Every finding on record at NHC Healthcare - Charleston

Based on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)24 received medications that had adequate/appropriate indications of use, for 1 of 6 residents reviewed for unnecessary medications. Specifically, the facility administered R24, a resident who does not have a history or diagnosis of blood glucose/sugar complications/diabetes, 10 units of insulin on two separate dates. The facility further failed to ensure that residents' orders were verified appropriately for accuracy and medications had an adequate/appropriate indication of use. R24 reported to facility staff/medical providers that her anxiety had worsened after this medication error, and she now questions every medication she receives from nursing staff at the facility. On 04/02/26 at 1:20 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/26/26. The IJ was related to 42 CFR 483.45 - Pharmacy Services.On 04/03/26 at 12:46 PM, the facility provided an acceptable IJ Removal Plan. On 04/03/26 at 1:16 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F757 at a lower scope and severity of D.An Extended Survey was conducted in conjunction with the Recertification Survey for non-compliance at F757, constituting substandard quality of care.Findings include:Review of the facility policy titled Pharmacy Services revealed, The center shall have procedures for pharmaceutical services to meet the needs of each patient. Medication administration and monitoring systems shall be defined to assure maximum benefit from medication(s) ordered and administered, following manufactures' specification and standards of practice. Support center efforts to effectively manage medications, reduce unnecessary medication, and assist in focusing on appropriateness of use and length of therapy for targeted medications. Review of the facility policy titled Nursing Services last revised in May 2025, revealed, The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses in the patient's individual medical record. Documentation guidelines related to orders include: the center must ensure that written medical care of each patient is supervised by a physician. Written and verbal orders constitute the attending physician's directions for the treatment of the patient in the center. General polices for orders: all orders should be directly entered into the Electronic Health Record (EHR) upon receipt, or if handwritten by a provider, should be entered into the EHR from the written orders.Review of R24's Face Sheet revealed R24 was admitted to the facility on [DATE], with diagnoses including but not limited to, bacterial pneumonia, primary hypertension, primary insomnia, major depressive disorder single episode, and generalized anxiety disorder. Review of R24's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/26, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that R24 was cognitively intact. Review of the Active Diagnosis section revealed R24 was not diagnosed with diabetes mellitus (diabetic retinopathy, nephropathy, and neuropathy) during this assessment period. Further review of the admission MDS revealed in the Medication section, R24 did not receive any type of injection, including but not limited to insulin. During this assessment period, R24 was receiving antianxiety, antidepressant, and antiplatelet medication. Review of R24 Care Plan edited on 03/24/26 revealed, [R24] has a diagnosis of anxiety and major depressive disorder, she receives antidepressant/antianxiety medication, which places her at risk for adverse effects of psychotropic drug use. Interventions include, assess resident's functional status prior to initiation of drug use to serve as a baseline; Assess/record effectiveness of drug treatment, monitor and report signs of sedation, hypotension, or anticholinergic symptoms; Pharmacy consultant review. Review of R24's Care Plan revealed that there were no Care Plan problems/interventions related to R24 being diabetic, having diabetic complications, which would indicate the use for insulin. Review of R24's Hospital Discharge summary dated [DATE], revealed, [R24] with a past medical history of asthma, prior history of Mycobacterium Avium Complex (MAC group of bacteria that can cause opportunistic infections), hypertension, chronic left lower lobe bronchiectasis (condition where damage causes the tubes in your lungs (airways) to widen or develop pouches). [R24] presented to the hospital due to worsening generalized weakness/fatigue and shortness of breath. During the duration of R24's hospitalization there was no indication that R24 had interventions/treatments related to diabetic complications. Review of R24's Prescription Order with an order receive date/start date of 03/25/26 and discharge date of 03/25/26, revealed an order description for Lantus Solostar U-100 Insulin (Insulin Glargine), insulin pen; 100 unit/ml (3 mL) amount 10 units subcutaneous (a method of administering medication just under the skin, between the fatty tissue and muscle) once a day at 9:00 AM. Further review revealed there was no diagnosis included for indication of use for this medication. This medication was ordered by Nurse Practitioner (NP)2 and was created and verified by Licensed Practical Nurse (LPN)4. Review of R24's Prescription Order with an order receive date/start date of 03/25/26 and discharge date of 03/30/26, revealed an order description for Insulin Glargine- insulin pen; 100 unit/mL (3 mL) amount 10 units subcutaneous once a day at 9:00 AM. Further review revealed there was no diagnosis included for indication of use for this medication. This medication was ordered by NP2 and was created and verified by Registered Nurse (RN)3. Review of R24's Medication Administration Record (MAR) dated 03/01/26 - 03/31/26, revealed an order for Lantus Solostar U-100 Insulin once a day at 9:00 AM with a start date and end date of 03/25/26. This medication was not administered on 03/25/26 due to the drug/item unavailable; there was no diagnosis or special instruction included for this medication/order. Review of R24's MAR dated 03/01/26 - 03/31/26, revealed an order for Insulin Glargine- 100 unit/mL (3 mL) 10 units subcutaneous once a day at 9:00 AM with a start date of 03/25/26 - 03/31/26. This medication was administered to R24 on 03/26/26 and 03/27/26. The order continued on 03/28/26, 03/29/26, and 03/30/26; however, R24 did not receive additional doses due to R24's refusal. Review of a Pharmacy Consolidated Delivery Sheet dated 03/25/26, revealed an order for Insulin Glargine- U10, 3 mL for R24 that was ordered by Medical Doctor (MD)1. Review of R24's Psychiatric Initial Evaluation dated 03/25/26 at 2:20 PM, by the Psychiatric Nurse Practitioner (NP)3 revealed, [R24] a resident at the facility due to having multiple medical problems, including with her lungs, neuropathy, and rehabilitating from a fall. Patient was referred due to anxiety, and reports feeling overwhelmed; she does not relax easily, asking for Xanax to go to bed/to fall asleep. She has been having depression, anhedonia (reduced ability to experience pleasure or a loss of interest in previously enjoyed activities), decreased appetite, low energy, trouble concentrating, feeling bad about herself, anxiety, restlessness, passive thoughts of not being here, no plan or intention, and denies Auditory Verbal Hallucinations (AVH). [R24] is worried about going home and her health getting better. Patient has a history of mental health care/medications/past therapy attempts about 40 - 50 years ago when getting a divorce. During that time, she suffered from depression/anxiety and took medications for her mental health. Plan for treatment includes generalized anxiety disorder, patient diagnosis with anxiety longer than six months ago, and continues to be treated with anxiety/anxiolytic medication. Moderate diagnosis with depression in the past, still having symptoms, adjustment disorder with emotional disturbance, the patient struggles with her current medical state, which is causing some mood changes, including depression and anxious emotions. Plan of care includes increasing Lexapro 10 mg (an antianxiety medication) and tapering off Xanax (an antianxiety medication) due to healthcare risks of dementia and respiratory depression. Take 1/2 of a tablet by mouth daily for two weeks, then stop if the patient struggles with tapering. Try long-acting benzodiazepines (sedative-hypnotic medications that, by increasing GABA neurotransmitter activity, reduce brain activity to treat anxiety, insomnia, and seizures) for tapering. The Psychiatrist Nurse Practitioner reviewed R24's current medications that she is receiving at the facility; there was no indication that the resident was receiving insulin during this review. Review of R24's Nurse Practitioner Progress Note dated 03/26/26 at 1:06 PM, and signed/revised on 04/01/26 at 8:19 AM, revealed, Chief complaint/nature of presenting problems seen today for follow up of cough and urine results. Recent orders and medication profile have been reviewed, . Medication list including dose and frequency is taken from the facility where patients reside and reflects the best information available at the time of the encounter. Several medications were reviewed during this visit including insulin glargine- 100 unit/mL (3 mL) insulin pen Once A Day 10 units, subcutaneous, Once A Day, TI for Lantus 03/25/2026 Active. There was no diagnosis or indication of use for this medication . Updated diagnoses on 03/30/26 at 6:03 AM include bronchiectasis, anxiety, urinary frequency, and primary hypertension. Clinical, correction under medication list disregard insulin glargine 10 units at bedtime at this is not a prescribed medication for this patient, revised on 04/01/26 at 8:19 AM by [NP1].Review of R24's Nurse Practitioner Progress Note dated 03/31/26 at 12:20 PM, revealed, Chief complaint/nature of presenting problem, seen today for follow up of chronic conditions following hospitalization for weakness, shortness of breath, fatigue. Today's visit, patient seen today for ongoing clinical follow-up, recent orders and medication profile have been reviewed, patient found resting in bed. She feels fatigued and doesn't want to do therapy today, . She's upset that she was advertently given insulin, her family is aware and this issue has already been addressed by the Director of Nursing (DON). Review of R24's Psychiatric Follow-up Evaluation dated 04/01/26 at 10:19 PM, revealed, Patient seen for follow-up for Generalized Anxiety Disorder (GAD) for medication monitoring since Lexapro increased . Last visit writer [NP3] ordered the following changes, increased Lexapro to 10 mg daily and taper off Xanax 0.25 mg 1/2 tablet a day. Xanax was not stopped; the patient is taking an increased dose of Lexapro with little relief for her anxiety. Patient is taking an increased dose of Lexapro with little relief for her anxiety at the present time; she is having an increase in anxiety due to recent events. Her anxiety is a eight out of ten on a scale of zero, meaning none and ten being the worst. She is sleeping fine, her blood pressure has been elevated lately as well, she is having some dry mouth and denies suicidal ideations. Provider [NP3] discussed Lexapro recently increased last week and recommended the patient to wait one more week before doing another medication change. Per her daughter, her medications are not working well at this time for anxiety under the circumstances; however, due to Lexapro being increased one week ago, she is willing to wait another week before increasing it again. Plan of care . is to continue current regimen Lexapro 10 mg daily, do not taper off Xanax due to patient being under increased stress and having increased anxiety right now (Xanax was not stopped at last visit), consider increasing Lexapro 20 mg daily next week. Review of R24's MAR dated 03/01/26 - 03/31/26, revealed an order for Alprazolam (generic name for Xanax) 0.25 MG as needed/PRN for anxiety. R24 received this medication on 03/28/26 and 03/30/26, despite her Psychiatric NP requesting this medication be stopped on 03/25/26, due to healthcare risks of dementia and respiratory depressionReview of R24's Social Services Progress Notes dated 04/02/26 at 6:22 PM, revealed, Master Social Worker (MSW) followed up with [R24] related to her anxiety, she was lying in bed with her husband at the bedside. She was first asleep then woke up while speaking with her husband. [R24] began to share about her medications and her anxiety. [MSW] allowed resident to freely share what she was feeling, [MSW] offered her a current medication list and she informed writer she already requested having one. [MSW] also offered her to follow up with medical staff related to her anxiety. [MSW] allowed her to share and offered coping mechanisms to assist with how she was feeling. Resident voiced thankfulness at the time of visit. Writer provided her with a business card and offered her to ask for writer or to call when needed. Resident sent for writer again to share what she was feeling and writer allowed resident to speak openly and freely. Resident shared her family has offered to move her to another facility and writer informed resident of assisting her and her family in their needs. However, resident stated she didn't want to move. [MSW] will follow up with resident again tomorrow.Review of R24's Medical Director (MD) Progress Note dated 04/03/26 at 6:18 PM, revealed, Chief complaint/nature of presenting problem: NHC [NAME] Medical Director visit following an incident, patient is seen in follow-up for MD visit after recent incident. It appears that an erroneous order for Lantus 10 units daily was entered in her record last week, and on both 03/26/26/ and 03/27/26 she received that medication. Realizing that this was not correct, she refused on 03/28/26 and 03/29/26. On 03/30/26, the error was discovered, and the medication was appropriately discontinued. In interviewing [R24] she cannot indicate any symptoms of hypoglycemia that might have occurred, but did say she may have felt peculiar. She also states that she feels peculiar today, clearly with no relation to insulin several days ago. Vital signs monitored regularly during those days disclosed nothing suggestive of the effects of the insulin. When the error was discovered, blood sugars were checked, and there was no hypoglycemia. There were no notes of anything out of the ordinary from her usual by any nurses during the days she received the insulin. There was a concern that the erroneous medication administration made her extremely anxious. However, she has known generalized anxiety disorder and has been seen by the psychiatric NP here with ongoing medication adjustment. She has been followed up on since the incident with no apparent change. In examining the medication administration record it is noted that the Xanax that she had ordered as needed for anxiety was not requested during any of this time. On recent follow-up with a psychiatric NP, the patient preferred to leave the current Lexapro dose where it is, with consideration for an increase later.During an interview on 03/31/26 at 11:03 AM, R24 revealed, A few days ago, I received 2 injections of insulin, but I am not diabetic. At first, I was agreeable to receiving the medication (03/26/26 and 03/27/26) because I was unsure if something had changed with blood sugars, if I had a change of condition. I've been having a lot of other health issues lately, so I didn't question the medication. After receiving the 2nd injection (03/27/26) I felt sleepy and was certain that this was an error. A male nurse attempted to give me two more doses of insulin, but I refused because I didn't want to have another reaction. During the interview with R24, she stated that her anxiety has increased/worsened due to the potential negative impact this could have had on her. R24 was also concerned about the health and well-being of other residents, specifically those who may have dementia/cognitive impairments that would not be able to communicate with staff if they received the wrong medication. R24 finally stated that the Director of Nursing (DON) is aware of this incident, and the resident, along with her Resident Representative, notified the DON of this situation. During an interview on 04/01/26 at 10:45 AM, R24 and her Resident Representative (RR) revealed that the resident received two insulin injections (03/26/26 and 03/27/26). During these injections, the nurse did not check the resident's blood sugar appropriately prior to administration. During the interview with R24 and her RR, both parties were visibly upset about this incident related to R24 inadvertently receiving insulin, R24 and her RR became tearful and frustrated because of this incident by the facility staff. During an interview on 04/01/26 at 11:15 AM, Nurse Practitioner (NP)1 revealed that the process of insulin administration is that providers write the order based on blood sugars, then nurses should check blood sugars and administer the insulin. NP1 is aware of inadvertent insulin medication that R24 was administered. NP1 at this time was only aware of inaccurate administration (03/26/26) but verified through the MAR during interview that the resident received the medication on 03/26/26 and 03/27/26. NP1 further stated that she was informed about this situation by the DON but was not at the facility at this time. NP1 returned to work the following Monday (03/30/26) and was educated on this situation, which revealed that NP2 ordered this medication, but she is not the NP for R24. The original order for R24 should have been Lexapro but was misinterpreted as insulin; Lexapro was recommended/ordered by the Psych NP to increase for Lexapro due to diagnosis of anxiety/ increased anxiety. During an interview on 04/01/26 at 12:08 PM, Licensed Practical Nurse (LPN)4, who is the Computer Order Entry Clerk, revealed that R24's order was left overnight, the night before. Most providers have hand-written orders. LPN4 further stated that she is unable to locate the handwritten order for this resident and further stated that when she put it in, it was for 10 units of Lantus handwritten on 03/24/26. LPN4 concluded that orders are verified several times before they make it to the Order/MAR, which includes verification by the nurse, physician, and pharmacy. During an interview on 04/01/26 at 12:15 PM, the Unit Manager (UM)1 revealed that orders are mostly handwritten by providers on a yellow sheet and are left for the Computer Order Entry Clerk to input into the electronic medical record for residents, orders are then verified by the pharmacy. UM1 stated that she was working the cart that day (03/26/26 and 03/27/26) and was the nurse that administered the insulin to the resident. UM1 stated, I remember asking [R24], I didn't know you were a diabetic, but [R24] never replied or corrected me. UM1 further stated that she did not check the resident's blood sugar prior to administering because sometimes insulin is used for a off-brand reason, [UM1] also stated that she did not observe [R24] have any side effect/negative impacts from this. UM1 finally stated that the facility administration is about to change the process of order entry into the electronic medical record and will now have providers putting in orders, UM1 was unsure about when this change will take effect and stated providers still have to be educated on the new process. An attempted interview on 04/01/26 at 3:26 PM, with LPN5 (Male Nurse Identified by R24) was unsuccessful; a voicemail message was attempted, but the mailbox was full/unable to leave a message. During an interview on 04/01/26 at 3:31 PM, the DON revealed that she was made aware of this incident on Monday (03/30/26) and began the investigation process by interviewing the resident and the nurses that were assigned to her and gave the resident insulin, along with the Computer Order Entry Clerk. The DON stated that they were unable to locate the physical handwritten order related to the insulin, but stated that the facility is changing the process on how orders are put into the medical record. The facility will now implement providers putting the orders into the record. During a phone interview on 04/01/26 at 4:44 PM, the Medical Director (MD) revealed that he was notified about R24 inadvertent administration of insulin this morning (04/01/26) and was notified by the residents Nurse Practitioner. The NP was made aware of this incident on Monday (03/30/26). They were informed that the order was written by a different NP, NP2. The MD further stated that the resident had a low risk for developing a negative side effect due to the low amount of insulin that she received but some potential side effects could be hypoglycemia/low blood sugar. The MD stated the resident's psycho-social status was discussed due to the resident's increased anxiety after this incident and he stated he was unsure if the resident was being followed by psychiatric services. During a follow phone interview with the MD on 04/02/26 at 8:58 AM, revealed that typically when there is a medication error, if the providers are the person to recognize the error, then they notify me about the medication. If it is a nurse that observes an error then they expect them to notify the DON which should then be relayed to the resident/resident representative, along with the MD, and any other responsible provider. The MD further stated that this incident is still being investigated by the facility Administration but the process moving forward beginning on 04/01/26, are for the providers to input the order into the electronic medical record. The MD finally stated that he would have expected for the facility Administration to notify him of the resident's change sooner but feels that they may have delayed the notification due to the resident not having a serious adverse reaction to the insulin. The notification may have also been delayed because the investigation is still ongoing about the staff member that ordered the insulin. During an interview on 04/02/26 at 10:17 AM, NP2 revealed that they were informed by Certified Nursing Assistant (CNA)1 that the resident had concerns about receiving insulin inappropriately. NP2 went to verify the order because the resident's NP, NP1, was not in house at this time. At that point, NP2 discovered that the order was written in her name, she then went to ask the Computer Order Entry Clerk (COEC) about how this happened and COEC admitted she made a mistake and entered Lantus instead of Lexapro that was ordered by the resident psych NP, NP3. NP2 further stated that this incident should have been caught by the pharmacy when they verified the order and changed the order from Lantus to insulin glargine- insulin pen; 100 unit/mL (3 mL); amt: 10 units; subcutaneous. NP2 finally stated the facility now is having providers put in their own orders, and this was in the process prior to this incident, but initiated on 04/01/26. During a phone interview on 04/02/26 at 11:09 AM, the Psychiatric Nurse Practitioner (NP)3 stated that the resident has a history of anxiety but since being administered the incorrect medication, her anxiety has increased. NP3 met with the resident yesterday, 04/01/26, and spoke with her about this incident.During an interview on 04/02/26 at 11:14 AM, CNA1 revealed that they were the first staff member that R24 reported this incident to, CNA1 further stated that she reported it to NP2 which prompted the investigation. CNA1 stated that the resident has been stating that she is anxious about this incident and overall care at the facility. During an interview on 04/02/26 at 11:41 AM, LPN3 revealed that she works at the facility on Thursdays during the day and on Sunday nights overnight. LPN3 stated that R24 is a very anxious resident but is alert and oriented times 3, very sharp. LPN3 further stated that she did not administer any insulin to R24 and is unsure why her name is signed off on the MAR for 03/30/26 at 9:00 AM for insulin medication that R24 refused when she clocked out of the facility at 7:02 AM. LPN3 provided copy of timeclock which confirmed she had already left the facility when the MAR was signed off. During an interview on 04/03/26 at 9:40 AM, the DON stated the facility realized that there is an error with the EMR. There is currently a glitch that is causing nurses sign off, they are not fully logging out which will cause the oncoming nurse to chart under the prior nurses' name. On 03/30/26, scheduled at 9:00 AM charted for 03/30/26 at 10:09 AM, LPN3 verified that she clocked out at 7:02 AM. DON confirmed today that this date refusal was completed by UM1 on 03/30/26. On 04/03/26 at 12:46 PM, the facility provided an acceptable IJ Removal Plan, which included the following: . Identification of Root CauseFollowing internal review, the facility determined that the event was the result of a breakdown in the medication order entry and verification process, specifically related to ensuring that orders are supported by a clearly identified source and accurately attributed to the appropriate provider prior to entry and administration.Identification of Other Residents at RiskOn March 30, 2026, the facility conducted a targeted audit of all residents in certified beds with active insulin orders to verify appropriate clinical indication. A total of 18 or 18 residents receiving insulin were reviewed, and 100% were confirmed to have a documented diagnosis of diabetes supporting the use on insulin therapy .Additionally, on April 2, 2026, consulting pharmacists initiated a 100% audit of all active medication orders to ensure accuracy and appropriate indication. As of April 3, 2026, no additional residents were identified as having received medications without appropriate indication.Systemic Corrective ActionsOn April 2, 2026, the facility initiated corrective actions to address the identified process gap. All licensed nursing staff were in-serviced by the DON on revised expectations for medication order verification, including the requirement to confirm the accuracy of all newly entered orders, validate clinical indication, and obtain clarification from the provider when any order is unclear prior to administration.On April 2, 2026, providers were notified by the DON and re-educated regarding expectations for order entry and authentication, including the requirement to ensure all orders are accurate, clearly intended, and appropriately attributed prior to signing.Additionally, the facility implemented enhanced controls requiring that all medication orders originate either directly from the provider or from clearly verified source documentation.Monitoring PlanBeginning April 2, 2026, the facility initiated a 100% audit of all newly entered medication orders for a period of seven days. This will be followed by weekly audits for four weeks and ongoing monitoring through the facility's Quality Assurance and Performance Improvement (QAPI) program to ensure sustained compliance. The audits will be conducted by the DON or designee.IJ RemovalIJ Removal Summary:The medication was discontinued on March 30, 2026 following provider evaluationThe resident remained clinically stable with no evidence of serious harmObjective clinical data, including a blood glucose of 166 mg/dL obtained on March 28, 2026, confirms that the resident was not experiencing and was not trending toward hypoglycemia or physiological instabilityA targeted audit confirmed that 18 of 18 residents receiving insulin had appropriate diagnoses, demonstrating no broader medication indication concernsA facility-wide audit confirmed that no additional residents were affectedSystemic corrective actions have been implemented to ensure proper medication order verification and prevent recurrenceConclusion The facility alleges that it is in compliance as of April 3, 2026, as corrective actions have been implemented, the affected resident remains stable, all residents have been reviewed for potential impact, and system changes have been established to prevent recurrence.

Based on observation, record review, interview, facility policy review, manufacturer and pharmacy labeling review, the facility failed to ensure that drugs and biologicals were properly stored in 2 of 2 medication rooms.Findings include: Review of the facility policy titled MEDICATION STORAGE IN THE FACILITY revised on 2/25/2025, states, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier . All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. During observation on 03/31/2026 at approximately 10:55 AM, of the 200 Hall Medication Room refrigerator revealed the following:- 2 bottles of Augmentin 400mg (milligram)/5 ml (milliliter) Susp (Suspension) in active storage and labeled by pharmacy Do No Use After 3/28/26 and Do Not Use After 3/27/26- 1 opened vial of Purified Protein Derivative/Aplisol 5 TU (test units) /1 ml (10 tests) approximately 20% (percent) full and undated when opened with manufacturer labeling stating: Once entered discard after 30 days. During an interview on 03/31/2026 at approximately 11:06 AM, Registered Nurse (RN)1 verified that the opened vial of Aplisol had not been dated when opened and that the bottles of Augmentin were expired. During an observation on 03/31/2026 at approximately 3:05 PM, of the Hall 100 Medication Room revealed:- 8 Fecal Occult Blood Tests Lab Kits Enhanced Readability by Consult Diagnostics Lot 0822192 with an expiration date of 12/03/2025, located on the 2nd shelf of the shelving unit to left of the refrigerator. During an interview on 03/31/2026 at approximately 3:16 PM, Licensed Practical Nurse (LPN)1 verified that the fecal occult blood tests had expired on 12/03/2025. During an interview on 04/01/2026 at approximately 5:21 PM, the medication storage findings were reviewed with the Director of Nursing (DON) who stated those things should not be left in active storage and that Aplisol should have been dated when opened.

Based on observation, interview and review of facility policy, the facility failed to ensure Resident (R)9's dignity was protected for 1 of 1 residents observed with catheter bag. Specifically, R9's catheter bag was not covered.Findings include: Review of the facility's policy titled Administrative Procedures Manual . Establishing a Customer Satisfaction Culture revised 2-1-2011 states, Respect your privacy, dignity, and confidentiality. During an observation on 03/31/2026 at approximately 11:11 AM, during the 200 Hall initial tour, a Certified Nursing Assistant (CNA) rolled R9 in his wheelchair to a table in the common area opposite the nursing station and walked away leaving him at the table. Further observation revealed a fully visible and uncovered urinary bag approximately 3/4 full, was hanging beneath R9's wheelchair. During an observation on 03/31/2026 at approximately 11:25 AM, R9 was observed sitting at the same table, with the urinary bag beneath his wheelchair, still uncovered and visible. Further observation revealed multiple staff members, other residents, and a visitor were in the immediate area. During an interview on 03/31/2026 at approximately 11:28 AM, Registered Nurse (RN)2, who was standing at the nursing station, viewed R9 and his wheelchair and confirmed that his urinary bag was not covered and stated it should be covered. During an interview on 04/01/2026 at approximately 5:23 PM, the Director of Nursing stated that urinary bags should be covered to protect resident's dignity.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments for 4 of 4 residents listed on the Missing Obra Assessment Report were corrected, completed and transmitted in a timely manner.Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0, revealed, Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Review of the Missing OBRA Assessment report provided by the State Agency included 4 residents with missing assessments. Review of the missing assessments revealed the 4 assessments were coded as completed by the MDS Coordinator but not submitted after the completion. During an interview on 04/02/2026 at 2:50 PM, the MDS Coordinator and the Assistant Regional Nurse confirmed that the missing OBRA assessments were completed and not sent to the state agency timely. They were showing in their computer system as completed but not transmitted.

Based on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)24's Medical Doctor/Director was informed in a timely manner of an inadvertent administration of a medication, for 1 of 3 residents reviewed.Cross reference F757 Findings include:Review of the facility policy titled Policies and Procedures Regarding Change in Patient Status last revised in 2025 revealed, The patient or patient representative is encouraged to be involved in all decision-making regarding changes in the plan of care. Notification of the patient representative, charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative. When a significant change in medical condition has occurred, or the patient is assessed to be critically ill, the attending physician will be notified immediately. Should the attending physician or physician extender not be available, the alternate physician will be notified. When a medical condition is identified and the attending/alternate physician in unavailable, the charge nurse will take the steps necessary to assure appropriate medical care is provided, including but not limited to, contacting the center's Medical Director. Review of R24's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to, bacterial pneumonia, primary hypertension, primary insomnia, major depressive disorder single episode, and generalized anxiety disorder. Review of R24's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/26, revealed that R24 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that R24 was cognitively intact. Review of the Active Diagnosis section of the MDS revealed R24 was not diagnosed with diabetes mellitus (diabetic retinopathy, nephropathy, and neuropathy) during this assessment period. Further review of the admission MDS revealed R24 did not receive any type of injection, including but not limited to insulin. During this assessment period, R24 was receiving antianxiety, antidepressant, and antiplatelet medication. Review of R24's Medication Administration Record (MAR) dated 03/01/26 - 03/31/26, revealed an order for Insulin Glargine-100 unit/mL (3 mL) 10 units subcutaneous once a day at 9:00 AM with a start date of 03/25/26 - 03/31/26. Further review of the MAR revealed this medication was administered to R24 on 03/26/26 and 03/27/26. The order continued on 03/28/26, 03/29/26, and 03/30/26; however, R24 did not receive additional doses due to refusal.Review of R24's Nurse Practitioner Progress Note dated 03/26/26 at 1:06 PM and signed/revised on 04/01/26 at 8:19 AM, revealed, Chief complaint/nature of presenting problems seen today for follow up of cough and urine results. Recent orders and medication profile have been reviewed, . Medication list including dose and frequency is taken from the facility where patients reside and reflects the best information available at the time of the encounter. Several medications were reviewed during this visit including insulin glargine-100 unit/mL (3 mL) insulin pen Once A Day 10 units, subcutaneous, Once A Day, TI for Lantus 03/25/2026 Active. There was no diagnosis or indication of use for this medication . Updated diagnoses on 03/30/26 at 6:03 AM include bronchiectasis, anxiety, urinary frequency, and primary hypertension. Clinical, correction under medication list disregard insulin glargine 10 units at bedtime at this is not a prescribed medication for this patient, revised on 04/01/26 at 8:19 AM by [NP1].Review of R24's Nurse Practitioner Progress Note dated 03/31/26 at 12:20 PM, revealed, Chief complaint/nature of presenting problem, seen today for follow up of chronic conditions following hospitalization for weakness, shortness of breath, fatigue. Today's visit, patient seen today for ongoing clinical follow-up, recent orders and medication profile have been reviewed, patient found resting in bed. She feels fatigued and doesn't want to do therapy today, . She's upset that she was advertently given insulin, her family is aware and this issue has already been addressed by the Director of Nursing (DON). Review of R24 Medical Director (MD) Progress Note dated 04/03/26 at 6:18 PM, revealed, Chief complaint/nature of presenting problem: NHC [NAME] Medical Director visit following an incident, patient is seen in follow-up for MD visit after recent incident. It appears that an erroneous order for Lantus 10 units daily was entered in her record last week, and on both 03/26/26 and 03/27/26 she received that medication. Realizing that this was not correct, she refused on 03/28/26 and 03/29/26. On 03/30/26, the error was discovered, and the medication was appropriately discontinued .During a phone interview on 04/01/26 at 4:44 PM, the Medical Director (MD) revealed that he was notified about R24's inadvertent administration of insulin this morning (04/01/26) and was notified by the residents Nurse Practitioner. The NP was made aware of this incident on Monday (03/30/26). The MD further stated that he would have expected to be notified sooner about this incident.

Based on observation, record review, interview, and policy review, the facility failed to utilize personal protective equipment (PPE) for enhanced barrier precautions (EBP) for one of two residents (Resident (R) 61) reviewed for EBP out of a sample of 18 residents. This created the potential for transmission of infection to staff and other residents. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions dated February 2025, revealed, Providers and partners must wear gloves and a gown for the following high-contact patient care activities: . device care or use: central line, urinary catheter, feeding tube . Review of R61's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed admitted on [DATE] with diagnoses gastrostomy (an opening in the stomach for a feeding tube), and dysphagia (difficulty swallowing) following cerebral infarction (stroke). Review of R61's Care Plan under the RAI (Resident Assessment Instrument) tab of the EMR revealed a problem area of requires tube feeding related to dysphagia/protein calorie malnutrition created 10/04/24. Review of R61's Orders tab of the EMR dated 10/04/24 indicated, give all medication via peg [feeding] tube .Klonopin (anti-anxiety medication) 1mg [milligram] every six hours dated 03/31/25, and Seroquel (anti-psychotic medication) 25mg three times daily, dated 01/08/25. During an observation on 05/14/25 at 1:24 PM, Registered Nurse (RN)1 brought crushed Klonopin and Seroquel into R61's room. R61's door had an EBP sign on it which indicated to wear gown and gloves RN1 washed her hands and donned gloves. RN1 checked the feeding tube for placement, flushed the tube with water, administered each medication separately, ending by flushing the tube with water, and securing the abdominal binder. RN1 did not wear a gown during the administration of R61's medications per the gastrostomy tube. During an interview on 05/15/25 at 2:22 PM, Certified Nurse Aide (CNA)1 stated staff were to wear a gown and gloves when doing any contact activity with a resident who has a feeding tube. During an interview on 05/15/25 at 3:07 PM, RN1 stated that EBP were followed when providing wound care, any line care (for intravenous medications) and maybe feeding tubes. When asked if a gown was to be worn when doing a dressing change for a feeding tube site or administering medications via a feeding tube, RN1 stated she was unsure in a nursing facility setting, that a gown was not used for those activities. During an interview on 05/15/25 at 3:09 PM, Unit Manager (UM)2 stated EBP was utilized whenever anything was administered through a feeding tube, when providing wound cares, or with any contact activities of daily living (ADLs) with someone with wounds, lines, feeding tubes, etc. During an interview on 05/15/25 at 3:12 PM, the Assistant Director of Nursing (ADON) stated that residents on EBP had signs on their doors and caddies with PPE on their side of the room. It was expected that nurses wore gowns and gloves when they administered medications via a feeding tube, flushed a feeding tube, or changed a feeding tube dressing. During an interview on 05/15/25 at 3:21 PM, the Director of Nursing (DON) reported the expectation that staff follow EBP with any prolonged contact with residents with catheters, drains, feeding tubes, or colonization with a MDRO (multi-drug-resistant bacteria). This included wearing a gown and gloves with a feeding tube dressing change or administering medications via a feeding tube.

Based on interviews, record review, and review of facility policy, the facility failed to protect Resident (R)1 from neglect. Specifically, R1 was admitted to a local hospital with severe bruising, multiple infected wounds, and a foul odor. R1 later expired in the hospital on [DATE]. On [DATE] at 3:40 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation. On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and the immediacy of the IJ was removed as of [DATE]. The facility remained out of compliance at F600 at a lower scope and severity of D. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation last revised on [DATE], states, Abuse, Neglect, Misappropriation of Property and Exploitation, as hereafter defined, will not be tolerated by anyone . The patient has the right to be free from Abuse, Neglect, Misappropriation of Property and Exploitation . Neglect: the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Facility's Policy titled Pressure Ulcer Treatment Protocols and Wound Care Guidelines last revised on [DATE], revealed, Department: Nursing, Objectives, assess status of patients skin integrity, Assessments: . Daily skin observations with ADL's, weekly skin/wound assessments, Care and Treatment .cleanse, cover, protect, skin care. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: history of falling, macular degeneration, depression, irritable bowel syndrome, diplopia, and enterocolitis due to Clostridium difficile. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 was cognitively intact. Further review of the MDS revealed R1 did not have any unhealed pressure ulcers or injuries. Review of R1's Physician Orders dated [DATE], revealed the following order, Monitor R LOWER ARM for signs and symptoms of infection and document in nurses notes any abnormalities noted. Notify MD of new findings. If multiple sites document concern in progress note. Twice a day. Review of R1's Physician Orders dated [DATE], revealed the following order, WOUND CARE DOCTOR TO EVAL & TREAT WEEKLY AS NEEDED. MAY PERFORM DEBRIDEMENT IF APPROPRIATE. Review of R1's Electronic Medical Record under the tab Wound Management revealed on [DATE] at 6:25 PM, R1 had a skin tear on her right lower forearm with a documented wound healing status as stable. Further review revealed, on [DATE] at 11:36 AM, R1's right lower forearm skin tear was documented as healed. No additional wounds were documented for R1. Review of R1's Weekly Skin Observation dated [DATE] revealed, R1 had skin tears to the right and left arms and right and left lower legs. No open lesions or wound infections noted. Incontinence care is the only listed skin treatment/intervention provided. Review of an Incident/Investigation Report from the local police department dated [DATE], revealed, .upon arrival at [local hospital] it was reported that during routine checks, the staff on duty observed the victim to have abnormal bruising on her entire body. The nurse advised that the victim was covered in skin tears, hematomas, multiple mepilex, out of date dressings, wounds oozing with greenish pus and the victim having a foul smell. The resident was under the care of NHC [NAME]. Review of Photographic Evidence submitted by the local police department revealed, 14 images of R1 showing multiple different wounds, severe bruising to the lower back and waist, and greenish drainage on multiple wound beds and dressings. Review of R1's Hospital Medical Records dated [DATE] - [DATE], revealed the following: 1. A Physician Note dated [DATE] stated, R1 presented to a local emergency department from NHC with abdominal pain and a fall from bed. R1 appears jaundiced on exam. 2. A nurses note dated [DATE] at 11:36 AM, stating, R1 has large bruising across her lower back and abrasions and tears on her arms and legs covered with mepilex bandages. 3. A Computed Tomography (CT) scan dated [DATE] that revealed R1 had nondisplaced fractures of the posterior left eighth and ninth ribs and numerous additional old and subacute bilateral rib fractures and subcutaneous hematoma in the midline of the lower back. 4. Progress notes stating that R1 was admitted to the hospital from the emergency department on [DATE] with the following diagnoses including but not limited to: Sepsis, Methicillin-Sensitive Staphylococcus aureus (MSSA), left flank hematoma and multiple skin wounds. Review of a Hospital Wound Care Consult dated [DATE], states on [DATE], R1 had the following wounds present on admission to the hospital: large skin tear to the left retinal leg, skin tear to the left and right anterior knees, left medial foot wound, skin tear to the right anterior second toe, skin tear to the right radial arm, skin tear to the right and left posterior elbows, skin tear to the left posterior brachial arm, skin tear to the right and left posterior hands, skin tear to the right lower arm and breakdown of the buttocks. During an interview on [DATE] at 8:32 AM, a Detective (DET) from the local police department stated, they were contacted by a local hospital on [DATE] with reports that R1 had severe bruising, wounds that were seeping, and had a foul odor. The DET also states R1 had a staph infection and was septic and was not expected to survive the next 48 hours. During an interview on [DATE] at 12:09 PM, R1's Resident Representative (RR) stated upon admission to NHC [NAME], R1 only had a skin tear on her right arm. RR also reports that upon admission to the hospital on [DATE], R1 was reported to have multiple oozing foul-smelling wounds, severe bruising to her back side and infected wounds covered in old dressings. RR reports that R1 expired on [DATE]. During an interview on [DATE] at 12:30 PM, the Wound Care Nurse (WCN) stated, she did not complete R1's admission skin assessment, however, R1 only had a skin tear on her right arm. The WCN further states, R1 did not have any open wounds or pressure ulcers and that her initial skin tear on her right arm had healed. The WCN stated, if a resident were to develop any new wounds it would be reported to her and then to the Nurse Practitioner (NP). During interview on [DATE] at 12:41 PM, Registered Nurse (RN)1 stated, R1 only had skin tears on her arms and her leg and R1 did not have any severe bruising, open wounds or pressures sores. During an interview on [DATE] at 12:52 PM, the Admissions Nurse (AN) stated, she completed R1's admission skin observation and R1 only had a large skin tear to her right arm and had no other wounds. During an interview on [DATE] at 1:37 PM, the Director of Nursing (DON) stated, she was unaware if [R1] was seen by wound care, but that [R1] only had bruising and skin tears. The DON was unaware of any additional wounds on [R1]. Lastly, the DON stated, it is her expectation that the nurses report to the wound care nurses with any new wounds found on residents. On [DATE], the facility provided an acceptable IJ Removal Plan, which included the following: This allegation of non-compliance has the ability to adversely affect all residents. All patients in certified beds had a skin audit performed for any new, known or worsened skin breakdown to include skin tears and pressure injuries. Any newly identified or worsened area were immediately reported to the patient's provider and responsible party. Skin audits completed on [DATE] by nursing management team with no new areas of concerns identified. Education was provided to all licensed nurses on how to perform a skin assessment, proper treatments based on physician orders, and proper documentation. All in-house nursing partners educated on [DATE] by Assistant DON and remaining nurses education will be completed [DATE] by ADON and designee. Education to all certified nurse aides on how to observe skin while performing ADL care as well as provide skin care and pressure relief. All in-house nursing partners educated on [DATE] by Assistant DON and remaining CNA education will be completed [DATE] by ADON and designee. For ongoing monitoring, the DON or designee will review all patients with skin treatments to review for changes in wound appearances. Any new admission will be included in this monitoring. Changes in skin condition will be reported to the patient's provider. Daily x2 weeks, twice per week for 2 weeks, Weekly for 1 month and Monthly until deemed no concerns by the QA committee. A QAPI meeting was held on [DATE] with the Administrator, DON, Assistant DON, Nurse Manager, Assistant Regional Nurse, Social Worker Director, HIM Director, and Dietary Manager. The alleged events were discussed in detail and processes that need to be completed and implemented to assure resident safety from situations of neglect are followed up on appropriately. The processes will be communicated to all partners through the in-service listed above. Compliance of the above was achieved on [DATE].

Based on interview and record review, the facility failed to ensure enough staff was working to ensure care was provided in a timely manner for seven residents (Resident (R)15, R23, R35, R37, R19, R46, and R159) of total sample of 20 residents. Findings include: 1. Review of a Face Sheet, found in R15's electronic medical records (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R15 was cognitively intact. During an interview on 10/31/23 at 10:06 AM, R15 said on the weekends there are not enough staff. R15 stated he has had to wait over an hour at times to get assistance. R15 said there have been times that his colostomy bag exploded before he could get help to empty it but has been able to contain the feces with a brief. During an interview on 11/02/23 at 1:02 PM, Licensed Practical Nurse (LPN) 7 said staffing on the weekends is very bad. She said the staff tries to work together as a team, but it is difficult to make sure call lights are answered timely. She said last weekend she remembered it took her quite a while to assist R15 with his colostomy. She said R15 was nice about it. LPN7 said she had time-consuming wound care to complete and so R15 had to wait until she was available. 2. Review of a Face Sheet, found in R23's EMR under Face Sheet, indicated R23 was readmitted to the facility on [DATE] with a Displaced fracture of right femur. Review of R23's admission MDS with an ARD date of 10/31/23 indicated the resident had a BIMS score of 10 out of 15, indicating R23 was moderately impaired cognitively. Review of a Care Plan, found in R23's EMR under Care Plan, dated 09/25/23, indicated R23 had Urinary Incontinence . Goal included .Patient will be clean and dry with prompt toileting, incontinence care as needed . Approaches included, Assist with toileting per patient's needs. Review of a Progress Note, found in R23's EMR under Social Worker Progress Note, dated 10/25/23, indicated She [R23] is alert and able to make her needs/wants known. Resident scored a 10 on her BIMS. During an interview on 10/31/23 at 4:45 PM, R23 said this past Sunday, 10/29/23, she could not get anyone to answer her call light. R23 said she had to be assisted to the bathroom because she is not able to bear full weight on her broken leg. R23 said she had to wet herself. She said it made her feel mad, but she just went with the flow. She said that was not the first time it happened. R23 stated there is not enough help on the weekend. During an interview on 11/01/23 at 1:10 PM, R23's family member (FM) 9 was in the room and said her sister had visited on a weekend and it had taken 25 minutes for someone to answer R23's call light. FM 9 said R23 had to go in her brief. R15 and R23 reside on the [NAME] Unit (CU). Review of NHS Healthcare Call offs, given by the facility, indicated on Saturday, 10/28/23 and Sunday, 10/29/23 one CNA called off on the 7:00 PM to 7:00 AM shift on 10/28/23 and one CNA called off on the 7:00 AM to 7:00 PM shift on 10/29/23. 36917 3. On 10/31/23 at 2:37 PM, R35's FM4 stated that on Saturday, (10/21/23), R35 was soaking wet and needed to be cleaned and changed. The call light was activated. FM4 stated that a staff member responded 1.5 hours later. On 10/31/23 at 9:31 AM, R35 stated on weekends mostly, it takes a long time to get call light answered. R35 stated the nurses tell him they do not have time to get ice for his Juven, which tastes better when cold. R35 stated the nurses tell him they do not have time to assist him with his CPAP (assisted breathing for sleep apnea) at night. 4. On 10/31/23 at 3:49 PM during an interview, R37's FM 1 stated there have been times when there was not enough staff to get R37 up in the chair. 5. On 10/31/23 at 11:04 AM, R19 said the weekends have less staff and you have to wait longer for help. R19 could not give any specific examples of staff shortage affecting her care. 6. On 10/31/23 at 1:48 PM during an interview, R46's FM2, stated a couple of weeks ago on the weekend she found R46 soiled. FM2 stated R46 wears briefs and was wet enough that urine had soaked through to his clothes. FM 2 stated she visited on Sunday afternoon around 3:00 PM and R46 was still in bed and not dressed. FM2 said the facility is always short staffed on the weekends. 7. On 10/31/23 at 11:36 AM, R159 stated that she asked the medication nurse for some water yesterday morning. The nurse did not get it for her but said they will pass the water when they get time. R159 said, I have to wait for a diaper change because they say they are shorthanded, more so during the evening or night. The whole system is screwed up. Review of Resident Council Minutes (RCM) for a meeting held on 08/09/23, with 11 residents and two staff members in attendance, revealed concerns that call lights were not answered in a timely manner, and that residents waited too long for assistance. Review of the RCM on 09/13/23, with eight residents in attendance, revealed concerns that staff took too long to answer the call light. A review of the facility Summary of Grievances report also documented grievances/concerns regarding timely call light response on the following dates in 2023: June 21, July 7,20, October 3, 11th, No documentation, prior to survey exit date, was provided to identify the complainants of the grievances or if the grievances were resolved. During an interview on 11/02/23 at 2:15 PM the Staffing Coordinator (SC) said there is an on-call supervisor who is responsible for finding replacements for weekend call offs and will come into work if necessary. During an interview on 11/02/23 at 2:20 PM the Administrator said the facility has been hiring staff and the goal is to eliminate agency staff. He said there are currently four full time licensed nursing positions and one or two CNA positions to be filled.

Based on interview and record review, the facility failed to order medication in a timely manner and failed to administer medication when it was available for 1 (Resident (R)15) of 2 residents reviewed for antibiotic use. Findings include: During an interview on 10/31/23 at 10:14 AM, R15 said the cream for his shingles ran out over the weekend and he had not gotten any since. He said the nurse told him the pharmacy does not deliver on the weekend. Review of a Face Sheet, found in R15's electronic medical record (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R15 was cognitively intact. Review of a Prescription Order, located in R15's EMR under Orders, indicated Primary Clinical Category Acute Infections, dated 10/25/23, documented erythromycin ointment .Apply 0.25 inches to affected area on right upper eyelid and forehead 3x daily Dx: (diagnosis) Shingles. The pharmacy fill date was documented to be 10/25/23 at 11:59 AM and 10/30/23 at 11:27 AM. Review of R15's Medication Administration Record (MAR), located in R15's EMR under Reports, indicated the erythromycin was not administered on 10/29/23 through 10/31/23. The documented reason indicated Drug/Item Unavailable and awaiting pharmacy. Review of a Resident Progress Note, located in R15's EMR under Progress Notes, dated 10/29/23 at 7:26 PM, indicated Patient is aware that ointment has been reordered. Currently awaiting pharmacy delivered [sic]. Will continue treatment until blisters have crusted/healed as ordered by MD. RP [responsible person] and provider notified. Review of a Resident Progress Note, located in F15's EMR under Progress Notes, dated 10/20/23 at 12:31 PM, indicated Patient was made aware that erythromycin was ordered. We will continue with treatment until healed. Provider notified. During an interview on 11/01/23 at 12:16 PM, the [NAME] Unit Manager (UM2) confirmed the missed doses of the eye ointment on 10/30/23 and 10/31/23. She said the resident was ill on 10/29/23 and refused the ointment. UM2 said the pharmacy delivered medication late in the evening so that is why it was not administered on 10/30/23. During a second interview on 11/01/23 at 12:50 PM, R15 said he did not refuse the eye ointment on the weekend, he said they ran out on Saturday. He only refused the oral medications because he was sick to his stomach. R15 said the nurse told him the medication was out and the pharmacy did not deliver on the weekend. During an interview on 11/01/23 at 2:32 PM, Licensed Practical Nurse (LPN) 12 confirmed he had overlooked the eye ointment and failed to administer it on 10/31/23. He said the night shift nurse reported the eye ointment had been ordered so he did not look in the top drawer of the medication cart for it. During an interview on 11/02/23 at 9:39 AM, the Pharmacist said the facility should have a backup pharmacy that could deliver on the weekends. She said if they had been made aware he was completely out of the ointment, they could have arranged something for them.

Based on interview and record review, the facility failed to ensure care was provided in a dignified and timely manner for 3 (Resident (R)15, R23, R35) of 4 residents reviewed for dignity out of a total sample of 20 residents. This resulted in R15's colostomy (a pouch on the outside of the body to hold stool) bag exploding and R23 feeling mad about having to wet herself but having to go with the flow. Findings include: 1. Review of a Face Sheet, found in R15's electronic medical records (EMR) under Face Sheet, indicated R15 was admitted to the facility on [DATE] with a diagnosis of Encounter for attention to colostomy. Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R15 was cognitively intact. During an interview on 10/31/23 at 10:06 AM, R15 said on the weekends there are not enough staff. He has had to wait over an hour at times to get assistance. R15 said there have been times that his colostomy bag exploded before he could get help to empty it but has been able to contain the feces with a brief. During an interview on 11/02/23 at 1:02 PM, Licensed Practical Nurse (LPN) 7 said staffing on the weekends is very bad. She said the staff tries to work together as a team, but it is difficult to make sure call lights are answered timely. She said last weekend she remembered it took her quite a while to assist R15 with his colostomy. She said R15 was nice about it. LPN7 said she had time-consuming wound care to complete and so R15 had to wait until she was available. 2. Review of a Face Sheet, found in R23's EMR under Face Sheet, indicated R23 was readmitted to the facility on [DATE] with a Displaced fracture of right femur [leg]. Review of R23's admission MDS with an ARD date of 10/31/23 indicated the resident had a BIMS score of 10 out of 15 indicating R23 was moderately impaired cognitively Review of a Care Plan, found in R23's EMR under Care Plan, dated 09/25/23, indicated R23 had Urinary Incontinence . Goal included .Patient will be clean and dry with prompt toileting, incontinence care as needed . Approaches included, Assist with toileting per patient's needs. During an interview on 10/31/23 at 4:45 PM, R23 said this past Sunday she could not get anyone to answer her call light. R23 said she had to be assisted to the bathroom because she is not able to bear full weight on her broken leg. R23 said she had to wet herself. She said it made her feel mad, but she just went with the flow. She said that was not the first time it happened. R23 said there is not enough help on the weekend. During an interview on 11/01/23 at 1:10 PM, R23's family member (FM) 9 was in the room and said her sister had visited on a weekend and it had taken 25 minutes for someone to answer R23's call light. She said R23 had to go in her brief. During an interview with the Director of Nursing (DON) on 11/01/23 at 3:00 PM, the interviews with R15 and R23 were shared. The DON was unaware of call lights not being answered timely. Follow up with DON on 11/02/23 at 1:17 PM indicated she had not spoken with R15 and R23 about their care. During an interview on 11/02/23 at 2:44 PM, Certified Nursing Assistant (CNA) 4 said she had stopped working on the weekends in the first part of October and now works Monday through Thursday. She said when she did work the weekends, resident's would complain to her about how long it took to answer the call light. She said there are multiple call outs both on the weekends and the weekdays. 36917 3. Review of the quarterly MDS assessment with an ARD of 10/28/23, revealed R35 had a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. R35 also was assessed as having incontinence of bowel and bladder, sometimes has moderately impaired ability to make concrete requests, and is non-interviewable. Review of the EMR for R35 revealed diagnoses of a displaced bimalleolar fracture of the left lower leg, a history of falling, and unspecified dementia. On 10/31/23 at 2:37 PM during an interview, R35's FM11 stated that when she arrived at the facility on Saturday, 10/21/23 at 11:15 AM, R35 was soaking wet and needed to be cleaned and changed. FM11 stated that she activated the call light for staff assistance. FM11 stated that a staff member responded 1.5 hours later at 12:45 PM. An unidentified staff member entered the room and removed the soiled adult diaper on R35 and replaced it with a clean adult diaper but did not provide perineal care for R35. The unidentified staff member then stated to R35 and FM11, I will never come back to this facility, it is too unorganized. Cross Reference: F725-Sufficient Nursing Staff.

Based on review of facility policy, record review, and interviews, the facility failed to ensure 1 of 1 resident was served meals in accordance with allergies, intolerances and preferences. Specifically, Resident (R)1 was served pineapples, which was documented as an allergy in her medical record. Findings include: Review of the facility policy titled, Food Intolerances and Allergies, with a reviewed/revised date of September 2021 revealed: A true food allergy may cause a variety of symptoms including nausea, GI distress, vomiting, hives, or cold like symptoms . It is imperative to determine if a patient has a known food intolerance or allergy and steps should be taken to avoid contact with this food item(s). Menus should be adjusted as needed to provide proper substitutes. The facility admitted R1 on 06/09/22 with diagnoses including but not limited to, [CONDITION(S)], morbid (severe) obesity due to excess calories. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/22 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R1 has moderately impaired cognition. Review of R1's Care Plan located in the Electronic Medical Record (EMR) revealed there was no nutritional care plan to address R1's allergy to pineapple. Review of the undated 5 week menu revealed, for dinner on Monday of Week 1, a escalloped pineapple bake was served. Additionally, dinner on Saturday of Week 3 revealed that pineapple chicken thighs was served. Review of R1's meal card to include: breakfast, lunch and dinner for the month of September, revealed in bold red font, ALLERGIES: PINEAPPLE. On 09/09/22 an interview with R1 was unable to be conducted, due to the resident being discharged . An interview on 09/09/22 at 2:45 PM with the Food Service Manager (FSM) revealed, the incident (R1 being served pineapple) was an overlook on everyone's behalf. The FSM further revealed it was a mistake and the resident had no negative outome. The pineapples were given to the resident, however the resident did not eat it. There is now a new plan in place where it's three kitchen staff that check the food trays and menu cards prior to giving the food to the residents. The trays also get checked by nursing staff prior to giving the food to the residents. An interview on 09/09/22 at 3:30 PM with R1's Resident Representative (RR) revealed R1 did not eat the pineapple served to her because she was able to identify it based on its smell. R1's RR had a meeting with the facility a few days later and staff apologized and stated it was an error on their behalf. An interview on 09/09/22 at 3:45 PM with the Director of Nursing (DON) revealed, the DON was aware that R1 was allergic to pineapples, but was not aware of the severity of R1 eating pineapples. The DON further stated R1 did not suffer any side effects or any negative outcomes because the pineapples were caught before the resident ate them. The DON stated her expectations from the kitchen staff is to check the food and then checked on the unit before the food is given to the residents.

Based on observation, interview and review of the facility policy and procedures, the facility failed to ensure: 1) Dietary employees were wearing hair coverings upon entering the food preparation area of the kitchen, 2) Dietary employees in food preparation areas and taking food temperatures were not wearing artificial nails or nail polish, 3) The meat slicer was free of food debris on the surface of the cutting blade and on the surface underneath the cutting blade. 4) The food stored in the refrigerator located in the nourishment pantry was labeled, dated, and expired food was discarded. 5) Staff was observed setting up trays without cleansing hands. The findings included: An observation on 10/18/2017 at approximately 11:30 AM of Dietary Employee #1 entered the kitchen and walked through the food preparation area without a hairnet covering the hair on his/her head. The observation was verified by the Executive Chef. The Executive Chef said the employees usually enter the kitchen from a door in the back of the kitchen and he/she said he saw the employee walk in the kitchen without hair covering on and instructed him/her to place hair covering on immediately. Dietary Employee #1 was later observed with hair covered. During an observation on 10/18/17 at approximately 11:40 AM, the Dietary Employee #2 was taking the food temperatures on the serving line by inserting the thermometer probe directly into the food and was not wearing gloves, had long artificial nails attached to his/her fingernails. On 10/18/17 at approximately 11:45 AM observed a dietary employee in the food preparation area, he/she had red nail polish on his/her fingernails and was not wearing gloves. On 10/18/17 at approximately 12:30 PM, the Executive Chef said the dietary staff are not supposed to wear fake nails or nail polish. The facility policy and procedure titled: Safety & Sanitation Best Practice Guidelines, Original Date: 2003, Revised Date 10/2014, Page Number A-1, Section Personnel, Section Number A, Subject: Hygienic & Safety Practices, states: .3. Hair Restraints for Dietary Partners: (Food Code 2-402.11) (a.) Dietary partners shall wear hair restraints such as hats, hair coverings, or nets, bead restraints, and clothing that covers body hair, that are designed and word to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single use articles. .5. All Dietary partners shall keep their fingernails trimmed, filed and maintained so the edges and surfaces are cleanable and not rough. Unless wearing intact gloves in food repair, a food service partner may not wear fingernail polish or artificial fingernails when working with exposed food. (Food Code 2-302.11). During initial tour on 10/16/2017 at 10:55 AM , the meat slicer which was covered with a plastic bag, when the plastic bag cover was removed, observed food debris on the surface of the cutting blade and on the landing surface underneath the cutting blade. The Executive Chef verified this observation and stated: The meat slicer is rarely used and will get it cleaned now. The facility policy and procedure titled: Safety & Sanitation Best Practice Guidelines, Original Date: 2003, Revised Date 01/2011, Page Number F-30, Section: Cleaning Procedures, Section Number F Subject: Slicer, states: Slicer, Frequency: After each use Method: .1. After each use, turn off, set slice blade setting at zero, and unplug. 2. Wash all removable parts in detergent solution in pot and pan sink. Rinse in clear water and sanitize in sanitizing solution 3. Allow to air dry 10. After removable parts have been air dried, reassemble. Cover slicer with cover, food approved plastic bag, or film when not in use. During initial tour on 10/16/2017 at 11:02 AM the refrigerator located in the Nourishment Pantry of the Ashley unit contained the following: Multiple containers of unmarked leftovers, an opened, half empty bottle of Dasani water with no label or date, and an 8 ounce carton of milk with a sell by date of October 14. The observations were verified by LPNs (Licensed Practical Nurses) #1, #2, and #3. The items were discarded upon discovery by LPNS #1, #2, #3. The facility policy and procedure titled: Safety & Sanitation Best Practice Guidelines, Original Date: 2003, Revised Date 01/2011, Page Number C-35, Section: Sanitation, Section Number C Subject: Nourishment Pantries, states, .2. Potentially hazardous foods lacking a manufacturer's expiration date will be covered, labeled, and dated with use by date and placed in refrigerator.4.Nursing and Dietary partners will monitor and discard perishable foods after 3 days. Other items such as beverages .will be discarded at appropriate. An observation on 10/16/2017 at approximately 12:47 PM during the lunch meal service on the 200 Unit revealed CNA #2 cleansing his/her hands and then bringing a lunch tray into room 222. After knocking on the door he/she set the lunch tray on the overbed table and proceeded to touch and arrange the over bed table and pull the privacy curtain around the resident. The CNA then went back to the over bed table and proceeded to set up the lunch tray, (removing the plastic covers from glasses, removing the silverware from the napkin, opening straws and affixing them in the beverages), without first cleansing his/her hands. A second observation on 10/16/2017 at approximately 12:50 PM during the lunch meal service revealed CNA #2 cleansing his/her hands and taking a tray in a resident room on the 200 Unit. After entering the room and placing the tray on the over bed table he/she pushed the table with his/her hands within reach of the resident, CNA #2 then went over to the light above the resident's bed and pulled the string to turn on the light. He/she then went back to the food tray and proceeded to set up the tray for the resident without first cleansing his/her hands. Review on 10/19/2017 at approximately 10:40 AM of the facility policy titled, Tray Passing on the Units, states, Sanitize hands before and after each tray, if you touch the patient you must clean your hands before you continue passing trays. Review on 10/19/2017 at approximately 11:15 AM of the facility policy titled, Hand Washing, states under, General Instructions, 1. Hands should be thoroughly washed before and after providing care. and number 2 states, Proper hand-washing techniques should be followed at all times.

Based on record review and interview, the facility failed to accurately assess Resident #100 related to urinary incontinence. (1 of 1 resident reviewed for urinary incontinence) The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Record review on 10/18/17 revealed a Bowel and Bladder assessment dated [DATE] which indicated the resident was occasionally incontinent. A three day Bladder assessment dated [DATE] revealed Resident #100 had incontinent episodes. Review of the Comprehensive Nursing Assessments dated 8/7/17, 9/7/17 and 10/7/17 listed Resident #100 as incontinent of bladder. Review of the Admission Minimum (MDS) data set [DATE] listed Resident #100 as always continent of bladder. Review of the Quarterly Minimum (MDS) data set [DATE] listed the resident as always incontinent. During an interview with Certified Nursing Assistant (CNA)#3 on 10/18/17 at 3:15 PM, he/she stated Resident #100 had always been incontinent. During an interview with the Minimum Data Set (MDS) Coordinator on 10/19/17, he/she stated Resident #100 had been occasionally incontinent since admission. He/she after reviewing the MDS confirmed the Admission and Quarterly MDS had been coded incorrectly.

Based on record review, interview and review of facility's policy, Committee - Patient Care Planning, the facility failed to include all required disciplines in the Care Plan Conferences of 4 of 12 Sampled Residents reviewed for Care Planning. Care Plan Conference signature sheets did not include signatures of a Certified Nursing Assistant and/or a Dietary Representative for Residents #9, #76, #100 and #112. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 10/19/2017 at approximately 10:36 AM revealed the Care Plan for Resident #9 dated 09/29/2017 did not include a signature to indicate attendance of a Certified Nursing Assistant. In an interview on 10/19/2017 at approximately 10:47 AM the Minimum Data Set (MDS) Coordinator #1 stated that s/he was not aware that CNA's were to be included in the Care Plan Process. Review of the facility policy entitled Committee - Patient Care Planning on 10/19/2017 at approximately 10:47 AM revealed the following disciplines are to be included in Care Plan Development: Nursing, Social Work, Recreation, Dietary and Other Disciplines as Appropriate for the Resident. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Record review on 10/18/17 of the current care plan dated 9/11/17 revealed there was no documentation the certified nursing assistant with responsibility for the resident was not included in the care plan process. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Review on 10/17/2017 at approximately 3:22 PM of the Plan of Care conference signature sheet for Resident #76 indicated a Certified Nursing Assistant (CNA) involved with the care for Resident #76 did not have input into developing the Plan of Care. A CNA did sign the signature page 2 weeks after the interdisciplinary team had finished developing the plan of care for Resident #76. The facility admitted Resident #112 with [DIAGNOSES REDACTED]. Review on 10/19/2017 at approximately 11:19 PM of the Plan of Care for Resident #112 revealed that a CNA involved with the care for Resident #112 did not have input into the development of the plan of care.

Based on observations, record reviews and interviews the facility failed to assure that it was free of unnecessary drugs, related to absence of indication for use for an ophthalmic antibiotic, in 1 of 5 resident records reviewed for unnecessary medications. This finding related to Resident #193 who had been admitted on [DATE] with [DIAGNOSES REDACTED]. (Cross refer to F428) The findings include: On 10/18/17 at approximately 10:35 AM a review of the September and October, 2017 physicians orders for Resident #193 revealed order # (number) 7 dated 9/15/17 for [MEDICATION NAME] 0.3% (percent) EYE DR (drops) PLACE 2 DROPS IN EACH EYE 4 TIMES DAILY. WAIT 5 MINUTES BETWEEN DROPS. [MEDICATION NAME] is an antibiotic and further review of the resident's medical record failed to identify an indication for use of this medication. Based on September and October, 2017 MARs (medication administration records), the medication had been prescribed on 9/14/17 (order # 5) and discontinued on 9/15/17 with one dose administered on 9/14/17 at 9:00 PM and one dose administered on 9/15/17 at 9:00 AM. Physician orders [REDACTED].# 1) were not provided by the facility. Continued review of the September and October, 2017 MARs revealed that it had been started on 9/15/17 at 1:00 PM (order # 7) and was administered four times daily thereafter. The MARs for September and October, 2017 identified the ophthalmic antibiotic as Maintenance with no stop date. On 10/18/17 at approximately 11:46 AM the Unit Manager reviewed the medical record and stated that he/she was unable to find an indication for use. On 10/18/17 at approximately 12:20 PM the Director of Nursing completed a review of the medical record and stated that he/she had been unable to find an indication for use and that he/she would contact the physician. On 10/18/17 at approximately 12:37 PM the Consultant Pharmacist reviewed the medical record, was unable to find an indication for use and stated that he/she would check the pharmacist computer to see if there was additional information related to pharmacist review.

Based on observations, record reviews and interview the Consultant Pharmacist failed to identify that an indication for use was missing for the Ofloxacin Eye Drops prescribed for Resident #193 on 9/15/15. (Cross refer to F329) The findings include: On 10/18/17 at approximately 12:43 PM, subsequent to not finding an indication for use of Ofloxacin Eye Drops (prescribed 9/15/17) in the medical record of Resident 193, the Consultant Pharmacist reviewed his/her computerized record of reviews for this resident. On 10/18/17 at approximately 12:48 PM he/she stated that a review had been conducted, but that the absence of an indication for use had not been caught during the review.

Based on observations, interviews, and record reviews the facility failed to notify the physician and responsible party in a timely manner regarding incorrect doses of insulin provided and critically low or high blood sugar results for 3 residents (R250, R230, and R259) out of a total of 22 residents diagnosed with [REDACTED]. Findings include: 1. Review of the Medical Record revealed R230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his admission Minimum Data Set (MDS) (a comprehensive physical and psychosocial assessment) completed on 6/29/16, the resident had a current active [DIAGNOSES REDACTED]. Review of the care plan indicated R230 was at risk of complications related to abnormal blood sugar and staff was to ensure laboratory tests were obtained per order, obtain finger stick blood sugar results (FSBS), report abnormal findings to physician (including specific directions to notify physician of any FSBS results of <60 and >500. Current physician orders revealed the following medications/orders related to blood sugars/[DIAGNOSES REDACTED].>-[MEDICATION NAME] 100 U/ml vial Give 22 Units SQ (subcutaneously) in the evening -[MEDICATION NAME] 100 Units/ml - Give 48 Units SQ each morning -[MEDICATION NAME] 100 Units/ml FSBS (Finger Stick Blood Sugar) -Before meals and at bedtime. Sliding Scale specific directions were given, dosing depended on the FSBS reading. The physician had ordered FSBS to be done four times a day (QID) and they were scheduled for 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m. The specific orders for Sliding Scale (SS) Insulin (the amount of insulin to be determined based on the FSBS). The SS orders were: For FSBSs of: 0-250 = 0 Units 251-300 = 4 Units SQ 301 - 350 = 6 Units SQ 351 - 400 = 8 Units SQ 401 - 450 = 10 Units SQ 451 - 500 = 12 Units SQ If BS <60 or >500 Call MD, Record Site The following exceptions did not show the MD had been notified. 6/27/16 - 4:30 p.m. - 341 No Insulin was documented as given - should have received 6 Units 6/27/16 - 9:00 p.m. - 436 - No Insulin was documented as given - should have received 10 Units 6/28/16 - 4:30 p.m. 527 gave 5 Units - There was no order for a FSBS greater than 500. The MD was not notified and an Unidentified Nurse* gave an incorrect dose. 7/2/16 - 4:30 p.m. - 422 - Gave 20 Units - No standing order for that dose. No MD Notification/documentation in nurses notes (NNs) said covered with SS 8/2/16 - 3-11 shift - According to the NNs only documented as 3p-11p shift (no specific time given) - BS 381 was given 10 U and 8 Units according to SS. There was no order to administer 10 Units then 18 Units. 8/4/16 - 6:30 a.m. - 579 - Gave 14 Units - There was no standing order other than to notify physician for further direction, which did not occur. 2. Review of the Medical Record revealed R259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R259s Minimum Data Set (MDS- a comprehensive physical and psychosocial assessment) indicated the resident had a current Active Diagnosis of Type 2 diabetes. Review of the admission care plan dated 9/2/16 indicated that R259 had a [DIAGNOSES REDACTED]. R259's Physician order [REDACTED]. Check FSBS twice daily; Notify MD if less than 60, greater than 500. On 9/6/16 at 4:30 p.m. R259 had a BS of 432. According to the NNs, the physician was notified and gave orders for Sliding Scale Insulin (the amount of insulin to be determined based on the FSBS). The resident was not provided correct insulin coverage on 9/6/16. He was given 6 units and should have received 10 Units. There was no evidence the MD was notified of the error. The Sliding Scale Insulin orders were: For FSBSs of: 0-250 = 0 Units 251-300 = 4 Units SQ 301 - 350 = 6 Units SQ 351 - 400 = 8 Units SQ 401 - 450 = 10 Units SQ 451 - 500 = 12 Units SQ If <60 or if >500 Call MD, Record Site 3. Per record review the facility failed to notify the physician and responsible party in timely manner 4 out of 5 times when R250 ' s blood sugar levels dropped below 60 on 9/13/15, 9/15/16, 9/17/16, and 9/18/16. Review of the History and Physical (H&P) dated 9/11/16 revealed, R250 is an [AGE] year old resident was admitted to the facility on [DATE] following a 3 day hospitalization for repeated episodes of [MEDICAL CONDITION] (commonly known as [MEDICAL CONDITION] or passing out). Per physician note, no definite sign of [MEDICAL CONDITION] (stroke) or cardiac arrhythmia event was found. Work up for [MEDICAL CONDITION] was negative. No definitive cause was noted. The H&P stated the resident had multiple other medical problems which could predispose the resident to it, these included hypertension, diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION] (TIA). The mental status assessment revealed resident was oriented to person only. Concentration is quite limited and he/she can lose the thread of conversation. The physician (MD) admission orders [REDACTED]. No sliding scaling insulin was ordered. Review of manufacturer guidelines of [MEDICATION NAME] stated: IMPORTANT SAFETY INFORMATION for [MEDICATION NAME]. Do not take [MEDICATION NAME] during episodes of low blood sugar. The most common side effect of insulin, including [MEDICATION NAME], is low blood sugar ([DIAGNOSES REDACTED]), which may be serious and life threatening. It may cause harm to your heart and brain. [MEDICATION NAME] may cause serious side effects that can lead to death, such as severe allergic reactions. According to the American Diabetes Association, [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 milligrams per deciliter (mg/dl). [DIAGNOSES REDACTED] may also be referred to as an insulin reaction or insulin shock. Signs of [DIAGNOSES REDACTED] include: confusion, headaches, dizziness, shakiness, sweating, rapid heartbeat, [MEDICAL CONDITION], lack of coordination, unconsciousness, and blurred vision. An Interim Care Plan for Diabetes dated 9/08/16 for R250 documented: Goal: No unrecognized complications. Interventions: Blood sugar checks twice a day, medications as ordered, diet as ordered, observe for signs and symptoms of hypo/[MEDICAL CONDITION], nail care, and labs as ordered. The September 2016 Medication Administration Record (MAR) revealed a physician's orders [REDACTED]. The September 2016 MAR revealed on 9/13/16 at 6:30 a.m. R250 blood sugar (BS) was taken by Licensed Practical Nurse (LPN) 13 and results were documented as 57. Review of Nurses Notes dated 9/13/16 revealed, no documentation reflecting the physician and responsible party were notified of the 6:30 a.m. low BS result. Review of the facility's MD Notification Book revealed a document entitled, Nursing Concerns dated 9/14/16. The concern documented was: Resident has 2 mornings of low 50's blood sugars. Nursing assessment: Vital signs stable. What does resident, family or nurse want done? Review insulin regimen. MD/NP response: Left blank. Form was signed by LPN13. Review of Nurses Notes dated 9/14/16 on the 3:00 p.m. -11:00 p.m. shift documented, NP (Nurse Practitioner) on unit, aware of resident's FSBS and history of [DIAGNOSES REDACTED]. New orders received to decrease [MEDICATION NAME] to 20U daily SQ. Responsible party aware of new orders. The September 2016 MAR revealed on 9/14/16 a new physician's orders [REDACTED]. The September 2016 MAR revealed on 9/15/16 at 6:30 a.m. R250 blood sugar (BS) was taken by LPN13 and results were documented as 54. Review of Nurses Notes dated 9/13/16 revealed, no documentation reflecting the physician and responsible party were notified of the 6:30 a.m. low BS result. A Laboratory Report dated 9/15/16 revealed R250's Blood Glucose level is Low at 69, Hemoglobin A1c was 6.2, and Potassium was 3.7. Review of the facility's MD Notification Book revealed a document entitled Nursing Concerns dated 9/16/16. The concern documented was: Resident continues to have low FSBS in am. Nursing assessment: Left blank. What does resident, family or nurse want done? Left blank. MD/NP response: Left blank. It was signed and dated 9/19/16. The September 2016 MAR revealed on 9/17/16 at 6:30 a.m. R250's blood sugar (BS) was taken by LPN13 and results were documented as 50. Review of Nurses Notes dated 9/17/16 revealed, no documentation reflecting the physician and responsible party were notified of the 6:30 a.m. low BS result. On 9/18/16 at 5:12 a.m. LPN14 documented on R250's MAR, Resident asymptomatic at this time refused snack of juice, crackers, or sandwich. 60cc med pass given. The September 2016 MAR revealed on 9/18/16 at 6:30 a.m. R250's blood sugar (BS) was taken by LPN14 and results were documented as 46. At 8:33 a.m. LPN14 documented the resident complained of a headache and was administered Tylenol 325mg 2 tablets by mouth. Per record review no nurse ' s notes were documented on 9/18/16. No documentation was found regarding physician and responsible party notification of the 6:30 a.m. low BS result. The Nurses Notes dated 9/19/16 documented, New orders received to decrease [MEDICATION NAME] to 10U SQ daily. RP (responsible party) on unit visiting with resident aware of new order. The September 2016 MAR revealed on 9/21/16 at 6:30 a.m. R250's blood sugar (BS) was taken by LPN13 and results were documented as 48. Review of the facility's MD Notification Book revealed a document entitled Nursing Concerns dated 9/21/16. The concern documented was: Blood sugar 48 this a.m. Nursing assessment: Left blank. What does resident, family or nurse want done? Left blank. MD/NP response: Just making MD aware MD/NP response: Left blank. It was signed and dated by LPN13 on 9/21/16. A Nurse's Note dated 9/21/16 at 11:30 a.m. documented D/c (discontinue) [MEDICATION NAME] dx (diagnosis): [DIAGNOSES REDACTED]. Family notified. On 9/21/16 a new physician's orders [REDACTED]. On 9/19/16 at 9:45 a.m., R250 was observed and was alert and verbally responsive however, difficulty was noted with following the thread of conversation at times during the Stage 1 interview. The resident was well groomed. No signs of distress, shakiness, irritability, or sweating were noted. R250 responded with short pleasant responses and no complaints were voiced. On 9/20/16 at 8:30 a.m. R250 was resting quietly in bed, eyes closed, no signs of distress were noted. The call light was within the resident's reach. On 9/21/16 at 11:10 a.m. R250 was observed sitting in a wheelchair in his/her room, head resting in hands, easily aroused stated he dozed off for a minute. Responded appropriately. No signs of distress noted. Call light within reach. An interview was conducted with the Director of Nursing (DON) on 9/23/16 at 2:21 p.m. She stated she reviewed the record of R250 and could not find documentation where the physician was notified in a timely manner on 9/13/16, 9/15/16, 9/17/16, and 9/18/16. The DON further stated it was her expectation that each staff member report significant findings to physicians' right away and document all actions taken in the nurse's notes, including MD notification and nursing assessment at the time of the event. In response to requests for copies of facility's policy on diabetes management and reporting critical findings to physicians, the DON stated the facility did not have specific policies to address these areas of concern. An interview was conducted with R250's physician on 9/23/16 at 4:30 p.m. He stated he received calls all the time from the nursing staff regardless of the time of day. He further stated in reference to this particular resident and the dates in question, 9/13/16, 9/15/16, 9/17/16 and 9/18/16, he could not recall specifically receiving a call about out of range blood sugars below 60 at or around 6:30 a.m. He stated he felt in general the staff were good about notifying him in a timely fashion about all significant changes or concerns.

Based on record review, observations, and interviews, the facility failed to ensure comprehensive blood sugar management for 2 of 11 sampled residents (R230 and R259) with sliding scale insulin orders. Findings include: 1. Review of the Medical Record revealed R230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his most recent full Minimum Data Set (MDS), an admission assessment completed on 6/29/16, the resident had a current active [DIAGNOSES REDACTED]. Review of the care plan indicated R230 was at risk of complications related to abnormal blood sugar and staff was to ensure laboratory tests were obtained per order, obtain finger stick blood sugar results (FSBS), report abnormal findings to physician (including specific directions to notify physician of any FSBS results of <60 and >500. Current physician orders for R230 revealed the following medications/orders related to blood sugars/[DIAGNOSES REDACTED].>-[MEDICATION NAME] 100 U/ml vial Give 22 Units SQ (subcutaneously) in the evening -[MEDICATION NAME] 100 Units/ml - Give 48 Units SQ each morning -[MEDICATION NAME] 100 Units/ml FSBS (Finger Stick Blood Sugar) -Before meals and at bedtime. Sliding Scale specific directions were given, dosing depended on the FSBS reading. The physician had ordered FSBS to be done four times a day (QID) and they were scheduled for 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m. The specific order for Sliding Scale (SS) Insulin (the amount of insulin to be determined based on the FSBS results) were: For FSBSs of: 0-250 = 0 Units 251-300 = 4 Units SQ 301 - 350 = 6 Units SQ 351 - 400 = 8 Units SQ 401 - 450 = 10 Units SQ 451 - 500 = 12 Units SQ If BS <60 or >500 Call MD, Record Site Review of the Medication Administration Records (MARs) for June - September 2016 revealed the following BSs, either not treated or dosed incorrectly. June 2016 FSBS 1. June 27 -4:30 p.m. - FSBS 341 (documented by an unidentified nurse*) No insulin was administered - should have received 6 Units of insulin. 2. June 27 - 9:00 p.m. - FSBS 436 (documented by an unidentified nurse*) - No insulin was administered - should have received 10 Units of insulin. 3. June 28 - 4:30 p.m. FSBS 527 (documented by an unidentified nurse*) the nurse gave 5 Units of insulin - There was no order for a FSBS greater than 500. The MD was not notified and the nurse gave an incorrect dose. July 2016 FSBS 4. July 2 - 4:30 p.m. - FSBS 422 - RN1 gave 20 Units of insulin - No standing order for that dose. No MD Notification. Documentation in NNs by RN1 said covered with SS. 5. July 9 - 9:00 p.m. - FSBS 425 - RN4 gave 8 Units of insulin - should have been given 10 Units August 2016 FSBS 6. [DATE] - NN - BS 306 - According to NNs by an unidentified nurse*, SS coverage given, it was not documented on the MAR 7. [DATE] - 6:30 a.m. -FSBS 518 - RN16 gave 14 Units of insulin - There was no standing order for administering any insulin for that reading, other than to notify physician for further direction. 8. [DATE] - 3-11 shift - According to the NNs by LPN10 only documented as 3p-11p shift (no specific time given) - BS 381 was given 10 U and 8 U/according to SS. There was no order to administer 10 Units then 8 Units. Had the BS been done at a specific time as ordered, the appropriate dose for a BS of 381 would have been 8 units - not 18 units. It was not documented on the MAR. 9. [DATE] - 6:30 a.m. - FSBS 579 - RN16 gave 14 Units of insulin - There was no standing order other than to notify physician for further direction. 10. [DATE] - 11:30 a.m. - FSBS 169 - LPN5 gave 4 Units of insulin - there should not have been any insulin given. 11. [DATE] - 11:30 a.m. - FSBS 300 - unidentified nurse* gave no insulin - should have given 4 Units of insulin. September 2016 12. 9/11/16 -11:30 a.m. - FSBS 336 - LPN7 did not document on the MAR - should have given 6 Units. Summary for R230, from June through September 2016: 2. Review of the Medical Record revealed R259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R259s Minimum Data Set (MDS) indicated the resident had a current [DIAGNOSES REDACTED]. Review of the admission care plan dated 9/2/16 indicated that R259 had a [DIAGNOSES REDACTED]. R259s Physician order [REDACTED]. Check FSBS twice daily; Notify MD if less than 60, greater than 500. The SS orders were: For FSBSs of: 0-250 = 0 Units 251 - 300 = 4 Units SQ 301 - 350 = 6 Units SQ 351 - 400 = 8 Units SQ 401 - 450 = 10 Units SQ 451 - 500 = 12 Units SQ If <60 or if >500 Call MD, Record Site On 9/6/16 at 4:30 p.m. R259 had a BS of 432. According to the NNs, the physician was notified and gave orders for Sliding Scale Insulin (the amount of insulin to be determined based on the FSBS). The resident was not provided correct insulin coverage on 9/6/16. He was given 6 units and should have received 10 Units. There was no evidence the MD was notified of the error. Staff Interview On 9/22/16 at approximately 2:30 p.m. the(NAME)Hall Unit Manager (UM) was interviewed about the discrepancy and stated that any FSBSs requiring coverage (administration of insulin for elevated BSs) should have been documented in the Nurse ' s Notes (NNs). Further review revealed that on 9/6/16 at 4:30 p.m. R259 had a BS of 432. According to the SS that would have required an insulin dose of 10 units. Instead, the nurse gave 6 units. The UM stated that was a medication error and identified the nurse that had made the error as LPN1. He was asked to have the LPN come meet with the surveyor for an interview. After 30 minutes, the surveyor sought out the Director of Nursing (DON). The DON brought LPN1 and the surveyor to her office. The DON presented the following: An addendum of notification of the physician, dated 9/22/16 at 4:30 p.m. She also provided documentation that LPN1 had received a Verbal Warning for the medication error. On 9/22/16 at 4:45 p.m. an interview was conducted with the Medical Director, who was also the primary care physician for R230 and R259. He stated he had been the Medical Director for approximately 8 years. He was familiar with both R230 and R259. All concerns regarding insulin, administration, using Sliding Scale parameters, documentation and follow up were discussed. The Medical Director stated this was the first time he had been advised of any problems in this area. On 9/22/16 at 4:55 p.m. an interview was conducted with the facility Regional Pharmacist/Director of Clinical Services, who had been with the facility for approximately 8 years. She stated this was the first time she had been advised of any problems in this area. She also stated it was her expectation that, as part of the Monthly Medication Regimen Reviews performed by their pharmacy consultant, that they would check for discrepancies and report those immediately. On 9/23/16 at 12:50 p.m. an interview was conducted with the Director of Nursing (DON). The DON was asked if there was a specific facility policy for blood sugars. The DON stated neither the facility or the pharmacy had a specific policy. She stated Dr. (name of R230 and R259s physician, who is also the facility Medical Director) has a specific standing order for sliding scale in his book. Dr. (name of R230 and R259s doctor) and Dr. (a second physician) are the 2 doctors seeing residents in the facility. The DON was informed the SS/FSBS order on the order sheet was contradictory to the order on the Medication Administration Record. The DON stated it will print 2 times on the MAR if there was an order to discontinue. Everything that is discontinued weekly is printed and Dr. (name of R230 and R259s doctor) signs it. The system automatically ended one and printed a new line with the new orders. The DON was asked if there was a Policy for reporting low blood sugar if there was no parameter in the physician order. The DON stated the nurses go by below 60 and over 500. Dr. (name of R230 and R259s doctor) standing orders. Nursing judgement if under 60 and over 500. They are educated that these are the standing orders for the blood sugars. The DON was asked where the nurses were to document. The DON stated if the BS was over 500 the nurse would have to enter a telephone order for what the doctor wanted done. It will print on the MAR indicated [REDACTED]. It would only show up when we print the whole month. The DON was asked if the blood sugar was extremely high or low when the nurse checks the blood sugar would the nurses notify the physician based on his standing orders. The DON stated Yes. The DON was also asked again about the issue with FSBS results. Though she had stated earlier that she believed some of the problem was with incorrect documentation (stating that nurses had erroneously documented the site the insulin was injected - see key below - instead of the actual number of units of insulin they administered), she now stated that she was going to take the issue to their next Quality Assurance meeting (scheduled for the following Tuesday 9/27/16). The key for documenting injection sites for insulin administration was: 1=Right interior gluteus 2=Left interior gluteus 3=Right lateral thigh 4=Left lateral thigh 5=Right upper extremity (arm) 6=Left upper extremity (arm) NOTE: There were no sites identified as number 7 or 8 9=Right upper quadrant (abdomen) 10=Left upper quadrant (abdomen) 11=Right lower quadrant (abdomen) 12=Left lower quadrant (abdomen)

Based on record reviews and staff interview, the facility failed to ensure the Quality Assurance (QA) committee identified and developed a plan of action to ensure a system was implemented to provide safe administration of insulin and protect residents from undue adverse medication consequences of blood glucose monitoring for 3 of 11 residents (R259, R230, R250) on sliding scale insulin out of a sample of 25 residents. Findings include: The facility provided a list of 11 residents with physician orders for blood glucose monitoring with sliding scale insulin coverage parameters. The facility failed to notify the physician and responsible party in a timely manner regarding incorrect doses of insulin provided and critically low or high blood sugar results for 3 of the 11 residents (R259, R230, R250) with sliding scale insulin orders. The facility failed to ensure comprehensive blood sugar management for 2 of 11 sampled residents (R230 and R259) with sliding scale insulin orders. Review of the facility ' s Quality Improvement (QI) Agenda for the months of January 2016- August 2016 revealed the facility had not identified concerns with the monitoring and administration of insulin for residents with physician orders [REDACTED]. The Medical Director and a Pharmacist were on the attendance lists for the QI meetings. On 9/22/16 at 4:45 p.m. an interview was conducted with the Medical Director, who was also the primary care physician for R230 and R259. He stated he had been the Medical Director for approximately 8 years. He was familiar with both R230 and R259. All concerns regarding insulin, administration, using Sliding Scale parameters, documentation and follow up were discussed. The Medical Director stated this was the first time he had been advised of any problems in this area. On 9/23/16 at 2:30 p.m. during an interview with the Director of Nurses (DON) she revealed that she realized the coding used for injection sites of insulin on the Medication Administration Record (MAR) was a problem. The DON stated the QI committee looked at areas that come up from their Stand Up Five Star meetings, My InnerView Reports, falls, pressure ulcers, weight loss, MDS/QI/QM, Pharmacy, Infection Control and Administrator Reports. The DON stated they had not developed and implemented any plan to address coding issues on the Medication Administration Records (MAR) sites for administering sliding scale insulin coverage for residents who are on blood glucose monitoring.

Based on observation during the initial tour of the facility on 9/19/16 from 9:00 a.m. to 9:30 a.m., and staff interviews the facility failed to ensure they provided a safe, functional, sanitary and comfortable environment for residents, staff and the public. There was a dark unidentified substance noted to be in 13 resident bathrooms, above the bathroom sinks and above the baseboards under the sinks. In one room, room 117, the substance was black. Findings include: 1. The public women ' s bathroom, nearest to the main dining room, was observed to have an ongoing strong, foul smell that emanated from the drain in the floor. The drain cover was also loose. The facility maintenance staff cleared out the drain and attempted to tighten the drain cover with a cement in the women's public restroom. It was noted to still be loose after repair attempts, so it was closed off until it could be properly sealed. 2. The following resident bathrooms were observed to have an unidentified dark substance above the bathroom sinks (near faucet) and around the base boards. In some cases it was a light brownish color, in others a bit darker in color. In one room, it was black. The following rooms were involved: Rooms 115 through 128 and room 205 were noted to have varying degrees of dark stains above the bathroom sinks, and under the sinks above the base board. The stains were brownish in color. Room 117 had a dark black substance in those areas. A tour of those areas was conducted with the Plant Operations Manager and the Director of Environmental Services on 9/20 /16 at 12:30 p.m. They both stated they were unaware of the identified concerns and would address them immediately as well as follow up with the Housekeeper assigned to those areas. The Plant Operations Manager used his bare hand to wipe across the stains in room 117. He stated he felt it was dirt and grime. The Plant Operations Manager also stated he would order a mold detection kit (though he did not feel that was the cause) and would go under the building to inspect further.