Every finding on record at Northern Oaks Living & Rehabilitation Center

Based on observation, interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 7 residents (Resident #1) reviewed for accuracy of MDS assessments. The facility failed to complete Resident #1's Hearing, Speech, Vision (Section B), Cognitive Patterns (Section C), Mood (Section D) and Health Conditions - Pain Assessment (Section J) on his Quarterly MDS assessment dated [DATE]. These failures could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could prevent residents from receiving correct care and services. Findings included: Record review of Resident #1's face sheet dated 07/01/26, revealed an [AGE] year-old male, with an original admission date of 10/26/23 with the latest admission date of 12/22/25. Resident #1 had diagnoses including COPD (a progressive lung disease that makes it difficult to breath), limitation of activities due to disability (restrictions in performing daily tasks caused by physical, mental or cognitive impairments), depressive episodes (a period of persistent low mood or loss of interest lasting at least two weeks), anxiety disorder (a mental health condition characterized by excessive uncontrollable worry about everyday issues), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness), radiculopathy (compression of the spinal nerve root), fusion of spine (surgical procedure that joins two or more vertebrae to stabilize the spine and reduce pain), and cognitive communication deficit (ability to communicate effectively is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem). Review of Resident #1's MDS Quarterly assessment dated [DATE] revealed Resident #1 was not assessed for Hearing, Speech, Vision (Section B), Cognitive Patterns (Section C), Mood (Section D) and Health Conditions - Pain Assessment (Section J) as the sections had dashes instead of scores. Review of Resident #1's Comprehensive Care Plan dated as revised on 6/30/26 reflected Resident #1 had care plans addressing chronic pain; antidepressant medication use; mood problem related to suicidal ideations, depression, anxiety and insomnia; ineffective coping relating to loss of family member; at risk for a communication problem relating to hearing deficit; at risk for impaired visual function relation to dry eyes; at risk for impaired cognitive function/dementia or impaired thought processes related to cognitive defect; radiculopathy; and rheumatoid arthritis. In a phone interview on 07/1/26 at 1:45 pm, the MDS Coordinator said she was responsible for completing the MDS assessments. She said Resident #1's quarterly MDS assessment dated [DATE] sections B, C, D, J was not filled out because the information was not in the chart so that information is dashed out on the MDS. When asked if the quarterly MDS assessment dated [DATE] was complete and accurate, she said yes because the information was not in the chart. When asked if those sections should have been filled out to make it complete and accurate, she said no because that information was not in the chart. When asked who was responsible for obtaining the information, she again said if the information was not in the chart she dashes it out. When asked if she attempts to get the information herself, she said no. In an interview on 7/1/26 at 1:50 pm, the ADON said she did not know anything about MDS assessments. In an interview on 7/1/26 at 2:00 pm, the Administrator stated that it was his expectation that if there was a way for staff to get the information that is needed to complete the assessment, staff should take the measures to get it. He said the DON was not available due to helping a sister facility.A record review of the facility policy Resident Assessment and Associated Processes, dated as last revised 4.2025, revealed the following [in part]: Policy: It is the policy of this facility that resident will be assessed and the findings documented in their clinical health record. There will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on interviews and record review, the facility failed to immediately inform the residents' representative about a significant change in the resident's physical status for 1 of 5 (Resident #1) of 5 residents reviewed for representative notification.The facility failed to notify Resident #1's Representative of a significant change on [DATE]. This failure could place residents at risk of not having their change of condition communicated to their physician, delay of treatment, and a decline in the residents' health and well-being.Findings include:Record review of Resident #1's electronic face sheet dated 05.05.2026 revealed a [AGE] year-old male admitted on 04.22.2026 with diagnoses that included: Type 2 Diabetes Mellitus (chronic high blood sugars) with foot ulcer (open wound), End Stage Renal Disease (kidney failure), Dependence on Renal Dialysis (lifesaving medical procedure), and Heart Failure. Record review of Resident #1's Medicare Part-A MDS dated 04.27.2026 revealed: Section C-Cognitive Patterns Resident #1 had a BIMS score of 13, meaning cognitively intact. Record review of Resident #1's Physician orders dated 05.01.2025 revealed: Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest. Record review of Resident #1's Care Plan dated 04.22.2026 addressed: needs hemodialysis related to end state renal disease. Record review of Resident #1's electronic medical record reviewed on [DATE] at 4:30 pm revealed no evidence that Resident #1's Representative was contacted on [DATE] by the facility of Resident # 1 requiring CPR or expiring in the facility. Record review of Resident #1's progress notes documented by LVN dated [DATE] at 9:45 PM revealed: Upon entering residents room resident was in bed with eyes opened but did not respond to verbal stimuli resident noted to have no pulse no respirations this nurse called the code and all available staff came in to assist. CPR initiated and continued for 20 minutes until EMS arrived. CPR was continued by EMS until it was decided to discontinue per EMT. Postmortem care provided by staff and resident moved to a private room to allow privacy for resident and family. Officer {Name} informed this nurse that another officer was on their way to notify the family. Physician notified and DON notified.During an interview on [DATE] at 2:04 PM Resident #1's Family Representative stated they had seen Resident #1 that morning and he was not short of breath, that he just looked tired. Resident #1's Family Representative stated he answered all his questions appropriately and did not seem disoriented. Resident #1's Family Representative stated no one called when they were doing CPR. Resident #1's Family Representative stated a police officer came to the house and told them and Resident #1 Family Representative passed after having CPR. Resident #1's Family Representative stated they came to visit regularly and did not notice him being short of breath or confused. Resident #1's Family Representative stated Resident #1 had been in the hospital about 2 weeks and had started dialysis in the hospital before being admitted to the nursing home. Resident #1's Family Representative stated that the facility had not notified them that Resident #1 had passed away. During an interview on 05.05.2026 at 5:35 pm the DON stated the nurse should have called to notify the family of CPR and death. The DON stated it was not the law enforcement's responsibility to notify the family. She stated she did not know why the nurse did not notify the family. She stated her expectation was that the nurse should have contacted the family or representative of any changes of condition, for all residents.During an interview on 05.05.2026 at 6:00 pm with LVN A stated she did not notify the family of death. LVN A stated since law enforcement notified the family that Resident #1 had passed away in the facility after attempts of CPR. Review of the facility's policy titled, Change in Condition dated 4.2025 revealed: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.Procedure1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to):Change or trending change in vial signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturationChange in ability or decline in physical function. Change in medical condition including but not limited to low/high blood sugar, hypoglycemic, episodes, or fever of unknown origin.5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation.The resident/resident representative will be notified of the change of condition and any changes in the resident's medical or nursing condition.

Based on observation, interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #55, Resident #78, and Resident #87) of 20 residents reviewed for unnecessary medications. The facility failed to ensure Resident #55's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #78's PRN Lorazepam discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #87's PRN Lorazepam was discontinued after 14 days or a documented rational for the continued provision of the medication. These failures placed residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.Findings included:Resident #55Review of Resident #55's electronic face sheet, accessed on 01/20/2026, revealed resident was a [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Anxiety, Dementia, and respiratory failure. Review of Resident #55's Discharge MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns no BIMS score recorded. Review of Section N: Medications revealed Resident #55 was not receiving anti-anxiety medications.Review of Resident #55's electronic physician orders revealed: Lorazepam Oral Tablet 0.5 MG give 1 tablet by mouth every 3 hours as needed for anxiety/restlessness, with a start date of 10/17/2025 and no end date.Review of Resident #55's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam or risperidone.Review of Resident #55's electronic MAR for December 2025 revealed one dose of Lorazepam was administered on 12/14/2025.Review of Resident #55's electronic MAR for January 2026 revealed one dose of Lorazepam was administered on 01/08/2026.Observation on 01/20/2026 1:00 pm revealed, Resident #55 was lying in bed with her eyes closed. Record review of Drugs.com for Lorazepam accessed on 01/07/2026 at https://www.drugs.com/lorazepam.html revealed: Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders.Resident #78Review of Resident #78's electronic face sheet, accessed 01/22/2026, revealed resident was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease, Cognitive Communication Deficit, and Depression.Review of Resident #78's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns no BIMS score recorded. Review of Section N: Medications revealed Resident #78 was not receiving anti-anxiety medications.Review of Resident #78's electronic physician orders revealed: Lorazepam Oral Tablet 0.5 MG give 1 tablet by mouth every 3 hours as needed for anxiety, with a start date of 07/04/2024 and no end date.Review of Resident #78's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam.Review of Resident #78's electronic MAR for December 2025 revealed no doses of Lorazepam had been administered.Review of Resident #78's electronic MAR for January 2026 revealed no doses of Lorazepam had been administered. Observation on 01/21/2026 at 2:56 PM revealed, Resident #78 was resting in bed with eyes closed. Unable to answer questions.Resident # 87Review of Resident #87's electronic face sheet, accessed on 01/22/2026, revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and cerebral infarction.Review of Resident #87's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns no BIMS score recorded. Review of Section N: Medications revealed Resident #50 was not receiving anti-anxiety medications.Review of Resident #87's electronic physician orders revealed: Lorazepam Oral Tablet 0.5 MG give 1 tablet by mouth every 2 hours as needed for anxiety/agitation/restlessness and Lorazepam Oral Tablet 0.5 MG give 2 tablets by mouth every 2 hours as needed for anxiety/agitation/restlessness, with a start date of 10/08/2025 and no end date.Review of Resident #87's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam.Review of Resident #87's electronic MAR for December 2025 revealed no doses of Lorazepam had been administered.Review of Resident #87's electronic MAR for January 2026 revealed no doses of Lorazepam had been administered.Observation on 01/20/2026 at 10:15 AM revealed, Resident #87 was up in electronic wheelchair. During an interview on 01/22/2026 at 12:03 PM, the DON stated that antianxiety medication, or any psych medications should not have been scheduled as PRN for more than 14 days. She stated that she did not know how this was missed and that it was her responsibility to check all new orders daily. She did not provide reasoning to why this was missed. She stated the only possible negative outcome would be that a resident could have been overmedicated unnecessarily. Review of document titled, Psychotropic Drug Use, revised 08/2017 revealed in part: .3. PRN orders for psychotropic drugs are limited to 14 days. Except for orders for PRN orders for anit-psychotic medications, if the attending physician believes that it is appropriate for the PRN psychotropic med order to be extended beyond 14 days, he or she should document their rational in the resident's medical record and indicate the duration for the PRN order; 4. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician evaluates the resident for the appropriateness of that medication.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts (medication cart for Hall 200/300) reviewed for pharmacy services. The facility failed to ensure Resident #2's Novolin 70/30 Flex pen (insulin- medication used to treat diabetes) was labeled with an open date on the medication cart for Hall 200/300. The facility failed to ensure Resident #69's Lantus Flex pen (insulin- medication used to treat diabetes) was labeled with an open date on the medication cart for Hall 200/300. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications.Findings Included: During an observation on 01/20/2026 at 11:15 am, the medication cart for Hall 200/300 contained Novolin 70/30 Flex pen with an open date for Resident #2, Lantus Flex pen with an open date for Resident #69, a bottle of Nitroglycerin with an expired date of 12/22/2025 for Resident #15, and a box of Ondansetron with an expired date of 12/07/2025. During an interview on 01/20/2026 at 11:30 am, RN-E stated all medications in multiuse vials should have been dated when opened. He stated it was the nurse's responsibility to date the medication when it is opened and to check the date prior to administering the medication. He stated that all expired medications should be removed from the cart, and the cart should be checked routinely for expired medications. He stated not putting the open date could lead to residents receiving expired medications. During an interview on 01/22/2026 at 12:03 PM, the DON stated that all multi use vials should have been dated when opened. She stated this should have been done by the nurse who opened the medication and should be checked each time the medication was administered. She stated that expired medications should be removed from the cart immediately. She stated not dating the medication could lead to the resident receiving expired medications. She stated the pharmacy did random medication cart checks but ultimately it was the nurse's responsibility to ensure all medications that require dating were dated. The DON stated the facility did not have a policy referring to the dating of insulin or other multiuse dose medications. Review of facility policy titled, Medication Access and Storage, revised 05/2017, revealed in part: .outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy.

Based on observations, interviews, and record review the facility failed to dispose of mediations that were expired in accordance with professional standards for 1 of 3 medication carts (medication cart for Hall 200/300) reviewed for pharmacy services. The facility failed to ensure Resident #15's Nitroglycerin (medication used to treat chest pain) was not expired and was on the medication cart for Hall 200/300. The facility failed to ensure Resident #33's Ondansetron (medication used to treat nausea) was not expired and was on the medication cart for Hall 200/300. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications.Findings Included: During an observation on 01/20/2026 at 11:15 am, the medication cart for Hall 200/300 contained Novolin 70/30 Flex pen with an open date for Resident #2, Lantus Flex pen with an open date for Resident #69, a bottle of Nitroglycerin with an expired date of 12/22/2025 for Resident #15, and a box of Ondansetron with an expired date of 12/07/2025. During an interview on 01/20/2026 at 11:30 am, RN-E stated all medications in multiuse vials should have been dated when opened. He stated it was the nurse's responsibility to date the medication when it is opened and to check the date prior to administering the medication. He stated that all expired medications should be removed from the cart, and the cart should be checked routinely for expired medications. He stated not putting the open date could lead to residents receiving expired medications. During an interview on 01/22/2026 at 12:03 PM, the DON stated that all multi use vials should have been dated when opened. She stated this should have been done by the nurse who opened the medication and should be checked each time the medication was administered. She stated that expired medications should be removed from the cart immediately. She stated not dating the medication could lead to the resident receiving expired medications. She stated the pharmacy did random medication cart checks but ultimately it was the nurse's responsibility to ensure all medications that require dating were dated. The DON stated the facility did not have a policy referring to the dating of insulin or other multiuse dose medications. Review of facility policy titled, Medication Access and Storage, revised 05/2017, revealed in part: .outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy.

Based on observation, interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 20 (Resident #37) residents reviewed for hospice services. The facility failed to make sure that information on hospice care, that included the Texas Medicaid Hospice Recipient Election/Cancellation form, was included in Resident #37's current clinical record. The facility failed to make sure that information on hospice care, that included the Physician Certification of Terminal Illness form, was included in Resident #37's current clinical record. The facility failed to make sure that information on hospice care, that included current interdisciplinary notes, was included in Resident #37's current clinical record. The facility failed to ensure a staff member was designated to communicate with hospice agencies.These failures could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings includedRecord review of Resident #37's electronic face sheet dated 01/21/2026 reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive brain disease characterized by abnormal protein clumps that disrupt brain function leading to a combination of severe fluctuating cognitive decline and visual hallucinations). Further review of the face sheet reflected she had a POA.Record review of Resident #37's significant change MDS dated [DATE] reflected no BIMS score implementing cognition. Further review of the MDS reflected she had a condition or chronic disease that may result in a life expectancy of less than six months. Record review of Resident #37's care plan dated 1/08/2026 reflected Resident #37 had a terminal prognosis related to neurocognitive disorder with Lewy bodies and was on hospice services. Interventions to the terminal prognosis included: Facility responsibilities: Provide ADL assistance at the same level as other residents in the facility. Communicate with the agency if there is any concern with frequency of assigned visits.[hospice agency] is available to communicate with an educate the facility 24 hours a day/7days a week.[hospice agency] holds care plan meeting on Tuesdays unless otherwise scheduled. Hospice RN will coordinate reviews and IDT notes and will discuss changes in the patient POC with the facility staff. Hospice skilled nurse to visit 1-3x/wk- designee. Hospice Aide to visit 1-3x/wk- C.N.A. assigned- designee. Hospice Social Worker to visit 1-2x/month- or designee. Hospice Chaplain to visit 1-2x/month- or designee. Hospice Physician to visit PRN- [hospice physician].Hospice Volunteer to visit 1-7x/month.Hospice responsibilities: Hospice IDT will communicate with patient/family/facility medical director, patients attending, and other physicians as needed to coordinate hospice care.Provide copy of revocation form.Record review of physician order dated 1/08/2026 reflected an order to admit to hospice care.Record review of Resident #37's electronic chart on 1/21/2026 reflected no evidence that the facility had obtained Texas Medicaid Hospice Recipient Election/Cancellation form, Physician Certification of Terminal Illness form, current interdisciplinary notes, or evidence of communication between the facility and the hospice provider for Resident #37.During an observation on 1/21/2026 at 9:05 a.m., the hospice binder located behind the nurses' station reflected an OOH-DNR form for Resident #37. No other hospice documentation was in the binder for Resident #37. During an interview on 1/21/2026 at 10:05 a.m., Resident #37's POA stated she had been present at the facility since last night when she was notified by the hospice nurse that Resident #37 had a change in condition. Resident #37's POA stated the hospice nurse had been present that morning and the hospice nurse went to talk to the nursing facility staff about medication administration earlier that morning. She stated the hospice staff had participated in the last care plan meeting the facility had and she was present during that care plan meeting as well. She stated the hospice nurse was at the facility frequently. She did not voice any concerns about the hospice care.During an interview on 01/22/2026 at 9:09 a.m., the DON stated she could call the hospice company as needed. She stated the hospice binders were left behind the nurses' station. She found the binder for Resident #37 and there was no CTI, no care plan, no election form, and no communication forms found in the binder. She stated that the hospice was at the facility every day for Resident #37. She stated she would call the hospice company to get those items and stated sometimes the MR will upload the documents into the electronic medical record. She stated the charge nurses could communicate with the hospice providers but did not reveal a designated person that communicated with the hospice company.During an interview on 01/22/2026 at 9:55 a.m., the MR stated she did not have any paperwork that had not been uploaded into Resident #37's chart. She stated she could reach out to the hospice company to get the paperwork if needed. During an observation on 1/22/2026 at 11:26 a.m., there was a posting displayed on the first hallway to the right of the nurses' station naming the former ADON as the hospice coordinator.During an interview on 1/22/2026 at 1:16 p.m., the HR director stated the former ADON's last day was 11/7/2025. The DON was present during the interview, and she did not have a response as to who the hospice coordinator was since the former ADON's last day.Record review of contract between the facility and the hospice agency with no date reflected no evidence of a designated hospice coordinator. Further review of the contract reflected 7. Documentation. [hospice agency] personnel will document [hospice agency] services that are furnished in accordance with this agreement. To the extent allowed by law, [hospice agency] agrees to make available to the LTCF the [hospice agency] patient's consent to hospice care and all other pertinent forms, including those listed below: A. Texas Medicaid Hospice Recipient Election/Cancellation form; B. Texas Medicaid Hospice-LTCF Assessment form; C. Physician Certification of Terminal Illness form; D. Medicare Election Statement, if dually eligible; E. [hospice agency] interdisciplinary assessments; F. [hospice agency] Plan of Care; G. Current interdisciplinary notes, which include the following: Nurses' notes and summaries, physician orders and progress notes, and medication and treatment sheets during the hospice certification period.Review of facility's policy titled, End of Life Care; Hospice and/or Palliative Care, revised on January 2022, reflected no designated person for collaboration with hospice representatives, no evidence on how the facility will coordinate the hospice care planning process for each resident receiving hospice services, or no evidence on how the facility will ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #76) reviewed for incontinent care.The facility failed to ensure CNA-C and CNA-D provided proper incontinent care to Resident #76 by not cleaning his penis or genital area when performing a brief change.This failure could place residents at-risk for infection and skin breakdown due to improper care practices.Findings Included:Review of Resident #76's electronic face sheet, accessed 01/22/26, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses including surgery on the urinary system, obstructive and reflux uropathy (blockage in the urinary tract), and calculus of ureter (stones in the ureter (tube that transports urine from the kidney to the bladder).Record review of Resident #76's admission MDS assessment, dated 12/29/25, revealed a BIMS score of 10 which indicated moderately impaired cognition. Section H revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #76's care plan, revised 01/13/25, revealed: Resident has bowel/bladder incontinence related to Alzheimer's. Interventions: Wash, rinse and dry perineum.During an observation for incontinent care of Resident #76 with CNA's C & D on 01/20/2026 at 2:14 PM, CNA-C sanitized her hands and donned gloves. CNA-C removed Resident #76's soiled brief and dropped it to the floor. CNA-C wiped the resident's entire buttocks multiple times with the same wipe. CNA-C stepped away to get new gloves. CNA-D sanitized her hands and donned gloves and applied a clean brief on the resident. No peri-care or cleansing of the penis was performed during this observation. During a joint interview on 01/20/26 at 2:30 p.m. CNA-C and CNA-D stated they had not realized that they were performing peri-care. They stated they knew how to properly clean the penis, but they were just changing his wet brief and that the penis was usually cleaned during his shower. They stated they did not see any risk or negative outcomes to not cleaning Resident #76's penis or peri-area. During an interview on 01/22/2026 at 11:51 a.m., The DON stated the penis and peri-area must be cleaned every time incontinent care was performed. She stated not providing proper incontinent care could have led to urinary tract infections. She stated she was responsible for ensuring that CNAs were trained properly. The DON did not provide an explanation on when staff were trained and how staff were trained. Record review of the facility's policy titled Perineal Care, not dated, revealed in part: It is the policy of this facility to: 1. Cleanse perineum 2. Eliminate odor 3. Prevent irritation or infection.Procedures.The basic infection control-concept for peri-care is to wash from the cleanest area to the dirtiest area. Rinse cloth and proceed with cleansing of the anal area.

Based on interviews and record review, the facility failed to ensure residents or the resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option they preferred for 1 of 20 (Resident #37) residents reviewed for antipsychotic consents. The facility failed to ensure Resident #37 or her representative signed a consent for antianxiety medication lorazepam prior to administering the medication to Resident #37. This failure could affect residents who received psychoactive drugs by placing them at risk of not being informed of their medications risks and benefits to make informed decisions regarding their care.Findings included:Record review of Resident #37's electronic face sheet dated 01/21/2026 reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive brain disease characterized by abnormal protein clumps that disrupt brain function leading to a combination of severe fluctuating cognitive decline and visual hallucinations) and generalized anxiety disorder. Further review of the face sheet reflected she had a POA.Record review of Resident #37's significant change MDS dated [DATE] reflected no BIMS score implementing cognition. Further review of the MDS reflected she had physical (hitting and kicking), verbal (screaming at others, cursing at others, or threatening others), and other (hitting self, pacing, rummaging, or disruptive sounds) behavioral symptoms. Record review of Resident #37's care plan dated 1/12/2026 reflected Resident #37 had antianxiety medication used related to anxiety disorder. One of the interventions was to educate the resident and their family about risks, benefits, and the side effects of antianxiety medication drug being given. Another intervention was to give antianxiety medication lorazepam and monitor for side effects such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, depression, dizziness, lightheadedness, impaired thinking, memory loss, forgetfulness, nausea, upset stomach, and blurred vision. Record review of physician order dated 1/10/2026 reflected lorazepam intensol oral concentrate 2mg/ml give 0.5ml by mouth every 2 hours as needed for anxiety; restlessness created by RN A.Record review of Resident #37's MAR dated January 2026 reflected Resident #37 received lorazepam twice on 1/13/2026, three times on 1/14/2026, once on 1/19/2026, twice on 1/20/2026, and twice on 1/21/2026.Record review of Resident #37's electronic medical chart on 1/21/2026 reflected no evidence Resident #37 or her representative had consented to lorazepam.During an interview on 1/21/2026 at 10:05 a.m., Resident #37's POA stated she was notified of the medication by the hospice staff and did not remember the facility staff telling her about any side effects of the medication but knew it would make Resident #37 drowsy since lorazepam was for anxiety.During an interview on 1/22/2026 at 9:10 a.m., the DON stated she expected for the charge nurse to get a consent for lorazepam when they put the order into the electronic medical record. She stated Resident #37's lorazepam order was put into the electronic medical record by RN A (a night shift nurse) and she did not know why the consent would not have been obtained. She stated consents would have been kept in the electronic medical record under the documents tab. She stated the MR uploaded paper documents into the electronic medical record and those documents would be stored in a wired basket behind the nurses' station if they were waiting for MR to upload them. She verified Resident #37's lorazepam's consent was not in the wired basket. She stated consents would let residents and families know of the side effects of the medication and should be obtained prior to antianxiety medication being administered to a resident.During an interview on 1/22/2026 at 9:26 a.m., LVN B stated the nurses were responsible for obtaining medication consent for psychoactive medications. She stated the nurses got the consent when they took the order for the medication that required a consent and had a paper under the computer monitors at the nurses' station of what medications needed consents. She stated lorazepam would have needed to have a consent prior to it being administered. She stated after the consent was filled out, the process would have been to get a physical signature on the form or a verbal consent from the resident or their POA. She stated the consent should have been uploaded into the electronic medical record by the MR. She stated she was unaware that there was no consent for Resident #37's lorazepam.During an interview on 1/22/2026 at 9:55 a.m., the MR stated she did not have any paperwork for Resident #37 that was waiting to be uploaded into her chart.During a telephone interview on 01/22/2026 at 10:30 a.m., RN A stated she had received the order for the lorazepam from the hospice nurse and entered the order into Resident #37's electronic record. She stated she specifically remembered telling the hospice nurse that the hospice nurse had to talk to the family about the medication due to it was in the middle of the night. She stated she also knew that Resident #37's family was particular about Resident #37's care. She stated she began the consent paperwork for the day shift nurse to get the paperwork signed and did not know where that paper would be now if it was not in the electronic medical record. She stated medication consent should have been gotten before the nurse gave the medication. She stated if hospice got the consent, the facility still should have it on file. She stated it was the responsibility of the nurse who was going to give the medication to make sure the consent had been obtained. Record review of facility's posted Residents' Rights posting on 1/22/2026 at 9:49 a.m. reflected Participation in your care You have a right to: .Refuse treatment, care or services. Receive information about prescribed psychoactive medication from the person who prescribes the medication or that person's designee; have any psychoactive medications prescribed and administered in a responsible manner as mandated by the Texas Health and Safety Code, S242.505; and refuse to consent to the prescription of psychoactive medications.Record review of facility policy titled Care and Treatment Psychotropic Drug Use dated August 2017 reflected On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents, from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record.Upon change of condition or initiation of a new order for psychoactive medications, the Licensed Nurses shall complete the Verification of Informed Consent form prior to the initiation of the new medication.Review of drugs.com accessed on 01/22/2026 at https://www. https://www.drugs.com/lorazepam.html, reflected lorazepam .Drug class: Benzodiazepines .Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Warnings Lorazepam can slow or stop your breathing, especially if you have recently used an opioid medication, alcohol, or other drugs that can slow your breathing. These effects can be fatal. MISUSE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH. Keep this medicine where others cannot get to it. Lorazepam may be habit-forming and should be used only by the person it was prescribed for. This medicine should never be shared with another person, especially someone who has a history of drug abuse or addiction. Do not stop using lorazepam without asking your doctor. You may have life-threatening withdrawal symptoms if you stop using the medicine suddenly after long-term use. Some withdrawal symptoms may last up to 12 months or longer. Get medical help right away if you stop using lorazepam and have symptoms such as: unusual muscle movements, being more active or talkative, sudden and severe changes in mood or behavior, confusion, hallucinations, seizures, or thoughts about suicide.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent surveys and investigations of the facility including any plans of correction, without identifying information about complainants or residents, for 1 of 1 facility reviewed for resident rights. The facility failed to ensure the investigations that occurred on 1/26/2025, 3/07/2025, 5/25/2025, 8/01/2025, 10/16/2025, 11/07/2025, and 1/15/2026 with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents and the residents' family members or representatives at risk for violation of the right to review the facility's survey and investigation findings without asking the facility to review the reports. Findings included:During an observation on 1/22/2026 at 11:27 a.m., the last survey results dated 10/29/2024 were in a bin labeled survey binder at the beginning of the first hall to the right of the nurses' station. There was a sign above the bin informing the public of the binder's location. Review of the survey results binder reflected no results for investigations performed after the last standard survey dated 10/29/2024. During an interview on 1/22/2026 at 12:58 p.m., the ADMN stated he was responsible for updating the survey binder with the most recent survey results. He stated he was unaware the investigations needed to be in the survey binder as well as the standard survey results with plan of corrections. He verified the last standard recertification survey dated 10/29/2024 was the last results placed in the survey binder. He stated he had never been asked for the investigation findings for the investigations performed on 1/26/2025, 3/07/2025, 5/25/2025, 8/01/2025, 10/16/2025, 11/07/2025, and 1/15/2026 in the binder. The ADMN stated he would have provided those results if he had been asked for them. He stated the survey binder was monitored by other ADMNs from sister facilities during the mock surveys. He did not provide the last time the mock survey had been performed but did state that no one had every told him that the investigation survey findings needed to be in the binder. He stated he did not know if the facility had a policy on the survey binder results. He stated he expected the regulations to be followed.During exit conference on 1/22/2026 at 2:40 p.m., no policy was provided on the survey results posting.

Based on observation, interview, and record review, the facility failed to periodically review and revise for 1 (Resident #2) of 5 residents reviewed for care plans - The facility failed to update the care plan to remove the intervention floor mat from bedside to prevent falls for Resident #2. This deficient practice could place residents in the facility at risk of not receiving care appropriate for their needs and could lead to injury. Review of Resident #2's electronic face sheet dated 11/06/2025 reflected a [AGE] year-old female with an admission date of 01/09/2024 and most recent admission date of 02/12/2025. Resident #2's diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, lack of coordination, unsteadiness of feet, abnormalities of gait and mobility, difficulty in walking, and repeated falls. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00 indicating severe cognitive impairment. Section on Functional Abilities and Goals revealed Resident #2 required assistance with transfers. Section - Health Conditions revealed Resident #2 had no calls since the prior assessment.Review of Resident #2's comprehensive care plan reviewed on 11/06/2025, reflected Resident #2 had ADL deficit related to decreased mobility and generalized muscle weakness. Part of the interventions included 1 staff to participate with transfers and repositioning in bed. Further review of care plan reflected Resident #2 was at risk for falls last revised by MDS coordinator on 06/26/2025. Part of the interventions included Floor mats at bedside. Continued review of care plan reflected Resident #2 had falls with and without injuries last revised by MDS coordinator on 08/08/2025. The focus statement included 2/25/25: Has had a fall with no injury. 2/27/25: [Resident #2] had a fall with no injury. 3/10/25 [Resident #2] had a fall with no injury. 3/11/25: [Resident #2] had a fall with no injury. 3/13/25: [Resident #2] had an assisted fall with no injury. 3/14/25: [Resident #2] had a fall with no injury. 4/2/25: [Resident #2] had a fall with no injury. 4/4/25: [Resident #2] had a fall with no injury. 4/13/25: [Resident #2] had a fall with no injury. 4/19/25: [Resident #2] had a fall with no injury. 4/20/25: [Resident #2] had a fall with no injury. 5/6/25: [Resident #2] had a fall with no injury. 5/25/25: [Resident #2] had a fall with injury. 6/24/25: [Resident #2] had a fall with no injury. 6/27/25: [Resident #2] had a fall with injury. 7/12/25: [Resident #2] had a fall with injury. 7/17/25: [Resident #2] had a fall with no injury 7/21/25: [Resident #2] had a fall with no injury. 7/25/25: [Resident #2] had a fall with no injury. 8/7/25: [Resident #2] had a fall with injury. Review of Resident #2's IDT-Care Plan Review dated 10/28/2025 reflected no mention of floor mats at bedside with additional nursing plan of care Continue with current plan of care. Review of Resident #2's Progress Notes dated 11/05/2025 at 2:15 p.m. written by LVN D, read in part Yelling was heard from other resident's stating She fell, she fell. Upon this nurse entering area resident was found sitting on the floor with bleeding noted to forehead and abrasion noted with dry blood present. Further review of progress notes since 10/08/2025 reflected no other documented falls by Resident #2.Review of Resident #2's Fall Risk Evaluation performed on 11/05/2025 reflected a score of 17 and a high-risk category. Further review reflected a history of 3 or more falls in the past 3 months. During an observation on 11/06/2025 at 10:08 a.m., Resident #2 was lying in bed on a scoop mattress and bed was in the lowest position. Resident was resting peacefully with unlabored breathing, and her eyes were closed. No floor mat was observed beside her bed.During an interview and observation on 11/06/2025 at 1:19 p.m., Resident #2 was sitting in a wheelchair in the lobby area attached to the dining room. She had steri-strips (adhesive wound strips) attached to her forehead covering a wound with no fresh drainage observed. She could not answer questions about where the wound on her forehead had come from looking confused and then feeling of her forehead when asked. There was one staff member sitting in a chair in that lobby and other residents surrounded her. There was a television on for the residents to watch. Resident #2 did not appear to be in any pain and was calm during interview. During a telephone interview on 11/06/2025 at 1:02 p.m., Resident #2's Representative stated she had been informed of the fall Resident #2 had on 11/05/2025. She stated Resident #2 had fallen out of bed in the past and the facility had changed her mattress to a scoop mattress which had helped tremendously. She stated she had asked for a floor mat during a care plan meeting but was told the facility does not use floor mats due to state guidelines. Resident #2's Representative stated she had participated in care plan meetings and that is where they had discussed the scoop mattress instead of the floor mat.During an interview on 11/06/2025 at 1:41 p.m., CNA A stated she had worked for the facility for approximately 2 months. She stated she had worked on the hall Resident #2 resided on and knew about her care. She stated Resident #2 had mostly fallen at night in the past and there had never been a floor mat used beside her bed. She stated she did not know how to look up a care plan. She stated when she asked to look at care plans, due to questions about the care she needed to provide, she had been told to ask the charge nurses about a resident's care needs. During an interview on 11/06/2025 at 2:50 p.m., CNA B stated he was working on Resident #2's hall today and had worked on that hall at nights sometimes. He stated she did not have a floor mat beside her bed today and could not remember if she ever had a floor mat. He stated Resident #2 had a scoop mattress to help prevent falling out of bed and he would make sure to keep her bed in the lowest bed position when she was in bed. He stated at night, he checked on Resident #2 more frequently than other residents to help prevent her from falling as well. He stated if he needed to know something about a resident plan of care, he had to ask the charge nurse.During an interview on 11/06/2025 at 2:58 p.m., LVN D stated she knew how to look up care plans. She stated she did not update the care plans, but the MDS RN would update them when needed. She stated the interventions that were being provided to Resident #2 included keeping her bed in the lowest position because she was a high fall risk. She stated a floor mat was like a fall mat but not as thick. She stated that Resident #2 did not have a fall in her room the last time, but the fall was in the lobby beside the kitchen. She stated she was on shift that day and had assessed the resident after the fall. She stated she did not believe there were any changes to Resident #2's care plan after that fall.During an observation on 11/07/2025 at 8:40 a.m., Resident #2 was lying in bed on a scoop mattress and bed was in the lowest position. Resident was resting peacefully with unlabored breathing, and her eyes were closed. The room was dim, and no floor mat was observed beside her bed. During an interview on 11/07/2025 at 8:44 a.m., CNA C stated she was an agency CNA and had just gotten access to the resident records this morning to be able to chart for the residents including Resident #2. She stated this was her first day working in the facility. She stated she did not know if the care plan was listed on the kiosk but would look. She logged into the resident's charting and saw floor mat beside bed listed. She stated she did not know why there was no floor mat in Resident #2's room but did see housekeeping pick up a floor mat this morning to clean it but could not remember which room that was from. She stated floor mats were needed to minimize injury. She stated if she had noticed the floor mat not being present, she would have reported it to the charge nurse.During an interview on 11/07/2025 at 8:53 a.m., the MDS coordinator stated she was working as a charge nurse on the hall that Resident #2 resided on today. She stated after a fall, the actual fall care plan was updated with new interventions, and a floor mat was not listed on the actual fall care plan as determine by herself and the DON. She stated the risk for fall care plan had intervention for floor mat beside Resident #2's bed but that was not the care plan that staff went by when providing care. She stated the floor mat had been put in the care plan by a different nurse two years ago and that was why it was on the care plan now. She stated the care plans should match the orders and since there was not an order for a floor mat, the staff should not put a floor mat down. When asked why the floor mat beside the bed was listed in the kiosk for the CNAs, she stated the CNAs should speak to the charge nurses to know what interventions were appropriate for the residents. The MDS coordinator stated she participated in care plan meetings. She stated after a fall, the actual fall care plan interventions were updated and the risk for falls care plan stayed the same. She stated the risk for falls care plan was put in place years ago and were due to the baseline care plan. She stated since the resident did not need a floor mat, the CNAs were providing care as needed for Resident #2 and no negative effect occurred from not placing the floor mat beside bed.During an interview on 11/07/2025 at 9:08 a.m., when the DON was asked how she monitored and provided oversight in order to assure care and services were implemented based upon the care plan the DON responded she looked at the actual falls care plan when there was a fall. The DON stated she and the MDS coordinator did not look at the risk for falls care plan because everyone residing in the facility was at risk for falls. She stated Resident #2's at risk for falls care plan had been placed about 2 years ago and she had not looked at interventions for that care plan. She stated the floor mat should not have been on the care plan if direct care staff were not providing that intervention but added the floor mat was not an intervention for an actual fall. The DON did not reveals why the floor mat was still on the care plan when it was not in use and had not been used. She stated Resident #2 would not benefit from a floor mat to help prevent her from falling and she did not see any negative impact from not placing a floor mat beside Resident #2's bed. She stated both her and the MDS coordinator updated the care plans. The DON stated she could resolve out and delete an intervention on a care plan but did not look at the at risk for falls care plan interventions. She stated during care plan meetings, the facility staff involved in that care plan would look at the actual fall care plan and not review the risk for fall care plan. She stated that if the care plan specifies a floor mat beside bed that meant there would be a floor mat placed beside that resident's bed. She stated direct care staff should not have placed a floor mat beside Resident #2's bed due to that was not part of the focus care plan for the actual fall. She stated the charge nurses were responsible for implementing interventions and monitoring that interventions were carried out by the CNAs. She stated the nurses knew not to go by the interventions on the focus: at risk for falls care plan and no negative impact had occurred from the floor mat being on the care plan interventions. She stated CNAs have access to the care plans using the kiosk. She stated temporary staff were oriented on the kiosk system by other CNAs and nurses. During an interview on 11/07/2025 at 9:25 a.m., the ADMN stated he expected the direct care staff to follow care plans to the best of their ability. He stated the direct care staff should reach out to himself or the DON if an intervention could not be carried out. He stated he had not been notified by staff that the floor mat beside Resident #2's bed could not be performed. He stated he expected for the IDT to monitor that the direct care staff followed the care plans. He clarified that the IDT consisted of department heads including the medical director, the MDS coordinator, the DON and himself. He stated the IDT communicated the interventions to the nurses who were expected to report those interventions to the CNAs. He stated he did not think there were any negative consequences from the floor mat not being beside Resident #2's bed when she was in bed. He stated he felt the care plan should reflect what the resident's care needs were and felt the interventions should be followed. Review of facility policy titled Comprehensive Person-Centered Care Planning revised on 12/2023 reflected: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.Review of facility policy titled Fall Management System revised on 01/2022 reflected: 1. On admission, the Fall Risk Evaluation will be completed to determine his/her risk for sustaining a fall.2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes.a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.4. Review of the fall incident will include investigation to determine probable causal factors.5. The investigation will be reviewed by the Inter Disciplinary Team.6. Resident's care plan will be updated.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #1, Resident #2, and Resident #3) of 12 residents observed for assistance with ADL's. Resident #1, Resident #2, and Resident #3 had body odor and poor hygiene due to the facility failing to provide showers This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care, skin breakdown, feelings of poor self-esteem, and lack of dignity. Findings included: Record review of Resident #1's Face sheet dated 3.7.25 revealed a [AGE] year-old female admitted on 10.28.24, with diagnoses of Chronic heart failure, hypertension, and dementia. Record review of Resident #1's Quarterly MDS assessment dated 3.7.25 revealed a BIMS score of 15 indicating no cognitive deficit. Record review of Resident #1's Care Plan dated 3.7.25 indicated Resident requires x1 supervision/limited assistance with assistance bathing/showering x3 a week and as necessary. Record review of Resident #1's Shower log for February 2025 revealed the following dates marked not applicable from 2.22.25 to 3.6.25. Only days that showed shower complete were 2.22.5 and 2.27.25. During an interview on 3.7.25 at 11:15 am Resident #1 stated she was not exactly sure when she got her last shower. She stated she has never refused a shower. She stated the only time she told them no was when it was too late at night by the time they got to her and would like a shower the next day. Observation on 3.7.25 at 11:15 am Resident #1 had an odor and hair was messy. Record review of Resident #2's Face sheet dated 3.7.25 revealed a [AGE] year-old male admitted on 12.12.23, with diagnoses of diabetes mellitus, anemia, and muscle weakness. Record review of Resident #2's Quarterly MDS assessment dated 3.7.25 revealed a BIMS score of 8 indicating moderate cognitive deficit. Record review of Resident #2's Care Plan dated 3.7.25 indicated required to have x1 staff assistance with bathing/showering x3 weekly and as necessary. Record review of Resident #2's Shower log for February 2025 revealed the following dates marked not applicable: from 2.22.25 to 3.6.25. During an interview on 3.7.25 at 10:45 am Resident #2 stated his main issue was not getting showers. He stated he was not sure why he has not gotten a shower in a while and would really like one. Observation on 3.7.25 at 10:45 am Resident #2 had an odor, dry flakey skin, and long fingernails. Record review of Resident #3's Face sheet dated 3.7.25 revealed a [AGE] year-old male admitted on 6.1.17, with diagnoses of type 2 diabetes, heart disease, and pressure ulcer. Record review of Resident #3's Quarterly MDS assessment dated 3.7.25 revealed a BIMS score of 15 indicating no cognitive deficit. Record review of Resident #3's Care Plan dated 3.7.25 indicated Resident Requires (x2) staff participation with bathing. Record review of Resident #3's Shower log for February 2025 revealed the following dates marked not applicable: from 2.22.25 to 3.6.25. During an interview on 3.7.25 at 11:55 pm Resident #3 stated he was not sure how long it has been since he received a shower. He stated he was not sure what was going on because the facility does not offer a shower or if they forgot about him. He stated he has never refused a shower. Observation on 3.7.25 at 10:45 am Resident #3 had an odor, dry flakey skin, and was wearing same clothing from previous day. During an interview on 3.7.25 at 12:05 pm NA stated the shower log sheet was then turned into the nurse and the nurse was to go into the system and mark showered task was completed. She stated on the shower log she also must complete a skin assessment, adls, hygiene, etc. she stated so even if a resident refuse there was a refusal sheet that the resident must sign. She stated overall she knows when she was working that all her residents do get their showers. She stated she cannot speak for all the hallways. She stated based on looking at the shower logs, the residents were not getting their showers. She stated she knows Resident #1 did get a shower on 2.22.25 and 2.27.25 because she gave the resident their shower. She stated the other residents, Resident #2 and Resident #3 has not received a shower and was not exactly sure why they have not received their shower, they are not on her rotation. During an interview on 3.7.25 at 12:35 pm DON stated that when she looked back at the shower logs for resident's #1, #2, and #3 documentation showed not applicable. She stated not applicable means the resident did not receive a shower. She stated that she would go and review all shower log sheets to see if maybe her staff was not giving showers or not documenting correctly in the system. During an interview on 3.7.25 at 1:15 pm Administrator stated that showers should be completed for each resident according to their bath schedule. He stated if residents do not receive their showers, they could have poor hygiene or skin breakdown. During an interview on 3.7.25 at 1:20 pm DON stated she could only find shower logs for two residents. She stated that she even spoke to one of her CNA's that stated that they did not get to showers, to verify if what she was reviewing was correct. She stated the shower logs in the system do look to be correct and residents have been missing their showers. She stated if residents miss their showers they could smell or have skin breakdown. Record review of Bath, Tub/ Shower policy not dated revealed It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation.

48883 Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 18 (Resident #60) residents reviewed for comprehensive care plans. The facility failed to implement care plan for Resident #60 to receive house shake with meals. These failures could place residents at risk of not having preferences and weight goals being met. Findings included: Resident #60 Record review of Resident #60's electronic face sheet dated 10/29/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: malnutrition. Record review of Resident #60's Quarterly MDS assessment dated [DATE] revealed: resident was rarely/never understood and no BIMS score. Further review of MDS assessment revealed diagnoses to include: malnutrition. Record review of Resident #60's IDT-BIMS assessment dated [DATE] revealed BIMS score of 03 meaning severe cognitive impairment. Record review of Resident #60's electronic physician orders dated 10/28/2024 revealed order written on 08/28/2024 stated, Provide resident with House Shakes with every meal at the request of the resident. Record review of Resident #60's comprehensive care plan completed on 10/21/2024 revealed Resident #60 had nutritional problem r/t GERD, Lewy bodies dementia, mechanically altered diet d/t edentulous status date initiated: 01/10/2024 revision on: 03/18/2024. Interventions included: House shake with every meal. Date initiated: 09/02/2024. Record review of Resident #60's comprehensive care plan during investigation on 10/29/2024 revealed: Resident #60 had nutritional problem r/t GERD, Lewy bodies dementia, mechanically altered diet d/t edentulous status date initiated: 01/10/2024 revision on: 03/18/2024. Interventions included: House shake per orders. Record review of Resident #60's electronic physician orders during investigation on 10/29/2024 revealed order written on 10/28/2024 which stated, Provide resident with House Shakes with meals. During an observation on 10/27/2024 at 11:42 a.m., Resident #60 was sitting in dining room eating meat that appeared to be a mechanical texture, potatoes, carrots, and cake. Meal was served on a red plate that had separated areas. Personal meal ticket for Resident #60 sitting beside her plate showed Serve shake with meals. No shake observed with meal. During an observation on 10/27/2024 at 12:00 p.m., a staff member sitting next to Resident #60, assisting her with her meal. No shake observed on table at that time. During an interview on 10/28/2024 at 3:23 p.m., the DON stated all diabetic residents were given snacks at bedtime. She stated there were snacks available for all resident but that snacks were not handed to residents unless they requested them. During an interview on 10/28/2024 at 3:33 p.m., the ADMN stated all diabetic residents were to be offered snack at bedtime. He stated all residents were verbally offered snacks and that the residents knew to ask for snacks if they wanted them. During an interview on 10/29/2024 at 12:51 p.m., the MDS coordinator stated she thought care plan should show what facility staff were doing for the resident. She stated she tried to be specific on care plans and care plan stating house shake with all meals is okay. MDS coordinator stated audits to care plans are don't often and facility IDT members will update care plans often. When asked, If a care plan should include diabetic resident preference of wanting a snack after dinner, she stated I believe that a resident is able to request a snack at bedtime and all the residents have the right to request. If we had an order for snack at bedtime, we would carry it over into the care plans. She stated the care plans do not have a huge effect on the facility's residents because the facility had orders and other documentation to look at for residents' care. She stated the whole IDT team monitors that care plans are accurate and resident specific and added everyone can have an effect on the care plan. During an interview on 10/29/2024 at 1:19 p.m., the DON stated nurse management team was responsible for care plans. She stated care plans were updated daily and more often than daily when needed. She stated she expected for comprehensive care plans to be resident specific. She stated there was a difference in Resident #60's physician orders and her care plan. She stated they updated the care plan and orders after speaking with dietician and physician for clarification on orders. She stated the words resident request were removed from the orders. She stated if a diabetic resident requested a snack at bedtime, it did not need to be on care plan unless there was an order to give snack at bedtime. She denied stating all diabetic residents were to be given a snack at bedtime. She stated facility staff follow orders and she did not know if any negative effect would occur to resident care if care plan was not specific. The DON stated she did not know if the care plan needed to say house shake with every meal instead of per orders. She stated that meal tickets would have house shake listed on it to let CNAs know shake to be given. She denied any negative effect on residents from care plans not being specific. During a follow up interview on 10/29/2024 at 3:34 p.m., the DON stated nurse aides would know about administering house shakes with meals by looking at the care plan in the Kardex and by looking at meal tickets. She stated that care plan changes were also verbally communicated with nurse aides to notify them of changes in the care plans. Review of facility policy titled Comprehensive Person-Centered Care Planning revision date 12/2023 revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Person-centered care - means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven(7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, and any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan.

Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by a team of qualified persons after each assessment for 2 of 18 (Resident #50, and Resident #281) residents reviewed for comprehensive person-centered care plans. 1. The facility failed to revise Resident #50's comprehensive care plan to remove use of medication no longer ordered within 7 days of the completion of the comprehensive assessment. 2. The facility failed to include hospice services within 7 days of the completion of Resident #281's comprehensive assessment. Thes failures could affect the residents by placing them at risk for not receiving current care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #50 Record review of Resident #50's electronic face sheet dated 10/29/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 08/30/2024 and initially on 12/12/2023 with diagnoses to include: personal history of malignant neoplasm of prostate (prostate cancer), and acute kidney failure. Record review of Resident #50's Quarterly MDS assessment date 09/12/2024 revealed: BIMS score of 08 which indicated moderate cognitive impairment. Further review of MDS assessment revealed resident had an indwelling catheter. Record review of Resident #50's comprehensive care plan completed on 05/14/2024, 07/10/2024, 09/24/2024, and care plan reviewed on 10/29/2024 revealed: Resident #50 had indwelling catheter with interventions that included Administer medication per physician's orders; Myrbetriq (medication to treat overactive bladder). Monitor effectiveness and side effects. Date initiated: 12/30/2023 Record review of Resident #50's electronic physician orders dated 10/29/2024 revealed no active order for medication Myrbetriq. Further review of physician orders revealed Myrbetriq had been discontinued on 02/17/2024. Resident #281 Record review of Resident #281's electronic face sheet dated 10/29/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: malignant melanoma of skin (skin cancer). Record review of Resident #281's Admission MDS assessment dated [DATE] revealed BIMS score of 02 meaning severe cognitive impairment. Further review of MDS assessment revealed resident had received hospice care while a resident. Record review of Resident #281's electronic physician orders dated 10/16/2024 revealed resident had been admitted to hospice care for terminal diagnosis of malignant melanoma of skin (aggressive skin cancer). Record review of Resident #281's comprehensive care plan revealed no evidence of hospice care addressed prior to care plan initiated on 10/27/2024. During an interview on 10/29/2024 at 12:51 p.m., the MDS coordinator stated any IDT member was responsible for care plans. She stated IDT members included ADON, DON, wound nurse, and MDS coordinator. She stated her expectation for care plans would be to include orders, diagnoses, and plan of care. She stated IDT members tried to put any type of behaviors in the care plan. She stated she thought care plan should show what facility staff were doing for the resident. MDS coordinator stated audits to care plans are don't often and facility IDT members will update care plans often. She stated that hospice services should be included into care plans. She stated the care plans do not have a huge effect on the facility's residents because the facility had orders and other documentation to look at for residents' care. She stated the whole IDT team monitors that care plans are accurate and resident specific and added everyone can have an effect on the care plan. During an interview on 10/29/2024 at 1:19 p.m., the DON stated nurse management team was responsible for care plans. She stated care plans were updated daily and more often than daily when needed. She stated she expected for comprehensive care plans to be resident specific. The DON stated she expected for hospice services to be included into comprehensive care plan. She stated care plan was updated on 10/27/2024 to include hospice services. She verified that Resident #281 was admitted into hospice care on 10/16/2024. She did not know if there was a specific time frame in which care plan needs to be updated. She denied any negative effect on residents from care plans not being specific. Review of facility policy titled Comprehensive Person-Centered Care Planning revision date 12/2023 revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments .

Based on interview, and record review, the facility failed to accurately assess each resident's status for 1 of 18 (Resident #19) residents reviewed for assessment accuracy. The facility failed to code Resident #19's Quarterly MDS assessment records accurately. MDS assessment coded that resident had received anticoagulation (medications that stop blood from clotting too easily) medication when resident did not receive that type of medication. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment records. Finding included: Record review of Resident #19's electronic face sheet dated 10/29/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 02/02/2024 and initially on 06/01/2017 with diagnoses to include: atherosclerotic heart disease (condition when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff). Record review of Resident #19's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 which indicated cognitively intact. Further review of the MDS Section N - Medications revealed Resident #19 was taking anticoagulant medication and was not taking antiplatelet medication. Record review of Resident #19's electronic physician orders dated 10/29/2024 revealed no evidence Resident #19 was taking or had been prescribed anticoagulant medications. Resident had a physician order dated 06/06/2024 for clopidogrel bisulfate 75mg, an antiplatelet (medications that prevent platelets from sticking together) medication. and for aspirin 81mg. During an interview on 10/29/2024 at 12:46 p.m., the MDS coordinator stated she was responsible for MDS assessments. She stated she answered MDS assessment questions to the best of her ability. She stated clopidogrel bisulfate and aspirin were not anticoagulant medications. The MDS coordinator stated she did not believe any negative effect would have occurred to the resident from coding MDS assessment incorrectly for anticoagulant medication usage. She stated she had mistakenly coded the assessment incorrectly. She stated she monitored that MDS assessments are correct and that she was RUG certified. She stated she could reach out to clinical MDS resource if she had any questions about MDS assessments. During an interview on 10/29/2024 at 1:17 p.m., the DON stated the MDS coordinator was responsible for MDS assessments. She stated her expectation would be for the MDS assessment to be completed in a timely manner and for them to be accurate. She stated that clopidogrel bisulfate and aspirin were not anticoagulant medications but were antiplatelet medications. She stated no effect would have occurred to resident other than billing. During an interview on 10/29/2024 at 10:50 a.m., the ADMN stated the facility did not have policy for accuracy of assessments. He stated he expected the facility to follow the RAI manual. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf accessed on 10/29/2024): N0415: High-Risk Drug Classes: Use and Indication .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 4 halls (hall 200 and hall 300) reviewed for environmental conditions by failing to ensure: 1. The door and the door casing of the entrance door of the community shower room was damaged. 2. The public bathroom on Hall 300 had damage to the tile on the wall and the wall to the right of the entrance was splattered with dark spots. 3. The wall in the community shower across from the toilet was dirty and the cove base trim was pulled back exposing damage to the drywall and wood. 4. The door and the door casing of the exit door on Hall 200 that led to the smoke area was damaged. 5. A light fixture in the hallway of Hall 300 next to the emergency exit contained numerous dead bugs and was brown in color. These failures could affect resident by placing them at a risk for diminished quality of life due to the lack of a well-kept environment. Findings include: During an observation on 09/19/2023 at 9:35 a.m., the doorframe of the exit/entrance door that led into the community shower room on Hall 300 was damaged with chunks in the paint that exposed the wood, and the door frame was covered with several layers of old paint. Observation of the small bathroom in the community shower room revealed the wall across from the toilet was splattered with a white substance and the vinyl cove base trim (the piece of trim installed around the baseboard of a room that created a transition between the floor and the wall) was pulled back from the wall in several areas exposing a black substance from water damage, a strip of dried glue, chipped paint, and damaged dry wall. Observation of the sink in the community bathroom revealed a layer of crusty build-up around the faucet handles and the particles of unknown substance were observed in the sink. During an observation on 09/19/2023 at 10:10 a.m., the public bathroom located in Hall 300 had a missing tile from the wall and the wall to the right of the entrance was splattered with dark spots. During an observation on 09/19/2023 at 10:25 a.m., the entrance/exit door that led to the outside designated smoking area located off Hall 200 was damaged. The door frame was cracked, and large parts of the door casing boards were broken or missing, which exposed raw, unpainted wood, nails not flush with the boards, and a gap that let in air and light. Observation revealed the door sweep (metal surface mounted to the bottom of the door) was broken and twisted, did not cover the right side of the bottom of the door and let in air and light. The door, which was originally white, was stained black to grey in color in several areas and had scraps across the surface. The floor at the bottom of the baseboard was covered in a thick, dark layer of dirt. During an observation on 09/19/2023 at 11:30 a.m., the fluorescent light fixture at the end of the hallway of Hall 300 next to the emergency exit contained a large number of dead bugs, with a huge concentration of bugs carcasses at the end of the fixture furthest from the door and was brown in color. During an interview on 09/19/2023 at 12:36 p.m., CNA A said the process to make repairs in the facility was for the staff who found an issue was supposed to document the issue in the maintenance binder located at the nurses' station or to call the Maintenance Manager or Assistant Maintenance Manager. During an interview on 09/19/2023 at 1:12 p.m., CNA C said she was normally assigned to Hall 100 and Hall 200. CNA C said if she saw something in need of repair, she would write it down in the maintenance book. During an interview on 09/19/2023 at 1:42 p.m., the Maintenance Director said when something in the building needed to be repaired, the Assistant Maintenance Director and he were the only staff who were available to make repairs. The Maintenance Director said he relied on nursing staff to write down what they saw in the residents' rooms that needed to be repaired because he could not go into every room, every day, and make inspections. The Maintenance Director said the log in the maintenance book did not have a space to prompt the staff to add the name of the person making the request, so he was unable to identify the employee to ask for more information. The Maintenance Director said the staff need to be descriptive when documenting a repair request. During an interview on 09/19/2023 at 2:08 p.m., the Assistant Maintenance Director said the process for making repairs in the facility was for staff to write down issues in the maintenance book located at the nurses' station. The Assistant Maintenance Director said the staff had been in-serviced many times to be more descriptive when documenting the maintenance log, but she still had difficulty determining what the problem was. The Assistant Maintenance Director said the sinks pulled away from the wall after the resident pushed down on it and the staff were not documenting when repairs were needed. During an interview on 09/20/2023 at 9:56 a.m., the ADON said she knew there was issues that needed to be repaired because the building was older. The ADON said the sinks in the residents' bathrooms separating from the wall should be an immediate concern and immediate action taken to fix. The ADON said with building being older, she would expect minor issues. The ADON said exposed drywall at the baseboards was not an acceptable living environment. During an interview on 09/20/2023 at 10:41 a.m., the Administrator said the sinks separating from the walls in the residents' bathrooms were more cosmetic than a repair issue. The Administrator said the issue was not of immediate nature. The Administrator said the environment of the facility over-all does not affect the residents' rights. The Administrator said the maintenance log policy had room for improvement. Record review of facility policy, Maintenance & Facilities, Environmental Management, not dated, revealed the policy was to establish an environmental plan to ensure a physical environment was a safe, neat, sanitary environment and met regulations to protect the health and safety of the residents, employees, and others. #1 of the policy revealed that furnishing, equipment, and accessories would be maintained in good order; #4 revealed inspections of the buildings and equipment would be done on a schedule; #5 revealed inspections would be documented.

Based on observation, interviews and record reviews, the facility failed to ensure that residents had the right to a safe, clean, comfortable, and homelike environment for 6 (Resident #2, Resident #3, Resident #4, For Resident #5, For Resident #6, and Resident #7) of 8 residents reviewed for a clean and comfortable environment. 1. The facility failed to ensure a broken windowsill in Resident #2's bedroom was repaired, and the exposed wood was repainted. 2. The facility failed to ensure Resident #3 had access to cold water when the bathroom faucet was not repaired and missing cove base trim in the bathroom was not repaired or replaced that exposed damaged dry wall and wood. 3. The facility failed to repair the cove base trim in Resident #4's bedroom that exposed damaged dry wall and wood and failed to repair the bathroom sink that had dislodged from the wall. 4. The facility failed to repair the cove base trim in Resident #5's bedroom that exposed damaged dry wall and wood and repair the damaged dry wall behind the headboard that had broken off and formed a large pile of drywall to accumulate on the floor. 5. The facility failed to clean bugs from the florescent light fixture over the top of head of the bed and repair the missing cove base trim in the bedroom that exposed damaged dry wall and wood for Resident #6. 6. The facility failed to repair the broken toilet seat after Resident #7 reported the seat was damaged and uncomfortable to sit on. These failures could place residents at risk of a decrease in quality of life and self-worth. Findings include: Record review of Resident #2's face sheet, dated 09/19/2023, revealed an [AGE] year-old male who was admitted into the facility on [DATE]. Resident #2's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Chronic (persisting) Embolism (obstruction of an artery) and Thrombosis (blood clot within a blood vessel) of left Femoral Vein (large blood vessel in the thigh), and Essential (Primary) hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 02, which indicated severe cognitive impact. During an observation on 09/18/2023 at 6:25 p.m., the windowsill in Resident #2's room, was observed to be broken along the outside of the sill in a crooked manner and unpainted wood was exposed. During an interview on 09/18/2023 at 6:28 p.m., Resident #2's family member said the board on the windowsill had been broken since Resident #2 had moved into the facility and that it made the room look in disrepair. Resident #2's family member said the resident who resided with Resident #2 moved out the week before and the bed was moved at that time. Resident #2's family member said the staff who moved the Resident #2's roommate were aware of the broken windowsill. Record review of Resident #3s face sheet, dated 09/20/2023, revealed a [AGE] year-old-female who was admitted into the facility on [DATE]. Resident #3's diagnoses included Anxiety, Chronic (persisting) Diastolic Heart Failure (condition in which the heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly), and Type II Diabetes (problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #3's Quarterly MDS, 08/17/2023, revealed Resident #3 had a BIMS score of 12, which meant a moderate cognitive impairment. During an observation on 09/19/2023 at 2:31 p.m., observed Resident #3's bathroom sink, and noticed the faucet had separate knobs for cold and hot water. Observed the handle on the cold-water valve was missing. The cove base trim missing from the bottom of the wall at the floor level approximately one foot on the side wall to approximately four feet on the wall facing the toilet, exposing a black substance from water damage, chipped paint, damaged wood, and damaged dry wall. During an interview on 09/19/2023 at 2:31 p.m., Resident #3 said she had broken the faucet knob that morning. Resident #3 said she noticed half the knob was on the cartridge (screw that stands up to hold the faucet handle) and when she turned handle, the other piece broke off. Resident #3 said she told her nurse that the handle was broken but could not remember who she told. Record review of Resident #4's face sheet, dated 09/19/2023, revealed an [AGE] year-old male who was admitted into the facility on [DATE]. Resident #4's diagnoses included Malignant Neoplasm (term for cancer) of Unspecified Part of Lung, Secondary Malignant Neoplasm (new cancer that occurs as a result of previous treatment) of Bone, and Essential (Primary) Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). Record review of Resident #4's Comprehensive Admission MDS, dated [DATE], revealed a BIM score of 05, which indicated severe cognitive impact. During an on observation on 09/19/2023 at 10:05 a.m., the vinyl cove base trim (the piece of trim installed around the baseboard of a room that created a transition between the floor and the wall) in Resident #4's room was missing in the area by the entrance door, exposing damaged dry wall that was brown and black in color, and chipped paint. The entrance door to Resident #4's bedroom had chunks of wood missing and unpainted wood exposed. Observation in Resident #4's bathroom revealed the bathroom sink was dislodged from the wall at the back of the basin and a layer of crusty build-up around the cold-water knob. The bathroom wall had a large area of the wall near the vinyl cove base trim covered in white drywall mud and pieces of the cove base trim were pulled back exposing damaged and discolored drywall and wood covered in a black substance. The handrail near the toilet had fallen off and dislodged. During an interview on 09/19/2023 at 3:02 p.m., Resident #4's family member said the facility could do better with the repairs in the facility. Resident #4's family member said Resident #4's room was always filthy and dirty. Resident #4's family member said she visited Resident #4 every Sunday and had to ask the employees to clean his room. Resident #4's family member said she visited the facility on Sunday, 09/17/2023, and informed the CNA on duty the issue with the cleanliness. Record review of Resident #5's face sheet, dated 09/19/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #5's diagnoses included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest of task), Essential (Primary) Hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), and Dysphagia (difficulty swallowing). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed Resident #5 had a BIMS score of 00, which indicated severe cognitive impact. During an observation on 09/19/2023 at 10:20 a.m., observed the vinyl cove base trim had fallen off the bottom of the right wall near the entrance to Resident #5's bedroom approximately a foot in length, that exposed damaged drywood and chipped paint. Observed an area behind Resident #5's headboard where damaged dry wall had broken off the wall and formed a large pile of a powder substance and chunks of white drywall to accumulate on the floor under and beside the bed. During an interview on 09/19/2023 at 3:40 p.m., Resident #5's family member said she felt Resident #5's room and tray table need to be cleaned and cleared off. Resident #5's family member said overall, she would give the facility a B+ in cleanliness. Record review of Resident #6's face sheet, dated 09/19/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #6's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified Hydronephrosis (abnormal enlargement or swelling of a kidney due to dilation of the kidney calices [collects urine] and kidney pelvis), and Type II Diabetes (problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 14, which indicated intact cognition. During an observation on 09/19/2023 at 11:00 a.m., observed the fluorescent light fixture directly above the head of Resident #6's bed contained a large amount of dead bugs inside the plastic cover and was brown in color. Observed an external electrical box with two outlets that had partially detached from the wall by the windowsill and the windowsill contained dirt debris and peeling paint around the windowpane. During an interview on 09/19/2023 at 11:00 a.m., Resident #6 said when she laid down in bed, she could see the bugs in the light fixture, and it bothered her at night. Resident #6 said she was unable to clean it herself. Record review of Resident #7's face sheet, dated 09/20/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #7's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Pulmonary Hypertension (condition that affects the blood vessels in the lungs), and Acute (recent) Kidney Failure. Resident #7's face sheet identified her as a self sufficient financial responsible party and did not have a Power of Attorney. During an observation on 09/19/2023 at 10:46 a.m., observed the bathroom of Resident #7 had an area of cove base trim missing from the wall in the corner, approximately 2 feet in length, exposing damaged drywall with a black substance, chipped paint, and damaged exposed wood. Resident #7's toilet seat hinge on the left side was broken and had come completely off the lid. The toilet seat was unstable and moved left and right on the toilet rim. During an interview on 09/19/2023 at 10:46 a.m., Resident #7 said she had reported the broken toilet seat to the nurse, housekeeping, and maintenance. Resident #7 said she had reported the toilet seat approximately 2 weeks prior because when she sat on the toilet, the seat pinched her bottom. Resident #7 could not remember the specific name of the employee she talked to but said she knew the maintenance man was aware because he came in her room and looked at the toilet. Resident #7 said the bottom of the wall in the bathroom had been exposed since she moved in. During an interview on 09/19/2023 at 10:31 a.m., Housekeeper A said at times the residents would tell her that their room did not get cleaned when she had her days off. Housekeeper A said she would tell the residents to report unclean rooms to the Housekeeping Supervisor. Housekeeper A said there was a logbook located at the nurses' station to report any issues that needed to be repaired. Housekeeper A said she would log the issue in the book and text the Maintenance Supervisor. Housekeeper A said she had seen the windowsill in Resident #2's room and said the condition of the windowsill would be an issue she would report as a work order in the maintenance logbook. During an interview on 09/19/2023 at 12:56 p.m., CNA B said if she saw an issue that needed to be repaired, she would put the issue down in the maintenance log and then tell the Maintenance Manager. CNA B said she was assigned Hall 200 but was not aware Resident #7's toilet seat was broken. CNA B said the broken toilet seat had been reported and documented in the maintenance log and she thought the issue had been addressed. Record review of the maintenance log, dated 08/21/23 through 09/09/2023, revealed Resident #7's room number had been documented on 09/04/2023 as a need of toilet. The document revealed completion date with only the Maintenance Manager's initials documented. During an interview on 09/19/2023 at 1:42 p.m., the Maintenance Director said he or the Maintenance Assistant would check the maintenance log to see if something in the building needed to be repaired several times a day. The Maintenance Director said the employee who noticed or saw the need for a repair was responsible for documenting in the maintenance logbook. The Maintenance Director said he in-serviced staff at the all-staff meetings to not call or text him because he could not keep up with verbal messages. The Maintenance Director said the staff were told to put the request for repairs in writing in the maintenance logbook. The Maintenance Director said he looked at the log in for Resident #7's toilet and observed the log said toilet. The Maintenance Director said he went into Resident #7's bathroom and did not find an issue or see the toilet seat was broken. The Maintenance Director said the log in the maintenance book did not have a space to prompt the staff to add the name of the person making the request, so he was unable to identify the employee to ask for more information. The Maintenance Director said the staff need to be descriptive when documenting a repair request. During an interview on 09/19/2023 at 2:08 p.m., the Assistant Maintenance Director said the facility could be cleaner and needed repairs in many areas including the common areas and the residents' rooms. The Assistant Maintenance Director said she was aware of the areas missing the strip of cove base trim in many of the residents' room and bathrooms, but cove base trim pulled off or fell off easy when it got old. The Assistant Maintenance Director said the housekeeping staff could be more trained on reporting what needed to be repaired and how to clean. During an interview on 09/20/2023 at 9:56 a.m., the ADON said the broken windowsill in Resident #2's room and cove base trim that had come of the bottom of the walls in areas of the facility and exposed damaged dry wall and wood was not an acceptable living environment. During an interview on 09/20/2023 at 10:41 a.m., the Administrator said the windowsill in Resident #2's room should have been fixed. The Administrator said the water faucet handle in Resident #3's bathroom should have been reported and fixed immediately. The Administrator said the environment of the facility over-all does not affect the residents' rights. The Administrator said the maintenance log policy had room for improvement. Record review of facility policy, Federal Residents Rights, not dated, revealed Safe Environment - Residents had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving supports of daily living safely. Record review of facility policy, Maintenance & Facilities, Environmental Management, not dated, revealed the policy was to establish an environmental plan to ensure a physical environment was a safe, neat, sanitary environment and met regulations to protect the health and safety of the residents, employees, and others. #3 of the policy revealed the facility would put a system in place for reporting repairs and requests (paperwork orders or TELS); #11 of the policy revealed the procedure would include identifying and reporting safety issues.

Based on observations, interviews, and record reviews, the facility failed to properly store food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to store foods in the refrigerators and freezers properly. These findings placed residents at risk of food borne illnesses. Findings included: During an observation and interviews on 08/27/23 beginning at 9:49AM in 1 of 1 kitchen with DC revealed: Breakfast Freezer -Corn tortillas with a date of 5/15 with obvious white crystals touching the food items and throughout the bag. Walk-In Refrigerator -2 Whole sandwiches that were not sealed, did not have a label to identify what the item was, an/or when it had been prepared. DC said they were tuna fish sandwiches that had been made in her time off. She said the person that made them should have put a label on them to identify what they were and when they were made, as well as ensuring that the wrapping was sealed around them. -1 container with a label that stated pudding with a date of 8/26 that was not completely sealed shut. -1- 48oz plastic jar of Mayonnaise that was 3/4 full that did not have an opened date on the jar. -1-46oz bottle of vegetable juice that was 1/2 full that did not have an opened date on the bottle. -1 large plastic container that had a label of 8-24-23 2P (2PM) Snacks that was full. The DC said that the snacks for the afternoon of 8/24/23 had not been sent to the nurses station by kitchen staff to pass out, or else they would not have had any left. She said, they (nursing) would return the tubs empty to the kitchen. She said the snacks included health shakes for residents that were diabetics or maybe had weight loss and they had a physician orders. Dessert Freezer 1 package of unknown food item that appeared to be a thick pita bread, DC could only make out the word crust on the bag. The food item had obvious ice crystals touching it. She said items would be thrown away if they had the ice crystals on the food. Entree Freezer -1 clear zipper sealed bag of corndogs that had holes in bag due to the sticks poking through, soft and not frozen throughout. - 1 brown bag with a label of breakfast potatoes with a hole in the bag that was soft and not frozen throughout. - 1 clear zipper sealed bag of pulled pork with a pale yellow/brown color to meat and ice crystals throughout the meat and bag. The DC said the meat was not the color it should have been and due to the ice crystals on the food item, it should have been thrown away. She said the cooks had a checklist of items they had to clean weekly, and it was their responsibility and DM's to go through and check freezers and refrigerators to ensure they discarded items as needed. During an interview on 8/29/23 at 2:30PM with the DM, she said any food item that was in the freezer that had freezer burn on it should be thrown away. She said any time food was put in the refrigerator or freezer, the item should have had a label that identified what the food was and when it was placed in there. The DM said all the items should have been sealed. She said that the pudding and sandwiches had been from her new staff that she had just talked with about labeling things and ensuring that all things were closed. The DM said all the kitchen staff was responsible for ensuring that food items were stored properly meaning that all food items had a label that had the date it was opened or prepared and that it was supposed to be sealed shut. She said that the final responsibility was hers to ensure that her staff was storing food properly. Record review of facility policy labeled Food Storage undated revealed: Food products must be labeled and dated.

Based on interviews, and record reviews, the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Facility failed to include a resident group in the decision to change the timing/hours between the supper and breakfast meal; the current schedule is for 15 hours between the meal times. This failure placed residents at risk of their nutritional needs, preferences, and requests being met. Findings include: Record review of Facility Meal Service Times undated revealed Breakfast at 7:15AM, Lunch at 11:15AM and Supper at 4:15PM. This made the time between supper and breakfast the following morning at 15 hours between meals. Review of Resident Council minutes for past year . the meetings each begin with a pray and then go over 2 resident rights. Grievance forms are inside the resident council book. the meetings are broke down into each department and concerns typically minor. The meeting for 06/21/23 had a concern with the dietary dept. that if residents were not in the dining room between 415 and 430, then they would be told they had to eat in their room, then it would take a good amount of time for the staff to find the residents trays. Also, that not all residents received snacks in the evening. During an interview on 08/28/23 at 3:12PM with the Resident Council, they said the facility staff did not come to the resident council about the mealtime change and it had been like that for a few months. They said the staff did not offer a snack to everyone in the evening either. 4 out of the 16 residents said they were diabetic. They said they changed the mealtime about 2 months ago . Some of the residents said that the mealtime was too early. During an interview on 8/29/23 at 2:49PM with the DM, she said they had been having mealtime at that same time since she started a year and 8 months ago. She said the time of meal service only meant when they should start setting up and serving the meal, that did not necessarily mean the time the resident would get the meal. During an interview on 8/29/23 at 3:11PM with the ADM, he said they had only been doing the earlier time for dinner a couple of months. He said he thought they may have just talked with the resident council president and vice president, and they were ok with it. The ADM said they give out a bigger set of snacks in the evening about 7pm. The ADM said he had not been aware that residents might have felt that the dinner time was too early or that they were not getting snacks in the evening . He said would address it with beefing up the snack items and talk again with resident council about the times of meals. During an interview on 08/30/23 at 7:30PM facility staff said they did not have a policy regarding mealtimes and snacks.

Based on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice, and failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents (Resident #9, Resident #17 Resident #27) reviewed for skin integrity. The facility failed to follow physician's orders which led to missed treatments for Resident # 9, Resident #17 and Resident #27's pressure ulcers. These failures could place residents at risk of wound deterioration, wound development, and infection. Findings include: Record review of Resident #9's face sheet dated 08/29/2023 revealed, [AGE] year-old male admitted on [DATE] with the following diagnosis Chronic Respiratory Failure, Obstructive Pulmonary Disease, and Type 2 Diabetes. Record review of Resident #9's quarterly MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 9 (moderate cognitive impairment); Section M- Skin Conditions revealed Resident #9 was at risk of developing ulcer/injuries, 1 unstageable pressure ulcer and required pressure ulcer care. Record review of Resident #9's physician orders revealed an order with start date of 07/22/2023 Unstageable sacrum wound: cleanse with NS/Wound cleanser, pat dry, apply Santyl to wound bed, pack with calcium alginate, cover with silicone dressing QD and PRN until resolved. Every shift for Sacral wound Record review of Resident #9's TAR dated August 1, 2023 - August 31, 2023, revealed no evidence of treatment for order being completed on the night shift on 08/04/2023, 08/05/2023, 08/06/2023, 08/9/2023, 08/10/2023,08/24/2023 and both shifts on 08/23/2023. Record review of Resident #9's Physician orders revealed an order with start date of 07/31/2023 Coccyx Stage III Pressure Wound: cleanse with wound cleanser/normal saline apply Santyl to wound bd apply calcium alginate cover with silicone dressing every day until healed. Everyday shift for healing Record review of Resident #9's TAR dated August 1, 2023 - August 31, 2023, revealed no evidence of treatment for order being completed on 08/23/2023. Record review of Resident #17's face sheet dated 08/29/2023 revealed, [AGE] year-old female admitted on [DATE] with the following diagnosis Pressure ulcer of Sacral region stage 4, Type 2 Diabetes, Atherosclerotic Heart Disease of Native Coronary Artery, Heart Failure, Chronic Kidney. Record review of Resident #17's quarterly MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section M- Skin Conditions revealed Resident # 17 was at risk of developing pressure ulcers, 1 stage 4 that required pressure ulcer care. Record review of Resident #17's physician orders revealed start date of 06/25/2023 Stage 4 Pressure wound to sacrum: cleanse with Dakins solution, Apply with Santyl and pack with calcium alginate and cover with not adhesive dressing QD and PRN if soiled. Record review of Resident #9's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on 07/03/2023 and 07/04/2023. Record review of Resident #17's physician orders revealed start date of 06/25/2023 Stage 4 Pressure wound to sacrum: cleanse with Dakins solution, apply hydrofera blue and over with silicone dressing QD. Record review of Resident #9's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on 07/22/2023 and 07/23/2023. Record review of Resident #9's TAR dated August 1, 2023 - August 31, 2023, revealed no evidence of treatment for order being completed on 08/01/2023, 08/04/2023, 08/05/2023, 08/07/2023. Record review of Resident #27's face sheet dated 08/29/2023 revealed, [AGE] year-old female admitted on [DATE] with most recent readmitted [DATE], with the following diagnoses Unspecified Sequelae of Unspecified cerebrovascular Disease (Stroke), Hypertension (high blood pressure) and Type 2 Diabetes; and advance directive of DNR/Do Not Attempt Resuscitation. Record review of Resident #27's quarterly MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 14 (cognitively intact). Record review of Resident #27's physician orders revealed start date 07/01/2023 Stage 4 pressure ulcer right heel, cleanse with NS or Wound cleanser, pat dry, apply Santyl and calcium alginate to wound bed, and cover with silicone dressing, QD and PRN until resolved. Record review of Resident #27's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on 07/03/2023 and 07/04/2023. Record review of Resident #27's physician orders revealed start date 07/19/2023 Stage 4 pressure ulcer right heel, cleanse with NS or Wound cleanser, pat dry, apply Santyl and Hydrofera blue to wound bed, and cover with silicone dressing, QD and PRN until resolved. Record review of Resident #27's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on 07/22/2023 and 07/23/2023. Record review of Resident #27's TAR dated August 1, 2023 - August 31, 2023, revealed no evidence of treatment for order being completed on 08/01/2023, 08/02/2023, 08/04/2023, 08/07/2023. During an interview on 08/29/23 at 1:53 PM the DON stated she was responsible to ensure that wound care was completed. The DON stated that wound care was documented on the TAR , if there were days that were blank that meant treatment was missed that day. The DON stated she was aware that some treatments were missed but did not realize how many had been missed. The DON stated she guessed staff did not have time or the resident refused. The DON stated if resident refused it should have been documented that they refused. The DON stated the nurse assigned to the hall was responsible for completing wound care. The DON sated the effect on residents missing wound care treatments could have been wounds could have gotten bigger and/or worse. The DON stated her expectation was that wound care be completed if was on triggered on their schedule. The DON stated she monitored by looking at the TAR and looking for missed documentation. The DON did not provide a reason for failure of not completing because the nurses knew they were responsible to complete wound care on their hall. Record review of Facility policy titled, Wound Care & Treatment Guidelines, without a date revealed It is the policy of this facility to provide wound care to promote healing . Documentation of the treatment should be done immediately after the treatment.

Based on interview, observation, and record review the facility failed to revise the resident's care plan for 3 (Resident #37, #33 and #129) of 24 residents reviewed for comprehensive care plans. 1. The interdisciplinary team failed to review and revise the plan of care for Residents #37, #33 and #129. These failures could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #37's Face sheet dated 08/28/2023 revealed a [AGE] year-old female, with an initial admitted to the facility on [DATE] and a most recent admitted [DATE]. Record review of Resident #37 had a diagnosis of Dementia (impairment of memory and thinking). Record review of Resident #37's orders revealed: Oxygen Therapy r/t SOB Record review of Resident #37's MDS dated [DATE], Section C under Cognitive Patterns revealed a BIMS score of 10 (Moderately Impaired). Record review of Resident #37's Care Plan revealed, OXYGEN SETTINGS: O2 2-3 liter per minute via nasal prongs to maintain saturation greater than 92%. Observation on 08/27/23 at 02:23 PM, Resident #37 had placed her O2 tubing in her mouth. Resident #37 stated she placed the O2 in her nose but gets more air when it's placed in her mouth. An interview on 08/28/2023 at 11:00 AM, MA-B stated Resident #37 has placed her O2 tubing in her mouth for a long time. She stated it was the Residents Right to do so and should have been updated in the residents Care Plan. An interview on 08/28/2023 at 4:17PM MDS Coordinator stated, when the new orders came in, she would update the resident Care Plans. She also stated if staff noticed a behavior, they then would have made the revision change on the resident Care Plans. She stated she had noticed Resident #37 with her O2 tubing in her mouth but had not thought about revising the Care Plan although it should have been. The MDS Coordinator stated she could not say what the failure might have been. She stated it was a Residents Right to place the O2 tubing in her mouth and should be Care Planned if it's a behavior such as that. She stated it was the upper management that should have been monitoring these behaviors and revising the residents Care Plans. An interview on 08/29/23 at 2:50 PM DON stated, it was a Residents Right to place O2 tubing where they want it. She stated, with Resident #37, wanting to place the O2 tubing in her mouth, should have been revised in her Care Plan, which was usually done the same day. The DON stated upper manager heads, her included, were in charge of the Care Plans being monitored but it started with floor staff reporting to upper management. She stated the negative impact was poor communication from the nurses to upper management. She stated with the revisions not being made in her Care Plan could have possibly not allowed for Resident #37's wishes to be honored. The DON stated making an assumption of resident wishes and not following through with revising the Care Plan led to the failure. She stated her expectations were to honor resident wishes and revising their CP to match in a timely manner. The DON stated Resident #37's original admission of 5/4/2021 it should have already been updated. Record review of Resident #129's Face sheet dated 08/28/23 revealed an [AGE] year-old male that admitted to the facility on [DATE]. He had a diagnoses list that included Type 2 diabetes with foot ulcer, Other acute osteomyelitis (sudden onset bone infection) of left ankle and foot. Record review of Resident #129's EHR dated 08/29/23 did not reveal a completed admission MDS. Record review of Resident #129's Physician Orders dated 8/28/23 revealed: ceFAZolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously every 8 hours related to OTHER ACUTE OSTEOMYELITIS, LEFT ANKLE AND FOOT until 09/27/2023 21:59 . PICC LINE FLUSHING: FLUSH WITH 10 CC 0.9 % NS IV SOLUTION Q SHIFT every shift. Record review of Resident #129's Baseline Care Plan dated 08/22/23 did not reveal any care area that included his PICC line. During an observation and interview on 8/28/23 09:10 AM with Resident #129, he had a 2 lumen PICC line in his right arm with a date on the dressing of 8/27/23. He said he had it due to an infection in his foot. Resident #129 said he was supposed to be on ABX for 4 weeks. An interview on 08/29/23 at 3:14 PM DON stated Resident #129 was admitted into the facility on [DATE] and had a pic line in place and on antibiotic. She stated it would normally take 24-48 hours to update the Care Plan. The DON stated it should have already been addressed and revised in Resident #129's Care Plan before 08/28/2023. She stated the negative impact for not revising residents pic line in his cp was the nursing staff may have not known to flush the line and could have gotten occluded, needing replaced. If dressings are not changed when ordered, it could have led to further infection. The DON stated the IV nurse should have monitored with the MDS revising initial Care Plans. She stated she felt maybe the IV nurse not having done the Care Plans very long has led to the failure no knowing to place the pic line documentation where it should have been. The DON's expectations were for the Care Plans to be reviewed, updated, and completed within 24-48 hrs. Record review of Resident #33 Facesheet dated 08/28/202023 revealed a [AGE] year-old male with an admitted [DATE] with a diagnosis list that included Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Record review of Resident #33's Quarterly MDS dated [DATE] revealed a BIMS of 8 meaning moderate cognitive decline. He was always continent of bladder. Record review of Resident #33's Physician Orders dated 08/28/2023 did not reveal any orders for his foley catheter. Record review of Resident #33's Care plan last revised on 07/13/2023 did not reveal any care area regarding foley catheter. Record review of Resident #33's Progress Notes for 07/29/2023 through 08/28/2023 revealed a progress note dated 08/20/2023 Note Text: Day 3/5. Pt cont. on ABT Bactrim PO BID x 5 days Dx: UTI ID on 08/17/2023 . Intake and output adequate AEB clear, yellow urine in F/C drainage bag. This was the first mention of a foley catheter for the resident. Record review revealed there were no orders and no Care Plan for foley catheter . Record review of Resident #33's progress notes revealed foley catheter began on 08/20/2023 and did not include when foley catheter was placed or why. Record review for Resident #33 revealed no diagnosis for the foley catheter . An interview and observation on 8/28/23 at 9:49 AM with Resident #33, he said he got a catheter because he couldn't pee on my own Resident #33 had 300 cc of amber urine in foley catheter bag, with white sediment particles in tubing. An interview on 08/29/2023 at 3:06 PM the DON stated she was unaware Resident #33 had a Catheter in place until she spoke to the resident and read his progress notes. She stated she was not notified at the time of placement as the residents nurse was agency. She stated he did have a nasty UTI. stays in bed or chair and she didn't know realize he had one. She stated she was not sure how long she had to update the resident Care Plan, but had thought as soon as it happens, or as soon as it can be documented. The DON stated the MDS and herself monitored Care Plan's. She stated when Agency works in the facility, there was a binder they go over about the facility and how to use the electronic charting. She stated Agency has no accountability and they did not care. She stated at that time, the Agency nurse should have known to document as to where it would trigger them to update the Care Plan in a timely manner. She stated if the Agency nurse did not know or unaware, she should have asked another facility staff member, but stated she apparently didn't know. The DON stated 8 days from the time of Catheter placement until the time of the updated Care Plan is not acceptable. She stated the negative impact to the resident were a worsened UTI, and water retention. She stated what led to the failure was not knowing or not reviewing that morning with Agency, as well as the Agency nurse not notifying upper management. The DON stated her expectations were to be notified and immediately update the Care Plan in a timely manner. Review of Policy and Procedure for Comprehensive Person-Centered Care Plan dated 11/2013 with Revision/Review date(s) 1/2022 revealed: Policy It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline e care plan for each resident, within 48 hours of admission, that includes minimum health care information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care 4. The facility IDT will develop and implement a com prehensive person-centered care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MOS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident ' s goals and desired outcomes, preferences for future discharge and discharge plans.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for 5 (Resident #1, #3, #4, #5 and #6) of nine residents reviewed for diabetes. A. LVN A failed to hold Resident #1's insulin injection of [MEDICATION NAME] 60 units on [DATE] after she obtained a blood glucose level of 62mg/dl per physician orders. LVN A failed to follow physician orders [REDACTED].#1's blood sugar level every thirty minutes after the blood sugar level of 62mg/dl was obtained. On [DATE], Resident #1 was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated by facility staff and Emergency Medical Services, but despite all efforts, Resident #1 expired at 2:45AM in the facility. LVN E failed to contact Physician A and clarify orders for Resident #1's blood sugar level monitoring and obtain parameters for blood sugar levels when he was admitted on [DATE]. B. LVN B failed to contact Physician B and obtain or clarify orders for Resident #3 to have his blood sugar level checked and obtain parameters for blood sugar levels to be monitored when he was admitted on [DATE]. C. The ADON failed to contact Physician B and obtain or clarify orders for Resident #6 to have her blood sugar level checked and obtain blood sugar level parameters for blood sugar levels to be monitored when she was admitted on [DATE]. D. LVN C failed to monitor blood sugar levels and clarify blood sugar level parameters with Physician D when she obtained a blood sugar level of 481 on [DATE] and 501mg/dl on [DATE] for Resident #5. In addition, Resident #5 did not have parameters in place to notify Physician D for a high blood sugar level since admission on [DATE]. E. LVN C failed to monitor blood sugar levels and clarify blood sugar level parameters with Physician E when she obtained a blood sugar level of 418mg/dl on [DATE], 439mg/dl on [DATE] and 426mg/dl on [DATE] for Resident #4. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of Actual Harm at a pattern, that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place 22 diabetic residents in the facility at risk for delay in treatment, serious complications and /or death. Findings Include: A. Resident #1 Review of Resident #1's closed record Admission Record dated [DATE] revealed he was a [AGE] year old male, who was admitted to the facility on [DATE] under Physician A's care and had the following Diagnoses: [REDACTED]. The admission record also identified the following: Date of Discharge: [DATE] Time: 0200, Length of Stay: 3 days discharged to-Expired funeral home: (Local Funeral Home). Review of Resident #1's Entry Minimum Data Set ((MDS) dated [DATE], revealed that he was admitted to the facility from an acute hospital. Record review of Resident #1's Initial Assessment, dated [DATE] at 17:00 (5:00 PM), revealed Resident #1 was awake, alert and oriented to person, place and time. Resident #1 was able to follow simple commands. The initial assessment revealed Resident #1 had depression. Resident #1 used a walker, bedside commode and was occasionally incontinent of bowel and bladder. (The initial assessment did not address Resident #1's [DIAGNOSES REDACTED].) Record review of Resident #1's Fall Risk Evaluation dated [DATE] 1700 (5:00 PM), revealed the following: Mental Status Alert/Oriented x 3 (time, place, person) .G. Medications .Respond below based on the following types of medications: .Hypoglycemics 2. Takes ,[DATE] of these medications currently and/or within last 7 days . Review of Resident #1's Admission Care Plan dated [DATE], revealed Diabetes Goal: Blood sugars within normal ranges, diet Regular, Medication as ordered, nail care by licensed staff only. Review of Resident #1's Physician order [REDACTED]. If B/S (blood sugar) (trade name) Result <60MGS/DL and Resident is Alert Give 4oz of Juice or Regular Soda may add additional sugar packets & followed by snack. Recheck in 30 minutes. Notify MD if B/S remains below 60mgs/dl . If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. Insulin [MEDICATION NAME] Solution 100 unit/ml. Inject 50 units subcutaneously at bedtime for diabetes. [MEDICATION NAME] Solution 100 unit/ml (Insulin [MEDICATION NAME]) Inject 60 unit subcutaneously with meals for DM (Diabetes Mellitus). (There were not any orders on the physician orders [REDACTED]. According to the US National Library of Medicine, Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. The medical name of low blood sugar is [DIAGNOSES REDACTED]. Accessed on [DATE] https://medlineplus.gov/ency/article/ 6.htm According to [MEDICATION NAME].com, [MEDICATION NAME]® (insulin [MEDICATION NAME]) is a long-acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. Do not take [MEDICATION NAME]® during episodes of low blood sugar or if you are allergic to insulin or any of the inactive ingredients in [MEDICATION NAME]®. 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 or brain. Symptoms of serious low blood sugar may include shaking, sweating, fast heartbeat, and blurred vision. [MEDICATION NAME]® may cause serious side effects that can lead to death . Accessed on [DATE] https://www.[MEDICATION NAME].com/about-[MEDICATION NAME]/types-of-insulin According to Drugs.com, [MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood [MEDICATION NAME] is used to improve blood sugar control in adults and children with diabetes mellitus This medicine is sometimes used together with a long-acting or intermediate-acting insulin [MEDICATION NAME] is used to treat type 2 diabetes in adults . You should not use [MEDICATION NAME] if you are having an episode of [DIAGNOSES REDACTED] (low blood sugar) You should not use [MEDICATION NAME] you are having an episode of [DIAGNOSES REDACTED] (low blood sugar). Accessed [DATE] https://www.drugs.com/[MEDICATION NAME].html Record review of Resident #1's Medication Administration Record dated [DATE]-[DATE] revealed Resident #1 had a documented blood sugar on [DATE] at 1700 (5:00 PM) of 62mg/dl. A checkmark was documented with LVN A's initials on the medication administration record (MAR) for the medication administration of [MEDICATION NAME] Solution 100 UNIT/ml (Insulin [MEDICATION NAME]) Inject 60 unit subcutaneously with meals for DM (Diabetes Mellitus). (No other documented blood sugar levels after the [DATE] at 1700 (5:00 PM) were documented for Resident #1). Record review of Resident #1's electronic Progress Notes dated [DATE] revealed the following entries: [DATE] 6:36 AM, Resident adjusting well to facility, pleasant friendly Signed LVN C No documentation in progress notes or entire clinical or electronic record could be found between [DATE] 6:36 AM and 4:58 PM. [DATE] 16:58 (4:58PM), [MEDICATION NAME] Solution 100 Unit/ML Inject 60 units subcutaneously with meals for DM. Gave two glasses of orange juice first. Signed LVN A No documentation in progress notes or entire clinical or electronic record could be found between [DATE] 4:58PM- [DATE] 6:35AM, specifically no blood sugar level was documented after the reading on [DATE] at 1700 (5:00PM). [DATE] 06:35 AM, Upon returning from lunch shortly after 2 (a.m.) this nurse went to give a resident on hall 3 medication. Before completing this I heard staff member calling from down hall 4. The other nurse working stood up abruptly and hurried down hall 4. I turned and went down hall 4 myself, well behind her. I heard other nurse call out to get the crash cart and saw staff running to retrieve it. Before reaching doorway I heard her call out Is he a full code? I hurried to check his chart and went back to tell her that he was. I called this out before I reached doorway and she shouted call 911, by this time staff had brought crash cart to hallway outside his room. I was on the phone with 911 dispatch and was instructed to stay on the line while they obtained information. While on phone I printed out transfer papers. After getting off the phone I went back to resident's room to assist. The other nurse was doing chest compressions and CNA giving breaths until paramedics arrived. At which time they took over CPR. After paramedics stopped CPR I called the Administrator at 2:27 a.m., then I called the DON at 2:30a.m. and then I attempted to call residents wife at the number listed to be home phone. The phone rang several times and there was no answer. I then called her alternate number. It was the (local school district) I attempted again to call the home phone number listed, which rang several times. The CNA called out to me You are calling the resident's cell phone I then called the next contact listed at 2:36 a.m., leaving a message that it was imperative that he call the nursing home. I called again at 2:38 a.m. without an answer. After hanging up he called me back, I explained to him what had occurred and he stated that he would go to (spouse's) house and 'pound on the door' to let her know what had occurred . Signed LVN C. Record review of the 24 hour nursing report dated [DATE] and [DATE] revealed: [DATE] Resident: (Resident #1) Room (###) New admit, Diabetic, Regular Diet, Thin liquids, pills whole, ambulates with assistance (walker) . There was not any documentation regarding his blood sugar of 62mg/dl at 5:00PM or having to give him two glasses of orange juice by LVN A. (Specifically no follow up blood sugar level was documented after the reading on [DATE] at 1700 (5:00PM). [DATE] 24 hour report revealed no documentation regarding Resident #1. Specifically no blood sugar level documentation after the reading on [DATE] at 1700 (5:00PM). Record review of the Dietary intake record for Resident #1 revealed: [DATE] 17:34 (5:34 PM) exact meal percentage 100. Record review of the death certificate for Resident #1 issued [DATE] revealed cause of death Sudden Cardiac Death, [MEDICAL CONDITION], Hypertension, Diabetes Mellitus .[MEDICAL CONDITION] manner of death .natural .signed electronically by Physician A on [DATE]. In an interview on [DATE] at 3:18 PM, Physician A said that he was Resident #1's physician while he was a resident at the facility. He said that he had been made aware from the facility that he was found unresponsive after just a few days of being discharged from the hospital. He said he was not on call the day he was found unresponsive, but that the physician covering for him had received the call and then notified him. He said he was surprised to hear the news. He said that he had been his physician for a while and that he had been the physician to follow him in the hospital before he was discharged to the facility. He said that he did have a lot of medical issues, he could not recall right off the top of his head what all his [DIAGNOSES REDACTED]. He said he was discharged to the facility for therapy for a short stay and then was expected to return home. He said he did not recall receiving a phone call from the facility clarifying his orders. He said that he did not recall if he had given an order for [REDACTED]. He said that he did not recall giving an order, If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. He said he was not made aware that a nurse had administered his [MEDICATION NAME] 60 units with a blood sugar level of 62mg/dl. He said that is very unfortunate news, the nurse should have not administered that insulin with a blood sugar level of 62mg/dl. Physician A said that had he been notified of his blood sugar being 62mg/dl he would have given an order to hold the insulin dose at 5 PM and had them recheck it in thirty minutes, ensure juice, a snack or meal was offered to him. Physician A said in his medical opinion, to administer [MEDICATION NAME] 60 units to someone with a blood sugar of 62mg/dl is dangerous and sounds very unfortunate, I am not sure what happened there. Physician A said that Resident #1 had a lot of medical issues, he knew his life expectancy was not going to be long, however he did not anticipate him to pass away that soon. In an interview on [DATE] at 3:34 PM, LVN B said that she was working the evening of [DATE]. She said her shift was from 6PM-10PM and that she only passed medications, which included Resident #1. LVN B said LVN C was responsible for receiving report from LVN A and LVN C was in charge for the care for Resident #1 the evening of [DATE]. At this time, she was given the MAR to review, she verified her initials on the MAR and indicated that she had administered Resident #1's evening dose of Insulin [MEDICATION NAME] 50 units at approximately 2000 (8:00 PM) on [DATE], she said that a check mark indicated that the medication was administered. LVN B said she did not recall being notified of any changes by LVN C the evening of [DATE], specifically regarding the care of Resident #1. LVN B said that if there had been any changes specific to medication administration for Resident #1, LVN C would have informed her. When the surveyor asked When you administered the Insulin [MEDICATION NAME], do you recall his condition?, LVN B replied, He wasn't lethargic. I had a full conversation with him, I did his Nyastatin powder treatment at the same time I administered his insulin and he seemed fine. We exchanged conversation, he wanted to know if his rash was better. LVN B recalled that she thought Resident #1's son and wife were present in the room during the medication administration and treatment. She said that she always checks a resident's blood sugar prior to administering insulin. She said that the computer system should prompt you to input the blood sugar level before you can initial off that you have administered the medication. After she reviewed the MAR, she said that Resident #1's Insulin [MEDICATION NAME] order did not have an entry for blood sugar documentation. LVN B could not find Resident #1's blood sugar for the evening of [DATE] documented in his electronic or clinical chart. She said that she would consider any number below 60mg/dl to be a low blood sugar. She said that she would hold insulin if it was outside the parameters. She said that every resident receiving insulin should have parameters for blood sugar levels and if they did not, the physician should be contacted and give parameters. She said she was not aware that Resident #1's blood sugar was 62mg/dl at 5:00 PM. She indicated LVN A was his day time nurse that would have checked his blood sugar at 5:00 PM and administered the [MEDICATION NAME] injection on [DATE]. She said that LVN A no longer worked at the facility, that she was an agency nurse at the time. In an interview on [DATE] at 4:30 PM, RN A said that when a resident has a blood sugar level around 60mg/dl range or lower, you should hold insulin, give a glass of orange juice, recheck the resident's blood sugar level again in thirty minutes and if it has not come up, the physician should be notified. In an interview on [DATE] at 5:00 PM, LVN A said that she recalled working the day shift 6am-6pm on [DATE] and was Resident #1's charge nurse. She verified her initials that were on the MAR and confirmed that she had administered Resident #1's insulin dose at 5:00 PM on [DATE]. She said she recalled giving him [MEDICATION NAME] 60 units at 5:00 PM that day, she did recall his blood sugar being 62mg/dl, but said that she had given him some orange juice prior to the insulin administration and made sure he was about to eat his supper. She said that she did not recall any parameters in place to hold the insulin and was not aware of any orders to hold his insulin. She said that she did not recheck his blood sugar after administering the insulin. She said she went off shift around 6p.m. that evening and did not think there was a concern regarding his blood sugar, therefore she did not say anything in report to the oncoming night nurse. When asked what she considered a low blood sugar, she replied Apparently I thought that was low if I gave him two glasses of juice, anything under 70 would be considered low in my opinion. I do not think there was an order to hold if his blood sugar was below a certain number. That was why I gave him the juice and then his meal was coming right after that. When asked When you have a low blood sugar and have to give orange juice, was there anything else that should be done? LVN A replied If he was not alert or not talking to me I would be concerned, but he was alert, he took the juice, told him his meals was coming, I did go back and ensured that he had eaten. If there had been a change, such as him being lethargic I would have been concerned, but he wasn't lethargic. LVN A said that she should not have rechecked his blood sugar again, because he seemed fine. I knew that he would be getting his blood sugar checked with his evening insulin so I was not too concerned. When asked if she was aware of the physician order [REDACTED]. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. She replied No I was not aware of that order. LVN A said she did have access to the physician orders [REDACTED]. She said that the computer program should have alerted me if that was an order and that it did not alert her to hold the insulin. In an interview on [DATE] at 5:30 PM, the DON said that her expectation for insulin dependent diabetic residents in the facility to have their blood sugar level checked per physician orders [REDACTED]. When asked what she considered to be a low blood sugar level, she said It is usually different for each resident, depending on the resident, hard to say. When asked what her expectation for nurses to do in regards to holding an insulin injection, she said for signs and symptoms of [DIAGNOSES REDACTED] you need to watch for nausea, vomiting, poor appetite and per physician orders. She said she did not assist with the admission process for Resident #1 on the evening of [DATE]. The DON said that her expectation for her nurses checking blood sugar levels prior to insulin administration was for them to use their nursing judgment. She said her expectation was for her nurses to follow the physician's orders [REDACTED].#1's physician orders [REDACTED].<69mg/dl was pulled from a batch order, which were similar to standing orders that were generic orders used to help save time when inputting orders into the computer. She said that the batch orders still required the nurse to clarify with the physician before using the batch order. She felt that the admitting nurse had just clicked on that particular order by accident. She said that she was unsure if the admitting nurse had clarified the orders with the physician but would have assumed she had. In an interview on [DATE] at 6:48 PM, LVN C said that she was on duty as the charge nurse the evening of [DATE] from 6pm to 6am and she cared for Resident #1. She said that she had been Resident #1's night nurse since he was admitted on [DATE]. She said she saw him the evening of [DATE] at different times as she would go up and down the hall. She said LVN B was on duty and administered Resident #1's evening medications on [DATE]. She could not recall a specific time as to when she last saw him but did state she had not gone into his room that evening to care for him directly. She said since he was a new admit, she had told the CNAs to check on him regularly and make sure he did not try and get up out of bed without assistance. LVN C said that he was a very large man and they would have to have called EMS if he were to fall, therefore she made sure the CNAs kept a close watch on him. She said that she took shift report change from LVN A that evening and did not recall anything specific about Resident #1 that she was to watch for, specifically low blood sugar. LVN C said that around 1:45 AM on [DATE] she recalled coming from a resident's room that she was giving a PRN medication to. She said that when she came out of the room, she saw CNAs running to get the crash cart and at that time LVN D asked me to verify the code status for Resident #1. She said I hurried and found his chart and saw that he was a full code, I told LVN D that he was a full code and called 911, by the time I got down to Resident #1's room, LVN D had already initiated the full code and was administering CPR. She said that within just a few minutes, EMS arrived and took over. She said that Resident #1 was unable to be resuscitated. LVN C said she contacted Physician A's on call answering service and another physician was taking call that evening. She said that she could not remember the details of who the covering physician was but did recall he returned the call placed with the answering service and she informed him that Resident #1 had expired, she said that he informed her he would let Physician A know. In a telephone interview on [DATE] at 8:38 PM, CNA A said she cared for Resident #1 the evening of [DATE] from 6PM to approximately [DATE] at 2:00 AM, when he expired. She said that the last time she saw Resident #1 was around 1:00 AM, she had gone into his room and given him ice and water. She said he was awake and mentioned he was about to try and get some rest. She said that he did not appear sweaty or shaky. She indicated that he was a very large man and she had checked on him regularly throughout the entire weekend to ensure that he was familiar with the call light system, and did not attempt to get up without assistance. She said he did use his call light but a few times staff had found him trying to get out of bed without calling for assistance. She said that he required two people to assist him with transfers. She said he would ambulate with a walker to the bedside commode. He was alert and oriented each time she had checked on him, however on [DATE] he did appear more depressed and upset from the previous two evenings (,[DATE]-[DATE]) she had cared for him and that Resident #1 verbalized several times to her that he wanted to go home Monday ([DATE]) regardless of what anyone said. CNA A said she did not report this to anyone, she just figured he was still adjusting to the facility and missed being at home with his wife. She said she did notice the last time she assisted him to the bedside commode he appeared weaker and more assistance was given to him by her and another staff member during the transfer. She said that she could not recall the specific time she transferred him to the bedside commode but remembered it was pretty late. She indicated that she had been the CNA to pass evening snacks on Hall 4 around 8:00 PM that evening, however when she offered Resident #1 a snack, he told her that he did not want one. CNA A said at that time, she observed fast food in Resident #1's room, specifically a hamburger, milkshake and a coke that had been brought in by his family. CNA C said she found him unresponsive when she was about to take her break around 2:00 AM on [DATE]. She said that she went down the hall to check on everyone and as she entered Resident #1's room, she found him on his left side of the bed with his feet dangling off the bed. She said he was laying on his left arm and that his head was kind of tilted back but facing toward the quarter side rail. She said his airway was not blocked or covered. She said he still had color to his face and did not recall him appearing sweaty or clammy. She said at this time she realized he was not responding to her voice and yelled down the hall for help. CNA C said that LVN D immediately responded to her call for help and began assessing Resident #1. She said that LVN D advised two other staff to obtain the crash cart and at that time, LVN C was coming down the hall and LVN D asked her to confirm his code status. She said she assisted LVN D with placing Resident #1 on the floor. She said LVN D confirmed his full code status with LVN C and LVN D then initiated CPR, LVN C was told to call 911 and at that time, I started assisting LVN D with CPR. She said that LVN D did hook the automated external defibrillator to Resident #1 and remembered that it attempted a couple of times to shock him but by this time the EMS team had arrived and took over but they were unsuccessful as well. In an interview on [DATE] at 8:32 AM, LVN E said that she had been the nurse to enter the admission orders [REDACTED]. She said that she was called in on her day off to help with Resident #1's admission. She said she did not specifically recall receiving an order for [REDACTED]. She explained that batch orders are orders that are put in the 'que' in the computer system that are already orders that are typed and you can click them and add to them if needed for specific instructions for resident's. She said she was not sure if they were specific for one doctor. At this time of the interview, LVN E reviewed Resident #1's physician orders [REDACTED]. She said that the orders were confirmed using a communication method telephone, however she stated that she had not contacted Physician A to clarify or verify his orders, she had entered the orders from his discharge paperwork from the hospital. She said that she did remember calling the hospital about his orders but did not remember exactly what about. She said when residents are admitted to the facility and have orders for insulin but did not have an order for [REDACTED]. She said that when an order for [REDACTED]. She said that when this prompt is setup, the computer system will not allow you to check off on the medication administration until you enter the blood sugar level. Upon review of Resident #1's electronic and paper clinical chart, LVN E said that there was not an actual order for blood sugar levels or parameters, however she had entered two separate orders for parameters for a low blood sugar level for Resident #1 using the batch orders that were already in the system. The orders she said she retrieved from the batch orders were: If B/S (blood sugar) Accucheck Result <60MGS/DL and Resident is Alert Give 4oz of Juice or Regular Soda may add additional sugar packets & followed by snack. Recheck in 30 minutes. Notify MD if B/S remains below 60mgs/dl. Every 24 hours as needed. If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. Furthermore, in the same interview, LVN E said I must have accidentally clicked on one too many batch orders. At this time she confirmed that she had not received that order from Physician A via telephone as reflected on the printed orders. She said Resident #1 did admit to the facility for skilled therapy and that residents that were at the facility for skilled therapy should have a skilled nursing note in their chart each day. At this time, she verified with both the electronic and paper clinical record that there were not any skilled nursing notes done for Resident #1 from [DATE]-[DATE]. LVN E said that there was not a blood sugar level entry from [DATE]-[DATE] documented on the MAR for Resident #1's evening insulin administration of Insulin [MEDICATION NAME] 50 units subcutaneously. She said she was not sure why it was not there unless it was done on supplemental documentation, however upon review of the supplemental documentation, she said it was not documented. LVN E said that she would not have administered the [MEDICATION NAME] 60 units to Resident #1 on [DATE] at 5:00PM with his blood sugar being 62mg/dl, she said she would have used her nursing judgement and held it because 62 was too low to the threshold, which in her opinion was 60mg/dl. She said she would have given him a snack and rechecked his blood sugar level in about thirty minutes. When asked if there were orders to hold the insulin at any time, she said yes, there were orders to hold if less than 60mg/dl. When asked what she does in a situation when there are two orders for parameters of low blood sugar, she said she would err on the side of caution and would have went with the order that said to hold if it was less than 69mg/dl. LVN E said the signs and symptoms of [DIAGNOSES REDACTED] were sweating, shaking irritability, unresponsive and potentially the person could die. She said the purpose of insulin was to lower blood sugar. She said that the complications when giving insulin with a blood sugar already around a low range, was it could potentially make the resident bottom out (drop their blood sugar level to a dangerous level). She said that the facility had recently in serviced her regarding insulin administration, when to give it, when to hold it and explained the different types of insulin. Record review Resident #1's electronic Medication Administration Record for [DATE]-[DATE] revealed no prompt or entry to queue the nursing staff to enter a blood sugar level. Record review of the in service dated [DATE] revealed the following: Subject: Insulin & Blood Sugars Instructor: (DON) Insulin Administration and Blood Sugar Checks Nurses should follow physician orders [REDACTED]. Nurses should ensure that snacks are offered to all diabetic patients as ordered and notify the physician if the patient was not consuming meals or displaying signs and symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Document the communication with the physician in the patient's medical record and notify family. Nursing judgement was the first line of defense to protect the well being of the patients. Please make sure that you have a firm understanding of the types of insulin, signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED], and ensure that you are adequately assessing the patient before administering the insulin. Make sure that you are familiar with each patient's orders pertaining to holding insulin doses and when to notify the physician but also exercise good nursing judgement at all times. In an interview on [DATE] at 9:09 AM,

Based on interview and record review, the facility failed to ensure that residents are free from significant medication errors for one (Resident #1) of 9 residents reviewed for significant medication errors. LVN A failed to hold Resident #1's insulin injection of [MEDICATION NAME] 60 units on [DATE] after she obtained a blood glucose level of 62mg/dl per physician orders. LVN A failed to follow physician orders [REDACTED].#1's blood sugar level every thirty minutes after the blood sugar level of 62mg/dl was obtained. On [DATE], Resident #1 was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated by facility staff and Emergency Medical Services, but despite all efforts, Resident #1 expired at 2:45AM in the facility. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of Actual Harm, isolated, that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place 19 insulin dependent residents at risk for delay in treatment, serious complications and /or death. The findings included: Resident #1 Review of Resident #1's closed record Admission Record dated [DATE] revealed he was a [AGE] year old male, who was admitted to the facility on [DATE] under Physician A's care and had the following Diagnoses: [REDACTED]. The admission record also identified the following: Date of Discharge: [DATE] Time: 0200, Length of Stay: 3 days discharged to-Expired funeral home: (Local Funeral Home). Review of Resident #1's Entry Minimum Data Set ((MDS) dated [DATE], revealed that he was admitted to the facility from an acute hospital. Record review of Resident #1's Initial Assessment, dated [DATE] at 17:00 (5:00 PM), revealed Resident #1 was awake, alert and oriented to person, place and time. Resident #1 was able to follow simple commands. The initial assessment revealed Resident #1 had depression. Resident #1 used a walker, bedside commode and was occasionally incontinent of bowel and bladder. (The initial assessment did not address Resident #1's [DIAGNOSES REDACTED].) Record review of Resident #1's Fall Risk Evaluation dated [DATE] 1700 (5:00 PM), revealed the following: Mental Status Alert/Oriented x 3 (time, place, person) .G. Medications .Respond below based on the following types of medications: .Hypoglycemics 2. Takes ,[DATE] of these medications currently and/or within last 7 days . Review of Resident #1's Admission Care Plan dated [DATE], revealed Diabetes Goal: Blood sugars within normal ranges, diet Regular, Medication as ordered, nail care by licensed staff only. Review of Resident #1's Physician order [REDACTED]. If B/S (blood sugar) (trade name) Result <60MGS/DL and Resident is Alert Give 4oz of Juice or Regular Soda may add additional sugar packets & followed by snack. Recheck in 30 minutes. Notify MD if B/S remains below 60mgs/dl . If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. Insulin [MEDICATION NAME] Solution 100 unit/ml. Inject 50 units subcutaneously at bedtime for diabetes. [MEDICATION NAME] Solution 100 unit/ml (Insulin [MEDICATION NAME]) Inject 60 unit subcutaneously with meals for DM (Diabetes Mellitus). According to the US National Library of Medicine, Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. The medical name of low blood sugar is [DIAGNOSES REDACTED]. Accessed on [DATE] https://medlineplus.gov/ency/article/ 6.htm According to [MEDICATION NAME].com, [MEDICATION NAME]® (insulin [MEDICATION NAME]) is a long-acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. Do not take [MEDICATION NAME]® during episodes of low blood sugar or if you are allergic to insulin or any of the inactive ingredients in [MEDICATION NAME]®. 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 or brain. Symptoms of serious low blood sugar may include shaking, sweating, fast heartbeat, and blurred vision. [MEDICATION NAME]® may cause serious side effects that can lead to death . Accessed on [DATE] https://www.[MEDICATION NAME].com/about-[MEDICATION NAME]/types-of-insulin According to Drugs.com, [MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood [MEDICATION NAME] is used to improve blood sugar control in adults and children with diabetes mellitus This medicine is sometimes used together with a long-acting or intermediate-acting insulin [MEDICATION NAME] is used to treat type 2 diabetes in adults . You should not use [MEDICATION NAME] if you are having an episode of [DIAGNOSES REDACTED] (low blood sugar) You should not use [MEDICATION NAME] you are having an episode of [DIAGNOSES REDACTED] (low blood sugar). Accessed [DATE] https://www.drugs.com/[MEDICATION NAME].html Record review of Resident #1's Medication Administration Record dated [DATE]-[DATE] revealed Resident #1 had a documented blood sugar on [DATE] at 1700 (5:00 PM) of 62mg/dl. A checkmark was documented with LVN A's initials on the medication administration record (MAR) for the medication administration of [MEDICATION NAME] Solution 100 UNIT/ml (Insulin [MEDICATION NAME]) Inject 60 unit subcutaneously with meals for DM (Diabetes Mellitus). (No other documented blood sugar levels after the [DATE] at 1700 (5:00 PM) were documented for Resident #1). Record review of Resident #1's electronic Progress Notes dated [DATE] revealed the following entries: [DATE] 6:36 AM, Resident adjusting well to facility, pleasant friendly Signed LVN C No documentation in progress notes or entire clinical or electronic record could be found between [DATE] 6:36 AM and 4:58 PM. [DATE] 16:58 (4:58PM), [MEDICATION NAME] Solution 100 Unit/ML Inject 60 units subcutaneously with meals for DM. Gave two glasses of orange juice first. Signed LVN A No documentation in progress notes or entire clinical or electronic record could be found between [DATE] 4:58PM- [DATE] 6:35AM, specifically no blood sugar level was documented after the reading on [DATE] at 1700 (5:00PM). [DATE] 06:35 AM, Upon returning from lunch shortly after 2 (a.m.) this nurse went to give a resident on hall 3 medication. Before completing this I heard staff member calling from down hall 4. The other nurse working stood up abruptly and hurried down hall 4. I turned and went down hall 4 myself, well behind her. I heard other nurse call out to get the crash cart and saw staff running to retrieve it. Before reaching doorway I heard her call out Is he a full code? I hurried to check his chart and went back to tell her that he was. I called this out before I reached doorway and she shouted call 911, by this time staff had brought crash cart to hallway outside his room. I was on the phone with 911 dispatch and was instructed to stay on the line while they obtained information. While on phone I printed out transfer papers. After getting off the phone I went back to resident's room to assist. The other nurse was doing chest compressions and CNA giving breaths until paramedics arrived. At which time they took over CPR. After paramedics stopped CPR I called the Administrator at 2:27 a.m., then I called the DON at 2:30a.m. and then I attempted to call residents wife at the number listed to be home phone. The phone rang several times and there was no answer. I then called her alternate number. It was the (local school district) I attempted again to call the home phone number listed, which rang several times. The CNA called out to me You are calling the resident's cell phone I then called the next contact listed at 2:36 a.m., leaving a message that it was imperative that he call the nursing home. I called again at 2:38 a.m. without an answer. After hanging up he called me back, I explained to him what had occurred and he stated that he would go to (spouse's) house and 'pound on the door' to let her know what had occurred . Signed LVN C. Record review of the 24 hour nursing report dated [DATE] and [DATE] revealed: [DATE] Resident: (Resident #1) Room (###) New admit, Diabetic, Regular Diet, Thin liquids, pills whole, ambulates with assistance (walker) . There was not any documentation regarding his blood sugar of 62mg/dl at 5:00PM or having to give him two glasses of orange juice by LVN A. (Specifically no follow up blood sugar level was documented after the reading on [DATE] at 1700 (5:00PM). [DATE] 24 hour report revealed no documentation regarding Resident #1. Specifically no blood sugar level documentation after the reading on [DATE] at 1700 (5:00PM). Record review of the Dietary intake record for Resident #1 revealed: [DATE] 17:34 (5:34 PM) exact meal percentage 100. Record review of the death certificate for Resident #1 issued [DATE] revealed cause of death Sudden Cardiac Death, [MEDICAL CONDITION], Hypertension, Diabetes Mellitus .[MEDICAL CONDITION] manner of death .natural .signed electronically by Physician A on [DATE]. In an interview on [DATE] at 3:18 PM, Physician A said that he was Resident #1's physician while he was a resident at the facility. He said that he had been made aware from the facility that he was found unresponsive after just a few days of being discharged from the hospital. He said he was not on call the day he was found unresponsive, but that the physician covering for him had received the call and then notified him. He said he was surprised to hear the news. He said that he had been his physician for a while and that he had been the physician to follow him in the hospital before he was discharged to the facility. He said that he did have a lot of medical issues, he could not recall right off the top of his head what all his [DIAGNOSES REDACTED]. He said he was discharged to the facility for therapy for a short stay and then was expected to return home. He said he did not recall receiving a phone call from the facility clarifying his orders. He said that he did not recall if he had given an order for [REDACTED]. He said that he did not recall giving an order, If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. He said he was not made aware that a nurse had administered his [MEDICATION NAME] 60 units with a blood sugar level of 62mg/dl. He said that is very unfortunate news, the nurse should have not administered that insulin with a blood sugar level of 62mg/dl. Physician A said that had he been notified of his blood sugar being 62mg/dl he would have given an order to hold the insulin dose at 5 PM and had them recheck it in thirty minutes, ensure juice, a snack or meal was offered to him. Physician A said in his medical opinion, to administer [MEDICATION NAME] 60 units to someone with a blood sugar of 62mg/dl is dangerous and sounds very unfortunate, I am not sure what happened there. Physician A said that Resident #1 had a lot of medical issues, he knew his life expectancy was not going to be long, however he did not anticipate him to pass away that soon. In an interview on [DATE] at 3:34 PM, LVN B said that she was working the evening of [DATE]. She said her shift was from 6PM-10PM and that she only passed medications, which included Resident #1. LVN B said LVN C was responsible for receiving report from LVN A and LVN C was in charge for the care for Resident #1 the evening of [DATE]. At this time, she was given the MAR to review, she verified her initials on the MAR and indicated that she had administered Resident #1's evening dose of Insulin [MEDICATION NAME] 50 units at approximately 2000 (8:00 PM) on [DATE], she said that a check mark indicated that the medication was administered. LVN B said she did not recall being notified of any changes by LVN C the evening of [DATE], specifically regarding the care of Resident #1. LVN B said that if there had been any changes specific to medication administration for Resident #1, LVN C would have informed her. When the surveyor asked When you administered the Insulin [MEDICATION NAME], do you recall his condition?, LVN B replied, He wasn't lethargic. I had a full conversation with him, I did his Nyastatin powder treatment at the same time I administered his insulin and he seemed fine. We exchanged conversation, he wanted to know if his rash was better. LVN B recalled that she thought Resident #1's son and wife were present in the room during the medication administration and treatment. She said that she always checks a resident's blood sugar prior to administering insulin. She said that the computer system should prompt you to input the blood sugar level before you can initial off that you have administered the medication. After she reviewed the MAR, she said that Resident #1's Insulin [MEDICATION NAME] order did not have an entry for blood sugar documentation. LVN B could not find Resident #1's blood sugar for the evening of [DATE] documented in his electronic or clinical chart. She said that she would consider any number below 60mg/dl to be a low blood sugar. She said that she would hold insulin if it was outside the parameters. She said that every resident receiving insulin should have parameters for blood sugar levels and if they did not, the physician should be contacted and give parameters. She said she was not aware that Resident #1's blood sugar was 62mg/dl at 5:00 PM. She indicated LVN A was his day time nurse that would have checked his blood sugar at 5:00 PM and administered the [MEDICATION NAME] injection on [DATE]. She said that LVN A no longer worked at the facility, that she was an agency nurse at the time. In an interview on [DATE] at 4:30 PM, RN A said that when a resident has a blood sugar level around 60mg/dl range or lower, you should hold insulin, give a glass of orange juice, recheck the resident's blood sugar level again in thirty minutes and if it has not come up, the physician should be notified. In an interview on [DATE] at 5:00 PM, LVN A said that she recalled working the day shift 6am-6pm on [DATE] and was Resident #1's charge nurse. She verified her initials that were on the MAR and confirmed that she had administered Resident #1's insulin dose at 5:00 PM on [DATE]. She said she recalled giving him [MEDICATION NAME] 60 units at 5:00 PM that day, she did recall his blood sugar being 62mg/dl, but said that she had given him some orange juice prior to the insulin administration and made sure he was about to eat his supper. She said that she did not recall any parameters in place to hold the insulin and was not aware of any orders to hold his insulin. She said that she did not recheck his blood sugar after administering the insulin. She said she went off shift around 6p.m. that evening and did not think there was a concern regarding his blood sugar, therefore she did not say anything in report to the oncoming night nurse. When asked what she considered a low blood sugar, she replied Apparently I thought that was low if I gave him two glasses of juice, anything under 70 would be considered low in my opinion. I do not think there was an order to hold if his blood sugar was below a certain number. That was why I gave him the juice and then his meal was coming right after that. When asked When you have a low blood sugar and have to give orange juice, was there anything else that should be done? LVN A replied If he was not alert or not talking to me I would be concerned, but he was alert, he took the juice, told him his meals was coming, I did go back and ensured that he had eaten. If there had been a change, such as him being lethargic I would have been concerned, but he wasn't lethargic. LVN A said that she should not have rechecked his blood sugar again, because he seemed fine. I knew that he would be getting his blood sugar checked with his evening insulin so I was not too concerned. When asked if she was aware of the physician order [REDACTED]. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. She replied No I was not aware of that order. LVN A said she did have access to the physician orders [REDACTED]. She said that the computer program should have alerted me if that was an order and that it did not alert her to hold the insulin. In an interview on [DATE] at 5:30 PM, the DON said that her expectation for insulin dependent diabetic residents in the facility to have their blood sugar level checked per physician orders [REDACTED]. When asked what she considered to be a low blood sugar level, she said It is usually different for each resident, depending on the resident, hard to say. When asked what her expectation for nurses to do in regards to holding an insulin injection, she said for signs and symptoms of [DIAGNOSES REDACTED] you need to watch for nausea, vomiting, poor appetite and per physician orders. She said she did not assist with the admission process for Resident #1 on the evening of [DATE]. The DON said that her expectation for her nurses checking blood sugar levels prior to insulin administration was for them to use their nursing judgment. She said her expectation was for her nurses to follow the physician's orders [REDACTED].#1's physician orders [REDACTED].<69mg/dl was pulled from a batch order, which were similar to standing orders that were generic orders used to help save time when inputting orders into the computer. She said that the batch orders still required the nurse to clarify with the physician before using the batch order. She felt that the admitting nurse had just clicked on that particular order by accident. She said that she was unsure if the admitting nurse had clarified the orders with the physician but would have assumed she had. In an interview on [DATE] at 6:48 PM, LVN C said that she was on duty as the charge nurse the evening of [DATE] from 6pm to 6am and she cared for Resident #1. She said that she had been Resident #1's night nurse since he was admitted on [DATE]. She said she saw him the evening of [DATE] at different times as she would go up and down the hall. She said LVN B was on duty and administered Resident #1's evening medications on [DATE]. She could not recall a specific time as to when she last saw him but did state she had not gone into his room that evening to care for him directly. She said since he was a new admit, she had told the CNAs to check on him regularly and make sure he did not try and get up out of bed without assistance. LVN C said that he was a very large man and they would have to have called EMS if he were to fall, therefore she made sure the CNAs kept a close watch on him. She said that she took shift report change from LVN A that evening and did not recall anything specific about Resident #1 that she was to watch for, specifically low blood sugar. LVN C said that around 1:45 AM on [DATE] she recalled coming from a resident's room that she was giving a PRN medication to. She said that when she came out of the room, she saw CNAs running to get the crash cart and at that time LVN D asked me to verify the code status for Resident #1. She said I hurried and found his chart and saw that he was a full code, I told LVN D that he was a full code and called 911, by the time I got down to Resident #1's room, LVN D had already initiated the full code and was administering CPR. She said that within just a few minutes, EMS arrived and took over. She said that Resident #1 was unable to be resuscitated. LVN C said she contacted Physician A's on call answering service and another physician was taking call that evening. She said that she could not remember the details of who the covering physician was but did recall he returned the call placed with the answering service and she informed him that Resident #1 had expired, she said that he informed her he would let Physician A know. In a telephone interview on [DATE] at 8:38 PM, CNA A said she cared for Resident #1 the evening of [DATE] from 6PM to approximately [DATE] at 2:00 AM, when he expired. She said that the last time she saw Resident #1 was around 1:00 AM, she had gone into his room and given him ice and water. She said he was awake and mentioned he was about to try and get some rest. She said that he did not appear sweaty or shaky. She indicated that he was a very large man and she had checked on him regularly throughout the entire weekend to ensure that he was familiar with the call light system, and did not attempt to get up without assistance. She said he did use his call light but a few times staff had found him trying to get out of bed without calling for assistance. She said that he required two people to assist him with transfers. She said he would ambulate with a walker to the bedside commode. He was alert and oriented each time she had checked on him, however on [DATE] he did appear more depressed and upset from the previous two evenings (,[DATE]-[DATE]) she had cared for him and that Resident #1 verbalized several times to her that he wanted to go home Monday ([DATE]) regardless of what anyone said. CNA A said she did not report this to anyone, she just figured he was still adjusting to the facility and missed being at home with his wife. She said she did notice the last time she assisted him to the bedside commode he appeared weaker and more assistance was given to him by her and another staff member during the transfer. She said that she could not recall the specific time she transferred him to the bedside commode but remembered it was pretty late. She indicated that she had been the CNA to pass evening snacks on Hall 4 around 8:00 PM that evening, however when she offered Resident #1 a snack, he told her that he did not want one. CNA A said at that time, she observed fast food in Resident #1's room, specifically a hamburger, milkshake and a coke that had been brought in by his family. CNA C said she found him unresponsive when she was about to take her break around 2:00 AM on [DATE]. She said that she went down the hall to check on everyone and as she entered Resident #1's room, she found him on his left side of the bed with his feet dangling off the bed. She said he was laying on his left arm and that his head was kind of tilted back but facing toward the quarter side rail. She said his airway was not blocked or covered. She said he still had color to his face and did not recall him appearing sweaty or clammy. She said at this time she realized he was not responding to her voice and yelled down the hall for help. CNA C said that LVN D immediately responded to her call for help and began assessing Resident #1. She said that LVN D advised two other staff to obtain the crash cart and at that time, LVN C was coming down the hall and LVN D asked her to confirm his code status. She said she assisted LVN D with placing Resident #1 on the floor. She said LVN D confirmed his full code status with LVN C and LVN D then initiated CPR, LVN C was told to call 911 and at that time, I started assisting LVN D with CPR. She said that LVN D did hook the automated external defibrillator to Resident #1 and remembered that it attempted a couple of times to shock him but by this time the EMS team had arrived and took over but they were unsuccessful as well. In an interview on [DATE] at 8:32 AM, LVN E said that she had been the nurse to enter the admission orders [REDACTED]. She said that she was called in on her day off to help with Resident #1's admission. She said she did not specifically recall receiving an order for [REDACTED]. She explained that batch orders are orders that are put in the 'que' in the computer system that are already orders that are typed and you can click them and add to them if needed for specific instructions for resident's. She said she was not sure if they were specific for one doctor. At this time of the interview, LVN E reviewed Resident #1's physician orders [REDACTED]. She said that the orders were confirmed using a communication method telephone, however she stated that she had not contacted Physician A to clarify or verify his orders, she had entered the orders from his discharge paperwork from the hospital. She said that she did remember calling the hospital about his orders but did not remember exactly what about. She said when residents are admitted to the facility and have orders for insulin but did not have an order for [REDACTED]. She said that when an order for [REDACTED]. She said that when this prompt is setup, the computer system will not allow you to check off on the medication administration until you enter the blood sugar level. Upon review of Resident #1's electronic and paper clinical chart, LVN E said that there was not an actual order for blood sugar levels or parameters, however she had entered two separate orders for parameters for a low blood sugar level for Resident #1 using the batch orders that were already in the system. The orders she said she retrieved from the batch orders were: If B/S (blood sugar) Accucheck Result <60MGS/DL and Resident is Alert Give 4oz of Juice or Regular Soda may add additional sugar packets & followed by snack. Recheck in 30 minutes. Notify MD if B/S remains below 60mgs/dl. Every 24 hours as needed. If Resident is alert and able to take by mouth. Hold Insulin and Oral Hypoglycemics for FSBS <69, give a glass of orange juice or oral glucose replacement and recheck blood sugar in 30 minutes every 24 hours as needed. Furthermore, in the same interview, LVN E said I must have accidentally clicked on one too many batch orders. At this time she confirmed that she had not received that order from Physician A via telephone as reflected on the printed orders. She said Resident #1 did admit to the facility for skilled therapy and that residents that were at the facility for skilled therapy should have a skilled nursing note in their chart each day. At this time, she verified with both the electronic and paper clinical record that there were not any skilled nursing notes done for Resident #1 from [DATE]-[DATE]. LVN E said that there was not a blood sugar level entry from [DATE]-[DATE] documented on the MAR for Resident #1's evening insulin administration of Insulin [MEDICATION NAME] 50 units subcutaneously. She said she was not sure why it was not there unless it was done on supplemental documentation, however upon review of the supplemental documentation, she said it was not documented. LVN E said that she would not have administered the [MEDICATION NAME] 60 units to Resident #1 on [DATE] at 5:00PM with his blood sugar being 62mg/dl, she said she would have used her nursing judgement and held it because 62 was too low to the threshold, which in her opinion was 60mg/dl. She said she would have given him a snack and rechecked his blood sugar level in about thirty minutes. When asked if there were orders to hold the insulin at any time, she said yes, there were orders to hold if less than 60mg/dl. When asked what she does in a situation when there are two orders for parameters of low blood sugar, she said she would err on the side of caution and would have went with the order that said to hold if it was less than 69mg/dl. LVN E said the signs and symptoms of [DIAGNOSES REDACTED] were sweating, shaking irritability, unresponsive and potentially the person could die. She said the purpose of insulin was to lower blood sugar. She said that the complications when giving insulin with a blood sugar already around a low range, was it could potentially make the resident bottom out (drop their blood sugar level to a dangerous level). She said that the facility had recently in serviced her regarding insulin administration, when to give it, when to hold it and explained the different types of insulin. Record review Resident #1's electronic Medication Administration Record for [DATE]-[DATE] revealed no prompt or entry to queue the nursing staff to enter a blood sugar level. Record review of the in service dated [DATE] revealed the following: Subject: Insulin & Blood Sugars Instructor: (DON) Insulin Administration and Blood Sugar Checks Nurses should follow physician orders [REDACTED]. Nurses should ensure that snacks are offered to all diabetic patients as ordered and notify the physician if the patient was not consuming meals or displaying signs and symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Document the communication with the physician in the patient's medical record and notify family. Nursing judgement was the first line of defense to protect the well being of the patients. Please make sure that you have a firm understanding of the types of insulin, signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED], and ensure that you are adequately assessing the patient before administering the insulin. Make sure that you are familiar with each patient's orders pertaining to holding insulin doses and when to notify the physician but also exercise good nursing judgement at all times. In an interview on [DATE] at 9:09 AM, the DON said that Resident #1 did not have orders when discharged from the hospital on [DATE] for blood sugar levels to be checked or parameters to monitor his blood sugar levels. She said her expectations were for the nurses to clarify with the physician upon admission when blood sugar levels are to be checked and what parameters the physician wanted for blood sugar monitoring. She said she had reviewed Resident #1's physician orders [REDACTED]. She said it was not okay to put an order into the computer system as a telephone order without actually speaking to the physician. The DON verified that there was an order to hold Resident #1's insulin if a blood sugar level was less than 69mg/dl. She verified that Resident #1 had received 60 units of [MEDICATION NAME] on [DATE] at 16:58 (4:58 PM) with a blood sugar level of 62mg/dl. She said the only documentation in Resident #1's electronic and paper clinical chart for that specific time was that LVN A had given two glasses of orange juice when the insulin was administered. She said that there was not any documentation that showed his blood sugar level had been rechecked or monitored after the insulin was administered and that there was not any documentation that his blood sugar level had been checked prior to the evening dose of Insulin [MEDICATION NAME] 50 units at 2000 (8:00 PM). The DON explained that the reason the in service for insulin administration had been conducted was due to

Based on interview and record review, the facility failed to ensure that four (Residents #1, #2, #3, and #4) of seven residents reviewed for unnecessary drugs received adequate monitoring while receiving [MEDICATION NAME] (a blood thinner). A. Resident #1 had an order, dated 04/28/16, to have his PT/INR levels tested every other Wednesday in the morning due to receiving [MEDICATION NAME]. Resident #1 did not have his PT/INR levels checked from the date of the order until 06/19/16 when he was discovered to have a bruise on his left arm that extended from his elbow to his wrist. Resident #1's PT/INR level was tested on [DATE] and the results revealed his INR level was critically high. Resident #1's PT/INR level was not checked between the test on 06/20/16 and his discharge to the hospital on [DATE]. Resident #1's PT/INR was checked at the hospital on [DATE] and his INR was 4.8, which was identified by the lab as critical. B. Resident #2 had an order, dated 03/24/16, to have his PT/INR levels tested every other Wednesday in the morning due to receiving [MEDICATION NAME]. Resident #2's PT/INR level was not checked between 04/13/16 and 05/16/16. Resident #2 did not receive two ordered lab test. C. Resident #3 had an order, dated 06/16/16, to have his PT/INR levels tested every other Wednesday in the morning due to receiving [MEDICATION NAME]. Resident #3's PT/INR was not tested from 06/16/16 until 07/20/16. Resident #3 did not receive two ordered lab test. D. Resident #4 had an order, dated 05/31/16, not to receive [MEDICATION NAME] until his INR was below 2.0. Resident #4 also had an order, dated 06/02/16, to have a PT/INR level tested on e time on 06/02/16. The PT /INR test ordered for 06/02/16 was not conducted, but Resident #4 continued to receive his [MEDICATION NAME] from 06/02/16 through 0614/16. Resident #4's PT/INR was not checked until 06/15/16. This failure could affect the seven residents receiving [MEDICATION NAME] by placing them at risk for receiving unnecessary doses of medication and experiencing undesirable side effects as well as potentially causing undetected health issues, delayed treatment, uncontrolled bleeding, and death. Findings included: Resident #1 Record review of Resident #1's Admission Record, undated, revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS revealed Resident #1 required the physical assistance of staff with transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed that Resident #1 received an anticoagulant (medication to thin the blood) on all seven days prior to the date of the MDS. Record review of Resident #1's Physician Telephone Orders revealed an order from Physician A, signed and dated on 04/28/16, that ordered a PT/INR every other Wed (Wednesday) AM. According to the U.S. National Library of Medicine a [MEDICATION NAME] time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. PT is measured in seconds. Most of the time, results are given as what is called INR (international normalized ratio). If you are not taking blood thinning medicines, such as [MEDICATION NAME], the normal range for your PT results is . (an) INR of 0.8 to 1.1 If you are taking [MEDICATION NAME] to prevent blood clots, your doctor will most likely choose to keep your INR between 2.0 and 3.0. INR results higher than 3.0 may put you at even higher risk for bleeding. INR results lower than 2.0 may put you at risk for developing a blood clot. (https://medlineplus.gov/ency/article/ 2.htm-Accessed on 07/27/16) Record review of Resident #1's Order Recap Report, dated 06/20/16, revealed an order given by Physician A for [MEDICATION NAME] Tablet 10 MG (Milligram) ([MEDICATION NAME] Sodium) Give 1 tablet by mouth in the afternoon for anticoagulant. The order for [MEDICATION NAME] had a start date of 04/24/16 and order date of 04/23/16. According to the U.S. National Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is a medication used to prevent blood clots from forming or growing larger in your blood and blood vessels. [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. The U.S. National Library of Medicine also indicated if a person was prescribed [MEDICATION NAME] the doctor would order a blood test (PT ([MEDICATION NAME] test) reported as INR (international normalized ratio) value) regularly . to check . (the) body's response to [MEDICATION NAME]. (https://medlineplus.gov/druginfo/meds/ a 7.html-Accessed on 07/27/16) Record review of Resident #1's lab results from a local clinic, dated 04/29/16, revealed a PT/INR test was conducted on 04/29/16. The results were an INR of 2.83. Record review of Resident #1's lab results from a local clinic, dated 05/11/16, revealed on 05/11/16 at 1:30 AM the resident refused to have his blood drawn to conduct the scheduled PT/INR test. Additional documentation revealed Resident #1 refused another lab drawn on 05/12/16 at 1:22 AM. Record review of Resident #1's lab results from a local clinic revealed no further PT/INR test were performed or attempted from 05/13/16 until 06/20/16. Record review of Resident #1's nurses notes revealed the following entries: 06/19/16 1:36 PM Daughter in to see resident. Large bruise noted to left arm reaching from elbow to wrist. This nurse told daughter I would follow up and research lab draws and labs. Date of last lab draw 6/3/16 (lab unrelated to PT/INR test) . (Physician A) called and notified of resident status. Signed by LVN D. 06/19/16 6:04 PM MD called with order for STAT PT/INR. Signed by LVN D 06/20/16 7:35 AM Bruise remains to arm. Lab in facility to draw PT/INR without problems . Signed by LVN F 06/20/16 10:40 AM (Physician A) called and received new order for hold [MEDICATION NAME] today 06/20/16 and tomorrow 06/21/16 and d/c (discontinue) [MEDICATION NAME] 10 mg and restart [MEDICATION NAME] 8 mg daily (on 06/22/16). Resident and family notified. Signed by LVN B 06/20/16 11:16 AM Rec'd (received) critical labs of PT 63.4 and INR 6.46. Notified family and called (Physician A's) office . Signed by the DON Record review of Resident #1's Medication Administration Record, [REDACTED]. Record review of Resident #1's lab results from a local clinic, dated 06/20/16, revealed the following results from a PT/INR test conducted on 06/20/16: Test Name: INR Out of Range: 6.46 (H!) Reference Rang: .80-1.20 The lab results also revealed the results were identified as critical and called to the facility on 11:16 AM on 06/20/16. In an interview on 07/19/16 at 4:30 PM Physician A, Resident #1's physician, stated he had given orders 04/28/16 to monitor Resident#1's PT/INR levels every other Wednesday. He stated that due to the high dose of [MEDICATION NAME] Resident #1 was receiving and potential side effects that could occur to Resident #1, he was not comfortable checking this level every month. Physician A stated that he had only received two PT/INR levels regarding Resident #1 and they were dated 04/29/16 and 06/20/16. He did not have record of any refusals for attempts that the lab had made to draw a PT/INR on Resident #1 and also indicated that it was not appropriate to attempt a lab draw at 2:00 AM in the morning. Physician A stated the PT/INR test should have resumed every other Wednesday after the STAT PT/INR on 06/20/16. In an interview on 07/20/16 at 3:54 PM LVN D stated she was the nurse on duty on 06/19/16 when the daughter of Resident #1 brought to her attention the bruise on Resident #1's arm. LVN D stated that she knew he was on a large dose of [MEDICATION NAME] and could not find a recent PT/INR results, therefore she obtained an order for [REDACTED]. LVN D was not sure when the bruise on Resident #1's arm appeared but felt that Resident #1 could have bumped his arm anywhere and not reported to staff. LVN D stated that for any residents on [MEDICATION NAME] standing routine lab orders should be in place to monitor a residents PT/INR level and if there is not an order then the nurse on duty should obtain a clarification order via telephone with the physician. Based on the order given on 04/28/16 for Resident #1 to have a PT/INR test every other Wednesday, a PT/INR test should have been conducted on the following dates before the resident was discharged to the hospital on [DATE]: 05/11/16, 05/25/16, 06/08/16, 6/22/16, and 07/06/16. A PT/INR test was attempted on 05/11/16 and 05/12/16, but was not reattempted. A STAT PT/INR was conducted on 06/20/16. No PT/INR tests were attempted after the one conducted on 06/20/16. Record review of Resident #1's Medication Administration Record, [REDACTED]. Record review of Resident #1's Medication Administration Record, [REDACTED]. Record review of Resident #1's lab results from a local hospital, dated 07/14/16, revealed Resident's PT/INR levels were tested on [DATE] and his INR was 4.8, which was identified by the lab as critical. Record review of the pharmacy consultant's documentation for April 2016, May 2016, and June 2016 revealed no documentation related to Resident #1's [MEDICATION NAME] or PT/INR labs. Resident #2 Record review of Resident #2's Order Summary Report, dated 04/29/16, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's Significant Change MDS, dated [DATE], revealed a BIMS score of 13, indicating he was cognitively intact. Resident #2's MDS indicated he required the physical assistance of staff for transfers, dressing, toileting, and personal hygiene. The MDS also revealed Resident #2 received an anticoagulant (medication to thin the blood) on all seven days prior to the date of the MDS. Record review of Resident #2's lab results from a local clinic, dated 03/21/16, revealed his PT/INR was tested on [DATE] and his INR was 1.38. Included on the lab results was a note handwritten by facility staff for his [MEDICATION NAME] to be increased from 7 MG daily to 8 MG every day and for his PT/INR to be checked every other Wednesday started 03/30/16. Record review of Resident #2's Physician Telephone Orders revealed an order, dated 03/24/16 and signed by Physician A, to change [MEDICATION NAME] to 8 mg PO (by mouth) Q (each) day and an order for [REDACTED]. Record review of Resident #2's lab results for a local clinic, dated 03/30/16, revealed his PT/INR was checked on 03/30/16. The lab results revealed Resident #2's INR was 2.62 and the reference range was .80-1.20. Included on the lab results was a note handwritten by facility staff that Resident #2's PT/INR levels were to be checked routinely every other Wednesday. Record review of Resident #2's lab results from a local clinic, dated 04/13/16, revealed his PT/INR was checked on 04/13/16. The lab results revealed Resident #2's INR was 4.63 and the reference range was .80-1.20. Included on the lab results was a note handwritten by facility staff that Resident #2's [MEDICATION NAME] was to be held on 04/14/16 and restarted at 7 MG daily on 04/15/16, and that Resident #2's PT/INR should be checked on a two week schedule routinely. Record review of Resident #2's lab results from a local clinic revealed no PT/INR test between 04/15/16 and 05/16/16. Based on Resident #2's physician order, dated 03/24/16, for Resident #2's PT/INR to be checked every other Wednesday Resident #2's PT/INR should have been checked on 04/27/16 and 05/11/16. Record review of Resident #2's lab results from a local clinic, dated 05/16/16, revealed his PT/INR level was tested on [DATE] at 1:50 AM and the results revealed the following: Test Name: INR Out of Range: 3.94 (High) Reference Rang: .80-1.20 Record review of Resident #2's clinical record revealed he was discharged to the hospital in June 2016 for issues unrelated to his [MEDICATION NAME] therapy. Record review of the pharmacy consultant's documentation for April 2016, May 2016, and June 2016 revealed no documentation related to Resident #2's [MEDICATION NAME] or PT/INR labs. Observation and interview with Resident #2 on 07/20/16 at 9:53 AM revealed no obvious signs of bruising visible to the surveyor. Resident #2 stated his skin is checked regularly. Resident #2 did not express any concerns related to bruising. Resident #3 Record review of Resident #3's Order Summary Report, dated 06/28/16, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's Admission MDS, dated [DATE], revealed a BIMS of 3, which indicated sever cognitive impairment. The MDS revealed Resident #3 required the physical assistance of staff for transfers, locomotion, dressing, eating, toileting, personal hygiene, and bathing. The MDS also revealed Resident #3 received an anticoagulant (medication to thin the blood) on three days prior to the date of the MDS. Record review of Resident #3's Physician Telephone Order, dated 06/09/16 and signed by Physician A, revealed an order for [REDACTED]. Record review of Resident #3's lab results did not reveal a PT/INR test conducted on 06/10/15 as ordered on [DATE]. Record review of Resident #3's lab results from a local clinic, dated 06/15/16, revealed a PT/INR test was conducted on 06/15/16. The lab results revealed Resident #3's INR was 1.11 and with a reference range of .80-1.20. Hand written by facility staff on the lab results was a note that indicated Resident #3 was currently on 2 MG of [MEDICATION NAME] daily for [MEDICAL CONDITION] Fibrillation, and that is should be increased to 3 MG daily and the resident's PT/INR level checked every other Wednesday. Record review of Resident #3's Order Summery Report, dated 06/28/16 and signed by Physician A on 07/01/16, revealed the following orders: PT/INR Every Other Wednesday Start 6/29/16 (Order received date 06/16/16) and [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 3 mg by mouth in the evening for A-Fib ([MEDICAL CONDITION]) (Order date 06/16/16). Record review of Resident #3's lab results did not reveal any PT/INR test conducted between 06/29/16 and 07/20/16. Based on the order given on 06/16/16 Resident #3's PT/INR level should have been conducted on 06/29/16 and 07/13/16. Record review of Resident #3's Physician Orders, dated 07/20/16, revealed an order was given on 07/2016 for a STAT PT/INR. Record review of Resident #3's lab results for a local clinic, dated 07/21/16, revealed a PT/INR test was conducted on 07/21/16. The lab results indicated Resident #3's INR was 1.12 with a reference range of .80-1.20. Hand written by facility staff was a note on the lab results that Physician A was contacted with the results on 07/21/16 and ordered Resident #3's [MEDICATION NAME] increased to 3.5 MG daily. Record review of the pharmacy consultant's documentation for April 2016, May 2016, and June 2016 revealed no documentation related to Resident #3's [MEDICATION NAME] or PT/INR labs. Observation and interview with Resident #3 on 07/21/16 at 11:53 AM revealed no obvious signs of significant bruising visible to the surveyor. Resident #3 did have a bruise on the large toe of his left foot, but it was unrelated to his [MEDICATION NAME] therapy. Resident #3 did not express any concerns related to bruising. Resident #4 Record review of Resident #4's Admission Record, dated 07/21/16, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated moderate cognitive impairment. The MDS revealed Resident #4 required the physical assistance of staff for transfers, locomotion, dressing, toileting personal hygiene, and bathing. The MDS also revealed Resident #4 received an anticoagulant (medication to thin the blood) on all seven days prior to the date of the MDS. Record review of Resident #4's discharge orders from a local hospital, dated 05/31/16, revealed Resident #4 was discharged from the hospital back to the facility with the following order: [MEDICATION NAME] 4 mg oral tablet 1 tab(s) orally once a day START when INR is below 2.0. The DON signed on the discharge orders that they were noted on 06/01/16. Record review of Resident #4's Order Summary Report, dated 06/01/16, revealed an order dated 06/01/16 for a one time PT/INR test on 06/02/16. Record review of Resident #4's lab results revealed no PT/INR test was conducted on 06/02/16. Further review revealed the first PT/INR test conducted after the resident's return to the facility on [DATE] was on 06/15/16. Review of the PT/INR conducted on 06/15/16 revealed Resident #4's INR was 1.72. In an interview on 07/21/16 at 4:02 PM the Nurse Consultant stated the lab reported the only PT/INR test conducted on Resident #4 were on 06/15/16 and 07/21/16. Record review of Resident #4's Medication Administration Record [REDACTED]. Record review of the pharmacy consultant's documentation for April 2016, May 2016, and June 2016 revealed no documentation related to Resident #4's [MEDICATION NAME] or PT/INR labs. In an interview on 07/20/16 at 2:03 PM with the DON, she stated that the facility did not have a policy in regards to anticoagulant therapy. In an interview on 07/20/16 at 4:05 PM the DON stated that her expectation when a resident was on a blood thinner, especially [MEDICATION NAME], that there be an order for [REDACTED]. The DON stated once the lab received the order the facility relied on the lab to ensure routine labs were conducted as scheduled. The DON stated her expectation would be for the nurses to adhere to the orders given by the physician for lab work and that if a resident refused or a lab was missed the doctor would be notified for each occurrence. She stated that the tracking of labs was done using the lab book that was kept at the nurse's station. The DON stated the lab personnel either provided a print out from the lab company of all the residents who had labs drawn on the day the lab came in or lab personnel completed a sheet specific to resident if it is not a routine lab. The DON stated these forms are what were in the lab book. The DON stated this was also where it is documented if a resident refused a lab. She stated she was unaware that the labs were being drawn between the hours of 1:30 AM and 3:00 AM and indicated that that was ridiculous and her expectation would be around 5:00AM at the earliest for a resident to receive a blood draw. The DON did say that her expectation when a resident refused a lab draw would be for the nurse on duty to notify the physician and that a reasonable attempt should be made to try and obtain the lab work again. She did not feel that a reasonable attempt would be at the same time the next day at 2:00 AM with a resident who was cognitively impaired. Record review of the facility's Order Listing Report for Anti-Coagulants, dated 07/20/16, revealed seven residents were prescribed [MEDICATION NAME].