Every finding on record at Oak Haven Rehab and Nursing Center

Based on observations, record reviews, and interviews the facility failed to ensure skilled documentation for two (#1 and #7) of three residents sampled was completed daily, failed to ensure a change in condition and transfer evaluation was conducted for one (#1) of one sampled resident prior to transferring to an acute care facility, and failed to ensure one (#6) of one resident medical record contained documentation related to the dislodgement of an indwelling urinary catheter. Findings included: 1.An observation and interview were conducted on 4/12/26 at 9:20 a.m. with Resident #7 and spouse. The spouse reported wanting the resident to lay down after therapy but has not informed anyone of the wishes, will do so on Monday (next day). The resident was observed lying in bed with breakfast tray on the over-bed table. Review of Resident #7's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and Encounter for surgical aftercare following surgery on the circulatory system. Review of Resident #7's active physician orders revealed the resident was receiving occupational therapy five times a week for 30 days starting on 3/28/26 and physical therapy five times a week for 30 days starting on 3/30/26. The orders did not include an order for a skilled daily note to be completed daily. Review of Resident #7's Assessments showed no skilled documentation on 3/30, 3/31, 4/4, 4/7, 4/10, and 4/11/26. An interview was conducted on 4/12/26 at 1:40 p.m. with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member stated daily skilled notes are done for residents receiving therapy. She reviewed Resident #7's assessments which showed the resident was not receiving daily skilled assessments and stated they were working on trying to get nurses to remember to do the daily assessment and a progress note did not take place of the assessment. 2.Review of Resident #1's admission Record showed the resident was admitted on [DATE] and discharged on 11/14/25. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease, morbid (severe) obesity due to excess calories, generalized muscle weakness, and other abnormalities of gait and mobility. Review of Resident #1's November 2025 Medication Administration Record (MAR) showed staff had confirmed the documentation of a skill assessment daily on 11/8 - 11/10/25 during the day shift and 11/11 to 11/13/25 during the evening shift. Review of Resident #1's assessments showed on 11/8/25 an admission/readmission assessment was completed. The available assessments showed no skilled assessments from 11/9 to 11/13/25, despite staff documentation on the MAR showing the daily assessments had been completed. Review of Resident #1's progress notes on 11/11/25 at 8:10 a.m. showed Emergency Medical Services (EMS) were called per the resident's representative request. The note showed the resident had complained of itching as a result of an allergic reaction and redness was noted to bilateral upper extremities. The resident did receive an epinephrine injection prior to transferring to the acute care facility. The progress note did not show the resident's primary care physician had been notified. Review of Resident #1's progress notes showed on 11/11/25 at 1:38 p.m. the resident arrived back at facility via stretcher. Review of Resident #1's assessments showed no change in condition and/or transfer assessment had been completed at the time of the resident's allergic reaction episode or transfer to the acute care facility. Review of the policy - Change in Resident Condition or Status, Resident Rights, revised 6/2023, showed Facility shall notify the resident, his or her attending physician, and representative of changes in the residence medical/mental condition and/ or status (e.g. Changes in level of care, billing/ payments, residents rights, etcetera (etc.)). The guideline was To ensure the facility provides timely notification in accordance with state and federal regulations as it pertains to residents' rights.1. The nurse will notify their residents attending physician or physician on call when there has been a (an): g. need to transfer the resident to a hospital/ treatment center; i. specific instruction to notify the physician of changes in the residence condition.5. The nurse will record in the residence medical record information relative to changes in the resident's medical/ mental condition or status. 3.An observation and interview were conducted on 4/12/26 at 9:35 a.m. with Resident #6. The resident was observed lying in bed. The resident stated the catheter (urinary) had come out at 3 a.m. this morning and was told they were waiting for a Certified Nursing Assistant (CNA) to show up. The observation did not reveal the resident had a urinary catheter. Review of Resident #6's progress notes did not reveal a note describing the dislodgement of a urinary catheter on 4/11 and/or 4/12/26. Review of Resident #6's active physician orders included the following:Indwelling urinary catheter care every shift and as neededIndwelling urinary catheter: monitor every shift, notify the physician or changes in urinary appearance (color, consistency, odor, etc.) and/or no urinary output every shift.Indwelling urinary catheter size 18 french (fr) 10 milliliter (mL) for diagnosis of neurogenic bladder. An interview was conducted on 4/12/26 at 2:00 p.m. with Staff A. The observation with Staff A revealed urinary tubing under Resident #6's dress hem to the drainage bag. The staff member stated there was no urine in the drainage bag hanging from the wheelchair. The unknown CNA assisting Resident #6's roommate stated the drainage bag had not emptied today. An interview was conducted on 4/12/25 at 2:05 p.m. with Staff A and Staff B, LPN. Staff B stated she had gotten in report this morning at approximately 7:00 a.m. that Resident #6's foley (indwelling catheter) had come out at 2:00 a.m. and the night shift nurse had spoken with the primary care provider about putting in a 16 fr (size) instead of an 18 fr catheter. Staff B reported putting in a 16 fr catheter about an hour ago and had informed the resident she would be to check on the resident. Staff A stated it was not appropriate to delay the insertion by approximately 9 hours. Staff A and Staff B reviewed Resident #6s progress notes and confirmed the notes did not include information related to the dislodgement of foley and/or if the physician had been notified. Staff A stated the delay in inserting the catheter would only be appropriate if doing a toileting trial. An interview was conducted on 4/12/26 at 3:18 p.m. with the Director of Nursing (DON). The DON stated the skilled daily evaluations were for patients receiving therapy. She stated the expectation was for anyone getting therapy should have a daily skilled note. The DON stated the nurses are to get a physician order, complete a transfer form, and a change in condition assessment when a resident was transferred or a change in condition. A review of Resident #1's progress notes did not show the physician was notified of the resident being transferred or of the change in condition. The DON stated on 4/12/26 at 5:10 p.m. the facility had realized they had issues completing daily skilled notes. The DON reported the night shift nurse, Staff C, Licensed Practical Nurse (LPN) was a new nurse and had received one on one training with the electronic medical record. Review of the policy - Documentation, revised 1/2026, revealed Services provided to the residents shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisciplinary team regarding the residence condition and response to care.2. The following information is to be documented in the resident medical record: a) objective observations. c) Treatments or services performed. d) Changes in the residents' condition. e) Care provided.3. Documentation in the medical record is required as updates/ changes in the residents plan of care is made.4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure/ treatment was provided; b) the name and title of the individual(s) who provided the care;c) the assessment data and/ or any unusual findings obtained during the procedure/ treatment; e) notification of family, physician or other staff, if indicated.

Based on record reviews and interviews the facility failed to maintain an effective, comprehensive Quality Assurance and Performance Improvement program (QAPI) related to the development and implementation of corrective actions or performance improvement activities as evidence by the continued absence of daily skilled assessments for residents receiving skilled services.Findings included:Review of Resident #7's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and Encounter for surgical aftercare following surgery on the circulatory system.Review of Resident #7's active physician orders revealed the resident was receiving occupational therapy five times a week for 30 days starting on 3/28/26 and physical therapy five times a week for 30 days starting on 3/30/26. The orders did not include an order for a skilled daily note to be completed daily.Review of Resident #7's Assessments showed no skilled documentation on 3/30, 3/31, 4/4, 4/7, 4/10, and 4/11/26.An interview was conducted on 4/12/26 at 1:40 p.m. with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member stated daily skilled notes are done for residents receiving therapy. She reviewed Resident #7's assessments which showed the resident was not receiving daily skilled assessments and stated they were working on trying to get nurses to remember to do the daily assessment and a progress note did not take place of the assessment.An interview was conducted on 4/12/26 at 3:18 p.m. with the Director of Nursing (DON). The DON reported the facility had identified an issue with skilled documentation and a Performance Improvement Plan (PIP) was started a couple of weeks ago. The expectation was for anyone getting therapy should have a daily skilled assessment. A continued interview was conducted on 4/12/26 at 5:10 p.m. with the DON. The DON reported and provided a copy of the PIP which started on 4/3/26. She stated the facility had educated all nurses on completing daily skilled notes and the goal was for all skilled residents would get them, if a note isn't done the facility calls the nurse back in. The Unit Managers are conducting audits of the skilled documentation. The administrator provided a detailed census report which listed 31 current residents receiving skilled services.Review of the audits completed showed audits were conducted on 4/5, 4/7, 4/9, and 4/11/26. The audits showed a total of 12 of the 31 residents had been audited for the daily skilled charting. The audit on 4/5 showed a total of 4 residents, of which 3 of those residents were also included among the five residents audited on 4/7. One of the residents had been audited on 4/5, 4/7, and 4/9. The audits did not show the clinical documentation of Resident #7 had been audited.During the interview on 4/12/16 at 5:10 p.m. the DON reviewed the audits conducted and confirmed the same residents were being audited. Review of the policy Quality Assurance and Performance Improvement (QAPI) program, undated, revealed This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are two:1. Provide a means to measure current and potential indicators of outcomes of care in the quality of life.2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services.4. Established systems through which to monitor and evaluate corrective actions.

Based on interview and record review the facility failed to file a grievance for one resident (#1) out of 3 residents reviewed for grievances.Findings included: Review of Resident #1's care plan note, dated 11/12/25 at 3:51 p.m., revealed a meeting was held by the Interdisciplinary Team (IDT) with Resident #1 and (via telephone) the resident's responsible party. The note showed concerns were addressed with the unit manager. Review of the November 2025 grievance log did not reveal any grievance had been filed by the resident, resident representative, or by the facility on behalf of the responsible party regarding concerns voiced during the IDT meeting and/or during the month of November. Review of Resident #1's admission Record revealed the resident was admitted on [DATE] and discharged on 11/14/25. An interview was conducted on 04/12/26 at 12:25 p.m. with the Social Service Director (SSD). The SSD acknowledged being the one in the facility handling grievances. The SSD reported when a family complains, the facility writes a grievance. The SSD stated if concerns are voiced during a care plan meeting, the concern is written as a grievance. The SSD read Resident #1's care plan meeting note, stated the SS assistant goes to the meeting, and the SSD did not know what Resident #1's concerns were. A continued interview was conducted on 4/12/26 at 12:45 p.m. with the SSD and a grievance filed on 11/9/25 in response to Resident #1's representatives feedback left on the facility's kiosk on 11/8/25. The SSD explained the representative had taken a survey upon exiting the facility, answering the feedback with a frowning face. The visit rating was 1 of 5 with key factors of nursing care, housekeeping/cleanliness, and customer service. The SSD provided a grievance written on 11/9/25. The SSD stated if family voiced concerns a grievance should have been written up. Review of a grievance (provided by the SSD), dated 11/9/25, based on information left by Resident #1's representative on the facility kiosk. The details of the complaint/grievance did not reveal any information, the SSD had investigated, and the investigation was a room change would be provided when available. The resident was notified of resolution on 11/10/25. The grievance did not reveal the resident representative had been contacted or any specific concerns had been voiced by the representative. The resolution showed the resident had and not the representative been notified of resolution. An interview was conducted on 4/12/26 at 1:46 p.m. with Staff A, Licensed Practical Nurse/Unit Manager. The staff member reported Resident #1 called the representative a lot and the unit manager would follow up with the representative, who voiced no concerns or issues. The staff member stated the representative was concerned about the resident's food allergies. Staff A stated they had spoken with the representative during the care plan meeting but didn't know of any concerns and just updated on the resident's medications (during the meeting). The staff member couldn't remember if the representative had any concerns and seemed to be satisfied. Review of policy - Grievances Resident Rights, revised 6/2023 revealed Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative.1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.3. All grievances, complaints were recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and/or in writing upon request including a rationale for the response.8. A primacy of a grievance and/ or complaint, the grievance officer will review and investigate the allegations and submit a report of such findings to the administrator within five (5) working days of receiving the grievance and/ or complaint.10. The grievance officer, administrator, and staff will take immediate action to prevent further potential violations of residents rights while the alleged violation is being investigated.11. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken.12. The resident, or person filing the grievance and/ or complaint on behalf of the resident, will be informed (verbally and/or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems.14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on observations, interviews, and record reviews the facility to failed to insert an indwelling catheter per physician orders for one (#6) of one resident sampled for urinary catheters and appropriately obtain vital signs for one (#1) of three residents sampled for monitoring of health conditions.Findings included: 1.On 4/12/26 at 9:35 a.m. an observation was made of Resident #6 lying in bed. The resident seemed minimally confused but answered questions appropriately. The resident reported the urinary catheter had come out at 3:00 a.m. this morning and was told staff were waiting for an aide to show up. The observation did not reveal a urinary drainage bag hanging near the resident. On 4/12/26 at 2:00 p.m. an observation was conducted with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) of Resident #6. The resident was sitting in wheelchair next to bed, urinary catheter tubing was seen coming from dress hem to drainage bag hanging from chair. Resident #6 stated the catheter was not in the bladder but in the uterus. The staff member confirmed there was no urine in the drainage bag and an unknown certified nursing assistant (CNA) who was assisting the resident's roommate reported not draining the urine bag today. An interview was conducted on 4/12/26 at 2:05 p.m. with Staff A, LPN/UM and Staff B, LPN. The staff member reported getting in report (from off going nurse) this morning around 7:00 a.m. that Resident #6s urinary catheter had come out at 2:00 a.m. and the nurse had talked to the primary care physician about putting a 16 french (fr) [size] catheter in instead of the ordered 18 fr. Staff B reported putting a 16 fr in about a hour ago, and had informed the resident the staff member would be back to check on the resident. Staff A stated it was not appropriate to delay the insertion of catheter by approximately 9 hours. The staff members reviewed Resident #6's progress notes which did not include any notes from the previous nurse with a description as to why, how, or when the catheter had come out or the physician had been notified. Staff A stated the delay would only be appropriate if the facility was doing a toilet trail with the resident. Review of Resident #6's active physician orders revealed an order, dated 3/10/26 for an indwelling urinary catheter, 18 fr with 10 milliliter (mL) balloon for the diagnosis of neurogenic bladder. The orders showed the resident was currently receiving the antibiotic Levaquin 750 milligram (mg) daily for a urinary tract infection for 10 days, beginning 4/6/26. Review of Resident #6's progress notes showed Staff B had documented a late entry on 4/12/26 at 2:41 p.m. (35 minutes after interview). The note revealed the resident had not voided since the foley had dislodged (approximately 12 hours prior) and a foley was reinserted with the return of 300 mL's of clear yellow urine. Review of Resident #6's care plan showed the resident had a risk for injury/infection related to (r/t) presence of catheter secondary to a diagnosis (dx) of neurogenic bladder. The interventions included: catheter size and balloon as per MD orders, check catheter tubing for patency as indicated/needed, monitor and document intake and output per MD orders, monitor for signs/symptoms (s/sx) (of) bacteriuria which included no output, and observe/monitor for a change in urinary output, and notify MD as indicated. Review of the policy - Catheter Care, Quality of Care, revised on 01/2024 revealed The facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. The guidelines showed the clinical nursing staff will receive education and training related to providing catheter care to minimize catheter associated infections.5. Changing indwelling catheters or drainage bags routinely and at fixed intervals that's not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised at the discretion of the medical provider.7. Observed the resident routinely for complications related to catheter use. Report new complications to the provider per the change in condition policy. 2.Review of Resident #1's admission Record showed the resident was admitted on [DATE] and discharged on 11/14/25. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and hypertensive heart disease without heart failure. Review of Resident #1's November 2025 Medications Administration Record (MAR) showed an order for nursing staff to obtain vital signs every shift for 5 days, 11/8 - 11/12/25. The MAR revealed the following:11/8/25 evening and night shift: blood pressure (bp) 119/87, temperature (temp) 98.2, pulse 71, respirations (resp) 16, and oxygen saturation (O2) 98 (%).11/9/25 day and evening shift: bp 127/77, temp 97.8, pulse 68, resp 18, and O2 97%.11/9/25 night shift and 11/10/25 day shift: bp 139/71, temp 97.9, pulse 70, resp 18, O2 97%.11/11/25 day and evening shift: bp 100/62, temp 97.9, pulse 62, resp 17, and O2 97%11/11/25 night shift revealed identical bp as day and evening shift, 100/62 and NA (not applicable) for temp, pulse, resp, and O2.11/12/25 evening and night shift: bp 117/61, temp 97.6, pulse 73, resp 19, and 97% O2.The MAR showed the resident's vital signs did not change over consecutive shifts on same and different days. During an interview on 4/12/26 at 5:59 p.m., the Director of Nursing (DON) reviewed Resident #1's vital signs documented as the same on consecutive shifts and stated they were quite a coincidence. The DON would not comment on the likeliness of the resident having the same vital signs over multiple shifts. Review of policy - Documentation, revised 01/2026, revealed, Services provided to the residents shall be documented in the residence medical record. The medical records should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. 2. The following information is to be documented in the resident medical record: c) treatments are services performed. d) Changes in the residents' condition.4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.11. Late entries in the medical records shall be dated at the time of entry in noted as a late entry.

Based on interview and record review the facility failed to ensure the medical record was complete related to Activities of Daily Living (ADLs) for 3 of 3 sampled residents (#1, #2, #3)Findings included: 1. Resident #2 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Parkinson’s, dementia, anemia, and hypotension. Review of the Minimum Data Set (MDS) dated [DATE] showed Section GG, Functional Abilities dependent for toileting hygiene, showering and bathing, upper and lower body dressing. Review of the care plans showed the resident had an ADL self-care deficit related to chronic medical conditions. ADL needs and participation vary as of 07/18/2022. Interventions included but not limited to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 07/18/2022. Review of the Activities of Daily Living for June 2025 showed bed mobility, behavior symptoms, bladder continence, bowel management, dressing, float heels while in bed, evening snack, locomotion off unit, locomotion on unit, oral care, personal hygiene, skin observation, toilet use, transferring, turning and positioning, walking in corridor, walk in room, amount eaten with fluids, eating, incontinence care every 2 hours and as needed was not documented as performed on the following dates: 07/03/25, 07/05/25, 07/07/25, 07/08/25, 07/10/25, 07/11/25, 07/16/25, 07/1925, 07/21/25, 07/2325, 07/24/25. During an interview on 07/28/2025 at 12:43 p.m. the Director of Nursing (DON) stated the ADLs for Resident #2 had not been documented as performed on the above dates. She stated she expected to see documentation of tasks performed. 2. Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to diabetes, Alzheimer’s disease, hypertension and dementia. Review of the quarterly MDS dated [DATE] showed a BIMs score of “0” or resident is rarely, never understood. Section GG, Functional Abilities showed she was dependent for toileting hygiene, shower and bathing, upper and lower dressing, and personal hygiene. Review of the care plan showed Resident #2 has an ADL self-care deficit related to chronic medical conditions as of 04/15/2025. Interventions included but not limited to the resident may need dependent assistance of one or two for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status as of 04/15/2025. The resident is not able to participate in this task as at all (toileting) and will need staff to move, cleanse, and dress them. This may require the dependent assistance of 2 people to be done thoroughly and safely as of 11/21/2024. Review of the Activities of Daily Living from 06/29/225 to 07/28/2025 showed Urinary Incontinence the following dates only has 1 or 2 incontinence activities performance documentation: 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. Bowel Incontinence the following dates only has 1 or 2 incontinence activities performance documentation 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. Toilet Use Self Performance the following dates only has 1 or 2 incontinence activities performance documentation: 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. During an interview on 07/28/2025 at 1:06 p.m. the DON verified documentation was missing for Resident #3 regarding incontinence care. The DON stated she expected the staff to document incontinence care. Review of the facility’s policy, “Documentation,” revised 01/2024 showed services provided to the resident shall be documented on the resident’s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident’s condition and response to care. Procedure: 2. The following information is to be documented in the resident medical record: C treatments or services performed; 8. Documentation of procedures and treatments will include care specific details, including: a) the date and time the procedure / treatment was provided; B) the name and title of the individual (s) who provided the care; D) whether the resident refused the procedure / treatment; f) the signature and title of the individual documenting. Review of the facility’s policy, “ADL Care and Services,” revised 01/2024 showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, nail care and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting). Review of the Record for Resident # 1 indicated diagnoses which included Type II Diabetes mellitus with foot ulcer, Type 2 Diabetes mellitus with Hyperglycemia, Encounter for removal of internal fixation device, Hyperthyroidism, PVD, Obesity, Hyperlipidemia, Gastro-esophageal Reflux Disease and Gastritis. Review of a discharge Minimum Data Set Assessment) dated 5/20/25 indicated Section GG Functional Abilities: Substantial /maximal assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene Review of the care plan for ADL Care, initiated 3/25/25, revealed: BED MOBILITY: the resident needs EXTENSIVE help to move and reposition the bed. Will need one- or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts. TOILETING: the resident will need the EXTENSIVE help of one or two staff to stand and transfer on and off the commode or bed pan. The resident will probably need you to wipe, redress, and wash their hands, but allow the resident to do any part of the activity they can to promote independence. Be prepared with 2 people to assist for resident safety during the transfer Transfer: the resident IS LIMITED TO EXTENSIVE and may need assistance x1 or x2 for transfers in and out of chair or bed BATHING: The resident NEEDS ASSIST LIMITED TO EXTENSIVE of 1-2 based on fatigue, weightbearing, weakness. Review of the Activities of Daily Living documentation from May 1 through May 20,2025 revealed bed mobility, behavior symptoms, bladder continence, bowel management, dressing, locomotion off unit, locomotion on unit, oral care, personal hygiene, , toilet use, transferring, turning and positioning incontinence care were not documented for the day shift and evening shifts on May 5,7,8,9,11, 12, 14,15, 19 2025. During an interview with the DON, on 7/28/25 at 3: 37 pm, the DON confirmed the documentation of ADL care for the above dates was not documented.

Based on observation, interview and record review the facility failed to ensure the weekly skin assessments were performed for 8 of 39 sampled residents (#19, #362, #90, #58, #8, #267, #5). The facility also failed to ensure wound care assessments were performed for 2 of 2 sampled residents of 14 non-pressure wounds (#90, #267). Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. No odors were noted. No skin impairments were observed. Her personal items were noted. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Chronic Respiratory Failure with hypoxia, diabetes, Chronic Obstructive Pulmonary Disease (COPD), obesity, Congestive Heart Failure (CHF), hypertension with HF, stage IV chronic kidney disease, ischemic cardiomyopathy, anemia, muscle weakness, Transient Ischemia Attack (TIA). Review of the annual, Minimum Data St (MDS) dated [DATE] showed Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). Section GG, Functional Abilities and Goals showed the resident needed moderate assistance. Review of the Weekly Skin Checks dated 06/21/2024 showed no areas of concern at this time. Weekly Skin Checks were not documented 06/28/2024, 07/05/2024, 07/12/2024. Review of the care plans showed Resident #19 was at risk for skin impairment related to anemia, diabetes, incontinence, obesity, use of antiplatelet medications, weakness/decreased mobility, initiated on 06/20/2023. Interventions included but not limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 06/20/2023; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD [medical doctor]/wound team as indicated as of 06/20/2023. 2. On 07/15/24 12:58 p.m. Resident #90 was sitting in bed eating her lunch. She was slumped down in the bed, her feet were almost touching the footboard. She was dressed in a hospital gown. A dressing was noted on her right lower leg and was dated 7/14/24. The television was playing. She had juice and fluids on her overbed table. She stated she had been in the hospital a few times for surgery. She stated she had been on antibiotics since being in the hospital for a urinary tract infection. She stated she had a nephrotomy tube. She stated she was not walking but receiving therapy. She stated the last time she was in the hospital was for her leg injury. She gets transferred to the wheelchair in the Hoyer lift. She stated, she was walking, something happened, started screaming. they called 911 and sent her to the hospital. Resident #90 was admitted on [DATE] 24 and readmitted on [DATE]. Review of the admission record showed diagnoses but not limited to laceration without foreign body right lower leg on 06/27/2024, Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), cirrhosis of the liver, obesity, hypertensive heart disease, muscle weakness, anemia. Review of the 5-day MDS showed a BIMS score of 10 (moderately impaired). Section GG, Functional Abilities and Goals showed the resident was dependent for care. Review of the Admission / Readmission Nursing Evaluation dated 06/27/2024 showed under the Skin Evaluation: warm and intact. The skin diagram was blank. The wound of the right lower leg was not documented. Review of the Weekly Skin Check dated 06/28/2024 showed a right lower leg (front) with soft cast in place. Review of the Weekly Skin Check dated 07/02/2024 showed right lower leg hematoma ruptured. Review of the e-chart showed the Weekly Skin Checks for 07/09/2024 and 07/16/2024 was not documented. Review of the Wound Care Physician note dated 07/16/2024 showed the visit was the initial visit. The right lower leg trauma wound was not healed. It was 1 x 2 x 0.1 in size. There was 10% slough and 90% granulation. Wound to right lower leg with open wound from hematoma due to traumatic injury. Sutures in place with wound well approximated. Review of the Resident #90 care plans showed the resident was at risk for skin impairment related to anemia, diabetes, incontinence, obesity, weakness/decreased mobility, history of chronic stasis ulcers to bilateral lower extremities, initiated 06/19/2024. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 06/19/2024; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 06/19/2024. Review of the Resident #90 care plans showed the resident had an open area on the right anterior lower leg as of 06/19/024. Interventions included but not limited to administer medications and treatments as ordered by the MD as of 06/19/2024, complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for signs and symptoms of infection. Report changes to MD as indicated as of 06/19/2024; encourage and assist resident to float heels when in bed, as tolerated as of 06/19/2024; medicate prior to wound treatments if indicated. Notify MD for unrelieved pain as of 06/19/2024. During an interview on 07/17/2024 at 9:20 a.m. the Director of Nursing (DON) stated the wound care nurse performs the weekly skin checks on the residents who have wounds and are followed by the wound care doctor. If the resident was not followed by the facility's wound care nurse the floor nurses were responsible for performing the weekly skin assessment. The wound sizes are documented on the wound care doctor's notes and are to be uploaded weekly. The wound care doctor was not here last week due to being ill. The facility's wound care nurse was to measure the wounds last week and document them. The DON stated whether the skin impairment was new or old, it should be documented on the Weekly Skin Assessment. The admission nurse does look at the skin and then the wound care nurse follows-up with a skin assessment the next day or Monday if it was a weekend. The wound nurse schedules the wound care doctor, if needed. If the resident does not have a pressure ulcer or major surgical wound a Weekly Skin Check was to be scheduled. The floor nurse has to do a head-to-toe and document anything found. The DON stated if the note stated, nothing new it meant there was nothing on the body. The DON verified there was not a Weekly Skin Check performed on 07/09/2024 and 07/1602024 for Resident #90. She also verified the Weekly Skin Sheets were not performed as per the protocol for Resident #19. The DON stated the wound nurse follows the pressure ulcers which are stage III or IV or complicated surgical wounds, the floor nurses follow the other wounds. During an interview on 07/17/2024 at 11:30 a.m. Staff A, Licensed Practical Nurse (LPN), facility wound care nurse stated Resident #90 was seen by the wound care doctor yesterday (07/16/2024). Staff A stated Resident #90 was to be seen last week but the wound care doctor did not visit the facility. Staff A stated she was out after the wound care doctor was out ill for a few days. Staff A stated she does not normally follow the surgical wounds. The nurse on the floor will normally follow the small wounds and surgical wounds. Staff A stated she did not know when the soft cast was removed from Resident #90. Staff A, LPN stated she saw the wound for the first time on 07/02/2024. She stated she did not document in the chart what the wound looked like on 07/02/2024. Staff A stated it looked like a surgical site, with the incision intact, and a blistering hematoma around the surgical area. She stated she did not measure the wound at that time. Staff A stated she did not count the sutures at that time. She stated wound care orders had been put in. She stated she had seen the wound every day due to the hematoma and was performing the wound care. Staff A stated the wound care doctor saw the wound per the nurse practitioner's request. The wound care doctor changed the wound care on 07/16/2024. Staff A, LPN stated the expectation was for the wound to be seen and documentation to occur. She stated the admission nurse was to look at it (wound) and document that they looked at it (the wound). She will follow up the next day or Monday. She stated she follows the residents herself. She stated she does a head-to-toe assessment on them. The nurses are expected to go to the weekly wound care doctor notes if needed to check for wound changes. She stated weekly they were supposed to do skin assessments. During an interview on 07/17/2024 at 11:52 a.m. the Director of Nursing (DON) stated a Weekly Skin Sheet Assessment should be performed once a week. She stated all the nurses have access to the wound doctor's notes. The Wound Nurse was responsible for uploading the wound doctor's assessment notes weekly. The DON stated all the nurses have access to the wound care doctor's notes. The wound care doctor visits on Tuesday and turns his notes in on Tuesday afternoon for Wednesday to upload into the computer system. The DON stated the wound care nurse performs the Weekly Skin Sheets on residents with wounds and the other nurses are to perform the Weekly Skin Sheets weekly. The DON stated the Skilled Documentation Notes were not a substitute for the Weekly Skin Sheets. The DON verified the Weekly Skin Sheets were missing as well as the Skilled Documentation Notes. 3. On 07/15/24 12:29 p.m. Resident #8 was observed sitting in her wheelchair beside her bed, eating her lunch, of hamburger, carrots, soup, pudding, salad and fluids. She was dressed and groomed for the day. She stated she had no complaints or concerns. She stated the staff answers all the call lights. She stated she was able to take her own shower. A bruise was observed on her left upper hand. Record reviewed revealed Resident #8 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but were not limited to Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, obesity, CHF, Pulmonary HTN, atrial fibrillation, stage III chronic kidney disease, anemia, and weakness. Review of the MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident needed maximal assistance with care. Review of the Resident #8 care plans showed the resident was at risk for skin impairment related to diabetes, incontinence, obesity, weakness/ decreased mobility, routine use of antiplatelet, initiated 09/12/2023. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 09/12/2023; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 09/12/2023. Review of the Admission / Readmission Nursing Evaluation dated 07/04/2024 showed no skin impairments or no documentation. Review of the Weekly Skin Check dated 07/05/2024 showed right lower leg (front) vascular ulcer 1 x 1 x 0. Upon re-admission from hospital rest of skin clear and intact at this time. Review of the e-chart showed the Weekly Skin Checks for 07/12/2024 was not documented Review of the Skilled Documentation Note showed the following: On 07/07/2024, under skin: bruise On 07/10/2024, under skin: bruise On 07/11/2024, under skin: bruise On 07/14/2024, under skin: bruise On 07/16/2024, under skin: abrasion, see below. Skin check today and nurse reported her observation on the Botox area, redness on the left side, and the right side is starting to change in color. Wound nurse for resident needs, to consult wound care doctor for evaluation and treatment. Review of the nursing progress note for 07/17/2024 showed upon skin assessment the resident was noted with unknown boil-like mass to left buttocks with purulent drainage and right lower buttocks with an excoriation, and bilateral lower extremity with redness. No edema noted at this time. When resident was asked how it happened, the resident claims to have history of boils to the buttock area. Resident made aware and MD made aware. During an interview on 07/17/2024 at 12:10 p.m. the DON verified the bruise was documented but location was not documented, and it should be. The DON verified the Weekly Skin Check was not performed weekly. The DON verified the chart was missing Skilled Documentation notes. 4. During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed: cleanse the right above knee amputation site with normal saline, pat dry, apply abdominal pad, wrap with kerlix secure with ace wrap daily and as needed as of 07/03/2024 cleanse left 1st digit / lateral foot with normal saline/wound cleanser, pat dry, apply Santyl and calcium alginate, cover with border gauze daily and as needed for the diabetic ulcer as of 07/03/2024 cleanse sacrum with normal saline/wound cleanser, pat dry, apply nystatin cream cover with border gauze daily and as needed for stage II ulcer as of 07/03/2024. cleanse left heel with normal saline/wound cleanser pat dry, apply Santyl and calcium alginate, cover with border gauze daily and as needed for stage II pressure ulcer. Review of the Admission / Readmission Nursing Evaluation dated 07/02/2024 showed skin tear to right antecubital, redness blanchable and open on coccyx, right knee (front) surgical incision, left heel Deep Tissue Injury (DTI), bilateral bruises to upper extremities, and bottom of left foot DTI. Review of the Weekly Skin Check dated 07/03/2024 showed 6 hemorrhoids nodules not in coccyx, AKA with 26 sutures noted right knee front, left heel DTI, fungal rash/MASD on sacrum, first digit lateral foot diabetic ulcer, and right forearm skin tear. Review of the Weekly Skin Check dated 07/13/2024 showed no new abnormalities noted. Review of the wound doctor's note dated 7/16/24 showed the visit was an initial visit. The left, medial diabetic foot ulcer was 1 x 1.5 x 1, grade I, with moderate sero-sanguineous exudate, 20% slough, and 80% granulation. The wound was to be cleansed, pat dry, apply Santyl, calcium alginate daily and prn. The left heel pressure ulcer was not healed. It was not healed. It was 3 x 5 x 0 and an unstageable pressure injury with 100% eschar. The wound was to be cleaned with betadine and leave open to air daily and prn. Review of the care plans for Resident #267 showed resident was at risk for further skin impairment related to anemia, diabetes, risk for malnutrition, weakness/ decreased mobility and cancer of right lower extremity including the hip as of 07/04/2024. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 07/08/2024; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 07/08/2024. Review of the care plan open area left heel and sacrum initiated 07/04/2024. Interventions included but not limited to complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for signs and symptoms (s/s) of infection. Report changes to MD as indicated as of 07/04/2024. PT/OT consult/referral as needed as of 07/04/2024. Wound Care MD/APRN consult as ordered/indicated as of 07/04/2024. Review of the care plan for surgical wound to (R) above knee amputation and was at risk for complications as of 07/04/2024. Interventions included but not limited to notifying MD for any s/s of infection (redness, increased pain, purulent drainage, swelling, foul odor, etc.) as of 07/04/2024. Observe/monitor for s/s of potential complications of wound. Notify MD as indicated as of 07/04/2024. Review of the care plan for diabetic ulcer of the 1st digit lateral foot as of 07/04/2024. Interventions included but not limited monitor for worsening of wound, change in skin status ie: s/s infection, non-healing, new areas to MD and update resident/representative as indicated as of 07/08/2024. Monitor/document wound: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated as of 07/08/2024. Monitor/document/report PRN any s/sx of infection: [NAME] drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever as of 07/08/2024. During an interview on 07/17/2024 at 3:40 p.m. Staff A, Licensed Practical Nurse (LPN) wound care nurse stated the resident was admitted with a (R) AKA and he had multiple wounds before admission. She stated he had a diabetic ulcer on the side of his big toe on the left foot. He had a DTI on the left heel as well. She stated the resident came in with a fungal rash on his sacrum. Staff A stated there were no wound sizes or assessment since on the resident since 07/02/2024. She stated the resident was admitted after the wound care doctor had left the faciity on [DATE]. Staff A stated on 07/09/2024 she was not at the facility and the wound care doctor did not send anyone to the facility either. Staff A, LPN stated the expectation for someone to have documented something about the wounds. Staff A stated she saw the resident yesterday (07/17/2024) and today (07/18/2024) and the coccyx was closed. She stated he scratches his head constantly. On admission it looked like a regular old skin area on his head. She stated when she saw him today, it looked like he had scratched the area. Staff A stated it should have been added to a Weekly Skin Sheet when it was observed. She stated that she had not documented yes today. Staff A stated the negative outcome for lack of assessment and documentation was not being able to see if the wounds had increased and got worse. Staff A stated, No one would know. She stated the head area was a scabbing area on his head. She stated, His wound on his toe had improved, more granulation than first when she first saw it. She stated the heel wound was still bothering him and was tender. She stated they were offloading his heel. She stated she called for an order to add more cushion to the dressing for the heel. During an interview on 07/17/2024 at 3:45 p.m. the DON verified the lack of wound care assessments for the resident. 50836 5. A review of Resident #362's Admission Record revealed an admitted [DATE] with a readmitted [DATE] and diagnoses to include pressure ulcer of sacral region, stage 4. A review of Resident #362's July 2024 physician orders revealed the following: -Cleanse Coccyx with Normal Saline/wound cleanser pat dry Apply skin prep to coccyx skin prep, apply collagen particle (collagen particle with Normal saline slurry) to wound bed cover with border foam dressing. QD (every day) and PRN (as needed). every day shift for wound AND as needed for damaged or missing dressing Active 7/3/2024 08:00 (a.m.). An attempt to interview Resident #362 was conducted on 7/15/2024 at 10:30 a.m. Resident #362 is not interviewable. A record review of the resident's Quarterly Minimum Data Set (MDS) revealed in Section C- Cognitive Patterns, dated 07/12/2024, a Brief Interview for Mental Status (BIMS) summary score of 00, showing the resident is not cognitively intact. In section M- Skin Conditions it revealed the presence of 1 stage 4 pressure injury that was present on admission. A review of Resident #362's care plan, dated 05/16/2024, revealed Resident #362 had an unavoidable pressure injury to his coccyx and was at risk for further skin impairment. The goal was to show signs of improvement. Interventions included: Skin checks to be weekly and as indicated. A review of the Resident #362's Skin Check records from 05/24/24 through 07/16/24 revealed four Skin Checks dated: 07/11/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment is in place to coccyx. no new skin concerns noted. 07/01/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new skin concern. 06/22/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: under wound care provider with tx [treatment] noted improving at this time no other skin integrity abnormalities noted at this time. 06/14/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment continue. No new skin concern noted. An interview was conducted on 07/17/2024 at 9:43 AM with the Director of Nursing (DON). The DON stated if a resident has an identified wound they should have a weekly wound assessment. She went on to state the bedside nurse and wound care nurse will do a weekly wound assessment not just a weekly skin check. 6. A review of Resident #58's Admission Record revealed an admitted [DATE] and diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter. A review of the July 2024 physician orders revealed the following: -cleanse Right lateral foot with normal saline/ wound cleanser apply collagen powder to wound bed, biopad collagen dressing, tritec silver cover with border gauze and PRN. every day shift for wound care AND as needed for missing/ damaged dressing, Active 5/28/2024 15:00 (3:00 p.m.). A review of Resident #58's care plans, initiated on 01/11/2023, revealed Resident #58 was at risk of skin impairment. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #58's Quarterly MDS, Section M, dated 04/08/2024, revealed the presence of 1 pressure wound that was facility acquired. It revealed Resident #58 has a stage 3 pressure injury. A review of Resident #58's Skin Check documents revealed skin checks dated: 07/10/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment to right lateral foot in place, no new skin concerns noted. 07/03/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new areas. Treatment in place for wound to foot. 06/25/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new skin concerns noted. 7. A review of Resident #5's Admission Record revealed an admitted [DATE] with diagnoses to include unspecified superficial injury of right ankle, subsequent encounter. A review of Resident #5's July 2024 physician orders revealed: -cleanse Right Medial Ankle with ns [normal saline]/ wound cleanser pat dry apply Honey gel, Calcium Alginate cover with Border Gauze. QD & PRN every day shift for DTI (deep tissue injury) AND as needed, start date:7/16/2024. A review of Resident #5's care plans, dated 11/09/2022, revealed Resident #5 is at risk for skin impairment with a goal of no new skin impairments. Interventions included: monitor/observe skin while providing routine care, notify nurse of any area of concern as indicated, skin checks weekly and as indicated. Report any s/s (signs and symptoms) of skin breakdown to MD/wound team as indicated. A review of Resident #5's Quarterly MDS, 07/07/2024, revealed in Section C- Cognitive Patterns a BIMS score of 09, which showed moderate cognitive impairment. Section M- Skin Conditions showed the resident had a stage 3 pressure injury present at the time of that assessment. A review of Resident #5's Skin Check documents revealed skin checks dated: 07/16/2024 -Section 1: site: is a body diagram that is not marked; Section 2. Comments: open dti found to the inner right heel, family and MD (Medical Doctor) made aware. 07/09/2024 - Section 1. site, Other (specify) no further documentation in that area; Section 2: comments: open dti to the inner right heel family and MD made aware. 07/02/2024 -Section 1: site: 49) right heel- dti; Section 2: Comments: open dti found to the inner right heel family and md made aware. An interview conducted on 07/17/2024 at 11:31 AM with Staff A, Licensed Practical Nurse (LPN)/wound care, and stated she has not had a chance to document the current wound assessments, but she has the measurements and descriptions in her personal notes. She stated Resident #5 wasn't seen last week because she was off sick. Staff A went on to state that she loaded the wound care doctor's note from yesterday. Staff A stated typically anything in the wound evaluation assessment would be done by the wound care nurse. She also stated Skin Checks were not her responsibility, but that generally when she is already seeing the resident she will do the Skin Check in addition to the Wound Evaluation. She stated Because a weekly skin assessment is done, I don't do measurements in the weekly skin check, wound assessments should be done weekly She further stated, I don't monitor [Resident #5] , she is seeing outside wound care. I would still take measurements. I still try to assess her weekly. During an interview conducted on 07/17/2024 at 11:51 AM the DON stated the outside doctor should send measurements. She stated that she would expect the staff to document measurements and descriptions of wounds weekly. The DON stated she was going to call the doctor this week to get measurements, but without them being uploaded the bedside nurses wouldn't have access to the records. She stated Staff A is responsible for uploading the note so the nurse can see them. The nurses have access to review the notes. She also stated if the doctors don't send notes the unit managers should call for the documents. She said, I follow who has appointments. She stated she expects weekly documentation on wounds the wound care doctor is following to be uploaded to the electronic medical record weekly. They should also have weekly skin assessments. She stated skilled notes are not skin assessments. Every week there should be an assessment apart from the Daily Skilled Nurses Note A review of the facility policy titled Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, effective October 2020, revised January 2024, revealed under the section titled Procedure: Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2.Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) c. Wash the skin after episodes of incontinence. d. Reposition resident as indicated on the care plan. A review of the facility policy titled, Standards and Guidelines: Documentation, effective October 2020, revised January 2024, revealed under the section titled Procedure: 1. Documentation in the medical record may be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record: a) objective observations; c) Treatments or services performed; d) Changes in the resident's condition; 3. documentation in the medical record is required as updates/ changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure /treatment was provided; b) the name and title of the individual(s) who provided the care; c) the assessment data and/or any unusual findings obtained during the procedure/treatment; d) whether the resident refused the procedure/ treatment; e) whether the resident refused the procedure/treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting. 14161

Based on observations, interviews, and record reviews, the facility failed to ensure treatment and services for pressure ulcers were consistent with professional standards for three residents (#5, #362, and #58) of three sampled residents. Findings included: 1. A review of Resident #362's Admission Record revealed an admitted [DATE] with a readmitted [DATE] and diagnoses to include pressure ulcer of sacral region, stage 4. A review of Resident #362's July 2024 physician orders revealed the following: -Cleanse Coccyx with Normal Saline/wound cleanser pat dry Apply skin prep to coccyx skin prep, apply collagen particle (collagen particle with Normal saline slurry) to wound bed cover with border foam dressing. QD (every day) and PRN (as needed). every day shift for wound AND as needed for damaged or missing dressing Active 7/3/2024 08:00 (a.m.). A review of Resident #362's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. An attempt to interview Resident #362 was conducted on 07/15/2024 at 10:30 a.m. Resident #362 is not interviewable. A record review of the resident's Quarterly Minimum Data Set (MDS) revealed in Section C- Cognitive Patterns, dated 07/12/2024, a Brief Interview for Mental Status (BIMS) summary score of 00, showing the resident is not cognitively intact. In section M- Skin Conditions it revealed the presence of 1 stage 4 pressure injury that was present on admission. A review of Resident #362's care plan, dated 05/16/2024, revealed Resident #362 had an unavoidable pressure injury to his coccyx and was at risk for further skin impairment. The goal was to show signs of improvement. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #362's Wound Evaluation- Weekly forms dated 06/20/2024 through 07/16/2024 revealed three Wound Evaluation forms in the electronic medical record (EMR). The Wound Evaluations were as follows: 06/20/2024: I. Wound Summary: Length: 1.4, Width: 1, Depth:0.2 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired),2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%; 4. Wound color: a. Pink. 06/26/2024: I. Wound Summary: Length: 1, Width: 0.6, Depth: 0.2 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%, 4. Wound color: a. Pink. 07/04/2024: I. Wound Summary: Length: 1.2, 3b. Width: 0.5, 3c. Depth:0.1 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%, 4. Wound color: a. Pink. An interview was conducted on 07/17/2024 at 9:43 AM with the Director of Nursing (DON). The DON stated if a resident has an identified wound they should have a weekly wound assessment. She went on to state the bedside nurse and wound care nurse will do a weekly wound assessment not just a weekly skin check. 2. A review of Resident #58's Admission Record revealed an admitted [DATE] and diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter. A review of the July 2024 physician orders revealed the following: -cleanse Right lateral foot with normal saline/ wound cleanser apply collagen powder to wound bed, biopad collagen dressing, tritec silver cover with border gauze and PRN. every day shift for wound care AND as needed for missing/ damaged dressing, Active 5/28/2024 15:00 (3:00 p.m.). A review of Resident #58's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. A review of Resident #58's care plans, initiated on 01/11/2023, revealed Resident #58 was at risk of skin impairment. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #58's Quarterly MDS, Section M, dated 04/08/2024, revealed the presence of 1 pressure wound that was facility acquired. It revealed Resident #58 has a stage 3 pressure injury. A review of Resident #58's Wound Evaluations revealed three Wound Evaluations in the EMR from 04/30/2024 through 07/16/2024. The Wound Evaluations were as follows: 05/08/2024: I. Wound Summary: Length: 1.5, Width: 1.7, Depth:0.01, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound Bed - 4. Wound color: a. Pink, b. White. 05/23/2024: I. Wound Summary: Length: 0.4, Width: 0.5, Depth:0, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound bed - 3b. granulation %-100%, 4. Wound color: a. Pink, b. white. 05/29/2024: I. Wound Summary: Length: 2.3, Width: 3.5, Depth:0, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound bed - 3b. granulation %-100%, 4. Wound color: a. Pink, b. white. 3. A review of Resident #5's Admission Record revealed an admitted [DATE] with diagnoses to include unspecified superficial injury of right ankle, subsequent encounter. A review of Resident #5's July 2024 physician orders revealed: -cleanse Right Medial Ankle with ns [normal saline]/ wound cleanser pat dry apply Honey gel, Calcium Alginate cover with Border Gauze. QD & PRN every day shift for DTI (deep tissue injury) AND as needed, start date:7/16/2024. A review of Resident #5's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. A review of Resident #5's care plans, dated 11/09/2022, revealed Resident #5 is at risk for skin impairment with a goal of no new skin impairments. Interventions included: monitor/observe skin while providing routine care, notify nurse of any area of concern as indicated, skin checks weekly and as indicated. Report any s/s (signs and symptoms) of skin breakdown to MD/wound team as indicated. An interview conducted on 07/15/2024 at 11:00 a.m. Resident #5 was found to be verbal but not interviewable. A review of Resident #5's Quarterly MDS, 07/07/2024, revealed in Section C- Cognitive Patterns a BIMS score of 09, which showed moderate cognitive impairment. Section M- Skin Conditions showed the resident had a stage 3 pressure injury present at the time of that assessment. A review of Resident #5's Electronic Medical Record revealed no weekly Wound Evaluations were completed between 6/17/2024 and 07/16/2024. Review of the EMR revealed skin checks dated: 07/16/2024: section 1: site: is a body diagram that is not marked. Section 2. Comments: open dti found to the inner right heel, family and MD (Medical Doctor) made aware., 07/09/2024: section 1. site, Other (specify) no further documentation in that area. Section 2: comments: open dti to the inner right heel family and MD made aware07/02/2024: section 1: site: 49) right heel- dti. Section 2: Comments: open dti found to the inner right heel family and md made aware. An interview conducted on 07/17/2024 at 11:31 AM with Staff A, Licensed Practical Nurse (LPN)/wound care, stated she has not had a chance to document the current wound assessments, but she has the measurements and descriptions in her personal notes. She stated Resident #5 wasn't seen last week because on Tuesday, she tested positive for COVID-19; which was about the same time the wound care doctor was out with COVID-19 also. Staff A stated she loaded the wound care doctor's note yesterday. Staff A stated typically anything in the wound evaluation assessment would be done by the wound care nurse. She also stated skin checks were not her responsibility, but that generally when she is already seeing the resident she will do the skin check in addition to the Wound Evaluation. She stated, Because a weekly skin assessment is done, I don't do measurements in the weekly skin check; wound assessments should be done weekly. She further stated, I don't monitor [Resident #5]. She is seeing outside wound care. I would still take measurements. I still try to assess her weekly. During an interview conducted on 07/17/2024 at 11:51 AM the DON stated the outside doctor should send measurements. She stated that she would expect the staff to document measurements and descriptions of wounds weekly. The DON stated she was going to call the doctor this week to get measurements, but without them being uploaded the bedside nurses wouldn't have access to the records. She stated Staff A is responsible for uploading the note so the nurse can see them. The nurses have access to review the notes. She also stated if the doctors don't send notes, the unit managers should call for the documents. She said, I follow who has appointments. She stated she expects weekly documentation on wounds the wound care doctor is following to be uploaded to the electronic medical record weekly. They should also have weekly skin assessments. She stated skilled notes are not skin assessments. Every week there should be an assessment apart from the daily skilled nurses note. A review of the facility policy titled, Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, effective October 2020 and revised January 2024, revealed under the section titled Procedure: Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2.Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs (activities of daily living). a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) c. Wash the skin after episodes of incontinence. d. Reposition resident as indicated on the care plan. A review of the facility policy titled, Standards and Guidelines: Documentation, effective October 2020 and revised January 2024, revealed under the section titled Procedure: 1. Documentation in the medical record may be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record: a) objective observations; c) Treatments or services performed; d) Changes in the resident's condition; 3. documentation in the medical record is required as updates/ changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure /treatment was provided; b) the name and title of the individual(s) who provided the care; c) the assessment data and/or any unusual findings obtained during the procedure/treatment; d) whether the resident refused the procedure/ treatment; e) whether the resident refused the procedure/treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting.

Based on record review, interview and review of the facility's policy Dialysis Care, the facility failed to ensure ongoing communication was established between the facility and dialysis center for three residents (#33, #35 and #268) of three residents reviewed for dialysis services. Findings included: Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to End stage renal disease, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and Dysphasia following cerebral infarction. Review of the Order Summary Report showed a current physician order dated 07/15/24 that revealed Dialysis [Tuesday]T, [Thursday]TH, {Saturday}Sat, [Local Dialysis Center] [Local Dialysis Center phone number] chair time: 12 Noon Transport Through [Local Transport Company] between 11:00- 11:15 am. Review of the Care Plan showed,Focus- At risk for complications r/t Hemodialysis dx: ESRD [end stage renal disease]. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - Hemodialysis-Resident receives [Hemodialysis]HD every [Tuesday]T-[Thursday]TH-[Saturday]S at [Local Dialysis Center], Local Dialysis Center Phone Number]. Chair time is 11:30 am-transported by [Local Transport Company], [Local Transport Company phone number], via W/C with P/U time of 10:45 am. - Hemodialysis-Right Upper Chest dialysis access port. Monitor site for s/s of infection, pain, drainage, increased temp, edema, etc. Notify physician of abnormal findings. Encourage resident to attend the scheduled dialysis appointments. Avoid blood pressure, blood work, IV insertion on affected arm. Monitor for dry skin and apply lotion as needed. Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of Resident #33's Dialysis Communication Book on 07/16/24 at 4:20 p.m., showed no communication book available and one single Dialysis Communication Form found at the nurses station. Review of the single Dialysis Communication Form dated 07/13/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. During an interview on 07/15/24 at 1:48 p.m., Resident #33 stated he went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 07/16/24 at 4:21 p.m. Staff D Registered Nurse (RN) stated, sometimes Dialysis writes back but most of the time they do not. Staff D stated the facility was responsible for completing pre and post checks on Residents before and after dialysis treatments. Review of Resident #33's dialysis book on 07/17/24 at 8:45 AM showed no communication dialysis book available. During an interview on 07/17/24 at 9:02 a.m., the Director of Nursing (DON) stated that Resident # 33's communication book must have been left at the dialysis center yesterday as the facility cannot find it. The DON stated the Nurse was calling the Dialysis Center to see if they have it. Review of Resident #33's Progress Notes revealed no ongoing communication between the facility and dialysis center. Review of the Admission Record showed Resident #35 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to End Stage Renal Disease [ESRD], Type 2 Diabetes Mellitus, muscle weakness (generalized), need for assistance with personal care and aneurysm of unspecified site. Review of the Order Summary Report showed a current physician order dated 10/27/23 Hemodialysis-Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. Review of the Care Plan showed, Focus- At risk for complications related to Hemodialysis dx: ESRD. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - Hemodialysis- Right Chest Permacath dialysis access port/line. Monitor site for s/s of infection, pain, drainage, increased temp, edema, etc. Notify physician of abnormal findings. - Provide snacks/meals to go with resident on dialysis days - Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. - Avoid blood pressure, blood work, IV insertion on affected arm- right. - Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. - Monitor for dry skin and apply lotion as needed. - Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. - Report abnormal labs to doctor as indicated. - Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of Resident #35's Dialysis Communication Book revealed the following Dialysis Communication Form entries: - Resident #35's Dialysis Communication Form dated 07/15/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #35's Dialysis Communication Form dated 07/08/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #35's Dialysis Communication Form dated 07/01/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. Review of Resident #35's Progress Notes revealed no ongoing communication between the facility and dialysis center. Review of the Admission Record showed Resident #268 was admitted to the facility on [DATE] with diagnoses that included but not limited to Chronic kidney disease stage four (severe), chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, recurrent, mild and muscle weakness (generalized). Review of the Order Summary Report showed a current physician order dated 07/15/24 Hemodialysis-Resident receives [Hemodialysis] HD every Tuesday, Thursday and Saturday at [Local Dialysis Center]-[Local Dialysis Center address]-Chair time is-10:20 am. Transported by [Local Transport Company] [Local Transport Company phone number] w/c with P/U time of 9:30 am. Review of the Care Plan showed,Focus- At risk for complications related to Hemodialysis dx: [Chronic Kidney Disease] CKD 4. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - [Hemodialysis] HD-Type: Right upper chest port-Permacath. Dialysis access port/line: Do not access this line-for Hemodialysis use only. - Hemodialysis- Right upper chest port-Permacath) dialysis access port/line: HD center to complete routine dressing changes. May reinforce the dressing if dislodged. May replace the dressing if unable to reinforce using sterile technique. - Hemodialysis-Offer Resident a packaged meal and/or snack on Tuesday., Thursday., Saturday. before HD appointment. -Hemodialysis-Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. - Avoid blood pressure, blood work, IV insertion on affected arm HD- Right upper chest port precautions-no lab draws, no BP's, etc. - Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. - Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. - Report abnormal labs to doctor as indicated. - Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. - Work with resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headaches, itching, anemia, bone demineralization, body image change and role disruption.) Review of Resident #268's Dialysis Communication Book revealed the following Dialysis Communication Form entries: - Resident #268's Dialysis Communication Form dated 07/04/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #268's Dialysis Communication Form dated 07/11/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. Review of Resident #268's Progress Notes revealed no ongoing communication between the facility and dialysis center. During an interview on 07/17/24 at 10:50 a.m., Staff F Licensed Practical Nurse (LPN), Unit Manager (UM) stated that the Dialysis Center will fill out the Dialysis Communication Form sometimes and sometimes not. Staff F LPN, UM stated that she does not call the Dialysis Center for an update when the Dialysis Communication Form was blank but stated I will call monthly to the Dialysis Center to get updated treatment and care notes. Staff F LPN, UN stated, when the forms are not completed, I do not want to bother the Dialysis Center all the time so I just call and get the dialysis care notes monthly and then have them scanned in the resident's medical record. Staff F LPN, UM stated the facility was completing resident pre and post assessments when a Resident goes out and returns from dialysis services. Staff F LPN, UM stated we just do not always get communication back from the dialysis center. During an interview on 07/17/24 at 11:00 a.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated it is my responsibility to make the dialysis books and have flow sheets in those books. Staff G LP, UM stated if the facility did not get any communication back from the dialysis center I will call and ask for each residents' treatment notes weekly. Staff G LPN, UM stated sometimes we get a call from the Dialysis Center or we call them for ongoing communication. Staff G LPN, UM stated when phone communication occurs with the dialysis center it will be documented in the progress notes. Staff G LPN, UM stated she called the Dialysis Center and they found Resident #33's dialysis communication book and will send the book back to the facility with the Resident #33 on his next scheduled dialysis appointment tomorrow 07/18/24. During an interview on 07/17/24 at 11:36 a.m., the Director of Nursing (DON) stated that she would expect the nurses to follow up with the dialysis center every time a resident comes back from dialysis. The DON stated there should be some sort of follow up whether it is on the communication form or by a phone call. The DON stated, if the Dialysis Communication Form comes back incomplete by the dialysis center the nurse should call the dialysis center, get a follow up, and then document communication in a progress note. The DON stated that the all Dialysis Communication Forms should be scanned into the medical record under the documents tab. The DON stated, there should be ongoing communication with the dialysis center every time a Resident returns from the Dialysis Center and be documented in the Resident's medical record. Review of the facility's policy Dialysis Care revised date 08/2023 showed, Procedure: 4. Correspondence from the dialysis center will be addressed by facility staff and will be recorded in the plan of of care. 5. The facility will communicate nonadherence of the dialysis regimen to the dialysis center as well as attending physician.

Based on observations, record review and interviews, the facility failed to ensure hand hygiene was performed during medication administration, the blood glucose monitoring machines were adequately disinfected, and blood pressure cuffs were cleaned between residents for 6 (#66, #86, #272, #67, #19, and #97) of 39 sampled residents; and the facility failed to ensure staff doffed Personal Protective Equipment (PPE) before entering/exiting two resident rooms (234 and 248) on droplet precautions. Findings included: On 07/16/2024 at 8:00 a.m. Resident #66 was observed during medication pass with Staff D, Registered Nurse (RN). Staff D, RN pushed the medication cart from the nurse's station to the resident's room. She was observed to not hand sanitize prior to medication pass. She entered the resident's room with a blood pressure machine. Staff D sat the blood pressure machine on the resident's bed and proceeded to take his blood pressure. The blood pressure was 117/68. Staff D exited the room with the blood pressure machine and sat it on the top of the mediation cart without cleaning it. Staff D proceeded to open the medication cart and started removing his medications. She had not hand sanitized. After administering the resident's medications, she exited the room and still had not performed hand sanitizing or cleaned the blood pressure machine. On 07/16/2024 at 8:15 a.m. Resident #86 was observed during medication pass with Staff H, Licensed Practical Nurse (LPN). Staff H was observed pushing the medication cart from the nurses' station and entered the resident's room with a blood pressure cuff, without hand sanitizing. Staff H took the resident's blood pressure. Staff H exited the room, applied gloves and cleaned the blood pressure cuff, removed his gloves, and did not hand sanitize. Staff H was observed touching his hair throughout the medication pass. Staff H entered the resident's room with gloves in place and took the box with the inhaler in it, into the resident's room. The resident was handed the inhaler to the resident and he took his medication. Staff put the inhaler back into the box and brought it back out of the resident's room. Staff H removed his gloves at the medication cart, he did not hand sanitize. He opened the cart and replaced the boxed inhaler back into the medication cart. He still had not hand sanitized. Staff H left the medication cart, went to the nurses' station, then down the hallway to another nurse's medication cart and retrieved insulin syringes. While returning to his medication cart, he stopped in room [ROOM NUMBER] due to the call light being on. He progressed to his cart. On his return he still had not hand sanitized. Staff H opened the medication cart and retrieved a multiple dose bottle of insulin. Staff H applied gloves without hand sanitizing. He removed the alcohol wipe from the cart and cleaned the top of the vial. He withdrew 10 units of insulin. Staff H entered the resident's room with glove in place and injected the insulin in the right arm of the resident. He removed his gloves, disposed of the syringe and washed his hands. On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, LPN. Staff J was observed applying gloves without hand sanitizing before entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart without a barrier. Staff J removed her gloves and washed her hands. On 07/16/2024 at 8:45 a.m. Resident #67 was observed during medication pass with Staff J, LPN. Staff J was observed to not perform hand sanitizing prior to medication administration. Staff J took a blood pressure machine into the resident's room and the blood pressure was taken, 141/65. Staff J returned to the medication cart and placed the used blood pressure cuff on the medication cart. Staff J did not clean the blood pressure cuff or hand sanitize. Staff J administered the medications to the resident. She returned to the medication cart and did not hand sanitize. Staff J was observed taking the dirty blood pressure cuff back into room [ROOM NUMBER]B and taking the blood pressure of the roommate in the room. She returned to the cart with the blood pressure cuff and laid it on the cart. On 07/16/2024 at 8:50 a.m. Resident #97 was observed during medication pass with Staff K, RN. Staff K did not hand sanitize prior to medication administration. Staff K placed the used blood pressure cuff on the medication cart without cleaning it. Upon leaving the room, she had not hand sanitized. Hand sanitizing was not performed after passing the medications. Staff K was observed using the uncleaned blood pressure cuff on Resident #12. On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. Staff H was sitting at nurses' station, moved the medication cart to the resident's room. Staff H washed his hands. Staff H laid the blood glucose monitor, lancet, bottle of strips and plastic cup on top of medication cart as well as 2 alcohol wipes. Staff H applied gloves. Staff H took the blood glucose monitor, lancet, bottle of strips and laid them on the (dirty) overbed table. The table had not been cleaned and had personal items as well as food on it. Staff H placed a strip in the blood glucose monitor. He laid the blood glucose monitor back on the overbed table as well as the bottle of strips. He opened an alcohol wipe and wiped the left pointer finger. He used a lancet. wiped the finger again with alcohol and placed a drop of blood on the strip. The blood sugar level was 140. He laid the blood glucose monitor on overbed table. He then picked up the blood glucose monitor, bottle of strips and used lancet and exited room. He put the used lancet and strip in the hazardous waste. He placed the dirty blood glucose monitor in the plastic cup and placed the bottle of strips on the cart. He took the blood glucose monitor out of the cup and wrapped a wipe from the Microdot Minute container and replaced into the same cup. 1/4 of the blood glucose monitor was not covered by the wrap. Staff H removed his gloves and hand washed. He had left the computer open to names and a paper with names on the medication cart while performing the blood glucose monitoring. During an interview Staff H, LPN stated he wraps the blood glucose monitor and leaves it for 3 minutes. During the interview he locked his cart and left and walked toward the nurses' station and then down the hallway out of view. The blood glucose monitor, and bottle of strips were left on the medication cart. He returned with insulin syringes in his hand. When he returned, he washed his hands. He replaced his gloves. He removed the insulin from the medication cart, removed it from the baggie and box. He used an alcohol wipe and cleaned the top of the insulin bottle. He removed 4 units on insulin. He entered the resident room and injected the insulin into her left arm post use of alcohol. Staff H returned to the cart and threw away the syringe in the hazardous container and removed his gloves. Staff H washed his hands. During an interview following the observation, Staff H stated he wraps the blood glucose monitor and leaves it for 3 minutes. then removes the wipe and lets it dry. He stated the blood glucose monitor was to be cleaned after each use and placed in the cart. Staff H stated the blood pressure cuffs are to be cleaned with the Microdot wipes also, after each resident. Staff H stated he lets the blood pressure cuff sit also. He stated he was supposed to hand sanitize between each resident, before and after medication pass, before and after glove changes. Staff H stated he washes his hands after gloves are removed and before gloves are put on. Staff H stated he washes his hands because the hand sanitizer breaks his hands out, so he just hand washes. During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration observation. The DON stated the staff was supposed to clean the blood pressure cuffs between residents. She stated they are supposed to hand sanitize before and after med pass, with gloves changes. The expectations were for medication boxes to not go into the resident's room, insulin was not to be left on the computer and out of a locked medication cart. The blood pressure cuffs, and blood glucose monitors need to be cleaned between residents. The DON stated they needed to instruct the staff on infection control, which included hand sanitizing or hand washing. Review of the facility's policy, Standards and Guidelines: Medication Administration, revised 01/2024 showed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Standards and Guidelines: Hand Hygiene Infection Control, revised 6/2023 showed Standard: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: The facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene and healthcare settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings to promote resident safety. These guidelines state that hand washing is necessary when health care personnel hands are visibly soiled. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by healthcare personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Situations that require hand hygiene include, but are not limited to: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) Before and after performing any invasive procedure (e.g., finger stick blood sampling) Before and after entering isolation precaution settings Before and after medication administration After removing gloves or aprons Review of the facility's policy, Standards and Guidelines: Disinfecting, revised 01/2024 showed Guideline: The facility will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal regulations, and national guidelines. Procedure: 1. EPA-registered healthcare disinfectant wipes will be used in accordance with manufacturer's instructions. An EPA- approved intermediate level disinfectant wipe is required for surfaces soiled with body fluid. Disinfectant wipes are used to clean the following items: B. Non-critical (i.e. contact with intact skin only) resident care equipment. Review of the EvenCare Proview Blood Glucose Monitoring System User's Guide, dated 2018 showed on page 40, 6. Caring for the Meter: caring for the meter is easy. Single-use medical protective gloves should be worn during disinfection procedures and also by anyone performing blood glucose testing on another person. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Use gloves should be removed and hands washed before proceeding to the next patient. Cleaning and Disinfecting Procedures for the Meter: the EVENCARE are ProView meter should be cleaned and disinfected between each patient. Disinfection Instructions: the meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Disinfection Instructions: step 1. Before disinfecting, clean the meter as described in Cleaning Your Meter process. Step 2. Wash hands with soap and water, put on single-use medical protective gloves. Step 3. Prepare the CaviWipe towelette or EPA-registered disinfecting wipe. Take out a wipe from the container and follow the instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid. Step 4. Wipe the glucose meter thoroughly including the front, back and sides and take care not to get any liquid in the test strip port or serial port. Do not wrap the meter in a wipe. Step 5. If using the CaviWipe towelette, allow to remain wet for two minutes. For other EPA- registered disinfectant wipes allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipes instructions for use. Dispose of wipe when finished. Step 6. After disinfection, users should take off gloves and wash hands thoroughly with soap and water before proceeding to the next patient 41015 An observation on 07/16/24 at 12:01 p.m., revealed Staff A, Licence Practical Nurse (LPN) exiting room [ROOM NUMBER] with the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained. During an interview on 07/16/24 at 12:03 p.m., Staff A, LPN stated Sorry that was my bad; the face shield should have been taken off before I left the room. An observation on 07/16/24 at 12:13 p.m., revealed Staff B Certified Nursing Assistant (CNA) exiting room [ROOM NUMBER] with a blue surgical mask under the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained. During an interview on 07/16/24 at 12:13 p.m., Staff B, CNA stated , I forgot to take it off when I left the room. During an interview on 07/17/24 at 5:46 p.m., the Director of Nursing (DON) stated, she would have expected the staff to don a N95 mask prior to entering a droplet precaution room and also doff the face shield and mask prior to leaving the room. The DON stated staff are expected to follow the instructions on the transmission based precaution signs. A review of the facility's Policy Standards and Guidelines: Screening, Testing, Return to work, Personal Protective Equipment, Isolation, Reporting revised date 06/24/24 showed, PPE (Personal Protective Equipment)/Hand Hygiene 1. Covid Unit- If the facility has an active Covid unit, then facility staff and visitors on the unit should wear full PPE including N95 mask and eye wear. 3. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door.

Based on record review and interview the facility failed to code the Minimal Data Set (MDS) accurately at discharge for one resident (#111) of three residents reviewed for close records. Findings included: Review of the Admission record showed Resident #111 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to malignant neoplasm of unspecified part of right bronchus or lung, chronic obstructive pulmonary disease, unspecified atrial fibrillation, chronic kidney disease, stage 3 B and generalized muscle weakness. Review of a physician order dated 04/22/24 showed, Send to Hospital for [treatment]Tx and [Evaluation] Eval. Review of progress notes revealed the following two progress notes: Change in Condition dated 04/20/24 showed, Situation: The change in conditions reported on the Evaluation are/were: Falls Nausea/Vomiting. Primary Care Provider Feedback Recommendations: Send to ER for treatment and evaluation. Physical Medicine and Rehabilitation Subsequent Evaluation dated late entry 04/23/24 showed, hospitalized . Review of the Discharge Return Anticipated /End of PPS Part A Stay MDS dated [DATE] revealed Section A 2105. Discharge Status was marked 01. Home/Community. During an interview on 07/17/24 at 3:20 p.m., Staff M, MDS Director reviewed Resident #111's medical record and stated stated Resident #111 was hospitalized at discharge. Staff M, MDS Director confirmed Resident #111's Discharge MDS was marked incorrectly as Resident #111 did not go home to the community but was hospitalized .

Based on record review and staff interviews, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate for two residents (# 7, #19) of 25 residents sampled. Findings included: 1. Review of Resident #19's Admission Record revealed an admitted [DATE] with diagnoses to include Anxiety Disorder and Major Depressive Disorder. Review of the Level I PASRR, dated 08/24/2023, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) the diagnosis of Depressive Disorder was not marked. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 2. Review of Resident #7's Admission Record revealed an admitted [DATE] with diagnoses to include Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder and Generalized Epilepsy and Epileptic Syndromes. Review of the Level I PASRR, dated 08/30/2023, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) the diagnoses of Bipolar Disorder and Depressive Disorder were marked. Part B Intellectual Disability (ID) or suspected Intellectual Disability (ID) the related condition of Epilepsy was not marked. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. An interview was conducted on 07/17/2024 at 2:55 p.m. with the Nursing Home Administrator (NHA) and the Admissions Director. The Admissions Director said she receives the PASRR's from the hospital and uploads them into the system. She also said once the resident is in the building the PASRR is reviewed by the clinical team; it does not get reviewed pre-admission. The NHA said the clinical team has a daily clinical meeting in which PASRR's are reviewed. She said the clinical team consists of the Director of Nursing (DON), the Assistant Director of Nursing (ADON), Unit Managers and Social Services.

Based on record review, interview and review of the Resident Assessment Instrument (RAI), the facility failed to ensure one resident (#106) of five residents reviewed for unnecessary medications had the care plan revised after a medication was discontinued. Findings included: Review of the Admissions Record showed Resident #106 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified convulsions, muscle weakness, and cognitive communication deficit. Review of the Medication Review Report showed Resident #106 had no antipsychotic drug regimen. Review of the Discontinued Physician Orders revealed Olanzapine Tablet 5 [milligrams] MG- Give 0.5 tablet by mouth two times a day for psychotic disorder. with discontinued date 06/12/24. Review of Care Plan showed the following care area: Focus- The resident uses antipsychotic medications r/t Behavior management Date Initiated: 05/31/2024. Goal- The resident will be/remain free of antipsychotic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions: Administer antipsychotic medications as ordered by physician. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms as indicated. Medication review as indicated/PRN. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 05/31/2024 Psych Services consult and follow up as ordered/indicated. During an interview on 07/16/24 at 3:44 p.m., the Director of Nursing (DON) reviewed Resident #106 current physician orders and care plan and stated the care plan should have been revised to reflect the discontinued antipsychotic use. During an interview on 07/17/24 at 1:55 at p.m., the Director of Nursing (DON) was asked for the facility's care plan policy. The DON stated the facility did not have a policy for care plans as the facility followed the RAI manual for care plans instructions. Review of the MDS 3.0 [Resident Assessment Instrument] RAI User's Manual for Long-Term Care Version 1.18.11 dated October 2023 showed, Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observation, interview and record review, the facility failed to ensure the Plan of Care was followed for 1 of 39 sampled residents (#267) related to an order for a medication, documentation of administering the medication and follow-up documentation. Findings included: During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated that on Saturday at 3 p.m., they told the aide he was in pain due to constipation. They requested a suppository. They stated the nurse came in an hour later and stated she would come back after she performed medication pass. The stated it was 3-4 hours later before he got a suppository. The wife stated she performed the majority of the care, bathing, cleaning him, lotion. She stated he wants her to provide his care. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed no orders for bowel regimen, Dulcolax suppository. Review of the physician orders showed no order for Dulcolax suppository on 07/13/2024. Review of the July 2024 MAR (medication administration record) did not show a Dulcolax Suppository had been administered on 07/13/2024. Review of the progress notes for 07/13/2024 showed no documentation related to abdominal pain, notification of physician for an order, receiving an order for a suppository or suppository administration for constipation. There was lack of documentation of results of the suppository. Review of the care plan for at risk for bowel irregularity related decreased mobility as of 07/08/2024. Interventions included but not limited to administer medications as per MD orders as of 07/08/2024. Monitor for and document resident's bowel movements as of 07/08/2024. Monitor medications for side effects of constipation/loose stools. Notify MD as indicated as of 07/08/2024. Monitor/observe for abdominal distention, abdominal pain/tenderness/discomfort, decreased bowel sounds, N/V, s/s of constipation, unresolved diarrhea, changes in mental status and notify MD/NP/PA as indicated as of 07/08/2024. During an interview on 07/17/2024 at 3:45 p.m. the Director of Nursing (DON) stated they normally review the bowel needs on admission, including review of the drugs and diagnoses to see if constipation or diarrhea medications are needed to be a standing order. The DON stated she would have to look into it (administration of suppository for constipation). The DON verified the resident did not have any bowel regimen orders. She stated the staff can call the medical provider 24-hours a day to get a medication order. During an interview on 07/17/2024 at 4:43 p.m. the DON confirmed there was not an order or a progress note about the constipation and suppository in the chart. The DON stated the wife told her the resident normally takes an oral medication daily at home. The DON stated she called the MD (medical doctor) for an order for Senna at bedtime for constipation while he was at the facility. During an interview on 07/17/2024 at 5:15 p.m. the DON stated she spoke with the resident's APRN (advanced practice registered nurse). The APRN told her she gave a nurse an order for a suppository. The APRN told the her she does not remember the nurse's name but it was an order for Docusate. The DON stated the Docusate suppository was an over-the-counter medication. The DON stated she spoke with Staff I, Licensed Practical Nurse (LPN) and Staff I stated she gave Resident #267 a suppository but forgot to document it. Staff I told the DON she gave the suppository around 5 p.m. She told the resident she would check on him again after medication pass. The DON state the normal process was for the nurse to call the MD for orders, document the order and give the medication, and document. During an interview on 07/18/2024 at 9:47 a.m., the APRN stated a nurse from the facility called her over the weekend about Resident #267 being constipated. The APRN stated she does not remember which nurse called. APRN stated she ordered a bowel regime. She stated she will either order an oral or a suppository depending on the resident's needs. She stated she ordered a suppository, because the nurse stated the resident had not had a bowel movement in a couple days, and that (suppository) works best. The APRN stated she expected the nurse to write an order based on the verbal order, give the medication and document. During an interview on 07/18/2024 at 9:56 a.m. Staff I, LPN stated she worked the weekends on the .3-11 p.m. shift. She stated she got report from the prior nurse. She stated she checked the resident's room and was told he was constipated and needed a suppository. She told the resident she would need an order for the suppository. She told him she would have to see if he had an order and if he didn't, she would need to call the MD for an order. Staff I, LPN told the resident to give her time to get the order. Staff I stated she got an order from the APRN between him asking and him getting it. She stated, He got the suppository about 5 pm. It was a crazy day. I was running. I went back around 7 p.m. and asked him any results. He had a bowel movement. She stated he said he was okay and relieved. The resident thanked her for the suppository. She stated she saw the resident during p.m. rounds. Staff I, LPN stated the resident told the nurse he was trying to pass the stool and needed help. The APRN gave her the order, but she did not write the order for the suppository. Staff I, stated, She was trying to just give it to him and try to eliminate (another task), made sure he had results. She stated she could not remember if the resident got any other meds. Staff I stated, When I get orders I am putting it in while talking to them, reading it back to them. I was trying to focus on the patient. I was making sure the patient was okay. I normally after giving the med, document. People were on the computer. She stated she normally document prn medications, new orders. Staff I stated, I did not document the results of the bowel movement, went back and asked him, if it worked. Review of the facility's policy, Standards and Guidelines: Medication Administration, revised 01/2024 showed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber orders, including any required time frame. 15. During administration of medications, the medication cart is kept closed and locked when out of sight of the individual administering the medication. It may be kept in the doorway of the residence room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart when not within sight of the individual administering medications. The cart should be clearly visible to the personnel and ministering medications, and all outward sides should be inaccessible to residents or others passing by. 17. As required or indicated for a medication, the individual administering the medication records in the residence medical record: a. The date and time the medication was administered; B. The dosage; C. The route of administration; E. Any complaints or symptoms for which the drug was administered if applicable; F. Any results achieved and when those results were observed if applicable; and G. The signature and title of the person administering the drug. 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Standards and Guidelines: Physician Orders, revised 01/2024 showed Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing. Procedure: 1. Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable. 2. Authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3. Drug and biological orders must be recorded on the physician's order sheet and the resident's electronic chart. 4. The staff and practitioner shall use approved abbreviations and symbols when ordering and or charting medications. 5. Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order. 6. Verbal telephone orders may be received by licensed personnel. Orders should be transcribed by the authorized personnel receiving the order and recorded in the resident's medical record. 7. The entry should contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 8. Orders for medication should include: a. Name and strength of the drug b. Number of doses, start and stop date, and or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration; e. Clinical condition or symptoms for which the medication is prescribed and 9. Physician orders should be followed and prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. 10. The resident will be informed of medication changes as they occur. If the resident is deemed incapable of making health care decisions, the residents responsible party will be informed of medication changes as they occur.

Based on observation, interview and record review, the facility failed to ensure medications were stored properly for 2 (#272 and #19) out of 6 medication administration observations. Findings included: On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, Licensed Practical Nurse (LPN). Staff J was observed entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart and went into the bathroom to wash her hands. The LPN was unable to visualize the unattended medication while she was in the bathroom. On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. The LPN placed the insulin bottle on the computer keyboard on the medication cart, entered the resident's room and injected the insulin. The LPN was unable to visualize the unattended medication while in the resident's room. During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration observation. The DON the expectations were medications were not to be left unattended out of a locked medication cart. Review of the facility's policy, Standards and Guidelines: Medication Storage and Labeling, revised 01/2024 showed Guideline: the facility stores all drugs and biological in a safe, secure, and orderly manner. Procedure: 1 drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on observation, interview, record review and review of the facility's policy Menu and Meals Service: Nourishment/Snacks, the facility failed to ensure one resident (#73) of one resident reviewed was provided a snack when requested. Findings included: During an interview on 07/15/24 at 10:56 a.m., Resident #73 stated, I am still hungry, I got two eggs but I still would like a snack. During an interview on 07/15/24 at 11:00 a.m., Staff C, Certified Nursing Assistant (CNA) was notified of Resident #73's snack request. Staff C, CNA stated, I am not his CNA but he gets double portions for his meals. An observation on 07/15/24 at 11:19 a.m., revealed Resident #73 continued to sit beside his bed in wheelchair with no snack visible on the bedside table. During an interview on 07/15/24 at 11:20 a.m., Resident #73 stated, No one ever brought me that snack. During an interview on 07/15/24 at 11:22 a.m., Staff D, Registered Nurse (RN) Nurse stated, I will go get him a snack and the CNA should have provided it when requested. During an interview on 07/15/24 at 11:36 a.m., Staff C, CNA stated, she never got the snack for Resident #106 but she told Resident #106's assigned CNA. During an interview on 07/15/24 at 11:51 a.m., Staff E, CNA stated Staff C, CNA never told her Resident #73 wanted a snack or she would have provided him one. During an interview on 07/15/24 at 11:55 a.m., Staff D, RN stated that any CNA could have provided Resident #73 with a snack, it did not have to be the assigned CNA. During an interview on 07/17/24 at 3:58 p.m., the Director of Nursing (DON) stated that any CNA can provide a resident a snack when requested, even if they are not assigned to that Resident. The DON stated the only consideration and what the facility educates on with snack requests is the CNA talks with the nurse prior to providing the snack so that the appropriate snack may be given. Review of the facility's policy Menu and Meals Service: Nourishment/Snacks revised date July 2024 showed, Snacks will be available for residents between meals based on request or as part of appropriate therapeutic diet, dietitian recommendation, or physician order.

Based on observation, interview and record review, the facility failed to ensure the medical record was accurate and complete related to to documentation of Skilled Nursing Documentation Notes for 3 (#8, #19, #267) of 39 sampled residents. Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. No odors were noted. No skin impairments were observed. Her personal items were noted. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Chronic Respiratory Failure with hypoxia, diabetes, Chronic Obstructive Pulmonary Disease (COPD), obesity, Congestive Heart Failure (CHF), hypertension with HF, stage IV chronic kidney disease, ischemic cardiomyopathy, anemia, muscle weakness, Transient Ischemia Attack (TIA). Review of the annual, Minimum Data St (MDS) dated [DATE] showed Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). Section GG, Functional Abilities and Goals showed the resident needed moderate assistance. Review of the physician orders showed Resident #19 was receiving therapy services, physical therapy, speech therapy and occupational therapy. Review of the Medication Administration Record (MAR) for July 2014 showed Skilled Patient to be charted daily in assessment as of 06/11/2024 to 07/09/2024. Review of the Skilled Documentation notes showed the following were not documented: 06/07/2024, 06/10/2024, 06/11/2024, 06/12/2024, 06/16/2024, 06/17/2024, 06/21/2024, 06/27/2024, 06/28/2024, 06/29/2024, 07/01/2024 07/05/2024, 07/07/2024, 07/11/2024, 07/13/2024, 07/14/2024, 07/15/2024 2. On 07/15/24 12:29 p.m. Resident #8 was sitting in her wheelchair beside her bed, eating her lunch, of hamburger, carrots, soup, pudding, salad and fluids. She was dressed and groomed for the day. She stated she had no complaints or concerns. She stated the staff answers all the call lights. She stated she was able to take her own shower. A bruise was observed on her left upper hand. Resident #8 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but were not limited to Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, obesity, CHF, Pulmonary HTN, atrial fibrillation, stage III chronic kidney disease, anemia, and weakness. Review of the MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident needed maximal assistance with care. Review of the physician orders showed Resident #8 was receiving therapy services, physical therapy and occupational therapy as of 07/05/2024. Admit resident to facility for skilled services as of 07/04/2024. Review of the Skilled Documentation notes showed the following were not documented: 07/05/2024, 07/06/2024, 07/08/2024, 07/09/2024, 07/12/2024, 07/13/2024, 07/15/2024 During an interview on 07/17/2024 at 12:10 p.m. the Director of Nursing (DON) verified the bruise was documented but location was not documented, and it should be. The DON verified the Weekly Skin Check was not performed weekly. The DON verified the chart was missing Skilled Documentation notes. 3. During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated that on Saturday at 3 p.m., they told the aide he was in pain due to constipation. They requested a suppository. They stated the nurse came in an hour later and stated she would come back after she performed medication pass. The stated it was 3-4 hours later before he got a suppository. The wife stated she performed the majority of the care, bathing, cleaning him, lotion. She stated he wants her to provide his care. They wanted him to go home so he does not get COVID. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed: Resident #267 was receiving therapy services, physical therapy and occupational therapy. Skilled patient to be charted daily in assessment as of 07/09/2024. Review of the July MAR showed skilled patient to be charted daily in assessment every day as of 07/10/2024. Review of the Skilled Documentation notes showed the following were not documented: 07/05/2024, 07/06/2024, 07/07/2024, 07/08/2024, 07/09/2024 Review of the facility's policy, Standards and Guidelines: Documentation, revised 01/2024 showed Guideline: Services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure: 1. Documentation in the medical record may be electronic, manual, or combination. 2. The following information is to be documented in the resident medical record: a) Objective observations; b) Medication administered; c) Treatments or services provided performed; d) Changes and the resonance condition; 3. Documentation in the medical record is required as updates / changes and the resident's plan of care are made. 8. Documentation of procedures and treatments will include care specific details, including: a) the date and time the procedure slash treatment was provided; b) the name and title of the individual (s) who provided the care; c) the assessment data and / or for any unusual findings obtained during their procedure / treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to 1.) failing to ensure proper storage of medication and biologicals, for 3 of 4 treatment carts, on 1 of 2 hallways (F761) and 2.) failing to maintain an effective infection control and prevention program to prevent the spread of infection by failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one (Resident #3) of 2 residents under transmission based precautions (F880) during the revisit survey conducted on 09/11/2024. Findings included: 1.) An observation on 09/11/2024 at 0917 AM revealed 3 treatment carts unlocked and unsecured across from the nurse's station. There were no staff near the carts, and the carts contained prescription medications for treatments. Photographic evidence was obtained. An interview was conducted on 09/11/2024 at 01:45 PM with Staff C, Licensed Practical Nurse (LPN). The LPN confirmed the treatment carts should not be left unlocked. She also stated the nurse is assigned a treatment cart correlates with their medication cart and assignment. An interview was conducted on 09/11/2024 at 02:02 PM the Director of Nursing, RN (DON). The DON stated the nurse has the keys to the treatment cart and there was also an extra set for the wound care nurse. She also stated all the carts should be locked when not being used. The facility policy titled Standards and Guidelines: Medication Storage and Labeling reveals under the section titled Procedure Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.) A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) infection. A review of Resident #3's physician orders revealed an order dated 9/7/2024 for contact precautions for MRSA every shift until 9/19/2024 at 9:43 AM. An observation was conducted on 9/11/2024 at 10:07 AM outside of Resident #3's room. A sign was posted to Resident #3's room door indicating Resident #3 was on contact precautions. The posted signage included directions for providers and staff to put on gloves before room entry, discard gloves before room exit, put on gown before room entry, and discard gown before room exit. An caddy was observed outside of Resident #3's room containing isolation gowns and gloves. Staff A, Occupational Therapist Assistant (OTA) was observed in Resident #3's room speaking to the resident at the bedside. Staff A, OTA was not observed wearing an isolation gown or gloves while inside of the resident's room. After Staff A, OTA exited Resident #3's room, an interview was conducted. Staff A, OTA stated she spoke to a nurse prior to entering Resident #3's room to find out why Resident #3 was on contact isolation precautions and was told she did not have to don PPE because the infection was in the resident's urine. Staff A, OTA also stated she did not touch the resident while she was inside of the resident's room. Staff A, OTA observed the signage posted to Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff A, OTA stated she received in-service education from the facility a few weeks ago related to infection control and the proper procedures for donning and doffing PPE. An observation was conducted on 9/11/2024 at 10:16 AM outside of Resident #3's room. Staff B, Registered Nurse (RN) and Unit Manager (UM) was observed pushing a cart with boxes of disposable gloves on it down the unit hallway. Staff B, RN UM was also observed entering Resident #3's room. Staff B, RN UM did not don an isolation gown or gloves before entering the resident's room. After Staff B, RN UM exited the room an interview was conducted. Staff B, RN UM stated she was conducting rounds on the unit and ensuring gloves inside of the resident rooms were stocked. Staff B, RN UM also stated Resident #3 was on contact isolation precautions and she did not don PPE before entering the room because she did not touch the resident. Staff B, RN UM observed the signage posted on Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff B, RN UM stated she received in-service education from the facility about two weeks ago related to infection control and the proper procedures for donning and doffing PPE. An interview was conducted on 9/11/2024 at 1:33 PM with the facility's Infection Preventionist (IP). The IP stated when a resident is on contact isolation precautions, all staff are to don an isolation gown and gloves prior to entering the resident's room. The IP also stated it does not matter if the staff member touches the resident or not while they are inside of the room, the staff don the appropriate PPE any time they enter the resident's room. The IP stated he conducted in-service education with the facility staff and discussed the difference between transmission based precautions and enhanced barrier precautions and the PPE required for each type of precautions used. An interview was conducted on 9/11/2024 at 2:22 PM with the DON. The DON stated facility staff should follow the instructions on the posted signage for a resident under transmission based precautions and donning the PPE is not optional when entering the resident's room. The DON also stated it does not matter what the staff member is doing inside of the room, all staff should be donning the appropriate PPE as ordered by the physician because the disease could be transmitted to other residents if PPE is not used. An interview was conducted on 9/11/2024 at 3:32 PM with the facility's Nursing Home Administrator (NHA) and DON. The NHA stated the facility's QAPI committee met following the previous survey to discuss the findings and began to develop a plan of correction. A facility wide audit was conducted to identify residents who were potentially effected by the deficient practice and facility wide education was conducted to all of the related areas identified during the previous survey. Audits were put into place to ensure the facility's education and processes had improved. The DON stated weekly audits of the medication carts were initiated and all nursing staff received education related to medication storage to ensure compliance. The DON also stated the audits mainly focused on the medication carts and not the treatment carts in the facility. The NHA stated four separate audits were put into place related to infection control, including sanitizing equipment, hand washing, PPE use, and glucometers. All types of transmission based precautions were reviewed as part of the education and explained to facility staff to ensure they understand. A review of the facility policy titled Standards and Guidelines: Transmission Based Precautions, last revised in February of 2024, revealed under the section titled Standard, all staff receive training on transmission based precautions upon hire and at least annually. The policy also revealed under the section titled Procedure: Initiation of Transmission-Based Precautions (Isolation), an order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively. The policy revealed the following under the section titled Procedure: Contact Precautions: - Intended to prevent transmission of infectious agents which are spread by direct of indirect contact with the resident or the resident's environment. - Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. - Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens. A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February of 2020, revealed under the section titled Policy Statement, this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The policy also revealed under the section titled Policy Interpretation and Implementation the objectives of the QAPI program are to: - Provide a means to measure current and potential indicators for outcomes of care and quality of life. - Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. - Reinforce and build upon effective systems and processes related to the delivery of quality care and services. - Establish systems through which to monitor and evaluate corrective actions. Photographic evidence obtained.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to 1.) failing to ensure proper storage of medication and biologicals, for 3 of 4 treatment carts, on 1 of 2 hallways (F761) and 2.) failing to maintain an effective infection control and prevention program to prevent the spread of infection by failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one (Resident #3) of 2 residents under transmission based precautions (F880) during the revisit survey conducted on 09/11/2024. Findings included: 1.) An observation on 09/11/2024 at 0917 AM revealed 3 treatment carts unlocked and unsecured across from the nurse's station. There were no staff near the carts, and the carts contained prescription medications for treatments. Photographic evidence was obtained. An interview was conducted on 09/11/2024 at 01:45 PM with Staff C, Licensed Practical Nurse (LPN). The LPN confirmed the treatment carts should not be left unlocked. She also stated the nurse is assigned a treatment cart correlates with their medication cart and assignment. An interview was conducted on 09/11/2024 at 02:02 PM the Director of Nursing, RN (DON). The DON stated the nurse has the keys to the treatment cart and there was also an extra set for the wound care nurse. She also stated all the carts should be locked when not being used. The facility policy titled Standards and Guidelines: Medication Storage and Labeling reveals under the section titled Procedure Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.) A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) infection. A review of Resident #3's physician orders revealed an order dated 9/7/2024 for contact precautions for MRSA every shift until 9/19/2024 at 9:43 AM. An observation was conducted on 9/11/2024 at 10:07 AM outside of Resident #3's room. A sign was posted to Resident #3's room door indicating Resident #3 was on contact precautions. The posted signage included directions for providers and staff to put on gloves before room entry, discard gloves before room exit, put on gown before room entry, and discard gown before room exit. An caddy was observed outside of Resident #3's room containing isolation gowns and gloves. Staff A, Occupational Therapist Assistant (OTA) was observed in Resident #3's room speaking to the resident at the bedside. Staff A, OTA was not observed wearing an isolation gown or gloves while inside of the resident's room. After Staff A, OTA exited Resident #3's room, an interview was conducted. Staff A, OTA stated she spoke to a nurse prior to entering Resident #3's room to find out why Resident #3 was on contact isolation precautions and was told she did not have to don PPE because the infection was in the resident's urine. Staff A, OTA also stated she did not touch the resident while she was inside of the resident's room. Staff A, OTA observed the signage posted to Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff A, OTA stated she received in-service education from the facility a few weeks ago related to infection control and the proper procedures for donning and doffing PPE. An observation was conducted on 9/11/2024 at 10:16 AM outside of Resident #3's room. Staff B, Registered Nurse (RN) and Unit Manager (UM) was observed pushing a cart with boxes of disposable gloves on it down the unit hallway. Staff B, RN UM was also observed entering Resident #3's room. Staff B, RN UM did not don an isolation gown or gloves before entering the resident's room. After Staff B, RN UM exited the room an interview was conducted. Staff B, RN UM stated she was conducting rounds on the unit and ensuring gloves inside of the resident rooms were stocked. Staff B, RN UM also stated Resident #3 was on contact isolation precautions and she did not don PPE before entering the room because she did not touch the resident. Staff B, RN UM observed the signage posted on Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff B, RN UM stated she received in-service education from the facility about two weeks ago related to infection control and the proper procedures for donning and doffing PPE. An interview was conducted on 9/11/2024 at 1:33 PM with the facility's Infection Preventionist (IP). The IP stated when a resident is on contact isolation precautions, all staff are to don an isolation gown and gloves prior to entering the resident's room. The IP also stated it does not matter if the staff member touches the resident or not while they are inside of the room, the staff don the appropriate PPE any time they enter the resident's room. The IP stated he conducted in-service education with the facility staff and discussed the difference between transmission based precautions and enhanced barrier precautions and the PPE required for each type of precautions used. An interview was conducted on 9/11/2024 at 2:22 PM with the DON. The DON stated facility staff should follow the instructions on the posted signage for a resident under transmission based precautions and donning the PPE is not optional when entering the resident's room. The DON also stated it does not matter what the staff member is doing inside of the room, all staff should be donning the appropriate PPE as ordered by the physician because the disease could be transmitted to other residents if PPE is not used. An interview was conducted on 9/11/2024 at 3:32 PM with the facility's Nursing Home Administrator (NHA) and DON. The NHA stated the facility's QAPI committee met following the previous survey to discuss the findings and began to develop a plan of correction. A facility wide audit was conducted to identify residents who were potentially effected by the deficient practice and facility wide education was conducted to all of the related areas identified during the previous survey. Audits were put into place to ensure the facility's education and processes had improved. The DON stated weekly audits of the medication carts were initiated and all nursing staff received education related to medication storage to ensure compliance. The DON also stated the audits mainly focused on the medication carts and not the treatment carts in the facility. The NHA stated four separate audits were put into place related to infection control, including sanitizing equipment, hand washing, PPE use, and glucometers. All types of transmission based precautions were reviewed as part of the education and explained to facility staff to ensure they understand. A review of the facility policy titled Standards and Guidelines: Transmission Based Precautions, last revised in February of 2024, revealed under the section titled Standard, all staff receive training on transmission based precautions upon hire and at least annually. The policy also revealed under the section titled Procedure: Initiation of Transmission-Based Precautions (Isolation), an order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively. The policy revealed the following under the section titled Procedure: Contact Precautions: - Intended to prevent transmission of infectious agents which are spread by direct of indirect contact with the resident or the resident's environment. - Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. - Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens. A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February of 2020, revealed under the section titled Policy Statement, this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The policy also revealed under the section titled Policy Interpretation and Implementation the objectives of the QAPI program are to: - Provide a means to measure current and potential indicators for outcomes of care and quality of life. - Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. - Reinforce and build upon effective systems and processes related to the delivery of quality care and services. - Establish systems through which to monitor and evaluate corrective actions. Photographic evidence obtained.

Based on observations, interviews, and review of facility policy, the facility failed to maintain storage and labeling of drugs and biologicals in accordance with professional standards for 3 of 3 medication carts inspected. Findings included: An inspection was conducted on 1/5/2023 at 11:38 AM of a medication cart on the 400 unit of the facility with Staff A, Licensed Practical Nurse (LPN). The inspection revealed the following: - A plastic medication storage bag containing two open bottles of Brimonidine 0.2% eye drops and a bottle of Dorzolamide Hydrochloride (HCl) and Timolol 22.3 milligrams (mg)/6.8 mg solution eye drops. The medication bag was labeled to contain Brimonidine 0.2% eye drops. - A brown plastic medication storage bag containing Retacrit 4000 units injection within a clear plastic storage bag labeled refrigerate. - A plastic medication storage bag containing a bottle of Latanoprost 0.005% eye drops. The yellow Date Opened label on the plastic bag had no date documented. - A green plastic container containing a bottle of Latanoprost 0.005% eye drops. The yellow Date Opened label on the plastic bag had no date documented. - A brown plastic medication storage bag containing Prevnar 20 injection within a clear plastic storage bag labeled refrigerate. - An silver colored metal container containing a Trelegy Ellipta 100 micrograms (mcg)/62.5 mcg/25 mcg inhaler. The metal container had a white sticker affixed to it which read Discard after 42 days. The cover of the metal container had a hand written date of 11/14/22, indicating the inhaler expired on 12/26/2022. - Two silver colored metal containers containing Breo Ellipta 200 mcg/25 mcg inhalers. The metal containers each had a white stick affixed to it which read Discard after 42 days with no date documented. - A plastic medication storage bag containing a Novolog Insulin Aspart Flexpen. The bag had a hand written date of 12/6/22 written on the label. The Novolog Flexpen had a white label reading Discard after 28 days, indicating the pen expired on 1/3/2023. An interview was conducted following the observation with Staff A, LPN. Staff A, LPN stated she attempted to check the medication cart daily to ensure the medication cart contained no expired medications and to ensure medications were properly dated. Expired medications should be discarded and medication should be dated when opened. Staff A, LPN stated if a medication is supposed to be refrigerated it should remain in the refrigerator until it is ready to be administered. An inspection was conducted on 1/5/2023 at 12:23 PM of a medication cart on the 200 unit of the facility with Staff B, LPN. The inspection revealed brown plastic medication storage bag containing Aplisol 0.1 ml (milliliters) injection within a clear plastic storage bag labeled refrigerate. An interview was conducted during the observation with Staff B, LPN. Staff B, LPN stated the Aplisol 0.1 ml should be stored in the refrigerator and not in the medication cart. An inspection was conducted on 1/5/2023 at 12:30 PM of a medication cart on the 200 unit of the facility with Staff C, LPN. The inspection revealed an open vial of Novolin 70/30 insulin stored in the manufacturer's box. No dated was documented on the box or the vial to indicate when the vial was opened. Staff C, LPN stated the medication should be labeled to indicate when it was opened. An interview was conducted on 1/5/2023 at 1:55 PM with the facility's Director of Nursing (DON). The DON stated nurses should be checking the medication carts to ensure medications are not expired and medications are labeled with the appropriate date. Nurses should be filling out the included label on the medication to indicate when the medication was opened. The DON stated medications should be stored properly and if they require refrigeration, they should be stored in the refrigerator. A telephone interview was conducted on 1/5/2023 at 2:05 PM with the facility's Consultant Pharmacist (CP). The CP stated if a medication has a label on it, it should be dated when opened as a general practice. Multiple medications should not be stored in one bag and the bag should contain only the information related to the medication that it's meant for. The CP stated if a medication would require refrigeration, it should be stored in the refrigerator until it is ready to be administered. A review of the facility policy titled Storage of Medications, revised November of 2020, revealed under the section titled Policy heading the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy also revealed the following, under the section titled Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers. 4. Drug containers that have missing, incomplete, improper,, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Photographic evidence obtained.

Based on observations, interviews and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen related to not labeling or dating foods, not maintaining refrigerator and freezer temperature logs, not implementing cleaning schedules and not utilizing sanitizing buckets for three days (5/23/22, 5/24/22 and 5/25/22) of four days observed. Findings included: On 05/23/2022 at 9:26 a.m., the initial kitchen tour was conducted with Staff J, Cook Manager. An observation of the walk-in cooler revealed no thermometer found inside the cooler. Also observed were food items not properly labeled and or dated to include: two opened containers of cottage cheese, white sliced cheese wrapped in clear plastic, an opened package of sliced turkey, a container of fruit (pale yellow in color and appeared to be diced) and a partially used pan of red gelatin with no date. Staff J, Cook Manager stated (red gelatin) was used as a dessert and was not sure exactly when, but it was for a supper meal. In addition, several food products were found with labels but no dates to include pound cake, chocolate pie, and whipped topping. Four packages of opened and partially used bread and rolls were located on the top shelf with no dates. On a cart were three trays with spilled liquid on them and lidded cups, approximately a total of 20-24 cups per tray which appeared to be filled with orange juice. The cups or trays were not labeled or dated. The floor of the walk-in was found to have a build-up of dirt and debris in the corners and running alongside of the wall and floor underneath the shelving unit. Staff J stated she was unsure of why there was no thermometer in the cooler or why staff were not labeling and dating products. Continuing with the tour an observation of the walk-in freezer revealed no thermometer was found inside. No dates of receipt were observed on cases of frozen parbaked rolls, mighty shakes, magic cups, pound cake, pie shells, and stuffed shells. Frozen meat products of roast beef and ground beef that were removed from the original box sitting on a metal, two tier cart was observed with no dates. In addition, an observation of the reach in refrigerator revealed no thermometer inside and three gallons of opened milk, not dated. The initial tour continued with Staff J and the observation of the dry storage room revealed no dates on several opened and or partially used food products, which included: a half-used bag of pasta, a bag of opened breadcrumbs, several packages of opened hot dog rolls. Additional observations during the tour revealed no sanitizing buckets being used and only one green bucket for cleaning was located under the cook's shelf with dirty water. Staff J, Cook Manager was not able to confirm if there was a policy or procedure related to the use of sanitizing buckets. In addition, a large industrial size circulating fan, located near the end of the tray line station was observed to have buildup of greasy dirt and debris covering the protective metal screen and the blades of the fan. At the time of the observation the fan was plugged in but not on. An observation was made of the four air vents located in the kitchen ceiling and dish room ceiling were noticeably wet with moisture and had signs of rust. During the tour, no cleaning schedules were observed posted or in binders anywhere in the kitchen to confirm kitchen cleaning was assigned and being completed daily. Staff J was not sure where they were located. An observation of the kitchen on 5/23/2022 at 12:00 p.m. revealed the large circulating fan was turned on and pointed in the direction of the steamtable and tray line during meal service. The fan still had dirt and debris on the protective screen. Also observed were several light fixtures in the ceiling, located above the steam table and reach in freezer with clear visibility of dead bugs inside the base of the light covers. A request was made at this time of Staff H, Regional Dietary Manager for documentation of recorded temperatures for the refrigerators and freezer and cleaning policies and schedules. This information was not provided to the survey team at the time of exit on 5/26/22. On 05/24/2022 at 4:43 p.m. an observation of the kitchen and interview with Staff H, Regional Dietary Manager revealed no sanitizing buckets in use. An observation inside the walk-in-cooler revealed on the shelf an open box containing portions of one ounce pre-package cream cheese and several 4-ounce cups of juice opened and leaking inside the box, along with an undated opened bag of whipped topping. An observation of the dry storage room revealed a clear plastic zip-closed bag of biscuits not labeled or dated, an opened box of jelly packets which contained several packets split open and a dark purplish-red dried substance was observed on the inside of the box. Staff H, at this time, stated he has not been in the facility in about seven months and was unaware of the issues. On 05/25/2022 at 10:00 a.m. an observation and interview with Staff H, Regional Dietary Manager, during an additional walk through of the kitchen revealed, three red sanitizing buckets not filled or being used. Also observed was a foam carton of food left over from breakfast and stored inside the microwave. Staff H stated it must be for an employee to have on break. Staff H, disposed of the container. The observation also showed dried food splatter inside of the microwave. Additional observations revealed five large boxes of juice base concentrate attached to the juice machine and undated. Further observations at this time of the walk-in cooler revealed a bucket of cottage cheese with a use by date of 5/23/2022, two open jugs of Italian salad dressing undated, and a roasting pan covered with plastic wrap with unknown food items that was not labeled or dated. On 05/25/2022 at 12:05 p.m. Staff H was provided with a second request for the missing documentation for staff cleaning schedules, and a policy for use of the sanitizing buckets. On 05/26/2022 at 10:56 a.m., an interview was conducted with Staff H, Regional Dietary Manager. Staff H stated he was unable to locate the cleaning policies or schedules. On 05/26/2022 at 11:45 p.m. Staff H, Regional Dietary Manager confirmed food items should be labeled, dated, and stored in sanitary conditions per regulation and policy. He stated the cleaning task should be completed after each shift and daily. Staff H, Regional Dietary Manager stated he will begin to in-service all employees regarding labeling and dating, taking, and recording of dish machine temperatures, implement daily weekly and monthly cleaning schedules, recording of temperatures for all refrigerators and freezers as well as cleaning and sanitizing of all equipment with regards to the proper use of the sanitizing buckets with documentation. A review of a policy titled, Food Receiving and Storage, with an effective date of 01/15/2021, showed the policy statement was to ensure: 1) Food Services staff will always maintain clean food storage areas. 7) Dry foods that are stored in bins will be removed from original packaging, labeled, and dated, such foods will be rotated using a first-in-first out system, 8) All foods in the refrigerator or freezer will be covered, labeled, and dated (use by date) 12) Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee. Photographic Evidence Obtained

Based on Interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the Advanced Registered Nurse Practitioner (ARNP), resident's sister and a state investigator and review of the resident's medical, hospital records and facility policies, it was determined that the facility neglected a resident by failing to ensure nursing staff provided necessary oversight to direct care staff during the breakfast meal on [DATE], for one (#66) of a sample of 8 residents requiring supervision or assistance with meals. Resident (#66), was known for obtaining and eating foods of a texture that were not compliant with her diet order which was pureed. The breakfast trays for both Resident #66 and her roommate, who was on a mechanical soft diet, were delivered to the residents' room. Resident #66 was allowed to remain in the room alone and unsupervised and was found nonresponsive, without breaths and pulse. Staff were able to eject chunks of the roommate's mechanical soft meal from her throat during compressions and a procedure described as a modified [MEDICATION NAME] maneuver. Resident #66 had been identified by the Speech Therapist as needing 100% supervision at meals to remain safe, identified by the Registered Dietitian as needing a pureed diet due to being a compulsive eater who did not like pureed consistency of foods and was known to take foods off other resident's trays, identified by the ARNP as having an Impulse Disorder and to be discouraged from taking food off of other resident's trays, identified by the Psychiatrist as having a history of taking other's food, and care planned for having an issue with compulsive eating with the planned Intervention of monitor resident during meal times. The facility's failure to provide the necessary oversight of nursing staff to ensure the resident was not provided with an opportunity to obtain a breakfast of foods not compliant with her diet, failure to follow their policy, and failure to follow their professional staff's recommendations and the resident's care plan, represented a failure that put Resident #66 at high risk of aspiration and death, and had the potential to affect other residents that require assistance and supervision during meals. This failure led to ongoing Immediate Jeopardy identified on [DATE]. Findings included: During an interview on [DATE] at 10:55 a.m., staff member M stated, On [DATE], around 7:00 a.m., Resident #66 came out of her room without clothing, so I took her back to get dressed while I waited for the schedule assignment. Staff member M stated an agency CNA came in and I did rounds with her but did not discuss Resident #66 with the agency CNA because Resident #66 was on my assignment. Staff Member M stated she was sick and wearing a mask and went to find staff member N, (staffing coordinator) to see about going home. Staff Member M, stated she was given the ok to go home at approximately 8:40 a.m. She reported that she noticed the last cart of breakfast trays coming on to the hall and she observed Resident #66 at the nurses' station before she left the building. She reported that the Resident asked if staff member M was leaving. Staff member M stated, Resident #66 had been eating in the solarium while the dining room was closed but I wasn't sure where she would be eating on [DATE]. The Facility's dining room was closed due to equipment repair in the kitchen for the first week to 10 days in December. Staff member M reported that she had been out sick from [DATE] at 8:40 a.m. until [DATE] and when she returned to work, she was told Resident #66 was spitting up whole waffles. Staff member M confirmed that Resident #66's roommate was on a mechanical soft diet. Staff member M described Resident #66 as always cruising around the building looking for food on dirty trays or in the garbage, as she would take it from anywhere. Staff member M continued, I feel bad. If I was not sick that day she may still be here. She was my favorite and I always had her. If she had someone from the agency they would not know that about her and I am not sure if it was on her care plan. During a review of the medical record for Resident #66, the following note written by the resident's nurse was reviewed: [DATE] 0845: Nurse went into residents room, found resident sitting in wheelchair with head down, resident assessed, was unresponsive, absence of pulse and not breathing, with brown and yellow vomit coming from mouth, nurse verified resident Full Code, called out for help. Code Blue and to call 911, aide and nurse laid resident on floor , mouth swept (sic) done to remove vomit, 2 nurses began CPR, (cardio [MEDICAL CONDITION] resuscitation) along with AED, (automatic external defibrillator) 0850 911 called 0855 AED placed, 0900 resident vomited and was turned onto right side mouth swept (sic) done to clear airway, 0903 CPR continued, EMT (Emergency medical technicians) arrived and continued CPR, 0905 resident still unresponsive, EMT continued CPR 0910 (resident's medical provider) called, message left, residents sister called and notified of residents condition. 0915 doctor called message left with answering service 0940 resident transferred by EMS via stretcher to hospital. 0950 PA (Physician's Assistant) called back notified of resident condition. On [DATE] at 12:56 PM in an interview with Staff E, RN Unit Manager she said she was called out of the conference room during the morning meeting and told Resident #66 was needing assistance, that she coded. She said she thinks the words were that she was choking. When she arrived at Resident #66's room, CPR was already in progress, with the crash cart already in the room, and compressions were in progress. The patient was blue. Someone else was doing respirations. The DON took over compressions and she took over the ambu bag. (A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also frequently used in hospitals as part of standard equipment found on a crash cart, in emergency room s or other critical care settings. Per Wikipedia). The nurse doing compressions initially was on the phone with the family. The nurse in charge of the resident was recording. So, at that time, she asked the people to go back to their assignment so EMTs could get in the room. The AED was in the room. It was already on. She was giving respirations, checking for a pulse. The resident started to vomit. So her head was turned. She had large chunks of food coming up. The DON did a mouth sweep. CPR continued. The AED said clear and continue. The resident started to vomit again. They continued CPR. By this time, EMTs arrived. They came to the door near to her room, so they had really fast access to her. The EMTs took over CPR. They intubated her and took over respirations. They started an intraosseous line. (Per Wikipedia, an intraosseous line is the process of injecting directly into the marrow of a bone. This provides a non-[MEDICATION NAME] entry point into the systemic venous system. This technique is used to provide fluids and medication when intravenous access is not available or not feasible.) She was flat lined. (Per the Merriam- Webster Dictionary, to flatline is to register on an electronic monitor as having no heartbeat or brain waves.) They did resuscitate her with medication. For just a minute she did have a pulse on the monitor. EMTs continued compressions. They continued bagging her. The whole time while transporting her onto the stretcher and into the ambulance. She said she stayed with the resident until she was in the ambulance. She said she wasn't with the resident when the event happened. The resident was already on the floor and CPR was already in progress. She said the resident was always stealing food from other residents in the dining room. She said she didn't know if she had taken food. Staff had to watch her vigilantly. She apparently had eaten solid foods. It wasn't puree. She had gotten it from somewhere else. The resident was supposed to be monitored during meals. She was supposed to be eating in the solarium. She wasn't supposed to be eating in her room. She was very mobile and had her own mind. She was not restrained. She was very friendly and outgoing. Staff E said she thought the resident was highly supervised, and didn't need a one on one. She repeated, the resident was highly supervised and was very mobile. She would not answer if she thought the situation was preventable. She said there were a lot of interventions in place. Supervision was daily, at every meal, every day that she did this. She said the resident taking food off others' trays was a daily behavior. On [DATE] beginning at 4:49 p.m., in an interview with Staff Nurse X, she said that she had taken the resident back to her nursing unit about 8:00 a.m. She reported that she 'parked 'the resident at the nursing station and returned to her assigned unit to pass her medications. She reported that shortly after that, she heard the other nurse call out for help. She reported that she called 911 and then went to the resident's room. She reported that she saw three nurses in the room attempting to resuscitate the resident. She reported that the DON was 'pushing up' on the resident's abdomen and chunks of food were coming out of the resident's mouth. She knew the served breakfast had been waffles and she described the vomited food as not fully chewed, not pureed, but chunks of yellow-brown waffles. The nurse reported that the resident was known to take other resident's food and both the resident and the roommate's breakfast trays were in the resident's room. An interview was conducted with Staff nurse D who confirmed she was assigned to Resident #66 on [DATE]. In the interview on [DATE] beginning at 12:45 p.m. Staff nurse D reported that she saw Resident #66 sitting in her room, with her head down. She said that she called to the resident several times without the resident responding. She said that she entered the room to check on the resident and was not able to get a response or feel a pulse. She reported that she went to the nurses' station, checked the resident's medical record for the advanced directive and once she saw the 'Full Code', she called out for help. She reported that she returned to the resident's room and began to resuscitate her with help from the DON and the unit manager. She reported that chunks of a brownish yellow substance were vomited. During an interview on [DATE] at 1:01 p.m., Staffing Coordinator N stated that she assigned staff member P, an agency aide, to complete staff member M's assignment. Staffing Coordinator N, stated that [DATE] was the first time staff member P worked at the facility. Staffing Coordinator N stated that Staff member P was added to the do not return list for the facility after staff member P and the Director of Nursing had some words. Staff member P did not complete her shift on [DATE] as she was asked to leave the facility somewhere between 10:00 a.m. and 11:00 a.m. Staffing Coordinator N stated on [DATE] when the code blue was called she ran with the second crash cart to Resident #66's room and observed CPR in progress. She stated, When the DON came in, I asked if we could have someone switch giving compressions. The DON took over compressions while a CNA bagged Resident #66. Staffing Coordinator N observed a dark yellow glob on Resident #66's left leg mid-thigh which she estimated as being the size of a yellow highlighter without the lid. She included that the resident had been laid on the floor. She reported that Resident #66's breakfast tray was not touched but her roommate's breakfast had been eaten. Staffing Coordinator N reported that once the DON took over compressions, three of the staff that had been in the room went out on the porch because they were so upset. Staffing Coordinator N added that she had asked staff member P, where she was when the code was called and she told me she was heating up food for a Resident in the pantry and that she had not been in the room for Resident #66 at all that morning. Staffing Coordinator N described Resident #66 as 'non-compliant' and constantly stealing food off other trays and would swipe it right in front of you and she would tell you no if you asked her to give it up. The roommate of Resident #66 was described as always getting up early and added that she would not have been in her room to eat breakfast by the time the code was called. Staffing Coordinator N reported that it was the roommate's tray that was the one opened with the food eaten. We have three meal carts that come out. Resident #66 was seen in the halls drinking her morning coke when staff member M and I were together. At this point, I am still not sure who passed the trays that were put in her room. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on [DATE] beginning at 12:40 p.m. who confirmed that Resident #66 was her patient. She reported that she hadn't been at the facility the morning of [DATE], but had come in later and was told what had happened. She reported that the resident was a smart lady who knew what she wanted and would bargain with her to get a soda. The provider reported that she would refuse to be weighed unless someone bought her a soda. She was compulsive about food and even when she asked friends of Resident #66, they confirmed that the resident had always been that way. The provider reported that she had observed Resident #66 in the back hall taking half eaten food off of resident's trays, once the resident was done with the tray and staff had collected it for disposal. She reported that the resident wanted to eat a regular texture diet but she wasn't safe to eat regular texture. On [DATE] at 11:30 a.m., in an interview with Resident #66's sister, she reported that she had been told that her sister had died in her sleep. She was told that her sister was found with no heartbeat, that EMS (Emergency Medical Services) had been there, had shocked her twice but she had no heartbeat. They took her to the hospital and she died there. The sister apologized for missing the initial call from the surveyor as she explained that she had been at her sister's funeral. The sister reported that they had lost their brother in (MONTH) and she thought the resident had had a hard time getting over that, as he had been her primary caregiver and would visit the resident frequently. The resident's sister reported that she visited less frequently and never stayed during meals, but she knew that her sister aspirated easily. She thought her sister probably ate with others. She was aware that her sister was on a pureed diet which she didn't like and reported that she had been in the facility the day before her sister died talking with staff about changing her diet. The sister reported that she was told by the Doctor that her sister had had a [MEDICAL CONDITION]. The Speech Therapy SLP (Speech & Language Pathologist) Evaluation and Plan of Treatment dated [DATE], showed a Certification period of [DATE]-[DATE] for Dysphagia Therapy. Per the Speech Therapy document, relevant [DIAGNOSES REDACTED]. The referral was made by nursing to determine the appropriateness of a diet upgrade. The document included the note, Per DON (Director of Nursing) patient is reportedly going in others' rooms taking foods that are not part of her puree diet order. This is however, not a new behavior resulting from diet downgrade to puree. Patient's girlfriends reported that patient had displayed behaviors whereby she will somehow obtain food items while at another center. Her friends advised this SLP that patient had previously choked on a large jawbreaker type candy in one instance. She also choked on a large ball of chewed chewing gum she had accumulated over some period of time prior to her admission at this facility. In (MONTH) of this year she choked on fig newtons she impulsively ate while in this setting. Chest x-ray on [DATE] had findings which were consistent with pneumonia. Patient returns with the following dx (diagnosis): choking and [MEDICAL CONDITION], aspiration pneumonia. The SLP document listed previous treatment and outcomes which included discontinued speech therapy with the resident on a mechanical soft diet. The Oral stage dysphagia was documented as due in part to edentulous status and poor safety awareness /impulsivity. Under the Background Assessment - Medical section the document included: Precautions: choking hazard, confusion, constant SUP (supervision) due to cognition, aspiration and pureed diet. Listed under the Recommendations section of the document, the SLP had recommended: Supervision for oral intake=Close supervision (100% supervision is recommended for this resident for any po (by mouth) intake other than puree diet due to no self-monitoring and total dependence on external cues for general safer swallowing strategies r/t -related to, impaired cognition.) Under the Assessment Summary on the document, the SLP documented under Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, choking. The SLP discharged the resident from therapy on [DATE] and indicated the resident was discharged to the Restorative Program. Resident #66, a [AGE] year old, was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the resident's medical record showed the most recent MDS (Minimum Data Set) assessment was dated [DATE]. Section C related to cognitive function indicated a BIMS (brief interview of mental status) score of 3, indicating severe cognitive impairment. A review of Section G related to functional status indicated the resident was self-sufficient once she was assisted into her wheelchair. She was identified as needing supervision by one person while eating. A review of Section K related to Swallowing/Nutritional Status indicated she required a mechanically altered diet. Quarterly Care plan conference summaries from [DATE] until [DATE] documented the IDT (interdisciplinary team) and family were aware of the resident's attempts to obtain food that was not compliant with her diet order and redirection unsuccessful. The Care Plan summaries included that will eat food from other resident's trays and attempts to take other's food. The Care Plan dated [DATE] included, SSD (Social Services Director) informed brother that further placement will be sought due to noncompliance. Review of the resident's Care plan initiated on [DATE] revealed the Focus of nutritional problem or potential nutritional problem related to mechanically altered, therapeutic diet, prefers to drink more than eating, dislikes puree texture and will take foods from other residents, compulsive eater. The Interventions included: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain the consequences of refusal. The Care plan initiated on [DATE] with the Focus of resistant to care at times, noncompliant with diet restrictions, takes others foods was reviewed. The Care plan initiated on [DATE] with the Focus of resident has an issue with compulsive eating related to the [DIAGNOSES REDACTED]. The Care plan initiated on [DATE] with the Focus of Behavioral Problem as evidenced by non-compliant with diet restrictions was reviewed. The Care plan initiated on [DATE] with a revision and cancellation date of [DATE] with the Focus of resident on restorative dining program to safely tolerate altered diet was reviewed and noted for the intervention of resident will participate in the restorative dining program to safely tolerate puree solids and thin liquids. A Referral to Restorative Nursing Program, dated [DATE] was reviewed which indicated the resident would attend the program 6 days a week for 12 weeks. Under Restorative Dining Program, the Goal read: continue to safely tolerate puree/thin liquids using general safe swallowing strategies - small bites, slowed rate, clearing out oral cavity prior to next bite. Resident #66 was not in the Restorative Dining Program at the time of her death. During the Recertification Survey ([DATE] - [DATE]) an interview with the Restorative Nurse was requested to understand how the facility identified those residents who needed supervision at meals, to ensure they were kept safe while eating. The interviews were conducted on [DATE] beginning at 1:36 p.m. with the Restorative Nurse and an Assistant Director of Nurses, (both Registered Nurses) which revealed that five residents were on the restorative dining program. It was confirmed by the two RN's that not all residents needed physical assistance with dining, as some residents needed only encouragement or cueing to finish their meals. Because of repairs that were required in the kitchen, the facility's dining room was closed for the first week to ten days of December. The two nurses were asked about the dining plan for residents, including those residents in the restorative dining program, who usually ate their meals in the dining room. The plan to maintain residents' ability to socialize with other residents during meals, as well as to remain safe while eating or receive cueing to finish their meal was requested. The two nurses reported that the plan was for residents to eat in their rooms or some could eat in the day room on station 2. The nurses reported that residents who needed assistance with their meals would be assisted. Both nurses reported that there was no documented plan, it was just something that had been discussed and everyone knew they had to supervise the residents where ever they were eating. In an interview conducted with Staff Aide BB, on [DATE] beginning at 7:00 a.m., it was revealed that she had started her shift early as [DATE] was the first day that the dining room was open for meals, as it had been closed for repairs to the kitchen. She reported that she wanted to make sure the Breakfast meal went ok. She reported that the dining room had been closed so her Restorative residents had to eat in their rooms with supervision or in the Day Room on Station one. She said she wasn't aware of a documented plan for dining while the dining room was closed, but tried to make sure her restorative residents got their meals. Review of the facility's policy entitled Meal Service, with a Last Date Revised of [DATE], revealed the Policy was: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients' / residents/ quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14 read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. The initial Nutrition Assessment by the Registered Dietitian (RD) was dated [DATE] and indicated that the resident's 'Feeding Ability was documented as one on one supervision at meals, restorative dining per ST (speech therapy). The Diet order at that time was Mechanical soft, NAS HCC (No Added Salt, House Consistent Carbohydrates) Honey Thick Liquids. The RDs comments read, Resident is working (with) ST for dysphagia, restorative dining for all meals, one on one supervision. Makes food preferences known, consuming 100% of meals. A re-entry Nutrition Assessment was conducted on [DATE] which identified the resident as readmitted from the hospital after choking episode on snacks family had brought in. Diet has been downgraded to puree and requires nurse supervision at meals/snacks for cueing and assistance. Eats 100% of meals. Resident has a tendency to grab other residents' snacks/food. In a review of a Nutrition note, dated [DATE], it was documented that the Resident will often complain of feeling hungry and take food that belongs to other residents and foods that are not of appropriate consistency. The resident's weight was documented on [DATE] as 163.8 lbs., a gain of one pound since her admission in (MONTH) (YEAR). Review of a Nutrition note dated [DATE], revealed CBW (current body weight) 161.4 lbs., no significant change however slightly down. Resident was seen by ST and was determined not to be appropriate for diet upgrade d/t (due to) compulsive behavior when eating. Resident continues to take food that does not belong to her and must be redirected. The resident's annual nutrition assessment, dated [DATE], confirmed the resident's weight was stable from the prior assessment (162 lbs.) and her diet consistency of pureed. The RD assessment read, Resident continues to receive a NAS/HCC/pureed thin liquid diet. Continues to take food from other residents, despite education and encouragement. A weight note documented by the RD on [DATE] revealed the resident had a weight loss of 8.1% in three months, with the current weight at 152.4 lbs. on [DATE]. The note included, resident does not like pureed consistency of foods and will often take foods off other resident's trays and pick foods off carts heading back to the dish room. Resident is on a pureed consistency related to being a compulsive eater. Several attempts have been made in the past with ST to offer solid foods under supervision however resident would continue to hoard food in mouth despite coaxing to slow down. MD does not feel it to be appropriate to upgrade resident's diet d/t history of aspiration. A weight note documented by the RD on [DATE] revealed the resident had lost weight and was at 148 lbs. on [DATE]. The RD documented resident dislikes pureed consistency of foods and will regularly ask for solid foods and seek out foods that may be accessible to her. Called sister to inform of weight loss and waiver form available acknowledging the risks and benefits of upgrading resident's diet. Sister stated she would like for her to eat solid foods however is concerned of resident hoarding food in mouth and would ideally like staff member to sit with resident during meals to cue her to slow down and take small bites. Informed sister that there is restorative dining available however it cannot be guaranteed that a staff member will always be present every time resident consumes a snack or any kind of food throughout the course of the day. Sister expressed understanding and stated that she brought resident a thanksgiving meal and broke up the turkey into very small pieces and constantly had to monitor and cue her to take small bites and she did well. In an interview with the Certified Dietary Manager (CDM) on [DATE] beginning at 5:20 p.m., residents on the Mechanical Soft diet had complained in the past that the French toast was too dry. The CDM reported that she serves Waffles with two syrups (individual packets) to residents on Mechanical Soft diets when French toast is the planned breakfast menu item. She confirmed that on [DATE], residents on Mechanical Soft diets received waffles instead of the French toast. A Social Service Quarterly note dated [DATE] stated resident is alert with confusion. Moderately impaired cognition. Resident still wanders throughout the facility and sometimes takes food off of used dietary trays. A Nursing note dated [DATE] stated Resident noted taking food and drinks off of used trays, when nurse took milk from resident, resident threw milk at nurse and all over the floor. CNA reported resident taking food off of roommate's tray also and was aggressive and cursing at staff when approached about not taking food off of trays. Resident redirected. ARNP and psyche notified. On [DATE] a Nurse's note documented the CNA reported resident going into dining room attempting to take food and drink off of dirty tables. When CNA stopped her, the aide reported resident cursing at her and calling her names. Nurse was able to educate resident on infection control and she should not be taking food and drink off of dirty tables. Resident redirected. Snack given. [DATE] Social Services Quarterly note documented Resident attempts to take food off of others' plates and stuffs it in her mouth before staff gets to her. Resident is redirected by staff as needed. Review of the facility's Meal Service policy, with a Last Date Revised of [DATE], revealed the Policy statement: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients'/residents/quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14 read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. Review of the facility's Abuse Policy (undated), revealed the intent of the policy was to protect residents from abuse, neglect and harm while they are residing at the facility. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Under the section entitled, Prevention, the policy includes under the procedure, that The interdisciplinary team will identify the vulnerabilities and interventions on resident care plan. Under the description of the facility's population, the policy identifies factors that could result in maltreatment of [REDACTED]. behaviors, residents with self - injurious behaviors, socially inappropriate behaviors , verbal outbursts, residents with communication disorders, those who are nonverbal and those that require heavy care and/or are totally dependent on staff. Also under Prevention, the policy includes that Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents. On [DATE] beginning at 2:50 p.m. the Administrator and Director of Nurses were interviewed related to the resident's status and the nurse's note. The DON confirmed that during 'shift change' the resident 'coded' and she assisted with compressions during CPR (Cardiopulmonary resuscitation). She reported that a brownish-yellow liquid was vomited which she described as normal during compressions. She denied that any solids, or 'chunks' of food or any substance were vomit

Based on interviews with the Nursing Home Administrator, the Director of Nurses, Nursing staff, the Advanced Registered Nurse Practitioner, a family member of the resident, and a state investigator; record review of the resident's medical record and hospital record, and review of facility policies, the facility failed to prevent & report neglect, through lack of monitoring during meals for one (Resident #66) of a sample of 8 residents requiring supervision or assistance with meals. Resident #66, who was assessed as needing supervision as she was known to seek out food that was not compliant with her Physician's diet order of Puree, and would impulsively eat that non-pureed food, was found alone in her room, with two breakfast trays, nonresponsive and without breath or pulse. Nursing staff performed CPR (Cardio [MEDICAL CONDITION] Resuscitation), which resulted in yellow-brownish chunks resembling waffles being ejected from her mouth. The facility failed to provide nursing oversight when Resident #66's aide, on the 7a to 3p shift on [DATE], was not made aware that Resident #66 should be provided with supervision during meals, including not allowing the resident to be left alone in her room with her roommate's breakfast of a mechanical soft texture, which provided Resident #66 the opportunity to eat waffles which were not pureed and of a texture consistent with physician's orders. Failure of facility staff to report a violation of neglect resulted in findings of ongoing Immediate Jeopardy on [DATE]. Findings included: Resident #66, a [AGE] year old, was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The Physician's Order, dated [DATE], ordered a NAS/HCC (No Added Salt, House Consistent Carbs) Pureed Texture diet. On [DATE] beginning at 4:49 p.m., in an interview with Staff Nurse X, it was revealed that she had taken Resident #66 back to her nursing unit about 8:00 a.m. She reported that she parked the resident at the nursing station and returned to her assigned unit to pass her medications. She reported that shortly after that, she heard the other nurse call out for help. She reported that she called 911 and then went to the resident's room. She reported that she saw three nurses in the room attempting to resuscitate the resident. She reported that the DON was 'pushing up' on the resident's abdomen and chunks of food were coming out of the resident's mouth. She knew the served breakfast had been waffles and she described the vomited food as not fully chewed, not pureed, but chunks of yellow-brown waffles. The nurse reported that the resident was known to take other resident's food and both the resident and the roommate's breakfast trays were in the resident's room. During an interview on [DATE] at 10:55 a.m., staff member M stated, On [DATE], around 7:00 a.m., Resident #66 came out of her room without clothing, so I took her back to get dressed while I waited for the schedule assignment. Staff member M stated an agency CNA came in and I did rounds with her but did not discuss Resident #66 with the agency CNA because Resident #66 was on my assignment. Staff Member M stated she was sick and wearing a mask and went to find staff member N, (staffing coordinator) to see about going home. Staff Member M, stated she was given the ok to go home at approximately 8:40 a.m. She reported that she noticed the last cart of breakfast trays coming on to the hall and she observed Resident #66 at the nurses' station before she left the building. She reported that the Resident asked if staff member M was leaving. Staff member M stated, Resident #66 had been eating in the solarium while the dining room closed but I wasn't sure where she would be eating on [DATE]. Staff member M reported that she had been out sick from [DATE] at 8:40 a.m. until [DATE] and when she returned to work, she was told Resident #66 was spitting up whole waffles. Staff member M confirmed that Resident #66's roommate was on a mechanical soft diet. Staff member M described Resident #66 as always cruising around the building looking for food on dirty trays or in the garbage, as she would take it from anywhere. Staff member M continued, I feel bad. If I was not sick that day she may still be here. She was my favorite and I always had her. If she had someone from the agency they would not know that about her and I am not sure if it was on her care plan. An interview was conducted with Resident #66's assigned nurse, on [DATE] beginning at 12:45 p.m. Staff nurse D reported that she saw Resident #66 sitting in her room, with her head down. She said that she called to the resident several times without the resident responding. She said that she entered the room to check on the resident and was not able to get a response or to feel a pulse. She reported that she went to the nurses' station, checked the resident's medical record for the advanced directive and once she saw the 'Full Code', she called out for help. She reported that she returned to the resident's room and began to resuscitate her with help from the DON and the unit manager. She reported that chunks of a brownish yellow substance were vomited. During a review of the medical record for Resident #66, the following note written by the resident's nurse was reviewed: [DATE] 0845: Nurse went into residents room, found resident sitting in wheelchair with head down, resident assessed, was unresponsive, absence of pulse and not breathing, with brown and yellow vomit coming from mouth, nurse verified resident Full Code, called out for help. Code Blue and to call 911, aide and nurse laid resident on floor , mouth swept (sic) done to remove vomit, 2 nurses began CPR, (cardio [MEDICAL CONDITION] resuscitation) along with AED, (automatic external defibrillator) 0850 911 called 0855 AED placed, 0900 resident vomited and was turned onto right side mouth swept (sic) done to clear airway, 0903 CPR continued, EMT (Emergency medical technicians) arrived and continued CPR, 0905 resident still unresponsive, EMT continued CPR 0910 (resident's medical provider) called, message left, residents sister called and notified of residents condition. 0915 doctor called message left with answering service 0940 resident transferred by EMS via stretcher to hospital. 0950 PA (Physician's Assistant) called back notified of resident condition. On [DATE] at 12:56 PM in an interview with Staff E, RN Unit Manager she said she was called out of the conference room during the morning meeting and told Resident #66 was needing assistance, that she coded. She said she thinks the words were that she was choking. When she arrived at Resident #66's room, CPR was already in progress, with the crash cart already in the room, and compressions were in progress. The patient was blue. Someone else was doing respirations. The DON took over compressions and she took over the ambu bag. There was somebody else recording. The nurse doing compressions initially was on the phone with the family. The nurse in charge of the resident was recording. So at that time she asked the people to go back to their assignment so EMTs could get in the room. The AED was in the room. It was already on. She was giving respirations, checking for a pulse. The resident started to vomit. So her head was turned. She had large chunks of food coming up. The DON did a mouth sweep. CPR continued. The AED said clear and continue. The resident started to vomit again. They continued CPR. By this time, EMTs arrived. They came to the door near to her room, so they had really fast access to her. The EMTs took over CPR. They intubated her and took over respirations. They started an intraosseous line. She was flat lined. They did resuscitate her with medication. For just a minute she did have a pulse on the monitor. EMTs continued compressions. They continued bagging her. The whole time while transporting her onto the stretcher and into the ambulance. She said she stayed with the resident until she was in the ambulance. She said she wasn't with the resident when the event happened. The resident was already on the floor and CPR was already in progress. She said the resident was always stealing food from other residents in the dining room. She said she didn't know if she had taken food. Staff had to watch her vigilantly. She apparently had eaten solid foods. It wasn't puree. She had gotten it from somewhere else. The resident was supposed to be monitored during meals. She was supposed to be eating in the solarium. She wasn't supposed to be eating in her room. She was very mobile and had her own mind. She was not restrained. She was very friendly and outgoing. Staff E said she thought the resident was highly supervised, and didn't need a one on one. She repeated, the resident was highly supervised and was very mobile. She would not answer if she thought the situation was preventable. She said there were a lot of interventions in place. Supervision was daily, at every meal, every day that she did this. She said the resident taking food off others' trays was a daily behavior. During an interview on [DATE] at 1:01 p.m., Staffing Coordinator N stated that she assigned staff member P, an agency aide , to complete staff member M's assignment. Staffing Coordinator N, stated that [DATE] was the first time staff member P worked at the facility and she added that Staff member P was added to the 'do not return' list for the facility after staff member P and the Director of Nursing had some words. Staff member P did not complete her shift on [DATE] as she was asked to leave the facility somewhere between 10:00 a.m. and 11:00 a.m. Staffing Coordinator N stated on [DATE] when the code blue was called she ran with the second crash cart to Resident #66's room and observed CPR in progress. She stated, When the DON came in, I asked if we could have someone switch giving compressions. The DON took over compressions while a CNA bagged Resident #66. Staffing Coordinator N observed a dark yellow glob on Resident #66 left leg mid-thigh which she estimated as being the size of a yellow highlighter without the lid. She included that the resident had been laid on the floor. She reported that Resident #66's breakfast tray was not touched but the roommate's breakfast had been eaten. Staffing Coordinator N reported that once the DON took over compressions, three of the staff that had been in the room went out on the porch because they were so upset. Staffing Coordinator N added that she had asked staff member P, where she was when the code was called and she told me she was heating up food for a Resident in the pantry and that she had not been in the room for Resident #66 at all that morning. Staffing Coordinator N described Resident #66 as 'non-compliant' and constantly stealing food off other's tray and would swipe it right in front of you and she would tell you no if you asked her to give it up. The roommate of Resident #66 was described as always getting up early and added that she would not have been in her room to eat breakfast by the time the code was called. Staffing Coordinator N reported that it was the roommate's tray that was the one opened with the food eaten. We have three meal carts that come out. Resident #66 was seen in the halls drinking her morning coke when staff member M and I were together. At this point, I am still not sure who passed the trays that were put in her room. Review of the facility's policy entitled Meal Service, with a Last Date Revised of [DATE], revealed the Policy was: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients' / residents/ quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14 read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. The Speech Therapy SLP (Speech & Language Pathologist) Evaluation and Plan of Treatment dated [DATE], showed a Certification period of [DATE]-[DATE] for Dysphagia Therapy. Per the Speech Therapy document, relevant [DIAGNOSES REDACTED]. The referral was made by nursing to determine the appropriateness of a diet upgrade. The document included the note, Per DON (Director of Nursing) patient is reportedly going in others' rooms taking foods that are not part of her puree diet order. This is however, not a new behavior resulting from diet downgrade to puree. Patient's girlfriends reported that patient had displayed behaviors whereby she will somehow obtain food items while at another center. Her friends advised this SLP that patient had previously choked on a large jawbreaker type candy in one instance. She also choked on a large ball of chewed chewing gum she had accumulated over some period of time prior to her admission at this facility. In (MONTH) of this year she choked on fig newton she impulsively ate while in this setting. Chest x-ray on [DATE] had findings which were consistent with pneumonia. Patient returns with the following dx (diagnosis): choking and [MEDICAL CONDITION], aspiration pneumonia. The SLP document listed previous treatment and outcomes which included discontinued speech therapy with the resident on a mechanical soft diet. The Oral stage dysphagia was documented as due in part to edentulous status and poor safety awareness /impulsivity. Under the Background Assessment - Medical section the document included: Precautions: choking hazard, confusion, constant SUP (supervision) due to cognition, aspiration and pureed diet. Listed under the Recommendations section of the document, the SLP had recommended: Supervision for oral intake=Close supervision (100% supervision is recommended for this resident for any po (by mouth) intake other than puree diet due to no self-monitoring and total dependence on external cues for general safer swallowing strategies r/t -related to, impaired cognition.) Under the Assessment Summary on the document, the SLP documented under Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, choking. The SLP discharged the resident from therapy on [DATE] and indicated the resident was discharged to the Restorative Program. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on [DATE] beginning at 12:40 p.m. who confirmed that Resident #66 was her patient. She reported that she hadn't been at the facility the morning of [DATE], but had come in later and was told what had happened. She reported that the resident was a smart lady who knew what she wanted and would bargain with her to get a soda. The provider reported that she would refuse to be weighed unless someone bought her a soda. She was compulsive about food and even when she asked friends of Resident #66, they confirmed that the resident had always been that way. The provider reported that she had observed Resident #66 in the back hall taking half eaten food off of resident's trays, once the resident was done with the tray and staff had collected it for disposal. She reported that the resident wanted to eat a regular texture diet but she wasn't safe to eat regular texture. A review of the resident's medical record showed the most recent MDS (Minimum Data Set) assessment was dated [DATE]. Section C related to cognitive function indicated a BIMS (brief interview of mental status) score of 3, indicating severe cognitive impairment. A review of Section G related to functional status indicated the resident was self-sufficient once she was assisted into her wheelchair. She was identified as needing supervision by one person while eating. A review of Section K related to Swallowing/Nutritional Status indicated she required a mechanically altered diet. The MDS documented the resident as standing 68 tall and weighing 152 lbs. The initial Nutrition Assessment by the Registered Dietitian (RD) was dated [DATE] and indicated that the resident's 'Feeding Ability was documented as one on one supervision at meals, restorative dining per ST (speech therapy). The Diet order at that time was Mechanical soft, NAS HCC (No Added Salt, House Consistent Carbohydrates) Honey Thick Liquids. The RDs comments read, Resident is working (with) ST for dysphagia, restorative dining for all meals, one on one supervision. Makes food preferences known, consuming 100% of meals. A re-entry Nutrition Assessment was conducted on [DATE] which identified the resident as readmitted from the hospital after choking episode on snacks family had brought in. Diet has been downgraded to puree and requires nurse supervision at meals/snacks for cueing and assistance. Eats 100% of meals. Resident has a tendency to grab other residents' snacks/food. In a review of a Nutrition note, dated [DATE], it was documented that the Resident will often complain of feeling hungry and take food that belongs to other residents and foods that are not of appropriate consistency. The resident's weight was documented on [DATE] as 163.8 lbs., a gain of one pound since her admission in (MONTH) (YEAR). Review of a Nutrition note dated [DATE], revealed CBW (current body weight) 161.4 lbs., no significant change however slightly down. Resident was seen by ST and was determined not to be appropriate for diet upgrade d/t (due to) compulsive behavior when eating. Resident continues to take food that does not belong to her and must be redirected. The resident's annual nutrition assessment, dated [DATE], confirmed the resident's weight was stable from the prior assessment (162 lbs.) and her diet consistency of pureed. The RD assessment read, Resident continues to receive a NAS/HCC/pureed thin liquid diet. Continues to take food from other residents, despite education and encouragement. A weight note documented by the RD on [DATE] revealed the resident had a weight loss of 8.1% in three months, with the current weight at 152.4 lbs. on [DATE]. The note included, resident does not like pureed consistency of foods and will often take foods off other resident's trays and pick foods off carts heading back to the dish room. Resident is on a pureed consistency related to being a compulsive eater. Several attempts have been made in the past with ST to offer solid foods under supervision however resident would continue to hoard food in mouth despite coaxing to slow down. MD does not feel it to be appropriate to upgrade resident's diet d/t history of aspiration. A weight note documented by the RD on [DATE] revealed the resident had lost weight and was at 148 lbs. on [DATE]. The RD documented resident dislikes pureed consistency of foods and will regularly ask for solid foods and seek out foods that may be accessible to her. Called sister to inform of weight loss and waiver form available acknowledging the risks and benefits of upgrading resident's diet. Sister stated she would like for her to eat solid foods however is concerned of resident hoarding food in mouth and would ideally like staff member to sit with resident during meals to cue her to slow down and take small bites. Informed sister that there is restorative dining available however it cannot be guaranteed that a staff member will always be present every time resident consumes a snack or any kind of food throughout the course of the day. Sister expressed understanding and stated that she brought resident a thanksgiving meal and broke up the turkey into very small pieces and constantly had to monitor and cue her to take small bites and she did well. In an interview with the Certified Dietary Manager (CDM) on [DATE] beginning at 5:20 p.m., residents on the Mechanical Soft diet had complained in the past that the French toast was too dry. The CDM reported that she serves Waffles with two syrups (individual packets) to residents on Mechanical Soft diets when French toast is the planned breakfast menu item. She confirmed that on [DATE], residents on Mechanical Soft diets received waffles instead of the French toast. During the Recertification Survey ([DATE] - [DATE]) an interview with the Restorative Nurse was requested to understand how the facility identified those residents who needed supervision at meals, to ensure they were kept safe while eating. The interviews were conducted on [DATE] beginning at 1:36 p.m. with the Restorative Nurse and an Assistant Director of Nurses, (both Registered Nurses) which revealed that five residents were on the restorative dining program. It was confirmed by the two RN's that not all residents needed physical assistance with dining, as some residents needed only encouragement or cueing to finish their meals. Because of repairs that were required in the kitchen, the facility's dining room was closed for the first week to ten days of December. The two nurses were asked about the dining plan for residents, including those residents in the restorative dining program, who usually ate their meals in the dining room. The plan to maintain residents' ability to socialize with other residents during meals, as well as to remain safe while eating or receive cueing to finish their meal was requested. The two nurses reported that the plan was for residents to eat in their rooms or some could eat in the day room on station 2. The nurses reported that residents who needed assistance with their meals would be assisted. Both nurses reported that there was no documented plan, it was just something that had been discussed and everyone knew they had to supervise the residents where ever they were eating. In an interview conducted with Restorative Aide BB, on [DATE] beginning at 7:00 a.m., it was revealed that she had started her shift early as [DATE] was the first day that the dining room was open for meals, as it had been closed for repairs to the kitchen. She reported that she wanted to make sure the Breakfast meal went ok. She reported that the dining room had been closed so her Restorative residents had to eat in their rooms with supervision or in the Day Room on Station one. She said she wasn't aware of a documented plan for dining while the dining room was closed, but tried to make sure her restorative residents got their meals. Resident #66's Care plan, initiated on [DATE] with a revision and cancellation date of [DATE], with the Focus of resident on restorative dining program to safely tolerate altered diet was reviewed and noted for the intervention of resident will participate in the restorative dining program to safely tolerate puree solids and thin liquids. A Referral to Restorative Nursing Program, dated [DATE], was reviewed which indicated the resident would attend the program 6 days a week for 12 weeks. Under Restorative Dining Program, the Goal read: continue to safely tolerate puree/thin liquids using general safe swallowing strategies - small bites, slowed rate, clearing out oral cavity prior to next bite. Resident #66 was not in the Restorative Dining Program at the time of her death. Quarterly Care plan conference summaries from [DATE] until [DATE] documented the IDT (interdisciplinary team) and family were aware of the resident's attempts to obtain food that was not compliant with her diet order and redirection was unsuccessful. The Care Plan summaries included that will eat food from other resident's trays and attempts to take other's food. The Care Plan, dated [DATE], included, SSD (Social Services Director) informed brother that further placement will be sought due to noncompliance. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of resident has an issue with compulsive eating related to the [DIAGNOSES REDACTED]. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of Behavioral Problem as evidenced by non-compliant with diet restrictions. Interventions included intervene prn (as necessary) to ensure the safety of the resident and others. Review of the resident's care plan, initiated on [DATE] and in place until her death on [DATE], revealed the Focus of resistant to care at times, noncompliant with diet restrictions, takes others foods included an intervention to educate the resident/family/caregivers of the possible outcomes of not complying with treatment. Review of the resident's Care plans, initiated on [DATE] and current until her death on [DATE], revealed the Focus of nutritional problem or potential nutritional problem related to mechanically altered, therapeutic diet , prefers to drink more than eating, dislikes puree texture and will take foods from other residents and is a compulsive eater. The Interventions included: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain the consequences of refusal. Further review of the resident's medical record revealed [REDACTED].#66 was known to wander through out the facility and eat food that she found unguarded. A Social Service Quarterly, dated [DATE], stated resident is alert with confusion. Moderately impaired cognition. Resident still wanders throughout the facility and sometimes takes food off of used dietary trays. A Nursing note, dated [DATE], stated Resident noted taking food and drinks off of used trays, when nurse took milk from resident, resident threw milk at nurse and all over the floor. CNA reported resident taking food off of roommate's tray also and was aggressive and cursing at staff when approached about not taking food off of trays. Resident redirected. ARNP and psyche notified. On [DATE], a Nurse's note documented the CNA reported resident going into dining room attempting to take food and drink off of dirty tables. When CNA stopped her, the aide reported resident cursing at her and calling her names. Nurse was able to educate resident on infection control and she should not be taking food and drink off of dirty tables. Resident redirected. Snack given. A [DATE] Social Services Quarterly note documented Resident attempts to take food off of others' plates and stuffs it in her mouth before staff gets to her. Resident is redirected by staff as needed. On [DATE] beginning at 2:50 p.m. the Administrator and Director of Nurses were interviewed related to the nurse's note dated [DATE], and their investigation into what had happened to allow Resident #66, to be without monitoring in her room with two breakfast trays - one of which was of a food consistency that was not consistent with Resident #66's Physician ordered diet. The DON confirmed that during 'shift change' the resident 'coded' and she assisted with compressions during CPR (Cardiopulmonary resuscitation). She reported that a brownish-yellow liquid was vomited which she described as normal during compressions. She denied that any solids, or 'chunks' of food or any substance were vomited by the resident. During the interview, the Director of Nurses (DON) explained that the resident was a wanderer who was able to self-propel around the building and would ask staff for money for a soda. The DON explained that the resident didn't like her pureed diet and was known to take other residents' food if it wasn't pureed. The DON reported that no breakfast trays remained on the floor at the time that staff were attempting to resuscitate Resident #66. Both the DON and the Administrator confirmed that the resident was known to take other resident's food but there was no physician's order for supervision during meals and staff were to check on the resident during meals as they were walking the halls. In an interview on [DATE] beginning at 9:15 a.m., when asked if she had submitted an immediate report to the State Agency, the Administrator asked, Why would we submit an immediate report? There had been no allegation made. After thinking about that answer she responded, The resident is not a resident of the facility any longer as a reason for why there had been no immediate report made. She then added that the facility had 15 days to investigate and submit a report. On [DATE] beginning at 10:20 a.m., a phone interview was conducted with a state investigator, who reported he had spoken with the Administrator and Director of Nurses on [DATE] about Resident #66. He reported that he was told that breakfast trays remained in the room with the resident and the facility staff surmised that Resident #66 had eaten her roommate's breakfast and had choked. The investigator confirmed that the resident had been pronounced dead at the hospital. Review of Resident #66's Emergency Department records, dated [DATE], found documentation under ED (Emergency Department) Rapid Triage, the Chief Complaint: arrives in [MEDICAL CONDITION] via EMS. EMS reports last normal per family @ approximately 0830 this AM. EMS reports 2 episodes of v-fib, shocked twice, otherwise in asystole. Pt (patient) arrives with IGEL in place. (Per www.intersurgical.com, IGEL is a second generation supraglottic airway device, used in anesthesia and resuscitation.) EMS administered [MEDICATION NAME] 300, [MEDICATION NAME] x 2 doses, Epi x 5. Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct [DIAGNOSES REDACTED]. Sudden [MEDICAL CONDITION] after FBA may occur secondary to asphyxiation. Case Report, Early Recognition of Foreign Body Aspiration as the Cause of [MEDICAL CONDITION] https://www.hindawi.com/journals/cricc/,[DATE]/ Documented under the heading of Cardiac - Respiratory Arrest - ED, was the History of Previous Illness: The patient presents in respiratory arrest, [AGE] year old with a history of previous [MEDICAL CONDITION] hypertension dementia, presents from her nursing home via EMS in [MEDICAL CONDITION]. As per EMS patient was last seen 45 minutes prior to their arrival. Patient was found unresponsive. When EMS got there patient was asystole. (Per the Medical Dictionary, asystole is a form of [MEDICAL CONDITION] in which there is no heart beat and the electrocardiogram tracing is straight.) ACLS protocol initiated. EMS reports that patient went into v. Fib twice and had to be shocked. She received [MEDICATION NAME] and [MEDICATION NAME] prior to her arrival to the ER. Upon arrival to the emergency room patient is still asystole with active CPR in progress. The onset was just prior to arrival. Witnessed arrest no. Initial cardiac rhythm asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation defibrillated. Preceding symptoms unknown. Risk factors consist of hypertension. Documented under the heading of Medical Decision Making, the subsection Endotracheal Intubation read: Indication: [MEDICAL CONDITION]. Documented under the heading of Person Information was the Visit Reason, which documented: [MEDICAL CONDITION] Arrival time at the ED was [DATE] 09:34:00. Disposition Type was Death/Expired/No Autopsy. Review of the hospital record dated [DATE] at 09:34 a.m. revealed the resident received a

Based on interviews with the Nursing Home Administrator, the Director of Nurses, Nursing staff, the Advanced Registered Nurse Practitioner, a family member of the resident, and a state investigator; record review of the resident's medical record and hospital record, and review of facility policies, the facility failed to prevent neglect, through lack of monitoring during meals, and fully investigate the circumstances for one (Resident #66) of a sample of 8 residents requiring supervision or assistance with meals. Resident #66, who was assessed as needing supervision as she was known to seek out food that was not compliant with her Physician's diet order of Puree, and would impulsively eat that non-pureed food, was found alone in her room, with two breakfast trays, nonresponsive and without breath or pulse. Nursing staff performed CPR (Cardio [MEDICAL CONDITION] Resuscitation), which resulted in yellow-brownish chunks resembling waffles being ejected from her mouth. The facility failed to provide nursing oversight when Resident #66's aide, on the 7a to 3p shift on [DATE], was not made aware that Resident #66 should be provided with supervision during meals, including not allowing the resident to be left alone in her room with her pureed breakfast and her roommate's breakfast of a mechanical soft texture, which provided Resident #66 the opportunity to eat waffles which were not pureed. Failure of facility staff to identify and investigate a violation of neglect resulted in findings of ongoing Immediate Jeopardy on [DATE]. Findings included: On [DATE] beginning at 4:49 p.m., in an interview with Staff Nurse X, it was revealed that she had taken Resident #66 back to her nursing unit about 8:00 a.m. She reported that she parked the resident at the nursing station and returned to her assigned unit to pass her medications. She reported that shortly after that, she heard the other nurse call out for help. She reported that she called 911 and then went to the resident's room. She reported that she saw three nurses in the room attempting to resuscitate the resident. She reported that the DON was 'pushing up' on the resident's abdomen and chunks of food were coming out of the resident's mouth. She knew the served breakfast had been waffles and she described the vomited food as not fully chewed, not pureed, but chunks of yellow-brown waffles. The nurse reported that the resident was known to take other resident's food and both the resident and the roommate's breakfast trays were in the resident's room. During an interview on [DATE] at 10:55 a.m., staff member M stated, On [DATE], around 7:00 a.m., Resident #66 came out of her room without clothing, so I took her back to get dressed while I waited for the schedule assignment. Staff member M stated an agency CNA came in and I did rounds with her but did not discuss Resident #66 with the agency CNA because Resident #66 was on my assignment. Staff Member M stated she was sick and wearing a mask and went to find staff member N, (staffing coordinator) to see about going home. Staff Member M, stated she was given the ok to go home at approximately 8:40 a.m. She reported that she noticed the last cart of breakfast trays coming on to the hall and she observed Resident #66 at the nurses' station before she left the building. She reported that the Resident asked if staff member M was leaving. Staff member M stated, Resident #66 had been eating in the solarium while the dining room closed but I wasn't sure where she would be eating on [DATE]. Staff member M reported that she had been out sick from [DATE] at 8:40 a.m. until [DATE] and when she returned to work, she was told Resident #66 was spitting up whole waffles. Staff member M confirmed that Resident #66's roommate was on a mechanical soft diet. Staff member M described Resident #66 as always cruising around the building looking for food on dirty trays or in the garbage, as she would take it from anywhere. Staff member M continued, I feel bad. If I was not sick that day she may still be here. She was my favorite and I always had her. If she had someone from the agency they would not know that about her and I am not sure if it was on her care plan. An interview was conducted with Resident #66's assigned nurse, on [DATE] beginning at 12:45 p.m. Staff nurse D reported that she saw Resident #66 sitting in her room, with her head down. She said that she called to the resident several times without the resident responding. She said that she entered the room to check on the resident and was not able to get a response or to feel a pulse. She reported that she went to the nurses' station, checked the resident's medical record for the advanced directive and once she saw the 'Full Code', she called out for help. She reported that she returned to the resident's room and began to resuscitate her with help from the DON and the unit manager. She reported that chunks of a brownish yellow substance were vomited. During a review of the medical record for Resident #66, the following note written by the resident's nurse was reviewed: [DATE] 0845: Nurse went into residents room, found resident sitting in wheelchair with head down, resident assessed, was unresponsive, absence of pulse and not breathing, with brown and yellow vomit coming from mouth, nurse verified resident Full Code, called out for help. Code Blue and to call 911, aide and nurse laid resident on floor , mouth swept (sic) done to remove vomit, 2 nurses began CPR, (cardio [MEDICAL CONDITION] resuscitation) along with AED, (automatic external defibrillator) 0850 911 called 0855 AED placed, 0900 resident vomited and was turned onto right side mouth swept (sic) done to clear airway, 0903 CPR continued, EMT (Emergency medical technicians) arrived and continued CPR, 0905 resident still unresponsive, EMT continued CPR 0910 (resident's medical provider) called, message left, residents sister called and notified of residents condition. 0915 doctor called message left with answering service 0940 resident transferred by EMS via stretcher to hospital. 0950 PA (Physician's Assistant) called back notified of resident condition. On [DATE] at 12:56 PM in an interview with Staff E, RN Unit Manager she said she was called out of the conference room during the morning meeting and told Resident #66 was needing assistance, that she coded. She said she thinks the words were that she was choking. When she arrived at Resident #66's room, CPR was already in progress, with the crash cart already in the room, and compressions were in progress. The patient was blue. Someone else was doing respirations. The DON took over compressions and she took over the ambu bag. There was somebody else recording. The nurse doing compressions initially was on the phone with the family. The nurse in charge of the resident was recording. So at that time she asked the people to go back to their assignment so EMTs could get in the room. The AED was in the room. It was already on. She was giving respirations, checking for a pulse. The resident started to vomit. So her head was turned. She had large chunks of food coming up. The DON did a mouth sweep. CPR continued. The AED said clear and continue. The resident started to vomit again. They continued CPR. By this time, EMTs arrived. They came to the door near to her room, so they had really fast access to her. The EMTs took over CPR. They intubated her and took over respirations. They started an intraosseous line. She was flat lined. They did resuscitate her with medication. For just a minute she did have a pulse on the monitor. EMTs continued compressions. They continued bagging her. The whole time while transporting her onto the stretcher and into the ambulance. She said she stayed with the resident until she was in the ambulance. She said she wasn't with the resident when the event happened. The resident was already on the floor and CPR was already in progress. She said the resident was always stealing food from other residents in the dining room. She said she didn't know if she had taken food. Staff had to watch her vigilantly. She apparently had eaten solid foods. It wasn't puree. She had gotten it from somewhere else. The resident was supposed to be monitored during meals. She was supposed to be eating in the solarium. She wasn't supposed to be eating in her room. She was very mobile and had her own mind. She was not restrained. She was very friendly and outgoing. Staff E said she thought the resident was highly supervised, and didn't need a one on one. She repeated, the resident was highly supervised and was very mobile. She would not answer if she thought the situation was preventable. She said there were a lot of interventions in place. Supervision was daily, at every meal, every day that she did this. She said the resident taking food off others' trays was a daily behavior. During an interview on [DATE] at 1:01 p.m., Staffing Coordinator N stated that she assigned staff member P, an agency aide , to complete staff member M's assignment. Staffing Coordinator N, stated that [DATE] was the first time staff member P worked at the facility and she added that Staff member P was added to the 'do not return' list for the facility after staff member P and the Director of Nursing had some words. Staff member P did not complete her shift on [DATE] as she was asked to leave the facility somewhere between 10:00 a.m. and 11:00 a.m. Staffing Coordinator N stated on [DATE] when the code blue was called she ran with the second crash cart to Resident #66's room and observed CPR in progress. She stated, When the DON came in, I asked if we could have someone switch giving compressions. The DON took over compressions while a CNA bagged Resident #66. Staffing Coordinator N observed a dark yellow glob on Resident #66 left leg mid-thigh which she estimated as being the size of a yellow highlighter without the lid. She included that the resident had been laid on the floor. She reported that Resident #66's breakfast tray was not touched but the roommate's breakfast had been eaten. Staffing Coordinator N reported that once the DON took over compressions, three of the staff that had been in the room went out on the porch because they were so upset. Staffing Coordinator N added that she had asked staff member P, where she was when the code was called and she told me she was heating up food for a Resident in the pantry and that she had not been in the room for Resident #66 at all that morning. Staffing Coordinator N described Resident #66 as 'non-compliant' and constantly stealing food off other's tray and would swipe it right in front of you and she would tell you no if you asked her to give it up. The roommate of Resident #66 was described as always getting up early and added that she would not have been in her room to eat breakfast by the time the code was called. Staffing Coordinator N reported that it was the roommate's tray that was the one opened with the food eaten. We have three meal carts that come out. Resident #66 was seen in the halls drinking her morning coke when staff member M and I were together. At this point, I am still not sure who passed the trays that were put in her room. Review of the facility's policy entitled Meal Service, with a Last Date Revised of [DATE], revealed the Policy was: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients' / residents/ quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14 read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. The Speech Therapy SLP (Speech & Language Pathologist) Evaluation and Plan of Treatment dated [DATE], showed a Certification period of [DATE]-[DATE] for Dysphagia Therapy. Per the Speech Therapy document, relevant [DIAGNOSES REDACTED]. The referral was made by nursing to determine the appropriateness of a diet upgrade. The document included the note, Per DON (Director of Nursing) patient is reportedly going in others' rooms taking foods that are not part of her puree diet order. This is however, not a new behavior resulting from diet downgrade to puree. Patient's girlfriends reported that patient had displayed behaviors whereby she will somehow obtain food items while at another center. Her friends advised this SLP that patient had previously choked on a large jawbreaker type candy in one instance. She also choked on a large ball of chewed chewing gum she had accumulated over some period of time prior to her admission at this facility. In (MONTH) of this year she choked on fig newton she impulsively ate while in this setting. Chest x-ray on [DATE] had findings which were consistent with pneumonia. Patient returns with the following dx (diagnosis): choking and [MEDICAL CONDITION], aspiration pneumonia. The SLP document listed previous treatment and outcomes which included discontinued speech therapy with the resident on a mechanical soft diet. The Oral stage dysphagia was documented as due in part to edentulous status and poor safety awareness /impulsivity. Under the Background Assessment - Medical section the document included: Precautions: choking hazard, confusion, constant SUP (supervision) due to cognition, aspiration and pureed diet. Listed under the Recommendations section of the document, the SLP had recommended: Supervision for oral intake=Close supervision (100% supervision is recommended for this resident for any po (by mouth) intake other than puree diet due to no self-monitoring and total dependence on external cues for general safer swallowing strategies r/t -related to, impaired cognition.) Under the Assessment Summary on the document, the SLP documented under Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, choking. The SLP discharged the resident from therapy on [DATE] and indicated the resident was discharged to the Restorative Program. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on [DATE] beginning at 12:40 p.m. who confirmed that Resident #66 was her patient. She reported that she hadn't been at the facility the morning of [DATE], but had come in later and was told what had happened. She reported that the resident was a smart lady who knew what she wanted and would bargain with her to get a soda. The provider reported that she would refuse to be weighed unless someone bought her a soda. She was compulsive about food and even when she asked friends of Resident #66, they confirmed that the resident had always been that way. The provider reported that she had observed Resident #66 in the back hall taking half eaten food off of resident's trays, once the resident was done with the tray and staff had collected it for disposal. She reported that the resident wanted to eat a regular texture diet but she wasn't safe to eat regular texture. Resident #66, a [AGE] year old, was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The Physician's Order, dated [DATE], ordered a NAS/HCC (No Added Salt, House Consistent Carbs) Pureed Texture diet. A review of the resident's medical record showed the most recent MDS (Minimum Data Set) assessment was dated [DATE]. Section C related to cognitive function indicated a BIMS (brief interview of mental status) score of 3, indicating severe cognitive impairment. A review of Section G related to functional status indicated the resident was self-sufficient once she was assisted into her wheelchair. She was identified as needing supervision by one person while eating. A review of Section K related to Swallowing/Nutritional Status indicated she required a mechanically altered diet. The MDS documented the resident as standing 68 tall and weighing 152 lbs. The initial Nutrition Assessment by the Registered Dietitian (RD) was dated [DATE] and indicated that the resident's 'Feeding Ability was documented as one on one supervision at meals, restorative dining per ST (speech therapy). The Diet order at that time was Mechanical soft, NAS HCC (No Added Salt, House Consistent Carbohydrates) Honey Thick Liquids. The RDs comments read, Resident is working (with) ST for dysphagia, restorative dining for all meals, one on one supervision. Makes food preferences known, consuming 100% of meals. A re-entry Nutrition Assessment was conducted on [DATE] which identified the resident as readmitted from the hospital after choking episode on snacks family had brought in. Diet has been downgraded to puree and requires nurse supervision at meals/snacks for cueing and assistance. Eats 100% of meals. Resident has a tendency to grab other residents' snacks/food. In a review of a Nutrition note, dated [DATE], it was documented that the Resident will often complain of feeling hungry and take food that belongs to other residents and foods that are not of appropriate consistency. The resident's weight was documented on [DATE] as 163.8 lbs., a gain of one pound since her admission in (MONTH) (YEAR). Review of a Nutrition note dated [DATE], revealed CBW (current body weight) 161.4 lbs., no significant change however slightly down. Resident was seen by ST and was determined not to be appropriate for diet upgrade d/t (due to) compulsive behavior when eating. Resident continues to take food that does not belong to her and must be redirected. The resident's annual nutrition assessment, dated [DATE] confirmed the resident's weight was stable from the prior assessment (162 lbs.) and her diet consistency of pureed. The RD assessment read, Resident continues to receive a NAS/HCC/pureed thin liquid diet. Continues to take food from other residents, despite education and encouragement. A weight note documented by the RD on [DATE] revealed the resident had a weight loss of 8.1% in three months, with the current weight at 152.4 lbs. on [DATE]. The note included, resident does not like pureed consistency of foods and will often take foods off other resident's trays and pick foods off carts heading back to the dish room. Resident is on a pureed consistency related to being a compulsive eater. Several attempts have been made in the past with ST to offer solid foods under supervision however resident would continue to hoard food in mouth despite coaxing to slow down. MD does not feel it to be appropriate to upgrade resident's diet d/t history of aspiration. A weight note documented by the RD on [DATE] revealed the resident had lost weight and was at 148 lbs. on [DATE]. The RD documented resident dislikes pureed consistency of foods and will regularly ask for solid foods and seek out foods that may be accessible to her. Called sister to inform of weight loss and waiver form available acknowledging the risks and benefits of upgrading resident's diet. Sister stated she would like for her to eat solid foods however is concerned of resident hoarding food in mouth and would ideally like staff member to sit with resident during meals to cue her to slow down and take small bites. Informed sister that there is restorative dining available however it cannot be guaranteed that a staff member will always be present every time resident consumes a snack or any kind of food throughout the course of the day. Sister expressed understanding and stated that she brought resident a thanksgiving meal and broke up the turkey into very small pieces and constantly had to monitor and cue her to take small bites and she did well. In an interview with the Certified Dietary Manager (CDM) on [DATE] beginning at 5:20 p.m., residents on the Mechanical Soft diet had complained in the past that the French toast was too dry. The CDM reported that she serves Waffles with two syrups (individual packets) to residents on Mechanical Soft diets when French toast is the planned breakfast menu item. She confirmed that on [DATE], residents on Mechanical Soft diets received waffles instead of the French toast. During the Recertification Survey ([DATE] - [DATE]) an interview with the Restorative Nurse was requested to understand how the facility identified those residents who needed supervision at meals, to ensure they were kept safe while eating. The interviews were conducted on [DATE] beginning at 1:36 p.m. with the Restorative Nurse and an Assistant Director of Nurses, (both Registered Nurses) which revealed that five residents were on the restorative dining program. It was confirmed by the two RN's that not all residents needed physical assistance with dining, as some residents needed only encouragement or cueing to finish their meals. Because of repairs that were required in the kitchen, the facility's dining room was closed for the first week to ten days of December. The two nurses were asked about the dining plan for residents, including those residents in the restorative dining program, who usually ate their meals in the dining room. The plan to maintain residents' ability to socialize with other residents during meals, as well as to remain safe while eating or receive cueing to finish their meal was requested. The two nurses reported that the plan was for residents to eat in their rooms or some could eat in the day room on station 2. The nurses reported that residents who needed assistance with their meals would be assisted. Both nurses reported that there was no documented plan, it was just something that had been discussed and everyone knew they had to supervise the residents where ever they were eating. In an interview conducted with Restorative Aide BB, on [DATE] beginning at 7:00 a.m., it was revealed that she had started her shift early as [DATE] was the first day that the dining room was open for meals, as it had been closed for repairs to the kitchen. She reported that she wanted to make sure the Breakfast meal went ok. She reported that the dining room had been closed so her Restorative residents had to eat in their rooms with supervision or in the Day Room on Station one. She said she wasn't aware of a documented plan for dining while the dining room was closed, but tried to make sure her restorative residents got their meals. Resident #66's Care plan, initiated on [DATE] with a revision and cancellation date of [DATE], with the Focus of resident on restorative dining program to safely tolerate altered diet was reviewed and noted for the intervention of resident will participate in the restorative dining program to safely tolerate puree solids and thin liquids. A Referral to Restorative Nursing Program, dated [DATE], was reviewed which indicated the resident would attend the program 6 days a week for 12 weeks. Under Restorative Dining Program, the Goal read: continue to safely tolerate puree/thin liquids using general safe swallowing strategies - small bites, slowed rate, clearing out oral cavity prior to next bite. Resident #66 was not in the Restorative Dining Program at the time of her death. Quarterly Care plan conference summaries from [DATE] until [DATE] documented the IDT (interdisciplinary team) and family were aware of the resident's attempts to obtain food that was not compliant with her diet order and redirection was unsuccessful. The Care Plan summaries included that will eat food from other resident's trays and attempts to take other's food. The Care Plan, dated [DATE], included, SSD (Social Services Director) informed brother that further placement will be sought due to noncompliance. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of resident has an issue with compulsive eating related to the [DIAGNOSES REDACTED]. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of Behavioral Problem as evidenced by non-compliant with diet restrictions. Interventions included intervene prn (as necessary) to ensure the safety of the resident and others. Review of the resident's care plan, initiated on [DATE] and in place until her death on [DATE], revealed the Focus of resistant to care at times, noncompliant with diet restrictions, takes others foods included an intervention to educate the resident/family/caregivers of the possible outcomes of not complying with treatment. Review of the resident's Care plans, initiated on [DATE] and current until her death on [DATE], revealed the Focus of nutritional problem or potential nutritional problem related to mechanically altered, therapeutic diet , prefers to drink more than eating, dislikes puree texture and will take foods from other residents and is a compulsive eater. The Interventions included: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain the consequences of refusal. Further review of the resident's medical record revealed [REDACTED].#66 was known to wander through out the facility and eat food that she found unguarded. A Social Service Quarterly, dated [DATE], stated resident is alert with confusion. Moderately impaired cognition. Resident still wanders throughout the facility and sometimes takes food off of used dietary trays. A Nursing note, dated [DATE], stated Resident noted taking food and drinks off of used trays, when nurse took milk from resident, resident threw milk at nurse and all over the floor. CNA reported resident taking food off of roommate's tray also and was aggressive and cursing at staff when approached about not taking food off of trays. Resident redirected. ARNP and psyche notified. On [DATE], a Nurse's note documented the CNA reported resident going into dining room attempting to take food and drink off of dirty tables. When CNA stopped her, the aide reported resident cursing at her and calling her names. Nurse was able to educate resident on infection control and she should not be taking food and drink off of dirty tables. Resident redirected. Snack given. A [DATE] Social Services Quarterly note documented Resident attempts to take food off of others' plates and stuffs it in her mouth before staff gets to her. Resident is redirected by staff as needed. On [DATE] beginning at 2:50 p.m. the Administrator and Director of Nurses were interviewed related to the nurse's note dated [DATE], and their investigation into what had happened to allow Resident #66, to be without monitoring in her room with two breakfast trays - one of which was of a food consistency that was not consistent with Resident #66's Physician ordered diet. The DON confirmed that during 'shift change' the resident 'coded' and she assisted with compressions during CPR (Cardiopulmonary resuscitation). She reported that a brownish-yellow liquid was vomited which she described as normal during compressions. She denied that any solids, or 'chunks' of food or any substance were vomited by the resident. During the interview, the Director of Nurses (DON) explained that the resident was a wanderer who was able to self-propel around the building and would ask staff for money for a soda. The DON explained that the resident didn't like her pureed diet and was known to take other residents' food if it wasn't pureed. The DON reported that no breakfast trays remained on the floor at the time that staff were attempting to resuscitate Resident #66. Both the DON and the Administrator confirmed that the resident was known to take other resident's food but there was no physician's order for supervision during meals and staff were to check on the resident during meals as they were walking the halls. In an interview on [DATE] beginning at 9:15 a.m., when asked if she had submitted an immediate report to the State Agency, the Administrator asked, Why would we submit an immediate report? There had been no allegation made. After thinking about that answer she responded, The resident is not a resident of the facility any longer as a reason for why there had been no immediate report made. She then added that the facility had 15 days to investigate and submit a report. On [DATE] beginning at 10:20 a.m., a phone interview was conducted with a state investigator, who reported he had spoken with the Administrator and Director of Nurses on [DATE] about Resident #66. He reported that he was told that breakfast trays remained in the room with the resident and the facility staff surmised that Resident #66 had eaten her roommate's breakfast and had choked. The investigator confirmed that the resident had been pronounced dead at the hospital. Review of Resident #66's Emergency Department records, dated [DATE], found documentation under ED (Emergency Department) Rapid Triage, the Chief Complaint: arrives in [MEDICAL CONDITION] via EMS. EMS reports last normal per family @ approximately 0830 this AM. EMS reports 2 episodes of v-fib, shocked twice, otherwise in asystole. Pt (patient) arrives with IGEL in place. (Per www.intersurgical.com, IGEL is a second generation supraglottic airway device, used in anesthesia and resuscitation.) EMS administered [MEDICATION NAME] 300, [MEDICATION NAME] x 2 doses, Epi x 5. Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct [DIAGNOSES REDACTED]. Sudden [MEDICAL CONDITION] after FBA may occur secondary to asphyxiation. Case Report, Early Recognition of Foreign Body Aspiration as the Cause of [MEDICAL CONDITION] https://www.hindawi.com/journals/cricc/,[DATE]/ Documented under the heading of Cardiac - Respiratory Arrest - ED, was the History of Previous Illness: The patient presents in respiratory arrest, [AGE] year old with a history of previous [MEDICAL CONDITION] hypertension dementia, presents from her nursing home via EMS in [MEDICAL CONDITION]. As per EMS patient was last seen 45 minutes prior to their arrival. Patient was found unresponsive. When EMS got there patient was asystole. (Per the Medical Dictionary, asystole is a form of [MEDICAL CONDITION] in which there is no heart beat and the electrocardiogram tracing is straight.) ACLS protocol initiated. EMS reports that patient went into v. Fib twice and had to be shocked. She received [MEDICATION NAME] and [MEDICATION NAME] prior to her arrival to the ER. Upon arrival to the emergency room patient is still asystole with active CPR in progress. The onset was just prior to arrival. Witnessed arrest no. Initial cardiac rhythm asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation defibrillated. Preceding symptoms unknown. Risk factors consist of hypertension. Documented under the heading of Medical Decision Making, the subsection Endotracheal Intubation read: Indication: [MEDICAL CONDITION]. Documented under the heading of Person Information was the Visit Reason, which documented: [MEDICAL CONDITION] Arrival time at the ED was [DATE] 09:34:00. Disposition Type was Death/Expired/No Autopsy. Review of the hospital record dated [DATE] at 09:34 a.m. revealed

Based on interviews with the Nursing Home Administrator, the Director of Nurses, nursing staff, and the resident's Nurse Practitioner, facility policies, the resident's family member, a investigator, and review of the resident's medical, hospital and Emergency Services records, the facility failed to ensure that Resident #66, one of a sample of 8 residents requiring supervision or assistance with meals, was provided with needed supervision at meals related to the resident's impulsive behavior toward food and known behavior of grabbing any food that was not within her diet restriction, and eating it quickly. Facility nursing staff failed to ensure the safety of Resident #66, on the morning of [DATE], when they were unaware that the resident was alone, in her room, with her roommate's breakfast which was not the food texture that she had been deemed safe to consume ; and failed to ensure that the resident's assigned aide was aware of the resident's need for supervision around food and her propensity to grab any non-pureed food that was available and to eat that non-pureed food quickly, which posed a choking hazard The facility failed to maintain the resident's safety at a meal, failed to follow facility policy related to Meal Service, failed to follow the resident's care plans identifying the resident as having issues with compulsive eating, requiring cues/supervision with decision making and having a behavioral problem as evidenced by her noncompliance with diet restrictions, with the planned interventions directing staff to 'monitor during meal times' , and 'intervene to ensure the safety of the resident, resulting in findings of Immediate Jeopardy on [DATE], which was on-going. Findings included: During a review of the medical record for Resident #66, the following note written by the resident's nurse was reviewed: [DATE] 0845: Nurse went into residents room, found resident sitting in wheelchair with head down, resident assessed, was unresponsive, absence of pulse and not breathing, with brown and yellow vomit coming from mouth, nurse verified resident Full Code, called out for help. Code Blue and to call 911, aide and nurse laid resident on floor , mouth swept (sic) done to remove vomit, 2 nurses began CPR, (cardio [MEDICAL CONDITION] resuscitation) along with AED, (automatic external defibrillator) 0850 911 called 0855 AED placed, 0900 resident vomited and was turned onto right side mouth swept (sic) done to clear airway, 0903 CPR continued, EMT (Emergency medical technicians) arrived and continued CPR, 0905 resident still unresponsive, EMT continued CPR 0910 (resident's medical provider) called, message left, residents sister called and notified of residents condition. 0915 doctor called message left with answering service 0940 resident transferred by EMS via stretcher to hospital. 0950 PA (Physician's Assistant) called back notified of resident condition. On [DATE] at 12:56 PM in an interview with Staff E, RN Unit Manager she said she was called out of the conference room during the morning meeting and told Resident #66 was needing assistance, that she coded. She said she thinks the words were that she was choking. When she arrived at Resident #66's room, CPR was already in progress, with the crash cart already in the room, and compressions were in progress. The patient was blue. Someone else was doing respirations. The DON took over compressions and she took over the ambu bag. (A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also frequently used in hospitals as part of standard equipment found on a crash cart, in emergency room s or other critical care settings. Per Wikipedia) The nurse doing compressions initially was on the phone with the family. The nurse in charge of the resident was recording. So at that time she asked the people to go back to their assignment so EMTs could get in the room. The AED was in the room. It was already on. She was giving respirations, checking for a pulse. The resident started to vomit. So her head was turned. She had large chunks of food coming up. The DON did a mouth sweep. CPR continued. The AED said clear and continue. The resident started to vomit again. They continued CPR. By this time, EMTs arrived. They came to the door near to her room, so they had really fast access to her. The EMTs took over CPR. They intubated her and took over respirations. They started an intraosseous line. (Per Wikipedia, an intraosseous line is the process of injecting directly into the marrow of a bone. This provides a non-[MEDICATION NAME] entry point into the systemic venous system. This technique is used to provide fluids and medication when intravenous access is not available or not feasible.) She was flat lined. (Per the Merriam- Webster Dictionary, to flatline is to register on an electronic monitor as having no heartbeat or brain waves.) They did resuscitate her with medication. For just a minute she did have a pulse on the monitor. EMTs continued compressions. They continued bagging her. The whole time while transporting her onto the stretcher and into the ambulance. She said she stayed with the resident until she was in the ambulance. She said she wasn't with the resident when the event happened. The resident was already on the floor and CPR was already in progress. She said the resident was always stealing food from other residents in the dining room. She said she didn't know if she had taken food. Staff had to watch her vigilantly. She apparently had eaten solid foods. It wasn't puree. She had gotten it from somewhere else. The resident was supposed to be monitored during meals. She was supposed to be eating in the solarium. She wasn't supposed to be eating in her room. She was very mobile and had her own mind. She was not restrained. She was very friendly and outgoing. Staff E said she thought the resident was highly supervised, and didn't need a one on one. She repeated, the resident was highly supervised and was very mobile. She would not answer if she thought the situation was preventable. She said there were a lot of interventions in place. Supervision was daily, at every meal, every day that she did this. She said the resident taking food off others' trays was a daily behavior. On [DATE] beginning at 4:49 p.m., in an interview with Staff Nurse X, she said that she had taken the resident back to her nursing unit about 8:00 a.m. She reported that she 'parked 'the resident at the nursing station and returned to her assigned unit to pass her medications. She reported that shortly after that, she heard the other nurse call out for help. She reported that she called 911 and then went to the resident's room. She reported that she saw three nurses in the room attempting to resuscitate the resident. She reported that the DON was 'pushing up' on the resident's abdomen and chunks of food were coming out of the resident's mouth. She knew the served breakfast had been waffles and she described the vomited food as not fully chewed, not pureed, but chunks of yellow-brown waffles. The nurse reported that the resident was known to take other resident's food and both the resident and the roommate's breakfast trays were in the resident's room. An interview was conducted with Staff nurse D who confirmed she was assigned to Resident #66 on [DATE]. In the interview on [DATE] beginning at 12:45 p.m. Staff nurse D reported that she saw Resident #66 sitting in her room, with her head down. She said that she called to the resident several times without the resident responding. She said that she entered the room to check on the resident and was not able to get a response or feel a pulse. She reported that she went to the nurses' station, checked the resident's medical record for the advanced directive and once she saw the 'Full Code', she called out for help. She reported that she returned to the resident's room and began to resuscitate her with help from the DON and the unit manager. She reported that chunks of a brownish yellow substance were vomited. During an interview on [DATE] at 10:55 a.m., staff member M stated, On [DATE], around 7:00 a.m., Resident #66 came out of her room without clothing, so I took her back to get dressed while I waited for the schedule assignment. Staff member M stated an agency CNA came in and I did rounds with her but did not discuss Resident #66 with the agency CNA because Resident #66 was on my assignment. Staff Member M stated she was sick and wearing a mask and went to find staff member N, (staffing coordinator) to see about going home. Staff Member M, stated she was given the ok to go home at approximately 8:40 a.m. She reported that she noticed the last cart of breakfast trays coming on to the hall and she observed Resident #66 at the nurses' station before she left the building. She reported that the Resident asked if staff member M was leaving. Staff member M stated, Resident #66 had been eating in the solarium while the dining room was closed but I wasn't sure where she would be eating on [DATE]. The Facility's dining room was closed due to equipment repair in the kitchen for the first week to 10 days in December. Staff member M reported that she had been out sick from [DATE] at 8:40 a.m. until [DATE] and when she returned to work, she was told Resident #66 was spitting up whole waffles. Staff member M confirmed that Resident #66's roommate was on a mechanical soft diet. Staff member M described Resident #66 as always cruising around the building looking for food on dirty trays or in the garbage, as she would take it from anywhere. Staff member M continued, I feel bad. If I was not sick that day she may still be here. She was my favorite and I always had her. If she had someone from the agency they would not know that about her and I am not sure if it was on her care plan. During an interview on [DATE] at 1:01 p.m., Staffing Coordinator N stated that she assigned staff member P, an agency aide, to complete staff member M's assignment. Staffing Coordinator N, stated that [DATE] was the first time staff member P worked at the facility. Staffing Coordinator N stated that Staff member P was added to the do not return list for the facility after staff member P and the Director of Nursing had some words. Staff member P did not complete her shift on [DATE] as she was asked to leave the facility somewhere between 10:00 a.m. and 11:00 a.m. Staffing Coordinator N stated on [DATE] when the code blue was called she ran with the second crash cart to Resident #66's room and observed CPR in progress. She stated, When the DON came in, I asked if we could have someone switch giving compressions. The DON took over compressions while a CNA bagged Resident #66. Staffing Coordinator N observed a dark yellow glob on Resident #66's left leg mid-thigh which she estimated as being the size of a yellow highlighter without the lid. She included that the resident had been laid on the floor. She reported that Resident #66's breakfast tray was not touched but her roommate's breakfast had been eaten. Staffing Coordinator N reported that once the DON took over compressions, three of the staff that had been in the room went out on the porch because they were so upset. Staffing Coordinator N added that she had asked staff member P, where she was when the code was called and she told me she was heating up food for a Resident in the pantry and that she had not been in the room for Resident #66 at all that morning. Staffing Coordinator N described Resident #66 as 'non-compliant' and constantly stealing food off other trays and would swipe it right in front of you and she would tell you no if you asked her to give it up. The roommate of Resident #66 was described as always getting up early and added that she would not have been in her room to eat breakfast by the time the code was called. Staffing Coordinator N reported that it was the roommate's tray that was the one opened with the food eaten. We have three meal carts that come out. Resident #66 was seen in the halls drinking her morning coke when staff member M and I were together. At this point, I am still not sure who passed the trays that were put in her room. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on [DATE] beginning at 12:40 p.m. who confirmed that Resident #66 was her patient. She reported that she hadn't been at the facility the morning of [DATE], but had come in later and was told what had happened. She reported that the resident was a smart lady who knew what she wanted and would bargain with her to get a soda. The provider reported that she would refuse to be weighed unless someone bought her a soda. She was compulsive about food and even when she asked friends of Resident #66, they confirmed that the resident had always been that way. The provider reported that she had observed Resident #66 in the back hall taking half eaten food off of resident's trays, once the resident was done with the tray and staff had collected it for disposal. She reported that the resident wanted to eat a regular texture diet but she wasn't safe to eat regular texture. Resident #66, a [AGE] year old, was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The Physician's Order, dated [DATE], ordered a NAS/HCC (No Added Salt, House Consistent Carbs) Pureed Diet Texture diet. The Speech Therapy SLP (Speech & Language Pathologist) Evaluation and Plan of Treatment dated [DATE], showed a Certification period of [DATE]-[DATE] for Dysphagia Therapy. Per the Speech Therapy document, relevant [DIAGNOSES REDACTED]. The referral was made by nursing to determine the appropriateness of a diet upgrade. The document included the note, Per DON (Director of Nursing) patient is reportedly going in others' rooms taking foods that are not part of her puree diet order. This is however, not a new behavior resulting from diet downgrade to puree. Patient's girlfriends reported that patient had displayed behaviors whereby she will somehow obtain food items while at another center. Her friends advised this SLP that patient had previously choked on a large jawbreaker type candy in one instance. She also choked on a large ball of chewed chewing gum she had accumulated over some period of time prior to her admission at this facility. In (MONTH) of this year she choked on fig newtons she impulsively ate while in this setting. Chest x-ray on [DATE] had findings which were consistent with pneumonia. Patient returns with the following dx (diagnosis): choking and [MEDICAL CONDITION], aspiration pneumonia. The SLP document listed previous treatment and outcomes which included discontinued speech therapy with the resident on a mechanical soft diet. The Oral stage dysphagia was documented as due in part to edentulous status and poor safety awareness /impulsivity. Under the Background Assessment - Medical section the document included: Precautions: choking hazard, confusion, constant SUP (supervision) due to cognition, aspiration and pureed diet. Listed under the Recommendations section of the document, the SLP had recommended: Supervision for oral intake=Close supervision (100% supervision is recommended for this resident for any po (by mouth) intake other than puree diet due to no self-monitoring and total dependence on external cues for general safer swallowing strategies r/t -related to, impaired cognition.) Under the Assessment Summary on the document, the SLP documented under Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, choking. The SLP discharged the resident from therapy on [DATE] and indicated the resident was discharged to the Restorative Program. A review of the resident's medical record showed the most recent MDS (Minimum Data Set) assessment was dated [DATE]. Section C related to cognitive function indicated a BIMS (brief interview of mental status) score of 3, indicating severe cognitive impairment. A review of Section G related to functional status indicated the resident was self-sufficient once she was assisted into her wheelchair. She was identified as needing supervision by one person while eating. A review of Section K related to Swallowing/Nutritional Status indicated she required a mechanically altered diet. Quarterly Care plan conference summaries from [DATE] until [DATE] documented the IDT (interdisciplinary team) and family were aware of the resident's attempts to obtain food that was not compliant with her diet order and redirection was unsuccessful. The Care Plan summaries included that will eat food from other resident's trays and attempts to take other's food. The Care Plan dated [DATE] included, SSD (Social Services Director) informed brother that further placement will be sought due to noncompliance. The Care plan initiated on [DATE] and current until her death on [DATE], had the Focus of resident has an issue with compulsive eating related to the [DIAGNOSES REDACTED]. The Care plan initiated on [DATE] and current until her death on [DATE] had the Focus of Behavioral Problem as evidenced by non-compliant with diet restrictions. Interventions included intervene prn (as necessary) to ensure the safety of the resident and others. Review of the resident's care plan initiated on [DATE] and in place until her death on [DATE], revealed the Focus of resistant to care at times, noncompliant with diet restrictions, takes others foods included an intervention to educate the resident/family/caregivers of the possible outcomes of not complying with treatment Review of the resident's Care plans initiated on [DATE] and current until her death on [DATE], revealed the Focus of nutritional problem or potential nutritional problem related to mechanically altered, therapeutic diet , prefers to drink more than eating, dislikes puree texture and will take foods from other residents and is a compulsive eater. The Interventions included: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain the consequences of refusal. The Care plan initiated on [DATE] with a revision and cancellation date of [DATE] with the Focus of resident on restorative dining program to safely tolerate altered diet was reviewed and noted for the intervention of resident will participate in the restorative dining program to safely tolerate puree solids and thin liquids. A Referral to Restorative Nursing Program, dated [DATE] was reviewed which indicated the resident would attend the program 6 days a week for 12 weeks. Under Restorative Dining Program, the Goal read: continue to safely tolerate puree/thin liquids using general safe swallowing strategies - small bites, slowed rate, clearing out oral cavity prior to next bite. Resident #66 was not in the Restorative Dining Program at the time of her death. During the Recertification Survey ([DATE] - [DATE]) an interview with the Restorative Nurse was requested to understand how the facility identified those residents who needed supervision at meals, to ensure they were kept safe while eating. The interviews were conducted on [DATE] beginning at 1:36 p.m. with the Restorative Nurse and an Assistant Director of Nurses, (both Registered Nurses) which revealed that five residents were on the restorative dining program. It was confirmed by the two RN's that not all residents needed physical assistance with dining, as some residents needed only encouragement or cueing to finish their meals. Because of repairs that were required in the kitchen, the facility's dining room was closed for the first week to ten days of December. The two nurses were asked about the dining plan for residents, including those residents in the restorative dining program, who usually ate their meals in the dining room. The plan to maintain residents' ability to socialize with other residents during meals, as well as to remain safe while eating or receive cueing to finish their meal was requested. The two nurses reported that the plan was for residents to eat in their rooms or some could eat in the day room on station 2. The nurses reported that residents who needed assistance with their meals would be assisted. Both nurses reported that there was no documented plan, it was just something that had been discussed and everyone knew they had to supervise the residents where ever they were eating. In an interview conducted with Staff Aide BB, on [DATE] beginning at 7:00 a.m., it was revealed that she had started her shift early as [DATE] was the first day that the dining room was open for meals, as it had been closed for repairs to the kitchen. She reported that she wanted to make sure the Breakfast meal went ok. She reported that the dining room had been closed so her Restorative residents had to eat in their rooms with supervision or in the Day Room on Station one. She said she wasn't aware of a documented plan for dining while the dining room was closed, but tried to make sure her restorative residents got their meals. Review of the facility's policy entitled Meal Service, with a Last Date Revised of [DATE], revealed the Policy was: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients' / residents/ quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14 read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. The initial Nutrition Assessment by the Registered Dietitian (RD) was dated [DATE] and indicated that the resident's 'Feeding Ability was documented as one on one supervision at meals, restorative dining per ST (speech therapy). The Diet order at that time was Mechanical soft, NAS HCC (No Added Salt, House Consistent Carbohydrates) Honey Thick Liquids. The RDs comments read, Resident is working (with) ST for dysphagia, restorative dining for all meals, one on one supervision. Makes food preferences known, consuming 100% of meals. A re-entry Nutrition Assessment was conducted on [DATE] which identified the resident as readmitted from the hospital after choking episode on snacks family had brought in. Diet has been downgraded to puree and requires nurse supervision at meals/snacks for cueing and assistance. Eats 100% of meals. Resident has a tendency to grab other residents' snacks/food. In a review of a Nutrition note, dated [DATE], it was documented that the Resident will often complain of feeling hungry and take food that belongs to other residents and foods that are not of appropriate consistency. The resident's weight was documented on [DATE] as 163.8 lbs., a gain of one pound since her admission in (MONTH) (YEAR). Review of a Nutrition note dated [DATE], revealed CBW (current body weight) 161.4 lbs., no significant change however slightly down. Resident was seen by ST and was determined not to be appropriate for diet upgrade d/t (due to) compulsive behavior when eating. Resident continues to take food that does not belong to her and must be redirected. The resident's annual nutrition assessment, dated [DATE] confirmed the resident's weight was stable from the prior assessment (162 lbs.) And her diet consistency of pureed. The RD assessment read, Resident continues to receive a NAS/HCC/pureed thin liquid diet. Continues to take food from other residents, despite education and encouragement. A weight note documented by the RD on [DATE] revealed the resident had a weight loss of 8.1% in three months, with the current weight at 152.4 lbs. on [DATE]. The note included, resident does not like pureed consistency of foods and will often take foods off other resident's trays and pick foods off carts heading back to the dish room. Resident is on a pureed consistency related to being a compulsive eater. Several attempts have been made in the past with ST to offer solid foods under supervision however resident would continue to hoard food in mouth despite coaxing to slow down. MD does not feel it to be appropriate to upgrade resident's diet d/t history of aspiration. A weight note documented by the RD on [DATE] revealed the resident had lost weight and was at 148 lbs. on [DATE]. The RD documented resident dislikes pureed consistency of foods and will regularly ask for solid foods and seek out foods that may be accessible to her. Called sister to inform of weight loss and waiver form available acknowledging the risks and benefits of upgrading resident's diet. Sister stated she would like for her to eat solid foods however is concerned of resident hoarding food in mouth and would ideally like staff member to sit with resident during meals to cue her to slow down and take small bites. Informed sister that there is restorative dining available however it cannot be guaranteed that a staff member will always be present every time resident consumes a snack or any kind of food throughout the course of the day. Sister expressed understanding and stated that she brought resident a thanksgiving meal and broke up the turkey into very small pieces and constantly had to monitor and cue her to take small bites and she did well. In an interview with the Certified Dietary Manager (CDM) on [DATE] beginning at 5:20 p.m., residents on the Mechanical Soft diet had complained in the past that the French toast was too dry. The CDM reported that she serves Waffles with two syrups (individual packets) to residents on Mechanical Soft diets when French toast is the planned breakfast menu item. She confirmed that on [DATE], residents on Mechanical Soft diets received waffles instead of the French toast. A Social Service Quarterly note dated [DATE] stated resident is alert with confusion. Moderately impaired cognition. Resident still wanders throughout the facility and sometimes takes food off of used dietary trays. A Nursing note dated [DATE] stated Resident noted taking food and drinks off of used trays, when nurse took milk from resident, resident threw milk at nurse and all over the floor. CNA reported resident taking food off of roommate's tray also and was aggressive and cursing at staff when approached about not taking food off of trays. Resident redirected. ARNP and psyche notified. On [DATE] a Nurse's note documented the CNA reported resident going into dining room attempting to take food and drink off of dirty tables. When CNA stopped her, the aide reported resident cursing at her and calling her names. Nurse was able to educate resident on infection control and she should not be taking food and drink off of dirty tables. Resident redirected. Snack given. [DATE] Social Services Quarterly note documented Resident attempts to take food off of others' plates and stuffs it in her mouth before staff gets to her. Resident is redirected by staff as needed. On [DATE] beginning at 2:50 p.m. the Administrator and Director of Nurses were interviewed related to the resident's status and the nurse's note. The DON confirmed that during 'shift change' the resident 'coded' and she assisted with compressions during CPR (Cardiopulmonary resuscitation). She reported that a brownish-yellow liquid was vomited which she described as normal during compressions. She denied that any solids, or 'chunks' of food or any substance were vomited by the resident. During the interview, the Director of Nurses (DON) explained that the resident was a wanderer who was able to self-propel around the building and would ask staff for money for a soda. The DON explained that the resident didn't like her pureed diet and was known to take other residents' food if it wasn't pureed. The DON reported that no breakfast trays remained on the floor at the time that staff were attempting to resuscitate Resident #66. Both the DON and the Administrator confirmed that the resident was known to take other resident's food but there was no physician's order for supervision during meals and staff were to check on the resident during meals as they were walking the halls. On [DATE] at 11:30 a.m., in an interview with Resident #66's sister, she reported that she had been told that her sister had died in her sleep. She was told that her sister was found with no heartbeat, that EMS (Emergency Medical Services) had been there, had shocked her twice but she had no heartbeat. They took her to the hospital and she died there. The sister apologized for missing the initial call from the surveyor as she explained that she had been at her sister's funeral. The sister reported that they had lost their brother in (MONTH) and she thought the resident had a hard time getting over that, as he had been her primary caregiver and would visit the resident frequently. The resident's sister reported that she visited less frequently and never stayed during meals, but she knew that her sister aspirated easily. She thought her sister probably ate with others. She was aware that her sister was on a pureed diet which she didn't like and reported that she had been in the facility the day before her sister died talking with staff about changing her diet. The sister reported that she was told by the Doctor that her sister had had a [MEDICAL CONDITION]. On [DATE] beginning at 10:20 a.m., a phone interview was conducted with a state investigator, who reported he had spoken with the Administrator and Director of Nurses on [DATE] about Resident #66. He reported that he had been told that breakfast trays remained in the room with the resident and the facility staff surmised that Resident #66 had eaten her roommate's breakfast and had choked. The investigator confirmed that the resident had been pronounced dead at the hospital. Review of Resident #66's Emergency Department records found documentation under ED (Emergency Department) Rapid Triage, the Chief Complaint: arrives in [MEDICAL CONDITION] via EMS. EMS reports last normal per family @ approximately 0830 this AM. EMS reports 2 episodes of v-fib, shocked twice, otherwise in asystole. Pt (patient) arrives with IGEL in place. (Per www.intersurgical.com, IGEL is a second generation supraglottic airway device, used in anesthesia and resuscitation.) EMS administered [MEDICATION NAME] 300, [MEDICATION NAME] x 2 doses, Epi x 5. Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct [DIAGNOSES REDACTED]. Sudden [MEDICAL CONDITION] after FBA may occur secondary to asphyxiation. Case Report, Early Recognition of Foreign Body Aspiration as the Cause of [MEDICAL CONDITION] https://www.hindawi.com/journals/cricc/,[DATE]/ Documented under t

Based on interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's family member, the Advanced Registered Nurse Practitioner, and a state investigator; review of the resident's medical record and hospital record, and facility policies , the facility's administration failed to utilize the facility's resources effectively and efficiently to ensure one (#66) of a sample of eight residents, requiring supervision or assistance with meals, was supervised to prevent her from access to a meal tray that contained breakfast foods that were not consistent with her Physician's ordered diet of Pureed foods. Resident #66 had a history of [REDACTED]. Facility Administration failed to ensure nursing staff provided adequate oversight of the aide's assignments to ensure that all aides were familiar with each residents' needs. The failure of the Administration to ensure nursing staff were familiar with and implemented each residents' plan of care resulted in the findings of ongoing Immediate Jeopardy on [DATE]. Findings included: 1. A review of the job description titled Administrator, undated, revealed the Major Purpose of the position was defined as: Responsible for planning, organizing, developing, directing, controlling, and supervising the general operations of Oak Haven Rehab and Nursing Center according to applicable federal, state and local laws, regulations, standards and guidelines. Responsible for ensuring that the highest degree of quality resident life is maintained. Additional Qualifications included: Responsible for planning, organizing, and directing all activities of the facility according to its policies, procedures, philosophy, and objectives. Participates in financial and cost-containment decisions. Ensures that the facility meets all related local, state, federal and accrediting -body rules and regulations. Coordinates and directs patient care in the facility according to adopted policies and procedures, state and federal regulations, and accepted accreditation standards. 2. A review of the job description titled, Director of Nursing , undated, revealed the Position Summary as : Must fulfill the goals and objectives of the Nursing Department in regard to patient/resident rights, patient/resident care and in the general working philosophy of the Nursing Department, as well as serve to reflect professionally the mission statement of the facility. Serves as a role model to nursing staff while facilitating outcomes-based care delivery, cost management, and enhanced customer satisfaction within the context of an interdisciplinary framework. The job description included the Position Description as: Provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. 3. On [DATE] at 11:30 a.m., in an interview with Resident #66's sister, she reported that she was told that her sister died in her sleep. She was told that her sister was found with no heartbeat, that EMS (Emergency Medical Services) had been there, had shocked her twice but she had no heartbeat. They took her to the hospital and she died there. The sister apologized for missing the initial call from the surveyor as she explained that she had been at her sister's funeral. The sister reported that they had lost their brother in (MONTH) and she thought the resident had a hard time getting over that, as he had been her primary caregiver and would visit the resident frequently. The resident's sister reported that she visited less frequently and never stayed during meals, but she knew that her sister aspirated easily. She thought her sister probably ate with others. She was aware that her sister was on a pureed diet which she didn't like and reported that she had been in the facility the day before her sister died talking with staff about changing her diet. The sister reported that she was told by the Doctor that her sister had had a [MEDICAL CONDITION]. 4. Review of the hospital Emergency Department (ED) Rapid Triage read under Chief Complaint: arrives in [MEDICAL CONDITION] via EMS, EMS reports last normal . at approximately 0830 this am. Under Physical Exam, it is documented, ears, nose, mouth and throat: oral mucosa moist, vomit in posterior pharynx. Continued review of Resident #66's Emergency Department records found: EMS reports 2 episodes of v-fib, shocked twice, otherwise in asystole. Pt (patient) arrives with IGEL in place. (Per www.intersurgical.com, IGEL is a second generation supraglottic airway device, used in anesthesia and resuscitation.) EMS administered [MEDICATION NAME] 300, [MEDICATION NAME] x 2 doses, Epi x 5. Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct [DIAGNOSES REDACTED]. Sudden [MEDICAL CONDITION] after FBA may occur secondary to asphyxiation. Case Report, Early Recognition of Foreign Body Aspiration as the Cause of [MEDICAL CONDITION] https://www.hindawi.com/journals/cricc/,[DATE]/ Documented under the heading of Cardiac - Respiratory Arrest - ED, was the History of Previous Illness: The patient presents in respiratory arrest, [AGE] year old with a history of previous [MEDICAL CONDITION] hypertension dementia, presents from her nursing home via EMS in [MEDICAL CONDITION]. As per EMS patient was last seen 45 minutes prior to their arrival. Patient was found unresponsive. When EMS got there patient was asystole. (Per the Medical Dictionary, asystole is a form of [MEDICAL CONDITION] in which there is no heart beat and the electrocardiogram tracing is straight.) ACLS protocol initiated. EMS reports that patient went into v. Fib twice and had to be shocked. She received [MEDICATION NAME] and [MEDICATION NAME] prior to her arrival to the ER. Upon arrival to the emergency room patient is still asystole with active CPR in progress. The onset was just prior to arrival. Witnessed arrest no. Initial cardiac rhythm asystole. Pre-arrival treatment reviewed with EMS, cardiopulmonary resuscitation defibrillated. Preceding symptoms unknown. Risk factors consist of hypertension. Documented under the heading of Medical Decision Making, the subsection Endotracheal Intubation read: Indication: [MEDICAL CONDITION]. Documented under the heading of Person Information was the Visit Reason, which documented: [MEDICAL CONDITION] Arrival time at the ED was [DATE] 09:34:00. Disposition Type was Death/Expired/No Autopsy. Further review of the hospital record, dated [DATE] at 09:34 a.m., revealed the resident received a Spiritual Assessment on [DATE] at 10:53 a.m. The written Progress Note explained, Chaplain responded to call from ED (Emergency Department), Patient has passed away. Chaplain met with patient's nurse and said a bedside prayer. 5. On [DATE] beginning at 10:20 a.m., a phone interview was conducted with a state investigator, who reported that he had been called out to investigate a death that occurred in the facility. He reported that he had begun a preliminary investigation by speaking with the Administrator and Director of Nurses on [DATE] about Resident #66. He reported that he was told that breakfast trays were observed in the room with the resident and the facility staff surmised that Resident #66 had eaten her roommate's breakfast and had choked. The investigator confirmed that the resident was pronounced dead at the hospital. 6. On [DATE] beginning at 2:50 p.m. the Administrator and Director of Nurses were interviewed related to the resident's status and the nurse's note from [DATE] timed at 0845. The DON confirmed that during 'shift change' the resident 'coded' and she assisted with compressions during CPR (Cardiopulmonary Resuscitation). She reported that a brownish-yellow liquid was vomited which she described as normal during compressions. She denied that any solids, or 'chunks' of food or any substance were vomited by the resident. During the interview, the Director of Nurses (DON) explained that the resident was a wanderer who was able to self-propel around the building and would ask staff for money for a soda. The DON explained that the resident didn't like her pureed diet and was known to take other residents' food if it wasn't pureed. The DON reported that no breakfast trays remained on the floor at the time that staff were attempting to resuscitate Resident #66. Both the DON and the Administrator confirmed that the resident was known to take other resident's food but there was no physician's order for supervision during meals and staff were to check on the resident during meals as they were walking the halls. In an interview on [DATE] beginning at 9:15 a.m., when asked if she had submitted an immediate report to the State Agency, the Administrator asked, Why would we submit an immediate report? There had been no allegation made. After thinking about that answer she responded, The resident is not a resident of the facility any longer as a reason for why there had been no immediate report made. 7. Resident #66, a [AGE] year old, was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The Physician's Order, dated [DATE], ordered a NAS/HCC (No Added Salt, House Consistent Carbs) Pureed Texture diet. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on [DATE] beginning at 12:40 p.m. who confirmed that Resident #66 was her patient. She reported that she hadn't been at the facility the morning of [DATE], but had come in later and was told what had happened. She reported that the resident was a smart lady who knew what she wanted and would bargain with her to get a soda. The ARNP reported that she would refuse to be weighed unless someone bought her a soda. She was compulsive about food and, even when she asked old friends of Resident #66, they confirmed that the resident had always been that way. The ARNP reported that she had observed Resident #66 in the back hall taking half eaten food off of residents' trays, once the resident was done with the tray, and staff had collected it for disposal. She reported that the resident wanted to eat a regular texture diet but she wasn't safe to eat regular texture. 8. A review of the resident's medical record showed the most recent MDS (Minimum Data Set) assessment was dated [DATE]. Section C related to cognitive function indicated a BIMS (brief interview of mental status) score of 3, indicating severe cognitive impairment. A review of Section G related to functional status indicated the resident was self-sufficient once she was assisted into her wheelchair. She was identified as needing supervision by one person while eating. A review of Section K related to Swallowing/Nutritional Status indicated she required a mechanically altered diet. The MDS documented the resident as standing 68 tall and weighing 152 lbs. The Speech Therapy SLP (Speech & Language Pathologist) Evaluation and Plan of Treatment, dated [DATE], showed a Certification period of [DATE]-[DATE] for Dysphagia Therapy. Per the Speech Therapy document, relevant [DIAGNOSES REDACTED]. The referral was made by nursing to determine the appropriateness of a diet upgrade. The document included the note, Per DON (Director of Nursing) patient is reportedly going in others' rooms taking foods that are not part of her puree diet order. This is however, not a new behavior resulting from diet downgrade to puree. Patient's girlfriends reported that patient had displayed behaviors whereby she will somehow obtain food items while at another center. Her friends advised this SLP that patient had previously choked on a large jawbreaker type candy in one instance. She also choked on a large ball of chewed chewing gum she had accumulated over some period of time prior to her admission at this facility. In (MONTH) of this year, she choked on fig newtons she impulsively ate while in this setting. Chest x-ray on [DATE] had findings which were consistent with pneumonia. Patient returns with the following dx (diagnosis): choking and [MEDICAL CONDITION], aspiration pneumonia. The SLP document listed previous treatment and outcomes which included discontinued speech therapy with the resident on a mechanical soft diet. The Oral stage dysphagia was documented as due in part to edentulous status and poor safety awareness /impulsivity. Under the Background Assessment - Medical section the document included: Precautions: choking hazard, confusion, constant SUP (supervision) due to cognition, aspiration and pureed diet. Listed under the Recommendations section of the document, the SLP had recommended: Supervision for oral intake=Close supervision (100% supervision is recommended for this resident for any po (by mouth) intake other than puree diet due to no self-monitoring and total dependence on external cues for general safer swallowing strategies r/t -related to, impaired cognition.) Under the Assessment Summary on the document, the SLP documented under Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, choking. The SLP discharged the resident from therapy on [DATE] and indicated the resident was discharged to the Restorative Program. The Care plan initiated on [DATE] with a revision and cancellation date of [DATE] with the Focus of resident on restorative dining program to safely tolerate altered diet was reviewed and noted for the intervention of resident will participate in the restorative dining program to safely tolerate puree solids and thin liquids. A Referral to Restorative Nursing Program, dated [DATE], was reviewed which indicated the resident would attend the program 6 days a week for 12 weeks. Under Restorative Dining Program, the Goal read: continue to safely tolerate puree/thin liquids using general safe swallowing strategies - small bites, slowed rate, clearing out oral cavity prior to next bite. Resident #66 was not in the Restorative Dining Program at the time of her death. During continued review of the medical record for Resident #66, the following note, written by the resident's nurse, was reviewed: [DATE] 0845: Nurse went into resident's room, found resident sitting in wheelchair with head down, resident assessed, was unresponsive, absence of pulse and not breathing, with brown and yellow vomit coming from mouth, nurse verified resident Full Code, called out for help. Code Blue and to call 911, aide and nurse laid resident on floor , mouth swept (sic) done to remove vomit, 2 nurses began CPR, (cardio [MEDICAL CONDITION] resuscitation) along with AED, (automatic external defibrillator) 0850 911 called 0855 AED placed, 0900 resident vomited and was turned onto right side mouth swept (sic) done to clear airway, 0903 CPR continued, EMT (Emergency medical technicians) arrived and continued CPR, 0905 resident still unresponsive, EMT continued CPR 0910 (resident's medical provider) called, message left, resident's sister called and notified of residents condition. 0915 doctor called message left with answering service 0940 resident transferred by EMS via stretcher to hospital. 0950 PA (Physician's Assistant) called back notified of resident condition. 9. An interview was conducted with Staff nurse D who confirmed she was assigned to Resident #66 on [DATE]. In the interview on [DATE] beginning at 12:45 p.m. Staff nurse D reported that she saw Resident #66 sitting in her room, with her head down. She said that she called to the resident several times without the resident responding. She said that she entered the room to check on the resident and was not able to get a response or feel a pulse. She reported that she went to the nurses' station, checked the resident's medical record for the advanced directive and once she saw the 'Full Code', she called out for help. She reported that she returned to the resident's room and began to resuscitate her with help from the DON and the unit manager. She reported that chunks of a brownish yellow substance were vomited. Interviews were conducted with facility staff who had been working on the resident's unit in the facility on the 7a to 3p shift on [DATE]. On [DATE], during an interview beginning at 4:49 p.m., Staff Nurse X, said that she had taken Resident #66 back to her nursing unit about 8:00 a.m. She reported that she 'parked 'the resident at the nursing station and returned to her assigned unit to pass her medications. She reported that shortly after that, she heard the other nurse call out for help. She reported that she called 911 and then went to the resident's room. She reported that she saw three nurses in the room attempting to resuscitate the resident. She reported that the DON was 'pushing up' on the resident's abdomen and chunks of food were coming out of the resident's mouth. She knew the served breakfast had been waffles and she described the vomited food as not fully chewed, not pureed, but chunks of yellow-brown waffles. The nurse reported that the resident was known to take other resident's food and both the resident and the roommate's breakfast trays were in the resident's room. On [DATE] at 12:56 PM in an interview with Staff E, RN Unit Manager, she said she was called out of the conference room during the morning meeting and told Resident #66 was needing assistance, that she coded. She said she thinks the words were that she was choking. When she arrived at Resident #66's room, CPR was already in progress, with the crash cart already in the room, and compressions were in progress. The patient was blue. Someone else was doing respirations. The DON took over compressions and she took over the ambu bag. (A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also frequently used in hospitals as part of standard equipment found on a crash cart, in emergency room s or other critical care settings. Per Wikipedia). The nurse doing compressions, initially, was on the phone with the family. The nurse in charge of the resident was recording. So, at that time, she asked the people to go back to their assignment so EMTs could get in the room. The AED was in the room. It was already on. She was giving respirations, checking for a pulse. The resident started to vomit. So, her head was turned. She had large chunks of food coming up. The DON did a mouth sweep. CPR continued. The AED said clear and continue. The resident started to vomit again. They continued CPR. By this time, EMTs arrived. They came to the door near to her room, so they had really fast access to her. The EMTs took over CPR. They intubated her and took over respirations. They started an intraosseous line. (Per Wikipedia, an intraosseous line is the process of injecting directly into the marrow of a bone. This provides a non-[MEDICATION NAME] entry point into the systemic venous system. This technique is used to provide fluids and medication when intravenous access is not available or not feasible.) She was flat lined. (Per the Merriam- Webster Dictionary, to flat line is to register on an electronic monitor as having no heartbeat or brain waves.) They did resuscitate her with medication. For just a minute she did have a pulse on the monitor. EMTs continued compressions. They continued bagging her. The whole time while transporting her onto the stretcher and into the ambulance. She said she stayed with the resident until she was in the ambulance. She said she wasn't with the resident when the event happened. The resident was already on the floor and CPR was already in progress. She said the resident was always stealing food from other residents in the dining room. She said she didn't know if she had taken food. Staff had to watch her vigilantly. She, apparently, had eaten solid foods. It wasn't puree. She had gotten it from somewhere else. The resident was supposed to be monitored during meals. She was supposed to be eating in the solarium. She wasn't supposed to be eating in her room. She was very mobile and had her own mind. She was not restrained. She was very friendly and outgoing. Staff E said she thought the resident was highly supervised, and didn't need a one on one. She repeated, the resident was highly supervised and was very mobile. She would not answer if she thought the situation was preventable. She said there were a lot of interventions in place. Supervision was daily, at every meal, every day that she did this. She said the resident taking food off others' trays was a daily behavior. During an interview on [DATE] at 1:01 p.m., Staffing Coordinator N stated that she assigned staff member P, an agency aide, to complete staff member M's assignment. Staffing Coordinator N, stated that [DATE] was the first time staff member P worked at the facility. Staffing Coordinator N stated that Staff member P was added to the do not return list for the facility after staff member P and the Director of Nursing had some words. Staff member P did not complete her shift on [DATE] as she was asked to leave the facility somewhere between 10:00 a.m. and 11:00 a.m. Staffing Coordinator N stated, on [DATE] when the code blue was called, she ran with the second crash cart to Resident #66's room and observed CPR in progress. She stated, When the DON came in, I asked if we could have someone switch giving compressions. The DON took over compressions while a CNA bagged Resident #66. Staffing Coordinator N observed a dark yellow glob on Resident #66's left leg mid-thigh which she estimated as being the size of a yellow highlighter without the lid. She included that the resident had been laid on the floor. She reported that Resident #66's breakfast tray was not touched, but, her roommate's breakfast had been eaten. Staffing Coordinator N reported that once the DON took over compressions, three of the staff that had been in the room went out on the porch because they were so upset. Staffing Coordinator N added that she had asked staff member P, where she was when the code was called and she told me she was heating up food for a Resident in the pantry and that she had not been in the room for Resident #66 at all that morning. Staffing Coordinator N described Resident #66 as 'non-compliant' and constantly stealing food off other trays and would swipe it right in front of you and she would tell you no if you asked her to give it up. The roommate of Resident #66 was described as always getting up early and added that she would not have been in her room to eat breakfast by the time the code was called. Staffing Coordinator N reported that it was the roommate's tray that was the one opened with the food eaten. We have three meal carts that come out. Resident #66 was seen in the halls drinking her morning coke when staff member M and I were together. At this point, I am still not sure who passed the trays that were put in her room. During an interview on [DATE] at 10:55 a.m., staff member M stated, On [DATE], around 7:00 a.m., Resident #66 came out of her room without clothing, so I took her back to get dressed while I waited for the schedule assignment. Staff member M stated an agency CNA came in and I did rounds with her but did not discuss Resident #66 with the agency CNA because Resident #66 was on my assignment. Staff Member M stated she was sick and wearing a mask and went to find staff member N, (staffing coordinator) to see about going home. Staff Member M, stated she was given the ok to go home at approximately 8:40 a.m. She reported that she noticed the last cart of breakfast trays coming on to the hall and she observed Resident #66 at the nurses' station before she left the building. She reported that the Resident asked if staff member M was leaving. Staff member M stated, Resident #66 had been eating in the solarium while the dining room was closed but I wasn't sure where she would be eating on [DATE]. The Facility's dining room was closed due to equipment repair in the kitchen for the first week to 10 days in December. Staff member M reported that she had been out sick from [DATE] at 8:40 a.m. until [DATE] and when she returned to work, she was told Resident #66 was spitting up whole waffles. Staff member M confirmed that Resident #66's roommate was on a mechanical soft diet. Staff member M described Resident #66 as always cruising around the building looking for food on dirty trays or in the garbage, as she would take it from anywhere. Staff member M continued, I feel bad. If I was not sick that day she may still be here. She was my favorite and I always had her. If she had someone from the agency they would not know that about her and I am not sure if it was on her care plan. 10. Review of Resident #6's Care plans, initiated on [DATE] and current until her death on [DATE], revealed: Focus of nutritional problem or potential nutritional problem related to mechanically altered, therapeutic diet , prefers to drink more than eating, dislikes puree texture and will take foods from other residents and is a compulsive eater. The Interventions included: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain the consequences of refusal. Review of the resident's care plan initiated on [DATE] and in place until her death on [DATE], revealed the Focus of resistant to care at times, noncompliant with diet restrictions, takes others foods included an intervention to educate the resident/family/caregivers of the possible outcomes of not complying with treatment. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of resident has an issue with compulsive eating related to the [DIAGNOSES REDACTED]. The Care plan, initiated on [DATE] and current until her death on [DATE], had the Focus of Behavioral Problem as evidenced by non-compliant with diet restrictions. Interventions included intervene prn (as necessary) to ensure the safety of the resident and others. 11. A Social Service Quarterly note, dated [DATE], stated resident is alert with confusion. Moderately impaired cognition. Resident still wanders throughout the facility and sometimes takes food off of used dietary trays. A Nursing note, dated [DATE], stated Resident noted taking food and drinks off of used trays, when nurse took milk from resident, resident threw milk at nurse and all over the floor. CNA reported resident taking food off of roommate's tray also and was aggressive and cursing at staff when approached about not taking food off of trays. Resident redirected. ARNP and psyche notified. On [DATE] a Nurse's note documented the CNA reported resident going into dining room attempting to take food and drink off of dirty tables. When CNA stopped her, the aide reported resident cursing at her and calling her names. Nurse was able to educate resident on infection control and she should not be taking food and drink off of dirty tables. Resident redirected. Snack given. [DATE] Social Services Quarterly note documented Resident attempts to take food off of others' plates and stuffs it in her mouth before staff gets to her. Resident is redirected by staff as needed. 12. Review of the facility's policy entitled, Meal Service, with a Last Date Revised of [DATE], found the Policy was: All patients/ residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the patients' / residents/ quality of life and helps to identify patients'/residents' needs and improve their overall nutritional status. Patients/residents will be properly groomed and their needs attended to during the meal service. Included under Procedure, point # 14, it read: Patients / residents eating in their rooms will be provided assistance as needed. Dependent diners and diners needing assistance will be provided required assistance and supervision as appropriate consistent with their plan of care. 13. During the Recertification Survey ([DATE] - [DATE]) an interview with the Restorative Nurse was requested to understand how the facility identified those residents who needed supervision at meals, to ensure they were kept safe while eating. The interviews were conducted on [DATE] beginning at 1:36 p.m. with the Restorative Nurse and an Assistant Director of Nurses, (both Registered Nurses) which revealed that five residents were on the restorative dining program. It was confirmed by the two RN's that not all residents needed physical assistance with dining, as some residents needed only encouragement or cueing to finish their meals. Because of repairs that were required in the kitchen, the facility's dining room was closed for the first week to ten days of December. The two nurses were asked about the dining plan for residents, including those residents in the restorative dining program, who usually ate their meals in the dining room. The plan to maintain residents' ability to socialize with other residents during meals, as well as to remain safe while eating or receive cueing to finish their meal was requested. The two nurses reported that the plan was for residents to eat in their rooms or some could eat in the day room on station 2. The nurses reported that residents who needed assistance with their meals would be assisted. Both nurses reported that there was no documented plan, it was just something that had been discussed and everyone knew they had to supervise the residents where ever they were eating. In an interview conducted with Staff Aide BB, on [DATE] beginning at 7:00 a.m., it was revealed that she had started her shift early as [DATE] was the first day that the dining room was open for meals, as it had been closed for repairs to the kitchen. She reported that she wanted to make sure the Breakfast meal went ok. She reported that the dining room had been closed so her Restorative residents had to eat in their rooms with supervision or in the Day Room on Station one. She said she wasn't aware of a documented plan for dining while the dining room was closed, but tried to make sure her restorative residents got their meals. 14. The initial Nutrition Assessment by the Registered Dietitian (RD) was dated [DATE] and indicated that the resident's 'Feeding Ability was documented as one on one supervision at meals, restorative dining per ST (speech therapy). The Diet order at that time was Mechanical soft, NAS HCC (No Added Salt, House Consistent Carbohydrates) Honey Thick Liquids. The RDs comments read, Resident is working (with) ST for dysphagia, restorative dining for all meals, one on one supervision. Makes food preferences known,

Based on observation of the resident, review of the resident's medical record, and interview with facility staff and the resident's responsible party, the facility failed to ensure that planned interventions to address one (#8) of three residents identified as having had a fall, of a sample of fourteen residents, had assessments completed that identified appropriate interventions to keep the resident free from a fall with injury. Resident #8's third fall in the facility resulted in a [MEDICAL CONDITION]. Findings include: Resident #8 was admitted on 12/04/13 after a hospitalization which identified her Advanced Dementia and Dehydration. At admission the facility assessed the resident and per the Admission Assessment form, completed on 12/04/13, identified that she was totally dependent on staff for her ADLs (Activities of Daily Living) and was at risk for falls as she was not ambulatory. An interim care, dated 12/04/13, plan included approaches to prevent a fall. A telephone order was noted, dated 12/04/13 for a string alarm due to poor safety awareness. Observation of the resident in her room on 01/21/14 at 1:15 p.m. revealed a thin, frail woman lying almost prone in an extended geri chair. Her knees were bent and drawn up, leaning and resting against the right arm rest of the chair. Pillows had been placed between her knees and shoulder against the side of the chair. A small white rectangular box was noted on the back of her chair with a string that was attached to her shoulder with a clip. An aide came into the room and identified the box and string as a 'string alarm', which would alert staff if she moved too far from the box. The facility identified that the resident had fallen out of the geri chair on 12/15/13. Review of the nurses notes, dated 12/15/13, revealed the resident was found "on the floor of the solarium, no apparent injuries noted. "A telephone order, dated 12/15/13, read, "discontinue string alarm to bed and wheelchair, sensor alarm to bed and wheelchair." A nurses note dated 12/18/13, written at 2:31 p.m. indicated, "staff responded to roommate calling out for staff, found resident sitting on floor with string alarm still attached, unsounding." The facility identified a third fall for resident #8 on 12/30/13. The nurses notes documented, "1400 (2:00 p.m.) 98/66 98.1 84 22, patient alert with confusion. string alarm alarmed , patient on floor on left side. patient complained of pain , movement of left leg. doctor ordered x ray of pelvis and left leg." On 12/31/13 the nurses note read, "x ray result called in to doctor, order to transfer to hospital for evaluation and treatment for [REDACTED]. On 01/22/14 beginning at 3:00 p.m. facility nursing staff were asked to explain how they were implementing their care plan to ensure that the resident was kept from falling. The Director of Nurses reviewed the assessments of the multiple falls and reported that they were not detailed and were not analyzing the situation around the fall, so a new plan could be formulated to prevent another fall. She agreed that there was not a plan to review medications to identify unnecessary medications or medications that could cause a symptom that could lead to a fall. The care plan approach indicated "evaluate medications to determine possibility to discontinue, discuss with doctor." The approach of "provide appropriate support/safety/enabler devices as needed in chair/wheelchair;bed and as ordered by physician and per therapy recommendation" had not been addressed as the use of the string alarm continued, even though the doctor had discontinued it and the resident had multiple falls (12/15/13, 12/18/13, 12/30/13) with the string alarm attached. Three approaches on the fall risk care plan were related to diversional activities and enlisting family/caregiver support and participation. Nurses notes related to the three falls did not identify whether the resident was involved in an activity or was sitting either in her room alone or at the nursing station without interaction. Observation of the resident on 01/21/14 at 1:15 p.m. revealed she was sitting in her room, having been brought from the dining room after lunch. On 01/22/14 at 9:30 a.m. the resident was observed in her room, in the geri chair with no television or radio playing. Review of the activity assessment, completed on 12/11/13, revealed the resident currently enjoyed being outdoors, listening to music and watching soap operas and movies on television. On 01/21/14 at 6:50 p.m. the resident's responsible party was interviewed by phone. The POA (power of attorney) reported that they phoned her after each fall, but she found it odd that they didn't' do something to prevent the falls. She said she understood the first fall, but then wondered at the second and third fall when she broke her hip. She said after the second fall they told her they were thinking of two approaches, one of which was a tray attached to her wheelchair. She said she told them that would be a good idea as the resident liked to look at magazines. She said she thought that could keep the resident occupied by looking through the magazine, rather than thinking she had to go somewhere and try to get up out of the chair. The POA reported that she put her into the nursing home as the resident thinks she can walk, but she can't. In an interview with the DON (new on 1/20/14), Interim DON and the Unit Managers on 01/22/14, at 3:00p.m. none of them could give an answer as to why the Care Plan and physician's order [REDACTED].

Based on observation of the resident, review of the medical record, and interview with the resident's responsible party and facility staff, the facility failed to ensure that one (#8) of three residents identified as being at risk for falls or who had had a fall, of a sample of fourteen residents, of a total facility census of 97 residents, had assessments completed that identified appropriate interventions to keep the resident free from a fall with injury. Resident #8's third fall in the facility resulted in a fractured hip. Findings include: The facility reported that on 12/15/13 the resident had had a fall at 15:16 (3:16 p.m.). Review of the electronic medical record for the day of the fall revealed a 'Skilled Documentation' note documenting, "s/p fall on 7-3, neuro remains at baseline as alert and oriented to staff. Vital signs within normal limits, neuro checks in place." Also in the electronic medical record was a note entitled Change in Condition, dated 12/15/13, which described the fall: "resident observed on floor of solarium, no apparent injuries noted, resident assisted into wheelchair, doctor notified, new orders in place. neuro checks initiated and remain at baseline for resident. alert and oriented to self." Review of the telephone orders on 12/15/13 revealed the new order related to the fall indicated, "discontinue string alarm to bed and wheelchair, sensor alarm to bed and wheelchair." The interim care plan for falls had been updated to reflect this new intervention. On 01/22/14 at 3:00 p.m. facility staff (Director of Nurses, Weekend RN Supervisor, RN Station 2 Unit Manager) discussed the resident's fall and facility's intervention. When asked what happened to cause the resident to fall on 12/15/13 and how interventions were determined, facility staff were only able to provide their opinions, as they were not able to refer to any documentation that had been made at the time of the fall. None of them could give an answer as to why the Care Plan and physician's order [REDACTED]. The DON (Director of Nurses) confirmed during that interview that there was no documentation of the analysis of the fall or how the decision came to be made to discontinue the string alarm and use a sensor alarm. During this interview a nurses note from 12/16/13 which described a rash like outbreak on the resident's buttocks was used as a reason for why the resident had gotten 'antsy' in her chair and contributed to her moving about and falling out of the chair. The facility identified a second fall as occurring for resident #8 on 12/18/13 at 14:00 (2:00 p.m.). Review of nurse notes revealed a note dated 12/18/13 written at 2:31 p.m. indicating, "staff responded to roommate calling out for staff, found resident sitting on floor with string alarm still unattached, unsounding. resident denies pain and no injury at this time, range of motion and neuro checks within normal limits. continue to monitor." This was the only note in the medical record about this fall. The nursing team present in the interview on 01/22/14 which began at 3:00 p.m., revealed that there had been no further investigation into the resident's fall and no change in the intervention. There was also no reference to the use of the string alarm rather than the sensor alarm, per the telephone order on 12/15/13. The interim care plan had been updated to reflect the fall on 12/18/13 (found sitting on floor) and a new intervention, "place resident in common areas to promote safety." On 12/19/13 a care plan for fall risk was developed which was triggered from the initial Minimum Data Set Assessment. Goals included "resident will not experience a preventable fall with injury over the next thirty days"; and "resident will not sustain an injury related to a fall through next review date." Multiple approaches were listed and included to assess the resident to determine the risk, orient the resident to the surroundings, assist to toilet and transfer after meals, provide appropriate support/safety/enabler devices as needed in chair/wheelchair/bed and as ordered by physician and per therapy recommendation, bed sensor alarm/bed alarm and chair sensor alarm/chair alarm, invite resident's participation in activity programs, and enlist family/caregiver support and participation. Nurses notes during December 2013 referred to the use of the string alarm and was silent regarding a sensor alarm. On 12/27/13 at 2:40 p.m. the nurses notes documented, "up in wheelchair, continues to get up unassisted, string alarm remains in place at this time. resident has been toileted, therapy working with her to find activity to keep busy, not successful, resident remains impulsive." Further review of nurses notes revealed a third fall on 12/30/13 at 4:58 p.m. "1400 - 2 p.m. - 98/66 98.1 84 22, patient alert with confusion. string alarm alarmed, patient on floor on left side, patient complain of pain, movement of left leg. patient no signs/symptoms of respiratory distress, physical and neuro assessment completed. skin tear to left elbow and left lower leg. unremarkable findings. treated patient skin tears. doctor notified, ordered x ray of pelvis and left leg. notified 'POA' (power of attorney)." A Nurses note dated 12/31/13 written at 12:34 a.m. indicated vital signs 120/62 66 20 97.6. resident alert, awake lying in bed with head of bed 45 degrees. skin warm and dry to touch. in no distress, no apparent pain. x ray result called in to doctor, order to transfer resident to hospital for evaluation and treatment for [REDACTED]." Review of the History and Physical from the hospital, dated 12/31/13 revealed the admitting [DIAGNOSES REDACTED]." Record review for resident #8 revealed an initial nursing assessment, completed on 12/04/13, identifying [DIAGNOSES REDACTED]. The assessment identified the resident as being alert to person and having speech that was sometimes understood. The assessment identified that the resident had fallen within the past thirty days, but the fall risk assessment did not identify the resident as being at risk of falls, having scored '9', with '10' as the score that indicated fall risk. However, the facility included a Fall care plan in the interim plan of care and there was a telephone order dated 12/04/13 for a 'string alarm to bed and chair'. The initial nursing assessment identified the resident as being totally dependent on others for all ADLs (activities of daily living). Observation of the resident on 01/21/14 beginning at 1:15 p.m. revealed a thin woman, lying almost prone, leaning on her right side, in a geri chair that had been extended to allow for her to stretch out. The resident's knees were drawn up and pillows were noted to be cushioning her right side against the chair, from her shoulder down to her drawn up knees. There was a pillow behind her head. Hanging off of a bar across the back of the chair was a small white rectangular box with a string that had a clip which was attached to the resident's jacket at the back of her right shoulder. During the observation, an aide came into the room and identified the box as the 'string alarm'. The aide indicated she wanted to assist the resident into bed, and pulled the privacy curtain. When the resident was in the bed, and the privacy curtain pulled back, the aide then identified another string and box on the far side of the bed as a 'sensor alarm'. Interview with the resident's Power of Attorney, on 01/22/14 at 6:50 p.m. revealed that she had been made aware of the resident's frequent falls. She added that she found it odd that they didn't do something to prevent them. She said that she was ok with the first fall, then wondered at the second one, and then another when she fell and broke her hip. She said she didn't think the resident had been the same since. She said she had been told after the second fall that they were thinking of two interventions, one being a tray they could attach to the wheelchair. She said she told them that a tray would be a good thing as the resident liked to look at magazines, and actually had several subscriptions. She said they could put the magazine on the tray and she would be occupied with turning the pages and looking at the pictures. It would keep her from thinking she had to go somewhere and try to get up and go. She said she just didn't understand why they didn't' take the extra steps to prevent her from falling after the first and second fall. She said she put the resident into the nursing home because she (the resident ) thinks she can walk, but she can't. The POA reported that she had been invited to a meeting where they all sit around and tell you what they are going to do for the resident. She said they had asked her what she liked to do and she told them - look at magazines.

Based on record review and interviews with the Medical Director, the Director of Nurses (DON), the Assistant DON (ADON), and residents, the facility failed to notify the attending medical practitioner of significant changes that required a need to significantly alter the medication regime, prevent adverse outcomes, and manage the deteriorating or potential deteriorating condition for three of nineteen residents (#2, #4, and #9). The failure by the staff to communicate information accurately and timely to the physician prevented the physician from providing appropriate telephone orders to care for an emergency situation after a massive dose of insulin was administered in error to resident #2. Additional staff, on another unit of the facility, failed to notify the physician of repeated missed doses of insulin, a total of 19, during which time the resident (#4) had elevations of blood sugar values in excess of 400 mg/DL. Resident #4 received two of the three prescribed types of insulin ordered for a period of ten days. The physician was not notified and had an incomplete clinical picture of the resident ' s diabetic management. A third resident, #9 was admitted to the facility with an insulin pump. The nursing staff stated they had no knowledge of the dose or frequency of the pump administration of insulin. There were no parameters defining physician notification of blood sugar levels, performed four times daily by the staff, and no emergency supplies of a special high dose insulin used for the pump. As a result of these findings, Immediate Jeopardy was identified on [DATE] and is ongoing. Findings include: 1.) Review of the face sheet for resident #4, an insulin dependent diabetic, revealed he was admitted to the facility on [DATE] with additional [DIAGNOSES REDACTED]. A physician ' s progress note, dated [DATE], stated the resident had chronic back pain was to received supportive care and a trial of a pain medication. Review of the physician ' s orders for [DATE] revealed that the resident received three types of insulin daily. The orders were as follows: [MEDICATION NAME] Insulin, 18 units injected twice daily at 7:00 a.m. and 4:30 p.m. [MEDICATION NAME], 25 units injected at bedtimes, 9:00 p.m. Regular Insulin, as needed four times daily. Dose to be determined by blood glucose level check before meals and at bedtime. Review of the MAR for January, 2011, revealed that from [DATE] at 5:00 p.m. to [DATE] at 5:00 p.m. the resident received no [MEDICATION NAME] Insulin. Nineteen doses were recorded as not given. Review of the nurse ' s notes revealed that there was no documentation that the physician was notified of the missed doses of [MEDICATION NAME] insulin. On [DATE] at 1:00 p.m. the physician was notified regarding pain in the hip but was not informed of the missed insulin doses. On [DATE] during an interview with the physician, he stated he was not notified regarding the multiple missed doses of [MEDICATION NAME] Insulin for resident #4. He stated he was notified by the staff of other concerns with the resident during that time frame. He further stated he was not informed regarding the two elevations of blood glucose over 400 mg/DL. He stated he would have expected a call from the nurse caring for the resident. He reviewed the record and confirmed the missed doses. Review of the [DATE] MAR revealed that on ,[DATE] at 9:00 p.m. and ,[DATE] at 4:30 p.m. the resident ' s blood glucose checks exceeded 400 (449, and 436). Per the physician ' s order, the sliding scale insulin coverage upper limit was: ,[DATE], give 8 units of regular insulin. The record revealed that the resident received eight units for each of the two elevations over 400 mg/DL. There was no documentation that the physician was notified of the elevations and the need to alter treatment for [REDACTED]. 2.) The face sheet of resident #2 stated she was [AGE] years old and admitted to the facility on [DATE] after a hospital stay for treatment of [REDACTED]. Review of the Recreation Participation Record, initiated on [DATE], revealed that the resident participated fully in four activities during her three day stay in the facility. Review of the Nursing Documentation flow sheet, Neurological evaluation section, dated [DATE] to [DATE], revealed that the resident was alert and oriented and speech was clear and appropriate. Review of the physician orders, dated [DATE], revealed that resident #2 received nothing by mouth, a continuous tube feeding solution, Glucerna 1.2 solution, was to be infused at 55 cc per hour via a [MEDICAL CONDITION] tube. Diabetic medications included: [MEDICATION NAME], 10 units daily at 9:00 p.m. Accuchecks (blood glucose levels) before meals and bedtime with sliding scale regular insulin coverage. Review of the MAR revealed that the range of blood sugars was from 75 to 418 for the three days that the resident was in the facility. Review of the nurse ' s notes revealed: On [DATE] at 3:00 p.m. the resident was admitted with a [MEDICAL CONDITION] tube in place. The resident was alert with mild confusion, some wheezing, and a urinary catheter in place. On [DATE] at 5:00 p.m. the resident pulled the [MEDICAL CONDITION] tube out. The physician was called orders were received to replace the tube in the morning. On [DATE] an untimed physician ' s order stated that the resident was to remain NPO (nothing by mouth) and to give [MEDICATION NAME] for low blood sugar as needed. Review of the facility protocol for [DIAGNOSES REDACTED], low blood sugar, stated to administer one injection of [MEDICATION NAME] for a blood sugar value lower than 60 mg/DL. Review of the MAR revealed no [MEDICATION NAME] was administered at this time. On [DATE] at 9:00 p.m. the blood sugar was 85. There was no documentation regarding the resident receiving any alternate nutrition, such as IV, at that time. On [DATE] at noon the nurse ' s note stated the residents ' Power of Attorney (POA) requested a permanent (Percutaneous Endoscopic Gastrostomy) PEG tube be inserted. There was no documentation of the resident receiving any alternate nutrition at that time. Review of the MAR revealed the blood sugar was recorded as 76 mg/DL at 11:30 a.m. On [DATE] at 1:00 p.m. the resident was sent to the hospital for insertion of a PEG tube. On [DATE] at 5:15 p.m. the resident returned with a second [MEDICAL CONDITION] tube inserted. On [DATE] the DON stated that the hospital thought the visit was for replacement of a PEG tube, not placement of an initial PEG tube. The appointment was rescheduled for [DATE], the next day. On [DATE] at 9:00 p.m. the resident pulled the [MEDICAL CONDITION] tube out a second time. The notes from 5:15 to 9:00 p.m. on [DATE] do not state if the resident received nutrition by tube feeding until the tube was pulled out. At " bedtime " the resident ' s blood sugar was recorded as 86 mg/DL. On [DATE] at midnight the blood sugar was 92 mg/DL. The [MEDICAL CONDITION] tube remained out. There was no documentation of any alternate source of nutrition. On [DATE] at 6:30 a.m. the resident left the facility for insertion of a PEG tube. On [DATE] at 10:40 p.m. the resident returned to the facility with the PEG tube inserted. On [DATE] at 12:00, a.m. or p.m. not specified, the tube feeding was infusing and the blood sugar was 418 mg/DL. Insulin coverage was given. On [DATE] at 2:00 p.m. the blood sugar was 453 mg/DL, the physician visited, and orders were received. On [DATE] a telephone order, obtained by nurse #3, dated [DATE], no time specified, stated to : Increase [MEDICATION NAME] to 20 units, start [DATE]; Give Insulin 10 units regular, IV (intravenous) x 1.; and Insert a peripheral line (I.E.: an intravenous access). Review of the MAR revealed: 10 units of regular insulin IV x 1 were recorded as given on [DATE] at 3:00 p.m. On [DATE] at 9:25 a.m. an interview with the nurse administering the IV insulin order on [DATE], nurse #1, revealed that she gave an entire multidose vial of regular insulin, 10 cc, with a concentration of 100 units per cc, or the equivalent of 1000 units of regular insulin. She stated she took the insulin from the emergency kit, a 10 cc syringe and two 10 cc prefilled syringes of normal saline for flushing the IV before and after the insulin. She stated she recognized her error after she had given the 1000 units of insulin and reported it immediately to nurses #7, #2, and #3. She stated she was hysterical and repeated that she gave " 10 cc " of insulin to all three nurses. She confirmed the syringe was a 10 cc size to nurse #2, an RN. Nurse #3, an LPN " desk nurse " , contacted the doctor by phone to report the error. She stated that nurse number #3 informed the physician that it was 100 units. She stated she was too upset to think clearly, but she repeated several times that she gave 10 cc of regular insulin. She stated she threw the bottle and the syringe in the red " sharps " box in the resident ' s room and was unable to retrieve it. Per the nurse ' s notes, dated [DATE] at 9:30 p.m., six hours after the insulin, the resident was found without respirations or a heart rate. CPR failed to revive the resident and she was pronounced dead on [DATE] at 10:00 p.m. On [DATE] 2:15 p.m. an interview with the physician revealed that he ordered blood sugar monitoring every thirty minutes for four hours after the error was reported to him. He was functioning with information of the resident having received 100 units of regular insulin. He stated he called the hospital pharmacist after the error and was informed of the half life of the insulin and how long to monitor for adverse drops in blood sugar. He stated he asked nurse #3 to clarify the units of insulin given and she stated to him 100 units. He did not know about the 1000 units until [DATE], after the resident died . He stated that if he had received the correct information regarding the insulin unit amount of 1000 units, he would have sent her to the hospital. He stated massive doses of insulin are known to cause electrolyte shifts that required intense monitoring. He could not state how much the insulin dose error contributed to the resident ' s death, stating she was very ill. On [DATE] at 10:00 a.m. an interview with the DON revealed that four nurses, including her, were aware of the medication error and the volume of insulin given (10 cc). She stated that none of the nurses consulted the MAR where the order provided the concentration of 100 units per cc, or the emergency drug kit inventory where the concentration and volume of the insulin bottle were listed. She confirmed that the physician was provided information only on the volume of insulin given, 10 cc, and not the correct unit dose. The DON stated that none of the four nurses who were aware of the error called the pharmacy to consult with the supplier of the insulin to determine the exact amount, in units, that the resident received. She was aware that the physician ' s orders for care of the resident after the insulin overdose were based on incorrect information. She discovered the actual amount administered to the resident after the investigation began on [DATE]. Multiple facility nurses failed to utilize pharmacy resources, available by phone and in writing on the MAR and the emergency drug kit inventory form, to clarify the correct dose, in units, of the insulin error. Failure to do so produced a cycle of events whereby the physician treated the resident with incorrect orders that contributed to the subsequent demise of resident #2. Per the attending physician interviews of [DATE] and [DATE], he stated he was never called by any of the four nurses aware of the medication error, with information of the correct about of insulin given, 1000 units. He stated that massive doses of insulin required acute care monitoring including electrolyte balancing. He stated he would have altered the treatment significantly if he had the correct information. 3.) Resident #9, per the face sheet, was a [AGE] year old, admitted to the facility on [DATE] with an infection of the arm. The face sheet included several other [DIAGNOSES REDACTED]. The hospital Medication profile, dated [DATE], stated that the resident had an insulin pump, to be maintained by the resident and family. Review of the hospital history and physical , dated [DATE], revealed that the resident had an infected elbow, possible gangrene, and healing was compromised with steroids and high blood sugar levels. A History and Physical form by the facility physician, dated [DATE], did not state that the resident had an insulin pump and insulin was not listed in the lower right corner, medication section. Review of the physician progress notes [REDACTED]. There was no documentation of an insulin pump. Review of the physician orders for [DATE], revealed no orders for insulin or diabetic monitoring for the insulin pump. Review of the MAR for January, 2011, revealed an undated entry for accuchecks before meals and at bedtime. There was a notation that the resident had an insulin pump. The intervention was begun on [DATE] at 11:30 a.m. The range of blood glucose values was: ,[DATE]. There was no documentation that the physician was notified regarding any of the results. On [DATE] at about 12:30 p.m. an observation of the resident was made. He was alert and oriented and demonstrated the insulin pump. He stated, later confirmed by his wife, that the insulin for the pump was 500 units per milliliter, five times the usual concentration of regular insulin. He stated his wife obtained the insulin from a local pharmacy and refilled the pump every three days. He stated he received a continuous dose throughout the day and received additional [MEDICATION NAME] doses based on the blood glucose values reported by the staff nurse. He was not aware of the insulin supply at the facility and if they could provide the insulin in an emergency. On [DATE] at 2:00 p.m. the DON stated she did not know that the resident had an insulin pump. She stated she did not know the concentration of regular insulin in the pump. She requested two other nurses join the interview. Nurse #7 and #8 joined the interview. Both nurses stated they did not know what concentration of regular insulin was needed for the pump. After discussing the 500 units per milliliter concentration, the DON and nurse #7 and #8 stated that they did not have that dose on hand. All three nurses stated there were no orders for emergency intervention in case of a diabetic crisis, no information regarding the pump functions and no physician orders to monitor the blood sugars until [DATE] at 5:30 p.m., after the surveyor requested to see an order. There was no documentation that the attending physician was informed of need to commence guidelines and treatment for [REDACTED]. On [DATE] at around 4:00 p.m. nurse #7 presented three telephone orders from the attending physician with information regarding the diabetic management of resident #9 and the insulin pump. Later, The DON stated she will have a diabetic specialist come to the facility to provide education to the staff on insulin pumps. She stated at this time there was no standard policy. The failure of facility staff to notify the physician of significant changes of condition and /or the need to alter treatment compromised the physician ' s ability to accurately access and treat these three residents. These findings were identified on each of the resident units in the facility and found to be at level K, widespread.

Based on observations, record review, and interviews of the facility staff, interviews with the Physician/Medical Director, and the Director of Nurses (DON), the facility failed to provide care while maintaining professional standards of practice related to the safe administration of insulin, the monitoring of blood sugars, and the disregard of physician's order [REDACTED].#4 and #9) of the 19 residents sampled. These actions potentially contributed to the unknown blood sugars of those residents who were not monitored, and the ultimate death of resident (#2). The failure to maintain standards of practice for eight of nineteen residents sampled (#2,#3,#4, #5,#6,#8,#9 and #10)caused medication errors related to the administration of insulin, along with insufficient monitoring of blood sugars and the provision of insulin coverage where needed. The total disregard for the following of physician's order [REDACTED]. The scope and severity of the findings included residents from throughout the facility and lead to a conclusion that the immediate jeopardy was widespread, level K. As a result of these findings, Immediate Jeopardy was identified on [DATE] and is ongoing. Findings Include: Per the Florida Statutes, Chapter 464 Nursing Part I Nurse Practice Act (ss 464XXX,[DATE].027): "(3)(a) 'Practice of Professional Nursing' means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based on applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to": The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance of any of the above acts. "(3) (b) 'Practice of practical nursing' means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist." 1.) Resident #9, per the face sheet, was admitted to the facility on [DATE] after hospitalization for an infected arm. Additional [DIAGNOSES REDACTED]. Review of the hospital medication profile, dated [DATE], revealed that the resident had an insulin pump to be maintained by the resident or his family. Review of the hospital physician consultation of [DATE], page 2 of 4, revealed that the resident ' s elbow x-ray revealed an infection. Page 3 of the consult stated the resident received a high dose of steroids with subsequent elevated blood glucose levels. The physician wrote that the resident had poor wound healing and item #4 stated " watch him closely with other supportive measures and blood sugar control " . It was planned that he was to receive four weeks of IV antibiotic therapy. On [DATE] the facility physician history and physical form contained no information regarding the presence of an insulin pump. The physical exam section stated that the abdomen was soft, non tender, and bowel sounds were present. The list of medications, confirmed by the DON as copied on the form by nurse #3 from the hospital medication list, failed to list insulin or the presence of an insulin pump. The self medication data collection and assessment sheet stated that the facility would administer all medications. It was signed by two nurses. There was no documentation of an insulin pump. Review of the physician's order [REDACTED]. A review of the MAR for [DATE], revealed blood glucose checks were initiated on [DATE] at 11:30 a.m., for before meals and at bedtime. A notation was written that the resident had an insulin pump. No documentation was found regarding a physician's order [REDACTED]. Per the MAR for [DATE], the range of blood glucose values was from 43 to 338 mg/DL. Review of the facility protocol for low blood sugar revealed that under the section of PROTOCOL: a reading below 60 mg/DL was to be managed while notifying the physician. There are six recording of blood sugar values lower than 60 mg/DL. There was no documentation that the physician was ever called. On [DATE] at 12:30 p.m. an observation of the resident was made. He was alert and oriented. He clearly explained to the two surveyors present, the management of the insulin pump. He stated the insulin was obtained by his wife and the pump refilled every three days. He stated he received a continuous dose of regular insulin, at three varying doses throughout the 24 hours sleep/wake cycle. He stated that the concentration of insulin was 500 units per milliliter, five times the normal concentration of insulin. He further stated he administered an additional [MEDICATION NAME] of insulin based on the blood glucose values that the facility nurse told him. Later, his wife stated that for very low blood sugars she gave an oral gel and called 911 for assistance. She was unable to recall an exact blood sugar number that required this response. Absent from the medical record was any physician contact informing him of the emergency procedures used by the resident. On [DATE] at 2:00 p.m. the DON stated she did not know that the resident had an insulin pump until the surveyor asked about it on [DATE]. She requested that nurse #7 and nurse #8 join the interview. All three nurses verbalized a total lack of knowledge regarding the extreme concentration of regular insulin, 500 units per milliliter; how the resident received his insulin supply; if the facility could supply an emergency supply; and what interventions the facility was to provide regarding emergency care if the resident were not able to manage the pump. The nurses failed to obtain information regarding the complex medical management of this medically fragile resident. After the interview, nurse #7, an ADON, called the physician and obtained extensive orders with instructions to contact a physician specialist regarding complications with diabetic management. The DON stated she had contacted a nurse consultant to request staff training with insulin pump therapy. 2.) Resident #4 was admitted to the facility on [DATE]. Per the facility face sheet, he was [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the [DATE] physician orders [REDACTED]. They were: [MEDICATION NAME], 25 units at bedtime, 9:00 p.m. [MEDICATION NAME] Insulin, 18 units, twice daily at 7:00 a.m. and 4:30 p.m. [MEDICATION NAME] Regular Insulin, amount to be determined by sliding scale after blood glucose levels checked before meals and at bedtime. Review of the MAR revealed that the resident did not receive [MEDICATION NAME] Insulin from [DATE] at 5:00 p.m. through [DATE] at 5:00 p.m. A total of 19 doses were recorded as not given. On [DATE] at around noon, an interview with the resident confirmed that he did not receive the [MEDICATION NAME] Insulin for multiple days. He stated that the nurse dropped the bottle and it was not replaced. He stated his blood sugar was elevated over 400 mg/DL at least twice during this period. Review of the MAR revealed two elevations of blood glucose over 400 mg/DL. , [DATE] at 9:00 p.m. it was 449 and on [DATE] at 4:30 p.m. it was 436. Both values exceeded the upper limits of the sliding scale for regular insulin, yet the physician was not called. There was no documentation that the physician was called regarding the multiple missed doses of [MEDICATION NAME] Insulin or the extreme elevations of blood sugar levels during this period. On [DATE] the DON stated she had no knowledge of the missed doses of insulin until the investigation of diabetic management revealed the details. She stated four nurses received disciplinary action so far. She stated that it was unacceptable for professional nurses to fail to obtain the insulin and to not inform the physician of the situations. Later on [DATE] the physician confirmed he had not been informed of the multiple missed doses of [MEDICATION NAME] Insulin. He stated he had been in the facility several times during this time frame and had never been informed. 3.) Review of the medical record for resident #2 revealed she was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Per the nursing comprehensive admission data, the resident was alert and her vital signs were stable at the time of admission, 1:15 p.m. The data stated that the resident had a [MEDICAL CONDITION] tube. Review of the physician's order [REDACTED]. [MEDICATION NAME], 10 units, was ordered to be injected at 9:00 p.m. every night for her diabetes. The resident was ordered heart and respiratory medications also. Physical and occupation therapy were ordered for increased mobility. The therapy evaluation, dated [DATE], stated that the resident walked and transferred independently prior to the hospitalization . The nursing documentation record contained five neurological assessments that stated the resident was alert and oriented, with clear and appropriate speech. Two hours after admission the resident pulled out the [MEDICAL CONDITION] tube. Four hours later the resident ' s blood sugar was documented in the nurse ' s notes as 85 mg/DL. Further review of the nurse ' s notes revealed that the resident was sent to the hospital on [DATE] at 1:00 p.m. and returned at 5:15 p.m. with a second [MEDICAL CONDITION] tube. There was no documentation regarding the feeding tube solution infusing from 5:dpm. to 9:00 p.m. At 9:00 p.m. on [DATE] the notes stated that the resident pulled out the [MEDICAL CONDITION] tube a second time. On [DATE] at 6:30 a.m. the notes stated that the resident was sent to the hospital for insertion of a PEG tube, a [MEDICAL CONDITION] tube used for long term tube feeding of residents. She returned at 10:40 p.m. on [DATE]. On [DATE] at noon, nurse #1 wrote that the blood sugar was 418 mg/DL and insulin was given. At 2:dpm. , the blood sugar was 453 mg/Dl and the physician visited. The next entry, no time specified, stated the blood sugar was 348. Review of the physician's order [REDACTED]. A peripheral IV was ordered to be inserted for access. Review of the MAR revealed that 10 units of Regular Insulin were recorded as given at 3:00 p.m. by nurse #1. On [DATE] at 9:45 a.m. an interview with nurse #1 revealed that she gave 1000 units of Regular insulin to resident #2, in error. She stated she obtained a multidose bottle from the emergency drug kit that contained 10 milliliters of insulin, with a concentration of 100 units per milliliter. She stated she realized her error immediately after giving the insulin dose and reported it to the ADON, #7, and the corporate RN for Quality Assurance, nurse # 2. She stated she was upset, hysterical, and repeated that she gave 10 milliliters of insulin by IV. She stated nurse #3, an LPN " desk nurse " , called the doctor to inform him. She stated that nurse #3 informed the physician of the volume but not the concentration of the insulin, thereby providing him with partial, inaccurate information of the situation. She stated someone said it was 100 units, and that was the information that was provided to the physician. On [DATE] at 10:00 a.m. the DON stated that she was informed of the error about one hour after the event. She stated she thought one of the four nurses involved had clarified to the physician the exact dose of insulin given. Based on the nurse ' s inaccurate insulin over dosage information, the physician ordered blood glucose monitoring every 30 minutes for four hours. In spite of the glucose levels dropping into the 84 to 87 range, the resident was found six hours after the error, at 9:30 p.m. on [DATE], without respirations and no audible heart rate. CPR was initiated, 911 was called and at 10:00 p.m. the resident was pronounced deceased . On [DATE] at 2:00 p.m. the physician stated he was informed that the resident received a vial of insulin, equivalent of 100 units. He ordered monitoring based on his information and the half life of intravenous insulin. He stated he was never notified of the actual dose administered, 1000 units of insulin, until [DATE], after the resident ' s death. He stated he would have ordered her transferred to the hospital for more critical management if he had received accurate information regarding the overdose. Additional findings for other diabetics: 1.) Information from the facility face sheet for resident #10 stated she was admitted to the facility on [DATE] at 10:00 a.m. The resident was [AGE] years old with [DIAGNOSES REDACTED]. Review of the nurses notes, dated [DATE] at 11:30 a.m., revealed the resident was found to have a blood sugar of 490 mg/DL and the practitioner was called. Orders were received to give 10 units of [MEDICATION NAME]and repeat the blood sugar at 1:30 p.m. At 1:30 p.m. the nurse ' s notes stated the blood sugar was 582 and the practitioner was called. A second dose of [MEDICATION NAME] Insulin, 10 units was ordered and the blood sugar to be repeated at 4:30 p.m. At 4:30 p.m. the blood sugar was recorded on the MAR as 402 mg/DL. Per the review of the physician's order [REDACTED]. She was informed of the resident ' s blood sugar of 402 mg/dl. An order was received to give 10 units [MEDICATION NAME] Insulin immediately (now) at 4:30 p.m. and to call the ARNP at 8:00 p.m. if the blood sugar was greater than 400. Review of the MAR revealed that the third dose of [MEDICATION NAME] Insulin, 10 units, was not transcribed as a " now " order. The 4:30 p.m. blood sugar of 402 mg/DL was documented in the sliding scale block a 4:30 p.m. with the 10 units of insulin written in the block below. The MAR showed the 4:30 p.m. blood sugar sliding scale upper limit was for 380 mg. /dl, and to give 6 units of insulin. The nurse documented 10 units of insulin in the sliding scale area indicating a routine dose of insulin, not an exception to the routine management. Information from the facility face sheet for resident # 6, stated she was admitted to the facility [DATE] at 2:51 p.m. The resident was [AGE] years old and had [DIAGNOSES REDACTED]. 2.) Per review of the physician's order [REDACTED]. Per physician's order [REDACTED]. The Insulin sliding scale was written as follows: ,[DATE]-give 2 units, ,[DATE]-give 4 units, ,[DATE]-give 7 units, ,[DATE]-give 10 units, ,[DATE]-give 12 units, and greater 349-give 15 units. On [DATE] at 6:00 p.m. there was no documentation of the blood sugar value or the Insulin coverage given if needed. Per the MAR, on [DATE] at 6:00 a.m., the blood sugar was documented as 154 mg/DL, and the insulin coverage given was documented as 2 units of insulin. Per the physician's order [REDACTED]. The nurse failed to follow the physician's order [REDACTED].#6. 3.) Information from the facility face sheet for resident #5, stated she was admitted to the facility [DATE] at 7:30 p.m. The resident was [AGE] years old and had [DIAGNOSES REDACTED]. Per the review of the physician's order [REDACTED]. The resident had a physician's order [REDACTED]. The Insulin sliding scale for Insulin was as follows: ,[DATE] give 2 units, ,[DATE] give 4 units, and the upper limit, greater than 400 mg/DL, instructed the nurse to call the medical doctor (M.D.). On the Medication Administration Record (MAR) of January of 2011, the blood sugar on [DATE] at 6:30 a.m. was documented as 173 mg/DL. Per the physician's order [REDACTED]. There was no documentation of the insulin administration for resident #5 on [DATE] at 6:30 a.m. 4.) Information from the facility face sheet for resident #3 stated he was admitted [DATE], and re-admitted on [DATE] at 11:00 a.m. The resident was [AGE] years old and had [DIAGNOSES REDACTED]. Per the review of the physician's order [REDACTED]. The physician's order [REDACTED]. The range was ,[DATE]; give 2 units, ,[DATE]; give 3 units, and ,[DATE] give 4 units, up to 8 units of [MEDICATION NAME] Insulin for blood sugar values of ,[DATE] mg/DL. Review of the [DATE] MAR, for resident #3, revealed four omissions from the record for blood sugar results and Insulin coverage. The omissions were: [DATE] at the 6:00 a.m., there was no documentation of a blood sugar value and no documentation of Insulin coverage. On [DATE] at 4:30 p.m. there was no documentation of a blood sugar value and no documentation of Insulin coverage. On [DATE] at 4:30 p.m. there was no documentation of a blood sugar value and no documentation of Insulin coverage. On [DATE] at 6:00 a.m., the blood sugar was documented 158. There was no documentation of the Insulin coverage. The physician orders [REDACTED]. This was not documented for resident #3. In an interview on [DATE] at 1:15 p.m., with the Director of Nurses (DON), she stated, " I could not find any insulin documented for those omissions. " 5.) Information from the facility face sheet for resident #8, revealed that she was admitted to the facility [DATE] at 1:30 p.m. The resident was [AGE] years old with [DIAGNOSES REDACTED]. Per the physician's order [REDACTED]. The insulin coverage began at ,[DATE] mg/DL; give 2 units, up to ,[DATE] mg/DL; give 8 units. On the January MAR, [DATE] at 6:30 a.m. the blood sugar is documented as 157. The physician order [REDACTED]. There was no documentation that the ordered Insulin was given. 6.) Resident #12 was re-admitted to the facility on [DATE] after hospitalization for [MEDICAL CONDITION]. Per the facility face sheet, the resident was [AGE] years old with as history [MEDICAL CONDITION] of the prostate, [MEDICAL CONDITION], hypertension and diabetes. Review of the care plan, [DATE], stated diabetes with complications. Review of the physician's order [REDACTED]. The physician ordered insulin coverage for elevated blood sugars based on a sliding scale. Review of the MAR for [DATE], revealed that the resident had unclear and incomplete documentation for the blood glucose testing of: [DATE] at 4:30 p.m. and 9:00 p.m. The amount of insulin for both incidences was unknown. On [DATE] at 4:30 p.m. and 9:00 p.m. the blood glucose values were unclear and the amount of insulin administered was unknown. On [DATE] the DON confirmed the documentation errors and omissions noted above. She stated additional nurses would be disciplined. She concurred that the Diabetic Management was unsatisfactory and required additional education.

Based on review of residents records, interviews of facility staff, interviews with the Physician/Medical Director, and interviews with the Director of Nurses (DON), the facility failed to follow physician ' s orders to assure the safe administration of insulin and the monitoring of blood glucose values to assure the prevention of life threatening clinical conditions such as insulin overdose and or [DIAGNOSES REDACTED] for three (#2, #4, and #9) of nineteen (19) residents sampled. These significant medication administration error actions potentially contributed to the death of one (#2) of the three residents. As a result of these findings, Immediate Jeopardy was identified on [DATE] and is ongoing. Findings Include: 1.) Per the facility face sheet, resident #2 was admitted to the facility on [DATE] after a hospital stay. The resident was [AGE] years old with a [DIAGNOSES REDACTED]. The past medical history section revealed that the resident has a history of diabetes, hypertension, [MEDICAL CONDITION], lung disease, and post surgical repair of an intracranial bleed (no date specified). Page two for the history and physical stated the laboratory data revealed: White Blood count 24.5 (norm reference not listed but upper limit of references was 10.5), Glucose was 549 and BUN was 24. The assessment and plan revealed that the resident was treated for [REDACTED]. The physician stated " watch for any further ketosis " . Per the Nursing Comprehensive Admission Data sheet, the resident was admitted to the facility on [DATE] at 1:15 p.m. The admitting [DIAGNOSES REDACTED]. The resident was assessed as alert with impaired cognition. Page two stated the resident used oxygen therapy continuous at two liters and diet was by feeding tube. Page four was checked for " DM/IDDM " , diabetic/insulin dependent diabetic. Review of the physician admission orders [REDACTED]. Review of the nurses notes, dated [DATE] at 5:00 p.m., the resident " pulled the N/G ([MEDICAL CONDITION] feeding tube) tube out. The physician was notified. Physician telephone orders were received on [DATE], no time specified, to replace the tube in the morning and give [MEDICATION NAME] for low blood sugar as needed. On [DATE] at 9:00 p.m. the blood sugar was recorded as 85 and no interventions were provided. Continued review of the nurses notes revealed that on [DATE] at 12:00 p.m. the physician was contacted and the resident was transported to the hospital at 1:00 p.m. for placement of a PEG (percutaneous feeding tube). Per the notes, the resident returned to the facility at 5:15 p.m. with a [MEDICAL CONDITION] tube in place, not the PEG tube. At 9:00 p.m. the note stated the resident again pulled the [MEDICAL CONDITION] tube out. On [DATE] at midnight the note stated that the [MEDICAL CONDITION] tube was out and the blood sugar was 92. The note stated the resident received nothing by mouth during the night after placement of the [MEDICAL CONDITION] tube at the hospital on [DATE]. On [DATE] at 6:30 a.m. the resident left the facility for the placement of the PEG tube, at the hospital. On [DATE] at 10:40 p.m. the resident returned to the facility. This note did not state whether the PEG tube was in place. The next nurse ' s note, dated [DATE] at 12:00, a.m. or p.m. not specified, stated the resident was alert with confusion, the tube feeding was infusing and the blood sugar was 418 (mg/DL). The nurse recorded that insulin coverage was given. On [DATE] at 2:00 p.m. the notes stated that the blood sugar (accucheck) was 453(mg/DL) and the doctor, visiting at the time, was notified by nurse #1. Review of the physician ' s telephone orders revealed an order, dated [DATE], no time specified, that stated " increase (upward arrow) [MEDICATION NAME] (insulin) to 20 units-start [DATE]; Give Insulin 10 units -R (regular) IV (intravenous) x 1. A second hand writing on the same order stated " insert peripheral line " . Nurse # 3, an LPN, signed the order as the receiving nurse. No time or date was found beside her signature. On [DATE] the next telephone order stated: Flush peripheral line with 10 cc n/s (normal saline) before and after meds and every shift when not in use. And monitor IV site every shift for signs and symptoms of infections. The order was signed by nurse #3 and the physician, no time specified. The next order, also dated [DATE], stated: Accu-check every 30 minutes x four hours. It was written and signed by nurse #3. No time was specified on the order and no start or stop parameters were listed to begin and end the monitoring. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The next note, [DATE], no time specified, was written by nurse #3, and stated " notified of accucheck of 348(mg/DL), see order to check accuchecks every 30 minutes " . On [DATE] at 5:30 p.m. nurse #3 wrote that the physician was notified of the blood sugar of 148. No new orders were received. On [DATE] at 5:55 p.m.. the blood sugar was record as 102 and the oxygen was infusing at four liters per minute. The pulse oximetry was 98% and tube feeding continued at 55 cc / hour. On [DATE] at 6:25 p.m. the nurse recorded the blood sugar as 87. On [DATE] at 6:55 p.m. the nurse recorded the blood sugar as 102. On [DATE] at 7:25 p.m. the nurse recorded the blood sugar as 86. On [DATE] at 7:55 p.m. the nurse recorded blood sugar 84; 8:25 p.m. the blood sugar was 87; at 8:55 p.m. the blood sugar was 79. On [DATE] at 9:25 p.m. the nurse recorded that the blood sugar was 87 and the oximetry was 96%, blood pressure was ,[DATE], pulse 93, and respirations were 20/ per minute. On [DATE] at 9:30 p.m. the nurses notes stated that the resident ' s respirations had ceased and she did not respond to shaking. No audible heart rate was found. CPR was initiated and 911 was called. On [DATE] at 9:45 p.m. emergency services arrived and CPR was " called " . The note stated that the resident ' s daughter was called and informed of the change of condition. On [DATE] at 10:00 p.m. the nurses note stated that " code called and resident pronounced " . At 10:05 p.m. the physician was notified and the daughter was taken to the room. At 10:15 p.m. the attending physician, also the medical director, was notified and the body was released to the funeral home. On [DATE] at 4:20 p.m. the note stated that the daughter was called and notified of a medication error. There was no further documentation in the nurse ' s notes. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On [DATE] at 9:45 a.m. an interview with nurse #1 revealed that she was the nurse caring for resident #2 on [DATE], during the day shift. She stated she received the order to administer 10 units of insulin by IV. She stated that after the IV needle/catheter was inserted she went to the emergency drug kit and took a multi-dose vial of regular insulin, containing 10 cc of insulin. Per the insulin label, each cc contained 100 units of insulin. The entire bottle contained 1000 units of insulin. She stated she also took two 10 cc prefilled syringes of normal saline for the before and after flushing of the IV. She stated that she then took a 10 cc syringe for administering the insulin. She stated she did not know why she chose the wrong syringe. She stated that at the time she was mentally unable to provide further information other than she gave the entire 10 cc of insulin. She stated she had never given IV insulin prior to [DATE]. She was suspended on [DATE] and terminated on [DATE]. On [DATE] at 10:00 a.m. during an interview with the Director of Nurses (DON), it was revealed that she was informed of the insulin medication error by the ADON on [DATE], about one hour after the event. She confirmed that four registered nurses and one practical nurse were aware of the error and none of the nurses clarified the exact amount of insulin, in units, that the resident had received. Nurse #3, the desk nurse, initially informed the physician that 10 cc of regular insulin was administered and later informed him that 100 units of regular insulin were given. On [DATE] at 2:15 p.m. an interview with the physician revealed that he was notified by the facility of the error with insulin administration for resident #2. He stated he was informed by nurse #3 that the resident had received 10 cc of insulin. He stated he asked the nurse for clarification of the dose in units of insulin and was told it equated to 100 units. He stated he then called the hospital pharmacist and was informed that the half life on IV insulin was one or two hours and the dose required monitoring for four hours. He stated that based on the information he had, he ordered the monitoring. He stated he was informed of the administration of 1000 units on [DATE], after the resident had died . He stated that if he had been aware of the actual amount of insulin given he would have ordered the resident to be transferred to acute care. He stated he did sign the death certificate with the primary cause of death [MEDICAL CONDITION] related to a urinary tract infection. He initially stated her overall condition was very poor and he was unable to specify how much the error contributed to her demise. He stated if she had a different medical history the large amount of insulin would have contributed greatly to the outcome, perhaps " 80 to 90% " . He stated that the large amount of insulin would have caused an electrolyte shift that would have required emergency medical management. He again stated that he was functioning with the knowledge that she received 100 units of insulin and not 1000 units. On [DATE], at 12:35 p.m., in an interview with the pharmacy supplier for the facility, it was revealed that the facility was supplied with only the 100 units per cc concentration of regular insulin, in a 10 cc multi-dose vial. She stated that was the concentration in the emergency drug kit. On [DATE] at 11:30 a.m. an interview with the DON confirmed that the nurses should have known the correct amount of insulin given to the resident in error. She stated that she was still investigating the error and that four nurses had been reprimanded. Nurse #1 had been terminated. She stated she had begun in-services and education related to insulin administration. 2.) Resident # 4 was readmitted to the facility on [DATE]. Per the facility face sheet, the resident was [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the physician order sheet for [DATE], revealed that the resident received three types of insulin daily. The orders stated that the resident received: [MEDICATION NAME] (long acting), 25 units at bedtime. [MEDICATION NAME], insulin glulisine, 18 units twice daily at 7:00 a.m.. and 4:30 p.m. Sliding scale regular insulin as needed per the blood glucose monitoring before meals and at bedtime. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at around noon an observation of the resident was made. When asked by the surveyor if he received his insulin regularly he stated that the [MEDICATION NAME] Insulin bottle was dropped by a nurse and he was without it for about one week. He stated that during that time his blood sugars had been elevated, at times over 400. He stated that the facility now had the [MEDICATION NAME] Insulin and he was doing fine. A nurse (#8) at the bedside confirmed that she was aware of the omissions and stated she thought the refill was delayed related to insurance problems. Review of the MAR indicated [REDACTED]. On [DATE] at 9:00 p.m. the blood sugar was 449 and the resident was given eight (8) units of regular insulin. On [DATE] at 4:30 p.m. the resident ' s blood sugar was 436 and he again received eight (8) units of regular insulin. Review of the sliding scale order for regular insulin stated: Blood glucose ,[DATE], give eight (8) units of insulin. There was no order regarding insulin doses for blood sugars above 360. There was no documentation that the physician was called either time. On [DATE] at 12:35 p.m. an interview with the pharmacy representative for the facility revealed that [MEDICATION NAME] Insulin was kept in stock and available at anytime for refill. She researched the file for resident #4 and stated that the last refill was called in on [DATE] and supplied to the facility on [DATE], in the early morning hours. She stated the pharmacy had no record of contact from the facility regarding a refill prior to [DATE]. They were not informed of a broken bottle. She stated a STAT order can be sent within four hours. She stated this insulin was not special order and the cost was only an additional two dollars over routine insulin bottles. She stated no insurance provider needed to approve the medication. On [DATE] during an interview with the DON, it was revealed that she was informed of the missed doses of insulin for resident #4 on [DATE]. She stated she was investigating the circumstances and she expected nurses to be disciplined related to the events. Later she informed the surveyors that four nurses received written reprimands related to the missed doses of [MEDICATION NAME] Insulin. She confirmed that this resident resided on the second wing of the facility and the staff involved was in addition to the staff involved with resident #2 on the other wing. On [DATE] at 2:15 p.m. an interview with the physician caring for resident #4 revealed that he was not informed of the missed doses of insulin or the elevated blood sugars. He reviewed the resident ' s record in the presence of the surveyors and confirmed the 19 missed doses and two elevated blood sugars over 400. He stated that he had visited the resident and been in the facility during this time and was never informed of the situation. He verbalized dissatisfaction with the situation. He also confirmed that he was the medical director. 3.) Per the face sheet, resident #9 was re-admitted to the facility on [DATE]. The face sheet stated that the resident was [AGE] years old, with [MEDICAL CONDITION] of the arm, [MEDICAL CONDITION], diabetes, impaired renal function, and [MEDICAL CONDITION]. Review of the hospital medication record, dated [DATE], revealed that the resident had an insulin pump to be maintained by the resident and his family. Review of the care plan list at the facility, dated [DATE], item #4 stated DM (diabetes). There was no mention of an insulin pump. The care plan itself stated that the resident had an insulin pump. Review of a history and physical, dated [DATE], revealed that the resident had a left elbow infection that was likely septic and exacerbation of [MEDICAL CONDITION] related to the infection. Review of the hospital records, dated [DATE], revealed that the resident had a PICC line for four weeks of planned antibiotic therapy. Review of the physician ' s orders for [DATE] revealed no orders for insulin administration or an insulin pump. An order was found for blood glucose monitoring before meals and at bedtime. The MAR indicated . There was no order for sliding scale insulin. Review of the blood glucose values ranged from 43 to 338. There were no interventions or physician contact recorded in the nurse ' s notes. Review of the physician history and physical, dated [DATE], revealed two different handwritings on the form. There was no documentation of the insulin pump or the dose of insulin received via the pump. The physician signed the form. It was later determined that nurse #3 had transcribed the medications in the lower right area. The DON stated that she obtained the information from the 3008 form and the hospital record. The DON stated she did not transcribe the insulin pump onto the facility form for the physician. A second form found in the facility medical record did not include diabetes in the medical history portion. The same handwriting, nurse #3, listed Insulin pump as the first medication. The medical record contained a " self medication data collection form that stated all medications would be administered by the nursing staff " . It was obtained on [DATE] upon admission and signed by nurses # 7 and #8. On [DATE] at 12:30 p.m. an observation of the resident was made. He was alert and oriented, seated in an oversized electric wheelchair. He stated he had an insulin pump attached to his right middle abdomen and demonstrated the pump. It was observed to be a very small catheter extending from the subcutaneous insertion site in the left abdomen to the hand held electronic pump. He demonstrated the pump setting varied three times throughout the day, with adjusted rates of constant delivery of regular insulin at a concentration of 500 units per cc. He stated that the staff checked his blood sugars, informed him of the results and he keyed the information into the hand held pump and received a [MEDICATION NAME] dose of insulin if needed. He stated his wife provided the insulin, supplied by special order to a community pharmacy. On [DATE] at 2:00 p.m. the DON stated she was not informed that the resident had an insulin pump until [DATE] during the investigation of resident #2. She requested nurses #7 and #8 attend the interview. Both nurses stated they were caring for the resident and were not aware of the concentration of insulin that the pump provided. Both nurses stated that the resident administered his own diabetic medication via the insulin pump. Neither nurse was aware of any interventions in case of a low or high blood glucose level. Nurse #8 stated that the resident received intravenous antibiotic therapy via a peripherally inserted Central Catheter (PICC) line. Both nurses stated they were aware that antibiotics could affect blood glucose levels. Later, nurse # 7 stated she had informed the physician of the need for diabetic management orders and provided the surveyors with a copy of the new orders on [DATE] at 3:45 p.m. She stated she redid the self medication data collection and assessment sheet to include the insulin pump. The DON confirmed that there were no physician orders concerning diabetic management for resident #9 from the admission on [DATE] to [DATE]. She stated the nursing education will include management of an insulin pump and she would contact the manufacturer for details regarding the pump. These findings resulted in findings of immediate jeopardy at scope and severity of level K, widespread due to the residents residing on different units of the facility and different staff involved. Per the DON, corrective actions began on [DATE] after the investigation of the medication error for resident #2. During the investigation additional information was discovered and as of the exit date [DATE], the DON stated that all corrective actions were not complete and additional education was planned.

Based on interviews with the Director of Nurses (DON), the pharmacy representative for the facility, staff nurses caring for residents, the Medical Director, and residents, in addition to record reviews, and observations the facility failed to provide routine and emergency medications to assure the accurate and timely administration of insulin for two of nineteen diabetic residents reviewed (#2 and #4). Additionally, the facility failed to provide emergency drugs, special, high dose insulin, for one of nineteen (#9) residents with special needs related to an insulin pump. These findings resulted in a massive dose of insulin administered to resident #2 by intravenous push contributing to her death, elevations of blood sugars into the 400 range while resident #4 was without insulin for 19 doses and the potential of a diabetic crisis for resident #9 with no supplies for the insulin pump. As a result of these findings, Immediate Jeopardy was identified on 1/19/2011 and is ongoing. The findings include: 1.) Per the face sheet, resident #4 was [AGE] years old and admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The physicians progress notes, dated 12/07/10, stated that the resident also had chronic pain. Review of the physician's order [REDACTED]. They were: Lantus Insulin (long acting) 25 units at bedtime, 9:00 p.m. Apidra Insulin, intermediate acting, 18 units twice daily at 7:00 a.m. and 4:30 p.m. Novolog Insulin, short acting, four times daily as needed on a sliding scale based on blood glucose levels. Review of the Medication Administration Record (MAR)for January 2011, revealed nineteen doses of Apidra Insulin were circled indicating not administered from January 14, 2011 at 5:00 p.m. through January 23,2011 at 5:00 p.m. The reverse side of the MAR contained one documentation dated 01/22/11 at 2:00 p.m. that stated Apidra (insulin) " not on cart, not found in fridge, pharmacy notified " . There was no other documentation regarding the missed doses. Review of the MAR containing the blood glucose levels and the amount of sliding scale insulin given revealed that 01/21/11 at 9:00 p.m. the blood sugar was 449. The documentation stated the resident received eight units of regular insulin. Further review revealed a second elevation over 400, on 01/23/11 at 4:30 p.m. the blood sugar was 436 and eight units of regular insulin was given. The physician's order [REDACTED]. There was no insulin dose for blood glucose values above 360. There was no documentation in the nurses notes stating the physician was called regarding the elevated blood sugars or the omissions of Apidra Insulin for 19 doses. On 01/25/11 at 12:35 p.m. an interview with the pharmacy representative for the facility revealed that the pharmacy did stock Apidra Insulin. She stated that the pharmacy was contacted on 01/23/11 that the resident required a refill. They had no other record of a request for a refill since the prior refill of 01/06/11. She stated that all residents are on automatic refill cycles of 28 days unless the pharmacy is contacted. They deliver to the facility twice daily, once daily on Saturday and Sunday, and as needed. Medications ordered STAT (urgent) are delivered within four hours. She stated the Apidra refill of 01/23/11 was not ordered STAT. Review of the Apidra Insulin label revealed that it was refilled on 01/23/11 and delivered at around 3:00 a.m. due to the early morning dose for 01/24/11. On 01/24/11 at around noon, an interview with the nurse caring for resident #4, stated that a nurse dropped the bottle of Apidra and it was broken. She stated that there was difficulty obtaining a refill. She was unsure of the details why. She stated she had not informed the physician of the missing doses. On 01/24/11 at around noon an observation of the resident was made. When asked if he received insulin in a timely manner, he stated to the surveyor that the Apidra bottle was dropped and broken and he was aware that he missed several doses. He stated his blood sugar was elevated , over 400 at times, during that time. He stated he was fine now. On 01/25/11 at 1:35 p.m. an interview with the DON revealed that she was informed of the missed doses of Apidra for resident #4. She stated her investigation was not complete. She stated she received the information from the Unit Manager. On 01/25/11 at 2:15 p.m. an interview with the physician caring for the resident confirmed that he was alert and oriented and fully aware of his insulin needs. The physician, also the medical director, stated he was not informed of the multiple (19) missed doses of Apidra Insulin. He reviewed the MAR and confirmed the two elevations of blood sugar over 400 during the time of the missed doses, January 13 to January 23, 2011. He stated he was not notified of either situation and that in fact he was in the facility almost daily during this time. He appeared to be upset over the findings and was shaking his head. He had no further comment. The DON later stated that four nurses received written disciple related to the failure to obtain the insulin needed for resident #4. 2.) Per the face sheet, resident #9 was readmitted to the facility on [DATE]. He was a [AGE] year old male with cellulitis of the arm. Other [DIAGNOSES REDACTED]. Review of the hospital medication sheet, dated 01/10/11 revealed that the resident had an insulin pump to be maintained by the patient and family. Review of the facility care plan, dated 01/10/11, revealed the diabetic management included a note stating the resident had an insulin pump. The care plan was checked to include: notify MD of extreme fluctuations of blood sugar; Administer medications as ordered and monitor the effects. Notify MD as needed. Review of the History and Physical, dated 01/06/11, revealed that the resident was hospitalized for [REDACTED].#5, page 3, stated " Hyperglycemia secondary to steroids " . The plan included: A PICC IV line for antibiotic treatment for [REDACTED]. A second physician note, dated 01/06/11, revealed that the resident had 32 medications listed, including Humulin insulin. The resident ' s admission weight was documented as 306.8 lbs. with a height of five feet eleven inches tall. The Skilled Care Alert Charting form , dated 01/10/11, was blank in the area of Diabetes. Review of the physician progress notes [REDACTED]. Review of a history and physical form, dated 01/11/11, revealed two different handwritings on the form, signed by the physician. There was no documentation of an insulin pump. The section for the physical, GI( gastrointestinal) stated: " soft/NT (nontender) and BS (bowel sounds) + " . There was no documentation regarding the insulin pump attached to the mid-abdomen, left side. The lower right side list of medications, written by a second person later identified as nurse #3, did not include insulin for the insulin pump. A second history and physical form, not dated, but signed by the physician, stated " insulin pump " under the medication section. No dose of delivery or strength of concentration was documented. Review of the physician progress notes [REDACTED]. Review of the physician's order [REDACTED]. On 01/26/11 at 12:30 p.m. an observation of the resident was made by two surveyors at the bedside. The resident was seated in an electric wheelchair, alert, oriented, and well versed on the insulin pump use. He stated he had managed the pump for three years with the assistance of his wife. He demonstrated that the pump was attached to a thin catheter that was attached just under the skin of the left middle abdomen. He showed the surveyors the screen on the pump, the size of a cell phone, had multiple options. It was set to deliver constant doses throughout the day, at three different levels related to wake/sleep/activity levels. He stated that based on the facility blood glucose testing values. The pump could be set to deliver a bolus dose of insulin. He stated that the cartridge of insulin for the pump contained regular insulin, 500 units per cc. He verified that it was five times the concentration of standard regular insulin. He stated his wife obtained the insulin from a special pharmacy and filled the pump every three days. Review of the MAR for January, 2011, revealed no documentation of the concentration of insulin needed to fill the pump, nor any emergency orders for high or low blood sugar values. Review of the MAR for January 2011 revealed that blood glucose values were checked four times daily and ranged from 43 to 410. There was no documentation of any intervention by the facility. On 01/26/11 at 2:00 p.m. an interview with the DON revealed that she did not know that the resident, #9, had an insulin pump. She stated the details were evolving as she began to audit the diabetic residents. She verified that the facility form of self administration of medications stated facility to provide all medications. The DON requested that the ADON, and nurse #8, caring for the resident, join the interview. Both nurses stated they were unaware of the concentration of insulin in the pump. After being informed that it was 500 units per cc, both stated that concentration was not kept in the facility emergency box and was a special order. Both nurses stated they did not have emergency guidelines for blood sugar parameters and interventions for resident #9. Review of the facility protocol for [DIAGNOSES REDACTED] stated to administer Glucagon for blood sugars lower than 60. Both nurses stated this was not done and the resident managed it himself. A telephone order, dated 01/25/11, after the surveyor requested clarification, stated to provide accuchecks before meals and at bedtime; and the resident had an insulin pump. It was signed by nurse #3, at 5:30 p.m.. On 01/26/11 at around 4:00 p.m., the ADON stated to the surveyors that she had redone the self medication form to include the insulin pump. The nurse provided three additional telephone orders, dated 01/26/11 at 3:33 p.m., clarifying the insulin pump and referring nurses to the physician managing the pump, a diabetic specialist. The failure of the facility to have diabetic management supplies on hand and guidelines in place for resident #9 placed the resident at risk for potential life threatening complications of extreme high or low blood sugar values. Severe extremes of blood sugar could render the resident unable to manage his insulin needs. 3.) Per the facility face sheet, resident #2 was admitted to the facility on [DATE] after a hospital stay. The resident was [AGE] years old with septicemia. Per the hospital history and physical, dated 01/08/11, the resident was hospitalized for [REDACTED]. Review of the laboratory Data, page 2, revealed: White blood count 24.5, severe elevation, Glucose 549, severe elevation , and BUN 24, severe elevation. The Assessment and Plan, page 3, stated that the resident was receiving IV fluids and an insulin drip (IV). The plan was to " watch for any further ketosis " , a complication of high blood sugars. Review of the physician orders, dated 01/16/11, revealed that resident #2 received nothing by mouth, a continuous tube feeding solution, Glucerna 1.2, to be infused at 55 cc per hour. The weight recorded on admission was 101 pounds. Medications included: Lantus Insulin, 10 units daily at 9:00 p.m. Accuchecks before meals and bedtime with sliding scale regular insulin coverage. Review of the nurse ' s notes revealed: On 01/16/11 at 3:00 p.m. the resident was admitted with a nasogastric tube in place. The resident was alert with mild confusion, some wheezing, and a urinary catheter in place. On 01/16/11 at 5:00 p.m. the resident pulled the nasogastric tube out. The physician was called orders were received to replace the tube in the morning. On 01/16/11 at 9:00 p.m. the blood sugar was 85. On 01/17/11 at noon the note stated the POA requested a more permanent PEG tube be inserted. On 01/17/11 at 1:00 p.m. the resident was sent to the hospital for insertion of a PEG tube. On 01/17/11 at 5:15 p.m. the resident returned with a nasogastric tube inserted. On 01/17/11 at 9:00 p.m. the resident pulled the nasogastric tube out a second time. On 01/18/11 at midnight the blood sugar was 92. On 01/18/11 at 6:30 a.m. the resident left the facility for insertion of a PEG tube. On 01/18/11 at 10:40 p.m. the resident returned to the facility with the PEG tube inserted. On 01/19/11 at 12:00, a.m. or p.m. not specified, the tube feeding was infusing and the blood sugar was 418. Insulin coverage was given. On 01/19/11 at 2:00 p.m. the blood sugar was 453, the physician visited and orders were received. On 01/19/11 a telephone order, obtained by nurse #3, dated 01/19/11, no time specified, stated to : Increase Lantus insulin to 20 units, start 01/20/11; Give Insulin 10 units regular, IV x 1.; and a third order, written in another handwriting stated to insert a peripheral line( I.E.: an intravenous access). Review of the MAR revealed that: 10 units of regular insulin IV x 1 were recorded as given on 01/19/11 at 3:00 p.m. On 01/25/11 at 9:25 a.m. an interview with the nurse administering the IV insulin order on 01/19/11, nurse #1, revealed that she gave an entire multidose vial of regular insulin, 10 cc with a concentration of 100 units per cc, or the equivalent of 1000 units of regular insulin. She stated she took the insulin from the emergency kit, a 10 cc syringe and two 10 cc prefilled syringes with normal saline for flushing the IV before and after the insulin. She stated she recognized her error and reported it immediately to nurse #7, #2, and #3. She stated she was hysterical and repeated that she gave " 10 cc " of insulin. She confirmed the syringe was a 10 cc size to nurse #2, an RN. Nurse #3, an LPN " desk nurse " contacted the doctor to report the error. She stated that nurse number #3 informed the physician that it was 100 units. She stated she was too upset to think clearly. On 01/25/11 an interview with the physician revealed that he ordered blood sugar monitoring every thirty minutes for four hours after the error was reported to him. He was functioning with information of the resident having received 100 units of regular insulin. He stated he called the hospital pharmacist after the error and was informed of the half life of the insulin and how long to monitor for adverse drops in blood sugar. He stated he asked nurse #3 to clarify the units of insulin given and she stated to him 100 units. He did not know about the 1000 units until 01/20/11, after the resident died . He stated that if he had received the correct unit amount he would have sent her to the hospital. He stated massive doses of insulin cause electrolyte shifts that required intense monitoring. He could not state how much the insulin dose error contributed to the resident ' s death, stating she was very ill. On 01/25/11 at 10:00 a.m. an interview with the DON revealed that four nurses, including herself, were aware of the medication error and the volume of insulin given (10 cc). She stated that none of the nurses consulted the MAR where the order provided the concentration of 100 units per cc. She confirmed that the physician was provided information only on the volume of insulin given and not the correct unit dose. The DON stated that none of the four nurses who were aware of the error called the pharmacy to consult with the supplier of the insulin to determine the exact amount, in units, that the resident received. She was aware that the physician's order [REDACTED]. Per the nurse ' s notes, dated 01/19/11 at 9:30 p.m., six hours after the insulin overdose, the resident was found without respirations or a heart rate. CPR failed to revive the resident and she was pronounced dead on 01/19/11 at 10:00 p.m.

Based on Administrator position description review, nursing policy review, review of pharmacy policies, interviews with care and administration staff, nursing department managers, the medical director, and the nursing home administrator (NHA), it was determined that the facility neglected to utilize the resources, under the leadership of the administrator, in a manner to provide the highest standard of care for three of nineteen residents sampled (#2, #4, and #9). The administration also failed to ensure that staff implemented the training received related to the safe management of diabetic residents. The errors and omissions related to diabetic care and management resulted in substandard quality of care, contributing to the demise of resident #2, and the potential risk of a diabetic crisis for residents #4 and #9. As a result of these findings, Immediate Jeopardy was identified on [DATE] and is ongoing. Findings include: 1.) Review of the Position Description for the Administrator, signed by the NHA and dated [DATE], revealed the following: Page 1, Essential Functions, item f: Ensures the provision of quality services through the design and implementation of facility wide quality assurance and program evaluation plans. Page 4, item 10: Recognizes the importance of educational development to self and staff at the facility. On [DATE] at 11:30 a.m. the DON and the NHA stated they were unaware of the extent of diabetic residents involved in errors of Diabetic Management until they began an audit of all diabetic residents ' records on [DATE], after the death of resident #2. The DON confirmed that the facility did not have a specific policy for management of a resident with an insulin pump, such as resident #9. She stated that four nurses were disciplined related to the medication error of resident #2, four additional nurses were disciplined related to the omissions of insulin for resident #4 , and other disciplinary action was expected. On [DATE], around 11:00 a.m., the NHA stated he would evaluate all the data collected related to Diabetic Management, any additional errors identified, and he confirmed the disciplinary actions of the nine nurses identified at the present time. He was aware of his responsibility to select and employ qualified staff members to ensure quality services to the residents. He stated he was working with the DON to obtain outside providers to educate the staff regarding insulin administration and insulin pump monitoring. The DON, present at the time of this interview, stated that nurses on the staff had failed to implement prior training related to the management of diabetic residents. She stated that she was unaware of the extent of the nurses involved in errors with diabetic medication administration and emergency supplies. 1.) Per the facility face sheet, resident #2 was admitted to the facility on [DATE] after a hospital stay. The resident was [AGE] years old with [MEDICAL CONDITION] and diabetes. Per the hospital history and physical, dated [DATE], the resident was hospitalized for [REDACTED]. Review of the Laboratory Data, page 2, revealed: White blood count 24.5, (severe elevation), Glucose 549, (severe elevation) , and BUN 24, (severe elevation). The Assessment and Plan, page 3, stated that the resident was receiving intravenous (IV) fluids and an insulin drip (IV). The plan was to " watch for any further ketosis " , a complication of high blood sugars. Review of the physician orders, dated [DATE], revealed that resident #2 received nothing by mouth, a continuous tube feeding formula, Glucerna 1.2 solution, was to be infused at 55 cc per hour via a [MEDICAL CONDITION] tube. Diabetic medications included: [MEDICATION NAME], 10 units daily at 9:00 p.m. Accuchecks before meals and bedtime with sliding scale regular insulin coverage. Review of the nurse ' s notes revealed: On [DATE] at 3:00 p.m. the resident was admitted with a [MEDICAL CONDITION] tube in place. The resident was alert with mild confusion, some wheezing, and a urinary catheter in place. On [DATE] at 5:00 p.m. the resident pulled the [MEDICAL CONDITION] tube out. The physician was called orders were received to replace the tube in the morning. On [DATE] at 9:00 p.m. the blood sugar was 85. On [DATE] at noon the note stated the POA requested a more permanent (Percutaneous Endoscopic Gastrostomy) PEG tube be inserted. On [DATE] at 1:00 p.m. the resident was sent to the hospital for insertion of a PEG tube and returned to the facility at 5:15 p.m. with a second [MEDICAL CONDITION] tube inserted. On [DATE] at 9:00 p.m. the resident pulled the [MEDICAL CONDITION] tube out a second time. On [DATE] at midnight the blood sugar was 92 mg/DL. On [DATE] at 6:30 a.m. the resident left the facility for insertion of a PEG tube and returned at 10:40 p.m. with the PEG tube inserted. On [DATE] at 12:00, a.m. or p.m. not specified, the tube feeding was infusing and the blood sugar was 418 mg/DL. Insulin coverage was given. On [DATE] at 2:00 p.m. the blood sugar was 453 mg/DL, the physician visited, and orders were received. On [DATE] a telephone order, obtained by nurse #3, dated [DATE], no time specified, stated to : Increase [MEDICATION NAME] to 20 units, start [DATE]; Give Insulin 10 units regular, IV x 1.; and a third order, written in another handwriting, stated to insert a peripheral line( I.E.: an intravenous access). Review of the MAR revealed: 10 units of regular insulin IV x 1 were recorded as given on [DATE] at 3:00 p.m. On [DATE] at 9:25 a.m. an interview with the nurse administering the IV insulin order on [DATE], nurse #1, revealed that she gave an entire multidose vial of regular insulin, 10 cc, with a concentration of 100 units per cc, or the equivalent of 1000 units of regular insulin. She stated she took the insulin from the emergency kit, a 10 cc syringe and two 10 cc prefilled syringes with normal saline for flushing the IV before and after the insulin. She stated she recognized her error after she had given the 1000 units of insulin and reported it immediately to nurse #7, #2, and #3. She stated she was hysterical and repeated that she gave " 10 cc " of insulin to all three nurses. She confirmed the syringe was a 10 cc size to nurse #2, an RN. Nurse #3, an LPN " desk nurse " , contacted the doctor by phone to report the error. She stated that nurse number #3 informed the physician that it was 100 units. She stated she was too upset to think clearly, but she repeated several times that she gave 10 cc or regular insulin. She stated she threw the bottle and the syringe in the red " sharps " box in the resident room and was unable to retrieve it. Per the nurse ' s notes, dated [DATE] at 9:30 p.m., six hours after the insulin, the resident was found without respirations or a heart rate. Cardiopulmonary resuscitation (CPR) failed to revive the resident and she was pronounced dead on [DATE] at 10:00 p.m. On [DATE] 2:15 p.m. an interview with the physician revealed that he ordered blood sugar monitoring every thirty minutes for four hours after the error was reported to him. He was functioning with information of the resident having received 100 units of regular insulin. He stated he called the hospital pharmacist after the error and was informed of the half life of the insulin and how long to monitor for adverse drops in blood sugar. He stated he asked nurse #3 to clarify the units of insulin given and she stated to him 100 units. He did not know about the 1000 units until [DATE], after the resident died . He stated that if he had received the correct information regarding the insulin unit amount of 1000 units, he would have sent her to the hospital. He stated massive doses of insulin cause electrolyte shifts that required intense monitoring. He could not state how much the insulin dose error contributed to the resident ' s death, stating she was very ill. On [DATE] at 10:00 a.m. an interview with the DON revealed that four nurses, including herself, were aware of the medication error and the volume of insulin given (10 cc). She stated that none of the nurses consulted the MAR where the order provided the concentration of 100 units per cc, or the emergency drug kit inventory where the concentration and volume of the insulin bottle were listed. She confirmed that the physician was provided information only on the volume of insulin given, 10 cc, and not the correct unit dose. The DON stated that none of the four nurses who were aware of the error called the pharmacy to consult with the supplier of the insulin to determine the exact amount, in units, that the resident received. She was aware that the physician's order [REDACTED]. She discovered the actual amount administered to the resident after the investigation began on [DATE]. On [DATE] the NHA stated he was not aware of the massive dose of insulin, 1000 units, administered to resident #2 on [DATE] until the investigation began on [DATE]. The DON confirmed that multiple facility nurses failed to utilize pharmacy resources, available by phone and in writing on the MAR and the emergency drug kit inventory form, to clarify the correct dose, in units, of the insulin error. Failure to do so produced a cycle of events whereby the physician treated the resident with incorrect orders that contributed to the subsequent demise of resident #2. 2.) Per the face sheet, resident #9 was readmitted to the facility on [DATE]. He was a [AGE] year old male with [MEDICAL CONDITION] of the arm. Other [DIAGNOSES REDACTED]. Review of the facility care plan, dated [DATE](the date of admission to the facility), revealed the Diabetic Management section included a note stating the resident had an insulin pump. The care plan was checked to include: notify MD of extreme fluctuations of blood sugar; Administer medications as ordered and monitor the effects. Notify MD as needed. Review of the History and Physical, dated [DATE], revealed that the resident was hospitalized for [REDACTED].#5, page 3, stated " [MEDICAL CONDITION] secondary to steroids " . The plan included: A PICC IV line for antibiotic treatment for [REDACTED]. The Skilled Care Alert Charting facility form, dated [DATE], was blank in the area of Diabetes. Review of the physician progress notes [REDACTED]. Review of a history and physical form, dated [DATE], revealed there was no documentation of an insulin pump. The section for the physical, GI( gastrointestinal) stated: " soft/NT (non tender) and BS (bowel sounds) + " . There was no documentation regarding the insulin pump, attached to the mid-abdomen, left side. Review of the physician's order [REDACTED]. Review of the physician progress notes [REDACTED]. On [DATE] at 12:30 p.m. an observation of the resident was made by two surveyors, at the bedside. The resident was seated in an electric wheelchair, alert, oriented, and well versed on the insulin pump use. He stated he had managed the pump for three years with the assistance of his wife. He demonstrated that the hand held pump was attached to a thin catheter that was attached just under the skin of the left middle abdomen. He showed the surveyors the screen on the pump, the size of a cell phone, had multiple options. It was set to deliver constant doses of regular insulin throughout the day, at three different levels related to wake/sleep/activity levels. He stated that based on the facility blood glucose testing values, the pump could be set to also deliver a [MEDICATION NAME] dose of insulin. He stated that the cartridge of insulin for the pump contained regular insulin, 500 units per cc. He verified that it was five times the concentration of standard regular insulin. He stated his wife obtained the insulin from a special pharmacy and filled the pump every three days. On [DATE] at 11:30 a.m. an interview with the NHA and the DON revealed that the nurse " should have known " about the resident ' s insulin needs. The NHA stated he was not aware of the extent of the problem with Diabetic Management. They both stated education for nurses was initiated on [DATE] and was ongoing. At 12:30 p.m. the DON stated she did not know that resident #9 had an insulin pump. Review of the MAR for January, 2011, revealed no documentation of the concentration of insulin needed to fill the pump, nor any emergency orders for high or low blood sugar values. Review of the MAR for [DATE] revealed that blood glucose values were checked four times daily and ranged from 43 to 410. There was no documentation of any intervention by the facility. On [DATE] at 2:00 p.m. an interview with the DON revealed that she did not know that resident #9 had an insulin pump. She stated the details were evolving as she began to audit the diabetic residents. She verified that the facility form of self-administration of medications stated that the facility was to provide all medications. The DON requested that the ADON, #7, and nurse #8, caring for the resident, join the interview. Both nurses stated they were unaware of the concentration of insulin in the pump. After being informed that it was 500 units per cc, both stated that concentration was not kept in the facility emergency box and was a special order. Both nurses stated they did not have emergency guidelines for blood sugar parameters and interventions for resident #9. Review of the facility protocol for [DIAGNOSES REDACTED] stated to administer [MEDICATION NAME] for blood sugars lower than 60. Both nurses stated this was not done and the resident managed the blood sugar himself. 3.) Resident # 4 was readmitted to the facility on [DATE]. Per the facility face sheet, the resident was [AGE] years old with diabetes and multiple [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. The orders stated that the resident received: [MEDICATION NAME] (long acting), 25 units at bedtime. [MEDICATION NAME], insulin glulisine, 18 units twice daily at 7:00 a.m. and 4:30 p.m. Regular insulin as needed per sliding scale according to the blood glucose monitoring before meals and at bedtime. Review of the medication administration record (MAR) for [DATE], revealed that 19 doses of [MEDICATION NAME] Insulin were not given from [DATE] at 5:00 p.m. to [DATE] at 5:00 p.m. The back of the MAR contained one entry, dated [DATE] at 2:00 p.m., that stated [MEDICATION NAME] Insulin was not on the medication cart and the pharmacy was notified. On [DATE] at around noon an observation of the resident was made. The resident was alert, oriented and ambulating with a walker. When asked by the surveyor if he received his insulin regularly, he stated that the [MEDICATION NAME] Insulin bottle was dropped by a nurse several days ago and he was without it for about one week. He stated that during that time his blood sugars had been elevated, at times over 400. He stated that the facility now had the [MEDICATION NAME]and he was doing fine. A nurse at the bedside, #8, confirmed that she was aware of the omissions and stated she thought the refill was delayed related to insurance problems. Review of the MAR revealed that the resident had two blood sugar elevations over 400 during the period without [MEDICATION NAME] insulin. On [DATE] at 9:00 p.m. the blood sugar was 449 and the resident was given eight (8) units of regular insulin. On [DATE] at 4:30 p.m. the resident ' s blood sugar was 436 and he again received eight (8) units of regular insulin. Review of the sliding scale order for regular insulin stated: Blood glucose ,[DATE], give eight (8) units of insulin. There was no order regarding insulin doses for blood sugars above 360. There was no documentation that the physician was called during the period of the nineteen missed doses or either time when the blood sugar exceeded the sliding scale coverage limits. On [DATE] at 12:35 p.m. an interview with the pharmacy representative for the facility revealed that [MEDICATION NAME] Insulin was kept in stock and available at anytime for refill. She researched the file for resident #4 and stated that the last refill was called in on [DATE] and supplied to the facility on [DATE], in the early morning hours. She stated the pharmacy had no record of contact from the facility regarding a refill prior to [DATE]. They were not informed of a broken bottle. She stated a STAT order can be sent within four hours. She stated this insulin was not special order and the cost was only an additional two dollars over routine insulin bottles. She stated no insurance provider needed to approve the [MEDICATION NAME]medication. On [DATE] during an interview with the DON, it was revealed that she was informed of the missed doses of insulin for resident #4 on [DATE]. Later she informed the surveyors that four nurses received written reprimands related to the missed doses of [MEDICATION NAME] Insulin. She confirmed that this resident resided on the second wing of the facility. Different staff cared for resident #4 and resident #2. On [DATE] at 2:15 p.m. an interview with the physician caring for resident #4 revealed that he was not informed of the missed doses of [MEDICATION NAME]or the elevated blood sugars, exceeding the sliding scale limits. He reviewed the resident ' s record in the presence of the surveyors and confirmed the 19 missed doses and two elevated blood sugars over 400. He stated that he had visited the resident and been in the facility during this time and was never informed of the situation. He verbalized dissatisfaction with the situation. He also confirmed that he was the medical director for the facility.