review the information and the determine if a need to update the MDS or care plan was warranted. The Administrator said this would be important in ensuring the care plans were up to date and accurate. The Administrator said the therapy department used a different electronic computer system to document and store therapy records. The Administrator said the therapy computer platform system linked with the nursing computer platform system and used the assessment to create the goals and interventions in the care plan. Record review of facility policy, Comprehensive Person-Centered Care Planning, dated 01/2022, revealed it was the policy of the facility that the IDT would develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. Record review of facility policy, Transfers, Types of, not dated, revealed the steps of types of transfer were: Sit-to-Stand-to-Chair Transfer 1. Position chair at a slight diagonal to the bed. Make sure the chair is stable, footrest removed or foot plates up. 2. Place the gait belt around the resident. 3. Stand facing the resident. 4. Tell the resident to move to the edge of the bed. 5. Block the resident's feet and knees. Grasp the gait belt. 6. Ask the resident to lean forward and stand on the count of three. 7. Bring the resident to a full standing position. 8. Have the resident reach with his/her hand to far side of the wheelchair as he/she pivots. Sit down gently. Bed-to-Chair (to Bed) Maximal Assist Pivot Transfer 1. Resident slides to edge of bed, placing feet apart, flat on floor. 2. You stand facing the resident the resident, grasping the safety belt with both hands at the resident's side. Block resident's knee. 3. At 1-2-3, stand resident up by straightening you knees. 4. Pivot resident, then guide him to sitting position in chair. Resident's strong-rm position is up to your preference and resident's physical ability. 5. When resident is in position in front of wheelchair, resident reaches back to grasp middle of arm rest and lowers himself into wheelchair. 6. You must steady the wheelchair as it has a tendency to move even with the brakes locked.

Based on observations, interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for accidents and supervision Resident #1 was locked outside, in the facility courtyard, on 12/6/19 for approximately four hours. Once found he was taken to the ER (emergency room ) where he was treated for [REDACTED]. This was determined to be Immediate Jeopardy (IJ) at past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed residents at risk for life-threatening accidents and injuries. Findings include: Review of Resident #1's Admission Record, accessed on 12/10/19, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed he required supervision with locomotion on and off unit, and extensive assistance with transfer. Review of his Brief Interview for Mental Status (BIMS), revealed he had a score of three, which indicated his cognitive function was severely impaired. Review of Resident #1's Care Plan, last revised on 5/31/19 revealed: Focus-Resident #1 is an elopement risk/wanderer related to [MEDICAL CONDITION], disoriented to time and place, impaired safety awareness. 5/21/19 Resident attempted to remove wander guard .Goal-Resident #1 will not leave facility unattended through the review date .Resident #1's safety will be maintained through the review date .Interventions-Assess for fall risk .Monitor Wander Guard placement on right ankle .Resident #1 on one on one supervision until wander guard is in place . Review of Resident #1's Nurse Progress Notes revealed: 8/28/19 2:34 p.m. Resident exit seeked. Staff outside to redirect back inside. Resident combative with staff. Resident brought back inside after multiple attempts by different staff . 8/31/19 10:12 p.m. Resident wandered toward the exit. Staff outside to redirect resident into the building. After multiple attempts, resident was then brought in by staff. Notified DON, daughter . 9/2/19 4:47 a.m. This nurse walked in with the resident sitting in the wheelchair with right foot propped on the left leg. Resident made a mark with a pencil on the wander guard and was using his fingers as if he were cutting the wander guard off. When asked what he was doing, resident responded well, this needs to come off. Reported to the oncoming nurse. 9/7/9 1:18 p.m. Psychiatrist A in for round with new order received and noted. D/C (discontinue) [MEDICATION NAME]. Call placed to resident's daughter with message left. Res (resident's) son notified and aware. 9/28/19 6:50 p.m. Approx. (approximately) 1500 (3:00 p.m.) resident was noted outside of front doors in lobby down walk way in wheelchair. Not easily redirected via staff. Exhibited aggressive behavior towards staff when staff attempted to redirect to come back inside facility . Review of the Provider Investigation Report, prepared by the Executive Director on 12/7/19 at 12:00 a.m., revealed: Description of the Allegation: On 12/6/19 I was notified by phone call from (LVN B) that at approximately 9:50 p.m. the resident (Resident #1's name) was unable to be located in the facility. LVN B reported that when the rounds were done at 9:15 p.m. they were unable to locate Resident #1 during their rounds and immediate search of the area and proceeded to notify the supervisor. Description of Assessment: The nursing staff was not allowed near the resident for immediate condution (sp) of head to toe assessment-police department informed staff to stay away from the resident. Blankets were immediately obtained and placed on the resident. Visual inspection showed that resident was lying on the ground when discovered by personnel and at the time of discovery he was found lying on the grass on facility premises (therapy gym courtyard). The resident was responsive to questions when found. Provider Response: After being notified by LVN B that they were unable to locate the resident I immediately headed to the building. I arrived at the building at 10:10 p.m. Upon entry into the building staff was actively trying to locate resident. Department heads were notified and instructed to return to building to help with search for the resident. LVN B initially received the call and after notifying me she then notified the police department. Resident #1's family, Physician A, PCP (primary care physician) and Medical Director were notified. Resident #1's family did come to the facility after being notified of incident. Police entered the facility at approximately 10:15 p.m. and assisted with the search. All department heads entered building and assisted with search, resident was found on the premises, located in a gated area outside the therapy gym. (Medication A's name) got the key to search the therapy gym and was accompanied by 2 police officers and a few staff members, resident was found lying on the ground, in the grass. We were instructed at this time by police department not to touch the resident. The Director of Therapy and Executive Director immediately grabbed blankets to cover Resident #1. (Name of ambulance service) arrived and took resident to Hospital A, at approximately 3:15 a.m., checked out and was all clear. Resident immediately went to his room and went to sleep. Review of the local temperature history on weather underground.com for 12/6/19, revealed the temperature dropped from 53 degrees at 6:00 p.m. to 47 degrees at 8:00 p.m. and to 44 degrees at 10:00 p.m. (accessed on 12/10/19 at https://www.wunderground.com/) Review of the police department report number 19- 3, dated 12/6/19, revealed, Tonight, 12/6/19, (facility name) called (police department) for a Silver Alert. The facility had a missing patient (Resident #1's name) [AGE] year-old who could not be located. The last time staff remembered seeing (Resident #1's name) was at 6:15 p.m. There was supposed to be 8 p.m. rounds, but the person who was supposed to be doing the rounds had to go to the hospital to pick up a patient. (Resident #1's name) can't walk and was in a wheelchair. Six on-duty and some off duty officers were called in to the facility. After a thorough search, (Resident #1's name) was found in the courtyard out of the physical therapy room. The door to that courtyard is supposed to be locked at 6 p.m.; however, staff forgot to lock the door. (Resident #1's name) was found with the wheelchair toppled over and his arm stuck in the wheels. It was a cold night. (Resident #1's name) body temperature was 94 degrees. (Resident #1's name) was transported to an ER (emergency room ) by ambulance. There were several things that did not appear to be done in a safe way for all the patients at the facility. 1. Bed checks are supposed to be done very (sic) two hours; however, the checks are not documented. 2. The door to this courtyard, which is not used at night was left unlocked . Review of the Emergency Department Physician Documentation dated 12/6/19 at 10:54 p.m., revealed the following: a 78-yr-old male presents emergency department for hypothermia. He currently resides in a nursing home. They were doing his 'nightly checked given his medications', and they found him in his wheelchair on the ground. He did have a bruise on his left forearm and left knee. Patient is alert and oriented times '14' which is his baseline. Apparently, patient denies any symptoms including runny nose, sore throat, headache, neck pain, chest pain, shortness of breath, back pain, abdominal pain, pain in his arms or legs. He denies parethesias or weakness. He does not remember how he fell . He was found next to his wheelchair. EMS (emergency medical service) checked his temperature, and it was 93. This was a forehead temperature. According to the Mayo Clinic: Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F (37 C). Hypothermia (hi-poe-THUR-me-uh) occurs as your body temperature falls below 95 F (35 C). When your body temperature drops, your heart, nervous system and other organs can't work normally. Left untreated, hypothermia can eventually lead to complete failure of your heart and respiratory system and eventually to death. Hypothermia is often caused by exposure to cold weather or immersion in cold water. Primary treatments for hypothermia are methods to warm the body back to a normal temperature .Shivering is likely the first thing you'll notice as the temperature starts to drop because it's your body's automatic defense against cold temperature - an attempt to warm itself. (accessed on 12/12/19 at https://www.mayoclinic.org/diseases-conditions/hypothermia/symptoms-causes/syc- 682) Review of the emergency department course of treatment dated 12/7/19 at 1:32 a.m., revealed: Resident #1 presented to the emergency department as a likely mechanical fall. Screening and blood work, and imaging was performed. A rectal temperature was 93.7 degrees and he was placed on a Bair Hugger (warming blanket). During his course in the ER he stopped shaking. His son was at his bedside and stated that he was at his baseline .Patient's temperature returned to normal and this was an internal thermometer. Spoke with the son and he feels comfortable with the father going home. With the father being at his baseline, having normal temperature, and no acute abnormalities requiring hospital admission he was discharged back to his nursing home. Observation and interview on 12/9/19 at 3:10 p.m., revealed Resident #1, dressed and groomed, sitting in his wheelchair in his room. His wander guard was attached to his wheelchair and he was being monitored one on one by CNA [NAME] When asked if he went outside and was unable to get back in the building, Resident #1 said, I don't know that I couldn't get back in the building, but I opened the door and went out because there were all kinds of animals . Resident #1's voice trailed off and he was unable to complete his sentence or participate in further conversation. Observation and interview on 12/9/19 at 2:02 p.m. revealed in the facility there was a hallway in front of the therapy gym. There was a door that was able to be locked leading from the hallway into the therapy gym. Once inside the therapy gym opposite from the interior door leading to the hallway was another door leading to a courtyard. The door leading to the courtyard locked from the outside, so once someone entered the courtyard they were unable to get back into the therapy gym. Once inside the courtyard, the gates were padlocked. (At the time of the incident on 12/6/19 the door leading to the courtyard was not alarmed as part of the wander guard system.) On 12/9/19 at 2:02 p.m. the door leading to the outside courtyard from the therapy gym had been equipped with an alarm and key-pad. The Physical Therapist (PT) said the lock had recently been installed with an alarm. He said previously, the door could not be locked to prevent residents exiting, because it was a fire exit door, but the door locked from the outside to not allow re-entry once someone went outside. The PT said when Resident #1 got out the door leading to the courtyard, and the door did not have a wander guard alarm. He said Resident #1 enjoyed being mobile and wandering around the facility. The PT said Resident #1 spent time in the front lobby with the coffee machine and liked to see how close he could get to the outside door before it alarmed. This surveyor tested the door inside the therapy gym leading to the courtyard, by pushing it open and the alarm immediately sounded requiring the therapy staff to press in a code on the key-pad to silence the alarm. In an interview on 12/9/19 at 2:07 p.m. Resident #1's daughter said Resident #1, who had dementia, was found outside in the courtyard laying tangled in his wheelchair. She said the wheelchair had turned over and Resident #1's arms were tangled in it. Resident #1's daughter said she was told by staff at the emergency room , that if Resident #1 had not been found and remained outside throughout the night, he would have passed away. She said the family was in the process of relocating Resident #1 to a locked facility and she was coming to pick him up today to discharge him and to transfer him to another facility out of town. In an interview with the Director of Nursing (DON) and the Executive Director (ED) on 12/9/19 at 2:31 p.m., the DON said she received a call on Friday night, 12/6/19, around 9:50 p.m., that the facility had a resident who could not be located. She said staff immediately started a (visual) sweep of the facility, searching for Resident #1. The DON said when she arrived at the facility at 10:00 p.m., the police were at the facility. She said a sweep was done inside and outside the facility. The DON said the medication aide opened the therapy gym and found the resident in the courtyard outside the gym. She said Resident #1 was directly off the concrete patio, lying in the grass. The DON said Resident #1 was transported to the hospital by ambulance for evaluation and his temperature, assessed by emergency personnel, was 92.7 when he arrived at the hospital, but within an hour his temperature was back up within normal limits. She said the resident was conscious when he was found. The DON said staff first noted Resident #1 was missing at 9:15 p.m., and that he was last seen by staff around 6:10 p.m. She said the Speech Therapist (ST) was the last one to see Resident #1 before he clocked out of the facility at 6:06 p.m. The ED said the door leading out to the courtyard from the therapy gym could not be locked from the inside because it was a fire exit door, but that the door was locked from the outside preventing anyone who went out the door from re-entering. She said the interior, door leading from the therapy gym into the hall of the facility, was supposed to be locked at the end of the day and it was locked. She said the ST had seen Resident #1 in the gym. She said the ST left the room. When the ST came back into the gym, he did not see Resident #1 and assumed the staff had come and got him, so he locked up and didn't check outside before leaving. The ED said there was no alarm on the door that would have been set off by Resident #1's wander guard and, when Resident #1 was determined to be missing, the staff was outside their timeframe (every two hours) for making rounds. The ED said the ST, medication aide and CNA B were suspended from duty, pending the outcome of the facility's investigation. The DON said Resident #1 returned to the facility at 2:00 a.m. with no significant findings. She said he was placed on one-on-one supervision. The DON said they had found placement for Resident #1 in a locked facility and they were keeping him on one-on-one supervision until discharge. In a telephone interview on 12/9/19 at 3:33 p.m., CNA B, said she was helping on all the halls, and remembered seeing Resident #1 at 6:00 p.m., in the dining room during supper. She said she remembered him being there because he kept going into the kitchen in his wheelchair and staff had to keep pulling him out. CNA B said, after supper, she started laying the residents down and the nurse (she identified the Medication Aide by name) passing medications, told her they needed to take the van and pick up a resident from the hospital. She said when she and the Medication Aide returned to the facility around 9:45 p.m., the medication aide (MA) was passing meds when he noticed Resident #1 was gone so we started checking the rooms. She said Resident #1 was found by the MA outside in the courtyard behind the therapy gym. CNA B said staff was supposed to do rounds every two hours. She said Resident #1 had tried a lot of times to get out of the facility and that he had a wander guard on. In a telephone interview on 12/9/19 at 4:30 p.m., the ST said he was in his office working, when he saw Resident #1 come into the gym and he thought Resident #1 went back out. He said he has no view of the back door of the gym while in his office and that the door leading outside had no lock or alarm on it. The ST said he finished working and left the gym. The ST said he believed he was not the last person to leave the gym, so he didn't lock the door leading from the gym to the hallway. The ST said he believed he asked the physical therapist if he was finishing up and then left. (The timeclock indicated the ST was the last one to leave at 6:06 p.m.) In a telephone interview on 12/9/19 at 4:45 p.m., the medication aide (MA) said he started passing medications on hall 3 around 6:40 p.m., when the facility received a call from the hospital that another resident was ready to be picked up. The MA said he notified the charge nurse, then he and CNA B left the facility to pick up the resident and returned around 8:00 p.m. when he started passing meds on hall 2 (where Resident #1 resided). The MA said he started at the front of the hall (closest to the nurse's station) and that Resident #1's room was at the far end of the hall. The MA said when he got to Resident #1's room, it was approximately 9:20 p.m., and he noticed that Resident #1 was not in his bed. The MA said he asked CNA B if she had seen Resident #1, and they looked in his room, but could not find him. The MA said he reported to the charge nurse that Resident #1 was missing, and the staff started searching for him. He said the charge nurse called the ED and DON and the police were called. He said everybody started arriving at the facility between 9:40 p.m. and 10:00 p.m. and started searching for Resident #1. The MA said he got into his car and went looking all over the campus. He said the interior door to the therapy gym was locked so no one thought about looking in there. The MA said he realized that the charge nurse had the key to the gym door, so he got the key, unlocked the door and looked inside. The MA said he looked through the glass door that led outside and saw Resident #1 outside on the grass. He said Resident #1 had a wander guard on his wheelchair, but there was no alarm on door that led outside from the therapy gym. The MA said, whoever was the last to leave the therapy gym, locked the door that lead to the hallway and neither the police or other searchers thought about the therapy gym. In an interview on 12/9/19 at 5:28 p.m., the ED said the procedure for therapy staff was that the last person out was to check inside the gym and outside to make sure the area was clear of residents before locking the interior door. In an interview on 12/10/19 at 9:10 a.m., the ED said none of the doors that led from the facility to the outside courtyards had been locked or alarmed because the gates leading out of the courtyards were locked and had a coded keypad. She said the nurses were responsible for checking the courtyards during rounds, with the exception of the courtyard outside therapy gym, which was the responsibility of the therapy department. In an interview on 12/10/19 at 9:53 a.m., LVN A said, it (Resident #1 exiting the building) was bound to happen. She said the facility was giving Resident #1 mixed signals by allowing him to sit in the front lobby with staff Monday-Friday, but on weekends there was no staff in the lobby and Resident #1 could not sit there. LVN A said, on weekends, Resident #1 kept trying to get through the locked doors between the resident hallways and the lobby. LVN A said Resident #1 was very cunning and had gotten out before and on more than one occasion, Resident #1 had exited the building and was almost to the gate leading out onto a busy street. She said Resident #1's family was aware because the facility had called them numerous times. In an interview on 12/10/19 at 10:10 a.m., CNA C said she arrived at the facility on 12/6/19 at 10:00 p.m. to search for Resident #1 and that he was found somewhere between 10:00 and 10:15 p.m. She said he was conscious and responsive, just cold. In an interview 12/10/19 at 11:45 a.m., CNA [NAME] said she had worked with Resident #1 in the past and he was exit-seeking from the second day he was here. She said she was not on-duty the day Resident #1 was missing, but heard he was found about 9:30 p.m. outside in the courtyard behind therapy. CNA [NAME] said she did not know Resident #1's condition when he was found. In an interview on 12/10/19 at 11:51 a.m., CNA D said, everyone knew Resident #1 was always trying to get out of the doors. She said she was off when he was discovered missing and that he was found lying on the ground hours later. When asked if she was made aware of Resident #1's condition when he was found, CNA D said, he was okay, just tired. She said Resident #1 was placed on one-on-one supervision, and an alarm system was placed on the outside courtyard doors. CNA D said Resident #1 was always trying to get out of the doors-he would sit by the door, waiting for someone to come in so he could grab the door and go out. She said sometimes Resident #1 was very aggressive, trying to get out. In an interview on 12/10/19 at 12:05 p.m., RN A said she was not in the facility on the day Resident #1 was missing. She said she was told he was found in the courtyard area by the therapy gym and he was there for about four hours before he was found. RN A said she thought Resident #1 got out of the building between 6:00 and 7:00 p.m. In an interview on 12/10/19 at 12:13 p.m. the Clinical Resource Nurse said, when she was called by the facility, she was told Resident #1 got into the therapy gym, went through the courtyard door, and when he got out there he couldn't get back in. She said the therapists didn't see him outside and assumed the nurses got him and they were not expecting anyone to be in the gym. The Clinical Resource Nurse said prior to Resident #1 being found outside, she was not aware of a protocol for the therapists to check the gym and courtyard upon leaving, but she knows there is a protocol now. She said the therapy door was not alarmed because someone was always in the gym--she had never seen the gym unattended. The Clinical Resource Nurse said dinner was at 5:30 p.m. She said, when the staff was questioned, they all said Resident #1 ate dinner. The Clinical Resource Nurse said the ST was the last to see Resident #1 and confirmed that he clocked out at 6:06 p.m. Review of the facility's Policy/Procedure for Nursing Administration (Policy Number: NACT 03), revised 5/2007 revealed: Section: Care and Treatment; Subject: rounds, Licensed Staff; Policy: It is the policy of this facility to ensure the safety and comfort of the resident and to assist in continuity of care and to identify potential change in condition. Procedures: 1. Residents will be checked by the nursing staff a minimum of every two (2) hours. 2. Observe resident for privacy, dignity and safety . It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 12/6/19 from 6:06 p.m. until he was found between 10:00 p.m. and 10:15 p.m. The facility took the following actions to correct the non-compliance: The Medication Aide, CNA B, and the ST were placed on suspension pending the outcome of the investigation. In-services were completed (verified by review of in-service attendance records) on Abuse/Neglect; reporting elopement; proper shift change reporting; therapy grounds check prior to leaving the building and locking the gym door-ensuring doors are closed and locked; head count of residents on halls; transport procedure; 2-hour rounds; resident in bed/room, and what constitutes a round. Resident #1 was placed on one-on-one supervision. Facility conducted staff interviews and counseling/disciplinary measures. Elopement drills were conducted; alarms were placed on the therapy room door and on the doors leading from the hallway out to a second courtyard utilized by the residents. The wander guard system and all facility egress doors were checked for locks and security. The incident was addressed in an off-cycle Quality Assurance meeting for trending and further recommendations provided by the committee. In an interview with the ED and DON on 12/9/19 at 2:31 p.m., the ED said the staff was in-serviced on making rounds every two hours and also counting heads which must be verified by the charge nurse. She said alarms were placed on all of the doors leading outside that could be accessed by the residents and the staff were in-serviced on the alarms. The ED said staff was also in-serviced on appropriate transportation and that the on-call transporter should be notified when a resident requires transport after hours. She said staff on-duty should not leave the facility to transport residents. Throughout the course of the investigation from 12/9/19 to 12/10/19 staff were interviewed and confirmed their understanding of the in-services provided by the facility. Staff interviewed included six CNAs, one LVN, one RN, one Medication Aide, the physical therapist, and speech therapist.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for one of eight residents (Resident #1) reviewed for abuse. LVN A forced pills into Resident #1's mouth by pinching the resident's nose closed. LVN A forced Resident #1 into the shower room while the resident was upset, agitated and combative. LVN A then held a washcloth over Resident #1's nose and mouth while in the shower room. Resident #1 sustained bruising to her left shoulder in the scapula area. LVN A was not suspended following the incident with Resident #1 and continued working the floor. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/18/2017. After verification on 8/21/17 of the facility's Plan of Removal the IJ was lowered effective 8/18/17 to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1 and placed her and the other 18 residents on hall 2 at risk for harm due to LVN A being allowed to remain in direct contact with the residents for three days after the abuse occurred. Findings Include: Record review of Resident #1's Admission Record printed on 8/18/17 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's annual MDS (Minimum Data Set) dated 8/10/17 revealed she had a BIMS (Brief Interview for Mental Status) score of seven which indicated her cognitive function was moderately impaired. The MDS documented Resident #1 required extensive assistance with activities of daily living such as bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also documented she was incontinent of bowel and bladder. The MDS documented she was able to ambulate through the facility in her wheelchair. The MDS indicated Resident #1 did not have any behaviors of physical or verbal behaviors directed toward others and no behaviors directed toward herself, and no behaviors of screaming or disruptive sounds. Documentation indicated that the behavior of rejecting care did not occur. The only behavior documented that had occurred during the look-back period for the MDS assessment was wandering. Record review of Resident #1's care plan for risk of impaired cognition with revision date 8/11/17 revealed: Focus: (Resident #1's name) is at risk for impaired cognitive function/dementia or impaired thought processes related to [MEDICAL CONDITION]--at risk for communication deficits. Goal: (Resident #1's name) will maintain current level of cognitive function through the review date. Target date: 10/29/17. (Resident #1's name) will be able to communicate basic needs on a daily basis through the review date. Target date: 10/29/17. Interventions: COMMUNICATION: Identify yourself at each interaction with (Resident #1's name). Face when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. Use simple, directive sentences. Provide with necessary cues-stop and return if agitated . Record review of Resident #1's care plan for anxiety and use of medication with revision date of 6/19/17 revealed: Focus: (Resident #1's name) takes [MEDICATION NAME] for anxiety. At risk for adverse reactions and increased fall risk. Goal: Will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Target date 10/29/17. Interventions: .Give anti-anxiety medication .Monitor/document side effects and effectiveness. Antianxiety side effects: .confusion and disorientation .Paradoxical Side Effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations .Monitor/record occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc . Record review of the facility's Investigation Report Form signed and dated 8/17/17 by the EDA revealed: Name of Resident: (Resident #1's name) Date Incident Occurred: 8/14/17 Time: App 10:00 a.m. Date Incident Reported: 8/14/17 Time: 4:10 p.m. Incident Reported By: (CNA B) and (CNA A) Job Position: CNA's Type of Allegation: Abuse (not stated as abuse) Resident Injured: Yes Bruising on scapula following shower room incident with combativeness Injuries required medical attention: No Did the medical record review indicate any previous or unexplained injuries? Yes Fading bruising to face due to previous fall Name(s) of witness(es) to the incident: (CNA C's name) Name of person(s) accused: (LVN A), LVN Is the accused individual(s) an: Employee was checked Summary of interview with person(s) reporting the incident: Today in the shower room, (Resident #1) was being combative and (LVN A) came in to help (CNA B, CNA A, and CNA C). During the process, (LVN A) had a washcloth over (Resident #1's) face and did that twice. Summary of interview with witness(es): (CNA B and CNA A) came in to my office together and reported the above. They stated (CNA C) was also in the shower room when the incident occurred. As soon as the report was recived (sic) (DON's name), DON was notified. He contacted (CNA C) via phone as she was out of the building. She reported the same basic scenario but did not indicate (LVN A) was holding the washcloth over her face just that (LVN A) had a washcloth in front of (Resident #1's) face. Summary of interview with resident: (Resident #1's) cognitive impairment does not allow her to accurately report events once any time has passed. She had been talking about seeing her mommy and daddy earlier in the day. Summary of interview with staff members having contact with the resident during the period of the incident: The charge nurse and all 3 aides assigned to (Resident #1's) care were involved in the incident. Others with contact with (Resident #1) included DON, ADON, and ED (EDA) who had some interaction with (Resident #1) and were aware of her significant confusion Monday. Summary of interview with resident's roommate (if applicable): N/A incident occurred in the shower room. Summary of interview with resident's family members/visitors: ADON spoke with (Resident #1's daughter). She was understanding and states she realizes what a challenging job we have and is thankful for the care her mom receives. Summary of investigator's findings: After interviewing all staff involved, the description of the incident is basically the same with the only difference being that the nurse states she was washing her face and (Resident #1) was biting the washcloth. There have been no prior concerns reported. Did the findings indicate that abuse occurred? No was checked. (if No, please explain) The nurse and staff were attempting to complete showering (Resident #1) while she was combative resulting in bruising to her scapula and a misunderstanding of the use of the washcloth. Additional dementia training and abuse, neglect training to be provided. Corrective action taken: In-servicing to be provided on dementia care and abuse ang (sic) neglect prevention and reporting. Did the resident and/or representative (sponsor) participate in determining the appropriate corrective action that was taken? Spoke with the daughter. Results of findings and corrective action taken reported to (check appropriate box below): Representative (sponsor) and CEO/ED (EDA) was checked. The Investigation Report did not contain documentation that indicated interviews were conducted with other residents on the hall where Resident #1 lived. The document did not contain information that indicated interviews were conducted with staff from all shifts who were in contact with Resident #1. In an interview and observation on 8/16/17 at 3:45 p.m. Resident #1 was in her room lying in bed on her right side. She was unable to participate in an interview. Observation of Resident #1's back revealed a 3cm x 3cm bruised area to the left scapula area. The bruise was yellow-green in color with a reddish speckling of a crisscrossed imprint pattern inside the bruising that matched the pattern of the mesh on the shower chair. In an observation and interview on 8/16/17 at 4:02 p.m. LVN A was on duty, working in the nurse's station. She said on 8/14/17 she took Resident #1 to her room to take her medications but Resident #1 spit them out twice. LVN A said it was time for Resident #1's shower and CNA B took Resident #1 in her wheelchair to the shower room. LVN A said she heard the screaming and yelling and went into the shower room to help. She said the CNAs got Resident #1's top and pants off and transferred her on to the shower chair. LVN A said CNA B was holding the shower nozzle and CNA A was washing Resident #1's feet and legs. LVN A said she was washing Resident #1's arm pits using shaving cream to control her body odor. LVN A said she was behind Resident #1 washing her. LVN A said she asked CNA B for a clean washcloth so she could wash Resident #1's face. She said she used a soapy cloth and then had CNA B rinse the cloth so she could rinse Resident #1's face. LVN A said some of the medication had crusted on Resident #1's mouth and she (LVN A) was washing Resident #1's mouth off. LVN A said she did not cover Resident #1's nose with the washcloth. She said she at no point covered her (Resident #1) nose and mouth with two other people in the same room. LVN A said Resident A was kicking and fighting the entire time they were trying to shower the resident. LVN A said Resident #1 kicked CNA C in the crotch. LVN A said she left after that and the two CNAs finished dressing Resident #1. In an interview on 8/16/17 at 4:39 p.m. the DON said he interviewed the three CNAs (CNA A, CNA B, and CNA C) and LVN A and all had consistent answers except for the perception of the wash cloth in front of Resident #1's face. When asked what his expectation of the staff was if a resident refused to take a shower, the DON said actually they should have backed off and I need to do more education on dementia care and how to respond. The DON said LVN A was allowed to return to work on 8/15/17, the day after the incident. The DON said he would not have let her work if he thought LVN A had intended to harm Resident #1. The DON said he was working with LVN A on communication. The DON said he needed to educate staff on reporting abuse in a timely manner. In a telephone interview on 8/16/17 at 5:10 p.m. CNA A said on 8/14/17 LVN A was trying to give Resident #1 her medicine so LVN A and CNA B took Resident #1 to her room. CNA A said when Resident #1 was brought out of her room, she had medicine powder all over her face. CNA A said she asked CNA B what happened and CNA B said LVN A held Resident #1's nose to get her to take her medicine. CNA A said she, CNA B and CNA C wanted to let Resident #1 calm down before she had her shower but LVN A said no, take her in. CNA A said after they took Resident #1 into the shower room CNA C left to go take care of another resident and LVN A came into the room. CNA A said LVN A put a dry washcloth over Resident #1' nose and mouth because she (LVN A) was afraid Resident #1 would start spitting. CNA A said Resident #1 was not spitting. CNA A said Resident #1 got quiet briefly and then her breathing changed and she was breathing heavily. CNA A said Resident #1 caught her breath and LVN A said look she wore herself out. CNA A said Resident #1 started kicking and thrashing and LVN A put the washcloth on Resident #1's nose and mouth again. CNA said CNA C came back into the room and LVN A left. She said the three CNAs dried Resident #1 and took her to her room. CNA A said Resident #1 had marks on her back from LVN A pushing her against the shower chair. She said Resident #1's wheelchair and the door hinge to the shower room were damaged from Resident #1 trying to back out of the shower room with LVN forcefully pushing her into the room. CNA A said neither she nor the other CNAs reported the incident immediately because they were afraid of LVN A, so they waited until LVN A left for the day and then reported it to the administrator on 8/14/17. A statement written by CNA A on 8/17/17 at 3:14 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: On Monday August 14, 2017 around 10 am (LVN A) at (name of facility) took (Resident #1) a resident at (name of facility) into her room after (Resident #1) became combative and was fighting and refusing to take her meds. (LVN A) had a CNA (CNA B) go into the room with her and (Resident #1) while (CNA C) and I tried to continue assisting other residents but heard (Resident #1) yelling and hollering in her room. When (Resident #1) was brought out she had powder from inside the pills all over her face. I then asked (CNA B) what had happened and was told (LVN A) had held (Resident #1's) nose shut and forced her to take the pills. It was (Resident #1's) shower day so (LVN A) then instructed 'us three CNAs' to go shower her. We attempted to get (Resident #1) inside the shower room but could not due to her fighting and hollering. 'Us three CNAs' decided to let (Resident #1) go back to her room to let her clam down and try again later. (LVN A) then came over to us and said that (Resident #1) would not calm down and to get her in there now. (LVN A) then forced (Resident #1) into the shower room causing the bottom hinge on the shower room door and (Resident #1's) right wheelchair brake to become broken due to (Resident #1) trying to back out of the shower room while (LVN A) forcefully pushed her in the shower room. (LVN A) had us transfer (Resident #1) into the shower chair and remove her clothes. (Resident #1) continued to holler and fight. (CNA E ) a CNA and CMA who works in Medical Records poked his head into the shower room to check what was going on and why (Resident #1) was in there yelling. As soon as he poked his head in, (LVN A) slammed the door in his face telling him to go. (Resident #1) continued (sic) to fight so (LVN A) then got a wash cloth (sic) and began to hold it over (Resident #1's) mouth and nose from behind. (LVN A) made the comment to us that she has had to do that to (Resident #1) before due to her spitting and biting. (Resident #1) was not however spitting at the time and only attempted to bite when (LVN A) got her arm too close to (Resident #1's) mouth. (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose for at least one minute, possibly longer. (CNA C) left the shower room to go assist other residents right after (LVN A) started to hold the wash cloth (sic) over (Resident #1's) mouth and nose and had heard (LVN A) say that she had done that before. While (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose, she instructed me to wash under her (Resident #1's) arms and had (CNA B) wash the soap off with the water. (LVN A) removed the wash cloth (sic) from (Resident #1's) nose and mouth when she started breathing heavily and calmed down. From looking at (Resident #1) it seemed as if she was going to pass out or stop breathing. (LVN A) then laughed saying look at her she wore herself out, she wasn't getting enough air. (Resident #1) began to fight and yell again and (LVN A) then got another wash cloth and held it over (Resident #1's) nose and mouth. (CNA C) then came back into the shower room. (LVN A) took the wash cloth (sic) off, left the shower room and 'us three CNAs' dried off (Resident #1) and got her dressed. The wash cloth was dry and was held over (Resident #1's) nose and mouth with so much force I believe it caused bruising to (Resident #1's) shoulders. When mentioned to the nurse the bruises on (Resident #1's) shoulders, she ignored my concerns. (CNA B) and I waited for (LVN A) to leave work that afternoon to go report the incident to (name of the EDA), the administrator and abuse coordinator for the facility, in fear that nothing would be done and (LVN A) would confront us and try to get back at us if she were to see us reporting the incident. She left work around 4 pm that day. Me and (CNA B) then went strait (sic) to (name of EDA) and reported the events with (Resident #1) that had happened that morning. After reporting what happened to (name of EDA), (CNA B) and I then went to get (Resident #1) up and toileted before supper. While sitting on the toilet (Resident #1) began talking about the events from that morning after (first name (ADON)) left after we showed her the bruising on (Resident #1's) shoulders and briefly explained to her what happened. (ADON) left to go to (EDA's) office and (Resident #1) began saying things like that lady was choking me, did y'all see her. (CNA B) and (CNA D) from another hall and I all heard (Resident #1) saying these things. (DON) then called me and (CNA B) into his office one at a time and had us tell him what happened while he wrote it down. We were told it would be investigated. The next day Tuesday August the 15th of 2017 (LVN A) showed up for work around 2 pm. She caught each of us three CNAs (CNA C, CNA B, and CNA A) by ourselves and questioned us if we were who tried to get her in trouble as she said. (LVN A) told me that (DON) told her he was going to let her keep her job because of the benefit of the doubt and that he said to her you know how young CNAs are. I acted like I had not said anything about what happened and she thanked me and said she could have lost her license over that. She asked me to let her know if I found out who had told. Ever since I started at (name of facility) in June 2017 I have seen (LVN A) verbally abuse residents and notice residents have fear towards her. In my time of working with (LVN A) since June 2017 I have seen her mistreat numerous residents and even the CNAs working with her. In my time of working at (name of facility) I have never seen (Resident #1) act as she did the morning of August 14, 2017. I have showered (Resident #1) numerous times and never had any experiences with her being combative or fighting. The statement was signed by CNA A and witnessed by two surveyors. In a telephone interview on 8/16/17 at 5:40 p.m. CNA B said the incident occurred on 8/14/17 around 10:00 a.m. CNA B said LVN A was going to give Resident #1's medications to her at the medication cart in Hall 2 but Resident #1 was refusing. CNA B said LVN A told her to take Resident #1 to her room and LVN A said to Resident #1 we're not going to do this in the hall and they took Resident #1 into her room. CNA B said LVN A held Resident #1's nose and forced her to take the pills into her mouth but Resident #1 spit them out. CNA B said LVN A then flushed the pills down the toilet. CNA B said she told LVN A that she could wait to give Resident #1 her shower, but LVN A said give her shower now. CNA B said she, CNA A and CNA C took Resident #1 to the shower and took off her clothes while Resident #1 was fighting, screaming and yelling. CNA B said LVN A came into the shower room, took a dry washcloth and put it over Resident #1's nose and mouth. When questioned if the wash cloth was placed in front of Resident #1's face or on her skin, CNA B repeated it was on her nose and mouth. CNA B said at that point Resident #1 got quiet and had labored breathing and I had to turn away. CNA B said when Resident #1 opened her eyes, LVN A put the washcloth on Resident #1's nose and mouth again. CNA B said LVN said look she wore herself out. CNA B said she held Resident #1's arms up so she could be washed under her arms. CNA B said CNA E started to come into the shower room because he had heard all of the yelling and screaming but LVN A closed the door in his face and said get out. CNA B said LVN A left the shower room, the three CNAs dried Resident #1 off, put her clothes on her and took her back to her room. CNA B said Resident #1 had marks on her back where LVN A had pushed her back into the shower chair. A statement written by CNA B on 8/17/17 at 2:00 p.m. confirmed the information provided in her phone interview on 8/16/17. Review of the written statement revealed: On Monday 14, 2017, (LVN A) which is my nurse for Hall 2 at (name of facility) was passing out med pass around 10:00 a.m. to (Resident #1). (Resident #1) refuse (sic) to take her pills. The nurse (LVN A) said, we are not doing this in the hall to (Resident #1). My nurse (LVN A) told me to take her to her room. So I, (CNA B) rolled her to her room and the nurse closed her door. Because (Resident #1) was still refusing to take her pills, the nurse pinch (sic) her nose so that she would open her mouth. When (Resident #1) open (sic) her mouth, the nurse (LVN A) put the pills inside her mouth but (Resident #1) spit the pills out of her mouth. So the nurse flush (sic) the pills into the toilet. Then I (CNA B) told (Resident #1) that today is her shower day. (Resident #1) refuse (sic) but the nurse (LVN A) said you have to take a shower right now. At that point she was resisant (sic) her shower and she was trying to hit and kick. So I told the nurse I can shower her later when she is calm. The nurse said no, shower her right now. So I rolled her to the shower room and (Resident #1) was still trying to get away by kicking and hitting. The shower door on Hall 2 on the bottom hinge is broken due to (Resident #1) resisting the shower. Then the nurse (LVN A) put a wash clothe (sic) on (Resident #1's) mouth and nose because (Resident#1) kept yelling help me, help me. When I saw (LVN A) put the wash cloth (sic) over her mouth and nose, I turn (sic) my head the other way because it was disturbing. Once I did not heard (sic) anymore yelling, I turn (sic) to look at (Resident #1) and she was motionless. The nurse said, that's because I cut the air from her. Once (Resident #1) started to move her head, arm and legs slowly the nurse grabbed another wash cloth (sic) close by the sink and put it over (Resident #1') mouth and nose again and then she removed the wash cloth (sic) and then we finished her shower. (CNA C) and (CNA A) help (sic) me with her shower. At some point (CNA E) poked his head inside the shower but (LVN A) closed the door. Later on around 1:00 p.m. (Resident #1's) daughter and son asked me what was wrong with their mother. I said please talk to the nurse. Around 3:00 p.m. on that same day we reported the abuse to (EDA's name). We were waiting for the nurse (LVN A) to leave because we were scare (sic). Then (DON's name) called us to his office and we told him everything that happened. When we were getting (Resident #1) up around 3:30 p.m. we told (ADON's name) what happen (sic) and showed her the red markings on (Resident #1's) upper back. On Tuesday, 15, 2017 after 2:00 p.m. the nurse (LVN A) followed me (CNA B) to the 'snowcone' truck. She was trying to find out who reported this abuse. This happened at (name of facility). The statement was signed by CNA B and witnessed by two surveyors. In a follow-up interview on 8/17/17 at 2:50 p.m. CNA B demonstrated Resident #1's reaction to the washcloth being placed over her face during the shower. CNA B demonstrated that Resident #1 was leaned back in the shower chair with her head back, eyes closed and her arms limp over the sides of the chair. CNA B started to cry stating she had just never seen anything like that and couldn't believe what had just happened. CNA B stated that on the day of the incident, Resident #1's daughter and son were there right after lunch and Resident #1 was crying. The daughter and son asked CNA B what was going on and CNA B responded she wasn't sure but thought it may have been associated with the incident that happened earlier in the shower room. In a telephone interview on 8/16/17 at 6:42 p.m. CNA C she worked from 6:00 a.m. to 12:30 p.m. on the day of the incident (8/14/17). She said it happened so fast. CNA C said LVN A and CNA B had gone to give Resident #1 her meds and when she came out of the room, Resident #1 had pills and powder all over her face. CNA C said she and CNA B took Resident #1 into the shower as ordered by LVN A. CNA C said she was taking Resident #1's shoes and pants off and Resident #1 was kicking at her but Resident #1 did not kick me. CNA C said I looked up and (LVN A's first name) had a dry washcloth over (Resident #1's name) nose and mouth. CNA C said she had to leave and go check on her residents and when she returned to the shower room LVN A was gone and she and CNA A and CNA B got Resident #1 dried off and dressed and Resident #1 was still fighting. CNA C said the DON called her that night and she told him exactly what had happened. CNA C said she came to work the next day (8/15/17) thinking that the EDA or DON might want to talk to her, but they didn't. CNA C said LVN A confronted her the next day and said we have to work together to which CNA C responded I don't know what you're talking about, I'm not the one who did anything wrong. When asked if the washcloth was in front of Resident #1's face or on her skin, CNA said it was on her nose and mouth and said (LVN A's name) doesn't treat her residents nice. A statement written by CNA C on 8/18/17 at 3:00 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: I and two other aides took (Resident #1) to the shower room to give her a shower since she had pills all over her. (Resident #1) was not happy and starting kicking, hitting, and trying to bit (sic). I was trying to take (Resident #1's) pants, shoes, and socks off so (CNA B) could give her a shower. (Resident #1) also tried to kick me in the face so I gave her a few moments then took her pants off. As I was about to head back to the hall since all aides and the nurse was in the shower room, I noticed (LVN A) had put a washcloth over (Resident #1's) mouth and nose. After I checked on the hall and came back in the shower room (Resident #1) was done with her shower and (LVN A) was out of the shower room. I helped (CNA B) and (CNA A) get (Resident #1) dressed and tried to calm her down. (Resident #1) did calm down. Then I had to leave work early that day. The wash cloth appeared to be touching (Resident #1's) mouth and nose. Like covering her lower face. The statement was signed by CNA C and witnessed by two surveyors. In an interview on 8/17/17 at 10:15 a.m. the EDA said the facility had not completed the investigation but it had been completed enough to determine it was not abuse. She said the facility was planning an in-service and would be training on prevention and reporting of abuse and addressing dementia specific stuff. She said the facility's determination that it was not abuse was based on their interviews with the staff that was present when the incident occurred. She said the DON talked to the aides who were there and the stories were similar but the difference in what happened was related to the washcloth. She said two staff said the nurse was just trying to wash Resident #1's face and as we looked at it and what goes on with residents we felt it was something different and needed to be addressed with dementia training. In an interview on 8/17/17 at 10:45 a.m. the DON said they had not completed the investigation but the nurse was working because of the interviews that were done determined the difference was the intent of the washcloth. He said the other stories matched. He said intent depends on who you talk to-if you talk to the CNAs, two of them didn't know what the intent was. He said the nurse said she held the washcloth in front of Resident #1's face to keep her from spitting on her. He said the bruises on Resident #1's scapula were from the netting on the shower chair. The DON said I'm sure they were trying to keep her in the shower chair. In a telephone interview on 8/17/17 at 11:05 a.m. Resident #1's daughter said the facility had notified her about the incident but she was not sure she received all of the information. The daughter said when she her mother on Monday 8/14/17 after the incident had occurred her mother (Resident #1) was not in a good mood. She said her mother had never had to take medication before and doesn't like to take it now. She said she had seen instances when her mother did not want to take the medication and she had seen LVN A push it at her and that sets mom off. The daughter said they probably had to get rough with her to get her shower done. When asked what her expectation was for staff responding to Resident #1's combativeness or resistance to care, the daughter said If I was the one doing it, I would back off. In a face-to-face interview on 8/21/17 at 1:50 p.m. Resident #1's daughter described the motion of LVN A pushing medication at Resident #1. The daughter said LVN A had tried to hand the pills to Resident #1 and when she would not take them the daughter demonstrated how LVN A forcefully extended her hand with the medication toward Resident #1 which upset Resident #1. When asked if she had ever been informed that Resident #1 exhibited problem behaviors during her shower, the daughter said no she had never heard anything negative. The daughter said during the care plan meetings she was always told the positive things her mother was doing. In an interview on 8/17/17 at 11:35 a.m. the ADON stated she did not know anything about the incident until after around 3:15 p.m. on 8/14/17 when the CNAs (CNA A and CNA B) wanted her to look at Resident #1's bruises on her back. She stated she asked what had happened and the CNAs told me about the incident and that they both had gone to the EDA. The ADON stated she didn't question the girls (CNAs) because they had already reported to the DON and EDA and they were taking care of it. In an interview on 8/17/17 at 12:09 p.m., CNA E stated he was walking down hall #2 where the shower room was located to take supplies to another room. CNA E stated he heard Resident #1 screaming in the shower room and stopped. He stated the door was locked so he knocked on the door and asked if they needed help. The door opened and LVN A said No. He stated he could tell there were other staff (CNAs) in the shower room. He stated he didn't know if they were in to give her a shower or to change her so he went on and delivered the supplies to the other resident. In an interview on 8/17/17 at 12:50 p.m. the HR Staff said she did not know anything about the incident with Resident #1. When asked if she was aware of any other incidents she said she would not provide any information due to fear of getting in trouble and losing her job. She said she was told in the past by this company that her information would be kept confidential and then she got in trouble by management for reporting an incident in the past. The HR staff declined to provide details. In an interview on 8/17/17 at 2:30 p.m. when asked if LVN A was suspended during the investigation, the DON said the day of the alleged abuse LVN A left at 2:00 or 3:00 p.m; her shift ended at 2:00 p.m. He said LVN A wasn't back on the floor until 2:30 p.m. the next day. The DON said We had done all of our interviews and everything we needed to do. She wasn't in the building (from the time she left her shift on 8/14/17 and returned to work on 8/15/17). I talked to all of the staff like I needed to. In an interview on 8/17/17 at 2:45 p.m. when asked if LVN A was suspended during the investigation, the EDA said At the time we received the report at 4:00 p.m. on 8/14/17, LVN A was not in the building and not expected to be back until 2:00 p.m. the next day. The EDA said by noon the following day (8/15/17) they got their information, we were not finding abuse and did not su(TRUNCATED)

Based on observation, interview and record review, the facility failed to have evidence that an alleged violation involving abuse was thoroughly investigated for one (Resident #1) of eight residents reviewed for abuse and failed to protect 19 residents including Resident #1 during the investigation. LVN A forced pills into Resident #1's mouth by pinching the resident's nose closed. LVN A forced Resident #1 into the shower room while the resident was upset, agitated and combative. LVN A then held a washcloth over Resident #1's nose and mouth while in the shower room. Resident #1 sustained bruising to her left shoulder in the scapula area. LVN A was not suspended following the incident with Resident #1 and continued working the floor. Interviews were not conducted with other residents and all staff having contact with the resident on the shift that the incident occurred. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/18/2017. After verification on 8/21/17 of the facility's Plan of Removal the IJ was lowered effective 8/18/17 to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1 and placed her and the other 18 residents on hall 2 at risk for harm due to LVN A being allowed to remain in direct contact with the residents for three days after the abuse occurred. Findings Included: Record review of Resident #1's Admission Record printed on 8/18/17 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's annual MDS (Minimum Data Set) dated 8/10/17 revealed she had a BIMS (Brief Interview for Mental Status) score of seven which indicated her cognitive function was moderately impaired. The MDS documented Resident #1 required extensive assistance with activities of daily living such as bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also documented she was incontinent of bowel and bladder. The MDS documented she was able to ambulate through the facility in her wheelchair. The MDS indicated Resident #1 did not have any behaviors of physical or verbal behaviors directed toward others and no behaviors directed toward herself, and no behaviors of screaming or disruptive sounds. Documentation indicated that the behavior of rejecting care did not occur. The only behavior documented that had occurred during the look-back period for the MDS assessment was wandering. Record review of Resident #1's care plan for risk of impaired cognition with revision date 8/11/17 revealed: Focus: (Resident #1's name) is at risk for impaired cognitive function/dementia or impaired thought processes related to [MEDICAL CONDITION]--at risk for communication deficits. Goal: (Resident #1's name) will maintain current level of cognitive function through the review date. Target date: 10/29/17. (Resident #1's name) will be able to communicate basic needs on a daily basis through the review date. Target date: 10/29/17. Interventions: COMMUNICATION: Identify yourself at each interaction with (Resident #1's name). Face when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. Use simple, directive sentences. Provide with necessary cues-stop and return if agitated . Record review of Resident #1's care plan for anxiety and use of medication with revision date of 6/19/17 revealed: Focus: (Resident #1's name) takes [MEDICATION NAME] for anxiety. At risk for adverse reactions and increased fall risk. Goal: Will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Target date 10/29/17. Interventions: .Give anti-anxiety medication .Monitor/document side effects and effectiveness. Antianxiety side effects: .confusion and disorientation .Paradoxical Side Effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations .Monitor/record occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc . Record review of the facility's Investigation Report Form signed and dated 8/17/17 by the EDA revealed: Name of Resident: (Resident #1's name) Date Incident Occurred: 8/14/17 Time: App 10:00 a.m. Date Incident Reported: 8/14/17 Time: 4:10 p.m. Incident Reported By: (CNA B) and (CNA A) Job Position: CNA's Type of Allegation: Abuse (not stated as abuse) Resident Injured: Yes Bruising on scapula following shower room incident with combativeness Injuries required medical attention: No Did the medical record review indicate any previous or unexplained injuries? Yes Fading bruising to face due to previous fall Name(s) of witness(es) to the incident: (CNA C's name) Name of person(s) accused: (LVN A), LVN Is the accused individual(s) an: Employee was checked Summary of interview with person(s) reporting the incident: Today in the shower room, (Resident #1) was being combative and (LVN A) came in to help (CNA B, CNA A, and CNA C). During the process, (LVN A) had a washcloth over (Resident #1's) face and did that twice. Summary of interview with witness(es): (CNA B and CNA A) came in to my office together and reported the above. They stated (CNA C) was also in the shower room when the incident occurred. As soon as the report was recived (sic) (DON's name), DON was notified. He contacted (CNA C) via phone as she was out of the building. She reported the same basic scenario but did not indicate (LVN A) was holding the washcloth over her face just that (LVN A) had a washcloth in front of (Resident #1's) face. Summary of interview with resident: (Resident #1's) cognitive impairment does not allow her to accurately report events once any time has passed. She had been talking about seeing her mommy and daddy earlier in the day. Summary of interview with staff members having contact with the resident during the period of the incident: The charge nurse and all 3 aides assigned to (Resident #1's) care were involved in the incident. Others with contact with (Resident #1) included DON, ADON, and ED (EDA) who had some interaction with (Resident #1) and were aware of her significant confusion Monday. Summary of interview with resident's roommate (if applicable): N/A incident occurred in the shower room. Summary of interview with resident's family members/visitors: ADON spoke with (Resident #1's daughter). She was understanding and states she realizes what a challenging job we have and is thankful for the care her mom receives. Summary of investigator's findings: After interviewing all staff involved, the description of the incident is basically the same with the only difference being that the nurse states she was washing her face and (Resident #1) was biting the washcloth. There have been no prior concerns reported. Did the findings indicate that abuse occurred? No was checked. (if No, please explain) The nurse and staff were attempting to complete showering (Resident #1) while she was combative resulting in bruising to her scapula and a misunderstanding of the use of the washcloth. Additional dementia training and abuse, neglect training to be provided. Corrective action taken: In-servicing to be provided on dementia care and abuse ang (sic) neglect prevention and reporting. Did the resident and/or representative (sponsor) participate in determining the appropriate corrective action that was taken? Spoke with the daughter. Results of findings and corrective action taken reported to (check appropriate box below): Representative (sponsor) and CEO/ED (EDA) was checked. The Investigation Report did not contain documentation that indicated interviews were conducted with other residents on the hall where Resident #1 lived. The document did not contain information that indicated interviews were conducted with staff from all shifts who were in contact with Resident #1. In an interview and observation on 8/16/17 at 3:45 p.m. Resident #1 was in her room lying in bed on her right side. She was unable to participate in an interview. Observation of Resident #1's back revealed a 3cm x 3cm bruised area to the left scapula area. The bruise was yellow-green in color with a reddish speckling of a crisscrossed imprint pattern inside the bruising that matched the pattern of the mesh on the shower chair. In an observation and interview on 8/16/17 at 4:02 p.m. LVN A was on duty, working in the nurse's station. She said on 8/14/17 she took Resident #1 to her room to take her medications but Resident #1 spit them out twice. LVN A said it was time for Resident #1's shower and CNA B took Resident #1 in her wheelchair to the shower room. LVN A said she heard the screaming and yelling and went into the shower room to help. She said the CNAs got Resident #1's top and pants off and transferred her on to the shower chair. LVN A said CNA B was holding the shower nozzle and CNA A was washing Resident #1's feet and legs. LVN A said she was washing Resident #1's arm pits using shaving cream to control her body odor. LVN A said she was behind Resident #1 washing her. LVN A said she asked CNA B for a clean washcloth so she could wash Resident #1's face. She said she used a soapy cloth and then had CNA B rinse the cloth so she could rinse Resident #1's face. LVN A said some of the medication had crusted on Resident #1's mouth and she (LVN A) was washing Resident #1's mouth off. LVN A said she did not cover Resident #1's nose with the washcloth. She said she at no point covered her (Resident #1) nose and mouth with two other people in the same room. LVN A said Resident A was kicking and fighting the entire time they were trying to shower the resident. LVN A said Resident #1 kicked CNA C in the crotch. LVN A said she left after that and the two CNAs finished dressing Resident #1. In an interview on 8/16/17 at 4:39 p.m. the DON said he interviewed the three CNAs (CNA A, CNA B, and CNA C) and LVN A and all had consistent answers except for the perception of the wash cloth in front of Resident #1's face. When asked what his expectation of the staff was if a resident refused to take a shower, the DON said actually they should have backed off and I need to do more education on dementia care and how to respond. The DON said LVN A was allowed to return to work on 8/15/17, the day after the incident. The DON said he would not have let her work if he thought LVN A had intended to harm Resident #1. The DON said he was working with LVN A on communication. The DON said he needed to educate staff on reporting abuse in a timely manner. In a telephone interview on 8/16/17 at 5:10 p.m. CNA A said on 8/14/17 LVN A was trying to give Resident #1 her medicine so LVN A and CNA B took Resident #1 to her room. CNA A said when Resident #1 was brought out of her room, she had medicine powder all over her face. CNA A said she asked CNA B what happened and CNA B said LVN A held Resident #1's nose to get her to take her medicine. CNA A said she, CNA B and CNA C wanted to let Resident #1 calm down before she had her shower but LVN A said no, take her in. CNA A said after they took Resident #1 into the shower room CNA C left to go take care of another resident and LVN A came into the room. CNA A said LVN A put a dry washcloth over Resident #1' nose and mouth because she (LVN A) was afraid Resident #1 would start spitting. CNA A said Resident #1 was not spitting. CNA A said Resident #1 got quiet briefly and then her breathing changed and she was breathing heavily. CNA A said Resident #1 caught her breath and LVN A said look she wore herself out. CNA A said Resident #1 started kicking and thrashing and LVN A put the washcloth on Resident #1's nose and mouth again. CNA said CNA C came back into the room and LVN A left. She said the three CNAs dried Resident #1 and took her to her room. CNA A said Resident #1 had marks on her back from LVN A pushing her against the shower chair. She said Resident #1's wheelchair and the door hinge to the shower room were damaged from Resident #1 trying to back out of the shower room with LVN forcefully pushing her into the room. CNA A said neither she nor the other CNAs reported the incident immediately because they were afraid of LVN A, so they waited until LVN A left for the day and then reported it to the administrator on 8/14/17. A statement written by CNA A on 8/17/17 at 3:14 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: On Monday August 14, 2017 around 10 am (LVN A) at (name of facility) took (Resident #1) a resident at (name of facility) into her room after (Resident #1) became combative and was fighting and refusing to take her meds. (LVN A) had a CNA (CNA B) go into the room with her and (Resident #1) while (CNA C) and I tried to continue assisting other residents but heard (Resident #1) yelling and hollering in her room. When (Resident #1) was brought out she had powder from inside the pills all over her face. I then asked (CNA B) what had happened and was told (LVN A) had held (Resident #1's) nose shut and forced her to take the pills. It was (Resident #1's) shower day so (LVN A) then instructed 'us three CNAs' to go shower her. We attempted to get (Resident #1) inside the shower room but could not due to her fighting and hollering. 'Us three CNAs' decided to let (Resident #1) go back to her room to let her clam down and try again later. (LVN A) then came over to us and said that (Resident #1) would not calm down and to get her in there now. (LVN A) then forced (Resident #1) into the shower room causing the bottom hinge on the shower room door and (Resident #1's) right wheelchair brake to become broken due to (Resident #1) trying to back out of the shower room while (LVN A) forcefully pushed her in the shower room. (LVN A) had us transfer (Resident #1) into the shower chair and remove her clothes. (Resident #1) continued to holler and fight. (CNA E ) a CNA and CMA who works in Medical Records poked his head into the shower room to check what was going on and why (Resident #1) was in there yelling. As soon as he poked his head in, (LVN A) slammed the door in his face telling him to go. (Resident #1) continued (sic) to fight so (LVN A) then got a wash cloth (sic) and began to hold it over (Resident #1's) mouth and nose from behind. (LVN A) made the comment to us that she has had to do that to (Resident #1) before due to her spitting and biting. (Resident #1) was not however spitting at the time and only attempted to bite when (LVN A) got her arm too close to (Resident #1's) mouth. (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose for at least one minute, possibly longer. (CNA C) left the shower room to go assist other residents right after (LVN A) started to hold the wash cloth (sic) over (Resident #1's) mouth and nose and had heard (LVN A) say that she had done that before. While (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose, she instructed me to wash under her (Resident #1's) arms and had (CNA B) wash the soap off with the water. (LVN A) removed the wash cloth (sic) from (Resident #1's) nose and mouth when she started breathing heavily and calmed down. From looking at (Resident #1) it seemed as if she was going to pass out or stop breathing. (LVN A) then laughed saying look at her she wore herself out, she wasn't getting enough air. (Resident #1) began to fight and yell again and (LVN A) then got another wash cloth and held it over (Resident #1's) nose and mouth. (CNA C) then came back into the shower room. (LVN A) took the wash cloth (sic) off, left the shower room and 'us three CNAs' dried off (Resident #1) and got her dressed. The wash cloth was dry and was held over (Resident #1's) nose and mouth with so much force I believe it caused bruising to (Resident #1's) shoulders. When mentioned to the nurse the bruises on (Resident #1's) shoulders, she ignored my concerns. (CNA B) and I waited for (LVN A) to leave work that afternoon to go report the incident to (name of the EDA), the administrator and abuse coordinator for the facility, in fear that nothing would be done and (LVN A) would confront us and try to get back at us if she were to see us reporting the incident. She left work around 4 pm that day. Me and (CNA B) then went strait (sic) to (name of EDA) and reported the events with (Resident #1) that had happened that morning. After reporting what happened to (name of EDA), (CNA B) and I then went to get (Resident #1) up and toileted before supper. While sitting on the toilet (Resident #1) began talking about the events from that morning after (first name (ADON)) left after we showed her the bruising on (Resident #1's) shoulders and briefly explained to her what happened. (ADON) left to go to (EDA's) office and (Resident #1) began saying things like that lady was choking me, did y'all see her. (CNA B) and (CNA D) from another hall and I all heard (Resident #1) saying these things. (DON) then called me and (CNA B) into his office one at a time and had us tell him what happened while he wrote it down. We were told it would be investigated. The next day Tuesday August the 15th of 2017 (LVN A) showed up for work around 2 pm. She caught each of us three CNAs (CNA C, CNA B, and CNA A) by ourselves and questioned us if we were who tried to get her in trouble as she said. (LVN A) told me that (DON) told her he was going to let her keep her job because of the benefit of the doubt and that he said to her you know how young CNAs are. I acted like I had not said anything about what happened and she thanked me and said she could have lost her license over that. She asked me to let her know if I found out who had told. Ever since I started at (name of facility) in June 2017 I have seen (LVN A) verbally abuse residents and notice residents have fear towards her. In my time of working with (LVN A) since June 2017 I have seen her mistreat numerous residents and even the CNAs working with her. In my time of working at (name of facility) I have never seen (Resident #1) act as she did the morning of August 14, 2017. I have showered (Resident #1) numerous times and never had any experiences with her being combative or fighting. The statement was signed by CNA A and witnessed by two surveyors. In a telephone interview on 8/16/17 at 5:40 p.m. CNA B said the incident occurred on 8/14/17 around 10:00 a.m. CNA B said LVN A was going to give Resident #1's medications to her at the medication cart in Hall 2 but Resident #1 was refusing. CNA B said LVN A told her to take Resident #1 to her room and LVN A said to Resident #1 we're not going to do this in the hall and they took Resident #1 into her room. CNA B said LVN A held Resident #1's nose and forced her to take the pills into her mouth but Resident #1 spit them out. CNA B said LVN A then flushed the pills down the toilet. CNA B said she told LVN A that she could wait to give Resident #1 her shower, but LVN A said give her shower now. CNA B said she, CNA A and CNA C took Resident #1 to the shower and took off her clothes while Resident #1 was fighting, screaming and yelling. CNA B said LVN A came into the shower room, took a dry washcloth and put it over Resident #1's nose and mouth. When questioned if the wash cloth was placed in front of Resident #1's face or on her skin, CNA B repeated it was on her nose and mouth. CNA B said at that point Resident #1 got quiet and had labored breathing and I had to turn away. CNA B said when Resident #1 opened her eyes, LVN A put the washcloth on Resident #1's nose and mouth again. CNA B said LVN said look she wore herself out. CNA B said she held Resident #1's arms up so she could be washed under her arms. CNA B said CNA E started to come into the shower room because he had heard all of the yelling and screaming but LVN A closed the door in his face and said get out. CNA B said LVN A left the shower room, the three CNAs dried Resident #1 off, put her clothes on her and took her back to her room. CNA B said Resident #1 had marks on her back where LVN A had pushed her back into the shower chair. A statement written by CNA B on 8/17/17 at 2:00 p.m. confirmed the information provided in her phone interview on 8/16/17. Review of the written statement revealed: On Monday 14, 2017, (LVN A) which is my nurse for Hall 2 at (name of facility) was passing out med pass around 10:00 a.m. to (Resident #1). (Resident #1) refuse (sic) to take her pills. The nurse (LVN A) said, we are not doing this in the hall to (Resident #1). My nurse (LVN A) told me to take her to her room. So I, (CNA B) rolled her to her room and the nurse closed her door. Because (Resident #1) was still refusing to take her pills, the nurse pinch (sic) her nose so that she would open her mouth. When (Resident #1) open (sic) her mouth, the nurse (LVN A) put the pills inside her mouth but (Resident #1) spit the pills out of her mouth. So the nurse flush (sic) the pills into the toilet. Then I (CNA B) told (Resident #1) that today is her shower day. (Resident #1) refuse (sic) but the nurse (LVN A) said you have to take a shower right now. At that point she was resisant (sic) her shower and she was trying to hit and kick. So I told the nurse I can shower her later when she is calm. The nurse said no, shower her right now. So I rolled her to the shower room and (Resident #1) was still trying to get away by kicking and hitting. The shower door on Hall 2 on the bottom hinge is broken due to (Resident #1) resisting the shower. Then the nurse (LVN A) put a wash clothe (sic) on (Resident #1's) mouth and nose because (Resident#1) kept yelling help me, help me. When I saw (LVN A) put the wash cloth (sic) over her mouth and nose, I turn (sic) my head the other way because it was disturbing. Once I did not heard (sic) anymore yelling, I turn (sic) to look at (Resident #1) and she was motionless. The nurse said, that's because I cut the air from her. Once (Resident #1) started to move her head, arm and legs slowly the nurse grabbed another wash cloth (sic) close by the sink and put it over (Resident #1') mouth and nose again and then she removed the wash cloth (sic) and then we finished her shower. (CNA C) and (CNA A) help (sic) me with her shower. At some point (CNA E) poked his head inside the shower but (LVN A) closed the door. Later on around 1:00 p.m. (Resident #1's) daughter and son asked me what was wrong with their mother. I said please talk to the nurse. Around 3:00 p.m. on that same day we reported the abuse to (EDA's name). We were waiting for the nurse (LVN A) to leave because we were scare (sic). Then (DON's name) called us to his office and we told him everything that happened. When we were getting (Resident #1) up around 3:30 p.m. we told (ADON's name) what happen (sic) and showed her the red markings on (Resident #1's) upper back. On Tuesday, 15, 2017 after 2:00 p.m. the nurse (LVN A) followed me (CNA B) to the 'snowcone' truck. She was trying to find out who reported this abuse. This happened at (name of facility). The statement was signed by CNA B and witnessed by two surveyors. In a follow-up interview on 8/17/17 at 2:50 p.m. CNA B demonstrated Resident #1's reaction to the washcloth being placed over her face during the shower. CNA B demonstrated that Resident #1 was leaned back in the shower chair with her head back, eyes closed and her arms limp over the sides of the chair. CNA B started to cry stating she had just never seen anything like that and couldn't believe what had just happened. CNA B stated that on the day of the incident, Resident #1's daughter and son were there right after lunch and Resident #1 was crying. The daughter and son asked CNA B what was going on and CNA B responded she wasn't sure but thought it may have been associated with the incident that happened earlier in the shower room. In a telephone interview on 8/16/17 at 6:42 p.m. CNA C she worked from 6:00 a.m. to 12:30 p.m. on the day of the incident (8/14/17). She said it happened so fast. CNA C said LVN A and CNA B had gone to give Resident #1 her meds and when she came out of the room, Resident #1 had pills and powder all over her face. CNA C said she and CNA B took Resident #1 into the shower as ordered by LVN A. CNA C said she was taking Resident #1's shoes and pants off and Resident #1 was kicking at her but Resident #1 did not kick me. CNA C said I looked up and (LVN A's first name) had a dry washcloth over (Resident #1's name) nose and mouth. CNA C said she had to leave and go check on her residents and when she returned to the shower room LVN A was gone and she and CNA A and CNA B got Resident #1 dried off and dressed and Resident #1 was still fighting. CNA C said the DON called her that night and she told him exactly what had happened. CNA C said she came to work the next day (8/15/17) thinking that the EDA or DON might want to talk to her, but they didn't. CNA C said LVN A confronted her the next day and said we have to work together to which CNA C responded I don't know what you're talking about, I'm not the one who did anything wrong. When asked if the washcloth was in front of Resident #1's face or on her skin, CNA said it was on her nose and mouth and said (LVN A's name) doesn't treat her residents nice. A statement written by CNA C on 8/18/17 at 3:00 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: I and two other aides took (Resident #1) to the shower room to give her a shower since she had pills all over her. (Resident #1) was not happy and starting kicking, hitting, and trying to bit (sic). I was trying to take (Resident #1's) pants, shoes, and socks off so (CNA B) could give her a shower. (Resident #1) also tried to kick me in the face so I gave her a few moments then took her pants off. As I was about to head back to the hall since all aides and the nurse was in the shower room, I noticed (LVN A) had put a washcloth over (Resident #1's) mouth and nose. After I checked on the hall and came back in the shower room (Resident #1) was done with her shower and (LVN A) was out of the shower room. I helped (CNA B) and (CNA A) get (Resident #1) dressed and tried to calm her down. (Resident #1) did calm down. Then I had to leave work early that day. The wash cloth appeared to be touching (Resident #1's) mouth and nose. Like covering her lower face. The statement was signed by CNA C and witnessed by two surveyors. In an interview on 8/17/17 at 10:15 a.m. the EDA said the facility had not completed the investigation but it had been completed enough to determine it was not abuse. She said the facility was planning an in-service and would be training on prevention and reporting of abuse and addressing dementia specific stuff. She said the facility's determination that it was not abuse was based on their interviews with the staff that was present when the incident occurred. She said the DON talked to the aides who were there and the stories were similar but the difference in what happened was related to the washcloth. She said two staff said the nurse was just trying to wash Resident #1's face and as we looked at it and what goes on with residents we felt it was something different and needed to be addressed with dementia training. In an interview on 8/17/17 at 10:45 a.m. the DON said they had not completed the investigation but the nurse was working because of the interviews that were done determined the difference was the intent of the washcloth. He said the other stories matched. He said intent depends on who you talk to-if you talk to the CNAs, two of them didn't know what the intent was. He said the nurse said she held the washcloth in front of Resident #1's face to keep her from spitting on her. He said the bruises on Resident #1's scapula were from the netting on the shower chair. The DON said I'm sure they were trying to keep her in the shower chair. In a telephone interview on 8/17/17 at 11:05 a.m. Resident #1's daughter said the facility had notified her about the incident but she was not sure she received all of the information. The daughter said when she her mother on Monday 8/14/17 after the incident had occurred her mother (Resident #1) was not in a good mood. She said her mother had never had to take medication before and doesn't like to take it now. She said she had seen instances when her mother did not want to take the medication and she had seen LVN A push it at her and that sets mom off. The daughter said they probably had to get rough with her to get her shower done. When asked what her expectation was for staff responding to Resident #1's combativeness or resistance to care, the daughter said If I was the one doing it, I would back off. In a face-to-face interview on 8/21/17 at 1:50 p.m. Resident #1's daughter described the motion of LVN A pushing medication at Resident #1. The daughter said LVN A had tried to hand the pills to Resident #1 and when she would not take them the daughter demonstrated how LVN A forcefully extended her hand with the medication toward Resident #1 which upset Resident #1. When asked if she had ever been informed that Resident #1 exhibited problem behaviors during her shower, the daughter said no she had never heard anything negative. The daughter said during the care plan meetings she was always told the positive things her mother was doing. In an interview on 8/17/17 at 11:35 a.m. the ADON stated she did not know anything about the incident until after around 3:15 p.m. on 8/14/17 when the CNAs (CNA A and CNA B) wanted her to look at Resident #1's bruises on her back. She stated she asked what had happened and the CNAs told me about the incident and that they both had gone to the EDA. The ADON stated she didn't question the girls (CNAs) because they had already reported to the DON and EDA and they were taking care of it. In an interview on 8/17/17 at 12:09 p.m., CNA E stated he was walking down hall #2 where the shower room was located to take supplies to another room. CNA E stated he heard Resident #1 screaming in the shower room and stopped. He stated the door was locked so he knocked on the door and asked if they needed help. The door opened and LVN A said No. He stated he could tell there were other staff (CNAs) in the shower room. He stated he didn't know if they were in to give her a shower or to change her so he went on and delivered the supplies to the other resident. In an interview on 8/17/17 at 12:50 p.m. the HR Staff said she did not know anything about the incident with Resident #1. When asked if she was aware of any other incidents she said she would not provide any information due to fear of getting in trouble and losing her job. She said she was told in the past by this company that her information would be kept confidential and then she got in trouble by management for reporting an incident in the past. The HR staff declined to provide details. In an interview on 8/17/17 at 2:30 p.m. when asked if LVN A was suspended during the investigation, the DON said the day of the alleged abuse LVN A left at 2:00 or 3:00 p.m; her shift ended at 2:00 p.m. He said LVN A wasn't back on the floor until 2:30 p.m. the next day. The DON said We had done all of our interviews and everything we needed to do. She wasn't in the building (from the time she left her shift on 8/14/17 and returned to work on 8/15/17). I talked to all of the staff like I needed to. In an interview on 8/17/17 at 2:45 p.m. when asked if LVN A was suspended during the investigation, the EDA s(TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited abuse for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement its policies and procedures to thoroughly investigate an allegation of abuse to Resident #1 by LVN A. LVN A was not suspended following the incident with Resident #1 and continued working the floor. The facility failed to ensure immediate reporting of allegations of abuse by staff without fear of reprisal. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/18/2017. After verification on 8/21/17 of the facility's Plan of Removal the IJ was lowered effective 8/18/17 to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1, and placed her and the other 18 residents on hall 2 at risk for harm due to LVN A being allowed to remain in direct contact with the residents for three days after the abuse occurred. Findings Include: Review of the facility's abuse prevention policy revised 11/28/2016 revealed: Policy/Procedure-Nursing Administration Section: Resident Rights Subject: Abuse Prevention POLICY: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident representatives, families, friends or other individuals. PR(NAME)EDURES: EMPLOYEE SCREENING- . 2. All employees will be properly screened for criminal background . 5. Licenses will be verified for all employees who hold licenses. TRAINING- . 1. Orientation program will include review of facility's policy on: . c. How staff should report their knowledge related to allegations without fear of reprisal . PREVENTION- All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Feedback regarding concerns will be given. The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Staff has knowledge of the individual residents' care needs. Supervision of staff to identify inappropriate behaviors (i.e., derogatory language, rough handling, ignoring residents while giving care, etc.) . IDENTIFICATION OF ABUSE- Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule out abuse . 3. Occurrences, patterns and trends will be assessed by Licensed staff and/or Interdisciplinary Team to determine the direction of the investigation. INVESTIGATION- All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/Designee will initiate an investigation. A licensed nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interview with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident' medical record; 5. An interview with staff members (on all shifts) having contact with the resident(s) during the period of the alleged incident; 6. Interviews with other residents to whom the accused employee provides care or services; 7. An interview with staff members (on all shifts) having contact with the accused employee; and 8. A review of all circumstances surrounding the incident. The person reporting the incident or allegation must follow the Abuse Prohibition Program checklist. All phases of the investigation will be kept confidential in accordance with the facility's policies governing the confidentiality of medical records and privilege of quality assurance/quality improvement programs. PROTECTION- If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps to prevent further potential abuse while the investigation is in progress; . 2. If the suspected perpetrator is an employee: a. Remove employee immediately from the care of any resident; b. Suspend employee during the investigation . DEFINITIONS-482.13(b) and (c) To assist the facility's staff members in recognizing incidents of abuse, the following definitions are provided Abuse-willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Mistreatment-means inappropriate treatment or exploitation of a resident . Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . Record review of Resident #1's Admission Record printed on 8/18/17 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's annual MDS (Minimum Data Set) dated 8/10/17 revealed she had a BIMS (Brief Interview for Mental Status) score of seven which indicated her cognitive function was moderately impaired. The MDS documented Resident #1 required extensive assistance with activities of daily living such as bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also documented she was incontinent of bowel and bladder. The MDS documented she was able to ambulate through the facility in her wheelchair. The MDS indicated Resident #1 did not have any behaviors of physical or verbal behaviors directed toward others and no behaviors directed toward herself, and no behaviors of screaming or disruptive sounds. Documentation indicated that the behavior of rejecting care did not occur. The only behavior documented that had occurred during the look-back period for the MDS assessment was wandering. Record review of Resident #1's care plan for risk of impaired cognition with revision date 8/11/17 revealed: Focus: (Resident #1's name) is at risk for impaired cognitive function/dementia or impaired thought processes related to [MEDICAL CONDITION]--at risk for communication deficits. Goal: (Resident #1's name) will maintain current level of cognitive function through the review date. Target date: 10/29/17. (Resident #1's name) will be able to communicate basic needs on a daily basis through the review date. Target date: 10/29/17. Interventions: COMMUNICATION: Identify yourself at each interaction with (Resident #1's name). Face when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. Use simple, directive sentences. Provide with necessary cues-stop and return if agitated . Record review of Resident #1's care plan for anxiety and use of medication with revision date of 6/19/17 revealed: Focus: (Resident #1's name) takes [MEDICATION NAME] for anxiety. At risk for adverse reactions and increased fall risk. Goal: Will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Target date 10/29/17. Interventions: .Give anti-anxiety medication .Monitor/document side effects and effectiveness. Antianxiety side effects: .confusion and disorientation .Paradoxical Side Effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations .Monitor/record occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc . Record review of the facility's Investigation Report Form signed and dated 8/17/17 by the EDA revealed: Name of Resident: (Resident #1's name) Date Incident Occurred: 8/14/17 Time: App 10:00 a.m. Date Incident Reported: 8/14/17 Time: 4:10 p.m. Incident Reported By: (CNA B) and (CNA A) Job Position: CNA's Type of Allegation: Abuse (not stated as abuse) Resident Injured: Yes Bruising on scapula following shower room incident with combativeness Injuries required medical attention: No Did the medical record review indicate any previous or unexplained injuries? Yes Fading bruising to face due to previous fall Name(s) of witness(es) to the incident: (CNA C's name) Name of person(s) accused: (LVN A), LVN Is the accused individual(s) an: Employee was checked Summary of interview with person(s) reporting the incident: Today in the shower room, (Resident #1) was being combative and (LVN A) came in to help (CNA B, CNA A, and CNA C). During the process, (LVN A) had a washcloth over (Resident #1's) face and did that twice. Summary of interview with witness(es): (CNA B and CNA A) came in to my office together and reported the above. They stated (CNA C) was also in the shower room when the incident occurred. As soon as the report was recived (sic) (DON's name), DON was notified. He contacted (CNA C) via phone as she was out of the building. She reported the same basic scenario but did not indicate (LVN A) was holding the washcloth over her face just that (LVN A) had a washcloth in front of (Resident #1's) face. Summary of interview with resident: (Resident #1's) cognitive impairment does not allow her to accurately report events once any time has passed. She had been talking about seeing her mommy and daddy earlier in the day. Summary of interview with staff members having contact with the resident during the period of the incident: The charge nurse and all 3 aides assigned to (Resident #1's) care were involved in the incident. Others with contact with (Resident #1) included DON, ADON, and ED (EDA) who had some interaction with (Resident #1) and were aware of her significant confusion Monday. Summary of interview with resident's roommate (if applicable): N/A incident occurred in the shower room. Summary of interview with resident's family members/visitors: ADON spoke with (Resident #1's daughter). She was understanding and states she realizes what a challenging job we have and is thankful for the care her mom receives. Summary of investigator's findings: After interviewing all staff involved, the description of the incident is basically the same with the only difference being that the nurse states she was washing her face and (Resident #1) was biting the washcloth. There have been no prior concerns reported. Did the findings indicate that abuse occurred? No was checked. (if No, please explain) The nurse and staff were attempting to complete showering (Resident #1) while she was combative resulting in bruising to her scapula and a misunderstanding of the use of the washcloth. Additional dementia training and abuse, neglect training to be provided. Corrective action taken: In-servicing to be provided on dementia care and abuse ang (sic) neglect prevention and reporting. Did the resident and/or representative (sponsor) participate in determining the appropriate corrective action that was taken? Spoke with the daughter. Results of findings and corrective action taken reported to (check appropriate box below): Representative (sponsor) and CEO/ED (EDA) was checked. The Investigation Report did not contain documentation that indicated interviews were conducted with other residents on the hall where Resident #1 lived. The document did not contain information that indicated interviews were conducted with staff from all shifts who were in contact with Resident #1. In an interview and observation on 8/16/17 at 3:45 p.m. Resident #1 was in her room lying in bed on her right side. She was unable to participate in an interview. Observation of Resident #1's back revealed a 3cm x 3cm bruised area to the left scapula area. The bruise was yellow-green in color with a reddish speckling of a crisscrossed imprint pattern inside the bruising that matched the pattern of the mesh on the shower chair. In an observation and interview on 8/16/17 at 4:02 p.m. LVN A was on duty, working in the nurse's station. She said on 8/14/17 she took Resident #1 to her room to take her medications but Resident #1 spit them out twice. LVN A said it was time for Resident #1's shower and CNA B took Resident #1 in her wheelchair to the shower room. LVN A said she heard the screaming and yelling and went into the shower room to help. She said the CNAs got Resident #1's top and pants off and transferred her on to the shower chair. LVN A said CNA B was holding the shower nozzle and CNA A was washing Resident #1's feet and legs. LVN A said she was washing Resident #1's arm pits using shaving cream to control her body odor. LVN A said she was behind Resident #1 washing her. LVN A said she asked CNA B for a clean washcloth so she could wash Resident #1's face. She said she used a soapy cloth and then had CNA B rinse the cloth so she could rinse Resident #1's face. LVN A said some of the medication had crusted on Resident #1's mouth and she (LVN A) was washing Resident #1's mouth off. LVN A said she did not cover Resident #1's nose with the washcloth. She said she at no point covered her (Resident #1) nose and mouth with two other people in the same room. LVN A said Resident A was kicking and fighting the entire time they were trying to shower the resident. LVN A said Resident #1 kicked CNA C in the crotch. LVN A said she left after that and the two CNAs finished dressing Resident #1. In an interview on 8/16/17 at 4:39 p.m. the DON said he interviewed the three CNAs (CNA A, CNA B, and CNA C) and LVN A and all had consistent answers except for the perception of the wash cloth in front of Resident #1's face. When asked what his expectation of the staff was if a resident refused to take a shower, the DON said actually they should have backed off and I need to do more education on dementia care and how to respond. The DON said LVN A was allowed to return to work on 8/15/17, the day after the incident. The DON said he would not have let her work if he thought LVN A had intended to harm Resident #1. The DON said he was working with LVN A on communication. The DON said he needed to educate staff on reporting abuse in a timely manner. In a telephone interview on 8/16/17 at 5:10 p.m. CNA A said on 8/14/17 LVN A was trying to give Resident #1 her medicine so LVN A and CNA B took Resident #1 to her room. CNA A said when Resident #1 was brought out of her room, she had medicine powder all over her face. CNA A said she asked CNA B what happened and CNA B said LVN A held Resident #1's nose to get her to take her medicine. CNA A said she, CNA B and CNA C wanted to let Resident #1 calm down before she had her shower but LVN A said no, take her in. CNA A said after they took Resident #1 into the shower room CNA C left to go take care of another resident and LVN A came into the room. CNA A said LVN A put a dry washcloth over Resident #1' nose and mouth because she (LVN A) was afraid Resident #1 would start spitting. CNA A said Resident #1 was not spitting. CNA A said Resident #1 got quiet briefly and then her breathing changed and she was breathing heavily. CNA A said Resident #1 caught her breath and LVN A said look she wore herself out. CNA A said Resident #1 started kicking and thrashing and LVN A put the washcloth on Resident #1's nose and mouth again. CNA said CNA C came back into the room and LVN A left. She said the three CNAs dried Resident #1 and took her to her room. CNA A said Resident #1 had marks on her back from LVN A pushing her against the shower chair. She said Resident #1's wheelchair and the door hinge to the shower room were damaged from Resident #1 trying to back out of the shower room with LVN forcefully pushing her into the room. CNA A said neither she nor the other CNAs reported the incident immediately because they were afraid of LVN A, so they waited until LVN A left for the day and then reported it to the administrator on 8/14/17. A statement written by CNA A on 8/17/17 at 3:14 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: On Monday August 14, 2017 around 10 am (LVN A) at (name of facility) took (Resident #1) a resident at (name of facility) into her room after (Resident #1) became combative and was fighting and refusing to take her meds. (LVN A) had a CNA (CNA B) go into the room with her and (Resident #1) while (CNA C) and I tried to continue assisting other residents but heard (Resident #1) yelling and hollering in her room. When (Resident #1) was brought out she had powder from inside the pills all over her face. I then asked (CNA B) what had happened and was told (LVN A) had held (Resident #1's) nose shut and forced her to take the pills. It was (Resident #1's) shower day so (LVN A) then instructed 'us three CNAs' to go shower her. We attempted to get (Resident #1) inside the shower room but could not due to her fighting and hollering. 'Us three CNAs' decided to let (Resident #1) go back to her room to let her clam down and try again later. (LVN A) then came over to us and said that (Resident #1) would not calm down and to get her in there now. (LVN A) then forced (Resident #1) into the shower room causing the bottom hinge on the shower room door and (Resident #1's) right wheelchair brake to become broken due to (Resident #1) trying to back out of the shower room while (LVN A) forcefully pushed her in the shower room. (LVN A) had us transfer (Resident #1) into the shower chair and remove her clothes. (Resident #1) continued to holler and fight. (CNA E ) a CNA and CMA who works in Medical Records poked his head into the shower room to check what was going on and why (Resident #1) was in there yelling. As soon as he poked his head in, (LVN A) slammed the door in his face telling him to go. (Resident #1) continued (sic) to fight so (LVN A) then got a wash cloth (sic) and began to hold it over (Resident #1's) mouth and nose from behind. (LVN A) made the comment to us that she has had to do that to (Resident #1) before due to her spitting and biting. (Resident #1) was not however spitting at the time and only attempted to bite when (LVN A) got her arm too close to (Resident #1's) mouth. (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose for at least one minute, possibly longer. (CNA C) left the shower room to go assist other residents right after (LVN A) started to hold the wash cloth (sic) over (Resident #1's) mouth and nose and had heard (LVN A) say that she had done that before. While (LVN A) held the wash cloth (sic) over (Resident #1's) mouth and nose, she instructed me to wash under her (Resident #1's) arms and had (CNA B) wash the soap off with the water. (LVN A) removed the wash cloth (sic) from (Resident #1's) nose and mouth when she started breathing heavily and calmed down. From looking at (Resident #1) it seemed as if she was going to pass out or stop breathing. (LVN A) then laughed saying look at her she wore herself out, she wasn't getting enough air. (Resident #1) began to fight and yell again and (LVN A) then got another wash cloth and held it over (Resident #1's) nose and mouth. (CNA C) then came back into the shower room. (LVN A) took the wash cloth (sic) off, left the shower room and 'us three CNAs' dried off (Resident #1) and got her dressed. The wash cloth was dry and was held over (Resident #1's) nose and mouth with so much force I believe it caused bruising to (Resident #1's) shoulders. When mentioned to the nurse the bruises on (Resident #1's) shoulders, she ignored my concerns. (CNA B) and I waited for (LVN A) to leave work that afternoon to go report the incident to (name of the EDA), the administrator and abuse coordinator for the facility, in fear that nothing would be done and (LVN A) would confront us and try to get back at us if she were to see us reporting the incident. She left work around 4 pm that day. Me and (CNA B) then went strait (sic) to (name of EDA) and reported the events with (Resident #1) that had happened that morning. After reporting what happened to (name of EDA), (CNA B) and I then went to get (Resident #1) up and toileted before supper. While sitting on the toilet (Resident #1) began talking about the events from that morning after (first name (ADON)) left after we showed her the bruising on (Resident #1's) shoulders and briefly explained to her what happened. (ADON) left to go to (EDA's) office and (Resident #1) began saying things like that lady was choking me, did y'all see her. (CNA B) and (CNA D) from another hall and I all heard (Resident #1) saying these things. (DON) then called me and (CNA B) into his office one at a time and had us tell him what happened while he wrote it down. We were told it would be investigated. The next day Tuesday August the 15th of 2017 (LVN A) showed up for work around 2 pm. She caught each of us three CNAs (CNA C, CNA B, and CNA A) by ourselves and questioned us if we were who tried to get her in trouble as she said. (LVN A) told me that (DON) told her he was going to let her keep her job because of the benefit of the doubt and that he said to her you know how young CNAs are. I acted like I had not said anything about what happened and she thanked me and said she could have lost her license over that. She asked me to let her know if I found out who had told. Ever since I started at (name of facility) in June 2017 I have seen (LVN A) verbally abuse residents and notice residents have fear towards her. In my time of working with (LVN A) since June 2017 I have seen her mistreat numerous residents and even the CNAs working with her. In my time of working at (name of facility) I have never seen (Resident #1) act as she did the morning of August 14, 2017. I have showered (Resident #1) numerous times and never had any experiences with her being combative or fighting. The statement was signed by CNA A and witnessed by two surveyors. In a telephone interview on 8/16/17 at 5:40 p.m. CNA B said the incident occurred on 8/14/17 around 10:00 a.m. CNA B said LVN A was going to give Resident #1's medications to her at the medication cart in Hall 2 but Resident #1 was refusing. CNA B said LVN A told her to take Resident #1 to her room and LVN A said to Resident #1 we're not going to do this in the hall and they took Resident #1 into her room. CNA B said LVN A held Resident #1's nose and forced her to take the pills into her mouth but Resident #1 spit them out. CNA B said LVN A then flushed the pills down the toilet. CNA B said she told LVN A that she could wait to give Resident #1 her shower, but LVN A said give her shower now. CNA B said she, CNA A and CNA C took Resident #1 to the shower and took off her clothes while Resident #1 was fighting, screaming and yelling. CNA B said LVN A came into the shower room, took a dry washcloth and put it over Resident #1's nose and mouth. When questioned if the wash cloth was placed in front of Resident #1's face or on her skin, CNA B repeated it was on her nose and mouth. CNA B said at that point Resident #1 got quiet and had labored breathing and I had to turn away. CNA B said when Resident #1 opened her eyes, LVN A put the washcloth on Resident #1's nose and mouth again. CNA B said LVN said look she wore herself out. CNA B said she held Resident #1's arms up so she could be washed under her arms. CNA B said CNA E started to come into the shower room because he had heard all of the yelling and screaming but LVN A closed the door in his face and said get out. CNA B said LVN A left the shower room, the three CNAs dried Resident #1 off, put her clothes on her and took her back to her room. CNA B said Resident #1 had marks on her back where LVN A had pushed her back into the shower chair. A statement written by CNA B on 8/17/17 at 2:00 p.m. confirmed the information provided in her phone interview on 8/16/17. Review of the written statement revealed: On Monday 14, 2017, (LVN A) which is my nurse for Hall 2 at (name of facility) was passing out med pass around 10:00 a.m. to (Resident #1). (Resident #1) refuse (sic) to take her pills. The nurse (LVN A) said, we are not doing this in the hall to (Resident #1). My nurse (LVN A) told me to take her to her room. So I, (CNA B) rolled her to her room and the nurse closed her door. Because (Resident #1) was still refusing to take her pills, the nurse pinch (sic) her nose so that she would open her mouth. When (Resident #1) open (sic) her mouth, the nurse (LVN A) put the pills inside her mouth but (Resident #1) spit the pills out of her mouth. So the nurse flush (sic) the pills into the toilet. Then I (CNA B) told (Resident #1) that today is her shower day. (Resident #1) refuse (sic) but the nurse (LVN A) said you have to take a shower right now. At that point she was resisant (sic) her shower and she was trying to hit and kick. So I told the nurse I can shower her later when she is calm. The nurse said no, shower her right now. So I rolled her to the shower room and (Resident #1) was still trying to get away by kicking and hitting. The shower door on Hall 2 on the bottom hinge is broken due to (Resident #1) resisting the shower. Then the nurse (LVN A) put a wash clothe (sic) on (Resident #1's) mouth and nose because (Resident#1) kept yelling help me, help me. When I saw (LVN A) put the wash cloth (sic) over her mouth and nose, I turn (sic) my head the other way because it was disturbing. Once I did not heard (sic) anymore yelling, I turn (sic) to look at (Resident #1) and she was motionless. The nurse said, that's because I cut the air from her. Once (Resident #1) started to move her head, arm and legs slowly the nurse grabbed another wash cloth (sic) close by the sink and put it over (Resident #1') mouth and nose again and then she removed the wash cloth (sic) and then we finished her shower. (CNA C) and (CNA A) help (sic) me with her shower. At some point (CNA E) poked his head inside the shower but (LVN A) closed the door. Later on around 1:00 p.m. (Resident #1's) daughter and son asked me what was wrong with their mother. I said please talk to the nurse. Around 3:00 p.m. on that same day we reported the abuse to (EDA's name). We were waiting for the nurse (LVN A) to leave because we were scare (sic). Then (DON's name) called us to his office and we told him everything that happened. When we were getting (Resident #1) up around 3:30 p.m. we told (ADON's name) what happen (sic) and showed her the red markings on (Resident #1's) upper back. On Tuesday, 15, 2017 after 2:00 p.m. the nurse (LVN A) followed me (CNA B) to the 'snowcone' truck. She was trying to find out who reported this abuse. This happened at (name of facility). The statement was signed by CNA B and witnessed by two surveyors. In a follow-up interview on 8/17/17 at 2:50 p.m. CNA B demonstrated Resident #1's reaction to the washcloth being placed over her face during the shower. CNA B demonstrated that Resident #1 was leaned back in the shower chair with her head back, eyes closed and her arms limp over the sides of the chair. CNA B started to cry stating she had just never seen anything like that and couldn't believe what had just happened. CNA B stated that on the day of the incident, Resident #1's daughter and son were there right after lunch and Resident #1 was crying. The daughter and son asked CNA B what was going on and CNA B responded she wasn't sure but thought it may have been associated with the incident that happened earlier in the shower room. In a telephone interview on 8/16/17 at 6:42 p.m. CNA C she worked from 6:00 a.m. to 12:30 p.m. on the day of the incident (8/14/17). She said it happened so fast. CNA C said LVN A and CNA B had gone to give Resident #1 her meds and when she came out of the room, Resident #1 had pills and powder all over her face. CNA C said she and CNA B took Resident #1 into the shower as ordered by LVN A. CNA C said she was taking Resident #1's shoes and pants off and Resident #1 was kicking at her but Resident #1 did not kick me. CNA C said I looked up and (LVN A's first name) had a dry washcloth over (Resident #1's name) nose and mouth. CNA C said she had to leave and go check on her residents and when she returned to the shower room LVN A was gone and she and CNA A and CNA B got Resident #1 dried off and dressed and Resident #1 was still fighting. CNA C said the DON called her that night and she told him exactly what had happened. CNA C said she came to work the next day (8/15/17) thinking that the EDA or DON might want to talk to her, but they didn't. CNA C said LVN A confronted her the next day and said we have to work together to which CNA C responded I don't know what you're talking about, I'm not the one who did anything wrong. When asked if the washcloth was in front of Resident #1's face or on her skin, CNA said it was on her nose and mouth and said (LVN A's name) doesn't treat her residents nice. A statement written by CNA C on 8/18/17 at 3:00 p.m. confirmed the information provided in her interview on 8/16/17. Review of the written statement revealed: I and two other aides took (Resident #1) to the shower room to give her a shower since she had pills all over her. (Resident #1) was not happy and starting kicking, hitting, and trying to bit (sic). I was trying to take (Resident #1's) pants, shoes, and socks off so (CNA B) could give her a shower. (Resident #1) also tried to kick me in the face so I gave her a few moments then took her pants off. As I was about to head back to the hall since all aides and the nurse was in the shower room, I noticed (LVN A) had put a washcloth over (Resident #1's) mouth and nose. After I checked on the hall and came back in the shower room (Resident #1) was done with her shower and (LVN A) was out of the shower room. I helped (CNA B) and (CNA A) get (Resident #1) dressed and tried to calm her down. (Resident #1) did calm down. Then I had to leave work early that day. The wash cloth appeared to be touching (Resident #1's) mouth and nose. Like covering her lower face. The statement was signed by CNA C and witnessed by two surveyors. In an interview on 8/17/17 at 10:15 a.m. the EDA said the facility had not completed the investigation but it had been completed enough to determine it was not abuse. She said the facility was planning an in-service and would be training on prevention and reporting (TRUNCATED)

Based on interview and record review, the facility failed to notify the physician with significant changes in condition (critical blood sugar values) for 3 of 8 residents reviewed for diabetes (Resident #12, #13, and #14) as evidenced by: a) failure to ensure Licensed Vocational Nurse (LVN) A and B notified the physician when Resident #14 was symptomatic of hypo/ [MEDICAL CONDITION] and her blood sugar level was at a critically low value (less than 30 or greater than 400.) The first glucometer reading LVN A took of Resident #14's blood sugar registered E4 on the meter (either too high for a reading or the strip was inserted incorrectly). b) failure to ensure licensed nurses (including LVN A and B) followed facility's physician notification protocol and Resident #13 and #14's care plan/physician orders [REDACTED]. Resident #13 and #14 were unstable diabetics with frequent fluctuations, often in critically high and low ranges. c) failure to ensure Resident #12 had blood sugar parameters defined in her clinical record. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical condition for Residents #12, #13 and #14. On 07/25/13 an Immediate Jeopardy (IJ) was identified. On 07/26/13 the IJ was lowered to potential for more than minimal harm at a pattern after the facility developed and implemented an action plan to remove the IJ prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure to notify physicians regarding residents' changes in condition, such as blood sugar that is outside of the parameters identified by physicians could affect the 13 residents the facility identified who received fingerstick blood sugar checks. These failures could result in diabetic complications and/or death. The findings included: RESIDENT #14 Review of Resident #14's face sheet dated 4/24/13 documented she was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident's Care Plan dated 10/25/11 and revised 7/2013 documented in part: Problem: Potential for hyper/[DIAGNOSES REDACTED] and other complications related to diabetes. Resident has episodes of low blood sugar levels and high blood sugar levels. Insulin dependent, sliding scale. Resident periodically refuses insulin. Goal: Will remain free of s/s (sign and symptoms) of hypo/[MEDICAL CONDITION] and other complications of diabetes through next review. Approach: (1) Assess/record/report to MD (medical doctor) s/s of hyper/[DIAGNOSES REDACTED] or other complications related to diabetes (2) Administer medications as ordered-monitor for effectiveness and side effects. [MEDICATION NAME] 1 mg (milligram){ as needed for blood sugar less than 50. Give orange juice if able to swallow. (3) Obtain and monitor lab/diagnostic work as ordered- report results to MD. Parameters greater than 401 or less than 50, notify MD, family and on call nurse.(4)Monitor consumption of snacks and document refusals. Also offer substitutes as appropriate Review of the July 2013 Physician order [REDACTED]. The physician ordered [MEDICATION NAME] N 25 units subcutaneous (SQ) every morning after breakfast and [MEDICATION NAME] N 12 units SQ every night after supper. The sliding scale for the May 2013 Medication Administration Record (MAR) documented: Blood Sugar between 0 - 150 = 0 units Blood Sugar between 151 - 200 = 4 units Blood Sugar between 201 - 250 = 8 units Blood Sugar between 251 - 300 = 12 units Blood Sugar between 301 - 350 = 16 units Blood Sugar between 351 - 400 = 18 units Blood Sugar 401 or greater = 18 units and call M.D. Review of the telephone orders documented on 4/15/13 - Notify physician if blood glucose is less than 40 or greater than 400. Comparison of the MAR and the rest of the clinical record documented Resident #14's out of range blood glucose readings were: April 2013: 4/03/13 at 6:30 a.m. CBG (capillary blood glucose) = 465; 4/03/13 at 11a.m. CBG = 405; 4/03/13 at 4 p.m. CBG = 436; 4/04/13 at 6:30 a.m. CBG = 409; 4/04/13 at 11a.m. CBG = 447; 4/04/13 at 4 p.m. CBG = 'HI'; 4/04/13 at 8 p.m. CBG = 'HI'; 4/08/13 at 6:30 a.m. CBG = 497; 4/08/13 at 11a.m. CBG = E-4; 4/08/13 at 4 p.m. CBG = 'HI'; 4/08/13 at 8 p.m. CBG = 'HI'; 4/09/13 at 6:30 a.m. CBG = E-4; 4/09/13 at 11 a.m. CBG = E-4; 4/09/13 at 4 p.m. CBG = E-4; 4/09/13 at 8 p.m. CBG = 'HI'; 4/10/13 at 6:30 a.m. CBG = 'HI'; 4/10/13 at 11 a.m. CBG = 'HI'; 4/10/13 at 4 p.m. CBG = 'HI'; 4/11/13 at 11 a.m. CBG = 410; 4/12/13 at 6:30 a.m. CBG = 407; 4/13/13 at 4 p.m. CBG = 447; 4/13/13 at 8 p.m. CBG = 'HI'; 4/14/13 at 6:30 a.m. CBG = 'HI'; 4/14/14 at 11 a.m. CBG = 'HI'; 4/14/13 at 8 p.m. CBG = 'HI'; 4/15/13 at 6:30 a.m. CBG = 450 (Values between 57 and 471 and multiple high readings) May 2013: 5/07/13 at 4 p.m. CBG = 403; 5/08/13 at 4 p.m. CBG = 028; 5/12/13 at 6:30 a.m. CBG = 42; 5/18/13 at 4 p.m. CBG = 43; 5/19/13 at 6:30 a.m.___ at 4 p.m. CBG = 33; 5/21/13 at 4 p.m. CBG = 49; 5/28/13 at 6:30 a.m. CBG = 485; 5/31/13 at 11 a.m. CBG = 'HI'. (Values between 21 and 461 and multiple high readings.) June 2013: 6/01/13 at 11 a.m. CBG = 427; 6/05/13 at 4 p.m. CBG = 500; 6/10/13 at 4 p.m. CBG = 39; 6/14/13 at 6:30 a.m. CBG = 468; 6/16/13 at 6:30 a.m. CBG = 'HI'. (Values between 29 and 500 and multiple 'HI' readings) July 2013: 7/02/13 at 6:30 a.m. CBG = 'HI'; 7/03/13 at 6:30 a.m. CBG = 435; 7/04/13 at 6:30 a.m. CBG = E-4; 7/06/13 at 6:30 a.m. CBG = E-4; 7/06/13 at 4 p.m. CBG = 39 after intervention it read 93; 7/08/13 at 11 a.m. CBG = 453; 7/08/13 at 4 p.m. CBG = 453; 7/0813 at 4 p.m. CBG = 38 after intervention it read 86; 7/09/13 at 11 a.m. CBG = E-4; 7/11/13 at 6:30 a.m. CBG = E-4; 7/11/13 at 11a.m. CBG = 429; 7/16/13 at 4 p.m. CBG = 34 the follow-up reading documented 219; 7/16/13 at 8 p.m. CBG = 'HI'; 7/17/13 at 11 a.m. CBG = 400; 7/18/13 at 11 a.m. CBG = 'HI'; 7/20/13 at 11a.m. CBG = 479; 7/21/13 at 6:30 a.m. CBG = 'HI'; 7/21/13 at 11 a.m. CBG = 451; and 7/23/13 at 11a.m. CBG = E-4. (Resident #14's blood sugar levels fluctuated between 'Lo' on 7/12/13 to 32 on 7/10/13 to 1114 on 7/22/13) (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #14's physician on these dates.) Review of Nurses Notes documented: 4/24/13 at 7:00 a.m. before breakfast accucheck - 471 administered routine [MEDICATION NAME] N 25 units with 10 units [MEDICATION NAME] R per sliding scale, breakfast then administered. Patient's appetite poor consumes one can of glucerna, before breakfast through breakfast without signs or symptoms of [MEDICAL CONDITION], denies any pain/discomfort. (There was nothing in the clinical record to indicate the physician was notified.) 4/29/13 7:15 a.m. Blood sugar = 'HI' insulin administered per MAR. 7:30 a.m. BS HI; 7:45 a.m. Blood Sugar (BS) HI; 8:10 a.m. BS = HI; 9:15 a.m. BS = HI on call provider paged, no acute distress observed. 10:00 a.m. BS = HI; 10:25 a.m. BS = 418. 5/07/13 at 1:15 a.m. LVN G documented (Aide) in Resident's room providing incontinent care when she noticed resident "not being her usual self." LVN G arrived in room to find resident lying supine in bed even-unlabored respirations, non-responsive to verbal questions. Finger stick glucose at 38. Administered 1 mg [MEDICATION NAME] Intra-muscular (IM) to right anterior thigh, tolerated well. 1:25 a.m. finger stick blood sugar - 51. Resident now responsive, given a cup of orange juice to drink and peanut butter crackers. 1:40 a.m. finger stick blood sugar-94, resident alert and oriented x 3. (There was no documentation indicating the doctor was notified of this occurrence.) 5/11/13 LVN A 10:30 a.m. Resident noted to be very lethargic, sweaty, staring into space. Non-responsive to verbal stimuli. Blood sugar check at this time. Blood sugar 39. Peanut butter crackers and 4 ounces of ensure given. 10:45 a.m. Blood sugar rechecked at this time. Blood sugar now 96. (There was no documentation indicating the physician was notified of this incident) 5/19/13 at 4:30 p.m. Accu checks done. Blood sugar 33. Peanut butter and crackers and 6 ounces Ensure given. Resident is alert and oriented x 2. No signs or symptoms of [DIAGNOSES REDACTED] noted. 5:30 p.m. Blood sugar rechecked at this time. Blood sugar now 117. (There was nothing in the clinical record to indicate the physician was notified. ) 5/22/13 at 2:30 a.m. LVN H documented C.N.A. doing check and change/repositioning found resident unresponsive, blood sugar check of 69 noted but resident unable to swallow. [MEDICATION NAME] 1 mg injection given IM. 2:45 a.m. Blood sugar-135 and drunk 240 ml glucerna. (There was no documentation the doctor was notified of the non-responsive status of Resident #14) 5/29/13 documented by LVN A at 6:30 a.m. Accuchecks done in index finger of right hand. Blood sugar 362. Covered with 25 units Humalog and 18 units regular insulin. Injection given sub q in left abdomen. Tolerated injection well. 5:20 p.m. Resident non-responsive. Blood sugar check. Blood sugar 21. [MEDICATION NAME] injection given in left deltoid at this time. Resident now alert enough to drink ensure. 5:30 p.m. Blood sugar rechecked now 62. Peanut butter crackers given. Husband at side. Resident more alert now. 5:45 p.m. Accucheck done in middle finger of left hand. Blood sugar is now 125. (There was no documentation indicating the doctor was notified of the low blood sugar reading.) 6/06/13 at 11:30 a.m. CBG remains 'Hi' 18 units [MEDICATION NAME] R given. 1:00 p.m. CBG is 284 Resident alert and oriented. (There was nothing indicating the doctor was notified of the 'HI' reading.) 5:40 p.m. called to resident's room. Husband states "I think she's low." CBG 29. Resident awake, confused. Ice cream spoon fed. Two 4oz of orange juice with sugar packets given. 5:50 p.m. CBG 48. Resident able to tolerate crackers and can of glucerna. 6:00 p.m. CBG 84. Resident alert, able to follow commands. Husband remains in room. (There was nothing indicating the doctor was notified of the blood sugar of 29 or 48.) 6/07/13 at 6:30 a.m. Accucheck performed using aseptic technique, reading E-4 on glucometer (which means blood sugar too high to register) 25 units [MEDICATION NAME] and 18 units regular insulin given sub q in right abdomen. 8 a.m. Doctor's office called, spoke with nurse. Nurse stated she would give the message to the doctor. 6/07/13 at 11:30 a.m. blood sugar check at this time. Is now registering 'HI' on glucometer. 18 units regular insulin given. Call placed to Doctor's office again. Nurse states she would give him the message. Awaiting response. 6/06/13 at 11:30 a.m. LVN I documented CBG remains 'Hi' 18 units [MEDICATION NAME] R given. 1:00 p.m. CBG is 284 Resident alert and oriented. 2:00 p.m. Blood sugar 404 (There was no documentation the physician was notified of the high blood sugar) 6/13/13 at 11:00 a.m. LVN A documented accuchecks done. Blood sugar 459. Covered with 18 units regular insulin. 1:30 p.m. Doctor notified of high blood sugar no new orders. 3:15 p.m. Resident perspiring, glassy eyed. Blood sugar check shows blood sugar of 46. Peanut butter cracker and apple juice (4 oz.) given. 3:30 p.m. accucheck done. Blood sugar now 86. 4:30 p.m. Blood sugar rechecked, is now 119. No insulin coverage required. (There was no indication the doctor was notified of the low blood sugar.) 6/16/13 at 6:30 a.m. LVN A documented accucheck performed in index finger of right hand using aseptic technique. One stick. Accucheck read 'HI'. 6:35 a.m. 'HI' blood sugar covered with [MEDICATION NAME]25 units and 18 units of regular insulin. (There was no documentation indicating the doctor was notified of the 'HI' reading. 06/16/13 at 03:00 a.m. LVN H documented resident found unresponsive. Finger stick blood sugar of 51 noted. [MEDICATION NAME] 1 mg IM given. 3:30 a.m. follow up blood sugar of 126 noted. 240 ml glucerna given. (There was no indication the doctor was notified of resident being found non-responsive) 7/02/13 at 12:30 a.m. (signature illegible) Called to resident room by staff. Resident in bed cold and clammy and trembling. CBG registered 'LO' on glucometer. [MEDICATION NAME] 1 mg IM administered to left thigh. 12:40 a.m. CBG 55. Resident is refusing Glucerna and juice. Becoming more alert, responding appropriately. 12:53 a.m. CBG 78. Sitting upright on the side of the bed drinking orange juice and eating crackers. (There was nothing in the clinical record to indicate the physician was notified.) 7/04/13 at 6:30 a.m. documented by LVN A accucheck done. Glucometer reads E-4. Insulin given per orders. 11:00 a.m. Blood sugar shows to be 37. Peanut Butter crackers and can of Glucerna given. 11:30 a.m. Accucheck done. Blood sugar now 92. Resident has shown no signs or symptoms of [DIAGNOSES REDACTED]. (There was nothing indicating the doctor was notified of either the E-4 reading or the low reading of 37) 7/05/13 at 4:30 p.m. LVN A documented, Alert and oriented, speech slightly slurred. Accucheck done. Blood sugar 38. Peanut butter crackers and 6 oz. soda given. 4:45 p.m. Blood sugar rechecked is now 86. (There was nothing indicating the doctor was notified of the low blood sugar reading) 7/06/13 at 430 p.m. LVN A documented Accucheck done. Blood sugar 39. (There was nothing indicating the doctor was notified of the 39 reading. 7/12/13 at 2:30 a.m. LVN G documented aide present in room to provide peri-care and noticed decreased alertness, resident sweating. Accucheck done read 'LO' administered Glucogen 1 mg to left thigh, tolerated well, remaining in room to monitor. 2:45 a.m. accucheck read 46, increased alertness with resident. Tolerating small amount of orange juice with one sugar packet and eating small amount peanut butter crackers. Resident stable, continuing to monitor. 3:00 a.m. accucheck read 131. 3:05 a.m. will contact physician in morning. (There was no documentation the doctor was notified of the low blood sugar, change in level of consciousness, or treatment administered.) 7/18/13 at 11:00 a.m. LVN E documented accucheck 'HI', sliding scale 18 units [MEDICATION NAME] R sq tolerated. (There was no indication the doctor was notified of the 'HI' reading.) 7/18/13 at 2:00 a.m. LVN H documeted nurse heard a noise, started to check on Hall 3 residents and found this resident unresponsive, clammy, sweating and jerking. Blood sugar check reads 49. [MEDICATION NAME] 1 mg injection given to the left thigh. 2:40 a.m. Resident smiling stated "thank you for helping me" after she is cleaned and given 1 can of glucerna. Blood sugar check of 119 noted. Husband and doctor will be notified in the morning. (There was nothing in the clinical record to indicate the physician was notified.) 7/20/13 at 11:30 a.m. LVN A documented blood sugar at this time is 479. 18 units regular insulin given subq in left abdomen. Tolerated injection well. (There was no indication the doctor was notified of this high blood sugar reading.) 7/22/13 at 11:00 a.m. LVN B documented blood sugar results E-4 when lab called with results critical high glucose results 1114. Notified doctor of results, his orders were as follows: continue current insulin at current sliding scale monitor for changes if blood sugar does not lower by the early morning to notify him again for possible order changes. 7/24/13 at 4:30 p.m. LVN A documented blood sugar reading E-4 (too high to register) informed doctor of giving 18 units of regular insulin. Doctor stated recheck blood sugar if still high follow sliding scale orders. Increase [MEDICATION NAME] N insulin to 30 units subq twice a day after breakfast and after supper. Review of Resident #14's 6/24/13 quarterly Minimum Data Set (MDS) Assessment documented she was diabetic and received seven days of insulin injections. During a telephone interview on 07/26/13 at 11:21 a.m. the Primary Care Provider J (PCP) said the facility would call him often because Resident #14 was a brittle diabetic. PCP J stated "I believe E-4 indicated 600 or higher I think? E-4 means high doesn't it?" PCP J said it was "OK" to give the insulin. During an interview on 7/27/13 at 11:10 a.m. the DON acknowledged she could not find where the doctor had been notified of the above incidents of abnormal blood glucose testing or changes in condition. She said she did not believe the doctor needed to be notified on 5/22/13 because Resident #14 was still above parameters and she responded to treatment. RESIDENT #12 The Admission Record face sheet dated 3/25/13 showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was an [AGE] year old female. Review of Resident #12's MDS assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to the day of the week, and her recall was good. Resident #12's care plan for Diabetes, dated 1/25/13 documented the goals as: "Resident will experience no adverse effects related to diabetes during the next 90 days. Resident will have blood sugar within range of 70 - 200 during the next 90 days. Resident will receive treatment if blood sugars out of range during the next 90 days." The approaches were: "Monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs of [MEDICAL CONDITION]-dry mouth, thirst, disorientation and drowsiness. Inform resident and family of diet restrictions and encourage their cooperation and compliance. Monitor for signs of [DIAGNOSES REDACTED]-confusion, hunger, weakness, shakiness, diaphoresis, lethargy. Administer medications and insulin as ordered. Monitor labwork as ordered. Administer orange juice and other concentrated sweets for low blood sugars. Administer insulin or other ordered medication for elevated blood sugar. Inform physician and family of any adverse findings." Review of nurse's notes in the current clinical record (from 3/13/13 to 7/25/13) documented: 4/28/13 at 7:00 a.m. - "blood sugar 58, held insulin at this time. Administered orange juice." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/07/13 at 6:50 a.m. - "blood sugar 47. Administered orange juice and peanut butter crackers. Rechecked blood sugar and was 94. Denied symptoms of [DIAGNOSES REDACTED]." There was no documentation of physician notification of the blood sugar reading. 5/11/13 at 6:40 p.m.- "resident sitting on floor at foot of bed. Stated was attempting to get to restroom by self but became weak and fell . Noted that no supper had been eaten. Blood sugar checked at 35. Had resident drink 8 ounces of orange juice with one teaspoon sugar and peanut butter crackers. Rechecked blood sugar at 7:20 p.m. and 104. Levimir dose for night held. Will continue to monitor blood sugar and pain from fall." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/25/13 at 4:50 a.m. - "awake and blood sugar 43. Orange juice and candy bar consumed. Alert now. No signs or symptoms of [DIAGNOSES REDACTED]. Blood sugar at 5:20 a.m. now 62-orange juice consumed." There was no documentation of physician notification of the blood sugar readings. 5/26/13 at 9:00 p.m. - "blood sugar 43- consumed orange juice. No signs/symptoms of [DIAGNOSES REDACTED]. At 9:30 p.m. blood sugar 57- orange juice and candy bar consumed." There was no documentation of physician notification of the blood sugar readings. 5/30/13 at 4:30 p.m. - "blood sugar 40. Administered peanut butter crackers and orange juice. Waited a few minutes. Blood sugar now 70." There was no documentation of physician notification of the blood sugar reading. 6/05/13 at 8:00 p.m.- "blood sugar 50. Orange juice to drink. Recheck at 8:15 p.m. blood sugar 98." There was no documentation of physician notification of the blood sugar reading. 6/07/13 at 6:15 a.m. - "blood sugar checked, glucometer reading "E4." Patient alert and oriented. States feels fine. Administered scheduled Levimir 12 units and [MEDICATION NAME] 10 units per sliding scale at this time. Rechecked blood sugar at 7:30 a.m. before breakfast. Results continue to be "E4." Patient continues to have no signs/symptoms of being effected by increased blood sugar. Attempted to call doctor but no answer. At 8:45 a.m. blood sugar checked and remains to have "E4." Patient ate 50% of breakfast. Attempted to reach doctor again-no answer. Message left to return call ASAP. At 9:30 a.m. still unable to reach doctor. Called hospice nurse. Orders to get a glucose draw now. At 11:45 a.m. blood sugar results read "HI." Administered 10 units [MEDICATION NAME] per sliding scale. At 1:12 p.m. lab results of 545. Results called to doctor. No new orders. At 2:40 p.m. blood sugar checked and is 241. Note: until 1:12 p.m. this nurse (LVN J) failed to notify the physician of the blood sugar findings and the erroneous readings of the glucometer. This nurse (LVN J) was no longer employed at the facility and unable to be reached for interview. Nurse's note the next morning, 6/08/13 at 6:30 a.m. showed Resident #12's blood sugar to be 24. Nurse's note 6/12/13 at 7:15 a.m. - "Paged doctor about blood sugar of 27. Administered Glucogen IM and Glucogen orally and came up to 63 then resident had breakfast, now up to 116. At 9:00 a.m. doctor never returned call but his nurse called and was informed of status. She stated just to fax incident to them for their records." 7/06/13 at 8:00 p.m.- "blood sugar 53 orange juice given with encouragement. Somewhat drowsy but answers appropriately." There was no documentation of physician notification of the blood sugar reading. The monthly physician orders [REDACTED]. During a telephone interview on 07/26/13 at 10:55 a.m. Resident #12's doctor said Resident #12 was a "very brittle" diabetic and the condition was difficult to control. He said he thought the E-4 reading meant it was too high. He was informed the E-4 reading per the manufacturer's guide meant the blood glucose level was too high or the strip was not properly inserted. He repeated the E-4 reading meant too high and the important part was everyone was on the same page about keeping her comfortable. Resident #13 Review of Resident #13's clinical record dated 09/22/11 documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's July 2013 Physician order [REDACTED]. Review of Resident #13's 5/31/13 quarterly MDS assessment documented she was not diabetic. Review of Resident #13's care plan initiated 09/08/11 documented Resident #13 had the potential for altered blood sugar related to history of diabetes documented a goal of no adverse effects related to diabetes during the next 90 days (target dated of 9/13/13.) Identified approaches were "monitor blood glucose as ordered and prn" (as needed), monitor for signs of [MEDICAL CONDITION], dry mouth, thirst, disorientation, drowsiness). The second identified goal included Resident #13 "will have blood sugar within range of 70-200" with identified approaches of: monitor for signs of [DIAGNOSES REDACTED]: confusion, hunger, weakness, shakiness, diaphoresis, lethargy; and administer medications and insulin as ordered. The last identified goal was Resident #13 will receive treatment if blood sugars out of range with identified approaches including: administer medications and insulin as ordered, monitor labwork as ordered, monitor for infections that may be related to high blood sugars, administer orange juice or other concentrated sweet for high blood sugars, administer insulin or other ordered medication for elevated blood sugar, and inform physician and family of any adverse findings - notify MD/family/on call nurse of blood sugars greater than 400 or less than 50. Review of Resident #13's Nurse's Notes documented: "3/30/13 4:30 p.m. Accu check done using aseptic technique BS (blood sugar) reading E-4 - too high to register." (There was no documentation the physician was notified of the error/ high blood glucose reading.) "6/16/13 4:30 p.m. Accu check performed in middle finger of left hand using aseptic technique x1 (one) stick. BS is now 439." (There was no documentation the physician was notified of the high blood glucose reading.) Review of the Treatment Administration Record (TAR) of Accuchecks before meals and before bed and notify the doctor of blood sugars less than 50 and above 400 (dated 2/03/13). documented: March 2013: 3/21/13 at 8 p.m. CBG = 403. (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #13's physician.) April 2013: 4/06/13 at 4 p.m. CBG = 406; 4/27/13 at 8 p.m. CBG = 400. (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #13's physician.) June 2013: 6/04/13 at 4 p.m. CBG = 414; 6/06/13 at 4 p.m. CBG = 404; 6/10/13 at 4 p.m. CBG = 403; 6/12/13 at 4 p.m. CBG = 403; 6/13/13 at 11 a.m. CBG = 413; 6/14/13 at 4 p.m. CBG = 400; 6/19/13 at 11 a.m. CBG = 401; 6/24/13 at 11 a.m. CBG = 404; 6/25/13 at 4 p.m. CBG = 404; 6/29/13 4 p.m. CBG = 414; 6/30/13 at 4 p.m. CBG = 407. (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #13's physician.) July 2013: (7/01/13 through 7/26/13) 7/01/13 at 4 p.m. CBG = 407; 7/03/13 at 4 p.m. CBG = 417; 7/04/13 at 11 a.m. CBG = 450; 7/06/13 at 11 a.m. CBG = 407; 7/06/13 at 4 p.m. CBG = 420; 7/07/13 at 11 a.m. CBG = 474; 7/07/13 at 4 p.m. CBG = "HI"; 7/08/13 at 4 p.m. CBG = 410; 7/09/13 at 11 a.m. CBG = 410; 7/10/13 at 4 p.m. CBG = 479; 7/11/13 at 4 p.m. CBG = 479; 7/12/13 at 11 a.m. CBG = 464; 7/12/13 at 4 p.m. CBG = 423; 7/13/13 at 11a.m. at E-4; 7/13/13 at 4 p.m. CBG = 419; 7/14/13 at 11a.m. CBG = 444; 7/14/13 at 4 p.m. CBG = 498; 7/15/13 at 4 p.m. CBG = 436; 7/16/13 at 4 p.m. CBG = 462; 7/18/13 at 4 p.m. CBG = 444; 7/19/13 at 11a.m. CBG = 409; 7/19/13 at 4 p.m. CBG = 420; 7/20/13 at 8 p.m. CBG = 409. (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #13's physician.) During an interview on 7/26/13 at 10:45 a.m. Resident #13's physician said he would have to double check to see if he was informed of Resident #13's E-4 reading on 7/13/13. During a follow up interview on 7/26/13 at 3:20 p.m. Resident #13's physician confirmed he was not notified of the 7/13/13 'E-4' reading. He said he expected the facility to notify him of abnormal readings. The doctor said Resident #13's [MEDICAL CONDITION] doctor put her on [MEDICATION NAME] 7 mg (milligrams) (a steroid) which necessitated her being on insulin to control blood sugar. The identified parameters to notify the doctor were any blood sugar levels below 50 and above 400. During an interview on 7/27/13 at 12:05 p.m. the Director of Nurses (DON) said Resident #13's doctor was notified "later" of the E-4 reading, but acknowledged it was "not that day." During an interview on 7/27/13 at 2:25 p.m. the Administrator acknowledged she could not find any evidence the listed findings were reported to the doctor. The facility submitted the following corrective action plan of removal on 07/26/13 at 4:14 p.m. The facility's 3rd revised POR dated 07/25/13 check date indicated in part: A). Area requiring attention: Diabetic Management. Corrective action taken: Medical Director initiated a diabetic management protocol. Persons responsible: Medical Director. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations: Protocol gives specific instructions on intervention for residents with an unknown CBG reading. B). Area requiring attention: Training on meter error messages, new diabetic management protocol. Corrective action taken: Training provided to all licensed nurses. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. All nursing staff to complete training prior to completing CBGs. C). Area requiring attention: Determine if treatment was provided today based on an E-4 reading. Corrective action taken: Reviewed diabetic readings for any E-4s documented today. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations. No E-4s readings were obtained today. D). Area requiring attention: Ongoing monitoring of compliance with training on meter error messages and new diabetic management protocol. Corrective action taken: DON and or designee will review diabetic CBGs daily and interview staff and or review the chart for any E4 reading. Following QA meeting on 08-05-13, if any non-compliance has occurred, daily monitoring will continue with QA meetings every Monday until compliance is met. Persons responsible: DON, Administrator. Date initiated and due completion: init: 07/25/13, comp: on going. Init: 08/05/13, comp: on going Follow up/comments/recommendations. Daily monitoring through August 5th. On 08-05-13, QA team will meet to determine compliance with protocol and training provided by DON and or designee. QA team to review compliance with training protocols. E). Area requiring attention: Physician notification of abnormal blood glucose levels. Corrective action taken: Inservice nursing staff on diabetes monitoring and following physician notification orders for low/hi glucose levels. Persons responsible: DON. Date initiated and due completion: init: 07/24/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. Nursing staff will follow emergency notification protocol for glucose monitoring unless the primary care physician has set different parameters for the resident. See attached physician notification protocol. F). Diabetic management- the [MEDICATION NAME] EZ blood glucose monitoring system may give you an E reading. 1. If you get an E-reading other than E-4 on a meter, use the handbook to guide you through what to do. See attached information from the handbook. 2. If you get an E reading of E-4, get another meter and do the CBG again. The E-4 reading means the blood glucose may be too high to be read by the system, or there may be a problem with the test strip. You cannot treat an E-4 reading, because you do not know if the blood glucose is high or not. 3. If you get an E-4 reading on two different units, you will follow the Medical Director's protocol to transport the resident to the ER. G). Diabetes inservice July 24, 2013. Glucometer QA is done daily. Record reading; recheck if the reading does not meet the parameters set for the solution in the manufacturer instruction. If the glucometer is not reading correctly place it out of service and a new meter will be provided for the cart. Symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] are specific for each individual and may vary from occurrence to occurrence. Each physician may have different HI/LO parameters for patients with diabetes. Follow the physician specific parameters and notify of LO/HI readings, condition of resident and interventions completed for the resident. Document in the clinical record interventions, response of the patient, notifications and any new orders/instructions received. If blood sugar is low and the diabetic is alert enough to safely swallow, they may eat foods that will provide approximately 15 grams of carbohydrates (4 oz fruit juice, 6 oz of soda, ice cream, crackers, 3-4 glucose tablets, etc). If the resident is not alert enough to safely swallow or is unconscious, [MEDICATION NAME] 1 mg IM is given. The injection may be given into the thigh muscle. [MEDICATION NAME] injections may cause some residents to vomit, monitor and position resident to reduce chances of as

Based on interview and record review the facility failed to ensure the Director of Nurses (DON) or Licensed Vocational Nurse (LVN) A and B provided services that met professional standards of quality for 3 of 8 residents reviewed for diabetes (Resident #12, #13 and #14) as evidenced by not notifying/consulting the physician or a supervising Registered Nurse (RN) for medical advice. This failure resulted in Resident #12, #13 and #14 not receiving proper medical treatment or proper nursing standard judgments for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] episodes. On 07/25/13 an Immediate Jeopardy (IJ) was identified. On 07/26/13 the IJ was lowered to potential for more than minimal harm at a pattern after the facility developed and implemented an action plan to remove the IJ prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to follow professional standards of practice during a diabetic medical emergency could affect the 13 residents identified as receiving blood sugar monitoring and could result in diabetic complications or death. The findings include: The Texas Administrative Code, Title 22, Examining Boards, Part 11, Texas Board of Nursing, Chapter 217, Licensure, Peer Assistance and Practice, Rule ? 217.11 Standards of Nursing Practice reflected: 1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; ... (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status.... ...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices... ...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care... Review of Texas Administrative Code Title 22, Part 11, Chapter 217, Rule 217.12 entitled Unprofessional Conduct dated 9/28/04 revealed unprofessional conduct was behaviors which included: Unsafe practice- Actions or conduct which included but was not limited to: Carelessly failing to perform nursing in conformity with the standards of minimum acceptable level of nursing practice as set out in Rule 217.11. RESIDENT #12 The Admission Record face sheet dated 3/25/13 showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was an [AGE] year old female. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to the day of the week, and her recall was good. Resident #12's care plan for Diabetes, dated 1/25/13 documented the goals as: "Resident will experience no adverse effects related to diabetes during the next 90 days. Resident will have blood sugar within range of 70 - 200 during the next 90 days. Resident will receive treatment if blood sugars out of range during the next 90 days." The approaches were: "Monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs of [MEDICAL CONDITION]-dry mouth, thirst, disorientation and drowsiness. Inform resident and family of diet restrictions and encourage their cooperation and compliance. Monitor for signs of [DIAGNOSES REDACTED]-confusion, hunger, weakness, shakiness, diaphoresis, lethargy. Administer medications and insulin as ordered. Monitor labwork as ordered. Administer orange juice and other concentrated sweets for low blood sugars. Administer insulin or other ordered medication for elevated blood sugar. Inform physician and family of any adverse findings." Review of nurse's notes in the current clinical record (from 3/13/13 to 7/25/13) documented: 4/28/13 at 7:00 a.m. - "blood sugar 58, held insulin at this time. Administered orange juice." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/07/13 at 6:50 a.m. - "blood sugar 47. Administered orange juice and peanut buter crackers. Rechecked blood sugar and was 94. Denied symptoms of [DIAGNOSES REDACTED]." There was no documentation of physician notification of the blood sugar reading. 5/11/13 at 6:40 p.m..- "resident sitting on floor at foot of bed. Stated was attempting to get to restroom by self but became weak and fell . Noted that no supper had been eaten. Blood sugar checked at 35. Had resident drink 8 ounces of orange juice with one teaspoon sugar and peanut butter crackers. Rechecked blood sugar at 7:20 p.m. and 104. Levimir dose for night held. Will continue to monitor blood sugar and pain from fall." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/25/13 at 4:50 a.m. - "awake and blood sugar 43. Orange juice and candy bar consumed. Alert now. No signs or symptoms of [DIAGNOSES REDACTED]. Blood sugar at 5:20 a.m. now 62- orange juice consumed." There was no documentation of physician notification of the blood sugar readings. 5/26/13 at 9:00 p.m. - "blood sugar 43- consumed orange juice. No signs/ symptoms of [DIAGNOSES REDACTED]. At 9:30 p.m. blood sugar 57- orange juice and candy bar consumed." There was no documentation of physician notification of the blood sugar readings. 5/30/13 at 4:30 p.m. - "blood sugar 40. Administered peanut butter crackers and orange juice. Waited a few minutes. Blood sugar now 70." There was no documentation of physician notification of the blood sugar reading. 6/05/13 at 8:00 p.m.- "blood sugar 50. Orange juice to drink. Recheck at 8:15 p.m. blood sugar 98." There was no documentation of physician notification of the blood sugar reading. 6/07/13 at 6:15 a.m. - "blood sugar checked, glucometer reading "E4." Patient alert and oriented. States feels fine. Administered scheduled Levimir 12 units and [MEDICATION NAME] 10 units per sliding scale at this time. Rechecked blood sugar at 7:30 a.m. before breakfast. Results continue to be "E4." Patient contiues to have no signs/ symptoms of being effected by increased blood sugar. Attempted to call doctor but no answer. At 8:45 a.m. blood sugar checked and remains to have "E4." Patient ate 50% of breakfast. Attempted to reach doctor again- no answer. Message left to return call ASAP. At 9:30 a.m. still unable to reach doctor. Called hospice nurse. Orders to get a glucose draw now. At 11:45 a.m. blood sugar results read "HI." Administered 10 units [MEDICATION NAME] per sliding scale. At 1:12 p.m. lab results of 545. Results called to doctor. No new orders. At 2:40 p.m. blood sugar checked and is 241. Note: until 1:12 p.m. this nurse (LVN J) failed to notify the physician of the blood sugar findings and the erroneous readings of the glucometer. This nurse (LVN J) was no longer employeed at the facility and unable to be reached for interview. Nurse's note the next morning, 6/08/13 at 6:30 a.m. showed Resident #12's blood sugar to be 24. Nurse's note 6/12/13 at 7:15 a.m. - "Paged doctor about blood sugar of 27. Administered Glucogen IM and Glucogen orally and came up to 63 then resident had breakfast, now up to 116. At 9:00 a.m. doctor never returned call but his nurse called and was informed of status. She stated just to fax incident to them for their records." 7/06/13 at 8:00 p.m.- "blood sugar 53 orange juice given with encouragement. Somewhat drowsy but answers appropriately." There was no documentation of physician notification of the blood sugar reading. The monthly physician orders [REDACTED]. During a telephone interview on 07/26/13 at 10:55 a.m. Resident #12's doctor said Resident #12 was a "very brittle" diabetic and the condition was difficult to control. He said he thought the E-4 reading meant it was too high. He was informed the E-4 reading per the manufacturer's guide meant the blood glucose level was too high or the strip was not properly inserted. He repeated the E-4 reading meant too high and the important part was everyone was on the same page about keeping her comfortable. RESIDENT #13 Review of Resident #13's clinical record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's July 2013 Physician order [REDACTED]. Review of Resident #13's Nurse's Notes documented: "3/30/13 at 4:30 p.m. Accu check done using aseptic technique BS (blood sugar) reading E-4 - too high to register." (There was no documentation the physician was notified of the error/ high blood glucose reading. ) Review of the July 2013 Treatment Administration Record (7/01/13 through 7/26/13) documented 7/13/13 at 1100 at E-4. (Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no notification of Resident #13's physician.) During an interview on 7/26/13 at 10:45 a.m. Resident #13's physician said he would have to double check to see if he was informed of Resident #13's E-4 reading on 7/13/13. During a follow up interview on 7/26/13 at 3:20 p.m. Resident #13's physician confirmed he was not notified of the 7/13/13 'E-4' reading. He said he expected the facility to notify him of abnormal readings. The doctor said Resident #13's [MEDICAL CONDITION] doctor put her on [MEDICATION NAME] 7 mg (milligrams) (a steroid) which necessitated her being on insulin to control blood sugar. He said the identified parameters to notify the doctor were any blood sugar levels below 50 and above 400. RESIDENT #14 Review of Resident #14's clinical record dated 4/24/13 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of the medication pass on 7/24/13 at 4:05 p.m. with LVN A revealed she administered [MEDICATION NAME] R insulin to Resident #14 in the medication room. LVN A performed a finger stick blood sugar test that revealed a reading of E4. LVN A proceeded to draw up 18 units of [MEDICATION NAME] R insulin into a syringe. She administered the insulin in the resident's abdomen at 4:10 p.m. Review of physician's orders [REDACTED]. Notify MD (Medical doctor) of blood sugar less than 50 or greater than 400. Review of Resident #14's treatment record for insulin administration for July 2013 documented in part, sliding scale-[MEDICATION NAME] R: BS (blood sugar) 0-150=0 units BS 151-200=4 units BS 201-250=8 units BS 251-300=12 units BS 301-350=16 units BS 351-400=18 units BS 401 or greater=18 units and call MD Review of the telephone orders documented: 4/14/13 at 9:30 a.m. Check blood glucose every 2 hours, treat with sliding scale per current order until blood glucose is less than 300. 4/15/13 Notify physician if blood glucose is less than 40 or greater than 400 Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] April 2013 4/08/13 at 11a.m. CBG = E-4; 4/09/13 at 6:30 a.m. CBG = E-4; 4/09/13 at 11 a.m. CBG = E-4; 4/09/13 at 4 p.m. CBG = E-4; June 2013: 6/01/13 at 11 a.m. CBG = 427; 6/05/13 at 4 p.m. CBG = 500; 6/10/13 at 4 p.m. CBG = 39; 6/14/13 at 6:30 a.m. CBG = 468; 6/16/13 at 6:30 a.m. CBG = 'HI'; July 2013 7/04/13 at 6:30 a.m. CBG = E-4; 7/06/13 at 6:30 a.m. CBG = E-4; 7/09/13 at 11 a.m. CBG = E-4; 7/11/13 at 6:30 a.m. CBG = E-4; and 7/23/13 at 11 a.m. CBG = E-4. Review of the Nurses Notes documented: 4/24/13 at 9:00 a.m. Accuchecks reads E-4 (too high to register, greater than 500) Doctor 's office notified. 4/24/13 9:30 a.m. Patient continues E-4 upon checking blood glucose. Doctor's office called back. Telephone order received to check blood glucose every two hours and administer regular insulin per sliding scale until blood glucose is less than 300, administer 10 units [MEDICATION NAME] R per sliding scale. 4/15/13 11:00 a.m. patient returns to facility with orders to continue scheduled insulin, obtain UA, and fax record of blood sugars in one week. Accucheck at 1120 - E-4 too high to register. Doctor's nurse notified. 6/07/13 at 6:30 a.m. Accucheck performed reading E-4 on glucometer (which means blood sugar too high to register) 25 units [MEDICATION NAME] and 18 units regular insulin given sub q in right abdomen. (dr's nurse notified and said would tell the doctor.) 6/22/13 at 11:30 a.m. Accucheck done. Glucometer read at E-4 (too high to register). Regular insulin 18 units given subq in left abdomen. Tolerated injection well. Doctor notified via telephone. Stated just watch her and if it doesn't come down by this evening call me. 7/04/13 by LVN A documented at 6:30 a.m. Accucheck done. Glucometer reads E-4. Insulin given per orders. 11 a.m. Blood sugar shows to be 37. Peanut Butter crackers and can of Glucerna given. 1130 a.m. Accuckeck done. Blood sugar now 92. Resident has snow no signs or symptoms of [DIAGNOSES REDACTED]. (There was nothing indicating the doctor was notified of either the E-4 reading or the low reading of 37) 7/20/13 LVN A documented at 6:30 a.m. Blood sugar check at this time. Glucometer reads E-4. 18 units regular insulin given. Call placed to doctor. No new orders received. 7/22/13 LVN B documented at 7:30 a.m. Blood sugar results E-4 (high) attempted to notify Doctor, left message, patient drinking water too fast and at large quantity when patient vomited large amount of light brown/clear emesis (vomit) explained to drink slow and smaller amount to prevent nausea/vomiting. 7/22/13 LVN B documented at 11 a.m. Blood Sugar results E-4 when lab called with results critical high glucose results 1114. Notified doctor of results, his orders were as follows: continue current insulin at current sliding scale monitor for changes if blood sugar does not lower by the early morning to notify him again for possible order changes. 7/24/13 LVN A documented at 4:30 p.m. Blood sugar reading E-4 (too high to register) informed doctor of giving 18 units of regular insulin. Doctor stated recheck blood sugar if still high follow sliding scale orders. Increase [MEDICATION NAME] N insulin to 30 units sub q twice a day after breakfast and after supper. Review of Resident's Care Plan dated 10/25/11 and revised 7/2013 documented in part: Problem: Potential for hyper/[DIAGNOSES REDACTED] and other complications related to diabetes. Resident has episodes of low blood sugar levels and high blood sugar levels. Insulin dependent, sliding scale. Resident periodically refuses insulin. Goal: Will remain free of s/s (sign and symptoms) of hypo/[MEDICAL CONDITION] and other complications of diabetes through next review. Approach: (1) Assess/record/report to MD (medical doctor) s/s of hyper/[DIAGNOSES REDACTED] or other complications related to diabetes (2) Administer medications as ordered-monitor for effectiveness and side effects. [MEDICATION NAME] 1 mg (milligram){ as needed for blood sugar less than 50. Give orange juice if able to swallow. (3) Obtain and monitor lab/diagnostic work as ordered- report results to MD. Parameters greater than 401 or less than 50, notify MD, family and on call nurse.(4)Monitor consumption of snacks and document refusals. Also offer substitutes as appropriate Review of Resident #14's 6/24/13 quarterly MDS Assessment documented she was diabetic and received seven days of insulin injections. Review of the 24 Hour Report documented the nurses had E-4 readings on: July 2013: 7/24/13 at 4 p.m.; 7/24/13 at 11 a.m.; 7/23/13 at 11 a.m.; 7/22/13 at 6 a.m.; 7/22/13 at 11a.m.; 7/22/13 at 6:30 a.m.; 7/20/13 at 6:30 a.m.; 7/11/13 at 6:30 a.m.; 7/09/13 at 11 a.m.(there was a follow up readying saying 281); 7/06/13 at 6:30 a.m.; 6/29/13 at 6:30 a.m.; 6/28/13 at 11 a.m.; 6/22/13 at 11 a.m.; 6/07/13 at 6 a.m. During an interview on 7/24/13 at 5:05 p.m. the DON said the nurses do not know what to do when they get an E-4 reading. The DON said the nurses are supposed to get another glucometer and check the reading again, that is the reason we have two glucometer's for every hall. The DON said the doctor did tell the nurses when they called to inform him of the E-4 reading that he "didn't care." The DON was made aware that the nurse had administered 18 units of insulin regardless with what the E-4 reading indicated. During a telephone interview on 07/26/13 at 11:21 a.m. the Primary Care Provider J (PCP) said the facility would call him often because Resident #14 was a brittle diabetic. PCP J stated "I believe E-4 indicated 600 or higher I think? E-4 means high doesn't it?" PCP J said it was "OK" to give the insulin. During a follow up interview on 7/26/13 at 3:20 p.m. the medical director said nurses were not to make a decision to administer insulin based on an "E-4" reading. He said the "standard" readings nurses were to inform doctors were below 50 and above 400. He said if the glucometer read error ("E") the nurses had to treat it as an error not a high reading. During an interview on 7/26/13 at 4:20 p.m. LVN A said " when you get a reading of E-4 that it meant the blood sugar was too high for their glucometer. You are suppose to re-test on another meter but I didn't have one on the cart. Because Resident #14 is on a sliding scale, you have to call the physician for anything over 400. When I get a reading of E-4, I tell the doctor I got a reading of E-4 and that means it is either too high or there is an error. I either re-check it (CBG) or if it is high I give the insulin. Our machines only measure up to 500. I called the doctor and he told me to give the insulin. I did not write the orders down. I don't know why I didn't write it down, maybe it was a hectic day or many things contribute to that. The first time I got an E-4 I freaked out and got another nurse and asked her what it meant". During an interview on 7/26/13 at 5:25 p.m. LVN B said "before the training, I understood E-4 meant the blood sugar was high. I would call the physician and he would give me orders to give the highest on the sliding scale. I did write the telephone orders down (note: there was no documentation of telephone orders in the residents chart). I saw the first E-4 on the 24 hour report and a nurse who worked here told me it meant the blood sugar was over 600". On 07/25/13 at 5:45 p.m., the administrator and DON were informed of the Immediate Jeopardy related to Residents #12, #13 and #14. The facility submitted the following corrective action plan of removal on 07/26/13 at 4:14 p.m. The facility's 3rd revised POR dated 07/25/13 check date indicated in part: A). Area requiring attention: Diabetic Management. Corrective action taken: Medical Director initiated a diabetic management protocol. Persons responsible: Medical Director. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations: Protocol gives specific instructions on intervention for residents with an unknown CBG reading. B). Area requiring attention: Training on meter error messages, new diabetic management protocol. Corrective action taken: Training provided to all licensed nurses. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. All nursing staff to complete training prior to completing CBGs. C). Area requiring attention: Determine if treatment was provided today based on an E-4 reading. Corrective action taken: Reviewed diabetic readings for any E-4s documented today. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations. No E-4s readings were obtained today. D). Area requiring attention: Ongoing monitoring of compliance with training on meter error messages and new diabetic management protocol. Corrective action taken: DON and or designee will review diabetic CBGs daily and interview staff and or review the chart for any E4 reading. Following QA meeting on 08-05-13, if any non-compliance has occurred, daily monitoring will continue with QA meetings every Monday until compliance is met. Persons responsible: DON, Administrator. Date initiated and due completion: init: 07/25/13, comp: on going. Init: 08/05/13, comp: on going Follow up/comments/recommendations. Daily monitoring through August 5th. On 08-05-13, QA team will meet to determine compliance with protocol and training provided by DON and or designee. QA team to review compliance with training protocols. E). Area requiring attention: Physician notification of abnormal blood glucose levels. Corrective action taken: Inservice nursing staff on diabetes monitoring and following physician notification orders for low/hi glucose levels. Persons responsible: DON. Date initiated and due completion: init: 07/24/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. Nursing staff will follow emergency notification protocol for glucose monitoring unless the primary care physician has set different parameters for the resident. See attached physician notification protocol. F). Diabetic management- the [MEDICATION NAME] EZ blood glucose monitoring system may give you an E reading. 1. If you get an E-reading other than E-4 on a meter, use the handbook to guide you through what to do. See attached information from the handbook. 2. If you get an E reading of E-4, get another meter and do the CBG again. The E-4 reading means the blood glucose may be too high to be read by the system, or there may be a problem with the test strip. You cannot treat an E-4 reading, because you do not know if the blood glucose is high or not. 3. If you get an E-4 reading on two different units, you will follow the Medical Director's protocol to transport the resident to the ER. G). Diabetes inservice July 24, 2013. Glucometer QA is done daily. Record reading; recheck if the reading does not meet the parameters set for the solution in the manufacturer instruction. If the glucometer is not reading correctly place it out of service and a new meter will be provided for the cart. Symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] are specific for each individual and may vary from occurrence to occurrence. Each physician may have different HI/LO parameters for patients with diabetes. Follow the physician specific parameters and notify of LO/HI readings, condition of resident and interventions completed for the resident. Document in the clinical record interventions, response of the patient, notifications and any new orders/instructions received. If blood sugar is low and the diabetic is alert enough to safely swallow, they may eat foods that will provide approximately 15 grams of carbohydrates (4 oz fruit juice, 6 oz of soda, ice cream, crackers, 3-4 glucose tablets, etc). If the resident is not alert enough to safely swallow or is unconscious, [MEDICATION NAME] 1 mg IM is given. The injection may be given into the thigh muscle. [MEDICATION NAME] injections may cause some residents to vomit, monitor and position resident to reduce chances of aspiration. Recheck blood sugar in 15 minutes. If the blood glucose is still below the LO parameter for that resident repeat the 15-15 rule until blood glucose is back into range. If the blood glucose is HI, administer insulin per the MD order, recheck in 15 minutes and notify physician. H). [MEDICATION NAME] EZ blood glucose monitoring system users guide dated July 2009 indicated: "E4" result. ? What it means: Your blood glucose may be too high to be read by the system, or there may be a problem with the test strip. ? What to do: Monitor your blood glucose again with a new test strip. If E4 shows on the display window again, contact your healthcare professional immediately. ? Important: It is recommended that you repeat the blood glucose test with a new test strip when: Your monitor displays an error message (for example, E4). ? Important: A result that is incorrect may have a serious medical outcome. Consult your healthcare professional before changing your diabetes medication program. I). Diabetic management protocol dated 07/25/13 indicated: Verbal orders given by the facility Medical Director on 07/25/13 at 9:35 p.m. and signed by the DON. ? Error messages on blood glucose meters. ? If you get an error message, repeat blood glucose check with another meter. ? If you get an E-4 message twice by two different meters, transport to the ER. ? After transporting resident for immediate care, notify the primary care physician and family. During a telephone interview on 07/26/13 at 10:42 a.m. the Medical Director said they had written the diabetic management protocol (see above). The director stated "there was no way of telling what E-4 means, it's not practical". "I understand that E-4 reading is wrong". During an interview on 7/26/13 at 10:45 a.m. the facility's medical director said the facility had notified him of the visit and the immediate jeopardy. He said they had a meeting last night to put a protocol in place to address it. He acknowledged there "was no way to see what" an E-4 reading meant. The Medical Director said Resident #12's and Resident #14's doctors probably thought an 'E-4' reading meant only that it was too high "as opposed to it's an error." He said the old glucometer's read 'hi' if the blood glucose level was above 450. He said the new meters read E-4 which did not "necessarily mean high." He said when the DON informed him the nurse did not recheck the reading he was "flabbergasted." During a follow up interview on 7/26/13 at 3:20 p.m. the medical director said nurses were not to make a decision to administer insulin based on an 'E-4' reading. He said the "standard" readings nurses were to inform doctors were below 50 and above 400. He said if the glucometer read error ('E') the nurses had to treat it as an error not a high reading. Surveyors confirmed through interviews, observations and reviews of inservice records on 7/26/13 the Plan of Removal had been implemented. On 7/26/13 at 5:45 p.m. the IJ was lowered to potential for more than minimal harm at a pattern. The facility remained out of compliance because not all nurses had been inserviced, and the facility had not yet monitored their plan for effectiveness. During a telephone interview on 07/26/13 at 10:42 a.m. the Medical Director said they had written the diabetic management protocol (see above). The director stated "there was no way of telling what E-4 means, it's not practical". "I understand that E-4 reading is wrong". A list provided by the Director of Nurses (DON) on 7/25/13 listed 13 residents who received insulin.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, well-being in accordance with the comprehensive assessment and plan of care for three of eight residents reviewed for diabetes (Residents #12, #13 and #14). The facility failed to assess, monitor, and coordinate care with the physician for Residents #12, #13 and #14 during and following hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) episodes as documented in the resident's care plan. Nurses did not reassess blood sugar readings of (E-4) test strip, which indicated an error. "E-4" readings indicate the blood sugar results could be high, or there could be a problem with the test strip. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical conditions/crises for Residents #12, #13 and #14. On 07/25/13 an Immediate Jeopardy (IJ) was identified. On 07/26/13 the IJ was lowered to potential for more than minimal harm at a pattern after the facility developed and implemented an action plan to remove the IJ prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to manage a critical blood sugar for a diabetic could result in further complication or death. The failure to monitor residents during and following hyper/hypoglycemic episodes (or any significant change of condition) could result in a deterioration in their condition that is unknown to staff and not reported to a physician. These failures could affect the 13 residents the facility identified who received finger stick blood sugar checks. Findings included: RESIDENT #14 Review of Resident #14's clinical record dated 4/24/13 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident's Care Plan beginning 10/25/11 and updated/revised 7/2013 documented in part: Problem: Potential for hyper/[DIAGNOSES REDACTED] and other complications related to diabetes. Resident has episodes of low blood sugar levels and high blood sugar levels. Insulin dependent, sliding scale. Resident periodically refuses insulin. Goal: Will remain free of s/s (sign and symptoms) of hypo/[MEDICAL CONDITION] and other complications of diabetes through next review. Approach: (1) Assess/record/report to MD (medical doctor) s/s of hyper/[DIAGNOSES REDACTED] or other complications related to diabetes (2) Administer medications as ordered-monitor for effectiveness and side effects. [MEDICATION NAME] 1 mg (milligram){ as needed for blood sugar less than 50. Give orange juice if able to swallow. (3) Obtain and monitor lab/diagnostic work as ordered- report results to MD. Parameters greater than 401 or less than 50, notify MD, family and on call nurse.(4)Monitor consumption of snacks and document refusals. Also offer substitutes as appropriate. Review of Resident #14's 6/24/13 quarterly Minimum Data Set (MDS) Assessment documented she was diabetic and received seven days of insulin injections. Review of physician's orders [REDACTED]. Review of Resident #14's treatment record for insulin administration for July 2013 documented in part, sliding scale-[MEDICATION NAME] R: BS (blood sugar) 0-150=0 units BS 151-200=4 units BS 201-250=8 units BS 251-300=12 units BS 301-350=16 units BS 351-400=18 units BS 401 or greater=18 units and call MD Observations of the medication pass on 7/24/13 at 4:05 p.m. with Licensed Vocational Nurse (LVN) A revealed she performed a finger stick blood sugar test that revealed a reading of E-4. LVN A proceeded to draw up 18 units of [MEDICATION NAME] R insulin into a syringe. She administered the insulin in the resident's abdomen at 4:10 p.m. During an interview on 7/24/13 at 4:07 p.m. LVN A said "I am not calling the physician because he'll say I don't care so why should I call". During an interview on 7/26/13 at 4:20 p.m. LVN A said "when you get a reading of E-4 that it meant the blood sugar was too high for their glucometer. You are supposed to re-test on another meter but I didn't have one on the cart. Because (Resident #14) is on a sliding scale, you have to call the physician for anything over 400. When I get a reading of E-4, I tell the doctor I got a reading of E-4 and that means it is either too high or there is an error. I either re-check it (CBG) or if it is high I give the insulin. Our machines only measure up to 500." She said on 7/24/13 "I called the doctor and he told me to give the insulin. I did not write the orders down. I don't know why I didn't write it down, maybe it was a hectic day or many things contribute to that. The first time I got an E-4 I freaked out and got another nurse and asked her what it meant." ([MEDICATION NAME] EZ blood glucose monitoring system users guide dated July 2009 indicated: "E4" result. ? What it means: Your blood glucose may be too high to be read by the system, or there may be a problem with the test strip. ? What to do: Monitor your blood glucose again with a new test strip. If E4 shows on the display window again, contact your healthcare professional immediately. ? Important: It is recommended that you repeat the blood glucose test with a new test strip when: Your monitor displays an error message (for example, E4). ? Important: A result that is incorrect may have a serious medical outcome. Consult your healthcare professional before changing your diabetes medication program.) Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] April 2013: E-4 on 4 occasions (4/08/13 at 11 a.m., 4/09/13 at 6:30 a.m., 4/09/13 at 11 a.m., and 4/09/13 at 4 p.m.) June 2013: 6/01/13 at 11 a.m. 427; 6/05/13 at 4 p.m. 500; 6/10/13 at 4 p.m. 39; 6/13/13 at 11 a.m. 459; 6/14/13 at 6:30 a.m. 468; 6/16/13 at 6:30 a.m. 'HI'; July 2013: E-4 on 5 occasions (7/04/13 at 6:30 a.m., 7/06/13 at 6:30 a.m., 7/09/13 at 11 a.m., 7/11/13 at 6:30 a.m., and 7/23/13 at 11 a.m.) Review of the 04/15/13 History and Physical from the hospital documented, in part "The patient's family says her blood sugar has been running high for a couple of weeks and she has been lethargic and anorexic." Later in the narrative, "a workup in the ER (emergency room ) revealed a blood sugar of greater than 500. Reiew of the 4/25/13 physician follow up visit from the hospital documented, in part: "the patient is a [AGE] year old female who presents to the office folowing a hospitalization . She was treated in the hospital for diabetes mellitus and UTI (urinary tract infection)" "Transition into care is described as the following: The paitent most recently recieved care from a hospital (admit to (hospital) on 04/15/13 with elevated temp (temperature) (103), altered level of conciousness, blood sugar greater than 500 , white count . 20,000 discharged date 4/19/13 to nursing home" Follow up for diabetes type II is descibed as the following: accucheck in office today after having breakfast 461. Review of the Nurses Notes documented: 4/24/13 9:00 a.m. Accuchecks reads E-4 (too high to register, greater than 500) Doctor's office notified. 4/24/13 9:30 a.m. Patient continues E-4 upon checking blood glucose. Doctor's office called back. Telephone order received to "check blood glucose every two hours and administer regular insulin per sliding scale until blood glucose is less than 300, administer 10 units [MEDICATION NAME] R per sliding scale." 6/07/13 6:30 a.m. Accucheck performed reading E-4 on glucometer (which means blood sugar too high to register) 25 units [MEDICATION NAME] and 18 units regular insulin given sub q in right abdomen. (Dr's nurse notified and said would tell the doctor.) 6/22/13 11:30 a.m. Accucheck done. Glucometer read at E-4 (too high to register). Regular insulin 18 units given subq in left abdomen. Tolerated injection well. Doctor notified via telephone. Stated just watch her and if it doesn't come down by this evening call me. 7/04/13 LVN A documented at 6:30 a.m. Accucheck done. Glucometer reads E-4. Insulin given per orders. 11:00 a.m. Blood sugar shows to be 37. Peanut Butter crackers and can of Glucerna given. 11:30 a.m. Accucheck done. Blood sugar now 92. Resident has no signs or symptoms of [DIAGNOSES REDACTED]. (There was nothing indicating the doctor was notified of either the E-4 reading or the low reading of 37) 7/20/13 LVN A documented at 6:30 a.m. Blood sugar check at this time. Glucometer reads E-4. 18 units regular insulin given. Call placed to doctor. No new orders received. 7/22/13 LVN B documented at 7:30 a.m. Blood sugar results E-4 (high) attempted to notify Doctor, left message, patient drinking water too fast and at large quantity when patient vomited large amount of light brown/clear emesis (vomit) explained to drink slow and smaller amount to prevent nausea/vomiting. 7/22/13 LVN B documented at 11:00 a.m. Blood Sugar results E-4 when lab called with results critical high glucose results 1114. Notified doctor of results, his orders were as follows: continue current insulin at current sliding scale monitor for changes if blood sugar does not lower by the early morning to notify him again for possible order changes. (There was no documented follow up for the E-4 reading or vomiting until 11:00 a.m.) 7/24/13 LVN A documented at 4:30 p.m. Blood sugar reading E-4 (too high to register) informed doctor of giving 18 units of regular insulin. Doctor stated recheck blood sugar if still high follow sliding scale orders. Increase [MEDICATION NAME] N insulin to 30 units sub q twice a day after breakfast and after supper. (Follow up note at 5:45 p.m. blood sugar was 259, 12 units of insulin given) Review of the 24 Hour Report documented the nurses had E-4 readings on 14 occasions in June and July 2013 (7/24/13 at 4 p.m.; 7/24/13 at 11 a.m.; 7/23/13 at 11 a.m.; 7/22/13 at 6 a.m.; 7/22/13 at 11 a.m.; 7/22/13 at 6:30 a.m.; 7/20/13 at 6:30 a.m.; 7/11/13 at 6:30 a.m.; 7/09/13 at 11 a.m. (there was a follow up reading saying 281); 7/06/13 at 6:30 a.m.; 6/29/13 at 6:30 a.m.; 6/28/13 at 11 a.m.; 6/22/13 at 11 a.m.; 6/07/13 at 6 a.m.). During an interview on 7/24/13 at 5:05 p.m. the Director of Nurses (DON) said the nurses do not know what to do when they get an E-4 reading. The DON said the nurses are supposed to get another glucometer and check the reading again, that is the reason we have two glucometer's for every hall. The DON said the doctor did tell the nurses when they called to inform him of the E-4 reading that he "didn't care." The DON was made aware that the nurse had administered 18 units of insulin regardless with what the E-4 reading indicated. During an interview on 07/25/13 at 7:25 p.m., the Administrator and DON were informed the above failures constituted an IJ situation. During this interview, the DON said they were aware the nurses had been administering insulin according to the E4 reading. The DON said the resident's doctor had told the nurses to administer the insulin because the E4 indicated a high glucose reading. During an interview on 7/26/13 at 5:25 p.m. LVN B said before the training, I understood E4 meant the blood sugar was high. I would call the physician and he would give me orders to give the highest on the sliding scale. I did write the telephone orders down (note: there was no documentation of telephone orders in the residents chart). I saw the first E-4 on the 24 hour report and a nurse who worked here told me it meant the blood sugar was over 600. During a telephone interview on 07/26/13 at 11:21 a.m. the Primary Care Provider J (PCP) said the facility would call him often because Resident #14 was a brittle diabetic. PCP J stated "I believe E-4 indicated 600 or higher I think? E-4 means high doesn't it?" PCP J said it was "OK" to give the insulin. RESIDENT #12 The Admission Record face sheet dated 3/25/13 showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was an [AGE] year old female. Review of Resident #12's MDS assessment dated [DATE] documented the resident as being able to repeat three words accurately, she was oriented to the day of the week, and her recall was good. Resident #12's care plan for Diabetes, dated 1/25/13 documented the goals as: "Resident will experience no adverse effects related to diabetes during the next 90 days. Resident will have blood sugar within range of 70 - 200 during the next 90 days. Resident will receive treatment if blood sugars out of range during the next 90 days." The approaches were: "Monitor blood sugar as ordered and as needed. Diet as ordered. Monitor for signs of [MEDICAL CONDITION]- dry mouth, thirst, disorientation and drowsiness. Inform resident and family of diet restrictions and encourage their cooperation and compliance. Monitor for signs of [DIAGNOSES REDACTED]- confusion, hunger, weakness, shakiness, diaphoresis, lethargy. Administer medications and insulin as ordered. Monitor lab work as ordered. Administer orange juice and other concentrated sweets for low blood sugars. Administer insulin or other ordered medication for elevated blood sugar. Inform physician and family of any adverse findings." The monthly physician orders [REDACTED]. Review of nurse's notes in the current clinical record (from 3/13/13 to 7/25/13) documented: 4/28/13 at 7:00 a.m. - "blood sugar 58, held insulin at this time. Administered orange juice." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/07/13 at 6:50 a.m. - "blood sugar 47. Administered orange juice and peanut butter crackers. Rechecked blood sugar and was 94. Denied symptoms of [DIAGNOSES REDACTED]." There was no documentation of physician notification of the blood sugar reading. 5/11/13 at 6:40 p.m. - "resident sitting on floor at foot of bed. Stated was attempting to get to restroom by self but became weak and fell . Noted that no supper had been eaten. Blood sugar checked at 35. Had resident drink 8 ounces of orange juice with one teaspoon sugar and peanut butter crackers. Rechecked blood sugar at 7:20 p.m. and 104. Levimir dose for night held. Will continue to monitor blood sugar and pain from fall." There was no documentation of physician notification of the blood sugar reading and the nurse holding the insulin. 5/25/13 at 4:50 a.m. - "awake and blood sugar 43. Orange juice and candy bar consumed. Alert now. No signs or symptoms of [DIAGNOSES REDACTED]. Blood sugar at 5:20 a.m. now 62- orange juice consumed." There was no documentation of physician notification of the blood sugar readings. 5/26/13 at 9:00 p.m. - "blood sugar 43- consumed orange juice. No signs/ symptoms of [DIAGNOSES REDACTED]. At 9:30 p.m. blood sugar 57- orange juice and candy bar consumed." There was no documentation of physician notification of the blood sugar readings. 5/30/13 at 4:30 p.m. - "blood sugar 40. Administered peanut butter crackers and orange juice. Waited a few minutes. Blood sugar now 70." There was no documentation of physician notification of the blood sugar reading. 6/05/13 at 8:00 p.m. - "blood sugar 50. Orange juice to drink. Recheck at 8:15 p.m. blood sugar 98." There was no documentation of physician notification of the blood sugar reading. 6/07/13 at 6:15 a.m. - "blood sugar checked, glucometer reading "E-4." Patient alert and oriented. States feels fine. Administered scheduled Levimir 12 units and [MEDICATION NAME] 10 units per sliding scale at this time. Rechecked blood sugar at 7:30 a.m. before breakfast. Results continue to be "E-4." Patient continues to have no signs/ symptoms of being effected by increased blood sugar. Attempted to call doctor but no answer. At 8:45 a.m. blood sugar checked and remains to have "E-4." Patient ate 50% of breakfast. Attempted to reach doctor again- no answer. Message left to return call ASAP. At 9:30 a.m. still unable to reach doctor. Called hospice nurse. Orders to get a glucose draw now. At 11:45 a.m. blood sugar results read "HI." Administered 10 units [MEDICATION NAME] per sliding scale. At 1:12 p.m. lab results of 545. Results called to doctor. No new orders. At 2:40 p.m. blood sugar checked and is 241. Note: this nurse (LVN J) failed to notify the physician of the blood sugar findings and the erroneous readings of the glucometer until 1:12 p.m. This nurse (LVN J) was no longer employed at the facility and was unable to be reached for interview. Nurse's note the next morning, 6/08/13 at 6:30 a.m. showed Resident #12's blood sugar to be 24. Nurse's note 6/12/13 at 7:15 a.m. - "Paged doctor about blood sugar of 27. Administered Glucogen IM and Glucogen orally and came up to 63 then resident had breakfast, now up to 116. At 9:00 a.m. doctor never returned call but his nurse called and was informed of status. She stated just to fax incident to them for their records." 7/06/13 at 8:00 p.m.- "blood sugar 53 orange juice given with encouragement. Somewhat drowsy but answers appropriately." There was no documentation of physician notification of the blood sugar reading. During a telephone interview on 07/26/13 at 10:55 a.m. Resident #12's doctor said Resident #12 was a "very brittle" diabetic and the condition was difficult to control. He said he thought the E-4 reading meant it was too high. He was informed the E-4 reading per the manufacturer's guide meant the blood glucose level was too high or the strip was not properly inserted. He repeated the E-4 reading meant too high and the important part was everyone was on the same page about keeping her comfortable. RESIDENT #13 Review of Resident #13's clinical record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's 5/31/13 quarterly MDS assessment documented she was not diabetic. Review of Resident #13's care plan initiated 09/08/11 documented Resident #13 had the potential for altered blood sugar related to history of diabetes documented a goal of no adverse effects related to diabetes during the next 90 days (target dated of 9/13/13.) Identified approaches were "monitor blood glucose as ordered and prn" (as needed), monitor for signs of [MEDICAL CONDITION], dry mouth, thirst, disorientation, drowsiness). The second identified goal included Resident #13 "will have blood sugar within range of 70-200" with identified approaches of: monitor for signs of [DIAGNOSES REDACTED]: confusion, hunger, weakness, shakiness, diaphoresis, lethargy; and administer medications and insulin as ordered. The last identified goal was Resident #13 will receive treatment if blood sugars out of range with identified approaches including: administer medications and insulin as ordered, monitor labwork as ordered, monitor for infections that may be related to high blood sugars, administer orange juice or other concentrated sweet for high blood sugars, administer insulin or other ordered medication for elevated blood sugar, and inform physician and family of any adverse findings - notify MD/family/on call nurse of blood sugars greater than 400 or less than 50. Review of Resident #13's July 2013 Physician order [REDACTED]. Notify physician if blood glucose is less than 50 or greater than 400 unless otherwise specified by physician. Review of Resident #13's Nurse's Notes documented: "3/30/13 4:30 p.m. Accucheck done using aseptic technique BS (blood sugar) reading E-4 - too high to register." (There was no documentation the physician was notified of the error/ high blood glucose reading.) Review of the July 2013 MAR (7/01/13 through 7/26/13) documented 7/13/13 at 11 a.m. at E-4. Comparison with the Nurses Notes, Physician Orders, and Physician Notes showed no documentation of notification of Resident #13's physician. During an interview on 7/26/13 at 3:20 p.m. Resident #13's physician confirmed he was not notified of the 7/13/13 'E-4' reading. He said he expected the facility to notify him of abnormal readings. The doctor said Resident #13's [MEDICAL CONDITION] doctor put her on [MEDICATION NAME] 7 mg (milligrams) (a steroid) which necessitated her being on insulin to control blood sugar. He said the identified parameters to notify the doctor were any blood sugar levels below 50 and above 400. A facility policy titled, "Care, Management and treatment of [REDACTED]. c) Hypoglycemic reactions: This can be caused by too much insulin, too little food or excessive physical activity. Observe for complaints of headache, light-headiness, confusion, emotional changes, memory lapses, numbness of lips and tongue, slurred speech, incoordination, staggering gait, double vision, drowsiness, convulsions, and eventually coma. Do an accu-check if symptomatic and accu-check is less than 70. If resident is alert and able to swallow give 4 oz (ounces) of juice with 1-2 packets of sugar. Continue to monitor and re-check within 15 minutes. This policy did not address when to contact the physician or any other symptoms or interventions for high blood sugar. Review of the facility protocol on physician notification dated April 2004 documented, in part: Lab Reports: Notify immediately: panic or Critical lab values, as soon as received. e. Glucose < (less than) 60 mg (milligrams) in a diabetic <50 mg in a non-diabetic> (greater than) 300 in anyone Old lab or Non-Emergencies: b. Glucose >300, patient on a sliding scale, physician is aware Use of nursing judgment and observation (for which an order is never required) is encouraged. A nurse should if; in his/her judgment an intervention needs to be made by the physician immediately. According to the American Diabetes Association, "Standards of Medical Care in Diabetes-2012, at http://care.diabetesjournals.org/content/35/Supplement_1/S11.full, the following was included under, "K. [DIAGNOSES REDACTED]": "Recommendations. Glucose (15-20 g) is the preferred treatment for [REDACTED]. If SMBG (blood glucose) 15 min after treatment shows continued [DIAGNOSES REDACTED], the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of [DIAGNOSES REDACTED]."... The facility submitted the following corrective action plan of removal on 07/26/13 at 4:14 p.m. The facility's 3rd revised POR dated 07/25/13 indicated in part: A). Area requiring attention: Diabetic Management. Corrective action taken: Medical Director initiated a diabetic management protocol. Persons responsible: Medical Director. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations: Protocol gives specific instructions on intervention for residents with an unknown CBG reading. B). Area requiring attention: Training on meter error messages, new diabetic management protocol. Corrective action taken: Training provided to all licensed nurses. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. All nursing staff to complete training prior to completing CBGs. C). Area requiring attention: Determine if treatment was provided today based on an E-4 reading. Corrective action taken: Reviewed diabetic readings for any E-4s documented today. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations. No E-4s readings were obtained today. D). Area requiring attention: Ongoing monitoring of compliance with training on meter error messages and new diabetic management protocol. Corrective action taken: DON and or designee will review diabetic CBGs daily and interview staff and or review the chart for any E4 reading. Following QA meeting on 08-05-13, if any non-compliance has occurred, daily monitoring will continue with QA meetings every Monday until compliance is met. Persons responsible: DON, Administrator. Date initiated and due completion: init: 07/25/13, comp: on going. Init: 08/05/13, comp: on going Follow up/comments/recommendations. Daily monitoring through August 5th. On 08-05-13, QA team will meet to determine compliance with protocol and training provided by DON and or designee. QA team to review compliance with training protocols. E). Area requiring attention: Physician notification of abnormal blood glucose levels. Corrective action taken: Inservice nursing staff on diabetes monitoring and following physician notification orders for low/hi glucose levels. Persons responsible: DON. Date initiated and due completion: init: 07/24/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. Nursing staff will follow emergency notification protocol for glucose monitoring unless the primary care physician has set different parameters for the resident. See attached physician notification protocol. F). Diabetic management- the [MEDICATION NAME] EZ blood glucose monitoring system may give you an E reading. 1. If you get an E-reading other than E-4 on a meter, use the handbook to guide you through what to do. See attached information from the handbook. 2. If you get an E reading of E-4, get another meter and do the CBG again. The E-4 reading means the blood glucose may be too high to be read by the system, or there may be a problem with the test strip. You cannot treat an E-4 reading, because you do not know if the blood glucose is high or not. 3. If you get an E-4 reading on two different units, you will follow the Medical Director's protocol to transport the resident to the ER. G). Diabetes inservice July 24, 2013. Glucometer QA is done daily. Record reading; recheck if the reading does not meet the parameters set for the solution in the manufacturer instruction. If the glucometer is not reading correctly place it out of service and a new meter will be provided for the cart. Symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] are specific for each individual and may vary from occurrence to occurrence. Each physician may have different HI/LO parameters for patients with diabetes. Follow the physician specific parameters and notify of LO/HI readings, condition of resident and interventions completed for the resident. Document in the clinical record interventions, response of the patient, notifications and any new orders/instructions received. If blood sugar is low and the diabetic is alert enough to safely swallow, they may eat foods that will provide approximately 15 grams of carbohydrates (4 oz fruit juice, 6 oz of soda, ice cream, crackers, 3-4 glucose tablets, etc). If the resident is not alert enough to safely swallow or is unconscious, [MEDICATION NAME] 1 mg IM is given. The injection may be given into the thigh muscle. [MEDICATION NAME] injections may cause some residents to vomit, monitor and position resident to reduce chances of aspiration. Recheck blood sugar in 15 minutes. If the blood glucose is still below the LO parameter for that resident repeat the 15-15 rule until blood glucose is back into range. If the blood glucose is HI, administer insulin per the MD order, recheck in 15 minutes and notify physician. H). [MEDICATION NAME] EZ blood glucose monitoring system users guide dated July 2009 indicated: "E4" result. ? What it means: Your blood glucose may be too high to be read by the system, or there may be a problem with the test strip. ? What to do: Monitor your blood glucose again with a new test strip. If E4 shows on the display window again, contact your healthcare professional immediately. ? Important: It is recommended that you repeat the blood glucose test with a new test strip when: Your monitor displays an error message (for example, E4). ? Important: A result that is incorrect may have a serious medical outcome. Consult your healthcare professional before changing your diabetes medication program. I). Diabetic management protocol dated 07/25/13 indicated: Verbal orders given by the facility Medical Director on 07/25/13 at 9:35 p.m. and signed by the DON. ? Error messages on blood glucose meters. ? If you get an error message, repeat blood glucose check with another meter. ? If you get an E-4 message twice by two different meters, transport to the ER. ? After transporting resident for immediate care, notify the primary care physician and family. During a telephone interview on 07/26/13 at 10:42 a.m. the Medical Director said they had written the diabetic management protocol (see above). The director stated "there was no way of telling what E-4 means, it's not practical". "I understand that E-4 reading is wrong". During an interview on 7/26/13 at 10:45 a.m. the facility's medical director said the facility had notified him of the visit and the immediate jeopardy. He said they had a meeting last night to put a protocol in place to address it. He acknowledged there "was no way to see what" an E-4 reading meant. The Medical Director said Resident #12's and Resident #14's doctors probably thought an 'E-4' reading meant only that it was too high "as opposed to it's an error." He said the old glucometer's read 'hi' if the blood glucose level was above 450. He said the new meters read E-4 which did not "necessarily mean high." He said when the DON informed him the nurse did not recheck the reading he was "flabbergasted." During a follow up interview on 7/26/13 at 3:20 p.m. the medical director said nurses were not to make a decision to administer insulin based on an 'E-4' reading. He said the "standard" readings nurses were to inform doctors were below 50 and above 400. He said if the glucometer read error ('E') the nurses had to treat it as an error not a high reading. Surveyors confirmed through interviews, observations and reviews of inservice records on 7/26/13 the Plan of Removal had been implemented. On 7/26/13 at 5:45 p.m. the IJ was lowered to potential for more than minimal harm at a pattern. The facility remained out of compliance because not all nurses had been inserviced, and the facility had not yet monitored their plan for effectiveness. A list provided by the DON on 7/24/13 at 5:00 p.m. documented there were 13 diabetic residents.

Based on observation, interview, and record review, the facility failed to ensure 1 of 8 residents (#14) observed on the medication pass was free from significant medication errors. The facility failed to ensure: a) Licensed Vocational Nurse (LVN) A administered the correct dose of [MEDICATION NAME] R insulin (medication used to treat elevated blood sugar), for Resident #14. LVN A gave 18 units of [MEDICATION NAME] R Insulin after getting a reading of E4 on the glucometer instead of retesting or calling Resident #14's physician. On 07/25/13 an Immediate Jeopardy (IJ) was identified. On 07/26/13 the IJ was lowered to potential for more than minimal harm at a pattern after the facility developed and implemented an action plan to remove the IJ prior to exit. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures could affect 13 residents by placing them at risk of not receiving their medications as ordered by the physician which could place them at risk of a decline in their health. The findings include: RESIDENT #14 Review of Resident #14's clinical record dated 04/24/13 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of the medication pass on 7/24/13 at 4:05 p.m. with LVN A revealed she administered [MEDICATION NAME] R insulin to Resident #14 in the medication room. LVN A performed a finger stick blood sugar test that revealed a reading of E4. LVN A proceeded to draw up 18 units of [MEDICATION NAME] R insulin into a syringe. She administered the insulin in the resident's abdomen at 4:10 p.m. Review of Resident's Care Plan beginning 10/25/11 and revised 7/2013 documented in part: Problem: Potential for hyper/[DIAGNOSES REDACTED] and other complications related to diabetes. Resident has episodes of low blood sugar levels and high blood sugar levels. Insulin dependent, sliding scale. Resident periodically refuses insulin. Goal: Will remain free of s/s (sign and symptoms) of hypo/[MEDICAL CONDITION] and other complications of diabetes through next review. Approach: (1) Assess/record/report to MD (medical doctor) s/s of hyper/[DIAGNOSES REDACTED] or other complications related to diabetes (2) Administer medications as ordered-monitor for effectiveness and side effects. [MEDICATION NAME] 1 mg (milligram){ as needed for blood sugar less than 50. Give orange juice if able to swallow. (3) Obtain and monitor lab/diagnostic work as ordered- report results to MD. Parameters greater than 401 or less than 50, notify MD, family and on call nurse.(4)Monitor consumption of snacks and document refusals. Also offer substitutes as appropriate Review of Resident #14's medication record for insulin administration for July 2013 documented in part, sliding scale-[MEDICATION NAME] R: BS (blood sugar) 0-150=0 units BS 151-200=4 units BS 201-250=8 units BS 251-300=12 units BS 301-350=16 units BS 351-400=18 units BS 401 or greater=18 units and call MD Review of physician's orders [REDACTED]. Notify MD (Medical doctor) of blood sugar less than 50 or greater than 400. During an interview on 7/24/13 at 5:05 p.m. the Director of Nurses (DON) said the nurses do not know what to do when they get an E-4 reading. The DON said the nurses are supposed to get another glucometer and check the reading again, that is the reason we have two glucometers for every hall. The DON said the doctor did tell the nurses when they called to inform him of the E-4 reading that he "didn't care." The DON was made aware that the nurse had administered 18 units of insulin regardless with what the E-4 reading indicated. During an interview on 07/25/13 at 7:25 p.m., the Administrator and DON were informed the above failures constituted an IJ situation. During this interview, the DON said they were aware the nurses had been administering insulin according to the E4 reading. The DON said the resident's doctor had told the nurses to administer the insulin because the E4 indicated a high glucose reading. During a telephone interview on 07/26/13 at 11:21 a.m. the Primary Care Provider J (PCP) said the facility would call him often because Resident #14 was a brittle diabetic. PCP J stated "I believe E-4 indicated 600 or higher I think? E-4 means high doesn't it?" PCP J said it was "OK" to give the insulin. During a follow up interview on 7/26/13 at 3:20 p.m. the medical director said nurses were not to make a decision to administer insulin off an 'E-4' reading. He said the "standard" readings nurses were to inform doctors were below 50 and above 400. He said if the glucometer read error ('E') the nurses had to treat it as an error not a high reading. During an interview on 7/26/13 at 4:20 p.m. LVN A said when you get a reading of E-4 that it meant the blood sugar was too high for their glucometer. You are suppose to re-test on another meter but I didn't have one on the cart. Because Resident #14 is on a sliding scale, you have to call the physician for anything over 400. When I get a reading of E-4, I tell the doctor I got a reading of E-4 and that means it is either too high or there is an error. I either re-check it (CBG) or if it is high I give the insulin. Our machines only measure up to 500. I called the doctor and he told me to give the insulin. I did not write the orders down. I don't know why I didn't write it down, maybe it was a hectic day or many things contribute to that. The first time I got an E-4 I freaked out and got another nurse and asked her what it meant. During an interview on 7/26/13 at 5:25 p.m. LVN B said "before the training, I understood E-4 meant the blood sugar was high. I would call the physician and he would give me orders to give the highest on the sliding scale. I did write the telephone orders down (note: there was no documentation of telephone orders in the residents chart). I saw the first E-4 on the 24 hour report and a nurse who worked here told me it meant the blood sugar was over 600." Review of the telephone orders documented: 4/14/13 9:30 a.m. Check blood glucose every 2 hours, treat with sliding scale per current order until blood glucose is less than 300. 4/15/13 Notify physician if blood glucose is less than 40 or greater than 400. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] April 2013: 4/08/13 at 11 a.m. CBG = E-4; 4/09/13 at 6:30 a.m. CBG = E-4; 4/09/13 at 11 a.m. CBG = E-4; 4/09/13 at 1600 CBG = E-4; June 2013: 6/01/13 at 11 a.m. CBG = 427; 6/05/13 at 4 p.m. CBG = 500; 6/10/13 at 4 p.m. CBG = 39; 6/13/13 at 11 a.m. CBG = 459; 6/14/13 at 6:30 a.m. CBG = 468; 6/16/13 at 6:30 a.m. CBG = 'HI'; July 2013: 7/04/13 at 6:30 a.m. CBG = E-4; 7/06/13 at 6:30 a.m. CBG = E-4; 7/09/13 at 11 a.m. CBG = E-4; 7/11/13 at 6:30 a.m. CBG = E-4; and 7/23/13 at 11 a.m. CBG = E-4. Review of the Nurses Notes documented: 4/15/13 11 a.m. patient returns to facility with orders to continue scheduled insulin, obtain UA, and fax record of blood sugars in one week. Accucheck at 11:20 a.m. - E-4 too high to register. Doctor's nurse notified. 4/24/13 9 a.m. Accuchecks reads E- 4 (too high to register, greater than 500) Doctor's office notified. 4/24/13 9:30 a.m. Patient continues E-4 upon checking blood glucose. Doctor's office called back. Telephone order received to "check blood glucose every two hours and administer regular insulin per sliding scale until blood glucose is less than 300, administer 10 units [MEDICATION NAME] R per sliding scale." 6/07/13 6:30 a.m. Accucheck performed reading E-4 on glucometer (which means blood sugar too high to register) 25 units [MEDICATION NAME] and 18 units regular insulin given sub q in right abdomen. (dr's nurse notified and said would tell the doctor.) 6/22/13 11:30 a.m. Accucheck done. Glucometer read at E-4 (too high to register). Regular insulin 18 units given subq in left abdomen. Tolerated injection well. Doctor notified via telephone. Stated just watch her and if it doesn't come down by this evening call me. 7/04/13 LVN A documented at 6:30 a.m. Accucheck done. Glucometer reads E-4. Insulin given per orders. 11 a.m. Blood sugar shows to be 37. Peanut Butter crackers and can of Glucerna given. 11:30 a.m. Accucheck done. Blood sugar now 92. Resident has no signs or symptoms of [DIAGNOSES REDACTED]. (There was nothing indicating the doctor was notified of either the E-4 reading or the low reading of 37) 7/20/13 LVN A documented at 6:30 a.m. Blood sugar check at this time. Glucometer reads E-4. 18 units regular insulin given. Call placed to doctor. No new orders received. 7/22/13 LVN B documented at 7:30 a.m. Blood sugar results E-4 (high) attempted to notify Doctor, left message, patient drinking water too fast and at large quantity when patient vomited large amount of light brown/clear emesis (vomit) explained to drink slow and smaller amount to prevent nausea/vomiting. 7/22/13 by LVN B documented at 11 a.m. Blood Sugar results E-4 when lab called with results critical high glucose results 1114. Notified doctor of results, his orders were as follows: continue current insulin at current sliding scale monitor for changes if blood sugar does not lower by the early morning to notify him again for possible order changes. 7/24/13 LVN A documented at 4:30 p.m. Blood sugar reading E-4 (too high to register) informed doctor of giving 18 units of regular insulin. Doctor stated recheck blood sugar if still high follow sliding scale orders. Increase [MEDICATION NAME] N insulin to 30 units sub q twice a day after breakfast and after supper. Review of the 24 Hour Report documented the nurses had E-4 readings on: July 2013: 7/24/13 at 4 p.m.; 7/24/13 at 11 a.m.; 7/23/13 at 11 a.m.; 7/22/13 at 6 a.m.; 7/22/13 at 11 a.m.; 7/22/13 at 6:30 a.m.; 7/20/13 at 6:30 a.m.; 7/11/13 at 6:30 a.m.; 7/09/13 at 11 a.m. (there was a follow up reading saying 281); 7/06/13 at 6:30 a.m.; 6/29/13 at 6:30 a.m.; 6/28/13 at 11 a.m.; 6/22/13 at 11 a.m.; 6/07/13 at 6:30 a.m. Review of the manufacturers information pamphlet dated 7/09 documented, in part: "E4" Results - What it Means: Your blood glucose may be too high to be read by the system, or there may be a problem with the test strip. What to Do: Monitor your blood glucose again with a new test strip. If E4 shows on the display window again, contact your healthcare professional immediately. "HI" Results - What it Means: Your monitor has determined that your blood glucose result is higher than 400 mg/dL or there may be a problem with the test strip. What to Do: Monitor your blood glucose again with a new test strip. If HI shows on the display window again, contact your healthcare professional immediately. Important: It is recommended that you repeat the blood glucose test with a new test strip when: LO shows on display window. HI shows on the display window. Your monitor display an error message (for example E-4). Important: A result that is incorrect may have a serious medical outcome. Consult your healthcare professional before changing diabetes medication program. Review of the Diabetes In-service dated 7/24/13 documented, in part: Symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] are specific for each individual and may vary from occurrence to occurrence. Each Physician may have differing HI/LO parameters for patients with Diabetes. Follow the Physician specific parameters and notify of LO/HI readings, condition of resident and interventions completed for the resident. Document in the clinical record interventions, response if the patient, notifications and any new orders/instructions received. The facility submitted the following corrective action plan of removal on 07/26/13 at 4:14 p.m. The facility's 3rd revised POR dated 07/25/13 indicated in part: A). Area requiring attention: Diabetic Management. Corrective action taken: Medical Director initiated a diabetic management protocol. Persons responsible: Medical Director. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations: Protocol gives specific instructions on intervention for residents with an unknown CBG reading. B). Area requiring attention: Training on meter error messages, new diabetic management protocol. Corrective action taken: Training provided to all licensed nurses. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. All nursing staff to complete training prior to completing CBGs. C). Area requiring attention: Determine if treatment was provided today based on an E-4 reading. Corrective action taken: Reviewed diabetic readings for any E-4s documented today. Persons responsible: DON. Date initiated and due completion: init: 07/25/13, comp: 07/25/13. Follow up/comments/recommendations. No E-4s readings were obtained today. D). Area requiring attention: Ongoing monitoring of compliance with training on meter error messages and new diabetic management protocol. Corrective action taken: DON and or designee will review diabetic CBGs daily and interview staff and or review the chart for any E4 reading. Following QA meeting on 08-05-13, if any non-compliance has occurred, daily monitoring will continue with QA meetings every Monday until compliance is met. Persons responsible: DON, Administrator. Date initiated and due completion: init: 07/25/13, comp: on going. Init: 08/05/13, comp: on going Follow up/comments/recommendations. Daily monitoring through August 5th. On 08-05-13, QA team will meet to determine compliance with protocol and training provided by DON and or designee. QA team to review compliance with training protocols. E). Area requiring attention: Physician notification of abnormal blood glucose levels. Corrective action taken: Inservice nursing staff on diabetes monitoring and following physician notification orders for low/hi glucose levels. Persons responsible: DON. Date initiated and due completion: init: 07/24/13, comp: Each nurse will complete training prior to working their next shift. Follow up/comments/recommendations. Nursing staff will follow emergency notification protocol for glucose monitoring unless the primary care physician has set different parameters for the resident. See attached physician notification protocol. F). Diabetic management- the [MEDICATION NAME] EZ blood glucose monitoring system may give you an E reading. 1. If you get an E-reading other than E-4 on a meter, use the handbook to guide you through what to do. See attached information from the handbook. 2. If you get an E reading of E-4, get another meter and do the CBG again. The E-4 reading means the blood glucose may be too high to be read by the system, or there may be a problem with the test strip. You cannot treat an E-4 reading, because you do not know if the blood glucose is high or not. 3. If you get an E-4 reading on two different units, you will follow the Medical Director's protocol to transport the resident to the ER. G). Diabetes inservice July 24, 2013. Glucometer QA is done daily. Record reading; recheck if the reading does not meet the parameters set for the solution in the manufacturer instruction. If the glucometer is not reading correctly place it out of service and a new meter will be provided for the cart. Symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] are specific for each individual and may vary from occurrence to occurrence. Each physician may have different HI/LO parameters for patients with diabetes. Follow the physician specific parameters and notify of LO/HI readings, condition of resident and interventions completed for the resident. Document in the clinical record interventions, response of the patient, notifications and any new orders/instructions received. If blood sugar is low and the diabetic is alert enough to safely swallow, they may eat foods that will provide approximately 15 grams of carbohydrates (4 oz fruit juice, 6 oz of soda, ice cream, crackers, 3-4 glucose tablets, etc). If the resident is not alert enough to safely swallow or is unconscious, [MEDICATION NAME] 1 mg IM is given. The injection may be given into the thigh muscle. [MEDICATION NAME] injections may cause some residents to vomit, monitor and position resident to reduce chances of aspiration. Recheck blood sugar in 15 minutes. If the blood glucose is still below the LO parameter for that resident repeat the 15-15 rule until blood glucose is back into range. If the blood glucose is HI, administer insulin per the MD order, recheck in 15 minutes and notify physician. H). [MEDICATION NAME] EZ blood glucose monitoring system users guide dated July 2009 indicated: "E4" result. ? What it means: Your blood glucose may be too high to be read by the system, or there may be a problem with the test strip. ? What to do: Monitor your blood glucose again with a new test strip. If E4 shows on the display window again, contact your healthcare professional immediately. ? Important: It is recommended that you repeat the blood glucose test with a new test strip when: Your monitor displays an error message (for example, E4). ? Important: A result that is incorrect may have a serious medical outcome. Consult your healthcare professional before changing your diabetes medication program. I). Diabetic management protocol dated 07/25/13 indicated: Verbal orders given by the facility Medical Director on 07/25/13 at 9:35 p.m. and signed by the DON. ? Error messages on blood glucose meters. ? If you get an error message, repeat blood glucose check with another meter. ? If you get an E-4 message twice by two different meters, transport to the ER. ? After transporting resident for immediate care, notify the primary care physician and family. During a telephone interview on 07/26/13 at 10:42 a.m. the Medical Director said they had written the diabetic management protocol (see above). The director stated "there was no way of telling what E-4 means, it's not practical". "I understand that E-4 reading is wrong". During an interview on 7/26/13 at 10:45 a.m. the facility's medical director said the facility had notified him of the visit and the immediate jeopardy. He said they had a meeting last night to put a protocol in place to address it. He acknowledged there "was no way to see what" an E-4 reading meant. The Medical Director said Resident #12's and Resident #14's doctors probably thought an 'E-4' reading meant only that it was too high "as opposed to it's an error." He said the old glucometer's read 'hi' if the blood glucose level was above 450. He said the new meters read E-4 which did not "necessarily mean high." He said when the DON informed him the nurse did not recheck the reading he was "flabbergasted." During a follow up interview on 7/26/13 at 3:20 p.m. the medical director said nurses were not to make a decision to administer insulin based on an 'E-4' reading. He said the "standard" readings nurses were to inform doctors were below 50 and above 400. He said if the glucometer read error ('E') the nurses had to treat it as an error not a high reading. Surveyors confirmed through interviews, observations and reviews of inservice records on 7/26/13 the Plan of Removal had been implemented. On 7/26/13 at 5:45 p.m. the IJ was lowered to potential for more than minimal harm at a pattern. The facility remained out of compliance because not all nurses had been inserviced, and the facility had not yet monitored their plan for effectiveness. A list of residents who received insulin was provided by the facility on 7/25/13 at 5:00 p.m. There were 13 residents listed who received insulin.