Every finding on record at Oxford Health & Rehab Center

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to protect resident property from misappropriation for one (1) of three (3) residents reviewed for misappropriation when a housekeeping employee took the resident's debit card from his room and used it to make unauthorized purchases. Resident #2 Findings included:A record review of the facility policy, titled, Abuse, Neglect and Exploitation, revealed Policy: This facility's policy is to protect each resident's health, welfare and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .A record review of the facility's investigation revealed that on 7/9/26, the Social Worker (SW) was notified that Resident #2 reported his debit card was missing. The SW interviewed the resident, who stated unauthorized charges had been made to his account. With the resident's permission, staff searched his room but were unable to locate the debit card. The resident contacted his financial institution and was informed the card had been used the previous day at a local gas station and grocery store. A police report was filed, and the bank stopped the pending transactions. On 7/10/26, law enforcement provided surveillance photographs from the grocery store identifying Housekeeper #1, an employee of the facility's contracted housekeeping services provider, as the individual using the resident's debit card. The contracted employee was immediately terminated, law enforcement continued its criminal investigation, and the facility re-educated all employees and contracted staff regarding abuse, neglect, and misappropriation of resident property.During an interview on 7/14/26 at 11:00 AM, Resident #2 confirmed his debit card had been taken from his room and used without his permission at a local gas station and grocery store for purchases totaling $181.51.Observation of the surveillance photographs with the Director of Nursing on 7/14/25 at 11:15 AM, she confirmed the individual depicted using the resident's debit card was Housekeeper #1.An interview with the Housekeeping Supervisor confirmed that Housekeeper #1's employment was terminated immediately after she was identified as the perpetrator.A record review of the admission Record revealed the facility admitted Resident #2 on 6/5/25, with diagnoses including type II diabetes mellitus and morbid obesity, A record review of the Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 6/3/26 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was cognitively intact.

Based on record review, staff interview and facility policy review, the facility failed to develop a comprehensive, person-centered care plan for a resident having multiple significant skin conditions requiring ongoing assessment and treatment for one (1) of three (3) residents reviewed for wound care. Resident #1Findings included:Record review of the facility policy, titled, Comprehensive Plan of Care, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Record review of the Wound Care Note, dated 1/14/26 revealed that upon admission, Resident #1 was identified as having a deep tissue injury to the left heel that was present on admission and a callus to the left great toe.Record review of the Wound Care Note, dated 2/4/26 revealed that Resident #1 developed moisture-associated skin damage (MASD) to the sacrum.Record review of the Wound Care Note, dated 2/11/26 revealed that Resident #1 developed an unstageable pressure ulcer to right upper sacrum.A record review of Resident #1's comprehensive care plan revealed no care plan addressing the resident's wounds, pressure injuries, skin impairment, repositioning needs, pressure-relieving devices, treatment regimen, despite the multiple clinically significant skin conditions and ongoing wound management.During an interview on 7/14/26 at 10:00 AM, the Minimum Data Set (MDS) Nurse stated the purpose of the comprehensive care plan was to provide an accurate picture of the residents' needs and guide staff in providing individualized care. She confirmed the resident did not have a care plan addressing any of his wounds or skin conditions and acknowledged that one should have been developed.During an interview on 7/14/26 at 10:15 AM, the Director of Nursing (DON) stated it was the facility's expectation that residents with wounds and skin impairments would have individualized care plans developed to direct their care. She acknowledged that Resident #1 should have had a comprehensive care plan addressing his wounds and skin conditions.Record review of the admission Record revealed the facility admitted Resident #1 on 1/14/26, with a diagnosis including Cerebrovascular Accident (CVA) and discharged him to the hospital on 2/17/26.

Based on observation, record review, resident and staff interviews, the facility failed to develop and implement comprehensive, person-centered care plans for three (3) of twenty-four (24) residents reviewed (Residents #5, #17, and #84). Specifically, the facility failed to develop care plan interventions addressing a physician-ordered fluid restriction for a resident receiving hemodialysis, failed to ensure the safe implementation of care plan interventions for a resident receiving Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, and failed to develop and implement a care plan addressing a resident's repeated refusal of physician-ordered weights. These failures resulted in Resident #5 exceeding the ordered fluid restriction and experiencing fluid volume overload requiring hospitalization and placed Residents #17 and #84 at risk for unsafe administration of tube feedings, inaccurate monitoring of intake, and lack of staff guidance for managing ongoing refusals of ordered care. Findings include: Review of the facility policy titled Comprehensive Plan of Care, revised 02/17/2025, revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs and all services identified in the resident's comprehensive assessment . Resident #5 On 3/09/2026 at 3:12 PM, during an interview conducted with Resident #5 the resident communicated by writing on a white board that she had recently been hospitalized . Record review revealed Resident #5 received hemodialysis on Monday, Wednesday, and Friday and had a physician order for a 1000 milliliter (ml) fluid restriction per day. Physician diet orders revealed the resident was ordered a renal diet with a 1000 milliliter fluid restriction, allowing 240 ml with each meal and 70 cubic centimeters (cc) with each medication pass. Record review of Nurses Notes dated 01/02/26 at 10:44 AM stated, Resident found to be in respiratory distress, oxygen (O2) 76%, on 3L (liters), Respiratory 30, Manual Blood pressure 150/68. O2 increased to 86% on 5L. Resident appearing weak and unable to ambulate safely independently, NP (Nurse Practitioner) at bedside with orders to send resident to ER (Emergency Room) for respiratory distress. Record review of hospital records revealed the resident was hospitalized on [DATE] for volume overload and discharged on 1/03/2026. The hospital assessment noted the resident presented with volume overload symptoms related to getting too much fluid at the nursing home. Record review of the resident's care plan revealed interventions addressing hemodialysis; however, the care plan did not include interventions to monitor or maintain the physician-ordered fluid restriction or to notify the physician when fluid restriction was exceeded. An interview conducted with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator on 3/11/2026 at approximately 2:05 PM revealed residents with fluid restrictions should have monitoring in place to ensure ordered fluid limits are not exceeded and the physician should be notified if restrictions are exceeded. Record review of the admission Record revealed the facility admitted Resident #5 on 8/27/2025 with diagnoses including End Stage Renal Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2026 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Section O of the MDS revealed the resident received dialysis services while residing in the facility. Resident #84 On 3/09/2026 at 11:00 AM, Resident #84 was observed in his room administering a brown liquid through his PEG tube using a syringe. Record review revealed there were no physician orders indicating the resident was permitted to independently administer tube feeding or supplements through the PEG tube. Review of the care plan interventions did not address the resident independently administering tube feeding or supplements. Record review also revealed no documentation indicating the resident had been assessed for the ability to safely self-administer tube feeding or supplements. An interview conducted with the MDS Coordinator on 3/12/2026 at approximately 9:00 AM revealed the comprehensive care plan should include interventions addressing physician orders and resident needs identified in the resident's comprehensive assessment. The MDS Coordinator stated care plans should include interventions for monitoring physician-ordered fluid restrictions for Resident # 5 and for Resident # 84 who receives dialysis and interventions to ensure tube feedings are administered safely according to physician orders. Record review of the admission Record revealed the facility admitted Resident #84 on 10/20/2022 with diagnoses including Malignant Neoplasm of the Larynx. Record review of the MDS with an ARD of 12/07/2025 revealed under Section C, a BIMS score of 10, indicating moderate cognitive impairment. Resident #17 Record review of Resident #17's care plan with Licensed Practical Nurse (LPN) #3 revealed the resident's ongoing refusal of weights had not been addressed in the care plan. LPN #3 stated, She has refused to be weighed since she was admitted . Record review of Resident #17's Order Summary dated 3/10/26 revealed a physician order for monthly weights dated 8/6/2024. Record review of Resident #17's weight record revealed the resident had not been weighed since the initial admission weights. During an interview on 3/10/2026 at 11:32 AM, the Assistant Director of Nursing (ADON) confirmed a care plan addressing the resident's refusal of weights had not been developed. The ADON stated Resident #17 had consistently refused to be weighed and that the physician and the resident's family were aware of the resident's refusals. Record review of care plan revealed no care plan had been developed to address the resident's refusal of monthly weights as ordered by the physician. During an interview on 3/11/2026 at 12:15 PM, the MDS Nurse stated that a care plan should have been developed once the resident demonstrated an ongoing pattern of refusing physician-ordered services. She further stated that the purpose of the care plan is to guide staff in providing appropriate care for the resident. Record review of the admission Record indicated that the facility admitted Resident #17 on 5/3/2024 with a medical diagnosis that included Secondary Hypertension. A record review of the Minimum Data Set (MDS) with an ARD of 1/14/26 revealed under section C, a BIMS summary score of 13 which indicated Resident #17 was cognitively intact.

Based on resident interview, record review, and staff interviews, the facility failed to ensure fluid restrictions were implemented and monitored for one (1) of six (6) residents reviewed for dialysis services, resulting in fluid volume overload that required a hospitalization. (Resident #5). Findings include:The facility did not provide a policy related to monitoring or implementing fluid restrictions for residents.Review of a statement on facility letterhead dated 3/11/26 and signed by the Administrator revealed (Proper Name of Facility) does not have a policy related to fluid restrictions or management of fluids. The staff follow physician orders.During an interview conducted with Resident #5 on 3/09/2026 at 3:12 PM, the resident communicated by writing on a white board and indicated she had recently been hospitalized . Record review revealed physician's order dated 08/28/25 for hemodialysis on Monday, Wednesday, and Friday and the resident had a physician order for a fluid restriction of 1000 milliliters (ml) per day. Record review of physician diet orders revealed Resident #5 was ordered a renal diet with a 1000 milliliter (ml) fluid restriction. The order indicated the resident may receive 240 ml with each meal and 70 cubic centimeters (cc) with each medication pass.Record review of Nurses Notes dated 01/02/26 at 10:44 AM stated, Resident found to be in respiratory distress, oxygen (O2) 76%, on 3L (liters), Respiratory 30, Manual Blood pressure 150/68. O2 increased to 86% on 5L. Resident appearing weak and unable to ambulate safely independently, NP (Nurse Practitioner) at bedside with orders to send resident to ER (Emergency Room) for respiratory distress.Record review of hospital records revealed the resident was hospitalized on [DATE] for volume overload and discharged on 1/03/2026. The hospital assessment noted the resident presented with volume overload symptoms related to getting too much fluid at the nursing home.Record review of the January 2026 Treatment Administration Record and Nurses Notes documentation revealed a lack of a continuous daily monitoring system to ensure the resident's fluid intake remained within the ordered restriction. Record review of Assessment History, revealed a lack of intake and output (I&O) documentation in order to properly monitor I&O's for the following dates of 01/03/26 through 02/05/26.Record review of fluid intake documentation dated 2/26/2026, 02/27/26, 03/02/26, 03/03/26, 03/04/26, 03/06/26, 03/07/26 and 03/08/26 revealed the resident received 480 ml at three separate times for the 24-hour period totaling 1,440 ml, which exceeded the ordered 1000 ml fluid restriction. Record review further revealed the physician was not notified when the fluid restriction was exceeded on these dates.An interview conducted with a Certified Nursing Assistant (CNA) #3 on 3/11/2026 at 11:30 AM revealed CNA #3 stated that she used the drinking cups on the resident's meal tray to document the resident's intake. She demonstrated how for the daily meals the resident would have two (2) eight-ounce cups of juice and coffee for breakfast and 2 eight-ounce cups of liquid for the lunch and supper meals. CNA #3 confirmed that each eight-ounce cup is 240ml and it would total 480ml per meal for a total of 1,440ml per 24-hour period. CNA #3 confirmed that this would be over the daily fluid intake ordered by the physician.During an interview conducted with the Director of Nursing (DON) on 3/11/2026 at 11:45 AM, the DON stated that she was unaware that the resident was receiving over her total daily fluid amount and although staff were documenting fluid intake, they were not totaling the intake at the end of the shift and were not notifying the physician when the resident exceeded the ordered 1000 ml restriction. The DON confirmed that they needed to do a better job monitoring the fluid intake and that it was not always documented and tracked daily to prevent fluid volume overload.An interview conducted with the Administrator on 3/11/26 at 2:05 PM revealed residents with fluid restrictions should have monitoring in place to ensure ordered fluid limits are not exceeded and the physician should be notified if restrictions are exceeded and confirmed that this was not occurring for Resident #5.Interview on 03/11/26 at 3:00 PM with the dialysis nurse at the dialysis facility confirmed that Resident #5 had come to dialysis on 12/28/25, 12/30/25 and was scheduled to come for dialysis on 01/02/26 but had to be sent to the ER prior to her chair time due to fluid overload.Record review of the admission Record revealed the facility admitted Resident #5 on 8/27/2025 with diagnoses that included End Stage Renal disease.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. MDS Section O revealed the resident received dialysis services while residing in the facility.

Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure staff treated residents with dignity and respect for two (2) of 24 residents reviewed for dignity (Resident #44 and Resident #84). Findings include: Review of the facility policy titled Resident Rights and Responsibilities with a revision date of 10/10/2022, revealed, The resident has a right to be treated with respect and dignity . Resident #44 During a resident interview conducted on 3/09/2026 at approximately 2:34 PM, Resident #44 stated that Certified Nursing Assistant (CNA) #2 had been rude to her. The resident stated that her son had washed her laundry and brought it back to the facility and when she asked the CNA to help her put her clothes away, the CNA stated, I'm not laundry. During an interview conducted with the Unit Manager Registered Nurse (RN) #1 on 3/10/2026 at approximately 2:05 PM, the Unit Manager stated the resident had previously complained that a CNA had been rude to her. The Unit Manager stated the CNA reportedly told the resident that her son should have folded her clothes. The Unit Manager stated the comment made the resident feel bad because she is close to her son. The Unit Manager stated she had a meeting with CNA #2 and spoke with her about how she speaks to residents. During an interview conducted with the Administrator and Assistant Director of Nursing (ADON) on 3/10/2026 at approximately 2:25 PM, the Administrator and ADON stated they were unaware the resident had reported the aide being rude to her and stated they were unaware of any education or in-service provided to the CNA regarding the concern. They stated, We expect our staff to treat residents with dignity and respect. During an interview conducted with CNA #2 on 3/12/2026 at approximately 10:05 AM, the CNA confirmed the resident had asked for help putting her clothes away. CNA #2 stated she told the resident, I'm not laundry, and acknowledged the statement could have been perceived as rude. CNA #2 confirmed that she should have just helped the resident with her needs. Record review of the admission Record revealed the facility admitted Resident #44 on 11/27/2020 with diagnoses that included Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/2025 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #44 was cognitively intact. Resident #84 On 3/11/2026 at approximately 12:53 PM, an observation was conducted of Licensed Practical Nurse (LPN) #6 providing Percutaneous Endoscopic Gastrostomy tube (PEG) site care to Resident #84. During the observation, the LPN closed the privacy curtain between residents but left the door open while providing care. Resident #84 was sitting close to the door during the care, and another resident was wheeled by in a wheelchair and waved at Resident #84 during the care.When asked about privacy and dignity during the observation, LPN #6 stated she forgot to close the door, and residents should be treated with dignity and have privacy during care. During an interview with the Director of Nursing (DON) on 3/11/26 at 2:30 PM, the DON stated the door should have been closed and residents should have privacy and be treated with dignity and respect. Record review of the admission Record revealed the facility admitted Resident #84 on 10/20/2022 with diagnoses that included Malignant Neoplasm of Larynx. Record review of the MDS with an ARD of 12/07/2025 revealed under Section C, a BIMS score of 10, indicating moderate cognitive impairment.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents' call lights were placed within reach for two (2) of 24 sampled residents. (Resident #11 and #104)Findings Include:Review of the facility policy titled, Call Lights: Accessibility and Timely Response, with an effective date of 10/10/2022 revealed Staff will ensure the call light is within reach of the resident and secured, as needed. Resident #11 An observation on 3/09/2026 at 11:15 AM revealed Resident #11 asleep and seated in a reclined position in her recliner without access to a call light. Two (2) call lights were observed wrapped around the bed rail and were not within reach of the resident. On 3/09/2026 at 12:25 PM, a subsequent observation revealed the resident remained asleep in the same reclined position in the recliner, and the call lights remained wrapped around the bed rail and inaccessible to the resident. During an observation and interview on 03/09/2026 at 2:55 PM, Resident #11 remained seated in a reclined position in the recliner with no call light accessible. Resident #11 revealed she had experienced falls in the past and stated that was the reason both call lights were wrapped around the positioning bar on her bed. The resident confirmed she was unable to reach a call light or notify staff if assistance was needed while sitting in the recliner and further stated, I guess I should have one of those call lights over at my recliner. During an interview and observation on 3/10/2026 at 11:00 AM, Certified Nurse Aide (CNA) #1 revealed that Resident #11 is at risk for falls and confirmed both call lights had been wrapped around the bed rails. CNA #1 further confirmed there was no call light positioned next to the resident when she was sitting in the recliner. CNA #1 stated, Staff is expected to make more frequent rounds on the resident and acknowledged this should have been noticed. Record review of the admission Record revealed the facility admitted Resident #11 on 11/01/2024 with medical diagnoses that include Parkinson's Disease, Muscle weakness, and Difficulty in walking. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 2/21/26 revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #11 has moderate cognitive impairment. Resident #104 During an observation and interview on 3/9/26 at 10:20 AM, Resident #104 was observed sitting in a recliner approximately ten (10) feet away from his bed. The residents call light was observed lying on top of the overbed light fixture and was not accessible to the resident. Resident #104 stated, I'm not sure how long that has been lying up there. I guess they put it up there when they buffed my floors. Resident #104 further stated, I can't reach it anyway, especially when I'm in my recliner. During an interview on 3/10/26 at 11:10 AM, Licensed Practical Nurse (LPN) #1 revealed the resident is impulsive and noncompliant; however, she confirmed the resident's call light should always be accessible to him. During an observation and interview on 3/10/26 at 11:15 AM, Resident #104 was observed sitting in his recliner with the call light wrapped around the base of the overbed table and not within reach of the resident. CNA #1 confirmed the call light was inaccessible to the resident and repositioned the overbed table next to the resident so he could reach it. Resident #104 stated to CNA #1, Yesterday, it was up on top of the overbed light when she came in. They must have put it up there when they buffed the floors. During an interview on 3/10/26 at 11:35 AM, the Assistant Director of Nursing (ADON) confirmed that it is the facility's expectation that call lights remain within residents' reach so they can notify staff when assistance is needed. During an interview on 3/10/26 at 3:50 PM, the Administrator confirmed that call lights should always be within reach of residents and acknowledged that call lights not being accessible could delay care needed by the resident. Record review of the admission Record revealed the facility admitted Resident #104 on 2/18/22 with medical diagnoses that include Osteoarthritis, Muscle weakness, and unsteadiness on feet. Record review of the MDS Section C with an ARD of 12/22/25 revealed a BIMS score of 08, which indicated Resident #104 has moderate cognitive impairment.

Based on Resident Council interviews, staff interviews, record review and facility policy review, the facility failed to implement an effective grievance process to ensure resident concerns were received, tracked, investigated, and resolved for three (3) of six (6) months of Resident Council meeting minutes reviewed.Findings include:Review of facility policy titled Grievance Policy with revised date 10/6/2025, revealed, .The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility .issuing written grievance decisions to the resident .3. A resident .may voice grievances with respect to care and treatment that has been furnished .the behavior of staff .and other concerns regarding their LTC (long term care) facility stay .7. Grievances may be voiced in the following forums .d. Verbal complaint during resident or family council meetings .9. d. The Grievance Official will take steps to resolve the grievance, record information about the grievance, and those actions on the grievance form .e. The Grievance Official .will keep the resident appropriately apprised of progress towards resolution of the grievances .10. Evidence demonstrating the results of all grievances will be maintained for a period of no less than three (3) years from the issuance of the grievance decision .11. The facility will make prompt efforts to resolve grievances.On 03/10/26 at 2:00PM the State Agency (SA) held a Resident Council meeting with Resident #12, Resident #21, Resident #22, Resident #25, Resident #35, Resident #39, Resident #43, Resident #46, Resident #52, Resident #65, Resident #67, Resident #96, Resident #104 and Resident #110 in attendance. When residents were asked if they had grievances that had not been addressed by the facility, 14 of the 16 residents' present reported they had voiced grievances to facility staff that had not been resolved and that it was in the meeting minutes. The residents stated that facility staff generally treated them well; however, they expressed multiple concerns regarding agency staff. Residents reported they were tired of having agency staff and stated that agency staff did not provide continuity of care because they did not know the residents or the facility routines. They stated that agency staff were frequently on their phones, they were rude and appeared uninterested in providing care. Residents also complained that agency nurses took excessive time to pass evening medications. Several residents stated that medications scheduled for 7:00-8:00 PM were sometimes not administered until 10:00-11:00 PM when agency nurses were working. Residents reported that these concerns had been ongoing for several months and stated the issues had been discussed repeatedly during Resident Council meetings. Residents indicated that the Licensed Social Worker (LSW) was aware of these concerns; however, they reported they had not received follow-up regarding their complaints and were unaware of any grievance investigation or outcomes.Record review of Resident Council meeting minutes dated 10/14/25, revealed, .Old Business .Medications (not getting medications on time (mainly agency staff nurses) having to wait until after 10/11 to get 8:00 meds-Only with agency .Record review of Resident Council meeting minutes dated 11/13/25, revealed, .New Business .Bad attitudes from Agency staff .Record review of Resident Council meeting minutes dated 12/9/25, revealed, .Old Business .Bad attitudes from Agency staff-no change .During an interview conducted on 3/10/26 at 3:25 PM with the Administrator and the Assistant Director of Nursing (ADON), they confirmed the facility had experienced problems with agency staff in the past, but stated each situation was addressed individually when complaints were reported. The Administrator and Assistant Director of Nursing (ADON) both confirmed that they didn't consider this issue a grievance and the things they considered to be grievances would be something such as missing items or missing clothing. When they were asked to describe the facility's grievance process, neither the Administrator nor the ADON were able to clearly describe the process. Both stated that the LSW handled grievances but did not provide additional information regarding how grievances were received, investigated, tracked, or how outcomes were communicated to residents. The Administrator and ADON did not indicate that grievances raised during Resident Council meetings regarding agency staff behavior and delayed medication administration would be considered grievances requiring investigation and follow-up.On 03/11/2026 at 8:24 AM, an interview was conducted with the Licensed Social Worker (LSW), she stated she was responsible for handling grievances and confirmed that she attended the resident council meetings each month. When asked about residents' grievances regarding how they were treated by agency staff, the LSW stated, It's written in every Resident Council meeting, and confirmed that the issue had not been resolved.Record review of the admission Record indicated that the facility admitted Resident #12 on 9/4/2024 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13 which indicated Resident #12 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #21 on 4/12/2022 with a medical diagnosis that included Cerebral Infarction, Unspecified. A record review of the MDS with an ARD of 3/4/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #21 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #22 on 2/14/2025 with a medical diagnosis that included Other Schizophrenia. A record review of the MDS with an ARD of 2/14/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #22 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #25 on 1/8/2019 with a medical diagnosis that included Cerebral Infarction, Unspecified. A record review of the MDS with an ARD of 12/14/25 revealed under section C, a BIMS summary score of 13 which indicated Resident #25 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #35 on 5/23/2024 with a medical diagnosis that included Other Cerebrovascular Disease. A record review of the MDS with an ARD of 2/10/26 revealed under section C, a BIMS summary score of 14 which indicated Resident #35 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #39 on 12/3/2025 with a medical diagnosis that included Type 2 Diabetes Mellitus without complications. A record review of the MDS with an ARD of 2/5/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #35 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #43 on 11/14/2025 with a medical diagnosis that included Chronic Kidney Disease, Stage 4. A record review of the MDS with an ARD of 2/17/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #43 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #46 on 11/16/2022 with a medical diagnosis that included Acute Upper Respiratory Infection. A record review of the MDS with an ARD of 1/29/26 revealed under section C, a BIMS summary score of 14 which indicated Resident #46 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #52 on 2/6/2026 with a medical diagnosis that included Epilepsy, Unspecified, Not Intractable, with Status Epilepticus. A record review of the MDS with an ARD of 1/19/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #52 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #65 on 8/22/2025 with a medical diagnosis that included Hypothyroidism. A record review of the MDS with an ARD of 2/23/26 revealed under section C, a BIMS summary score of 12 which indicated Resident #65 had moderate cognitive impairment.Record review of the admission Record indicated that the facility admitted Resident #67 on 8/11/2025 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. A record review of the MDS with an ARD of 12/24/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #67 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #96 on 11/3/2023 with a medical diagnosis that included Type 2 Diabetes Mellitus with hyperglycemia. A record review of the MDS with an ARD of 1/27/26 revealed under section C, a BIMS summary score of 13 which indicated Resident #96 was cognitively intact.Record review of the admission Record indicated that the facility admitted Resident #104 on 2/18/2022 with a medical diagnosis that included Moderate Protein-Calorie Malnutrition. A record review of the MDS with an ARD of 12/22/25 revealed under section C, a BIMS summary score of 8 which indicated Resident #104 had moderate cognitive impairment.Record review of the admission Record indicated that the facility admitted Resident #110 on 7/17/2013 with a medical diagnosis that included Multiple Sclerosis. A record review of the MDS with an ARD of 12/4/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #110 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were free from misappropriation of resident property when a nurse removed medication dispensed for one resident and administered it to another resident for one (1) of twenty five (25) medication administration opportunities reviewed (Resident #67). Findings Include: Review of the facility policy titled Abuse, Neglect, and Exploitation revised 10/22 revealed under, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Record review of Resident #46's March 2026 Medication Administration Record (MAR) revealed an order dated 1/1/26, Seroquel oral tablet 200 MG (milligrams) give 1 (one) tablet by mouth one time a day due at 0800 (8 AM). On 3/11/26 at 7:30 AM, an observation of a medication pass with Licensed Practical Nurse (LPN) #5 revealed the LPN did not have Resident #46's ordered Seroquel 200 milligram tablet and stated Resident #46 was out of the medication. LPN #5 then removed two (2) 100 milligram tablets from Resident #67's Seroquel medication card and administered the medication to Resident #46. Record review of Resident #67's March 2026 MAR revealed an order dated 8/11/25, Seroquel oral tablet 100 MG (milligrams) give one (1) tablet by mouth at bedtime. An interview with LPN #5 on 3/11/26 at 8:46 AM confirmed he borrowed Resident #67's Seroquel to administer to Resident #46. He explained that he was not aware that he was not supposed to borrow medications and acknowledged Resident #67 lost two (2) doses of his medication which could create a medication shortage for him. LPN #5 further acknowledged medications belong to the resident for whom they were dispensed. An interview with the Director of Nursing (DON) on 3/11/26 at 1:39 PM confirmed medications should not be borrowed and stated the facility had a backup pharmacy available when medications were out of stock. She acknowledged medications dispensed by the pharmacy were considered the property of the resident for whom they were prescribed. Record review of the admission Record revealed the facility admitted Resident #67 on 8/11/25 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non Dominant Side. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #67 was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure written notification of a resident's hospital transfer was provided to the residents Resident Representative (RR) in accordance with transfer and discharge requirements for one (1) of two (2) residents reviewed for hospitalization. Resident #8 Findings Include:Review of the facility policy titled Transfer and Discharge, revised 2/10/25, revealed, 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.An interview with Resident #8 on 3/9/26 at 10:28 AM revealed she transferred from the facility to the hospital in January for a bowel perforation that required surgical repair.Record review of Resident #8's Progress Notes, dated 1/1/26, revealed the resident was transferred to the emergency room for severe abdominal pain.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/26 revealed an admission 5-Day combined with a discharge return anticipated MDS was completed.An interview with Social Services on 3/11/26 at 11:35 AM confirmed she did not mail a written notice of hospital transfer to Resident #8's representative because the resident had been in the facility less than 24 hours when she was transferred out.Record review of the admission Record revealed the facility re-admitted Resident #8 on 2/4/26 with medical diagnoses that included Unspecified Open Wound of Abdominal Wall.Record review of the MDS with an ARD of 2/11/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 7, indicating Resident #8 was moderately cognitively impaired.

Based on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment during the 7-day observation look-back period for two (2) of five (5) residents reviewed for unnecessary medication usage. Resident #11 and Resident #28. Findings Include: Review of facility policy titled MDS Assessments with revision date 3/11/2026, revealed, Policy: The purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the residents' status at the time of the assessment, by staff qualified to assess relevant care areas . Resident #11 A record review of the Order Summary Report revealed that Resident #11 has an order for Clonazepam oral tablet 0.5 milligram (mg.) Give 1 tablet by mouth every 12 hours related to anxiety disorder, with a start date of 1/6/26. Record review of Resident #11's Quarterly MDS with an Assessment Reference Date (ARD) of 2/3/26, revealed under section N, that Resident #11 did not receive seven (7) days of anti-anxiety medication for the observation look back period of 1/28/26 through 2/3/26. Record review of the Electronic Medication Administration Record (eMAR) for the MDS 7-day observation look-back period for antianxiety medication revealed Resident #11 received an anxiety medication between 1/28/26 and 2/3/26. An interview with the MDS Coordinator on 3/11/26 at 11:35 AM confirmed that Resident #11 was not coded on the 7-day look-back period for receiving an antianxiety medication. She confirmed the resident takes Clonazepam for her anxiety, and it should have been coded on her Quarterly MDS assessment. Record review of the admission Record revealed the facility admitted Resident #11 on 11/01/2024 with medical diagnoses that include Generalized Anxiety Disorder. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 2/21/26 revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #11 has moderate cognitive impairment. Resident #28 Record review of Resident #28's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/31/2025, revealed section N300 and N350 were coded incorrectly related to Resident #28 receiving insulin injections during the review lookback period. Record review of Resident #28's Medication Administration Record (MAR) for December 2025 revealed Resident #28 was not administered insulin at all during the month of December 2025. On 03/11/2026 at 2:42 PM, an interview was conducted with Minimum Data Set (MDS) Coordinator, and she confirmed that the Quarterly MDS assessment with an ARD of 12/31/2025 was coded incorrectly. The MDS Coordinator reviewed the December MAR and verified that Resident #28 did not receive insulin injections during the month of December 2025. The MDS Coordinator stated that the assessment had been completed by a Licensed Practical Nurse (LPN) and acknowledged that she was responsible for reviewing the assessment prior to signing and submitting it. The MDS Coordinator acknowledged that she did not always fully review assessments completed by other nursing staff prior to signing and submitting them, despite confirming that her signature verified the accuracy of the information contained in the assessment. The MDS Coordinator confirmed that by signing the assessment she was verifying that the information contained in the assessment was accurate. She further stated that inaccurate coding of the MDS assessment has the potential to affect the accuracy of resident assessment data used for care planning, quality measures, and facility reimbursement. During an interview conducted on 03/11/2026 at 2:46 PM with the Director of Nursing (DON), she stated that her expectation is for MDS assessments to be completed timely and accurately. Record review of the admission Record indicated that the facility admitted Resident #28 on 1/28/2008 with a medical diagnosis that included Type two (2) diabetes mellitus with diabetic polyneuropathy. A record review of the MDS with an ARD of 12/31/25 revealed under section C, a BIMS summary score of 15 which indicated Resident #28 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were prepared and administered by the same nurse in accordance with accepted nursing standards of practice for one (1) of six (6) residents observed during medication pass (Resident #98). Findings Include: Review of the facility policy titled Medication Administration, revised 6/8/23, revealed under, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. An observation on B-Hall on 3/11/26 at 7:58 AM revealed Licensed Practical Nurse (LPN) #4 removed a medicine cup containing prepared medications from the top of the medication cart and handed them to Registered Nurse (RN) #2, requesting that she administer the medications to Resident #98. RN #2 accepted the cup of medication and proceeded to Resident #98's room to administer them. An interview on 3/11/26 at 8:06 AM with LPN #4 and RN #2 confirmed LPN #4 prepared Resident #98's medications and handed them to RN #2 to administer. RN #2 acknowledged this was not a safe medication administration practice and stated the nurse who prepares the medication should be the one to administer it in order to reduce the risk of medication errors and maintain medication accountability. An interview with the Director of Nursing (DON) on 3/11/26 at 1:39 PM revealed only the nurse who prepares the medication should administer it and confirmed this was not an accepted nursing standard of practice. Record review of the admission Record revealed the facility admitted Resident #98 on 5/28/25 with medical diagnoses that included Acute Respiratory Failure with Hypoxia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #98 was cognitively intact.

Based on observation, record review, staff interviews and facility policy review, the facility failed to ensure tube feeding or supplements administered through a Percutaneous Endoscopic Gastrostomy (PEG) tube were administered according to physician orders for one (1) of two (2) residents with a PEG tube (Resident #84). Findings include:Review of the facility policy titled Enteral Nutrition, revised 3/17/2023, revealed liquid nutritional supplements and substitutes will be given to the resident as ordered by the physician.On 3/09/2026 at 11:00 AM, Resident #84 was observed in his room administering a brown liquid through his PEG tube using a syringe.A record review conducted on 3/09/2026 revealed there were no physician orders indicating the resident was permitted to independently administer tube feeding or supplements through the PEG tube. Record review also revealed no documentation indicating the resident had been assessed for the ability to safely self-administer tube feeding or supplements.An interview conducted with Registered Nurse (RN) #1 on 3/10/2026 at 2:00 PM revealed the tube feeding formula or supplements must be administered by staff, and staff are responsible for monitoring the resident's intake.An interview conducted with the Administrator and Assistant Director of Nursing on 3/10/2026 at 2:20 PM revealed the resident should not have been independently administering liquids through his PEG tube. The Assistant Director of Nursing stated allowing the resident to administer liquids independently would prevent staff from accurately monitoring intake and output and ensuring the feeding was administered appropriately.Record review of the admission Record revealed the facility admitted Resident #84 on 10/20/2022 with diagnoses that included Malignant Neoplasm of Larynx.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2025 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to ensure monitoring for adverse consequences of high-risk medications for one (1) of five (5) residents reviewed for medication regimen review. (Resident #4).Findings include:Review of the facility policy titled High Risk Medications, effective 2/10/2025, revealed, Policy: This facility recognizes that some medications are associated with a higher risk of adverse effects than others. These high-risk medications can include antidiabetics.The resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given. Record review of Resident #4's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2026 revealed orders for Insulin Glargine Solution 100 units/milliliter (U/ML), inject 98 units subcutaneously every 12 hours for diabetes mellitus (DM) related to TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION (E11.69). Start Date 12/29/2025, and Novolin R Injection Solution (Insulin Regular (Human)), inject 77 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION (E11.69).Start Date 12/04/2023. Review of the MAR and TAR lacked evidence of daily monitoring for signs and symptoms of hypoglycemia or hyperglycemia. During an interview on 03/11/2026 at 12:24 PM, the Director of Nursing (DON) confirmed monitoring for signs and symptoms of hypoglycemia and hyperglycemia had not been implemented for Resident #4. The DON stated the facility maintains standing orders requiring monitoring for diabetic residents and stated that physician orders are reviewed monthly by administrative nursing staff, and this issue should have been identified during that review process. The DON explained that monitoring for hypoglycemia and hyperglycemia is necessary to help prevent an episode from progressing into a medical emergency that could require hospitalization or result in serious harm.Record review of the admission Record indicated that the facility admitted Resident #4 on 4/23/2019 with medical diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated Resident #4 was cognitively intact.

Based on observation, staff interviews, and medication competency checklist review, the facility failed to ensure that insulin was properly labeled and stored in accordance with professional standards and manufacture's instruction for use after opening for one (1) of two (2) medication carts reviewed. C hall medication cartFindings Include:Review of the Medication Administration Competency Checklist revealed under, 23. Insulin dated when open. Also revealed under, 24. Insulin discarded after 28 days per manufacturer's instructions. An observation of the medication cart on C hall with Licensed Practical Nurse (LPN) #5 on [DATE] at 12:32 PM revealed the following insulins were in use and exceeded the manufacturer's 28-day room temperature storage limit or were not dated when opened: Resident #1 - Open vial of Insulin Lispro without an open dateResident #13 - Insulin Lispro vial with an open date of [DATE]Resident #13 - Insulin Glargine insulin pen without an open dateResident #44 - Insulin Aspart with an open date of [DATE]Resident #46 - Insulin Aspart with an open date of [DATE]Resident #46 - Fiasp Insulin with an open date of [DATE]Resident #67 - Insulin Lispro vial with an open date of [DATE] Record review of the manufacturer's storage instructions for Fiasp insulin, Insulin Lispro, Insulin Aspart, and Insulin Glargine revealed that once opened these insulins may be stored at room temperature for up to 28 days, after which the product should be discarded.An interview with LPN #5 on [DATE] at 12:48 PM confirmed the insulins were in use and were expired past the 28 days that insulin may be stored at room temperature. He revealed that once insulin was expired it lost its potency and may not be as effective at controlling residents' blood sugars. He confirmed Resident #1 and Resident #13 had insulin in use that was not labeled with an open date, revealing staff could not determine if they were administering expired insulin. An interview with the Director of Nursing (DON) on [DATE] at 1:39 PM revealed the insulin should be removed from the medication carts after 28 days from the open date. She stated the nurses were responsible for checking the insulins and ensuring they were not expired. The DON acknowledged that lack of dating the insulin when opening and the use of out-of-date insulin could cause the insulin to not be as effective.

Based on resident representative and staff interview, record review, and facility policy review, the facility failed to ensure pain management was provided for a resident that had diagnoses that included pain and chronic pain for one (1) of six (6) residents sampled. Resident #1Findings include:Record review of facility policy titled, Pain Management with a revised date of 3/10/25, revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .During a phone interview on 10/1/25 at 12:17 PM, Resident #1's representative revealed the resident had multiple wounds and was on antibiotics and was admitted to the facility from the hospital late in the evening on 7/25/25 and was sent back to the hospital on 8/6/25 and passed away on 8/25/25. She stated when the resident returned to the hospital it was determined that she had a decreased blood supply to her lower body and this caused excruciating pain. She stated that during the facility stay, the resident requested her pain medication and several times she did not receive it at all, or it was given long after it was requested. She stated it was unacceptable for the resident to have been in such severe pain and to not have the ordered medication given to her timely.A phone interview with Licensed Practical Nurse (LPN) #1 on 10/2/25 at 8:30 AM, revealed she was the nurse that admitted Resident #1 to the facility. She stated the resident had multiple wounds and complained of severe pain on admission, but she did not have pain medication available to administer to the resident. She confirmed she did not follow the process of obtaining pain medications for a resident with pain and she did not contact the pharmacy or the physician. She revealed a pain scale score was not checked or documented, but the resident had significant pain during part of her shift, and when the medication arrived around 3:00 AM, the resident was asleep. She stated the resident's condition was a sad situation and she had pain from the moment she was admitted till she left that shift. An interview with the Director of Nursing (DON) on 10/1/25 at 2:30 PM and 10/2/25 at 9:35 AM, revealed Resident #1 was admitted to the facility with multiple wounds and cellulitis of the perineum. She stated the facility had a system in place to allow medications to be obtained any time day or night through their medication dispensing system which could be accessed prior to medications delivered by their pharmacy. She acknowledged if a pain medication was needed, the on-call pharmacy provided a code for the narcotic to be obtained from the dispensing system. If no prescription was available, the provider would be notified to send a hard copy of prescription to the pharmacy so the staff could obtain the needed medication for the residents. After Resident #1's admission Health Status Note by LPN #1 which indicated the resident was having pain and medications were not available, was reviewed by the DON, she acknowledged this should not have occurred since the medication was available in their dispensing system. She acknowledged that a pain level score was not documented by LPN #1, but the nurse had documented in the progress note that the resident was experiencing pain. She acknowledged that each resident has the right to receive the care necessary and it was her expectation that each staff member follows the process to obtain the needed medications for each resident. She confirmed the nurse, therefore the facility, failed to follow the procedure for obtaining medication for a resident experiencing pain. Record review of Resident #1's Health Status Note dated 7/25/25 at 9:30 PM, revealed, Resident is complaining of pain at this time, but no medications are on hand for her. This was signed by LPN #1.Record review of Resident #1's Order Summary Report revealed an order dated 7/25/25 for Hydrocodone-Acetaminophen Tablet 5-325 milligram (mg) give one tablet by mouth every 8 hours as needed for pain.Record review of the Electronic Medication Administration Record (EMAR) revealed Resident #1 did not receive the ordered pain medication on 7/25/25.Record review of facility's Inventory list for medications in the dispensing system revealed that Resident #1's ordered medication, Hydrocodone/Acetaminophen 5-325 mg was available in the facility's medication dispensing system.Record review of Resident #1's admission Record revealed an admission date of 7/25/25, with diagnoses that included cellulitis of perineum, pressure ulcer, pain, and chronic pain.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #1 was cognitively intact.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure the residents rooms were clean and in good repair for three (3) of 90 resident's rooms observed during survey. Resident #12, #17 and #28. Findings Include: Review of the facility policy titled, Room and Restroom Daily Cleaning Duties with a revision date of 4/9/2020 revealed .Procedure .7. The third rag should be used to clean the bed. Wipe down all bed rails, head and foot boards . Review of the facility policy titled, Resident Room and Bathroom Complete/Deep Cleaning Policy with no revision date, revealed, It is the policy of Proper Name Services to Complete/Deep Clean all resident rooms on a monthly basis .Procedure .2. Beds .Headboards and rails will be included . 6. Cubicle Curtain .each cubicle curtain will be checked for cleaning. If needed, it will be replaced, and the old one will be washed in the laundry . Record review of a typed statement on facility letterhead, undated and signed by the Administrator revealed This facility does not have a policy related to environmental cleaning. Resident #12 An observation on 9/3/24 at 11:12 AM, of Resident #12's room revealed, the privacy curtain at the foot of the resident's bed had approximately 8 brown stains about 1-2 inches wide scattered over the curtain. Review of Resident #12's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that include Cerebral Infarction. Review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/24 revealed in section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #17 An observation and interview on 9/3/24 at 2:38 PM, with Resident #17 revealed, her closet door on one side had been broken for a long time and maintenance knew about it. She stated the nurses and aides must get my clothes out of the closet daily, so they see that only one side works. This observation revealed the resident's closet had double sliding doors and one door was off the track and propped against the clothes that were hung in the closet. Review of Resident #17's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Multiple Sclerosis. Review of Resident 17's MDS with an ARD of 6/18/24 revealed in section C, a BIMS score of 15, which indicated the resident was cognitively intact. Review of the List of Rooms to be done by Maintenance did not include Resident #17's room. An interview on 9/3/24 at 2:45 PM, with Licensed Practical Nurse (LPN) #2 revealed, they do Angel Rounds at the beginning of their shifts. She revealed these rounds were done to make sure the rooms were clean and there were no repairs needed in each room. An interview on 9/4/24 at 8:41 AM, with LPN #1, revealed all office nurses have assigned rooms that they make Angel Rounds on one time per week. She revealed they make these rounds to make sure the rooms were clean and there were not any needed repairs. She stated if they find something that maintenance needs to repair then they just call him. A review of the schedule for Angel Rounds revealed that all resident rooms were assigned to an administrative nurse. An interview on 9/4/24 at 10:21 AM, with the Maintenance Director confirmed that staff usually send him a text or a group email when repairs need to be made. He confirmed there was a maintenance log at the nurse's desk, but text and email were the best communication. He revealed the list of rooms that needed to be repaired was on the list that he provided and that was all the repairs that he was aware of. An interview and observation on 9/4/24 at 10:48 AM, with the Administrator, confirmed Resident #17's closet door was off track and should have been found on the Angel Rounds and maintenance should have been notified to keep the resident's room in good repair. The Administrator confirmed Resident #12's dirty privacy curtain. The Administrator acknowledged the privacy curtain needed to be changed out because it was dirty. An interview on 9/4/24 at 2:28 PM, with Housekeeping #2 revealed, that if she found a dirty privacy curtain, she would notify her supervisor and she would resolve it. An interview on 9/4/24 at 3:10 PM, with the District Manager for Housekeeping confirmed that if a housekeeper noticed that a privacy curtain was dirty then they can replace it. She said the rooms get deep cleaned one time monthly and curtains also get replaced then if they are dirty. Review of the Monthly Calendar for Deep Cleaning resident rooms revealed that Resident #12's room was due for a deep cleaning on 8/29/24 and Resident #28's room was due on 8/30/24. Resident #28 An observation on 9/3/24 at 11:35 AM, revealed dirty bilateral one-quarter length bed rails in Resident #28's room. The right bed rail had three areas approximately one inch long by one-quarter inch wide of brownish yellow substance on the interior part next to the mattress. The left bed rail had two areas of brown substance approximately one inch by one-half inch on the inner left bed rail and had a gray substance scattered along the entire length of the top bar of the quarter-sized bed rail. An observation on 9/4/24 at 7:38 AM, of Resident #28's room, revealed the right interior bed rail with brownish yellow substance scattered in three places approximately one inch by one-quarter inch. The left bed rail had two areas of brown substance approximately one inch by one-half inch on the inner left bed rail and had a grayish substance along the entire top edge of the quarter-sized bed rail. An interview on 9/4/24 at 11:18 AM, with District Housekeeping Supervisor, revealed that they cleaned resident rooms every day and that the staff deep cleaned the rooms once a month. She revealed that the daily resident room cleaning included spot checking the walls, cleaning the bathrooms, sweeping, mopping, and wiping down all high contact surfaces. She confirmed that cleaning the bed rails was part of the daily cleaning tasks and stated It is our responsibility. The District Housekeeping Supervisor revealed that the young ladies in housekeeping were new, and she was working on retraining them on things she had noticed that they needed to improve on. She also revealed that she would make sure the bed rails were cleaned from now on. An interview on 9/4/24 at 10:20 AM, with Registered Nurse (RN) Unit Manager confirmed that Resident #28's bedrails had the brownish yellow substance and the grayish substance on both bilateral rails. She revealed that dirty side rails could cause the spread of germs and stated, I will get them cleaned right now. The RN Unit Manager also revealed that it was everyone's responsibility to clean the side rails if they noticed them to be dirty. An interview on 9/4/24 at 10:25 AM, with Licensed Practical Nurse (LPN) #3, revealed that the Housekeeping Department was responsible for cleaning the bed rails. She observed and confirmed that Resident #28's bilateral side rails were dirty and stated, We don't know what it is. Record review of Resident #28's Admission Record revealed an admitted [DATE] and diagnoses that included Need for assistance with personal care, Cerebral infarction, and Anxiety disorder. Record review of Resident #28's MDS with ARD of 6/24/2024 revealed under section C, a BIMS score of 10 which indicates Resident #28 had moderate cognitive deficits. 45598

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan related to personal hygiene for one (1) of 20 sampled residents. Resident #31. Findings Included: Review of the facility policy titled, Comprehensive Plan of Care, dated 10/10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident Record review of Resident #31's Care Plan with a date initiated 2/27/24 revealed Focus: Resident requires staff assistance with ADL's (Activities of Daily Living) related to Dysphagia and History of CVA (Cerebrovascular Accident) with left sided hemiparesis. Goal: .will be provided with ADL's according to daily needs through next review . On 9/3/24 at 10:34 AM, an observation revealed Resident #31 lying in his bed and he wearing a short-sleeved shirt. The resident's shirt had an area of white, crusty substance on the right anterior sleeve and a quarter-sized, dried, brown substance on the upper, anterior chest area of the shirt. On 9/3/24 at 11:50 AM, an observation revealed Resident #31 lying in his bed and he had the same short-sleeved shirt on with the dried substance. On 9/4/24 at 7:40 AM, an observation revealed Resident #31 lying on his left side in his bed with the same short-sleeved T-shirt he had on the day before on 09/03/24. On 9/4/24 at 3:06 PM, an observation and interview with Certified Nursing Assistant (CNA) #1, revealed that Resident #31 was assigned to her today. She confirmed it is in his care plan to receive hygiene care. On 9/4/24 at 3:40 PM, an interview with Minimum Data Set (MDS) Coordinator, revealed that the comprehensive care plan was developed to provide patient-centered, individualized care for each resident. MDS Coordinator agreed that Resident #31's care plan was not followed when the staff failed to assist him with his ADL needs. Record review of Resident #31's Admission Record revealed an admitted [DATE] with diagnoses that included Need for Assistance with Personal Care, Cerebral Infarction with Hemiplegia and Hemiparesis affecting left non-dominant side. Record review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that he had severe cognitive deficits.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident dependent on staff for care for one (1) of 20 sampled residents. Resident #31 Findings Included: Review of the facility policy, Activities of Daily Living (ADL) with revised date of 09/15/2022 revealed , Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care . An observation on 9/03/24 at 10:34 AM, revealed Resident #31 lying in his bed and he wore a red short-sleeved T-shirt. Resident #31's shirt had an area of white, crusty substance on the right anterior sleeve and also a quarter-sized area of dried, brown substance on the upper center front of the shirt. An observation on 09/03/24 at 11:50 AM, revealed Resident #31 lying in his bed and he had the same red short-sleeved shirt on. An observation on 09/04/24 at 7:40 AM, revealed Resident #31 lying on his left side in his bed with the same red short-sleeved shirt he had on the day before on 09/03/24. An observation and interview on 09/04/24 at 3:06 PM, with Certified Nursing Assistant (CNA) #1, revealed that Resident #31 was assigned to her today. She revealed that this resident was on hospice services, and their CNAs came to the facility three times a week to bathe him. CNA #1 revealed that Resident #31 was on a pureed diet and would often drop food on his clothes or in his beard. She revealed that on the days that hospice didn't come, the facility CNAs were responsible for changing the residents' clothes and bathing them if needed. CNA #1 confirmed the dried white and brown substance on Resident #31's red shirt and stated, It looks like food. She revealed that she had been in and out of his room and had not noticed his dirty shirt and that she would change his clothes now. On 09/04/24 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #3 revealed that Resident #31 was assigned to her today and she had been in and out of his room all day. She revealed that she had not noticed that he had on the same shirt as yesterday or that it was dirty. LPN #3 revealed that she should have paid more attention to him and not been in a hurry and stated, There's no excuse for this. LPN #3 revealed that resident care was supposed to be the same whether hospice staff came in or not and stated, This falls on us, we should have already changed him. She also revealed that residents' clothes should be changed every day whether they were scheduled to have a bath or not. LPN #3 revealed that this facility was their home and stated, These residents should be treated like we want to be treated and we get to change our clothes every day. An interview on 09/04/24 at 3:25 PM, with Registered Nurse (RN) Unit Manager, revealed that she failed to check the shower book this morning to make sure that Resident #31 received his ADL care. She revealed that she fed Resident #31 earlier, had put a clothing protector on him, and had not noticed the dirty shirt he had on. Record review of Resident #31's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Need for Assistance with Personal Care, Cerebral Infarction with Hemiplegia and Hemiparesis affecting his left non-dominant side. Record review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that he had severe cognitive deficits.

Based on observation, resident and staff interview, the facility failed to ensure a resident had a properly fitting wheelchair for one (1) of 20 sampled residents. Resident #83 Findings Include: Record review of a typed statement on facility letterhead and signed by the Administrator, revealed This facility does not have a policy related to resident equipment, including wheelchairs. An observation and interview on 9/3/2024 at 11:20 AM, with Resident #83 revealed, she was sitting in a wheelchair in her room. The resident's feet were dangling down of the seat of the wheelchair and did not touch the floor. The resident revealed she propelled herself throughout the facility in the wheelchair and admitted it was difficult to do this because her feet did not touch the floor. An interview with Certified Nurse Aide (CNA) #2 on 9/4/2024 at 11:05 AM, confirmed Resident #83 used her wheelchair to propel herself about the facility and this was her method of mobility. An interview with Resident #83, on 9/4/2024 at 11:40 AM, revealed she would like a better fitting wheelchair so that her feet could touch the floor and it would be more comfortable. An observation and interview, on 9/4/2024 at 11:45 AM, with Registered Nurse (RN) # 2, confirmed Resident #83's wheelchair was too tall for her and acknowledged the resident would have trouble with foot propulsion since her feet did not contact the floor. An interview with the Occupational Therapist (OT) on 9/4/2024 at 11:54 AM revealed, when a resident admits to the facility, someone usually goes and gets an available wheelchair from inside the facility. He revealed the wheelchair was not customized to fit Resident #83 and stated her feet should reach the floor to safely self-propel. An interview with the Administrator on 9/4/2024 at 1:50 PM, confirmed Resident #83 should have a proper fitting wheelchair to meet the resident's needs. Review of the Admission Record revealed the facility admitted Resident #83 on 8/1/2024 with medical diagnoses that included Unspecified fracture of the left femur. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/2024 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates Resident #83 was cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to ensure that one (1) of three (3) residents reviewed was free from misappropriation of property, Resident #1. Findings Include: Record review of facility policy titled: Abuse, Neglect, and Exploitation with revised date of 10/10/2022 documented under Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Record review of Administrator statement on facility letterhead documented on August 22, 2023, the following: RE: Allegation of Narcotic Diversion The allegation was made on August 17, 2023, at approximately 2:00pm, that RN (Registered Nurse proper name), RN could have possibly taken resident (proper name) 5mg (milligrams) Percocet while administering her 2pm medication .Upon conclusion of the investigation, on Monday August 21, 2023, the employee was terminated, and the MS Board of Nursing and the Attorney General's (AG) office were notified. The final investigation was sent into the MSDH on 08/22/23. This statement was signed by Administrator. On 08/22/23 at 10:00 AM, an observation and interview with Resident #1 revealed her sitting in her wheelchair in her room with her head and neck positioned slightly forward and she was unable to raise her head upright. Resident #1 revealed that there was a situation last week that happened with her medication. Resident #1 revealed that on 08/17/23, she went up to the Nurse's desk between 1:00 PM and 2:00 PM and asked for her pain medicine and afternoon medicines. Resident #1 revealed that Licensed Practical Nurse (LPN) #1 was her nurse that day, but she (LPN) was busy at the computer, so the Registered Nurse (RN) #1 offered to help, she took the medication cart keys from LPN, and went and got her medicine. Resident #1 revealed that she looked at her medication that was handed to her by RN, and stated to her, Where's my Percocet? Resident #1 revealed that the pain pill she had given her looked like a Tylenol and said, I know what that looks like. Resident #1 revealed that RN told her that sometimes the suppliers change, and the medicine can sometimes come in different shapes and colors. Resident also revealed that she took the Tylenol; but this didn't help with the pain. Resident #1 revealed that she told LPN #1 that she didn't get her Percocet and the LPN went to the Director of Nursing (DON) and reported this, the staff came in to talk to her, and the RN got fired. Resident #1 said, I don't' think she's (RN) mean and tried to withhold it from me; I have no idea what happened to the Percocet. Resident #1 revealed that the Assistant Director of Nursing (ADON) came in and checked on her a little later, the doctor came in to see her and they brought her a Percocet. She revealed that she had a lot of pain issues and had to have her pain medication and she was familiar with what it looked like. On 08/22/23 at 10:35 AM, an interview with LPN #1, revealed that on 08/17/23 at 1:30 PM, she was sitting at the desk updating doctors' orders when Resident #1 walked up to the desk using her rollator walker and asked for her 2:00 PM medications. LPN revealed that RN #1 was the Unit Manager that day, offered to get the medications for Resident #1 and brought Resident #1's pills to her in a medication cup. LPN #1 revealed that a couple minutes later, Resident #1 asked where her Percocet was, and she witnessed RN #1 point to the oval white pill in the cup and proceeded to tell her that Percocet comes in different shapes and sizes. LPN #1 revealed that this threw up a red flag to her because she identified the white pill as a Tylenol because it was white and oval shaped. She revealed that she reported this immediately to the DON. LPN #1 revealed that she and RN #1 then counted the entire cart, and a Percocet was missing from the Resident's drug card and had been signed out by RN #1; but was not in Resident #1's cup. LPN #1 stated, I would recognize it, because I have been giving it to her on a regular basis. She revealed that Resident #1 was concerned that her medications were wrong, and she was assured by LPN #1 that it would be taken care of. LPN #1 revealed that the Percocet was the same shape, size and color as before which was a round white pill and it had been signed out of the Narcotic book; but had not been signed off on the Medication Administration Record (MAR). On 08/22/23 at 2:20 PM, a phone interview with the DON, revealed that last Thursday, August 17, 2023, LPN #1 had reported to her that she was afraid that RN #1 had taken Resident #1's Percocet. DON revealed that LPN #1 had reported to her that resident had walked up to the nursing station and asked for her 2:00 PM medications, and RN #1 offered to help and took the medication cart keys and gave resident her medications. DON revealed that LPN #1 had told her that she didn't see the Percocet in the medication cup, that she saw what looked like a Tylenol. The DON revealed that she, LPN #1, and RN #1 went immediately and completed a narcotic count, and she sent out a message to the ADM and ADON for an emergency meeting. DON revealed that when ADM arrived back at the facility, they looked at surveillance camera footage and saw suspicious activity on the video footage with RN#1. She stated that RN #1 shuffled her hands back and forth with the Percocet in her hand, turned the medication cup upside down in her hand and clenched her fist closed and threw the medication cup in the trash can. DON stated that when they interviewed RN #1 that she denied the allegation, and told them that she put Resident #1's Tylenol in one medication cup and put the Percocet and other scheduled medications in a second medication cup. RN #1 revealed that Resident #1 had refused the Tylenol, so she gave her the cup of pills and threw the Tylenol in the trash. DON revealed that they looked through all trash bags and could not find any medication. The DON revealed that they had RN #1 do a urine drug screen and she tested positive for Oxycodone, Benzos, and Amphetamines. RN #1 had informed DON that she had taken an oxycodone on Monday night, 08/14/23 but did not have a prescription for it. The DON revealed that they reported this to the Attorney General's Office and to the Mississippi State Board of Nursing on 08/21/23. On 08/22/23 at 3:50 PM, a phone interview with RN #1, revealed that on 08/17/23, she was asked to give Resident #1 her 2:00 PM medications because LPN #1 was busy. She stated that Resident #1 was very serious about her medications, and she came up to the desk asking for her Percocet and her other scheduled medications and that Resident #1 normally asked for Tylenol as well. She revealed that she pulled her regular medications and put in one medication cup and put her Tylenol in a different medication cup. She revealed that Resident #1 refused the Tylenol and she put the Tylenol in the trash. She stated that she handed the resident her medications, left the med cart, and went into the break room to get her coffee and then returned to the nursing station. She then revealed that Resident#1 came up to the nursing station and questioned whether she got her Percocet, and I pointed it out to her in the cup. She stated that she was required to take a drug test and it was positive for opioids; but she had taken an oxycodone on Monday night from her family member's bottle. She also revealed that the next day on 08/18/23, she went to Urgent Care and had another drug screen and results were negative. RN stated, I did not take the Percocet. Record review of Resident #1's Controlled Drug Record was documented that RN #1 signed out an Oxycodone/Apap tablet 5-325 mg on 08/17/23 at 1:30 PM. Record review of Daily Staff Roster dated 08/17/23 revealed that RN #1 was B-Unit Manager, and that LPN #1 was B Unit Nurse. Record review of Employee Timecards revealed that RN#1 was working on 08/17/23 with start time of 7:21 AM and a stop time of 4:57 PM. Record review of Employee Timecards for LPN #1, revealed that she was working on 08/17/23 with start time of 6:32 AM and stop time of 6:49 PM. Record review of Facility Investigation documented that the allegation was reported to the Mississippi Board of Nursing and confirmation was received on August 21, 2023, at 3:44 PM. Record review also revealed that RN #1 was terminated on 08/21/23 at approximately 4:30 PM by phone call from ADM with DON as witness to the conversation. Record review of Resident #1's Face Sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses to include: Conversion disorder with seizures or convulsions, Polyneuropathy, Age-related Osteoporosis without current pathological fracture, Other Muscle Spasm, Repeated Falls, Sciatica, left side, Chronic Pain, and Dystonia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/20/23 documented under Section C a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that resident was cognitively intact.

Based on observation, staff interview, physicians' interview, review of the manufacturer's instructions for glucose meter (glucometer), insert for germicidal wipes used at the facility, resident record review, and facility policy review, the facility (a.) failed to ensure nursing staff cleaned and disinfected a multi-use glucometer before and after fingerstick blood glucose testing for three (3) of five (5) sampled residents observed for blood glucose fingersticks, Residents #15, #27, and #122 and (b.) failed to perform proper hand hygiene and glove use for (4) of 5 sampled residents, Residents #15, #27, #122, and #230 and (c.) failed to use a barrier and perform hand hygiene for one (1) of 5 sampled residents observed during blood glucose monitoring for Residents #230. This practice had the potential to affect 32 of 32 residents who received blood glucose monitoring, out of a total of 43 residents with Diabetes. The facility's failure of not following standard precautions for infection control by not disinfecting the glucometer between residents, placed these and other residents who received blood glucose finger sticks (32 total residents out of 42 diabetic residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood-borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 4/6/21 at 7:40 AM, when Licensed Practical Nurse #9 failed to clean and disinfect a multi-use blood glucometer per manufacturer's guidelines before and after use. The facility failed to follow standard precautions of infection control while performing blood glucose finger sticks without cleaning/disinfecting the Glucometer before use between three (3) residents. IJ existed at: 483.80 Infection Prevention & Control CFR (s): 483.80(a)(1)(2)(4)(e)(f) - F 880 - Scope and Severity K The State Agency (SA) notified the Administrator on 4/7/21, at 9:20 AM, of the IJ and provided the Administrator with the IJ Template. An acceptable Removal Plan was received on 4/8/21, in which the facility alleged all actions were completed on 4/8/21, and the IJ was removed as of 4/8/21. The SA validated the Removal Plan and determined the IJ was removed on 4/9/21, prior to exit. The scope and severity for CFR(s) 483.80(a)(1)(2)(4)(e)(f),was lowered from a K to a scope and severity of a E, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled, Surveillance Plan revised date 11/28/2017, revealed . Process Surveillance reviews practices directly related to resident care, to identify compliance with established policies and procedures based on recognized guidelines. Process Surveillance determines for example if the facility has and implements procedures in place to: .b. Use appropriate hand hygiene prior to and after all procedures .h. ensure proper that reusable equipment is appropriately cleaned, disinfected, or reprocessed. Record review of the facility policy titled, Standard Precautions, effective date 9/19/14, revealed It is the policy of (Proper Name of Management Company) facilities to provide patient care services that reflects the Standard Precautions infection control practices when interacting with residents. Standard Precautions components include, but are not limited to, the following: Hand Hygiene . Record review of the facility policy titled Infection Prevention Program, revised date 11/28/17, revealed Education of Staff, Residents and Visitors: Education addressing the principles and practices for the preventing transmission of infectious agents shall be provided to all facility staff, as well as anyone who may have direct or indirect contact with the residents or medical equipment . A review of the Center for Disease Control and Prevention guidelines last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Record review of a policy presented by the facility related to disinfection of equipment titled Infection Control, with a revised date of 11/28/17, revealed, It is the policy of (Proper Name of Management Company) facilities to operate in compliance with Environmental Protection Agency (E.P.A.) guidelines for the management of healthcare associated infections. (H.A.I.) . Procedure: E.P.A. approved products shall be used for disinfecting in the event of H.A.I. Appropriate supplies shall be available in each resident area. The policy did not specifically address the cleaning of glucometers. In an interview on 4/9/21 at 10:30 AM with the Risk Manager stated when asked about a policy on disinfection of equipment policy, This is the disinfection policy. RN #4 presented the policy Infection Control with a revised date of 11/28/17. Resident #122 An observation on 4/6/21 at 7:40 AM, revealed Licensed Practical Nurse (LPN) #9 took the glucometer out of the top drawer of the medication cart and did not disinfect the glucometer. While at the medication cart, LPN #9 did not wash her hands or use hand sanitizer. LPN #9 entered Resident #122's room. LPN #9 performed the blood glucose fingerstick using the EVENCARE G3 meter, placed the meter back on the tray, then removed her gloves while in the resident room and performed hand hygiene. LPN #9 returned to the medication cart, put on gloves, and wrapped the meter in a MAGICARE Premium Alcohol wipe. LPN #9 removed her gloves and did not perform hand hygiene. Record review of Resident #122's Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #122's Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) dated 3/21/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #122 was cognitively intact. Resident #122's Electronic Medical Record (eMAR) for April 2021 revealed a blood glucose documented on 4/6/21 at 7:30 AM and signed by LPN #9. Resident #27 An observation of a blood glucose fingerstick using the EVENCARE G3 meter on 4/6/21 at 10:05 AM, with Resident #27, revealed LPN #9 took the glucometer out of the top drawer of the medication. LPN #9 did not disinfect the glucometer, she did not wash her hands or use hand sanitizer prior to putting gloves on. LPN #9 entered Resident #27's room. LPN #9 performed the blood glucose fingerstick using the EVENCARE G3 meter and placed the meter on the tray. LPN #9 removed her gloves. She did not perform hand hygiene. LPN #9 returned to the medication cart, put on gloves, and wrapped the meter in a MAGICARE Premium Alcohol Wipe. LPN #9 removed her gloves and did not perform hand hygiene. Record review of Resident #27's Face Sheet revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27's MDS with an ARD dated 1/13/21 for revealed a BIMS score of 15 which indicated Resident #27 was cognitively intact. Record review of Resident #27's Administration Record (EMAR) for dated 4/6/21 revealed a documented blood sugar at 10:09 AM. Interview on 4/6/21 at 10:10 AM, with LPN #9 revealed she had not performed any other blood glucose fingersticks since the earlier one on Resident #122. LPN #9 stated that she used the alcohol wipes to disinfect the glucometer because this is how she was oriented when she was hired one month ago. SA asked LPN #9 if she had any other wipes in the cart, and she produced Micro-Kill Germicidal Alcohol wipes that were in the medication cart drawer. When asked what she used the Micro-Kill Germicidal Alcohol wipes for, she stated that she cleans the medication cart off with them when she finishes her medications for the shift. She was asked why she did not use the Micro-Kill Germicidal Alcohol wipes on the glucometer. She stated because they told me to use alcohol wipes and that is why they stay in the top drawer. She was asked who told her to use the alcohol wipes and she stated the supervisor. She stated I do not know her name. She is in one of the front offices, but she is not the Unit Supervisor. Resident #15 An observation of a blood glucose fingerstick using the EVENCARE G3 meter, on 4/6/21 at 8:05 PM, with Resident #15, revealed LPN #10 gathered her supplies to include the glucometer. She did not disinfect the glucometer and did not wash her hands prior to putting on gloves. She entered Resident #15's room and placed the glucometer on the overbed table with no barrier. LPN #10 performed the blood glucose fingerstick using the EVENCARE G3 meter, removed her left glove, and held the meter in her gloved right hand. LPN #10 returned to the medication cart and placed a clean glove on her left hand. LPN #10 got a Micro-Kill Germicidal Alcohol wipe out of the container, using her left hand, and wrapped the meter up. She stated she will leave it wrapped up for two (2) to five (5) minutes. She removed her gloves and did not wash her hands. Review of the Micro-Kill containter label, Directions For Use: Disinfecting: To disinfect hard, non porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface should remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. The label included effective disinfection of 12 Bactericidal and 11 Virucidal pathogens which included [CONDITION(S)] B, [CONDITION(S)] C and [CONDITION(S)] ([CONDITION(S)]). Record review of Resident #15's Face Sheet revealed Resident #15 was admitted to the facility on [DATE]. Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's e-MAR for April 2021 revealed a blood glucose had been obtained for 4/6/21 at 8:00 PM and was initialed by LPN #9. During an interview with LPN#10 on 4/6/21 at 8:10 PM, the SA asked LPN #10 had she used the glucometer prior to this fingerstick and LPN #10 stated, no and that this was the first fingerstick she had done on this shift. The SA asked LPN #10 was the glucometer clean when she removed it from the drawer. LPN #10 stated that she should have cleaned it before using it. She stated she should have washed her hands before and after performing the fingerstick. LPN #10 stated that she was hired in August and completed the new hire videos and computer trainings. LPN #10 stated that she was put with random nurses for orientation to the medication cart and procedures. LPN #10 stated that she was taught to wash her hands, put gloves on, disinfect the glucometer using the Micro-Kill Germicidal Alcohol wipes and keep it wrapped up for two (2) to five (5) minutes, perform the accu-check, disinfect the glucometer, and wash her hands. Resident #230 On 04/06/21 at 08:05 PM, an observation of a bedside fingerstick glucose for Resident # 230 performed by Licensed Practical Nurse (LPN) #1, revealed LPN #1 carried a disinfected glucometer and supplies into the room on a barrier and placed it on the bedside table. LPN #1 wore gloves into the room. She removed the glucometer from the barrier and placed in it on a chair while she performed the fingerstick. LPN #1 did not remove her gloves and perform hand hygiene when she completed the fingerstick blood glucose. With the same gloves on, LPN #1 picked up a pair of pajamas from the bed and held them in her right hand while she administered oral medications to Resident #230. She exited the room, removed her gloves at the medication cart and appropriately disinfected the glucometer with disinfectant wipes and then used hand sanitizer. An interview, on 4/6/21 at 8:15 PM, with LPN #1, revealed that she realized she put the glucometer on the chair and should not have done that. She stated that she contaminated the monitor when she placed it on the chair. She stated she should have removed her gloves when she finished with the fingerstick, because her gloves were contaminated, and she could have spread germs by touching the other things in the room. On 04/08/21 at 09:25 AM, an interview with LPN #2, Infection Preventionist, revealed that staff should remove gloves between procedures and perform hand hygiene. LPN #2 stated that LPN #1 should have removed her gloves when she finished the blood glucose fingerstick and performed hand hygiene before touching anything else because of possible contamination with blood. LPN #2 confirmed the glucometer should always be placed on the barrier. The purpose of the barrier is to prevent contamination of the glucometer. Record review revealed LPN #1 performed a glucometer competency checklist on 11/19/20 with instruction to wash hands following the proper disposal of the used test strip. An interview on 4/8/21 at 11:10 AM with RN #2, Unit Supervisor. RN #2 stated she is responsible for any of the glucometer audits for the nurses and she stated that she does random audits but, she has not had a new nurse on her unit but if she had, that she would do the audit. The SA asked RN #2 if someone failed to wash their hands or disinfectant the glucometer, what could be a concern and RN #2 stated you could take something from one resident to the next resident. RN #2 stated residents do not have their own personal glucometers, unless on isolation. During an interview on 4/9/21 at 10:45 AM with the Corporate Nurse Consultant (CNC) reports her role is to oversee the facility is following State and Federal Regulations. She states that in the past I have discussed ways to do glucometer checks and med pass. I also help with protocols and policies. When asked about any negative outcomes of not washing hands appropriately or not cleaning and disinfecting the glucometer the CNC stated, We expect the Director of Nurses (DON) and Infection Preventionist (IP) to carry out task. It's an infection control issue. When asked about nurses following policies that had been implemented by the facility the CNC confirmed nurses should follow the established policies. During an interview with on 4/9/21 at 11:00 AM, with the Director of Nurses, (DON) stated there were no infections in the facility. The DON reports that when a nurse is hired, they are trained during orientation on medication pass and glucometer checks, then that is validated by a preceptor. The competencies should be completed within the same month. She stated when asked about the outcome of not properly cleaning the glucometer, There would be a risk for transmission of infection from resident to resident. She further reports that hand hygiene should be used before entering the resident's room and when completing a task and gloves are supposed to be worn with any risk of coming into contact with bodily fluids. When asked about in-services on infection control the DON reports that in-services are done Quite frequently. They do audits annually and also do weekly and monthly audits. We completed a skills fair in November. The DON reports that nurses should be following CDC (Centers of Disease Control) guidelines when cleaning glucometers. During an interview with the Facility Administrator on 4/9/21 at 11:50 AM, stated when asked should nurses clean the glucometer according to established guidelines, she stated, Yes they should be following CDC guidelines. It was a deficient practice. I don't argue it's a deficient practice. She further stated, I'm know I'm responsible to see there are people to follow the guidelines. I know it all sets with me. During an interview with Resident # 122's primary Physician on 4/9/21 at 3:45 PM, when asked if he was aware of an issue with the facility related to glucometer cleaning. The Physician reports he was aware. When asked about negative outcomes he reports it's an infection control issue. It's unfortunate. During an interview with the Medical Director, on 4/9/21 at 4:05 PM, when asked what a negative outcome would be if nurses did not properly clean the glucometer, the Medical Director stated, If they didn't clean it at all, blood could potentially come in contact with the nurses' gloves and get on the glucometer. It could be a blood borne pathogen hazard, it's infection control. A review of the Manufacturer's User Guide for the EVENCARE G3 glucose monitor (used by the facility), revealed under section titled Cleaning and Disinfecting Procedures for the Meter the meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA registration # -8) [MEDICATION(S)] Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA registration # -10),Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA registration -12), [MEDICATION(S)] Micro-Kill Bleach Germicidal Bleach Wipes (EPA registration # -1). A review of the manufacturer's package of MAGICARE PREMIUM DISINFECTING WIPES (used by the facility in the deficient practice) revealed the ingredients are 75% alcohol and water. Review of an untitled document on facility letterhead provided by the facility dated 4/8/21 and signed by the Administrator revealed, Prior to April 7, 2021 (proper name of facility) did not have a policy to clean glucometers. Record review of a typed statement on facility letterhead dated April 9,2021, revealed This facility does not have a specific policy on hand washing and gloves. We follow CDC guidelines. The document was signed by the Facility Administrator. Record review of a document typed by the facility dated 4/9/21 Diabetic Residents at OHRrevealed there were 42 resident names listed on the diabetic list. Another list provided by the facility Diabetic Residents at [NAME] with Blood Sugar Checks revealed 32 residents receive blood sugar checks. Record review of a typed statement from LPN #2, Infection Preventionist, revealed that during the week of the annual survey, there was zero residents in the facility that had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an Inservice Attendance Record dated 3/12/21 with an attached agenda included handwashing/infection. LPN#9 or LPN#10's names were not listed as having attended the in-service. Record review of an Inservice Attendance Record dated 3/31/21 with a brief description of the in-service revealed Glucometer check off regarding cleaning-disinfecting & proper procedure checking blood sugars. LPN #1, LPN #9 and LPN #10's names were listed as an attendees. Record review of LPN #10's Licensed Nurse Competency dated 8/24/20 revealed LPN #10 had a check mark under Basic Nursing Skills- Capillary blood glucose with a completion date listed as 8/26/20 and under Medication Management- Glucometer checks with a completion date listed as 8/27/20 Record review of a Glucometer Competency Checklist dated 9/13/20 revealed LPN #10 had Yes marked under each skill observed and documentation indicated, Nurse Passed Competency Check -Yes. Record review of LPN#9 Licensed Nurse Competency dated 3/1/21 revealed LPN #9 had a check mark under Basic Nursing Skills- Capillary blood glucose and under Medication Management-Glucometer checks with a completion date listed as 3/1/21. Record review of the General Orientation Checklist dated 3/1/21 for LPN # 9 revealed General Purpose: This check list outlines the information, which new employees will want to become familiar with during his/her introduction period. The orientation checklist included, Infection Control. Record review of a Glucometer Competency Checklist dated 3/10/21 and 4/8/21 revealed LPN #9 had Yes marked under each skill observed and documentation indicated, Nurse-Passed Competency Check -Yes. The facility provided an acceptable Removal Plan for the IJ on 4/8/21. Review of the facilitys Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan The facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcome. On 04/06/21, a licensed nurse cleaned the glucometer with a 75% alcohol [NAME] care disinfectant wipe. The facility failed to properly clean a glucometer and disinfect the multi-patient resident use glucometer (Evencare G3 meter) per Environment Protection Agency (EPA) registered disinfectant observed for Resident #15, Resident #27, and Resident #122. This nurse was previously in-serviced on March 31, 2021. She completed her competency with accuracy by using the appropriate EPA approved disinfectant wipe. Each unit manager conducted a physical assessment on all residents that have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Thirty-six (36) residents have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. All [NAME] wipes were removed immediately from all medication carts and supply rooms on April 7,2021 and were replaced with EPA approved wipes per manufacturer's instructions. All Glucometers were cleaned with EPA approved wipes. The facility has a total of 12 multi patient glucometers in use. 3. An Emergency QA meeting was conducted on 04/07/21 at 10:00 AM with the following: Medical Director, Nurse Practitioner, DON, Infection Preventionist, QA nurse, Administrator and ADON on the Immediate Jeopardy and removal plan for proper cleaning of glucometers. Immediately, a directive in-service began and was conducted by RN #1 and RN #2 for all Licensed Nurses on proper disinfection on glucometer check with return demonstration. Neither of these individuals are employees of this facility. The following topics were discussed in the QA meeting. a. All diabetic residents at risk to suffering adverse outcomes b. Removal of [NAME] care wipes from all medication carts c. Directive in-services for all licensed nurses d. Policy revision on Glucometer Disinfection. 4. A Directive in-service began on 04/07/21 being conducted with all Licensed nurses by RN #1 and RN #2. The in-service consists of appropriate technique, including a return demonstration on properly cleaning and disinfection glucometers before and after each use. All nurses will be educated prior to their next shift and no staff will be allowed to work until properly in-serviced. A total of 41 out of 57 nurses have been in-serviced at this time. Facility asserts that it is in compliance on April 8, 2021 at 10:00 AM. On 4/9/21, the SA validated the facility's Removal Plan through observation, staff interviews, record reviews, and review of in-service sign-in sheets. The SA verified the facility had implemented the following to remove the IJ: 1. Interview with the DON and Nurse Practitioner revealed that the thirty-six (36) residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Observation of all medication carts verified that all [NAME] wipes were removed immediately from all medication carts and supply rooms on April 7,2021 and were replaced with EPA approved wipes per manufacturer's instructions. Interview with the DON revealed all Glucometers were cleaned with EPA approved wipes. The facility has a total of 12 multi patient glucometers in use. 3. Interview with the DON, Nurse Practitioner and Administrator and record review of the sign-in sheets revealed an Emergency QA meeting was conducted on 04/07/21 at 10:00 AM with the following: Medical Director, Nurse Practitioner, DON, Infection Preventionist, QA nurse, Administrator and ADON on the Immediate Jeopardy and removal plan for proper cleaning of glucometers. The following was discussed: All diabetic residents at risk to suffering adverse outcomes, Removal of [NAME] care wipes from all medication carts, Directive in-services for all licensed nurses, Policy revision on Glucometer Disinfection. Immediately, a directive in-service began and was conducted by RN #1 and RN #2 for all Licensed Nurses on proper disinfection on glucometer check with return demonstration. 4. Interview with the DON and eight nurses and record review of the sign-in sheets revealed a Directive in-service began on 04/07/21 being conducted with all Licensed nurses by RN #1 and RN #2. The in-service consists of appropriate technique, including a return demonstration on properly cleaning and disinfection glucometers before and after each use. All nurses will be educated prior to their next shift and no staff will be allowed to work until properly in-serviced. A total of 41 out of 57 nurses have been in-serviced at this time. The SA validated that all corrective actions to remove the IJ had been completed as of 4/8/21, and the IJ was removed on 4/9/21, prior to exit.

Based on therapist interview, record review, facility's policy and manufactures instructions, the facility failed to ensure Resident #4's care plan was updated to address the resident's baseline setting as guidance relate to the pervious electrical stimulation treatments for one (1) of five (5) residents reviewed. Findings include: Review of the facility policy entitled "Comprehensive Plan Of Care" Effective 10/27/14 revealed, "The plan of care will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the resident's ability to meet his/her objectives". Review of the manufactures instructions "Electrotherapy (Electrical Stimulation)" 2008 revealed, on page 8, "[MEDICATION NAME] placement and stimulation settings should be based on the guidance of the prescribing practitioner." Review of Resident #4's Care Plan for Potential for Impaired Skin Integrity revealed "Therapy to check electro-nerve stimulator for proper functioning and notify nurse immediately if resident c/o (complained of) pain/burning when electro-nerve stimulator is in use" role responsible was listed as PT (Physical Therapy). There was no documented evidence the PT notified the nurse after resident's complaints of pain on 3/6/15. There was no documented evidence of the electrical stimulation baseline setting as guidance from previous electrical stimulation treatments. An interview on 4/9/15 at 5:35 PM with Resident #4 revealed the resident reported the electrical stimulation on 3/6/15 was turned up too high and caused pain [MEDICAL CONDITION] therapy. The resident stated, "l told the female (Occupational Therapist Assistant) OTA the electrical nerve stimulation was burning and hurting. The OTA stated she was unable to remove the [MEDICATION NAME] during treatment and she would get the therapist. The male therapist reported I had only 20 seconds left for treatment. I told him I was burning and in pain and wanted the treatment to stop. The male therapist later removed the [MEDICATION NAME]. I was still burning and in very much pain when I returned to my room, then I told the RN (Registered Nurse) about it." On 4/10/15 at 11:00 AM, an interview with the Physical Therapist (PT) revealed Resident #4 was assigned to his/her workload. Record review with PT revealed there was no documented evidence of the electrical stimulation settings during Resident #4's treatment on 3/6/15 and no baseline setting as guidance from pervious electrical stimulation treatments. Review of the Accident/Incident Report for Resident #4, dated 3/6/15 at 4:45 PM,revealed "Resident reported to this nurse that (his/her) back/buttock was burning. This Nurse assess resident and noted 4 dime size redden areas. Resident reported that electrical nerve stimulation was high and therapy staff turns down it continued to burn staff turn off machine due to only 20 sec left." Review of the facility's "Skin/Wound QI Log" dated 4/8/15 revealed the following right buttocks 2nd degree burn measurments: Wound 1 was five (5.0) centimeter (cm) X 5.0 cm X 0.0 cm Wound 2 was 5.0 cm X 1.0 cm X 0.0 cm Wound 3 was 1.0 cm X 1.5 cm X 0.0 cm. Review of the nurse practicioner's progress note dated 3/22/15 revealed a [DIAGNOSES REDACTED]. Review of the physician's progress note dated 3/24/15 revealed a [DIAGNOSES REDACTED]. The facility admitted Resident #4 on 4/29/14, with [DIAGNOSES REDACTED].

Based on observation, resident interview, staff interview, therapist interview, record review, manufacturer's instructions, and policy review, the facility failed to ensure Resident #4 was free [MEDICAL CONDITION] painful injuries during the physical therapy electrical stimulation treatment on 3/6/15 for one (1) of five (5) residents reviewed. Findings include: Review of the manufacturer's instructions for the (Electrical Stimulation) Therapy System dated 2008 revealed, on page 8, "Adverse Effects: Skin irritation [MEDICAL CONDITION] the [MEDICATION NAME] have been reported with the use of powered muscle stimulators. Potential adverse effects with TENS (Transcutaneous electrical nerve stimulation) are skin irritation and [MEDICATION NAME] burns." On page 32 the instructions state, "Check the [MEDICATION NAME] contact regularly during the treatment." Review of the therapy department policy titled, "Electrical Stimulation Policy and Procedure", revised 5/1/13 and stamped with the facility name, read, "Adjust frequency based on treatment protocol and patient tolerance. Frequently ask patient for verbal feedback for over intense sensation or if sensation is not matching intensity. Stop treatment at any point that patient perception of level is out of line and perform sensory testing to assess safety of modality use. Examine skin after treatment is complete and [MEDICATION NAME] are removed." Review of Resident #4's Accident/lncident Report dated 3/6/15 at 4:45 PM revealed "Resident reported to this nurse that (his/her) back/buttock was burning. This Nurse assess resident and noted 4 (four) dime size redden areas. Resident reported that electrical nerve stimulation was to (too) high and therapy staff turn down. It continued to burn. Staff turn off machine due to only 20 sec left." On 4/9/15 at 5:35 PM during an interview, Resident #4 reported on 3/6/15 during therapy treatment, the electrical stimulation was turned up too high and caused pain and burns. The resident stated, "l told the female (Occupational Therapist Assistant) OTA the electrical nerve stimulation was burning and hurting. The OTA stated she was unable to remove the [MEDICATION NAME] during treatment and she would get the therapist. The male therapist reported I had only 20 seconds left for treatment. I told him I was burning and in pain and wanted the treatment to stop. The male therapist later removed the [MEDICATION NAME]. I was still burning and in very much pain when I returned to my room, then I told the RN (Registered Nurse) about it." Resident #4's Progress Note by the Nurse Practitioner, e-signed on 3/8/15 at 7:36 PM, revealed the "Nurse requests visit r/t (related to) patient received a burn to her lower back yesterday while using (electrical stimulation) at therapy. Exam: Lower back with 3 small areas (dime-size) on right side and one small area on left lower back. Diagnosis & Assessment: Electrical burn." lnterview on 4/10/15 at 10:30 AM with the Director of the Therapy Department/Occupational Therapist revealed the Occupational Therapist Assistant (OTA) made him/her aware of Resident #4's complaint of burning and discomfort during treatment on 3/6/15. The Director stated, "l turned the electrotherapy setting down and continued Resident #4's treatment with only 20 second of treatment left." After the resident's treatment, the assigned Physical Therapist (PT) removed the [MEDICATION NAME]. Resident #4's name was on the plastic bag with four (4) [MEDICATION NAME] that were reused during the resident's electrical stimulation treatments. After being made aware of the resident's burn wounds on 3/9/15, the [MEDICATION NAME] were discarded. Record review with PT revealed there was no documented evidence of the electrical stimulation settings during Resident #4's treatment on 3/6/15 and no baseline setting as guidance from previous electrical stimulation treatments. Record review revealed there was no documented evidence that the facility therapist staff stopped the treatment and checked Resident #4's skin and the [MEDICATION NAME] contact when the resident complained of burning/pain during the electrical nerve stimulation treatment on 3/6/15. Observation on 4/9/15 at 5:30 PM with Register Nurse (RN) of Resident #4's wounds revealed two (2) dime size wounds with a scab on the right lower back area and 1 dime size wound on the right mid-upper gluteal region with a small amount of reddish drainage noted. lnterview with the RN revealed the burn wounds were now being treated with [MEDICATION NAME] three times daily. According to the facility's "Skin/Wound QI Log" dated 4/8/15 the [MEDICAL CONDITION] documented as 2nd [MEDICAL CONDITION] the following measurments: Wound 1 was five (5.0) centimeter (cm) X 5.0 cm X 0.0 cm Wound 2 was 5.0 cm X 1.0 cm X 0.0 cm Wound 3 was 1.0 cm X 1.5 cm X 0.0 cm. Review of the nurse practicioner's progress note dated 3/22/15 revealed a [DIAGNOSES REDACTED]. Review of the physician's progress note dated 3/24/15 revealed a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. On 3/13/15, the facility received a new order for [MEDICATION NAME] Cream to lower back and right [MEDICAL CONDITION] times a day (TID). The facility received an order adding wound guard with the [MEDICATION NAME] on 3/25/15. The facility admitted Resident #4 on 4/29/14, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 1/13/15 revealed Resident #4's "Brief lnterview for Mental Status (BIMS) Summary Score" was coded "13" which indicated the resident was cognitively intact.

Based on observation, staff interview, record review and facility policy review the facility failed to administer pain medications as ordered by the physician during wound care for one (1) of eight (8) resident's records reviewed for pain resulting in the resident yelling and grimacing during wound care. (Resident #1) Findings Include: Review of a standard of practice entitled, "Wound Care Essentials: Practice Principles", published in 2008 by Lippincott, Williams, and Wilkins, explained, "The goal of pain management in the pressure ulcer patient is to eliminate the cause of pain, to provide [MEDICATION NAME], or both." Review of the facility's policy entitled, "Pain Protocol Policy", read, "It is the policy of this facility that the pain protocol will be as follows: Complete PRN (as needed) Medication Sheet on all residents requiring PRN pain medication; Following the administration of the pain medication; To document PRN medication; To follow up on results of PRN pain medication." Also reviewed the facility policy entitled, "PRN Medication Policy", undated, stated, "It is the policy of this facility that PRN Medications will be given as follows: For the reason specified in the order". Record Review revealed Resident #1 had a physician's orders [REDACTED]. The physician's orders [REDACTED].#7 on 03/10/14 at 5:52 PM. Interview with Licensed Practical Nurse (LPN) #6 at 11:20 AM on 03/19/14 confirmed Resident #1 experienced pain during wound care of a Stage 3 pressure sore and pain meds were usually given before the treatment. LPN #6 stated she told the resident's med nurse (LPN #7) to give her PRN pain medication. LPN #6 said LPN #7 stated the resident did not have but one tablet left and Resident #1 usually gets two tablets. LPN #6 told LPN #7 to check the Emergency Drug Kit (EDK) and LPN #7 said there wasn't any [MEDICATION NAME]. LPN #6 confirmed the physician was not called for an alternate order for pain medication. Interview with LPN # 7 on 03/19/14 at 11:50 AM confirmed that Resident #1 had an order written [REDACTED]. LPN #7 stated at 11:55 AM on 03/19/14 that she checked the EDK (Emergency Drug Kit) for the availability of the medication ([MEDICATION NAME]). Upon observation at that time with surveyor revealed that there was a quantity of ten (10) [MEDICATION NAME] 5/325 mg tablets in the EDK, LPN #7 admitted she did not actually look at the EDK to check if medication was available to administer to Resident #1. LPN #7 also confirmed that the [MEDICATION NAME] 7.5/325 had not yet been ordered from the pharmacy. Observation of Resident #1's Stage 3 pressure ulceration to the right hip on 03/19/14 at 11:20 AM revealed Resident #1 had facial grimacing and yelled out, "Oh God, Oh God", when LPN #6 cleansed the wound with saline soaked gauze. Resident #1 also had facial grimacing and yelled, "Oh girl, Oh God", when the wound bed was measured with a wooden cotton tip swab. Resident #1 was admitted to the facility on [DATE] with diagnosis, which included [MEDICAL CONDITIONS] and Hypertension. Most recent assessment dated [DATE] of Brief Interview for Mental Status (BIMS) was rated a seven (7), indicating Resident #1 had moderate cognitive impairment.

Based on observation, staff interview, facility policy review, and record review, the facility failed to follow the care plan related to pain medication administration for one (1) of 19 residents care plans reviewed. (Resident #1) Findings Include: Review of the facility's policy entitled, "Total Care Plan Policy", undated, failed to address following the plan of care for the resident. Record review revealed a care plan for Resident #1, with a problem onset date of 01/28/14, for Potential for Pain. The goal was listed as pain will be lessened with medication and staff intervention. The interventions included monitor for S/S (sign and symptoms) of pain-facial grimacing, restlessness, changes in vital signs, and administer medication as ordered. Interview with LPN #8 on 03/21/14 at 2:55 PM confirmed a care plan was put into place because Resident #1 was experiencing pain due to contractures and experiencing pain during wound care. LPN #8 confirmed the care plan was current and was the care plan staff should have followed for the resident's care. Observation of Resident #1's Stage 3 pressure ulceration to the right hip on 03/19/14 at 11:20 AM revealed Resident #1 had facial grimacing and yelled out when the Stage 3 pressure wound bed was touched and calmed quietly after LPN #6 stopped touching the wound bed. Resident #1 was admitted to the facility on [DATE] with diagnosis, which included [MEDICAL CONDITIONS] and Hypertension. Most recent assessment dated [DATE] of Brief Interview for Mental Status (BIMS) indicated cognition was rated a seven (7), indicating Resident #1 had moderate cognitive impairment. Review of the Minimum Data Set (MDS), dated [DATE], showed pressure ulcer and pain had triggered on the Care Area Assessment (CAA).

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement measures to prevent pain during wound care for one (1) of seven (7) residents reviewed for pressure sores. (Resident #1) Findings Include: Review of the facility's policy entitled, "Pain Protocol Policy", stated, for Moderate Pain and Severe Pain, "Administer PRN (as needed) pain medications as ordered". "It is the policy of this facility that the pain protocol will be as follows: Complete PRN (as needed) Medication Sheet on all residents requiring PRN pain medication; Following the administration of the pain medication; To document PRN medication; To follow up on results of PRN pain medication." Also reviewed the facility policy entitled, "PRN Medication Policy", undated, stated, "It is the policy of this facility that PRN Medications will be given as follows: For the reason specified in the order." Review of the facility's policy, dated 04/10/13, entitled, "treatment of [REDACTED]. [REDACTED]." Observation of Resident #1's treatment of [REDACTED].#1 had facial grimacing and yelled out, "Oh God, Oh God", when Licensed Practical Nurse (LPN) #6 began to cleanse the wound with saline soaked gauze. Resident #1 also had facial grimacing and yelled, "Oh girl, Oh God", when the wound bed was measured with a wooden cotton tip swab. The observation noted Resident #1 calmed quietly after LPN #6 stopped touching the wound bed. Interview with LPN #6 at 11:20 AM on 03/19/14 confirmed Resident #1 was yelling and grimacing and appeared to experience pain. LPN #6 stated, "Usually we give her pain meds before, but I told her med (medication) nurse to give it to her and she said they didn't have but one (1 tablet) left and she usually gets two (2 tablets). I told her to check the EDK and she (med nurse) said there wasn't any in there, so no she (Resident #1 didn't get any (pain medication)." LPN #6 confirmed she felt the resident was in pain due to the yelling when the wound bed was touched. LPN #6 confirmed the physician was not called for an alternate order for pain medication. Record Review of the "Daily evaluation of Skin Ulcers", dated 03/19/14 revealed LPN #6 documented Resident #1 experienced pain during the treatment. Interview with LPN #7 on 03/19/14 at 11:50 AM confirmed Resident #1 had orders dated 03/10/14 by the attending physician for [MEDICATION NAME] 5/325 two (2)tablets every four (4) hours as needed (PRN) for pain and [MEDICATION NAME] 7.5/325 one every 4 hours as needed when [MEDICATION NAME] out for chronic pain. LPN #7 stated at 11:55 AM on 03/19/14 that she checked the Emergency Drug Kit (EDK) for the availability of the medication ([MEDICATION NAME]). Observation at that time with surveyor revealed there was a quantity of ten (10) [MEDICATION NAME] 5/325 mg tablets in the EDK. LPN #7 stated, "They're usually not any in there", and admitted she did not actually look at the EDK to check if the medication was available to administer to Resident #1. LPN #7 also confirmed the [MEDICATION NAME] 7.5/325 had not yet been ordered from the pharmacy and stated, "I will send the new order to the pharmacy now". Resident #1 was admitted to the facility on [DATE] with diagnosis, which included [MEDICAL CONDITIONS] and Hypertension. Most recent assessment dated [DATE] of Brief Interview for Mental Status (BIMS) indicated cognitive decision making skills were rated a 7, indicating Resident #1 had moderate cognitive impairment. This MDS Also coded under Section J, "1. Yes" for "Pain; received PRN pain medication".

Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of four (4) residents, Resident #1, was not neglected as evidenced by failure of facility staff to transfer Resident #1 with assistance of two (2) staff members and the total mechanical lift as required by Resident #1's assessment and care plan. Resident #1 was diagnosed with [REDACTED].#1 by herself. It was determined that CNA #2 had also transferred Resident #1 with the use of the mechanical lift by herself three (3) times on 7/20/13. Findings include: Observation on 8/15/13 at 5:00 p.m. revealed Resident #1 was in a Broda Chair with an immobilizer on the left leg. Resident #1 was alert and confused. There were no bruises or skin tears to the exposed skin. CNA #3 and CNA #4 transferred Resident #1 from the Broda chair to the bed with the total mechanical lift and small criss-cross sling. Fracture bars were used. Both CNA #3 and CNA #4 stated that two (2) people were required to assist when the total lift was used and the Activity of Daily Living (ADL) care plan was to be followed. Observation of the door panel to Resident #1's room on 8/15/13 at 5:00 p.m. revealed a yellow sticker with "T2/R2" and "Fx bars" documented on the panel along with a green dot. The Director of Nursing was present and stated that "T2" represented the total lift with two (2) person assist, the "R2" represented that the resident required two (2) persons with repositioning and the green dot was full code status. Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/13 revealed that Resident #1 required total assistance of two (2) persons with transfers. Review of Resident #1's care plan dated 4/22/11 with a review date of 6/5/13 revealed that Resident #1 required the total lift for transfers and two (2) staff assistance with all ADLs due to behaviors such as pulling away or pushing away from staff during care. Review of the "Resident ADL Record & Care Plan" dated June 2013 revealed that Resident #1 required the total lift with assistance of two (2) CNAs. Review of a nurse's note, dated 7/27/13 at 6:00 p.m., revealed Resident #1 was in bed with swelling noted to thigh extending to foot with internal rotation noted to the leg. Slight discoloration observed to the inside thigh which measured 8.0 x 8.0 centimeters (cm) and the extremity warm to touch. Resident yells out when leg touched and repositioned. The physician was notified and the Responsible Party (RP) was in the room. Resident #1 was transferred to the emergency room at 6:32 p.m. Review of a nurse's note dated 7/27/13 at 9:40 a.m. revealed that Resident #1 was admitted to the hospital with [REDACTED]. Interview with Certified Nurse Aide (CNA) #1 on 8/16/13 at 9:47 a.m. revealed that she had transferred Resident #1 from the Geri-chair to the shower bed (7/27/13) and from the shower bed back to the Geri-chair with the mechanical lift by herself. CNA #1 stated that she'd also transferred Resident #1 from the Geri-chair to the bed around 2:00 p.m. on 7/27/13 and there had been no swelling or bruising of the resident's leg when she had rolled her over to get the lift pad and to clean her up. CNA #1 stated that Resident #1 had not acted any differently, that she had not hollered any more than was ordinary while receiving care. CNA #1 stated that Resident #1's knee might have been a little puffy but thought that was just [MEDICAL CONDITION] that she sometimes gets when sitting up. CNA #1 stated that she had been trained on abuse/neglect and knew that if she didn't follow the rules and care plan that it could be considered neglect. CNA #1 admitted that by not following the care plan for two (2) person assist and the lift for Resident #1 was considered neglect. CNA #1 stated that she had been trained on the use of the lifts and there was always supposed to be two (2) people when the Total lift was used. CNA #1 stated that she had been trained to follow the care plan and that she was aware of the system on the door to determine what lift and assistance was required. CNA #1 stated that she had not gone the nurse (7/27/13) to ask for assistance, but had asked another CNA ,who didn't come, so she decided to go ahead and transfer Resident #1 by herself. CNA #1 admitted to transferring Resident #1 by herself on other occasions when Resident #1's family was in the room. Review of a written statement dated 7/27/13 and signed by Certified Nurse aide (CNA) #1 revealed that she had transferred Resident #1 with a Total lift by herself around 9:00 a.m. (7/27/13) to and from the shower bed and then again at 2:00 p.m. she transferred Resident #1 to bed by herself. Review of a documented statement dated and signed by CNA #1 on 7/29/13 revealed that she knew it was against procedure and policy to put a resident to bed by herself when the order is staff times two (2), but that she had went against policy and operated the lift by herself. Review of a Personnel Action dated 7/27/13 revealed that Ceretified Nurse Aide (CNA) #1 was suspended pending investigation due to failure to follow policy/procedure related to using two (2) staff with the Total lift, related to (Resident #1) with femur fracture of unknown origin. (Personnel file revealed that CNA #1 had been disciplined 4/6/13 for transferring a resident without a lift as ordered). An attempt was made to call Certified Nurse Aide (CNA) #2 on 8/15/13 at 5:30 p.m. without success. Review of a written statement by CNA #1 dated 7/27/13 at 6:23 p.m. revealed that she had started the 3-11 shift and was getting Resident #1 up and noticed that the Resident's knee was swollen and thought that it was from her laying on it, so got her up. CNA #2's statement revealed that when she laid Resident #1 down (after supper) she hooked her up to the lift and laid her back down; when her bottom hit the bed her left leg just went in, so she called the nurse and reported it. Review of the same statement with additional date of 7/28/13 at 10:20 a.m. revealed that CNA #2 used the lift (with Resident #1) and was alone both times. Review of a written statement dated 7/29/13 at 1:36 p.m. and signed by Certified Nurse Aide (CNA) #2, revealed that CNA acknowledged that she was supposed to use a lift with two (2) people and had entered (Resident #1's) room and assisted her to the dining room, having a careless moment. CNA #2 documented that it was hard to find people to help (no documentation that someone was asked to assist). Review of a Personnel Action form dated 7/28/13 revealed that Certtified Nurse Aide #2 was suspended pending investigation due to failure to follow policy/procedure related to using two (2) staff with the Total lift related to (Resident #1) with femur fracture of unknown origin. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/13 at 4:15 p.m. revealed that CNA #2 had reported that something was wrong with Resident #1's leg (7/27/13). LPN #1 stated that she and the supervisor examined Resident #1's leg and noted that her left knee was swollen with no redness or bruising. LPN #1 stated that she lifted Resident #1's leg slightly and there was an area measuring 8.0 centimeters (cm) x 8.0 cm that was discolored and the leg was turned inward. LPN #1 stated that Resident #1 cried, but cries a lot normally. LPN #1 stated that the physician was notified and Resident #1 was sent to the hospital. LPN #1 stated that the CNA had reported using the lift on Resident #1. LPN #1 stated that two (2) staff members were required when using the total lift for safety. LPN #1 stated that no one had come and asked her for assistance that evening. Interview with Licensed Practical Nurse (LPN) #2 on 8/16/13 at 9:00 a.m. revealed that she had helped investigate the incident with Resident #1 (7/27/13 fracture). LPN #2 stated that two (2) CNAs had admitted to transferring Resident #1 by themselves that day per written statements. LPN #2 stated that when she spoke to CNA #2 that she reported while transferring Resident #1 to bed the resident's leg got caught up underneath her body, the CNA straightened her out and then she went to get the nurse. LPN #2 stated that two (2) persons are required for use of the total lift; policy. Interview with Licensed Practical Nurse (LPN) #2 on 8/16/13 at 1:10 p.m. revealed that the interim care plan was initiated and followed until the interdisciplinary care plan was initiated. LPN #2 stated that the CNAs were to follow their Activity of Daily Living (ADL)/Care plan to give care to the residents. LPN #2 stated that she could not find a specific policy to "follow care plan", but that's why the care plan was there (to follow). LPN #2 stated that all staff had been in-serviced on ADL/Care plan at various times. Interview with the Director of Nursing (DON) on 8/15/13 at 4:30 p.m. revealed that she had further investigated Resident #1's fracture of 7/27/13 on the following Monday (7/29/13). The DON stated that both CNA #1 and CNA #2 had been suspended pending investigation as they had transferred Resident #1 with the lift and no assistance (7/27/13). The DON stated that CNA #1 had worked the 7-3 shift and CNA #2 had worked 7-3 and had stayed over to work part of 3-11. The DON stated that she didn't know exactly when or what shift the fracture had occurred but that nothing was apparently wrong on the prior 11-7 shift before 7/27/13. The DON stated that the nurse (LPN #1) was notified around 6:00 p.m. (7/27/13) when CNA #2 said that Resident #1's leg went in when she put her back to bed after supper; (fracture) may have happened at that time. The DON stated that the bottom line was that CNA #1 and CNA #2 both didn't follow the care plan for Resident #1. The DON stated that the unit was not understaffed and there should have been no reason why either could have gotten assistance. Interview with the Director of Nursing (DON) on 8/16/13 at 12:15 p.m. revealed that the policy was for two (2) persons or more for any transfer with the Total lift. The DON stated that there were stickers on the door to determine lift, assistance needed and type of sling to use. The DON stated that all CNAs were checked off on use of the lift and in-serviced for the system in place. Review of the facility's "Abuse, Neglect, or Exploitation Policy", provided by the DON, revealed the definition of neglect as "the failure of a caretaker to supply for the vulnerable adult the food, clothing, supervision, or other services which are necessary to maintain his/her mental or physical health."

Based on observation, interview, record review and policy review, the facility failed to ensure that the care plan was implemented /followed for one (1) of four (4) residents reviewed, Resident #1, as evidenced by two (2) staff members transferred Resident #1 on 7/27/13 at least five (5) different times with a mechanical lift without assistance of another staff member. Resident #1 was assessed and care planned for two (2) person assistance and the mechanical total lift for all transfers. Resident #1 was diagnosed with [REDACTED]. Findings include: Cross refer to F-224 for the facility's failure to follow the care plan for Resident #1 that included the use of two (2) staff members and use of the Total lift for any transfers. Review of Resident #1's care plan dated 4/22/11 with a review date of 6/5/13 revealed that Resident #1 required the total lift for transfers and two (2) staff assistance with all ADLs due to behaviors such as pulling away or pushing away from staff during care. Review of the "Resident ADL Record & Care Plan" dated June 2013 revealed that Resident #1 required the total lift with assistance of two (2) CNAs. Interview on 8/16/13 at 1:10 p.m. with Licensed Practical Nurse (LPN) #2 revealed that the interim care plan was initiated and followed until the interdisciplinary care plan was initiated. LPN #2 stated that the CNAs were to follow their Activity of Daily Living (ADL)/Care plan to give care to the residents. LPN #2 stated that she could not find a specific policy to "follow care plan", but that's why the care plan was there (to follow). LPN #2 stated that all staff had been in-serviced on ADL/Care plan at various times. Review of the facility's "Interim Care Plan Policy", provided by LPN #2 on 8/16/13 at 1:10 p.m., revealed that the interim care plan is utilized to provide guidance to facility staff concerning the resident and his/her care needs until the Interdisciplinary care plan can be developed by day 21. Review of the facility's "Resident ADL Record and Care Plan Policy" provided by LPN #2 on 8/16/13 at 1:10 p.m., revealed that it is the policy of this facility that the Resident ADL Record and Care Plan will be done as follows: On admission and Updated by day 21, when there is a change in the resident's condition, and upon completion of a new MDS (Minimum Data Set).

Based on observation, interview, record review and policy review, the facility failed to provide adequate supervision and monitoring to ensure that accidents did not occur for one (1) of four (4) residents, Resident #1, as evidenced by two (2) staff members were transferring the resident with the total lift by themselves on 7/27/13 for at least five (5) transfers. Resident #1 was diagnosed with [REDACTED]. Findings include: Cross refer to F-224 for the facility's failure to ensure that supervision was in place to ensure that staff transferred residents appropriately with adequate assistance per assessment and care plan. Resident #1 was transferred without the assistance of another staff member as required by the assessment and care plan. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/13 revealed that she required total assistance of two (2) persons with transfers. Review of Resident #1's care plan dated 4/22/11 with a review date of 6/5/13 revealed that Resident #1 required the total lift for transfers and two (2) staff assistance with all ADLs due to behaviors such as pulling away or pushing away from staff during care. Review of the "Resident ADL (Activity of Daily Living) Record & Care Plan" dated June 2013 revealed that Resident #1 required the total lift with assistance of two (2) Certified Nurse Aides. Review of a nurse's note, dated 7/27/13 at 6:00 p.m., revealed Resident #1 was in bed with swelling noted to thigh extending to foot with internal rotation noted to the leg. Slight discoloration observed to the inside thigh which measured 8.0 x 8.0 centimeters (cm) and the extremity warm to touch. Resident yells out when leg touched and repositioned. The physician was notified and the Responsible Party (RP) was in the room. Resident #1 was transferred to the emergency room at 6:32 p.m. Review of a Nurse's Note dated 7/27/13 at 9:40 a.m. revealed that Resident #1 was admitted to the hospital with [REDACTED]. Interview on 8/16/13 at 9:47 a.m. with Certified Nurse Aide (CNA) #1 revealed that she had transferred Resident #1 from the Geri-chair to the shower bed (7/27/13) and from the shower bed back to the Geri-chair with the mechanical lift by herself. CNA #1 stated that she'd also transferred Resident #1 from the Geri-chair to the bed around 2:00 p.m. on 7/27/13 and there had been no swelling or bruising of the resident's leg when she had rolled her over to get the lift pad and to clean her up. CNA #1 stated that Resident #1 had not acted any differently, that she had not hollered any more than was ordinary while receiving care. CNA #1 stated that Resident #1's knee might have been a little puffy but thought that was just edema that she sometimes gets when sitting up. CNA #1 stated that she had been trained on abuse/neglect and knew that if she didn't follow the rules and care plan that it could be considered neglect. CNA #1 admitted that by not following the care plan for two (2) person assist and the lift for Resident #1 was considered neglect. CNA #1 stated that she had been trained on the use of the lifts and there was always supposed to be two (2) people when the Total lift was used. CNA #1 stated that she had been trained to follow the care plan and that she was aware of the system on the door to determine what lift and assistance was required. CNA #1 stated that she had not gone the nurse (7/27/13) to ask for assistance, but had asked another CNA ,who didn't come, so she decided to go ahead and transfer Resident #1 by herself. CNA #1 admitted to transferring Resident #1 by herself on other occasions when Resident #1's family was in the room. Review of a written statement dated 7/27/13 and signed by Certified Nurse Aide (CNA) #1 revealed that she had transferred Resident #1 with a Total lift by herself around 9:00 a.m. (7/27/13) to and from the shower bed and then again at 2:00 p.m. she transferred Resident #1 to bed by herself. Review of a documented statement dated and signed by CNA #1 on 7/29/13 revealed that she knew it was against procedure and policy to put a resident to bed by herself when the order is staff times two (2), but that she had went against policy and operated the lift by herself. An attempt was made to call Certkified Nurse Aide (CNA) #2 on 8/15/13 at 5:30 p.m. without success. Review of a written statement by CNA #1 dated 7/27/13 at 6:23 p.m. revealed that she had started the 3-11 shift and was getting Resident #1 up and noticed that the Resident's knee was swollen and thought that it was from her laying on it, so got her up. CNA #2's statement revealed that when she laid Resident #1 down (after supper) she hooked her up to the lift and laid her back down; when her bottom hit the bed her left leg just went in, so she called the nurse and reported it. Review of the same statement with additional date of 7/28/13 at 10:20 a.m. revealed that CNA #2 used the lift (with Resident #1) and was alone both times. Review of a written statement dated 7/29/13 at 1:36 p.m. and signed by Certified Nurese Aide (CNA) #2, revealed that CNA acknowledged that she was supposed to use a lift with two (2) people and had entered (Resident #1's) room and assisted her to the dining room, having a careless moment. CNA #2 documented that it was hard to find people to help (no documentation that someone was asked to assist). Interview with Licensed Practical Nurse (LPN) #1 on 8/15/13 at 4:15 p.m. revealed that CNA #2 had reported that something was wrong with Resident #1's leg (7/27/13). LPN #1 stated that she and the supervisor examined Resident #1's leg and noted that her left knee was swollen with no redness or bruising. LPN #1 stated that she lifted Resident #1's leg slightly and there was an area measuring 8.0 centimeters (cm) x 8.0 cm that was discolored and the leg was turned inward. LPN #1 stated that Resident #1 cried, but cries a lot normally. LPN #1 stated that the physician was notified and Resident #1 was sent to the hospital. LPN #1 stated that the CNA had reported using the lift on Resident #1. LPN #1 stated that two (2) staff members were required when using the total lift for safety. LPN #1 stated that no one had come and asked her for assistance that evening. Interview with the Director of Nursing (DON) on 8/15/13 at 4:30 p.m. revealed that she had investigated Resident #1's fracture of 7/27/13. The DON stated that both CNA #1 and CNA #2 had been suspended pending investigation as they had transferred Resident #1 with the lift and no assistance (7/27/13). The DON stated that the nurse (LPN #1) was notified around 6:00 p.m. (7/27/13) when CNA #2 said that Resident #1's leg went in when she put her back to bed after supper; (fracture) may have happened at that time. The DON stated that the bottom line was that CNA #1 and CNA #2 both didn't follow the care plan for Resident #1. The DON stated that the unit was not understaffed and there should have been no reason why either could have gotten assistance.

Based record review, staff interview, and policy review, the facility failed to ensure that the the Physician was notified for low and/or high blood glucose levels for 15 of 32 sampled Residents reviewed with the [DIAGNOSES REDACTED]. This is for Resident #1, #5, #7, #11, #14, #22, #23, #26, #34, #36, #40, #41, #42, #43, and #44. There were 59 Residents out of a census of 136 in the facility with the [DIAGNOSES REDACTED]. These actions were determined an Immediate Jeopardy (IJ) at a "K" level on 5/1/12 at 3:55 p.m. The Administrator, Director of Nursing and Nurse Consultant were notified at that time. The Immediate Jeopardy at a "K" level began on 4/17/12 at 5:25 a.m. when Resident #9 was found unresponsive with a blood glucose of 30 mg/dl; was given jelly by mouth; and then identified to have no pulse or respirations. The facility provided a Credible Allegation of Compliance on 5/4/12 at 3:00 p.m. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on 5/4/12 to an "E" level; which constitutes no actual harm. with the potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's " April 2012 DMAR " revealed a blood sugar reading on 4/9/12 at 8:00 a.m. of 30 (mg/dl). There was documentation that Resident #1 was given juice. There was no documentation on the DMAR or the Nurse's Notes that the blood sugar was rechecked. There was no assessment documented in the Nurse's Notes as stated in the Diabetic protocol. There was no documentation that the Physician was notified. Review of Resident #1's April 2012 Physician order [REDACTED].= follow Diabetic Protocol policy; 61-150 =0U; 151-200 = 3U; 201-250 = 5U; 251-300 =8 U; 301-350 = 10U; 351-400 = 12U; >400 = 15U; recheck BS in 4 hours; Follow S/S Guidelines for BS >200- call MD if BS over 400 on the second check ... " with the original order " dated 4/10/10 " . Interview on 5/4/12 at 4:50 p.m. with the ADON confirmed that there was no documentation that the Diabetic Protocol was followed for treatment of [REDACTED]. Resident #5 Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the April 2012 physician's orders [REDACTED]. Review of Resident #5's April 2012 Physician's monthly orders revealed an order originating on 1/7/11 for "Accu Checks (blood glucose levels) to be done AC (before meals) & (and) HS ( hour of sleep), cover w/ [MEDICATION NAME] Insulin per S/S (sliding scale): 0-60 mg/dl = Follow Diabetic Protocol Policy. 61 - 150 = 0 units; 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; greater than 400 = 15 units; recheck in four (4) hours. Follow Sliding Scale guidelines for blood sugar greater than 200. Call MD if blood sugar is over 400 on the second check." A review of Resident #5's March 2012 DMAR revealed that there was no documentation for the 6:30 a.m. blood glucose testing on 3/26/12. Review of Resident #5's March 2012 Diabetic Record, MAR and Nurse's Notes on 3/26/12 revealed that there was no documentation of the 6:30 a.m. blood glucose result. The March 2012 physician's orders [REDACTED]. A review of Resident #5's February 2012 DMAR revealed an Accu Check with a blood sugar of 155 mg/dl on 2/21/12. There was no documentation of the Sliding Scale insulin dose being administerd. The February 2012 physician's orders [REDACTED].=3U. Review of Resident #5's February 2012 DMAR revealed that there was no documentation of the [MEDICATION NAME] Insulin 3 U sliding scale dose being administered. Review of the Nurse's Notes 2/15/12 through 2/27/12 revealed that there was no documentation of the Accu Check results or the 3 U of [MEDICATION NAME] Sliding Scale Insulin administration. There was no indication in the Nurse's Notes regarding notifying the Physician of holding insulin dosages. Review of Resident #5's January 2012 DMAR revealed that there was no blood glucose results documented on 1/2/12 at 6:30 a.m. Review of Resident #5's January 2012 DMAR and physician's orders [REDACTED]. dated 12/17/11 through 1/18/12 revealed that there was no documentation of the 1/7/12 6:30 a.m. blood glucose level. There was no indication in the Nurse's Notes that the Physician was notified or why the glucose was not tested . Interview on 5/2/12 at 1:45 p.m. with Licensed Practical Nurse (LPN) #22 revealed that she received an in-service regarding the facility's new Hypoglycemic Protocol this morning (5/2/12). LPN #22 reported that she usually works the C Hall on the 7:00 a.m. to 3:00 p.m. shift. LPN #22 reported that the previous protocol stated if the Accu Check is less than 60 mg/dl you treat it with one (1) glass of sweetened orange juice. Wait 15 minutes and recheck. If the blood sugar was still less than 60 mg/dl, give the Glucose Gel; if the resident is conscious or the [MEDICATION NAME] one (1) milligram (mg.) injection if the resident is not conscious, re-check the blood sugar in 15 minutes. If it was still less than 60 mg/dl, notify the physician. LPN #22 reported that all this information was supposed to be documented in the Nurse's Notes. Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the April 2012 physician's orders [REDACTED]. Cover with [MEDICATION NAME] Insulin per sliding scale. 0 - 150 = 0 units; 61 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units. > or over 400 = 15 units. Recheck blood sugar in four (4) hours. Follow s/s guidelines for BS > 200. Call MD if BS over 400 on second check." Resident also had orders stating to administer Insulin with meals or 15 minutes before. Do not give extra insulin on follow up after high before meals reading. Administer [MEDICATION NAME] 3 units after lunch plus sliding scale if consumed less than 50 % of lunch, hold insulin. Give 10 units [MEDICATION NAME] every morning (7:30 a.m.). [MEDICATION NAME] 24 units every hour of sleep (8:00 p.m.). Review of the DMAR Accucheck dated April 2012 revealed that on 4/26/12 at 6:30 a am.. the blood sugar was 59 (mg/dl). A snack was documented as being given to Resident #7. On 4/27/12, at 6:30 a.m. Resident #7's glucose was 48 (mg/dl). A snack/juice was documented as being given. There was no documentation in the Nurse's Notes regarding the low blood sugar episodes. There was no documentation that the Physician was notified that Resident #7 had experienced low blood sugars two (2) consecutive days. Review of the DMAR dated March 2012 revealed that on 3/3/12 at 8:00 p.m. Resident #7 had a blood sugar of 167 (mg/dl) documented. There was no documentation to state that the sliding scale insulin was administered as ordered. There was no documentation that the Physician was notified regarding not administering the Insulin. On 3/13/12 at 6:30 a.m. Resident #7's blood sugar was 52 (mg/dl) and a snack was documented as being given. There was no documentation that the blood sugar was rechecked. On 3/15/12 at 6:30 a.m. Resident #7's blood sugar was 58 (mg/dl). There was no documented evidence that the blood sugar was rechecked in 15 minutes. Review of the February 2012 DMAR revealed that on 2/2/12 at 6:30 a.m.; 2/6/12 at 8:00 p.m.; and on 2/7/12 at 6:30 a.m., there was no documented evidence that the blood sugar was checked. There was no documented evidence that the Physician was notified. On 2/21/12 at 6:30 a.m. Resident #7's blood sugar was 49 (mg/dl) and juice and snack was given. There was no documented evidence that the blood sugar was rechecked within 15 minutes. There was no indication as to why the blood sugar was not rechecked. Interview on 5/3/12 at 12:20 p.m. with LPN #20 was conducted regarding documentation of the blood sugars in the Nurse's Notes. LPN #20 stated that if they (residents) have problems with blood sugars, we document it in the Nurse's Notes. Resident #11 Record review revealed that Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].= Diabetic Protocol; 61-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 = 12 units; over 400 = 15 units; and recheck blood sugar in 4 hours; Call physician if blood sugar is over 400 on second stick." Resident #11 also received [MEDICATION NAME] 30 Units subcutaneous at bedtime for treatment of [REDACTED]. Record review revealed that Resident #11 had a documented blood glucose level of 24 mg/dl on 04/24/12 at 8 p.m. The blood glucose was rechecked at 9:00 p.m. and was 199 mg/dl. There was no documentation that Resident #11 received the [MEDICATION NAME] 36 units at bedtime as ordered. There was no order noted to hold the [MEDICATION NAME] at that time and no documentation that the Physician was notified of holding the insulin. Interview on 05/03/12 at 12:45 p.m. with Licensed Practical Nurse (LPN) #21 confirmed "Nurse was supposed to recheck blood sugar in 15 minutes, I don't see documentation that she provided juice and she didn't notify the physician as policy stated." LPN #21 also stated that the Nurse for Resident #11 did not write any documentation in the Nurse's Notes as to why the [MEDICATION NAME] 30 units was held on 04/08/12 and 04/24/12. LPN #21 stated that she did not see documentation that the Physician was notified. Resident #14 Record review revealed that Resident #14 was admitted to the facility on [DATE]. Resident #14 had [DIAGNOSES REDACTED]. Review of Resident #14's DMAR and February 2012 physician's orders [REDACTED]. "If Blood Sugar less than 60 mg/dl, Follow Diabetic Protocol." Review of Resident #14's Nurse's Notes dated 2/2/12 through 2/14/12 revealed that there was no documentation of the 43 mg/dl low blood glucose reading on 2/3/12 at 6:30 a.m., or the treatment after 15 minutes to follow up on the blood sugar per Accu Check. There was no documentation that the Physician was notified of the low blood sugar. Resident #22 Record review revealed that Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #22's April DMAR revealed the following blood glucose readings per Accu Check: 1) 4/2/12 at 6:30 a.m. a blood glucose of 50 mg/dl. 2) The following dates and times revealed an elevated blood sugar level at 4:30 p.m. on 4/12/12, of 412 mg/dl; on 4/13/12, the glucose was 435 mg/dl; on 4/15/12, glucose was 476 mg/dl, and on 4/16/12 glucose was 598 mg/dl. Further review of the DMAR revealed that there was no documentation for the treatment or the 15 minute follow up Accu Check for the low blood sugar at 6:30 a.m. on 4/2/12, or the four (4) hour recheck glucose testing for the 4:30 p.m. high blood sugars on 4/12/12, 4/13/12, 4/15/12, and 4/16/12 as stated above. Review of Resident #22's April 2012 DMAR and physician's orders [REDACTED].= Follow Diabetic Protocol Policy. For blood sugar greater than 350 give ten (10) units and recheck in four (4) hours. Review of Resident #22's Nurse's Notes on 4/2/12 revealed that there was no documentation for the 6:30 a.m. low blood sugar of 50 mg/dl, or the treatment and 15 minute follow up blood glucose. Review of the Nurse's Notes on 4/12/12 through 4/13/12, 4/15/12, and 4/16/12, revealed that there was no documentation for the four (4) hour follow up glucose per Accu Check related to the elevated 4:30 p.m. blood glucose's on those dates. Further review of the Nurse's Notes revealed that there was no documentation that the Physician was notified of the low and high blood sugars. Resident # 23 Record review revealed that Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the April 2012 physician's orders [REDACTED]. [MEDICATION NAME] 4 units SQ pc (after) lunch plus sliding scale. [MEDICATION NAME] 3 units SQ after breakfast plus sliding scale. These orders originated on 9/6/11. Resident #23 also had orders to check finger stick blood glucose tid AC meals and administer [MEDICATION NAME] per sliding scale after meals. If Resident ate < 25 %, hold [MEDICATION NAME] but cover with sliding scale; 25% - 50% give 2 units plus sliding scale if needed. > 50% give 4 units plus sliding scale if needed. Further orders stated "Finger stick blood glucose at 9:00 p.m. and 3:00 a.m. Blood glucose < 65 give 40 grams carbohydrate snack by mouth and recheck blood glucose in 30 minutes and repeat blood glucose until it is > 100. 90 - 100 no change from order. > 140 use sliding scale coverage. Review of Resident #23's DMAR for January 2012 revealed that on 1/1/12 at 4:30 p.m. that the blood sugar was 423 mg/dl, with seven (7) units of [MEDICATION NAME] Insulin administered. There was no recheck of the blood sugar documented. On 1/9/12, the blood sugar was 40 mg/dl at 3:00 a.m. "Glucogan" was documented as being administered. The blood glucose at 3:15 a.m. was 116 mg/dl. There was no documentation in the Nurse's Notes related to the condition of the resident when the glucose was 40 mg/dl. On 1/17/12 at 3:00 a.m. the blood glucose was 45 mg/dl. "Juice and crackers" were documented as being administered. There was no documentation that the blood glucose level was rechecked. There was no documentation in the Nurse's Notes regarding the Resident's condition or a recheck of the blood glucose level. On 1/19/12 at 3:00 a.m. the blood glucose was 50 mg/dl. "Juice and snack" was documented as being administered. There was no documentation of the blood glucose being rechecked. There was no documentation in the Nurse's Notes regarding the Resident's status during the times that the glucose was in the low range. Review of Resident #23's DMAR for February 2012 revealed that on 2/3/12, at 4:30 p.m. the blood sugar was 518 mg/dl. There was no repeated Accucheck documented. On 2/5/12, at 11:30 a.m. the blood glucose was 439 mg/dl. At 4:30 p.m. on 2/5/12, the blood glucose was 61 mg/dl. "Juice given" was documented. There was no recheck until the next scheduled blood glucose at 9:00 p.m. On 2/16/12 at 3:00 a.m. the blood sugar was 61 mg/dl. "O" (orange juice) was documented as the intervention. There was no documented recheck of the glucose after the orange juice was given. On 2/24/12 at 4:30 p.m. the blood sugar was 407 mg/dl. There was no repeated Accucheck documented. On 2/19/12 at 11:30 a.m. and on 2/29/12 at 3:00 a.m. there was no documentation of a blood sugar being obtained. Review of Resident #23's DMAR for March 2012 revealed that on 3/6/12 at 7:30 a.m. the blood sugar results was 400 mg/dl. On 3/16/12 at 4:30 p.m. the blood sugar was 400 mg/dl. On 3/17/12 at 4:30 p.m. the blood sugar was 414 mg/dl. On 3/21/12 at 4:30 p. m. the blood sugar was 405 mg/dl. On 3/22/12 at 4:30 p.m. the blood sugar was 411 mg/dl. On 3/25/12 at 4:30 p.m. the blood sugar was 421 mg/dl. There was no documentation that a repeat Accucheck was done as ordered by the Physician. On 3/11/12 at 3:00 a. m., 3/25/12 at 3:00 a.m. and 3/31/12 at 9:00 p.m. there was no documentation of Accuchecks being done as ordered. Review of Resident #23's DMAR for April 2012 revealed that on 4/15/12 at 3:00 a.m.; on 4/22/12 at 9:00 p.m.; and at 3:00 a m. there was no documentation of Accuchecks being done as ordered by the Physician. There was no documentation that the Physician was notified of the glucose levels; or the glucose levels not being obtained as ordered. Resident #26 Record review revealed that Resident # 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/22/12 revealed that Resident #26 was cognitively alert. Review of the April 2012 physician's orders [REDACTED]. Review of Resident #26 physician's orders [REDACTED].= Follow Diabetic Protocol Policy; 61-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 8 units; 301-350 = 10units; 351-400 =12 units; >over 400 = 15units. Recheck in four (4) hrs. Follow S/S Guidelines for BS > 200, Call MD if BS over 400 on the second check." Review of Resident #26 DMAR for January 2012 revealed that on 1/5/12 at 8:00 p m. there was no documentation that an Accucheck was obtained as ordered. The next Accucheck was done on 1/6/12 at 6:30 a.m. On 1/10/12 at 11:30 a. m. the blood sugar was 421 mg/dl, with 15 units of [MEDICATION NAME] Sliding Scale (SS) coverage. There was no recheck in fours (4) hours (hrs) documented. On 1/28/12 at 6:30 a. m. the blood sugar was 41 mg/dl. There was no actions or rechecks documented. On 1/31/12 at 6:30 a. m. there was no blood sugar documented, and no documentation as to why the blood sugar was not obtained as ordered by the Physician. There was no documentation that the Physician was notified of the glucose levels. Review of Resident #26's DMAR for February 2012 revealed that on 2/7/12 at 4:30 p m. and 8:00 p.m. there was no documentation that a blood sugar was obtained as ordered and no documentation that the Physician was notified. Review of Resident #26's Diabetic Medication Administration (MAR): Accu-Check and Sliding Scale Insulin Administration Record for March 2012 revealed that on 3/11/12 at 4:30 p.m. the blood sugar was 68 mg/dl. The blood sugar at 8:00 p.m. was not documented. On 3/30/12 at 11:30 a.m. there was no results of a blood sugar documented. There was no documentation in the Nurse's Notes to explain the reasons that the blood sugar was not obtained. There was no documentation that the Physician was notified. Review of Resident #26's DMAR for April 2012 revealed that on 4/30/112 at 6:30 a.m. and 11:30 a.m. there was no documentation that the blood sugars were obtained. There was no documentation as to why the blood glucose was not obtained as ordered. There was no documentation that the Physician was notified. Resident #34 Record review revealed that Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Accuchecks were also ordered as needed for signs and symptoms of hyper/[DIAGNOSES REDACTED]. Resident #34 also had orders for [MEDICATION NAME] 85 units daily; [MEDICATION NAME] 80 units every hour of sleep; and [MEDICATION NAME] Insulin 58 units three (3) times a day with meals. Review of Resident #34's Care Plan revealed: a "potential for abnormal blood sugars related to disease of diabetes mellitus, and to maintain blood sugars within normal range (70-120) with diet, medications, and staff interventions. Care Plan problem onset dated 04/12/12." Review of the DMAR for April 2012 revealed that on 04/13/12 at 4:30 p.m. the blood glucose was 51 mg/dl. On 04/14/12 at 4:30 p.m. the blood glucose was 58 mg/dl. On 04/15/12 at 4:30 p.m. the blood glucose was 54 mg/dl. On 05/16/12 at 4:30 p.m. the blood glucose was 55 mg/dl on the DMAR. The documentation revealed that orange juice was given for each of the four (4) blood sugars below 60 mg/dl. There was no documentation in the Nurse's Notes on the aforementioned dates concerning low blood glucose levels or any interventions. There was no documentation found in Resident #34's medical record to show that the blood glucose was rechecked in 15 minutes as per policy or that the Physician was notified of the glucose levels. Resident #36 Record review revealed that Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the April 2012 physician's orders [REDACTED]. An order on 3/22/12 revealed "Accu checks before BRST/supp (before breakfast and supplement) sliding scale using [MEDICATION NAME] Insulin. BS < 50 Activate [DIAGNOSES REDACTED] Protocol. BS 50 - 70 give 4 oz OJ (orange juice) if symptomatic; BS 71 - 150 = 2 units; 201 -250 = 4 units; BS 251 - 300 = 6 units; 301 - 350 = 8 units; > 350 = 10 units and call MD." Review of the DMAR revealed that on 4/2/12 at 4:30 p.m. Resident #36 had a blood glucose reading of 50 mg/dl. The documentation stated "snack" was administered. There was no documentation related to what the snack consisted of, or that a repeat blood sugar was tested per facility policy. Review of the DMAR revealed that on 4/24/12 at 4:30 p.m. Resident #36's blood glucose was 30 mg/dl. "Juice" was documented as being given. There was no documentation of the amount of juice that was administered. At 5:00 p.m. the blood sugar was rechecked and registered 101 mg/dl. Interview on 5/4/12 at 10:15 a.m. revealed that LPN #20 was unable to find documentation in the chart that the Diabetic Protocol was followed for Resident #36 on 4/2/12 at 4:30 p.m. and 4/24/12 at 4:30 p.m. LPN #20 reviewed the chart for 4/2/12, when Resident had blood sugar reading of 50 mg/dl at 4:30 p.m. LPN #20 stated that she did not see any documentation that the Physician was notified, and that a re-check was done within 15 minutes as the policy stated. LPN #20 reviewed the chart for 4/24/12 when resident had blood sugar reading of 30 mg/dl at 4:30 p.m. LPN #20 stated that she did not see any documentation that the Physician was notified, and that no re-check was done within 15 minutes as the policy stated. LPN #20 stated, " It should be documented in the Nurse's Notes but I don't see it. " Resident #40 Record review revealed that Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #40's April 2012 Physician order [REDACTED].=Follow Diabetic Protocol Policy; 61-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 8 units;301-350= 10 units; 351-400 = 12 unit; >OVER 400 = 15 units. RECHECK IN 4 HOURS. Follow Sliding Scale guidelines for Blood Sugar >200. Call MD if blood sugar OVER 400 on SECOND CHECK." Review of Resident #40's April 2012 DMAR revealed that on 4/23/12 at 6:30 a.m. Resident #40's accucheck blood sugar reading was 537 mg/dl. There was no documentation that indicated blood sugar levels were rechecked as per facility policy or that the Physician and Responsible Party were notified. The blood glucose was not checked again until 11:30 a.m. (five hours later). Interview with LPN #10 on 5/4/12 confirmed that the glucose level was not rechecked in the time frame ordered. Resident #41 Record review revealed that Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. There was also an order [REDACTED]. 71 - 150 = 2 units; 125 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; and > 350 = 10 units and notify MD. This was implemented on 3/6/2012. Record review revealed that on 3/28/12 at 8:00 p.m. there was no documentation that a blood glucose reading was obtained. There was no Insulin injection noted as being administered and no reason documented to hold the Insulin. There was no documentation that the Physician was notified. On 4/9/12 at 6:00 a.m. Resident #41 had a blood glucose reading of 48 mg/dl. There was no documentation that the facility policy was implemented regarding, administering treatment, notifying Physician or repeating the blood glucose in 15 minutes. Interview with LPN #6 on 5/3/12 at 11:50 a.m. indicated that LPN #6 was unable to find documentation in the chart that a blood glucose reading was obtained or that an insulin injection was given to Resident #41 on 3/28/12 at 8:00 p.m. LPN #6 reviewed the chart for 4/9/12, when resident had a blood sugar reading of 48 mg/dl at 6:00 a.m. LPN #6 stated that she was unable to find any documentation that the Insulin was withheld; that the Physician was notified; that Resident #41 was given orange juice or Karo syrup, or that Accu Check was repeated in 15 minutes. LPN #6 stated that the Diabetic Protocol Policy was not followed for this resident on 4/9/12 at 6:00 a.m. Resident #42 Record review revealed that Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Resident #42 also received [MEDICATION NAME] 100 mg daily and Glimepiride 4 mg daily for treatment of [REDACTED]. Review of the DMAR for February 2012 revealed that on 02/11/12 at 6:30 a.m. the blood glucose was 59 mg/dl. Orange juice was documented as being given for treatment. There was no documentation that the blood glucose was rechecked in 15 minutes as per policy. There was no documentation in the Nurse's Notes on 02/11/12 concerning the low blood glucose or any interventions. Interview on 05/04/12 at 4:10 p.m. with Licensed Practical Nurse (LPN) #6 confirmed that she could not find documentation in the Nurse's Notes that interventions were put into place concerning the low blood glucose of 59 mg/dl on 02/11/12. LPN #6 stated: "I don't see where the blood sugar was rechecked on 02/11/12, and documentation that the Physician was notified." Resident #43 Record review revealed that Resident #43 was admitted to the facility on [DATE]. Resident #43 had [DIAGNOSES REDACTED]. Review of the Admission MDS with an ARD of 1/10/12 revealed that Resident #43 was moderately impaired in cognitive skills for daily decision making. Review of Resident #43's DMAR for February 2012 through April 2012 revealed the following low blood sugar readings: On 4/17/12 at 4:30 p.m. the blood sugar was 56 mg/dl. "Meal given" was documented. There was no follow up blood sugar after the meal was given. On 4/25/12 at 4:30 p.m. the blood sugar was 58 mg/dl. "Juice and sugar" was documented as being given. There was no follow-up blood sugar documented. On 3/7/12 at 4:30 p.m. the blood glucose level was 58 mg/dl. "Snack given" was documented. There was no follow up Accu Check to check the glucose level documented. On 3/8/12 at 4:30 p.m. glucose was 48 mg/dl. "Snack given" was documented. There was no follow- up blood sugar documented. On 3/22/12 at 4:30 p.m. glucose was 58 mg/dl. "Snack given" was documented. There was no follow - up Accu Check to check the glucose level documented. On 2/10/12 at 11:30 a.m. there was no glucose result documented. On 2/14/12 at 4:30 p.m. the glucose was 31 mg/dl. "Karo and Juice given" was documented. There was no follow up glucose level per Accu Check documented. On 1/30/12 at 4:30 p.m. glucose was 55 mg/dl. "Karo" was documented as being given. There was no follow-up glucose per Accu Check documented. The treatments given for the aforementioned low blood sugars were not documented in specific amounts of juice, Karo or sugar. There was no documentation that Physician was notified of the glucose levels. Review of Resident #43's 1/4/12, Physician's admission orders [REDACTED]. 70 to 150 = 0 U; 151 to 200 = 1 U; 201 to 250 = 2 U; 251 to 300 = three 3 U; 301 to 350 = 4U; greater than 350 give 5 U and notify MD. Resident #44 Record review revealed that Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #44's April 2012 DMAR revealed that on 4/2/12 at 8:00 p.m. a low blood glucose of 42 mg/dl was obtained. Further review of the DMAR revealed that there was no documentation for the treatment or the 15 minute follow up glucose per Accu Check as per facility policy. Review of Resident #44's April 2012 physician's orders [REDACTED]. Review of Resident #44's April 2012 Diabetic Record, MAR, and Nurse's Notes dated 4/2/12 at 3:05 a.m. to 10:35 p.m. revealed that there was no documentation of the low blood glucose readings, treatments rendered, follow-up blood glucose testing, or Physician notification. Interview on 5/3/12 at 4:45 p.m. with LPN #17 revealed that she attended an in-service last evening (5/2/12) on the new Hypoglycemic Protocol and Diabetic Protocol. LPN #17 reported that the previous protocol instructed to treat blood sugar below 60 mg/dl with juice and sugar. Recheck in 15 minutes, if still below 60 mg/dl, treat again and notify the Phys

Based on observation, staff interview, record review, and policy review, the facility failed to ensure that (1) Physician's orders were implemented regarding the treatment of [REDACTED].#5, #7, #9, #11, #14, #15, #21, #22, #23, #26, #28, #32, #34, #36, #40, #41, #42, #43, #44. There were 59 Residents out of a census of 136 with the [DIAGNOSES REDACTED]. (2) The facility failed to monitor the control tests for the glucose meters and the test strips to ensure that accurate readings of the blood sugars were achieved. This is for 10 of 10 blood glucose meters in the facility. There were three (3) blood glucose meters on the A Hall; four (4) on the B Hall; and three (3) on the C Hall. (3) The facility failed to ensure that facility staff, including Agency Nurses were knowledgeable in the facility policy's for identifying the "Code Status" of Residents; and initiating CardioPulmonary Resuscitation (CPR). Resident #9 was found on [DATE] at 5:25 a.m. unresponsive with a blood glucose level of 30 mg/dl. LPN #1 (Agency Nurse) called to another hall in the facility and asked LPN # 2 what to do if someone had a low blood sugar. LPN #1 administered jelly to Resident #9, and she remained unresponsive. It was noted that Resident #9 was without pulse and respirations. LPN #1 called LPN #2 and LPN #3 to the hall and stated that Resident #9 had died on her. LPN #2 asked what the Resident's code status stated on the chart. LPN #2 realized that Resident #9 was a Full Code. CPR was initiated at 5:35 a.m. LPN #1 did not know how to use the Ambu Bag. The Emergency Medical Technicians (EMT's) arrived at 5:45 a.m. and continued CPR. The Coroner was notified and arrived at 6:15 a.m. and Resident #9 was pronounced as being expired. (4) The facility also failed to ensure that the Physician's Orders on [DATE] at 3:00 p.m. were implemented for every 15 minute checks on Resident #9. Also, to leave Resident #9's door open, due to Resident refusing to use a bed chair alarm to alert staff when she attempted to ambulate without assistance. Resident #9 had a history of [REDACTED]. (5) The facility failed to ensure that there was documentation in the Nurse's Notes to reflect the status of Resident's when the blood sugars were not in normal range. There was no documentation as to why the Insulins were held; and no notification that the Physician was notified. These actions were determined to be an Immediate Jeopardy (IJ) at a "K" level on [DATE] at 3:55 p.m. The Administrator, Director of Nursing, and Nurse Consultant were notified at that time. The Immediate Jeopardy at a "K" level began on [DATE] at 5:25 p.m. when Resident #9 was found unresponsive with a blood glucose of 30 mg/dl; was given jelly by mouth; and then identified to have no pulse or respirations. Resident #9 expired. The facility provided a Credible Allegation of Compliance on [DATE] at 3:00 p.m. Findings Include: Cross refer findings to F 309 for the facility's failure to ensure that Physician's orders were followed for Resident's with the [DIAGNOSES REDACTED]. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 3:00 p.m. "Allegation of Compliance An Immediate Jeopardy was called on [DATE] at 3:55pm related to the care of a diabetic resident, Resident #9 was noted with blood glucose of 46. Resident #9 was alert and oriented times 3 (oriented to person, place, and time). Resident #9 ' s skin was warm and dry to touch with respirations even and unlabored. The registered Nurse #1 (RN) administered four (4) ounces of orange juice with one pack of peanut butter and crackers. On [DATE] at 9:30pm, Resident #9 ' s blood glucose was rechecked and was noted to be 60. Resident #9 remained alert and oriented times three. On [DATE] at 10:30pm, RN #1 was called to Resident #9 ' s room. Resident #9 was diaphoretic with skin cool and clammy, lethargic and blood glucose was 38. Physician #1 was in the facility making rounds and was asked to check Resident #9. Physician #1 gave verbal orders as follows: (1) Gluca Gen Hypo Kit times one dose now intramuscular (2) Give Insta Glucose Gel times one tube now by mouth due to low blood (3) Re-check blood sugar every 15 minutes for one hour On [DATE] at 10:30 pm, RN #1 administered the Gluca Gen Hypo Kit and the Insta Glucose as ordered. The blood sugar was re-checked by RN #1 on Resident #9 at 10:45 pm and was noted to be 56. Resident #9 was given a cup of orange juice. RN #1 re-checked blood glucose on Resident #9 again at 11:00 pm and was documented as 98. Resident #9 was resting in bed and was alert and oriented times three. On [DATE] at 11:15 p.m., LPN #1 performed a blood glucose recheck for Resident #9 and documented it as 79. At 11:15 p.m. LPN #1 called Physician #1 and received an order to discontinue [MEDICATION NAME] 12 units to be administered at every hour of sleep and start [MEDICATION NAME] Insulin at 6 units subcutaneously every hour of sleep and to hold all sliding scale insulin on [DATE]. On [DATE] at 11:30 p.m. Resident #9 ' s blood sugar was rechecked by LPN #1 and was documented as 114. Resident #9 was alert and taking and asked LPN #1 to turn on the fan. On [DATE] at 1:00 am, LPN #1 entered the Resident #9 ' s room and noted Resident #9 to be lying in the bed with eyes closed and respirations even and unlabored with the skin noted to be warm and dry to touch. Review of documentation provided by Certified Nurse Assistant (CNA) #1 revealed that on [DATE] at 11:30 pm, Resident #9 had requested juices due to low blood sugar. CNA #1 went to the Nurses Station and reported to the nurse on duty, LPN #1, that Resident #9 ' s blood glucose needed to be checked. LPN #1 went to Resident #9 ' s room and checked the blood glucose. CNA #1 returned to Resident #9 ' s room at approximately 1:30 a.m. after Resident #9 was not looking " good " so LPN #1 returned to the room to check on the resident. At 3:30 a.m. to 4:00 a.m. on [DATE] CNA #2 went to Resident #9 ' s room to assist while CNA #1 was assisting another resident. When CNA #1 entered Resident #9 ' s room the Resident was sitting on the side of the bed and wanted to get up. CNA #1 informed Resident #9 that it was not a good idea to get up since the blood glucose was low. CNA #1 documented in the statement that " (Resident #9) was sweating really bad, very weak. It took Resident #9 a long time to respond as usual " . CNA #2 turned the air on for Resident #9 and left the room. CNA #1 documented in the statement that CNA #2 verbally told LPN #1 that Resident #9 was not looking good. CNA #2 documented in a statement dated [DATE] that Resident #9 was very sweaty and limp about 3:00 a.m. on [DATE] and that LPN #1 was notified that Resident #9 did not "look good " . There was no documented evidence in the Nurses Noted dated [DATE] to indicate that LPN #1 had checked on Resident #9 between the times of 1:00 a.m. and 5:25 a..m.(a.m.) On [DATE] at 5:25 am, LPN #1 entered Resident #9 ' s room and found Resident #9 to be unresponsive. Resident #9 ' s blood glucose was checked at that time and was documented as 30. LPN #1 attempted to give Resident #9 jelly and was unable to get a response. LPN #1 documented that [MEDICATION NAME] injection was administered per facility policy, which was [MEDICATION NAME] 1 milligram (mg). LPN #1 was unable to obtain a blood pressure or pulse and called the B Wing LPN #2 to assist. Resident #9 ' s chart was checked and it was determined that Resident #9 was a Full Code. LPN #3 and LPN #4 from A Wing initiated Cardiopulmonary Resuscitation (CPR) at 5:30 am and LPN #1 called for the ambulance then returned to the room to assist with the CPR. Documentation in the Nurses Notes dated on [DATE] at 5:45 am, revealed that the Emergency Medical Technicians (EMTs) arrived and started life saving measures. The Coroner documented in the medical record that upon arrival EMT ' s were present and there was no cardiopulmonary activity and no pupil reaction and Resident #9 was pronounced as expired at 6:28 a.m. The facility made changes to the " Code Status Policy " on [DATE] to enable the nursing staff to more easily identify if a resident was a full code or a no code status. This was accomplished with the implementation of the placement of a green dot on the medical record and on the faceplate outside the residents ' door for residents that were a full code; a red dot was placed on the medical record and on the faceplate outside the resident door for residents who chose to be classified as a no code. LPN#1 was an agency nurse and had worked in the facility since [DATE]. The staffing agency was notified by the Director of Nursing on [DATE] and informed the owner of the agency that LPN #1 would not be allowed to work in the facility again. LPN #2 was an agency nurse and had worked in the facility since [DATE]. The State Attorney General ' s Office, the State Department of Health Licensure and the State Board of Nursing were notified by the Director of Nursing of the incident involving Resident #9 on [DATE]. On [DATE] beginning at 5:00 p.m., an audit of the medical records was conducted by Assistant Director of Nursing, Quality Assurance LPN #1, Quality Assurance LPN #2, LPN #6, LPN #7, LPN #8, LPN #9 and LPN #10. There were 59 diabetic residents out of a total census of 138. The medical records were reviewed to determine if the documentation identified any blood glucose less that 60, any action taken, physician notification of any hypoglycemic episode, monitoring for repeat episodes, and any interventions related to the hypoglycemic episode. On A Unit, 15 diabetic Residents were reviewed. Hypoglycemic episodes were identified on 3 of the 15 Residents reviewed. The Residents identified with hypoglycemic episodes on Unit A include Resident #11, Resident #35, and Resident #34. Resident #11 no documentation was found on the hypoglycemic episode that occurred on [DATE] at 8:00 pm. LPN #11, who was the nurse involved, was in-serviced one-on-one on [DATE], by the Assistant Director of Nursing (ADON) reviewing the Diabetic Proctology to be followed during a hypoglycemic episode. Resident #35 had incorrect orders on the chart and Physician #2 was notified by the ADON on [DATE] at 8:30 p.m. for clarification orders related to the orders for the sliding scale insulin. Physician #2 issued new orders on [DATE] at 8:30 pm. Resident #35 had 3 hypoglycemic episodes ([DATE] at 7:30 am - [DATE] at 5:30 am - [DATE] at 7:30 am). On [DATE] at 7:30 am, a blood sugar of 42 was documented and juice was administered to Resident #35 by LPN #12. On [DATE] at 5:30 am Resident #35 was noted with a blood sugar of 45 and juice was administered by LPN #4. LPN #4 rechecked the blood glucose at on [DATE] at 5:50 am with blood sugar of 100. LPN #4 rechecked Resident #35 ' s blood glucose at 6:05 am on [DATE], with blood sugar of 152. LPN # 4 did not document that the Physician nor Responsible Party was notified. On [DATE] at 7:30 am, LPN #12 documented a blood sugar of 55 for Resident #35 and Sweetened orange juice was given, Resident #35 was eating cookies and sitting at the table awaiting the breakfast meal. At 8:00 am on [DATE] LPN #4 rechecked Resident #35 ' s blood sugar and documented a result of 108 and breakfast was served. On [DATE] at 11:30 am, Resident #35 ' s blood sugar was documented at 387. Sliding scale was followed as ordered and 12 Units of [MEDICATION NAME] Insulin was given as well as [MEDICATION NAME] seven (7) unit [MEDICATION NAME] which was a routine order from the Physician. The Physician and Responsible Party were notified on [DATE] at 2:20 p.m. by LPN #12. Documentation reflects that morning dose of scheduled insulin had been refused by Resident #35. Resident #34 had a hypoglycemic episode on [DATE] at 4:30pm with the blood glucose documented as 51. LPN #13 documented that a snack was provided. There was no documented follow up of the blood glucose or that the Physician was notified. LPN #14 documented on [DATE] at 4:30pm, blood glucose was 58 with no documentation that the Diabetic Protocol was followed. LPN #14 documented on [DATE] at 4:30 pm, blood glucose was 55 and documented that " OJ(orange Juice) " was given. Physician #1 was notified of the low blood sugars by LPN #14 on [DATE] at 10:00pm and new orders were received to " change Lantis Insulin to Levimir 40 units twice a day and [MEDICATION NAME] 10 units before meals. If blood sugar is less than 100, hold the insulin. Accu-checks four times a day " . No further episodes of [DIAGNOSES REDACTED] were documented for Resident #34. On [DATE] at 8:00am, the Director of Nursing began notifying the Physicians and Responsible Parties of Resident #11, Resident #35, and Resident #34 of the hypoglycemic episodes and the interventions. On [DATE] beginning at 5:00 p.m. 23 diabetic Residents on B Unit were reviewed. Hypoglycemic episodes were identified on 8 of the 23 Residents reviewed. The residents reviewed included Resident #23, Resident #36, Resident #1, Resident 41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #16 as 45 with orange juice and graham crackers given. The blood glucose was rechecked at an unknown time and was documented as 206. On [DATE] at 3:00 a.m., Resident #23 ' s blood glucose was documented by LPN #16 as 41 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 323. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #5 as 55 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 147. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 50 and a snack was given and there was no documented followup. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 30 and juice was given and the next blood glucose was documented at 5:00 p.m. on [DATE]. On [DATE] at 11:30 a.m. Resident #1 ' s blood glucose was documented by LPN #20 as 54 and orange juice was given and the next documented blood sugar was at 4:30 p.m. and was 142. On [DATE] at 6:30 a.m. Resident #41 ' s blood glucose was documented as 48 by LPN #16 and a snack was given. The next documented blood glucose was 173 on [DATE] at 11:30 a.m. On [DATE] at 8:00 p.m. LPN #17 documented Resident #44 ' s blood glucose as 42 and a snack was given. There was no documented evidence of a follow up or physician notification. On [DATE] at 11:30 a.m., LPN #15 documented Resident #7 ' s blood glucose as 54. Lunch was given. The next documented blood glucose was on [DATE] at 4:30 p.m. and was 182. On [DATE] at 6:30 a.m., LPN #16 documented Resident #7 ' s blood glucose 59 with a snack given and a follow up blood glucose of 66 on [DATE] at 6:45 a.m. On [DATE] at 6:30 a.m., LPN #17 documented Resident #7 ' s blood glucose as 48 with a snack with juice given. At 11:30 a.m. the blood glucose was documented at 200. On [DATE] at 6:30 a.m. LPN #18 documented Resident #31 ' s blood glucose as 59 with juice and a snack given. The next documented blood glucose was on [DATE] at 11:30 a.m. and was documented as 128. On [DATE] at 6:30 a.m. LPN #5 documented Resident #22 ' s blood glucose was documented as 50 with orange juice given and no documented followup. On [DATE] at 4:30 p.m., LPN #17 documented Resident #43 ' s blood glucose as 56 with juice and supper given and the next documented blood glucose was on [DATE] at 8:00 p.m. of 149. On [DATE] at 4:30 p.m. LPN #19 documented Resident 43 ' s blood glucose as 58 with juice and sugar given with no documented followup. Notification of Physician #1 and Physician #2 began on [DATE] at 8:00 am by the Director of Nursing. The Physicians and the Responsible Parties of Resident #23, Resident #36, Resident #1, Resident #41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43 were notified of the hypoglycemic episodes and the interventions. One-on-one in-service to LPN ' s began on [DATE] at 10:00 pm, conducted by the Assistant Director of Nursing and addressed the facility Diabetic Protocol. On C Unit, 21 diabetic Residents were reviewed and no hypoglycemic episodes were identified. The facility Diabetic Protocol was revised on [DATE] with the following changes: - To define " substantial snack: as being at least 1 ounce peanut butter, cheese, or meat OR 8 ounces of whole milk - To identify the amount of sugar (3 packs) to be used to sweeten the juice - To repeat the blood glucose check in 2 hours following any hypoglycemic episode (blood glucose less than 60) - To notify physician if the blood glucose registers 60 to 70 twice in a weekly period The RN ' s, LPN ' s, Agency Staff and CNA ' s were in-serviced on the Diabetic Protocol beginning on [DATE] on the 3pm-11pm shift and the 11pm-7 am shift. The in-service was done by LPN QA Nurse #1 and LPN QA Nurse #2. No RN, LPN, or CNA will be allowed to work until in-serviced. The protocol for orienting agency staff to the facility was revised on [DATE] to include Diabetic Protocol, Code Status, Emergency Procedures. The agency staff orientation includes the implementation of an evaluation check list that will be completed and signed by the agency nurse prior to the nurse working in the facility. The two agency nurse, Agency Nurse #1 and Agency Nurse #2, working on [DATE] were in-serviced addressing Diabetic Protocol, Code Status and Emergency Procedures by the QA LPN #2. The Staff Development person was in-serviced by the Administrator on [DATE] related to the evaluation check list and policies and procedures for agency staff. The facility Code Status Policy was updated on [DATE] to reflect the use of the colored dots to identify the Residents ' code status, (Green dot = Full Code and Red Dot = NO Code). The Code Status of all current Residents(138) were reviewed on [DATE] by the Assistant Director of Nursing, QA LPN #1, QA LPN #2, LPN #6, LPN #7 LPN #8, LPN #9 and LPN #10 beginning at 8:00pm. A green dot was placed on the end of the chart and on the nameplate outside the Resident ' s room to identify Residents who were designated as a Full Code and a red dot to identify Residents that were designated as a No Code. The admissions Coordinator is responsible for placing the appropriate colored dot on admission or on change of status. The admissions Coordinator was in-serviced on the dot system by the Administrator on [DATE] at 8:45 am. The RN ' s, LPN ' s, Agency Staff and CNA ' s were in-serviced on the colored dot system beginning on [DATE] on the 3pm-11pm shift and the 11 pm-7am shift. No RN, LPN, or CNA will be allowed to work until the in-serviced. The in-service to the nursing staff was done by LPN QA Nurse #1 and LPN QA Nurse #2. A Quality Assurance Committee meeting was called on [DATE] at 4:15 pm and was attended by the Medical Director, the Administrator, the Director of Nursing, the RN Nurse Consultant, the Assistant Director of Nursing, two QA Nurses. The Diabetic Protocol was addressed and the protocol was revised. The agency Nurse Evaluation was discussed and changes made. The Code Status Policy reviewed and revised with immediate implementation. On [DATE], it was discovered that the list of diabetic residents provided to the survey team on the entrance date of [DATE], did not match the list of diabetic residents whose medical records were audited on [DATE]. This was evidenced by the facility providing Resident names on a Resident list as referenced in the Allegation of Compliance that were not on the list that was provided to the survey team upon entrance. Interviews with the staff involved in the Medical Record review revealed that audit forms were not completed on the Residents that do not require accu-checks nor on the Residents who had no hypoglycemic episodes. Statements were obtained from staff members LPN #8 and LPN #9 on [DATE] confirming that the Residents who did not require accu-checks or have had no hypoglycemic episodes were reviewed and there were no concerns. Chart review forms were completed on [DATE] at 6pm." Addendum to AOC [DATE] "Re: Glucometer Control Checks" "On [DATE] concerns identified included: ? The glucometer control checks not being performed as directed by the manufacturer or the facility policy, ? Glucometer Serial numbers being worn off the back of the glucometer, ? Control Solution Record not being maintained for each individual serial numbered glucometers, ? Control solution not being dated when opened, ? Bottle of glucometer strips not being dated when opened. On [DATE] beginning at 11:10 a.m. all on duty nursing staff, including Registered Nurses (RN) and Licensed Practical Nurses (LPN) were in serviced by the Quality Assurance Nurse regarding the policy and procedure for the checking of the glucometer controls. The inservice included review of the facility policy " Quality Control Check (for the accu-check machine) " and Manufacturers Instructions which include for a control check to be performed: ? Before testing the first time ? With each new bottle of strips ? Whenever it is suspected that the meter or test strips may not be functioning properly ? If the test result appears to be abnormally high or low, or are not consistent with the resident ' s symptoms ? The test strip bottle has been left open or exposed to temperature below 40 degrees or above 86 degrees, light or humidity levels above 85%. ? To check the technique ? When the glucometer has been dropped ? When the glucometer has been stored below 14 degrees or above 1430 degrees or in humidity levels above 85% ? Dating and checking glucometer strips when the bottle was open and checking the expiration date to ensure that solution was not expired ? Each Monday night on the 11 p.m. to 7 a.m. shift a Glucometer Control Check will be perfumed and documented on the " Blood Glucose Monitoring System Quality Control Results Record " and, Dating of the control solution when the bottle was open and checking the expiration date to ensure the solution was not expired A 100% audit of all six (6) medication carts was conducted began on [DATE] at 11:45 a.m. The audit included checking to ensure that there was a glucometer on each medication cart and a " Blood Glucose Monitoring System Quality Control Results Record " was provided for the documentation of the control checks, and that the nurse could discuss the process for testing the control strips and that the control solution and the glucometer strips were not expired. Any glucose control strips and or control solutions that were not dated when opened were discarded. Glucometers were labeled according to the Medication Cart that it was to be maintained on: Upper A, Lower A, Upper B, Lower B, Upper C, Lower C. Two glucometers were observed on the Upper A, Lower A, Upper B, Lower B, Upper C and Lower C Medication Carts. There is one " Blood Glucose Monitoring System Quality Control Results Record " for each glucometer. The on duty nursing staff, including Registered Nurses and Licensed Practical Nurses was in serviced and no RN or LPN, facility or agency staff, will be allowed to work until inserviced regarding the facility policy and the manufacturer's ' s instructions for the testing of the controls for the blood glucose monitors. The in-service for the RN ' s and LPNs included review of the facility policy for testing of the glucometer controls. No RN or LPN will be allowed to work until in servicing has been performed. Monitoring of the process to ensure that the Quality Control Checks are performed as instructed by the Manufacturer and in accordance with the facility policy was conducted by Quality Assurance Nurse #1 and #2 and the Assistant Director of Nursing. Those Checks are documented on the " Control Solution Record " . HANDWRITTEN INFORMATION On [DATE] the 11p-7a shift will be inserviced and copy faxed to MSDH on Monday. No staff (RN, LPN) will be allowed to work until they have been inserviced on the Glucometer Control Checks. Verification of the Allegation of Compliance (AoC): Based on random observations, staff interviews, review of inservice records and record review beginning on [DATE] at 11:45 a.m. confirmed that immediate corrective actions were implemented. The facility had inservice documentation regarding the "Diabetic Protocol", "Code Status" and "Emergency Procedures". The facility checked all six (6) medication carts to ensure that the glucometers were calibrated and documented. An interview on [DATE] at 3:10 p.m. with LPN #25 on B-Wing (7a-7p shift) confirmed that she was in-serviced on the aforementioned policy's. LPN #25 was able to calibrate the glucometer and knew where to document the calibration. LPN #25 was able to state the Code Status of Resident's due to the red or green dot on each Resident's door. An interview on [DATE] at 3:15 p.m. with LPN #20 on B-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:20 p.m. with LPN #26 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information. There were two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:25 p.m. with LPN #20 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:30 p.m. with LPN #28 on C-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident ' door. An interview on [DATE] at 3:35 p.m. with LPN #29 on C-Wing (7:00 a.m. to 7:00 p.m. shift) revealed that they were in-serviced on the Diabetic Protocol, changes in the policys, Code Status; and information regarding the two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. LPN #29 stated that the Code Status is identified with a red or green dot on each the residents' door. An interview on [DATE] at 3:40 p.m. with LPN #14 on C-Wing (3:00 p.m. to 11:00 p.m. shift) confirmed of being in-serviced on the above information with two (2) glucometers on the upper medication cart and the labeled BGMSQCRR sheet labeled on the MAR. LPN #14 also confirmed that the Code Status is identified by a red or green dot on each the resident's door. An interview on [DATE] at 3:45 p.m. with RN #2 (7:00 a.m. to 3:00 p.m.) confirmed that she was in-serviced on the Code Status, the Diabetic Protocol and the glucometers. An interview on [DATE] at 3:48 p.m. with LPN #10 on (3:00 p.m. to l1:00 p.m. shift) confirmed that she was in-serviced on the Diabetic Protocol; checking the controls on the glucometers and the Code Status of residents. Other interviews on [DATE] with RNs, LPNs, and CNAs were conducted during the survey to confirm their understanding of the facility's policy changes regarding the Diabetic Protocol; Code Status; checking the glucometer controls; how to use the Ambu bag to include emergency measures; and notifying the Physician as per facility policy. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which constitutes actual harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

Based on observation, staff interview, record review, policy review, and review of the glucose meter manufacturer's instructions, the facility failed to; (1) Ensure that the Nursing Staff (including Agency Nursing Staff) were knowledgeable of the facility-specific "Diabetic Protocols" in order to provide measures for the management of hypoglycemic (Blood glucose level below 60 mg/dl milligrams per deciliter) and/or [MEDICAL CONDITION] (elevated blood sugars of 400 mg/dl) per facility policy. This is for 20 of 32 Residents with the [DIAGNOSES REDACTED].#5, #7, #9, #11, #14, #15, #21, #22, #23, #26, #28, #32, #34, #36, #40, #41, #42, #43, #44. There were 59 Residents out of a census of 136 in the facility with the [DIAGNOSES REDACTED]. (2) The facility failed to monitor the control tests for the glucose meters and the test strips to ensure that accurate readings of the blood sugars were achieved. This is for 10 of 10 blood glucose meters in the facility. There were three (3) blood glucose meters on the A Hall; four (4) on the B Hall; and three (3) on the C Hall. (3) The facility failed to ensure that facility staff, including Agency Nurse's) were knowledgeable in the facility policy's for identifying the "Code Status" of Resident's; and initiating CardioPulmonary Resuscitation (CPR). Resident #9 was found on [DATE] at 5:25 a.m. unresponsive with a blood glucose level of 30 mg/dl. LPN #1 (Agency Nurse) called to another hall in the facility and asked LPN # 2 what to do if someone had a low blood sugar. LPN #1 administered jelly to Resident #9, and she remained unresponsive. It was noted that Resident #9 was without pulse and respirations. LPN #1 called LPN #2 and LPN #3 to the hall and stated that Resident #9 had died on her. LPN #2 asked what the Resident's code status stated on the chart. LPN #2 realized that Resident #9 was a Full Code. CPR was initiated at 5:35 a.m. LPN #1 did not know how to use the Ambu Bag. The Emergency Medical Technicians (EMT's) arrived at 5:45 a.m. and continued CPR. The Coroner was notified and arrived at 6:15 a.m. and Resident #9 was pronounced as being expired. (4) The facility also failed to ensure that the Physician's Orders on [DATE] at 3:00 p.m. were implemented for every 15 minute checks on Resident #9. Also, to leave Resident #9's door open, due to Resident refusing to use a bed chair alarm to alert staff when she attempted to ambulate without assistance. Resident #9 had a history of [REDACTED]. (5) The facility failed to ensure that there was documentation in the Nurse's Notes to reflect the status of Resident's when the blood sugars were not in normal range. There was no documentation as to why the Insulins were held; and no notification that the Physician was notified. These actions were determined to be an Immediate Jeopardy (IJ) at a "K" level on [DATE] at 3:55 p.m. The Administrator, Director of Nursing, and Nurse Consultant were notified at that time. The Immediate Jeopardy at a "K" level began on [DATE] at 5:25 p.m. when Resident #9 was found unresponsive with a blood glucose of 30 mg/dl; was given jelly by mouth; and then identified to have no pulse or respirations. Resident #9 expired. The facility provided a Credible Allegation of Compliance on [DATE] at 3:00 p.m. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which constitutes actual harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Resident #9 Record review revealed that Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that Resident #9 was independent in cognitive skills for daily decision making. Review of the Diabetic MAR indicated [REDACTED]'s blood sugar was 45 (mg/dl) and juice was administered. There was no documentation that a recheck of the blood sugar was done. On [DATE], the blood sugar was 47 mg/dl at 5:30 a.m. [MEDICATION NAME] was documented as being administered. There was documentation in the Nurse's Note on [DATE], at 5:45 a.m. stating: "BS (blood sugar) was 47 (mg/dl). Resident would not open mouth to drink juice teeth were clenched et (and) she would not swallow, [MEDICATION NAME] 1 mg given et BS rechecked with result of 80 (mg/dl)." (The Nurse's Note did not state the time that the blood sugar was rechecked). On [DATE], at 4:00 a.m. blood sugar was documented as being 45 (mg/dl) with juice documented as being given to the Resident. The Nurse's Notes stated that the MD was faxed (does not state what information was faxed). On [DATE], at 11:00 a.m. the blood sugar was documented as being 54 (mg/dl) and juice was given. A recheck of the blood glucose was done at 11:30 a.m. and the results was 61 mg/dl. There was no documentation regarding additional treatments at that time. On [DATE], at 6:30 a.m. a blood sugar of 230 mg/dl was documented. Resident #9 received five (5) units of [MEDICATION NAME] R Insulin per sliding scale (S/S) protocol. Review of Resident #9 ' s Nurse's Notes dated [DATE], at 9:50 a.m. revealed: " Resident noted cool and clammy. Resident would look at this nurse by opening eyes slightly and turning eyes in the direction I was standing. BS (blood sugar) reading 27 (mg/dl). Glucose gel given. Resident being unresponsive [MEDICATION NAME] injection given-BS recheck (reading) 24 (mg/dl)- resident still unresponsive- respirations shallow and labored then, period of apnea followed with snoring. 911 phoned for transport. 10A (10:00 a.m.) EMTs (Emergency Medical Technicians) X (time) 2 (two) for transport BS increase (reading) 31 (mg/dl) resident still unresponsive at this time." Review of Resident #9's "Physician's Orders" on [DATE] revealed an order to " Transport to (the name of the local hospital) ER (emergency room ) for evaluation and possible admit (due to) decrease BS." Review of the Nurse's Notes revealed that Resident #9 returned from the hospital on [DATE] at 6:30 p.m. Review of Resident #9 ' s Nurse's Notes dated [DATE] at 8:40 a.m. revealed that the blood sugar reading at 7:10 a.m. was 48 (mg/dl). Orange juice was documented as being given. At 7:25 a.m. the blood sugar reading was 37 (mg/dl). Oral glucose was documented as being given. At 7:40 a.m. the blood sugar was 41 (mg.dl). [MEDICATION NAME] IM was documented as being given. At 7:50 a.m. the blood sugar was 58 (mg/dl). Resident #9's blood sugar reading on [DATE], after the hypoglycemic episode, was checked in two (2) hours and 30 minutes and documented at 11:30 a.m. on the DMAR AC (before) lunch with a blood sugar reading of 217 (mg/dl). Resident #9 was given four (4) units of [MEDICATION NAME] R Insulin per sliding scale. Record review revealed that there was no documented evidence that the staff notified the Physician in a timely manner to inquire if Resident #9 needed the Insulin to be administered at 11:30 a.m. on [DATE], as ordered per the sliding scale, due to the earlier hypoglycemic episodes. There was no documented evidence that the Physician was notified due to the hypoglycemic episodes that Resident #9 had previously that morning. The facility failed to document the amount of orange juice that was administered during the hypoglycemic episodes. There was no documented assessment to include Resident #9's vital signs and level of consciousness as stated per the facility's "Diabetic Protocol Policy". Interview on [DATE] at 4:50 p.m. with the Assistant Director of Nurses (ADON) confirmed the aforementioned findings. Review of the facility policy " Diabetic Protocol Policy ([DATE]) " revealed " ...For blood glucose below 60 ...Give sweetened orange juice (1 glass) or 1 tablespoon Karo syrup, ... Repeat accu-check in 15 minutes, If blood sugar remains below 60, administer Oral Glucose Gel if conscious and to swallow, [MEDICATION NAME] 1 mg injectable if resident not conscious or unable to swallow- Repeat accu-check in 15 minutes- If blood sugar remains below 60, notify MD for instructions- If unable to locate physician and is unresponsive or condition otherwise warrants, transfer resident to local emergency room for evaluation- If accu-check is above 60 on recheck, notify physician of hypoglycemic episode during office hours- resident requires insulin contact the physician concerning hypoglycemic episode before insulin is administered- Give substantial snack or meal following hypoglycemic episode- Repeat accu-check within 30 minutes following consumption of meal or snack ...Document in the nurse's notes: Date and time, Accu-check result, Sweetened juice or Karo given ( or other), Physician notification, Indication if new orders were given, Assessment: Vital signs, Level of consciousness, Skin: 1. Color, 2. Temperature, 3. Diaphoresis/dryness 4. Condition- restlessness, irritable, pain notification of the family, Nurse ' s signature and title. If low blood sugar is a recurring or frequent problem, notify physician for possible order changes. " Review of Resident #9 ' s Physician ' s Orders dated [DATE] revealed to " decrease [MEDICATION NAME] (Insulin) to 12 units at 8 PM (8:00 p.m.)." Review of Resident #9 ' s [DATE] Physician Orders revealed " Accu Check AC (before meals) and HS [MEDICATION NAME] R per facility sliding scale BS<17 5 = 0 U(unit); ,[DATE] = 3 U; ,[DATE] = 4 U; ,[DATE] = 5 U; ,[DATE] = 6 U; ,[DATE] = 7U; ,[DATE] = 8 U; ,[DATE] = 9 U; ,[DATE] = 10 U; ,[DATE] = 11U; ,[DATE] = 12 U; > 425 = 13 U; Follow S/S Guidelines for BS >200- call MD if BS over 400 on the second check. " The original order was " dated [DATE] " . Review of Resident #9 ' s February 2012 DMAR revealed the following findings: On [DATE] at 6:30 a.m. the blood sugar reading was 55 mg/dl and there was no documented recheck of the blood sugar in 15 minutes. There was no documentation of any treatment being administered as per the "Diabetic Protocol Policy". On [DATE] at HS (hour of sleep), the blood sugar reading was 268 mg/dl with no documentation to address if the resident received [MEDICATION NAME] R per sliding scale and/or [MEDICATION NAME] 12 units per physician ' s orders. Review of Resident #9 ' s [DATE] DMAR revealed that there was no documented blood sugar reading on [DATE] at 4:30 p.m. and at 8:00 p.m. There was no sliding scale insulin or [MEDICATION NAME] addressed as being administered as ordered. Review of Resident #9 ' s [DATE] DMAR revealed there was no documented blood sugar reading on [DATE] at 11:30 a.m.; on [DATE] at 6:30 a.m.; and on [DATE] at 4:30 p.m. Interview on [DATE] at 4:50 p.m. with the ADON confirmed that there was no documentation of the glucose levels as in the aforementioned findings. Review of Resident #9 ' s Nurse's Notes for [DATE] revealed the following: " 9:00 p.m. Resident noted with BS of 46 (mg/dl) alert and oriented (A & O) X three (3). Skin warm and dry to touch, respiration even and unlabored administered 4 oz (ounces) of orange juice with one (1) pack of peanut butter." At 9:30 p.m. "BS rechecked noted at 60 (mg/dl) alert and oriented X 3." At 10:30 p.m. " Called into resident's room per floor nurse, resident noted diaphoretic skin cool and clammy lethargic BS at 38 (mg/dl). MD at nurses station and came to room with V.O. (verbal order) 1 Give [MEDICATION NAME] Hypokit X 1 dose now IM; and 2 insta-Glucose Gel X 1 tube now d/t (due to ) decreased BS. MD orders carried out per this nurse at this time. Recheck BS every 15 minutes X 1 hour T 97.7, P74, R16, and BP,[DATE]." At 10:45 p.m. "BS = 56 (mg/dl) Resident requested a cup of orange juice and given." At 11:00 p.m. " BS at 98 (mg/dl), resting in bed alert and oriented x 3. Remain on fall observation with no fall noted this shift." At 11:15 p.m. "BS check 79 (mg/dl) gave orange juice with sugar called MD received N.O. (new order) to D/C (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] SubQ every HS (hour of sleep) and hold all S/S (sliding scale) on [DATE]." At 11:30 p.m." BS was 114 (mg/dl). Resident alert talking asked me to turn on fan in room." On [DATE] at 1:00 a.m. "Opened residents door and looked in on her, she was resting in bed, and eyes closed, resp even and unlabored...". Review of Resident #9 ' s Physician ' s Orders revealed the following findings: An order on [DATE] at 3:00 p.m. 1) Every 15 minute visual monitoring, 2) Keep room door open at all times for observation of resident d/t (due to ) refusal of alarms that would alert staff if resident getting up unassisted." There was no documented evidence that the facility; monitored Resident #9's blood sugar when it was less than 60 mg/dl on [DATE] at 9:00 p.m. within the 15 minute time frame; administered the correct amount of orange juice and or treatment per the facility's "Diabetic Protocol"; Made visual observations of Resident #9 every 15 minutes as ordered; and monitored the blood sugar on [DATE] from 1:00 a.m. until 5:25 a.m. Interview on [DATE] at 11:30 a.m. with the Director of Nurses (DON) #1 confirmed the aforementioned findings. Review of Resident #9's Physician's Orders revealed the following findings: An order on [DATE] at 3:00 p.m. stating; "1) Every 15 minute visual monitoring, 2) Keep room door open at all times for observation of resident d/t (due to ) refusal of alarms that would alert staff if resident getting up unassisted." On [DATE] (no time) " C.O. (communication order) Encourage resident to keep room door open at all X's (times) for observation of Resident d/t refusal of alarms that would alert staff if resident getting up unassisted." On [DATE] at 10:30 p.m. "1 Instant-glucose now along with [MEDICATION NAME] HypoKit DT (due to) low Blood Sugar, Recheck Blood Sugar Q (every) 15 minutes X 1 hour. " On [DATE] at 11:45 p.m. there was an order to "D/C [MEDICATION NAME] 12 U, start [MEDICATION NAME] 6U Q HS. Hold SS (sliding scale) insulin [DATE] then resume on [DATE]." Review of Resident #9's Nurse's Notes for [DATE] at 5:25 a.m. revealed " Entered residents room. Resident unresponsive BS checked 30 (mg/dl), attempted to give resident jelly unable to get responsive. Gave [MEDICATION NAME] injection per policy; Unable to obtain BP (blood pressure) or HR (heart rate) called for B wing nurse to come assist. Checked chart Resident full code. A wing Nurses initiated CPR at 5:30. This nurse called for ambulance and returned to room and took over CPR. 5:45A (a.m.) EMTs arrived and started life saving measures. 6:00A (a.m.) Coroner notified by EMTS and arrived at 6:15 AM ... 6:15 AM Family notified RP (name of RP) called. 7:00 A (a.m.) Family at bedside awaiting funeral home Rep ... 8:45 AM Funeral Home Rep arrived at facility (was contacted by floor nurse at approx 8:00 a.m.) family present at resident bedside, Resident body transported out of facility without complication via funeral home rep ... 9:00 AM MD notified via office nurse who stated that she would let the MD know about the resident passing". Review of the facility " Investigation of Events Related to (Name of Resident #9)" revealed; " On [DATE] resident was experiencing problem related to blood sugar requiring MD intervention. On [DATE] on ,[DATE] shift (Name of Licensed Practical Nurse, {agency nurse}) checked resident ' s blood sugar at 11:30 (p.m.) and it was 114 (mg/dl). Checked on resident at 1:00A (a.m. on [DATE]) and she was sleeping per documentation. At approximately 3:,[DATE]:00 a.m. (on [DATE]), two (2) CNA's were present in resident's room assisting her with getting back in bed and other personal needs. Resident at this time per CNA documentation was very sweaty, weak and limp. One of the CNA's left out of the room and met the nurse coming down the hall and told her that (Resident #9) was not looking good. The other CNA last saw resident at 4:45a.m. when she put cover on her (Resident #9) per her request. The nurse's documentation reflects that she was in resident's room at 11:15 p.m., 11:30 p.m., 1:00 a.m. and 5:25 a.m. The events occurring after 5:25 a.m. are detailed in nurse's statement." Interview on [DATE] at 7:10 a.m. with Licensed Practical Nurse (LPN) #1 revealed the following findings: "On [DATE], I was working the 11:00 p.m. to 7:00 a.m. shift (,[DATE] shift) on C Wing; There were two (2) LPN's on A Wing with three (3) Certified Nurse Assistants (CNA), and one (1) LPN on B Wing, and a Nurse in orientation with three (3) CNA's. I was alone on C Wing as the nurse with three (3) CNAs. I was aware of LPN #2's name only because we work for the same local agency. The nurse (Register Nurse {RN #1}) on the previous shift reported that Resident #9's blood sugar was in the 30's, given juice with sugar, and crackers. The resident's blood sugar was supposed to be checked every 15 minutes for an hour. At 11:15 a.m. the resident's blood sugar was 79 (mg/dl), I gave juice and sugar and the blood sugar was over 114 (mg/dl). Resident complained of being hot, she wanted more juice and requested this from CNA #2. The resident had fallen before (on [DATE]) and we were supposed to document on the resident regarding to the fall. Around 2:00 p.m. I informed a female CNA to assist with ambulating Resident #9 to the bathroom. Again, I checked on Resident #9 around 3:00 a.m. At 3:15 a.m. I informed the CNAs that (another resident) had to go to the bathroom." "On [DATE], at 5:25 a.m. Resident #9 was breathing when I entered the room by making a puffing type sound. The resident's mouth was blue, I did the sternum rub and the resident was unresponsive. I checked the blood sugar with a reading of 30 (mg/dl). I returned to the nursing station on C- Wing and phoned LPN #2 on the B-Wing. I asked LPN #2 what to do for a resident with a blood sugar of 30 (mg/dl) and was told to give jelly. I attempted to give the resident jelly but was unable to get a responsive. I returned to the nursing station to the medication room for [MEDICATION NAME] injection. I gave it to Resident #9 in the thigh area and did the sternum rub again. At 5:30 a.m. the resident was no longer breathing with no heart rate and no pulse with a blood sugar reading of 21 (mg/dl). I ran to get a stethoscope from the nursing station, then, to the end of the C Wing hall, and yelled for LPN #2 to come to (Resident #9's room). LPN #2 entered the room and I told LPN #2 that the resident died on me. LPN #2 left the room to phone LPN #3 on A Wing. LPN #2 checked the chart for Resident #9 ' s code status and I left the room to call the ambulance. LPN #3 made it to the resident's room and LPN #2 yelled that the resident was a full code. LPN #3 started CPR on the resident. I returned to the room and took over CPR. LPN #2 returned to the resident's room to get LPN #3 medication room key to get the ambu bag from A Wing. LPN #2 returned from A Wing with the ambu bag and gave it to LPN #3. LPN #2 had to leave the room due to a resident going bad on B Wing. The EMT's arrived to the facility about 5:45 a.m. and stated life saving measures." Further interview with LPN #1 revealed the following findings: 1) No one said anything was going on with Resident #9 prior to me going in at 5:25 a.m. and I know they (staff) are trying to put me under the bus. 2)Working with a local agency at this facility three (3) times; 3) Second time working on C Wing and 4) Orientation at the facility lasted about three (3) to four (4) hours and included; watching a video, and was told to read the facility policy book." Interview on [DATE] at 7:35 a.m. with LPN #4 revealed the following information: "On [DATE], I was working on A Wing with LPN #3. Between 5:,[DATE]:00 a.m. LPN #2 called LPN #3 on the phone and asked what the facility protocol was when a resident passes away. LPN #3 made her aware to check the resident's chart for the code status. When we made it to Resident #9's room the resident was in the room alone. The resident's mouth and hands were blue and no code had been called. Later, LPN #2 was returning to the resident's room in the hallway yelling that Resident #9 was a full code. LPN #3 started CPR on Resident #9. LPN #2 got the medication room keys from me and went to A Wing to get the Ambu bag. LPN #2 returned to the room with the Ambu bag and gave it to LPN #1. I left the resident's room to assist LPN #2 on B Wing". Further interview with LPN #4 revealed: "I had to read the policy book and attend two (2) in-services since the incident with Resident #9, about insulin, and the Diabetic Protocol. Interview on [DATE]/at 7:45 a.m. with LPN #3 revealed the following: "On [DATE], I was doing medication pass on A Wing between 5:,[DATE]:00 a.m. LPN #2 called me to ask if Resident #9 was a full code and the facility protocol when a resident ' s passes away. Resident #9 was on A Wing before moving to C Wing. Resident #9 would experience low BS but, she would let you know. Resident #9 would usually drop around 2:00 to 3:00 a.m. in the morning with the classic symptom of sweating; LPN #3 was made aware to check the resident ' s chart for the code status. When we made it to Resident #9 ' s room the resident was unconscious in the room alone. The resident's mouth and hands were blue. LPN #2 called a full code and I started CPR on Resident #9. LPN #2 went to A Wing to get the Ambu bag. LPN #2 returned to the room and gave the Ambu bag to LPN #1. LPN #1 did not know how to use the ambu bag." Further interview with LPN #3 revealed; "I had to read the facility's big policy book. There have been several in-services and the diabetic protocol was done twice since the incident occurred. Interview on [DATE]/at 9:05 a.m. with LPN #5 revealed the following: "On [DATE], I was orientating doing medication pass on B Wing with LPN #2. Between 5:,[DATE]:00 a.m., LPN #2 received a phone called to come to C Wing. Someone came and told me that they need me on C Wing. The nurse (LPN #1) was really freaked out trying to do CPR. Resident #9 was blue around the mouth and stuff was running out of the mouth. I had the ambu bag when the ambulance arrived. I stepped out of the way." Further interview with LPN #5 revealed: "As part of my orientation, I know where the ambu bag is located, in the medication room and how to inflate it (the ambu bag). Interview on [DATE] at 8:00 a.m. with CNA #1 revealed the following; "On [DATE], I was working 11:00 p.m. to 7:00 a.m. shift on A Wing. At 3:00 a.m. I wasin the hallway returning to A Wing with linens on a cart and saw that Resident #9's call light was on. Resident #9 was assigned to CNA #2. CNA #2 was caring for another resident and I answered Resident #9's call light. The resident was on the side of the bed. I asked what was wrong and she wanted to be put in the wheelchair. Resident #9 was sweating and really hot, but the room was cold. I turned the air on to cool the resident off. CNA #2 entered the room and assisted me with putting Resident #9 back to bed. The resident was dead weight and this was not usual for Resident #9. I reported to LPN #1 that Resident #9 was not feeling well and LPN #1 kept walking." Interview on [DATE] at 8:15 a.m. with LPN #2 revealed the following: "On [DATE], I was working on B Wing with LPN #5 who was the nurse in orientation. At 5:26 a.m. I just finished talking on the phone with the doctor and LPN #1 called me and asked what was the facility's protocol for a blood sugar of 30 (mg/dl). I told her to give jelly, sugar, syrup and then [MEDICATION NAME]. I was not told the resident was unresponsive. LPN #1 said that she would give Resident #9 some [MEDICATION NAME]. I told LPN #1 to try and get the blood sugar up first, then, call the doctor. Resident #9 usually asked the Nurse to check her blood sugar when it was in the 40's. LPN #1 later called me to her hall and said, I gave Resident #9 the [MEDICATION NAME], but she did not respond. LPN #1 asked me what was the protocol for a death and showed me the meter with a blood sugar reading of 21 (mg/dl). I called LPN #4, then LPN #3 and was told to check the chart to see if Resident #9 was a full code. LPN #3 told me to get the ambu bag from A-Wing in the oxygen room. LPN #1 was still at the desk. I had to leave because the CNA on my unit told me that a resident on my hall was going bad." Further interview with LPN #1 revealed that the Staff Development Nurse gave us the manual to read during orientation. Orientation for Agency Nurse was one (1) day; and she thought she signed something related to the facility policy. Telephone interview on [DATE] at 9:30 a.m. with RN #1 revealed the following: On [DATE], I was the 3:00 p.m. to 11:00 p.m. shift nurse on C Wing. Resident #9's blood sugar dropped to the 40's. I gave the resident juice and crackers. The resident's Physician was already in the building, so, I reported to the doctor that I had given her peanut butter crackers and he said it was ok. I can ' t remember the time I checked it after, but the blood sugar did go up. CNA #6 came and got me because Resident #9's skin was sweaty. I checked the blood sugar and it was in the 30 ' s. The doctor told me to give the Resident #9 the gel and the shot. The blood sugar came up to 98 (mg/dl). I gave the report to the Agency Nurse, can't remember the Agency Nurse's name." Interview on [DATE] at 11:45 a.m. with CNA #2 revealed the following: "I was assigned to C Wing on the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Resident #9 told me she was not feeling well and wanted some juice at 11:30 p.m. The resident said her blood sugar was low. LPN #1 checked Resident #9 ' s blood sugar after I told her. The resident wanted her blood sugar checked again around 1:30 a.m. and I told LPN #1. Around 3:15 a.m., Resident #9's call light was on again and CNA #1 answered the call light for me. Later, I went in the room and CNA #1 helped me to change Resident #9. Then, put the resident back to bed and CNA #1 told LPN #1 that Resident #9 was not feeling well. Resident #9 was complaining of being hot and we turned the air on and covered the resident up." Review of the facility "Orientation Package" and LPN #1's "Orientation File" to the facility revealed that there was no documented evidence that the facility ensured that the nursing staff was knowledgeable on: 1) Facility- specific Diabetic Protocol Policy to provide measures for the management of hypoglycemic and [MEDICAL CONDITION]; 2) Facility specific Code Status, Cardiopulmonary Resuscitation Policy and Ambu Bag Ventilation Policy; 3) Clinical skills checklist or skill check off that included: how to use the ambu bag; 4) By providing a facility tour on the location of the ambu bag, oxygen, and/or other emergency supplies; 5) A clinical skills checklist was done by the local agencies only. 6) That a Ambu bag provided for each of the three (3) Nurse's Station. Interview on [DATE] at 10:25 a.m. with the Staff Development Person confirmed the aforementioned findings. Further interview with the SDP revealed that there were two (2) local Staffing Agency's that provided Nurses for the facility. Telephone interview on [DATE] at 11:30 a.m. with DON #1 revealed the only documentation that the facility had that orientation was provided for LPN #1 was the " Local Agency Staffing Service " slip, listed four hours (4) for orientation on [DATE]. Interview on [DATE] at 12:30 p.m. with the facility Medical Director revealed: "We usually send a resident out to the local ER (emergency room ) after a hypoglycemic episode like Resident #9 ' s experienced on [DATE] at 9:00 p.m. Lately, the local hospital ER just returns the residents back to the facility." The Medical Director reported of being aware of the Immediate Jeopardy being identified and the policies being changed. Interview on [DATE] at 2:30 p.m. with Resident #9's Physician revealed that due to Resident #9's multi-medical conditions, when the resident was transferred to the local ER for treatment due to hypoglycemic episodes, the ER just returned the resident back to the facility. Review of the facility policy on "Diabetic Protocol Policy ([DATE])" revealed "For blood glucose below 60 give sweetened orange juice (1 glass) or 1 tablespoon Karo syrup. If resident is allergic to orange juice or whole milk. Repeat accucheck in 15 minutes. If blood sugar remains below 60 administer oral glucose gel if conscious and able to swallow. [MEDICATION NAME] 1 mg injectable if resident not conscious or unable to swallow. Repeat accucheck in 15 minutes. If blood sugar remains below 60 notify MD for instructions. If unable to locate physician AND resident is unresponsive or condition otherwise warrants, transfer resident to local emergency room for evaluation. If accu-check value is above 60 on recheck, notify the physician or hypoglycemic episode during office hours. If resident required insulin contact physician concerning hypoglycemic episode before insulin is administered. Give substantial snack or meal following hypoglycemic episode. Repeat accu-check within 30 minutes following consumption of meal or snack. Notify physician if hypoglycemic episodes occur frequently. Document in the nurse's notes: date and time; accu-check results; sweetened juice or Karo given (or other); Physician notification; indicate if new orders were given. Assessment of resident: vital signs, level of consciousness; skin (1) color; (2) temperature; (3) Diaphoresis/dryness; (4) condition. Restlessness, irritability, pain, notification of the family, and Nurse's signature and title. If blood sugar is a recurring or frequent problem, notify the physician for possible order changes." "Reminders - Notify Physician for blood glucose above 250 if resident has NO sliding scale orders" Review of the "Sliding Scale Insulin Policy" (with no implementation date) revealed: "It is the policy of this facility that the following sliding scale for insulin will be utilized unless otherwise ordered: 0 - 60 follow Diabetic Protocol. 61 - 150 = No Insulin; 151 - 200 = 3 Units SQ; 201 - 250 = 5 units SQ; 251 - 300 = 8 units SQ; 301 - 350 = 10 units SQ; 351 - 400 = 15 units SQ and recheck glucose in 4 hours. Follow sliding scale guidelines for glucose above 200. Call MD if glucose over 400 on the second check." Review of the manufacturer ' s instructions per facility pharmacy online date for " [MEDICATION NAME] Injectable (no date) " revealed " Dietary Considerations: Administer carbohydrates to patient as possible after response to treatment ... Warnings/ Precautions - Monitoring: Monitor blood glucose levels closely. Secondary [DIAGNOSES REDACTED]: Supplemental carbohydrate should be given to patient who responds to [MEDICATION NAME] for severe [DIAGNOSES REDACTED] to prevent secondary [DIAGNOSES REDACTED]. " Review of the facility's policy "Cardiopulmonary Resuscitation Policy" (with no implementation date) revealed: "It is the policy of this facility that CPR will be done as follows: Initiated only on those residents who have a full code status; To provided adequate emergency artificial ventilation and circulation to the resident in [MEDICAL CONDITION]; As an attempt to reverse the cause of [MEDICAL CONDITION]; and be performed by persons trained in CPR procedures." Review of the "Ambu Bag Ventilaion Policy" (with no implementation date) revealed "It is the policy of this facility that ambu bag ventilation will be utilized as follows: Check the medical record in order to make sure that the resident is not a "No Code". In order to provide artifical ventilations as in CPR connect the ambu bag to oxygen in order to increase the oxygen supplied to the lungs." The policy continues with step to step procedures. Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's " [DATE] DMAR " revealed a blood sugar reading on [DATE] at 8:00 a.m. of 30 (mg/dl). There was documentation that Resident #1 was given juice. There was no documentation on the DMAR or the Nurse's Notes that the blood sugar was rechecked. There was no assessment documented in the Nur

Based on observation, staff interview, record review, and policy review the facility failed to be administered in a manner that enables 20 of 32 Residents reviewed with the [DIAGNOSES REDACTED]. resident. This is for Resident #1, #5, #7, #9, #11, #14, #15, #21, #22, #23, #26, #28, #32, #34,#36, #40, #41, #42, #43, #44. The facility failed to (1) Ensure that the Nursing Staff (including Agency Nursing Staff) were knowledgeable of the facility-specific "Diabetic Protocols" in order to provide measures for the management of hypoglycemic (Bood glucose level below 60 mg/dl milligrams per deciliter) and/or [MEDICAL CONDITION] (elevated blood sugars of 400 mg/dl) per facility policy. There were 59 Residents out of a census of 136 in the facility with the [DIAGNOSES REDACTED]. (2) The facility failed to monitor the control tests for the glucose meters and the test strips to ensure accurate readings of the blood sugars were achieved.. This is for 10 of 10 blood glucose meters in the facility. There were three (3) blood glucose meters on the A Hall; four (4) on the B Hall; and three (3) on the C Hall. (3) The facility failed to ensure that facility staff, including Agency Nurse's) were knowledgable in the facility policy's for identifying the "Code Status" of Resident's; and initiating CardioPulmonary Resusitation (CPR). Resident #9 was found on [DATE] at 5:25 a.m. unresponsive with a blood glucose level of 30 mg/dl. LPN #1 (Agency Nurse) called to another hall and asked LPN # 2 what to do if someone had a low blood sugar. LPN #1 administered jelly to Resident #9, and she still remained unresponsive. It was noted that Resident #9 was without pulse and respirations. LPN #1 called LPN #2 and LPN #3 to the hall and stated that Resident #9 had died on her. LPN #2 asked what the Resident's code status stated on the chart. LPN #2 realized that Resident #9 was a Full Code. CPR was initiated at 5:35 a.m. LPN #1 did not know how to use the Ambu Bag. The Emergency Medical Techinicians (EMT's) arrived at 5:45 a.m. and continued CPR. The Coroner was notified and arrived at 6:15 a.m. and Resident #9 was pronounced as being expired. (4) The facility also failed to ensure that the Physician's Orders on [DATE] at 3:00 p.m.were implemented for every 15 minute checks on Resident #9. Also, to leave Resident #9's door open due to Resident refusing to use a bed chair alarm to alert staff when she attempted to ambulate without assistance. Resident #9 had a history of [REDACTED]. These actions were determined to be Substandard Quality of Care and an Immediate Jeopardy (IJ) at a "K" level on [DATE] at 3:55 p.m. The Administrator, Director of Nursing, and Nurse Consultant were notified at that time. The Immediate Jeopardy at a "K" level began on [DATE], when Resident #9 was found unresponsive with a blood glucose of 30 mg/dl; was given jelly by mouth; then identified to have to have no pulse or respirations. The facility provided a Credible Allegation of Compliance on [DATE] at 3:00 p.m. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which constitutes actual harm. The facility will remain out of compliance in order to monitor the effecitiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Cross refer findings to F 281 and F 309 for the facility's failure to ensure that professional standards of care are implemented regarding following the facility's "Diabetic Protocol"; following the Physician's orders; and ensuring that staff implemented a "Full Code" immediately when Resident #9 was found unresponsive and without a pulse or respirations. Allegation of Compliance An Immediate Jeopardy was called on [DATE] at 3:55pm related to the care of a diabetic resident, Resident #9 was noted with blood glucose of 46. Resident #9 was alert and oriented times 3 (oriented to person, place, and time). Resident #9 ' s skin was warm and dry to touch with respirations even and unlabored. The registered Nurse #1 (RN) administered four (4) ounces of orange juice with one pack of peanut butter and crackers. On [DATE] at 9:30pm, Resident #9 ' s blood glucose was rechecked and was noted to be 60. Resident #9 remained alert and oriented times three. On [DATE] at 10:30pm, RN #1 was called to Resident #9 ' s room. Resident #9 was diaphoretic with skin cool and clammy, lethargic and blood glucose was 38. Physician #1 was in the facility making rounds and was asked to check Resident #9. Physician #1 gave verbal orders as follows: (1) Gluca Gen Hypoo Kit times one dose now intramuscular (2) Give Insta Glucose Gel times one tube now by mouth due to low blood sugar (3) Re-check blood sugar every 15 minutes for one hour On [DATE] at 10:30 pm, RN #1 administered the Gluca Gen Hypo Kit and the Insta Glucose as ordered. The blood sugar was re-checked by RN #1 on Resident #9 at 10:45 pm and was noted to be 56. Resident #9 was given a cup of orange juice. RN #1 re-checked blood glucose on Resident #9 again at 11:00 pm and was documented as 98. Resident #9 was resting in bed and was alert and oriented times three. On [DATE] at 11:15 p.m., LPN #1 performed a blood glucose recheck for Resident #9 and documented it as 79. At 11:15 p.m. LPN #1 called Physician #1 and received an order to discontinue [MEDICATION NAME] 12 units to be administered at every hour of sleep and start [MEDICATION NAME] Insulin at 6 units subcutaneously every hour of sleep and to hold all sliding scale insulin on [DATE]. On [DATE] at 11:30 p.m. Resident #9 ' s blood sugar was rechecked by LPN #1 and was documented as 114. Resident #9 was alert and taking and asked LPN #1 to turn on the fan. On [DATE] at 1:00 am, LPN #1 entered the Resident #9 ' s room and noted Resident #9 to be lying in the bed with eyes closed and respirations even and unlabored with the skin noted to be warm and dry to touch. Review of documentation provided by Certified Nurse Assistant (CNA) #1 revealed that on [DATE] at 11:30 pm, Resident #9 had requested juices due to low blood sugar. CNA #1 went to the Nurses Station and reported to the nurse on duty, LPN #1, that Resident #9 ' s blood glucose needed to be checked. LPN #1 went to Resident #9 ' s room and checked the blood glucose. CNA #1 returned to Resident #9 ' s room at approximately 1:30 a.m. after Resident #9 was not looking " good " so LPN #1 returned to the room to check on the resident. At 3:30 a.m. to 4:00 a.m. on [DATE] CNA #2 went to Resident #9 ' s room to assist while CNA #1 was assisting another resident. When CNA #1 entered Resident #9 ' s room the Resident was sitting on the side of the bed and wanted to get up. CNA #1 informed Resident #9 that it was not a good idea to get up since the blood glucose was low. CNA #1 documented in the statement that " (Resident #9) was sweating really bad, very weak. It took Resident #9 a long time to respond as usual " . CNA #2 turned the air on for Resident #9 and left the room. CNA #1 documented in the statement that CNA #2 verbally told LPN #1 that Resident #9 was not looking good. CNA #2 documented in a statement dated [DATE] that Resident #9 was very sweaty and limp about 3:00 a.m. on [DATE] and that LPN #1 was notified that Resident #9 did not " look good " . There was no documented evidence in the Nurses Note dated [DATE] to indicate that LPN #1 had checked on Resident #9 between the times of 1:00 a.m. and 5:25 a..m. On [DATE] at 5:25 am, LPN #1 entered Resident #9 ' s room and found Resident #9 to be unresponsive. Resident #9 ' s blood glucose was checked at that time and was documented as 30. LPN #1 attempted to give Resident #9 jelly and was unable to get a response. LPN #1 documented that [MEDICATION NAME] injection was administered per facility policy, which was [MEDICATION NAME] 1 milligram (mg). LPN #1 was unable to obtain a blood pressure or pulse and called the B Wing LPN #2 to assist. Resident #9 ' s chart was checked and it was determined that Resident #9 was a Full Code. LPN #3 and LPN #4 from A Wing initiated Cardiopulmonary Resuscitation (CPR) at 5:30 am and LPN #1 called for the ambulance then returned to the room to assist with the CPR. Documentation in the Nurses Notes dated on [DATE] at 5:45 am, revealed that the Emergency Medical Technicians (EMTs) arrived and started life saving measures. The Coroner documented in the medical record that upon arrival EMT ' s were present and there was no cardiopulmonary activity and no pupil reaction and Resident #9 was pronounced as expired at 6:29 a.m. The facility made changes to the " Code Status Policy " on [DATE] to enable the nursing staff to more easily identify if a resident was a full code or a no code status. This was accomplished with the implementation of the placement of a green dot on the medical record and on the faceplate outside the residents ' door for residents that were a full code; a red dot was placed on the medical record and on the faceplate outside the resident door for residents who chose to be classified as a no code. LPN#1 was an agency nurse and had worked in the facility since [DATE]. The staffing agency was notified by the Director of Nursing on [DATE] and informed the owner of the agency that LPN #1 would not be allowed to work in the facility again. LPN #2 was an agency nurse and had worked in the facility since [DATE]. The State Attorney General ' s Office, the State Department of Health Licensure and the State Board of Nursing were notified by the Director of Nursing of the incident involving Resident #9 on [DATE]. On [DATE] beginning at 5:00 p.m., an audit of the medical records was conducted by Assistant Director of Nursing, Quality Assurance LPN #1, Quality Assurance LPN #2, LPN #6, LPN #7, LPN #8, LPN #9 and LPN #10. There were 59 diabetic residents out of a total census of 138. The medical records were reviewed to determine if the documentation identified any blood glucose less that 60, any action taken, physician notification of any hypoglycemic episode, monitoring for repeat episodes, and any interventions related to the hypoglycemic episode. On A Unit, 15 diabetic Residents were reviewed. Hypoglycemic episodes were identified on 3 of the 15 Residents reviewed. The Residents identified with hypoglycemic episodes on Unit A included Resident #11, Resident #35, and Resident #34. Resident #11 no documentation was found on the hypoglycemic episode that occurred on [DATE] at 8:00 pm. LPN #11 who was the nurse involved, was in-serviced one-on-one on [DATE], by the Assistant Director of Nursing (ADON) reviewing the Diabetic Procotol to be followed during a hypoglycemic episode. Resident #35 had incorrect orders on the chart and Physician #2 was notified by the ADON on [DATE] at 8:30 p.m. for clarification orders related to the orders for the sliding scale insulin. Physician #2 issued new orders on [DATE] at 8:30 pm. Resident #35 had 3 hypoglycemic episodes ([DATE] at 7:30 am - [DATE] at 5:30 am - [DATE] at 7:30 am). On [DATE] at 7:30 am, a blood sugar of 42 was documented and juice was administered to Resident #35 by LPN #12. On [DATE] at 7:30 am, a blood sugar of 42 was documented and juice was administered to Resident #35 by LPN #12. On [DATE] at 5:30 am Resident #35 was noted with a blood sugar of 45 and juice was administered by LPN #4. LPN #4 rechecked the blood glucose at on [DATE] at 5:50 am with blood sugar of 100. LPN #4 rechecked Resident #35 ' s blood glucose at 6:05 am on [DATE], with blood sugar of 152. LPN # 4 did not document that the Physician nor Responsible Party was notified. On [DATE] at 7:30 am, LPN #12 documented a blood sugar of 55 for Resident #35 and Sweetened orange juice was given, Resident #35 was eating cookies and sitting at the table awaiting the breakfast meal. At 8:00 am on [DATE] LPN #4 rechecked Resident #35 ' s blood sugar and documented a result of 108 and breakfast was served. On [DATE] at 11:30 am, Resident #35 ' s blood sugar was documented at 387. Sliding scale was followed as ordered and 12 Units of [MEDICATION NAME] Insulin was given as well as [MEDICATION NAME] seven (7) unit [MEDICATION NAME] which was a routine order from the Physician. The Physician and Responsible Party were notified on [DATE] at 2:20 p.m. by LPN #12. Documentation reflects that morning dose of scheduled insulin had been refused by Resident #35. Resident #34 had a hypoglycemic episode on [DATE] at 4:30pm with the blood glucose documented as 51. LPN #13 documented that a snack was provided. There was no documented follow up of the blood glucose or that the Physician was notified. LPN #14 documented on [DATE] at 4:30pm, blood glucose was 58 with no documentation that the Diabetic Protocol was followed. LPN #14 documented on [DATE] at 4:30 pm, blood glucose was 55 and documented that " OJ(orange Juice) " was given. Physician #1 was notified of the low blood sugars by LPN #14 on [DATE] at 10:00pm and new orders were received to " change Lantis Insulin to Levimir 40 units twice a day and [MEDICATION NAME] 10 units before meals. If blood sugar is less than 100, hold the insulin. Accu-checks four times a day " . No further episodes of [DIAGNOSES REDACTED] were documented for Resident #34. On [DATE] at 8:00am, the Director of Nursing began notifying the Physicians and Responsible Parties of Resident #11, Resident #35, and Resident #34 of the hypoglycemic episodes and the interventions. On [DATE] beginning at 5:00 p.m. 23 diabetic Residents on B Unit were reviewed. Hypoglycemic episodes were identified on 8 of the 23 Residents reviewed. The residents reviewed included Resident #23, Resident #36, Resident #1, Resident 41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #16 as 45 with orange juice and graham crackers given. The blood glucose was rechecked at an unknown time and was documented as 206. \On [DATE] at 3:00 a.m., Resident #23 ' s blood glucose was documented by LPN #16 as 41 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 323. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #5 as 55 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 147. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 50 and a snack was given and there was no documented followup. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 30 and juice was given and the next blood glucose was documented at 5:00 p.m. on [DATE]. On [DATE] at 11:30 a.m. Resident #1 ' s blood glucose was documented by LPN #20 as 54 and orange juice was given and the next documented blood sugar was at 4:30 p.m. and was 142. On [DATE] at 6:30 a.m. Resid3ent #41 ' s blood glucose was documented as 48 by LPN #16 and a snack was given. The next documented blood glucose was 173 on [DATE] at 11:30 a.m. On [DATE] at 8:00 p.m. LPN #17 documented Resident #44 ' s blood glucose as 42 and a snack was given. There was no documented evidence of a follow up or physician notification. On [DATE] at 11:30 a.m., LPN #15 documented Resident #7 ' s blood glucose as 54. Lunch was given. The next documented blood glucose was on [DATE] at 4:30 p.m. and was 182. On [DATE] at 6:30 a.m., LPN #16 documented Resident #7 ' s blood glucose 59 with a snack given and a follow up blood glucose of 66 on [DATE] at 6:45 a.m. On [DATE] at 6:30 a.m., LPN #17 documented Resident #7 ' s blood glucose as 48 with a snack with juice given. At 11:30 a.m. the blood glucose was documented at 200. On [DATE] at 6:30 a.m. LPN #18 documented Resident #31 ' s blood glucose as 59 with juice and a snack given. The next documented blood glucose was on [DATE] at 11:30 a.m. and was documented as 128. On [DATE] at 6:30 a.m. LPN #5 documented Resident #22 ' s blood glucose was documented as 50 with orange juice given and no documented followup. On [DATE] at 4:30 p.m., LPN #17 documented Resident #43 ' s blood glucose as 56 with juke and supper given and the next documented blood glucose was on [DATE] at 8:00 p.m. of 149. On [DATE] at 4:30 p.m. LPN #19 documented Resident 43 ' s blood glucose as 58 with juice and sugar given with no documented followup. Notification of Physician #1 and Physician #2 began on [DATE] at 8:00 am by the Director of Nursing. The Physicians and the Responsible Parties of Resident #23, Resident #36, Resident #1, Resident #41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43 were notified of the hypoglycemic episodes and the interventions. One-on-one in-service to LPN ' s began on [DATE] at 10:00 pm, conducted by the Assistant Director of Nursing and addressed the facility Diabetic Protocol. On C Unit, 21 diabetic Residents were reviewed and no hypoglycemic episodes were identified. The facility Diabetic Protocol was revised on [DATE] with the following changes: - To define " substantial snack: as being at least 1 ounce peanut butter, cheese, or meat OR 8 ounces of whole milk - To identify the amount of sugar (3 packs) to be used to sweeten the juice - To repeat the blood glucose check in 2 hours following any hypoglycemic episode (blood glucose less than 60) - To notify physician if the blood glucose registers 60 to 70 twice in a weekly period The RN' s, LPN' s, Agency Staff and CNA's were in-serviced on the Diabetic Protocol beginning on [DATE] on the 3pm-11pm shift and the 11pm-7 am shift. The in-service was done by LPN AQ Nurse #1 and LPN QA Nurse #2. No RN, LPN, or CNA will be allowed to work until in-serviced. The protocol for orienting agency staff to the facility was revised on [DATE] to include Diabet6ic Protocol, Code Status, Emergency Procedures. The agency staff orientation includes the implementation of an evaluation check list that will be completed and signed by the agency nurse prior to the nurse working in the facility. The two agency nurse, Agency Nurse #1 and Agency Nurse #2, working on [DATE] were in-serviced addressing Diabetic Protocol, Code Status and Emergency Procedures by the QA LPN #2. The Staff Development person was in-serviced by the Administrator on [DATE] related to the evaluation check list and policies and procedures for agency staff. The facility Code Status Policy was updated on [DATE] to reflect the use of the colored dots to identify the Residents ' code status, (Green dot = Full Code and Red Dot = NO Code). The Code Status of all current Residents(138) were reviewed on [DATE] by the Assistant Director of Nursing, QA LPN #1, QA LPN #2, LPN #6, LPN #7k LPN #8, LPN #9 and LPN #10 beginning at *:00pm. A green dot was placed on the end of the chart and on the nameplate outside the Resident ' s room to identify Residents who were designated as a Full Code and a red dot to identify Residents that were designated as a No Code. The admissions Coordinator is responsible for placing the appropriate colored dot on admission or on change of status. The admissions Coordinator was in-serviced on the dot system by the Administrator on [DATE] at 8:45 am. The RN ' s, LPN ' s, Agency Staff and CNA ' s were in-serviced on the colored dot system beginning on [DATE] on the 3pm-11pm shift and the 11 pm-7amshift. No RN, LPN, or CNA will be allowed to work until the in-serviced. The in-service to the nursing staff was done by LPN QA Nurse #1 and LPN QA Nurse #2. A Quality Assurance Committee meeting was called on [DATE] at 4:15 pm and was attended by the Medical Director, the Administrator, the Director of Nursing, the RN Nurse Consultant, the Assistant Director of Nursing, two QA Nurses. The Diabetic Protocol was addressed and the protocol was revised. The agency Nurse Evaluation was discussed and changes made. The Code Status Policy reviewed and revised with immediate implementation. On [DATE], it was discovered that the list of diabetic residents provided to the survey team on the entrance date of [DATE], did not match the list of diabetic residents whose medical records were audited on [DATE]. This was evidenced by the facility providing Resident names on a Resident list as referenced in the Allegation of Compliance that were not on the list that was provided to the survey team upon entrance. Interviews with the staff involved in the Medical Record review revealed that audit forms were not completed on the Residents that do not require accu-checks nor on the Residents who had no hypoglycemic episodes. Statements were obtained from staff members LPN #8 and LPN #9 on [DATE] confirming that the Residents who did not require accu-checks or have had no hypoglycemic episodes were reviewed and there were no concerns. Chart review forms were completed on [DATE] at 6pm. Addendum to AOC [DATE] Re: Glucometer Control Checks On [DATE] concerns identified included: ? The glucometer control checks not being performed as directed by the manufacturer or the facility policy, ? Glucometer Serial numbers being worn off the back of the glucometer, ? Control Solution Record not being maintained for each individual serial numbered glucometers, ? Control solution not being dated when opened, ? Bottle of glucometer strips not being dated when opened On [DATE] beginning at 11:10 a.m. all on duty nursing staff, including Registered Nurses (RN) and Licensed Practical Nurses (LPN) were in serviced by the Quality Assurance Nurse regarding the policy and procedure for the checking of the glucometer controls. The inservice included review of the facility policy " Quality Control Check (for the accu-check machine) ' and Manufacturers Instructions which include for a control check to be performed: ? Before testing the first time ? With each new bottle of strips ? Whenever it is suspected that the meter or test strips may not be functioning properly ? If the test result appears to be abnormally high or low, or are not consistent with the resident ' s symptoms ? The test strip bottle has been left open or exposed to temperature below 40 degrees or above 86 degrees, light or humidity levels above 85% ? To check the technique ? When the glucometer has been dropped ? When the glucometer has been stored below 14 degrees or above 1430 degrees or in humidity levels above 85% ? Dating and checking glucometer strips when the bottle was open and checking the expiration date to ensure that solution was not expired ? Each Monday night on the 11 p.m. to 7 a.m. shift a Glucometer Control Check will be perfumed and documented on the " Blood Glucose Monitoring System Quality Control Results Record " and, Dating of the control solution when the bottle was open and checking the expiration date to ensure the solution was not expired A 100% audit of all six (6) medication carts was conducted began on [DATE] at 11:45 a.m. The audit included checking to ensure that there was a glucometer on each medication cart and a " Blood Glucose Monitoring System Quality Control Results Record " was provided for the documentation of the control checks, and that the nurse could discuss the process for testing the control strips and that the control solution and the glucometer strips were not expired. Any glucose control strips and or control solutions that were not dated when opened were discarded. Glucometers were labeled according to the Medication Cart that it was to be maintained on: Upper A, Lower A, Upper B, Lower B, Upper C, Lower C. Two glucometers were observed on the Upper A, Lower A, Upper B, Lower B, Upper C and Lower C Medication Carts. There is one " Blood Glucose Monitoring System Quality Control Results Record " for each glucometer. The on duty nursing staff, including Registered Nurses and Licensed Practical Nurses was in serviced and no RN or LPN, facility or agency staff, will be allowed to work until inserviced regarding the facility policy and the manufactor ' s instructions for the t6esting of the controls for the blood glucose monitors. The in-service for the RN ' s and LPNs included review of the facility policy for testing of the glucometer controls. No RN or LPN will be allowed to work until in servicing has been performed. Monitoring of the process to ensure that the Quality Control Checks are performed as instructed by the Manufacturer and in accordance with th3e facility policy was conducted by Quality Assurance Nurse #1 and #2 and the Assistant Director of Nursing. Those Checks are documented on the " Control Solution Record " . HANDWRITTEN INFORMATION On [DATE] the 11p-7a shift will be inserviced and copy faxed to MSDH on Monday No staff (RN, LPN) will be allowed to work until they have been inserviced on the Glucometer Control Checks. Verification of the Allegation of Compliance (AoC): Based on random observations, staff interviews, review of inservice records and record review beginning on [DATE] at 11:45 a.m. confirmed that immediate corrective actions were implemented. The facility had inservice documentation regarding the "Diabetic Protocol", "Code Status" and "Emergency Procedures". The facility checked all six (6) medication carts to ensure that the glucometers were calibrated and documented. An interview on [DATE] at 3:10 p.m. with LPN #25 on B-Wing (7a-7p shift) confirmed that she was in-serviced on the aforementioned policy's. LPN #25 was able to calibrate the glucometer and knew where to document the calibration. LPN #25 was able to state the Code Status of Resident's due to the red or green dot on each Resident's door. An interview on [DATE] at 3:15 p.m. with LPN #20 on B-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:20 p.m. with LPN #26 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information. There were two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:25 p.m. with LPN #20 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:30 p.m. with LPN #28 on C-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident ' door. An interview on [DATE] at 3:35 p.m. with LPN #29 on C-Wing (7:00 a.m. to 7:00 p.m. shift) revealed that they were in-serviced on the Diabetic Protocol, changes in the policys, Code Status; and information regarding the two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. LPN #29 stated that the Code Status is identified with a red or green dot on each the residents' door. An interview on [DATE] at 3:40 p.m. with LPN #14 on C-Wing (3:00 p.m. to 11:00 p.m. shift) confirmed of being in-serviced on the above information with two (2) glucometers on the upper medication cart and the labeled BGMSQCRR sheet labeled on the MAR. LPN #14 also confirmed that the Code Status is identified by a red or green dot on each the resident's door. An interview on [DATE] at 3:45 p.m. with RN #2 (7:00 a.m. to 3:00 p.m.) confirmed that she was in-serviced on the Code Status, the Diabetic Protocol and the glucometers. An interview on [DATE] at 3:48 p.m. with LPN #10 on (3:00 p.m. to l1:00 p.m. shift) confirmed that she was in-serviced on the Diabetic Protocol; checking the controls on the glucometers and the Code Status of residents. Other interviews on [DATE] with RNs, LPNs, and CNAs were conducted during the survey to confirm their understanding of the facility's policy changes regarding the Diabetic Protocol; Code Status; checking the glucometer controls; how to use the Ambu bag to include emergency measures; and notifying the Physician as per facility policy. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which constitutes actual harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

Based on record review, staff interview and facility policy review the facility failed to ensure that 20 of 32 Resident's reviewed with the [DIAGNOSES REDACTED]. This is for Resident #1, #5, #7, #9, #11, #14, #15, #21, #22, #23, #26, #28, #32, #34, #36, #40, #41, #42, #43, #44. There was no documentation in some of the records as to the results of the glucose levels; no documentation as per facility policy regarding the resident's signs and symptoms; and/or no follow up documentation of repeated glucose levels. There was no documentation to explain why Insulin was held and if the Physician was notified. There was lack of information in regards to checking the glucose meters controls as stated per facility policy. There were 59 Residents out of a census of 136 in the facility with the [DIAGNOSES REDACTED]. The lack of documentation to ensure that these Resident's received the necessary care and services were determined to be an Immediate Jeopardy (IJ) at a "K" level on [DATE] at 3:55 p.m. The Administrator, Director of Nursing, and Nurse Consultant were notified at that time. The Immediate Jeopardy at a "K" level began on [DATE] at 5:25 p.m. when Resident #9 was found unresponsive with a blood glucose of 30 mg/dl; was given jelly by mouth; and then identified to have no pulse or respirations. Resident #9 expired. Resident #9 had a history of [REDACTED]. The facility provided a Credible Allegation of Compliance on [DATE] at 3:00 p.m. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which constitutes no actual harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Cross refer findings to F 309 for the facility's failure to ensure that there was documentation of the care and services required by the Resident's for the treatment of [REDACTED]. Review of the Clinical Records Policy (with no implementation date) revealed: "It is the policy of this facility that clinical records will be maintained as follows: Clinical records are to be as follows: Complete, Accurately documented, readily accessible and systematically original. The facility provided the following Allegation of Compliance (AoC). "Allegation of Compliance An Immediate Jeopardy was called on [DATE] at 3:55pm related to the care of a diabetic resident, Resident #9 was noted with blood glucose of 46. Resident #9 was alert and oriented times 3 (oriented to person, place, and time). Resident #9 ' s skin was warm and dry to touch with respirations even and unlabored. The registered Nurse #1 (RN) administered four (4) ounces of orange juice with one pack of peanut butter and crackers. On [DATE] at 9:30pm, Resident #9 ' s blood glucose was rechecked and was noted to be 60. Resident #9 remained alert and oriented times three. On [DATE] at 10:30pm, RN #1 was called to Resident #9 ' s room. Resident #9 was diaphoretic with skin cool and clammy, lethargic and blood glucose was 38. Physician #1 was in the facility making rounds and was asked to check Resident #9. Physician #1 gave verbal orders as follows: (1) Gluca Gen Hypoo Kit times one dose now intramuscular (2) Give Insta Glucose Gel times one tube now by mouth due to low blood (3) Re-check blood sugar every 15 minutes for one hour On [DATE] at 10:30 pm, RN #1 administered the Gluca Gen Hypo Kit and the Insta Glucose as ordered. The blood sugar was re-checked by RN #1 on Resident #9 at 10:45 pm and was noted to be 56. Resident #9 was given a cup of orange juice. RN #1 re-checked blood glucose on Resident #9 again at 11:00 pm and was documented as 98. Resident #9 was resting in bed and was alert and oriented times three. On [DATE] at 11:15 p.m., LPN #1 performed a blood glucose recheck for Resident #9 and documented it as 79. At 11:15 p.m. LPN #1 called Physician #1 and received an order to discontinue [MEDICATION NAME] 12 units to be administered at every hour of sleep and start [MEDICATION NAME] Insulin at 6 units subcutaneously every hour of sleep and to hold all sliding scale insulin on [DATE]. On [DATE] at 11:30 p.m. Resident #9 ' s blood sugar was rechecked by LPN #1 and was documented as 114. Resident #9 was alert and taking and asked LPN #1 to turn on the fan. On [DATE] at 1:00 am, LPN #1 entered the Resident #9 ' s room and noted Resident #9 to be lying in the bed with eyes closed and respirations even and unlabored with the skin noted to be warm and dry to touch. Review of documentation provided by Certified Nurse Assistant (CNA) #1 revealed that on [DATE] at 11:30 pm, Resident #9 had requested juices due to low blood sugar. CNA #1 went to the Nurses Station and reported to the nurse on duty, LPN #1, that Resident #9 ' s blood glucose needed to be checked. LPN #1 went to Resident #9 ' s room and checked the blood glucose. CNA #1 returned to Resident #9 ' s room at approximately 1:30 a.m. after Resident #9 was not looking " good " so LPN #1 returned to the room to check on the resident. At 3:30 a.m. to 4:00 a.m. on [DATE] CNA #2 went to Resident #9 ' s room to assist while CNA #1 was assisting another resident. When CNA #1 entered Resident #9 ' s room the Resident was sitting on the side of the bed and wanted to get up. CNA #1 informed Resident #9 that it was not a good idea to get up since the blood glucose was low. CNA #1 documented in the statement that " (Resident #9) was sweating really bad, very weak. It took Resident #9 a long time to respond as usual " . CNA #2 turned the air on for Resident #9 and left the room. CNA #1 documented in the statement that CNA #2 verbally told LPN #1 that Resident #9 was not looking good. CNA #2 documented in a statement dated [DATE] that Resident #9 was very sweaty and limp about 3:00 a.m. on [DATE] and that LPN #1 was notified that Resident #9 did not " look good " . There was no documented evidence in the Nurses Noted dated [DATE] to indicate that LPN #1 had checked on Resident #9 between the times of 1:00 a.m. and 5:25 a..m. On [DATE] at 5:25 am, LPN #1 entered Resident #9 ' s room and found Resident #9 to be unresponsive. Resident #9 ' s blood glucose was checked at that time and was documented as 30. LPN #1 attempted to give Resident #9 jelly and was unable to get a response. LPN #1 documented that [MEDICATION NAME] injection was administered per facility policy, which was [MEDICATION NAME] 1 milligram (mg). LPN #1 was unable to obtain a blood pressure or pulse and called the B Wing LPN #2 to assist. Resident #9 ' s chart was checked and it was determined that Resident #9 was a Full Code. LPN #3 and LPN #4 from A Wing initiated Cardiopulmonary Resuscitation (CPR) at 5:30 am and LPN #1 called for the ambulance then returned to the room to assist with the CPR. Documentation in the Nurses Notes dated on [DATE] at 5:45 am, revealed that the Emergency Medical Technicians (EMTs) arrived and started life saving measures. The Coroner documented in the medical record that upon arrival EMT ' s were present and there was no cardiopulmonary activity and no pupil reaction and Resident #9 was pronounced as expired at 6:29 a.m. The facility made changes to the " Code Status Policy " on [DATE] to enable the nursing staff to more easily identify if a resident was a full code or a no code status. This was accomplished with the implementation of the placement of a green dot on the medical record and on the faceplate outside the residents ' door for residents that were a full code; a red dot was placed on the medical record and on the faceplate outside the resident door for residents who chose to be classified as a no code. LPN#1 was an agency nurse and had worked in the facility since [DATE]. The staffing agency was notified by the Director of Nursing on [DATE] and informed the owner of the agency that LPN #1 would not be allowed to work in the facility again. LPN #2 was an agency nurse and had worked in the facility since [DATE]. The State Attorney General ' s Office, the State Department of Health Licensure and the State Board of Nursing were notified by the Director of Nursing of the incident involving Resident #9 on [DATE]. On [DATE] beginning at 5:00 p.m., an audit of the medical records was conducted by Assistant Director of Nursing, Quality Assurance LPN #1, Quality Assurance LPN #2, LPN #6, LPN #7, LPN #8, LPN #9 and LPN #10. There were 59 diabetic residents out of a total census of 138. The medical records were reviewed to determine if the documentation identified any blood glucose less that 60, any action taken, physician notification of any hypoglycemic episode, monitoring for repeat episodes, and any interventions related to the hypoglycemic episode. On A Unit, 15 diabetic Residents were reviewed. Hypoglycemic episodes were identified on 3 of the 15 Residents reviewed. The Residents identified with hypoglycemic episodes on Unit A included Resident #11, Resident #35, and Resident #34. Resident #11 no documentation was found on the hypoglycemic episode that occurred on [DATE] at 8:00 pm. LPN #11 who was the nurse involved, was in-serviced one-on-one on [DATE], by the Assistant Director of Nursing (ADON) reviewing the Diabetic Procotol to be followed during a hypoglycemic episode. Resident #35 had incorrect orders on the chart and Physician #2 was notified by the ADON on [DATE] at 8:30 p.m. for clarification orders related to the orders for the sliding scale insulin. Physician #2 issued new orders on [DATE] at 8:30 pm. Resident #35 had 3 hypoglycemic episodes ([DATE] at 7:30 am - [DATE] at 5:30 am - [DATE] at 7:30 am). On [DATE] at 7:30 am, a blood sugar of 42 was documented and juice was administered to Resident #35 by LPN #12. On [DATE] at 7:30 am, a blood sugar of 42 was documented and juice was administered to Resident #35 by LPN #12. On [DATE] at 5:30 am Resident #35 was noted with a blood sugar of 45 and juice was administered by LPN #4. LPN #4 rechecked the blood glucose at on [DATE] at 5:50 am with blood sugar of 100. LPN #4 rechecked Resident #35 ' s blood glucose at 6:05 am on [DATE], with blood sugar of 152. LPN # 4 did not document that the Physician nor Responsible Party was notified. On [DATE] at 7:30 am, LPN #12 documented a blood sugar of 55 for Resident #35 and Sweetened orange juice was given, Resident #35 was eating cookies and sitting at the table awaiting the breakfast meal. At 8:00 am on [DATE] LPN #4 rechecked Resident #35 ' s blood sugar and documented a result of 108 and breakfast was served. On [DATE] at 11:30 am, Resident #35 ' s blood sugar was documented at 387. Sliding scale was followed as ordered and 12 Units of [MEDICATION NAME] Insulin was given as well as [MEDICATION NAME] seven (7) unit [MEDICATION NAME] which was a routine order from the Physician. The Physician and Responsible Party were notified on [DATE] at 2:20 p.m. by LPN #12. Documentation reflects that morning dose of scheduled insulin had been refused by Resident #35. Resident #34 had a hypoglycemic episode on [DATE] at 4:30pm with the blood glucose documented as 51. LPN #13 documented that a snack was provided. There was no documented follow up of the blood glucose or that the Physician was notified. LPN #14 documented on [DATE] at 4:30pm, blood glucose was 58 with no documentation that the Diabetic Protocol was followed. LPN #14 documented on [DATE] at 4:30 pm, blood glucose was 55 and documented that " OJ(orange Juice) " was given. Physician #1 was notified of the low blood sugars by LPN #14 on [DATE] at 10:00pm and new orders were received to " change Lantis Insulin to Levimir 40 units twice a day and [MEDICATION NAME] 10 units before meals. If blood sugar is less than 100, hold the insulin. Accu-checks four times a day " . No further episodes of [DIAGNOSES REDACTED] were documented for Resident #34. On [DATE] at 8:00am, the Director of Nursing began notifying the Physicians and Responsible Parties of Resident #11, Resident #35, and Resident #34 of the hypoglycemic episodes and the interventions. On [DATE] beginning at 5:00 p.m. 23 diabetic Residents on B Unit were reviewed. Hypoglycemic episodes were identified on 8 of the 23 Residents reviewed. The residents reviewed included Resident #23, Resident #36, Resident #1, Resident 41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #16 as 45 with orange juice and graham crackers given. The blood glucose was rechecked at an unknown time and was documented as 206. On [DATE] at 3:00 a.m., Resident #23 ' s blood glucose was documented by LPN #16 as 41 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 323. On [DATE] at 3:00 a.m. Resident #23 ' s blood glucose was documented by LPN #5 as 55 and a snack was given. The next documented blood glucose was at 7:00 a.m. on [DATE] with a result of 147. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 50 and a snack was given and there was no documented followup. On [DATE] at 4:30 p.m. Resident #36 ' s blood glucose was documented by LPN #17 as 30 and juice was given and the next blood glucose was documented at 5:00 p.m. on [DATE]. On [DATE] at 11:30 a.m. Resident #1 ' s blood glucose was documented by LPN #20 as 54 and orange juice was given and the next documented blood sugar was at 4:30 p.m. and was 142. On [DATE] at 6:30 a.m. Resident #41 ' s blood glucose was documented as 48 by LPN #16 and a snack was given. The next documented blood glucose was 173 on [DATE] at 11:30 a.m. On [DATE] at 8:00 p.m. LPN #17 documented Resident #44 ' s blood glucose as 42 and a snack was given. There was no documented evidence of a follow up or physician notification. On [DATE] at 11:30 a.m., LPN #15 documented Resident #7 ' s blood glucose as 54. Lunch was given. The next documented blood glucose was on [DATE] at 4:30 p.m. and was 182. On [DATE] at 6:30 a.m., LPN #16 documented Resident #7 ' s blood glucose 59 with a snack given and a follow up blood glucose of 66 on [DATE] at 6:45 a.m. On [DATE] at 6:30 a.m., LPN #17 documented Resident #7 ' s blood glucose as 48 with a snack with juice given. At 11:30 a.m. the blood glucose was documented at 200. On [DATE] at 6:30 a.m. LPN #18 documented Resident #31 ' s blood glucose as 59 with juice and a snack given. The next documented blood glucose was on [DATE] at 11:30 a.m. and was documented as 128. On [DATE] at 6:30 a.m. LPN #5 documented Resident #22 ' s blood glucose was documented as 50 with orange juice given and no documented followup. On [DATE] at 4:30 p.m., LPN #17 documented Resident #43 ' s blood glucose as 56 with juke and supper given and the next documented blood glucose was on [DATE] at 8:00 p.m. of 149. On [DATE] at 4:30 p.m. LPN #19 documented Resident 43 ' s blood glucose as 58 with juice and sugar given with no documented followup. Notification of Physician #1 and Physician #2 began on [DATE] at 8:00 am by the Director of Nursing. The Physicians and the Responsible Parties of Resident #23, Resident #36, Resident #1, Resident #41, Resident #44, Resident #7, Resident #31, Resident #22, and Resident #43 were notified of the hypoglycemic episodes and the interventions. One-on-one in-service to LPN ' s began on [DATE] at 10:00 pm, conducted by the Assistant Director of Nursing and addressed the facility Diabetic Protocol. On C Unit, 21 diabetic Residents were reviewed and no hypoglycemic episodes were identified. The facility Diabetic Protocol was revised on [DATE] with the following changes: - To define " substantial snack: as being at least 1 ounce peanut butter, cheese, or meat OR 8 ounces of whole milk - To identify the amount of sugar (3 packs) to be used to sweeten the juice - To repeat the blood glucose check in 2 hours following any hypoglycemic episode (blood glucose less than 60) - To notify physician if the blood glucose registers 60 to 70 twice in a weekly period The RN ' s, LPN ' s, Agency Staff and CNA ' s were in-serviced on the Diabetic Protocol beginning on [DATE] on the 3pm-11pm shift and the 11pm-7 am shift. The in-service was done by LPN AQ Nurse #1 and LPN QA Nurse #2. No RN, LPN, or CNA will be allowed to work until in-serviced. The protocol for orienting agency staff to the facility was revised on [DATE] to include Diabetic Protocol, Code Status, Emergency Procedures. The agency staff orientation includes the implementation of an evaluation check list that will be completed and signed by the agency nurse prior to the nurse working in the facility. The two agency nurse, Agency Nurse #1 and Agency Nurse #2, working on [DATE] were in-serviced addressing Diabetic Protocol, Code Status and Emergency Procedures by the QA LPN #2. The Staff Development person was in-serviced by the Administrator on [DATE] related to the evaluation check list and policies and procedures for agency staff. The facility Code Status Policy was updated on [DATE] to reflect the use of the colored dots to identify the Residents ' code status, (Green dot = Full Code and Red Dot = NO Code). The Code Status of all current Residents(138) were reviewed on [DATE] by the Assistant Director of Nursing, QA LPN #1, QA LPN #2, LPN #6, LPN #7 LPN #8, LPN #9 and LPN #10 beginning at *:8:00pm. A green dot was placed on the end of the chart and on the nameplate outside the Resident ' s room to identify Residents who were designated as a Full Code and a red dot to identify Residents that were designated as a No Code. The admissions Coordinator is responsible for placing the appropriate colored dot on admission or on change of status. The admissions Coordinator was in-serviced on the dot system by the Administrator on [DATE] at 8:45 am. The RN ' s, LPN ' s, Agency Staff and CNA ' s were in-serviced on the colored dot system beginning on [DATE] on the 3pm-11pm shift and the 11 pm-7amshift. No RN, LPN, or CNA will be allowed to work until the in-serviced. The in-service to the nursing staff was done by LPN QA Nurse #1 and LPN QA Nurse #2. A Quality Assurance Committee meeting was called on [DATE] at 4:15 pm and was attended by the Medical Director, the Administrator, the Director of Nursing, the RN Nurse Consultant, the Assistant Director of Nursing, two QA Nurses. The Diabetic Protocol was addressed and the protocol was revised. The agency Nurse Evaluation was discussed and changes made. The Code Status Policy reviewed and revised with immediate implementation. On [DATE], it was discovered that the list of diabetic residents provided to the survey team on the entrance date of [DATE], did not match the list of diabetic residents whose medical records were audited on [DATE]. This was evidenced by the facility providing Resident names on a Resident list as referenced in the Allegation of Compliance that were not on the list that was provided to the survey team upon entrance. Interviews with the staff involved in the Medical Record review revealed that audit forms were not completed on the Residents that do not require accu-checks nor on the Residents who had no hypoglycemic episodes. Statements were obtained from staff members LPN #8 and LPN #9 on [DATE] confirming that the Residents who did not require accu-checks or have had no hypoglycemic episodes were reviewed and there were no concerns. Chart review forms were completed on [DATE] at 6pm. Addendum to AOC [DATE] Re: Glucometer Control Checks On [DATE] concerns identified included: ? The glucometer control checks not being performed as directed by the manufacturer or the facility policy, ? Glucometer Serial numbers being worn off the back of the glucometer, ? Control Solution Record not being maintained for each individual serial numbered glucometers, ? Control solution not being dated when opened, ? Bottle of glucometer strips not being dated when opened On [DATE] beginning at 11:10 a.m. all on duty nursing staff, including Registered Nurses (RN) and Licensed Practical Nurses (LPN) were in serviced by the Quality Assurance Nurse regarding the policy and procedure for the checking of the glucometer controls. The inservice included review of the facility policy " Quality Control Check (for the accu-check machine) ' and Manufacturers Instructions which include for a control check to be performed: ? Before testing the first time ? With each new bottle of strips ? Whenever it is suspected that the meter or test strips may not be functioning properly ? If the test result appears to be abnormally high or low, or are not consistent with the resident ' s symptoms ? The test strip bottle has been left open or exposed to temperature below 40 degrees or above 86 degrees, light or humidity levels above 85% ? To check the technique ? When the glucometer has been dropped ? When the glucometer has been stored below 14 degrees or above 1430 degrees or in humidity levels above 85% ? Dating and checking glucometer strips when the bottle was open and checking the expiration date to ensure that solution was not expired ? Each Monday night on the 11 p.m. to 7 a.m. shift a Glucometer Control Check will be perfumed and documented on the " Blood Glucose Monitoring System Quality Control Results Record " and, Dating of the control solution when the bottle was open and checking the expiration date to ensure the solution was not expired A 100% audit of all six (6) medication carts was conducted began on [DATE] at 11:45 a.m. The audit included checking to ensure that there was a glucometer on each medication cart and a " Blood Glucose Monitoring System Quality Control Results Record " was provided for the documentation of the control checks, and that the nurse could discuss the process for testing the control strips and that the control solution and the glucometer strips were not expired. Any glucose control strips and or control solutions that were not dated when opened were discarded. Glucometers were labeled according to the Medication Cart that it was to be maintained on: Upper A, Lower A, Upper B, Lower B, Upper C, Lower C. Two glucometers were observed on the Upper A, Lower A, Upper B, Lower B, Upper C and Lower C Medication Carts. There is one " Blood Glucose Monitoring System Quality Control Results Record " for each glucometer. The on duty nursing staff, including Registered Nurses and Licensed Practical Nurses was in serviced and no RN or LPN, facility or agency staff, will be allowed to work until inserviced regarding the facility policy and the manufacturers ' s instructions for the testing of the controls for the blood glucose monitors. The in-service for the RN ' s and LPNs included review of the facility policy for testing of the glucometer controls. No RN or LPN will be allowed to work until in servicing has been performed. Monitoring of the process to ensure that the Quality Control Checks are performed as instructed by the Manufacturer and in accordance with the facility policy was conducted by Quality Assurance Nurse #1 and #2 and the Assistant Director of Nursing. Those Checks are documented on the " Control Solution Record " . HANDWRITTEN INFORMATION "On [DATE] the 11p-7a shift will be inserviced and copy faxed to MSDH on Monday No staff (RN, LPN) will be allowed to work until they have been inserviced on the Glucometer Control Checks." Verification of the Allegation of Compliance (AoC): Based on random observations, staff interviews, review of inservice records and record review beginning on [DATE] at 11:45 a.m. confirmed that immediate corrective actions were implemented. The facility had inservice documentation regarding the "Diabetic Protocol", "Code Status" and "Emergency Procedures". The facility checked all six (6) medication carts to ensure that the glucometers were calibrated and documented. An interview on [DATE] at 3:10 p.m. with LPN #25 on B-Wing (7a-7p shift) confirmed that she was in-serviced on the aforementioned policy's. LPN #25 was able to calibrate the glucometer and knew where to document the calibration. LPN #25 was able to state the Code Status of Resident's due to the red or green dot on each Resident's door. An interview on [DATE] at 3:15 p.m. with LPN #20 on B-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:20 p.m. with LPN #26 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information. There were two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:25 p.m. with LPN #20 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:30 p.m. with LPN #28 on C-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident ' door. An interview on [DATE] at 3:35 p.m. with LPN #29 on C-Wing (7:00 a.m. to 7:00 p.m. shift) revealed that they were in-serviced on the Diabetic Protocol, changes in the policy's, Code Status; and information regarding the two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. LPN #29 stated that the Code Status is identified with a red or green dot on each the residents' door. An interview on [DATE] at 3:40 p.m. with LPN #14 on C-Wing (3:00 p.m. to 11:00 p.m. shift) confirmed of being in-serviced on the above information with two (2) glucometers on the upper medication cart and the labeled BGMSQCRR sheet labeled on the MAR. LPN #14 also confirmed that the Code Status is identified by a red or green dot on each the resident's door. An interview on [DATE] at 3:45 p.m. with RN #2 (7:00 a.m. to 3:00 p.m.) confirmed that she was in-serviced on the Code Status, the Diabetic Protocol and the glucometers. An interview on [DATE] at 3:48 p.m. with LPN #10 on (3:00 p.m. to l1:00 p.m. shift) confirmed that she was in-serviced on the Diabetic Protocol; checking the controls on the glucometers and the Code Status of residents. Other interviews on [DATE] with RN's, LPN's, and CNA's were conducted during the survey to confirm their understanding of the facility's policy changes regarding the Diabetic Protocol; Code Status; checking the glucometer controls; how to use the Ambu bag to include emergency measures; and notifying the Physician as per facility policy. Verification of the Allegation of Compliance (AoC): Based on random observations, staff interviews, review of inservice records and record review beginning on [DATE] at 11:45 a.m. confirmed that immediate corrective actions were implemented. The facility had inservice documentation regarding the "Diabetic Protocol", "Code Status" and "Emergency Procedures". The facility checked all six (6) medication carts to ensure that the glucometers were calibrated and documented. An interview on [DATE] at 3:10 p.m. with LPN #25 on B-Wing (7a-7p shift) confirmed that she was in-serviced on the aforementioned policy's. LPN #25 was able to calibrate the glucometer and knew where to document the calibration. LPN #25 was able to state the Code Status of Resident's due to the red or green dot on each Resident's door. An interview on [DATE] at 3:15 p.m. with LPN #20 on B-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:20 p.m. with LPN #26 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information. There were two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:25 p.m. with LPN #20 on A-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident's door. An interview on [DATE] at 3:30 p.m. with LPN #28 on C-Wing (7a-7p shift) revealed of being in-serviced on the above information ' s with 2 glucometers on upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. Code Status dot red or green on each the resident ' door. An interview on [DATE] at 3:35 p.m. with LPN #29 on C-Wing (7:00 a.m. to 7:00 p.m. shift) revealed that they were in-serviced on the Diabetic Protocol, changes in the policys, Code Status; and information regarding the two (2) glucometers on the upper medication cart and labeled with BGMSQCRR sheet labeled on the MAR. LPN #29 stated that the Code Status is identified with a red or green dot on each the residents' door. An interview on [DATE] at 3:40 p.m. with LPN #14 on C-Wing (3:00 p.m. to 11:00 p.m. shift) confirmed of being in-serviced on the above information with two (2) glucometers on the upper medication cart and the labeled BGMSQCRR sheet labeled on the MAR. LPN #14 also confirmed that the Code Status is identified by a red or green dot on each the resident's door. An interview on [DATE] at 3:45 p.m. with RN #2 (7:00 a.m. to 3:00 p.m.) confirmed that she was in-serviced on the Code Status, the Diabetic Protocol and the glucometers. An interview on [DATE] at 3:48 p.m. with LPN #10 on (3:00 p.m. to l1:00 p.m. shift) confirmed that she was in-serviced on the Diabetic Protocol; checking the controls on the glucometers and the Code Status of residents. Other interviews on [DATE] with RNs, LPNs, and CNAs were conducted during the survey to confirm their understanding of the facility's policy changes regarding the Diabetic Protocol; Code Status; checking the glucometer controls; how to use the Ambu bag to include emergency measures; and notifying the Physician as per facility policy. Based on verification of corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy at a "K" level was removed and the scope and severity lowered on [DATE] to an "E" level; which no actual harm. with the potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

Part I Complaint # 8648 Based on interview, record review and policy review, the facility failed to ensure that one (1) of four (4) residents (Resident #4) did not develop an avoidable pressure areas to both heels. Resident #4 was assessed as a high pressure ulcer risk and required total assistance for transferring and bed mobility. Resident #4 had daily body audits in place. It was determined that Resident #4 was in the bed for the majority of two (2) shifts and the "Pressure Sore Protocol" called for interventions of heel protectors or floating of the heels. These interventions were not documented as being performed prior to the development of a Stage IV and Stage I decubitus on Resident #4's heel. Resident #4 suffered actual harm by due to the lack of implementation of the preventative measures. Part II Complaint #8640 The facility also failed to ensure that one (1) of four (4) resident's reviewed (Resident #1) was properly assessed for skin impairments per facility policy prior to transfer to the emergency room (ER). This is for Resident #1 who was transferred to the ER with two (2) skin tears and one (1) blistered area. Resident #1 was not assessed for skin impairments as stated in the facility policy prior to being transferred to the ER. Findings Include: Part I Resident #4 was transferred to the hospital on [DATE] and expired at the hospital on [DATE]. Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed that Resident #4 had long and short term memory impairment and was severely impaired for cognitive skills for daily decision-making ability. Resident #4 required total assistance of two (2) persons for transfers and bed mobility and was identified to be incontinent of bowel and bladder. Resident #4 had one (1) Stage II decubitus on her coccyx area documented that had developed on [DATE]. Resident #4 was assessed for "Pressure Ulcer Risk" on [DATE] with a score of "14". On [DATE] Resident #4 had another "Pressure Ulcer Risk" completed with a score of "17". Scores from ,[DATE] document to follow the Pressure Sore Protocol. Review of the "Pressure Sore Protocol Policy" with an effective date of ,[DATE] revealed: "It is the policy of this facility that the Pressure Sore Protocol will be as follows: -Initiated with any resident who triggers at risk for pressure areas Assessment for Pressure Sore Potential triggers from ,[DATE]; Risk factors will be addressed on care plan; High Risk Pressure Relief Mattress; Pressure Relief Pad in wheelchair (as indicated); Residents in bed most of the time; Heel protectors or float heels; Wedge for positioning; Routine turning and repositioning every 2 hours or as specifically ordered; Guaze padding on oxygen tubing as indicated; Health shake daily until assessed by RD then as recommended per RD; Resident with poor appetite or other nutritional compromise; Notify RD for assessment; and Add preventative measures on care plan." Review of the "Prevention of Pressure Areas Policy" revealed: "It is the policy of this facility that prevention of pressure areas will be handled as follows: To ensure that any resident who enters the facility without a pressure sore will not develop pressure sores-Unless the individual's clinical condition demonstrates that they were unavoidable." The policy documents that "Application of pressure reduction or relief devices" will be provided." Review of a Nurse's Note dated [DATE] at 10:15 p.m. revealed that Resident #4 was noted to have breakdown area to right heel approximately 2 cm (centimeters) round, and an area beginning to breakdown to the left side of left heel. A new order for [MEDICATION NAME] and Band-Aid was obtained. Review of documentation in a Nurse's Note dated [DATE] at 4:15 a.m. was the first notation that Resident #4's heels were elevated on a pillow while in bed. Review of a Nurse's Note dated [DATE] at 12:00 p.m. revealed that Resident #4's right heel had a 3.5 cm x 3.0 cm. with an undetermined depth Stage IV decubitus ulcer. The wound bed was red, yellow and black in the center. The left heel was noted to have a Stage I decubitus which measured 2.0 cm x 1.0 cm that was non blanchable and red. Review of "Departmental Notes" for "MDS Note" dated [DATE] at 1:30 pm. revealed that Resident #4 had a Stage II pressure ulcer noted to the coccyx and treated as ordered. There were no stasis ulcers identified. The notes indicated that Geomattress was in place to the bed, turn and reposition every two (2) hours and as needed, [MEDICATION NAME] to vaginal area and lotion after showers as dry skin prevention was documented. There was no documented interventions that included heel protectors or floating heels for prevention of decubitus or breakdown to that area. Review of a "Daily Evaluation of Pressure Sores/Diabetic Ulcers" revealed that Resident #4 had a Pressure Ulcer on the left heel identified on [DATE] as a Stage I which measured 2 cm x 1 cm. and another Pressure Ulcer on the right heel identified on [DATE] as a Stage IV which measured 3.5 cm x 3.0 cm. x an undetermined depth. Review of a physician's orders [REDACTED]. Further physician's orders [REDACTED]. Apply Xenederm to Stage I decubitus ulcer to left heel daily for Resident #4 and to have heel pads on or float heels at all times. Further physician orders [REDACTED]. There were no prior orders or documentation that Resident #4 had received preventative heel protection prior to the identification of a Stage IV to the right heel and a Stage I to the left heel other than a Geomattress to the bed, and to turn/reposition every two (2) hours. Review of a "Report of Consultation" dated [DATE] revealed a recommendation for bilateral foot and heel precautions - float heels and/or heel boots for Resident #4. A [DIAGNOSES REDACTED]. Review of Resident #4's "Treatment Sheet" for [DATE] revealed to perform a daily head to toe skin evaluation for decubitus on ,[DATE] shift and to document 0=None, P=Problem see nurse's note, TX=Treatment in progress. The start date was [DATE]. On [DATE]-[DATE] it was documented as "O". Beginning [DATE] Tx was documented except for [DATE] and [DATE] and "O" was again documented. Review of the [DATE] Treatment Sheet documented that heel protectors were on bilateral or heels were floated at all times with a start date of [DATE] and was documented every shift from [DATE]-[DATE]. Review of the "Resident ADL Record & Care Plan" dated [DATE] for Resident #4 revealed "Float heels @ (at) all times". This was written on the side of the ADL Record but, there was no date to indicate when this intervention was added. Interview with CNA #3 on [DATE] at 4:40 p.m. revealed that she had provided care for Resident #4. CNA #3 stated that Resident #4 did not get up on the ,[DATE] shift. CNA #3 that Resident #4 was fed her supper in the bed. CNA #3 stated that Resident #4 was turned every two (2) hours. CNA #3 stated that they did not start floating Resident #4's heels until after the note was put up about the resident's heel sores. CNA #3 stated that she thought that there had to be an order before doing floating the heels. CNA #3 stated that after the sores had occurred that the big blue boots were placed on Resident #4 and pillows were used to keep the heels off of the bed. CNA #3 stated that the ADL care plan intervention of "floating Resident #4's heels at all times" was added after the resident had heel sores. Interview with LPN #4 on [DATE] at 3:55 p.m. revealed that the heel pressure ulcers on Resident #4 were found on the ,[DATE] shift at Stage I for the left heel and Stage IV for the right heel. LPN #4 stated that the physician and family were notified. LPN #4 stated that normally the resident would have heel pads or float the heels but was not sure if preventative measures were done prior to the heel sores. LPN #4 stated that the floor nurses do the body audits and then she picked the resident up for treatments. Interview with LPN #5 on [DATE] at 4:15 p.m. revealed that she had provided care for Resident #4 at times and had done some of the daily skin assessments. LPN #5 stated that she had not noticed any decubitus on Resident #4's heels. LPN #5 stated that she did note some dryness. LPN #5 stated that she thought that they had been floating Resident #4's heels prior to the decubitus. LPN #5 stated that she knew that Resident #5 was being turned because she had often assisted. Interview with the Director of Nursing (DON) on [DATE] at 11:30 a.m. revealed that the "Pressure Sore Protocol" had not been followed for the use of heel protectors or floating of the heels for Resident #4. The DON stated that that she could not find documentation prior to the breakdown on Resident #4's heels. The DON stated that Resident #4 was in the bed "most of the time" on the 3:00 p.m. to 11:00 p.m. shift and on the 11:00 p.m. to 7:00 a.m. shift. Unable to make an observation of Resident #4. She was transferred to the hospital on [DATE] and expired at the hospital on [DATE]. Part II Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) [DATE] revealed that Resident #1 had long and short term memory problems and was moderately impaired in cognitive daily decision-making skills. Resident #1 required total assistance of two (2) persons for transfers and was identified as being incontinent of bowel and bladder. Review of the physician's orders [REDACTED]. He/she continued to receive an antibiotic for UTI. Resident #1 was assessed upon admission for "Pressure Sore Potential" and scored "16", a score greater than six (6) designated a high risk and the Pressure Sore Protocol was to supposed to be followed. Review of Resident #1's "New Admit to Facility Care Plan" dated [DATE] revealed that nursing was to suppose to examine for any skin breaks. The "Incontinent" care plan had approaches to observe for signs and symptoms of skin breakdown such as redness/discoloration of the skin and blisters or actual breaks in the skin. Review of the admission orders Reminders" of "Head to Toe Skin Assessment" checked. There was no documented order for a time frame of skin assessments. Review of the facility's policy "Head to Toe Skin Evaluation Policy" with an effective date [DATE] revealed that a daily head to toe skin evaluation will be done on residents at high risk for development of pressure areas done by licensed nurse and documented on the MAR (Medication Administration Record) and a weekly evaluation will be done on all other residents and that pressure ulcers would be reported to the Wound Nurse and the Pressure Sore Protocol would be followed. Review of a physician's orders [REDACTED]. Review of the medical record revealed no further documentation of skin evaluations for Resident #1, after the initial evaluation in the Nurse's Note. On [DATE] it was documented that there were no breaks in the resident's skin. There was no documented Nurse's Transfer Note on [DATE] that would have included the condition of Resident #1's skin. Review of an ER record dated [DATE] at 2015 (8:15 p.m. revealed that Resident #1 had three (3) decubiti under the [DIAGNOSES REDACTED]. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 a.m. revealed that she had provided care for Resident #1 and was not aware of any skin concerns. CNA #1 stated that Resident #1 was incontinent and that pericare was provided every two (2) hours. CNA #1 state that she had not noticed any breakdown on the resident's bottom or hips. CNA #1 stated that she had been off for two (2) days and when she returned to work was informed that Resident #1 was in the hospital. Interview with the Director of Nursing (DON) on [DATE] at 3:30 p.m. revealed that there were no body audits documented for Resident #1, except for the admission note that documented no breakdown. The DON stated that daily body audits were supposed to be completed by the nurse on residents with an extremely high risk of pressure ulcers. The body audits are supposed to be done weekly and documented on the MAR. The DON stated that she could find no documentation of a daily or weekly body audit for Resident #1. The DON stated that a transfer note should have been done when the resident was transferred to the hospital which included a head to toe body audit. The DON stated that there was no documentation that this was completed for Resident #1's prior to her transfer on [DATE]. Further interview with the DON on [DATE] at 9:30 a.m. revealed that there was never an order written [REDACTED]. transfer sheet when the resident went out to the hospital." Interview with RN #1 on [DATE] at 3:45 p.m. revealed that she had admitted Resident #1 and had assessed and documented no skin problems. RN #1 stated that she was not aware of any skin problems that had developed during Resident #1's stay. RN #1 stated that if a resident was considered a high risk the skin should be looked at daily. RN #1 stated that Resident #1 did not have any decubitus. RN #1 stated the skin audit should have been printed out on the MAR for how often the skin audit should have been performed. Further interview with RN #1 on [DATE] at 11:40 a.m. revealed that she had failed to write the order for skin audits for Resident #1. RN #1 stated that the skin audits should have been completed at least weekly. Interview with LPN #1 on [DATE] at 11:00 a.m. revealed that skin audits should be done on residents at least weekly and that they are divided for each shift to do so many audits. LPN #1 stated that she did not recall Resident #1 having any skin problems and that no one had reported any to her. Interview with CNA #2 on [DATE] at 11:30 a.m. revealed that she had provided care for Resident #1 only a few days and was not aware of any broken areas of skin. CNA #2 did recall that Resident #1 might have had a blister on the inner thigh but reported she had reported this to the nurse. CNA #2 could not recall which nurse she reported this too. CNA #2 was on the schedule [DATE] and [DATE] as the provider of care for Resident #1. Interview with LPN #2 on [DATE] at 11:00 a.m. revealed that she did not do a transfer note when Resident #1 went to the hospital. LPN #2 was not aware of any skin problems for Resident #1 and did not recall anyone reporting any skin concerns. LPN #2 stated that skin assessments were usually done with transfers and at least weekly after admission. Interview with LPN #3 on [DATE] at 11:10 a.m. revealed that Resident #1 was a total lift for transfers, turned every two (2) hours and was incontinent. LPN #3 was not aware of any skin concerns for Resident #1. LPN #3 stated that no one reported a skin problem to her. LPN #3 stated that she had not completed a skin assessment prior to Resident #1's transfer to the hospital. LPN #3 stated that the Medication Nurse usually did the skin assessments. LPN #3 stated that Resident #1 was at risk for skin impairment and should have had a weekly skin assessment performed. LPN #3 stated that Resident #1's family came to the facility the evening after the resident was transferred to the hospital and reported that there was a blister on the resident and was upset about it. LPN #3 stated that the chart revealed no documentation of a blister. Record review revealed that Resident #1 had no skin breakdown upon admission. There was no documented skin assessments after the initial assessment of [DATE]. Resident #1 required assistance with turning/repositioning, was incontinent and was highly compromised with [MEDICAL CONDITION] which put him/her at further risk of breakdown. The facility failed to assess the condition of Resident #1's skin prior to transfer to the hospital to detect any concerns for possible treatment and further issues. The facility failed to follow their policy for performing and documenting skin assessments. Resident #1 had been discharged from the facility on [DATE] and was unavailable for interview/observation. Review of the policy for " Hospital Transfer/Return Form Policy " (no date) revealed " It is the policy of this facility that the Hospital Transfer Nurses Note and the Hospital Return Nurses Note forms will be utilized as follows: On any resident who is transferred to or returned from the hospital; Be used as the nurses notes to document Transfer and Return; Be completed and signed by a licensed nurse; Include a complete head to toe body assessment of the resident on transfer and return; Include a complete mental assessment of the resident: on transfer and return; Be maintained in the medical record as the nurses note; and Does not take the place of the transfer form which accompanies the resident to the hospital." Review of the " Evaluation of Skin Problems Excluding Ulcers Policy " revealed: " It is the policy of this facility that a weekly evaluation will be done on skin problems excluding ulcers as follows: .Evaluation to include at least the following problems: Abrasions, Bruises, Lacerations, Open [MEDICAL CONDITION], Rashes, Skin tears, Surgical Wounds and other as needed."