Every finding on record at Park Meadows Healthcare & Rehabilitation Center

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 5 residents reviewed for unnecessary medications (Resident #67), 1 of 2 residents reviewed for communication (Resident #112), 1 of 3 residents reviewed for respiratory services (Resident #12), and 1 of 4 residents reviewed for infections (Resident #10).Findings include: 1) Review of Resident #67's Quarterly MDS assessment dated [DATE] showed the resident is taking diuretics under Section N- Medications. Review of Resident #67's physician orders showed no order for diuretics. Review of Resident #67's Medication Administration Record (MAR) for February 2026 showed no diuretics were administered. During an interview on 4/23/2026 at 10:21 AM, Staff D, MDS Licensed Practical Nurse (LPN), stated, [Resident #67's name] is currently taking Hydralazine. Review of Resident #67's physician order dated 5/29/2024 read, Hydralazine HCl [hydrochloride] Tablet 50 MG [milligram], Give 50 mg by mouth three times a day for Hypertension, Hold if BP [Blood Pressure] less than 110/60. During an interview on 4/24/2026 at 8:24 AM, the Director of Nursing (DON) stated, Hydralazine is not a diuretic. During an interview on 4/24/2026 at 10:50 AM, Staff D, MDS LPN, stated, I was wrong [Resident #67's name] is not on diuretics. His assessment will need to be corrected. 2) During an interview conducted in Spanish on 4/20/2026 at 10:05 AM, Resident #112 stated that he did not speak English, she did not understand English and needed an interpreter when staff came to speak to her. Review of Resident #112's MDS assessment titled Modification of Quarterly/Medicare 5 day dated 3/17/2026 read, Section A- Identification Information. A1110. Language: B. Do you need or want an interpreter to communicate with a doctor or health care staff? 0. No. Review of Resident #112's skin exam dated 4/15/2026 read, History of Present Illness: Patient does not speak English, translator used through [name of an application] app and patient's son via the telephone. During an interview on 4/22/2026 at 1:41 PM, Staff T, LPN Unit Manager, stated, [Resident #112's name] doesn't speak much English. She would prefer Spanish. Her son is at bedside at times; if not, we will get staff to translate. During an interview on 4/22/2026 at 1:43 PM, Staff U, Certified Nursing Assistant (CNA), stated, [Resident #112's name] is a Spanish-speaking resident. I can understand a little bit of Spanish and if not, I will have another staff translate for me. During an interview on 4/23/2026 at 6:39 AM, the Director of Nursing stated, Resident #112's name] speaks more Spanish than English. During an interview on 4/23/2026 at 10:22 AM, Staff D, MDS LPN stated, [Resident #112's name] is Spanish speaking only. I don't know why it is coded this way. It will need to be corrected. 3) Review of Resident #12's admission record showed the resident was admitted on [DATE] with diagnoses to include tracheostomy status (onset date of 1/29/2026). Review of Resident #12's MDS assessment dated [DATE] showed the resident does not receive tracheostomy care under Section O- Special Treatments, Procedures, and Programs. Review of Resident #12's physician orders showed an order with a start date of 1/30/2026 that read, Change trach-as needed every 3 months. During an interview on 4/23/2026 at 10:22 AM, Staff D, MDS LPN, stated, [Resident #12's name] has a tracheostomy. The assessment will need to be corrected. 4) Review of Resident #10's quarterly MDS assessment dated [DATE] showed Septicemia (a life-threatening, emergency bloodstream infection that requires immediate hospital treatment) documented under Section I- Active Diagnoses. Review of Resident #10's physician order dated 12/25/2025 read, Cipro Oral Tablet 500 MG (Ciprofloxacin HCl), Give 500 mg by mouth two times a day for UTI [Urinary Tract Infection] for 7 Days. Review of Resident #10's physician orders revealed no additional antibiotics were ordered after 12/25/2025. Review of Resident #10's MAR from 12/25/2025 through 4/21/2026 revealed the resident received Cipro from 12/25/2025 through 1/01/2026. There was no additional documentation for the administration of antibiotics. Review of Resident #10's urinalysis and urine culture results dated 1/17/2026 showed no growth in 48 hours. Review of Resident #10's urinalysis and urine culture results dated 2/28/2026 showed no growth in 48 hours. During an interview on 4/23/2026 at 11:15 AM, Staff D, MDS LPN, stated that Resident #10's last quarterly assessment was completed on 2/12/2026 and confirmed that the MDS was inaccurate. During an interview on 4/23/2026 at 12:45 PM, the DON stated she was aware that there was a lot wrong with residents' MDS assessments, and there had been a lot of staff turnover in the MDS office. Review of the facility policy and procedure titled Comprehensive Assessments and Care Plan with the last review date of 1/28/2026 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment for each resident's functional capacity.

Based on record review and interview, the facility failed to obtain laboratory services to meet the needs of the residents for 2 of 9 residents reviewed for laboratory services (Residents #96 and #97).Findings include:1) Review of Resident #97's provider visit note dated 3/19/2026 read, Today patient is being seen for a follow up visit related to AMS [Altered Mental Status] and possible UTI [Urinary Tract Infection]. Patient had a fall last night. On exam she seems slightly more confused and drowsy than her baseline. Assessment/Plan: AMS, Fall Last night, Possible UTI? order UA [urinalysis] with C&S [Culture and Sensitivity] today, send out stat, follow up after results-history of recurrent UTIs.Review of Resident #97's physician order dated 3/25/2026 read, UA C&S D/T [due to] increased confusion and urinary frequency one time only for Confusion for 1 Day.Review of eMAR (electronic Medication Administration Record) note dated 3/26/2026 read, UA C&S D/T increased confusion and urinary frequency one time only for Confusion for 1 Day Pt [patient] Urine in Fridge.Review of Resident #97's provider visit note dated 3/26/2026 read, Today patient is being seen for acute care visit on dysuria with AMS. UA was ordered earlier in week, but wasn't sent out. Patient has concerns today still for UTI. Assessment/Plan: Dysuria, UA wasn't done earlier in week, today with straight catheter per bedside RN, discussed importance of urine send out prior to starting abx [antibiotic therapy] due to hx [history] of recurrent UTI with MDR [multidrug resistance], can start empiric treatment after urine sent out-cipro 250 mg BID [twice a day].Review of Resident #97's records did not show a urinalysis with culture and sensitivity on 3/19/2026 or 3/26/2026.During an interview on 4/22/2026 at 11:34 AM, the Director of Nursing stated, Urine will be collected and placed in lab refrigerator. The staff will do a lab requisition and add it the book unless it's a stat and they pick up usually within an hour or two. The doctors put the orders in unless they spoke to the nurse.During an interview on 4/22/2026 at 11:45 AM, the Advance Practice Registered Nurse #1 stated, I do feel there was a delay. This is the first time this has happened. There were two nurses involved. The one nurse collected the urine, and it spilled. The second nurse recollected the urine it was never logged and the lab did not pick it up.During an interview on 4/22/2026 at 12:06 PM, the Director of Nursing stated, [APRN #1's name] never told me what happened. I expect the nurses to follow the orders and if there is any problems to let me know.During an interview on 4/22/206 at 12:10 PM, Staff Y, Registered Nurse (RN), stated, The UA order previously placed was not collected and the provider walked up to me and told me to collect the urine specimen. It was a verbal order. I collected the specimen and labeled it and put it in the refrigerator. I told the night nurse to put in a lab requisition. When the [APRN #1's name] asked me about the urine, the patient was already sent to the hospital. She asked me what happened and I told her I collected the urine and apparently something happened that they didn't take the urine.2) Review of Resident #96's physician order dated 4/9/2026 read, U/A C&S May straight Cath If necessary one time only for 1 Day,Review of Resident #96's laboratory results did not document a UA for April 2026.During an interview on 4/22/2026 at 4:12 PM, Medical Doctor #1 stated, I can't recall if it was a verbal order. I cannot recall the reason why we ordered the UA. I cannot recall if it was due to altered mental status.During an interview on 4/22/2026 at 4:14 PM, Staff E, Licensed Practical Nurse (LPN), stated, Therapy was saying he was more confused and I messaged [Medical Doctor #1's name] to let him know.During an interview on 4/23/2026 at 6:40 AM, the Director of Nursing stated, I spoke to the nurse who signed off on the order, but don't see where they collected the urine. I spoke to the nurse, but she does not remember what happened.During an interview on 4/23/2026 at 7:15 AM, Staff Z, LPN, stated, I don't remember what happened with his order. I had picked up an extra shift and cannot recall. I have no idea he has been confused but able to answer questions. I don't know why they order the labs his confusion has been baseline.During an interview on 4/23/2026 at 11:57 AM, Laboratory Medical Biller stated, The only thing I have for [Resident #96's name] is on 4/1 for blood work. No UA ordered. For [Resident #97's name] last thing I have is February 20; nothing more recent.Review of the facility policy and procedures titled Diagnostics Labs Radiology Notification with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to provide or obtain timely laboratory, radiology and diagnostic services when ordered by a physician; physician assistant (PA); nurses practitioner (NP) or clinical nurse specialist (CNS) in accordance with State law, including scope of practice laws.

Based on observation, interview, and record review, the facility failed to ensure a safe and clean homelike environment for 2 of 5 residents reviewed, Residents #87 and #66. Findings include: 1) During an observation on 4/20/2026 at 1:45 PM, Resident #87 had his right arm in a splint and was using his left arm and hand to move items in the room. The pull string to turn on the light over the resident's bed was not within reach of the resident. The pull string does not reach the bed (Photographic evidence obtained). During an interview on 4/20/2026 at 1:45 PM, Resident #87 voiced concerns about not being able to reach the pull string to turn on the light that was over his bed. He commented he had spoken to maintenance and administration. Review of Resident #87's admission record showed the resident was admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side. During an observation on 4/21/2026 at approximately 1:00 PM, the pull string to the light over Resident #87's bed was not within reach of the resident. During an observation on 4/22/2026 at approximately 9:30 AM, the pull string to the light over Resident #87's bed was not within reach of the resident. During an interview on 4/24/2026 at 10:21 AM, the Administrator stated, I did observe the light string was not close enough to his [Resident #87's] bed to accommodate his needs and needs to be modified to make it longer. 2) During an observation on 4/21/2026 at 10:21 AM, there was a black colored substance around the base of the toilet in Resident #66's room (Photographic evidence obtained). During an interview on 4/22/2026 at 8:38 AM, the Environmental Services Director (ESD) stated, The rooms in the memory care unit are cleaned twice a day, once in the morning and once in the afternoon. The ESD verified there was a black colored substance around the base of the toilet in Resident #66's bathroom. During an interview on 4/22/2026 at 8:42 AM, Staff BB, Certified Nursing Assistant, stated, Housekeeping cleans twice a day and are very good. When it's clean it's nice [Resident #66's bathroom] but will wear off. The men in Resident #66's room will urinate on the floor.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) when entering a contact precautions room for 1 of 3 residents reviewed for transmission-based precautions (Resident #41), failed to ensure staff performed hand hygiene while administering medication administration and providing care for 3 of 8 residents reviewed (Residents #1, #11, and #90), and failed to ensure respiratory care equipment were appropriately maintained for 2 of 4 residents reviewed for respiratory services (Residents #12 and #97), to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 4/21/2026 at 11:18 AM, Staff AA, Licensed Practical Nurse (LPN), entered Resident #41's room. Staff AA did not wear a gown or gloves. Resident #41's room had a contact-precaution sign posted on the door and a bin with PPE outside of the room. During an interview on 4/21/2026 at 11:30 AM, Staff AA, LPN, stated, I forgot. I saw the light and went in. I know I should were gloves and gown before entering. Review of Resident #41's physician order dated 12/16/2025 read, Contact isolation - Candida Auris. All care provided in room every shift. During an interview on 4/23/2026 at 4:07 PM, the Assistant Director of Nursing/Infection Preventionist stated, Staff should be wearing gown and gloves before entering the room even if it is to answer a call light because you don't know what might happened in there. During an interview on 4/24/2026 at 8:24 AM, the Director of Nursing stated, The staff should follow the contact precautions guidelines and put on gown and gloves before entering the resident room. Review of the facility policy and procedures titled Transmission-Based Precautions with the last review date of 1/28/2026 read, Contact- direct contact with skin, or indirect contact with contaminated surfaces, and physical transfer of organism (usually on the hands of healthcare workers) from an infected or colonized person to a susceptible host. Guidelines for Contact Precautions. Gowns: 1. [NAME] gown upon entry into the room or cubicle. 2) During an observation on 4/22/2026 at 8:58 AM, Staff A, LPN, was preparing Resident #90's medications. Staff A was crushing acetaminophen. The package fell on the floor. Staff A proceeded to pick up the package from the floor. Staff A proceeded to dispose of the medication and clear medication plastic. Staff A did not wash her hands and proceeded to pour acetaminophen again and crush the medication. Staff A administered the medication to the resident without washing her hands. During an interview on 4/22/2026 at 9:16 AM, Staff A, LPN, stated, I did not do hand hygiene because I touched the package by the top and threw it away immediately. During an interview on 4/23/2026 at 6:37 AM, the Director of Nursing stated, Staff should perform hand hygiene after picking anything off the floor before resuming to pour medication for a resident. 3) During an observation on 4/20/2026 at 10:23 AM, Resident #97 was resting with her eyes closed. The nasal cannula tubing was on the floor. The tubing was dated 4/19/2026 (Photographic evidence obtained). During an observation on 4/21/2026 at 8:19 AM, Resident #97 was resting in bed. The nasal cannula was wrapped on the bed rail. The oxygen tubing was dated 4/19/2026. During an observation on 4/22/2026 at 8:36 AM, Resident #97 was lying in bed, with oxygen being administered by nasal cannula. The nasal cannula was dated 4/19/2026. 4) During an observation on 4/20/2026 9:53 AM, Resident #12 was sitting up in bed. The oxygen tubing connected to the trach mask was dated 4/5 (Photographic evidence obtained). During an observation on 4/21/2026 at 8:10 AM, Resident #12 was lying in bed, with oxygen being administered via the trach mask. The oxygen tubing was dated 4/5. During an interview on 4/22/2026 at 8:37 AM, Staff W, Registered Nurse (RN), stated, Oxygen tubing should be stored in a respiratory bag when not in use. If it falls on the floor, it should be changed and the tubing is changed every week. During an interview on 4/23/2026 at 6:50 AM, the Director of Nursing stated, The tubing is to be changed weekly on Sundays. If the tubing is not in use, it should be stored in a bag and if it falls on the floor it should be replaced. Review of the facility policy and procedures titled Oxygen Administration with the last review date of 1/28/2026 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 3. Assemble the equipment and supplies as needed. 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed. 5) During an observation on 4/22/2026 at 11:26 AM, Staff B, LPN Wound Care Nurse, cleaned Resident #1's wound and disposed of the soiled gauze and the soiled gloves. Without performing hand hygiene, Staff B donned a clean pair of gloves and applied the wound dressing. During an interview on 4/22/2026 at 2:32 PM, Staff B, LPN Wound Care Nurse, stated that maybe she should have washed her hands when she changed her gloves during Resident #1's wound care. Review of Resident #1's physician order dated 4/14/2026 read, Cleanse sacrum with wound cleanser and apply anti-microbial (AMD) and cover with ABD once daily every day shift. 6) During an observation on 4/23/2026 at 2:10 PM, Staff A, LPN, performed nephrostomy catheter dressing change for Resident #11. After removing the soiled dressing, Staff A removed the soiled gloves. Staff A did not perform hand hygiene and donned a clean pair of gloves to clean the nephrostomy catheter insertion site. After cleaning the catheter insertion site, Staff A removed the soiled gloves. Without performing hand hygiene, Staff A donned a clean pair of gloves and applied a transparent dressing over the nephrostomy catheter insertion site. During an interview on 4/23/2026 at 2:17 PM, Staff A, LPN, confirmed that she did not perform hand hygiene after removing the soiled gloves and reapplying clean gloves twice during nephrostomy catheter dressing change. During an interview on 4/23/2026 at 12:50 PM, the Director of Nursing stated that nurses should wash their hands after removing soiled gloves, before putting on clean gloves while doing wound care or a dressing change. Review of Resident #11's physician order dated 12/18/2025 read, Change nephrostomy dressing q [every] night and prn [as needed]. Observe for s/s [sign and symptoms] of infection every night shift. Review of the facility policy and procedures titled Hand Hygiene with the last review date of 1/28/2026 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves. 7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections.

Based on record review and interview, the facility failed to coordinate Preadmission Screening and Resident Review (PASRR) for the residents with newly evident or possible serious mental disorder for 2 of 4 residents reviewed for behavioral health (Residents #13 and #117).Findings include:1) Review of Resident #117's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include brief psychotic disorder (onset date of 2/26/2026), other recurrent depressive disorders (onset date of 2/26/2026), and post-traumatic stress disorder (onset date of 2/25/2026).Review of Resident #117's PASRR dated 1/27/2026 showed anxiety disorder and depressive disorder documented under mental illness or suspected mental illness in Section I. PASRR Screen Decision-Making. No brief psychotic disorder and post-traumatic stress disorder was documented.Review of Resident #117's psychiatry subsequent note dated 3/23/2026 read, Chief Complaint: Brief psychosis and depression.Review of Resident #117's physician order dated 4/4/2026 read, Escitalopram Oxalate Tablet 5 MG [milligram], Give 1 tablet by mouth one time a day for Depression.Review of Resident #117's physician order dated 4/6/2026 read, Aripiprazole Tablet 10 MG, Give 1 tablet by mouth one time a day for Brief psychotic disorder.2) Review of Resident #13's admission record showed the resident was admitted on [DATE] with diagnoses to include unspecified mood (affective) disorder (onset date of 4/2/2026] and major depressive disorder, recurrent (onset date of 3/27/2026).Review of Resident #13's PASRR dated 3/8/2026 showed no mental illness or suspected mental illness documented under Section I. PASRR Screen Decision-Making.Review of Resident #13's psychiatry subsequent note dated 3/12/2026 read, Chief Complaints: Depression, insomnia. Plan of Action: Start medication. Start Trazodone (Desyrel) 25 mg by mouth twice daily for daytime anxiety/depressive symptoms and 50 mg by mouth at bedtime for insomnia and depressive symptoms.During an interview on 4/21/2026 at 2:33 PM, the Director of Nursing stated, [Resident #117's name and Resident #13's name] are missing diagnosis on their PASSR Level I and they need to be corrected.Review of the facility policy and procedures titled Role of Admissions and Social Services in PASRR with the last review date of 1/28/2026 read, Policy: The facility will ensure each resident in a nursing facility is screened for mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.

Based on observation, interview, and record review, the facility failed to ensure resident-centered care plans were developed and implemented for 4 of 33 residents reviewed (Residents #11, #58, #39, and #112).Findings include: 1) Review of Resident #11's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with medical diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, overactive bladder, and other artificial openings of urinary tract status, and acute candidiasis of vulva and vagina. Review of Resident #11's care plan read, Focus: The resident has an artificial opening for bowel elimination (ostomy). Date initiated: 11/27/2025. Revision on: 03/05/2026. Interventions: Report any changes in bowel output to nurse such as swollen abdomen, resident complaining of pain, any change in color or consistency of the output. During an interview on 4/23/2026 at approximately 11:45 AM, Staff C, Minimum Data Set (MDS) Licensed Practical Nurse (LPN), stated, [Resident #11's name] had a nephrostomy catheter inserted. It was an error that [Resident #11's name] care plan had a focus area for a colostomy. [Resident #11's name] did not have a colostomy. During an interview on 4/23/2026 at 12:45 PM, the Director of Nursing (DON) stated, [Resident #11's name] did not have a colostomy. She had a nephrostomy. 2) Review of Resident #58's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include pulmonary fibrosis, morbid (severe) obesity due to excess calories, moderate protein-calorie malnutrition, feeding difficulties, malignant neoplasm of glottis, dysphagia, and gastro-esophageal reflux disease without esophagitis. Review of Resident #58's care plan read, Focus: [Resident #58's name] is a smoker/tobacco user. Date initiated 05/05/2016. Revision on: 03/14/2023. During an interview on 4/21/2026 at 8:37 AM, Resident #58 stated that she used to be a smoker but no longer smoked. During an interview on 4/22/2026 at 2:35 PM, Staff A, LPN, stated that Resident #58 did not get out of bed or go outside to smoke. During an interview on 4/23/2026 at 12:45 PM, the DON stated Resident #58 used to be a heavy smoker. She got up in the chair if she wanted, but she was mostly in bed. The DON confirmed that Resident #58 had not had a recent smoking evaluation because she no longer was an active smoker. 3) Review of Resident #39's admission record showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other seizures, other specified disorders of brain, unspecified dementia of unspecified severity with other behavioral disturbance, and restlessness and agitation. Review of Resident #39's care plan read, Focus: [Resident #39's name] has self care deficits AEB [as evidenced by] the needs for assistance for all ADL's [activities of daily living] care tasks. Resident needs help with dressing, grooming, bathing R/T [related to]: CVA [cerebrovascular accident] with (R) [right] hemiparesis/hemiplegia. Date initiated: 08/11/2022. Revision on: 0/21/2025. Interventions: Provide hands on assistance with dressing, grooming, bathing as needed. During an interview on 4/21/2026 at 3:00 PM, Staff G, LPN, stated, [Resident #39's name] is mostly independent. He is pretty steady. He moves on his own, and he shaves himself. His last care plan was done in June of 2025. During an interview on 4/21/2026 at 3:13 PM, Staff H, LPN Unit Manager, stated that Resident #39 was mostly independent. During an interview on 4/21/2026 at 3:15 PM, Staff C, MDS LPN stated that shaving was part of personal hygiene in the MDS Assessment. Resident #39 had his last MDS Assessment on 3/16/2026 and he was assessed as independent for personal hygiene. Staff C confirmed that Resident #39 had care plan focus areas that documented he needed assistance with all ADL activities. During an interview on 4/21/2026 at 4:45 PM, the DON confirmed that the most recent date of a care plan for Resident #39 was 6/29/2025 and that the focus areas in his care plan related to ADLs documented that he needed assistance. The DON stated that MDS assessments and care plans needed to align. During an interview on 4/22/2026 at 9:01 AM, Resident #39 stated, I have to obtain a razor from CNAs [Certified Nursing Assistants], but I get out of bed and shave on my own. During an interview on 4/22/2026 at approximately 4:45 PM, Staff C, MDS LPN, stated, The care plans in the facility are all jacked up. We are aware that the residents' care plans were not up to date. During an interview on 4/23/2026 at 12:45 PM, the DON stated she was aware that there was a lot wrong with residents' care plans and there had been a lot of staff turnover in the MDS office. 4) During an interview conducted in Spanish on 4/20/2026 at 10:05 AM, Resident #112 stated that he did not speak English, she did not understand English and needed an interpreter when staff came to speak to her. Review of Resident #112's care plan did not show a focus for communication. Review of Resident #112's skin exam dated 4/15/2026 read, History of Present Illness: Patient does not speak English, translator used through [name of an application] app and patient's son via the telephone. During an interview on 4/22/2026 at 1:41 PM, Staff T, LPN Unit Manager, stated, [Resident #112's name] doesn't speak much English. She would prefer Spanish. Her son is at bedside at times; if not, we will get staff to translate. During an interview on 4/22/2026 at 1:43 PM, Staff U, Certified Nursing Assistant (CNA), stated, [Resident #112's name] is a Spanish-speaking resident. I can understand a little bit of Spanish and if not, I will have another staff translate for me. During an interview on 4/23/2026 at 6:39 AM, the DON stated, Resident #112's name] speaks more Spanish than English. During an interview on 4/23/2026 at 10:22 AM, Staff D, MDS LPN, stated, [Resident #112's name] is Spanish speaking only. I don't see a focus for communication in her care plan. It will need to be added. Review of the facility policy and procedure titled Comprehensive Assessments and Care Plan with the last review date of 1/28/2026 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. Guidelines: 10. The plan of care reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 11. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally-competent and trauma-informed.

Based on observation, record review, and interview, the facility failed to ensure residents received their medications as prescribed by their physician for 2 of 10 residents reviewed for medication management (Residents #90, and #93) and failed to ensure the wound dressings were changed for 2 of 4 reviewed for skin conditions (Residents #112 and #119).Findings include: 1) Review of Resident #93's physician order dated 2/28/2026 read, Insulin Glargine Solution 100 units per milliliter (units/mL), inject 10 units subcutaneously once daily for diabetes; notify physician for blood sugar less than 70 milligrams per deciliter (mg/dL). Review of Resident #93's Medication Administration Record (MAR) for administration of Insulin Glargine for March 2026 showed the medication was held by Staff CC, Registered Nurse (RN), on the following dates: 3/2/2026 for blood sugar of 82 mg/dL; 3/3/2026 for blood sugar of 105 mg/dL; 3/6/2026 for blood sugar of 96 mg/dL; 3/9/2026 for blood sugar of 103 mg/dL; 3/10/2026 for blood sugar of 117 mg/dL; 3/11/2026 with no documented blood sugar; 3/13/2026 with no documented blood sugar; 3/15/2026 for blood sugar of 85 mg/dL; 3/16/2026 for blood sugar of 79 mg/dL; 3/20/2026 for blood sugar of 107 mg/dL; 3/23/2026 for unavailability; 3/25/2026 for blood sugar of 105 mg/dL; and 3/29/2026 for blood sugar of 84 mg/dL. Review of Resident #93's MAR for administration of Insulin Glargine for April 2026 showed the medication was held by Staff CC, RN, on the following dates: 4/6/2026 for blood sugar of 64 mg/dL; 4/7/2026 for blood sugar of 80 mg/dL; 4/10/2026 with no blood sugar documented; 4/13/2026 with no blood sugar documented; 4/17/2026 for blood sugar of 98 mg/dL; and 4/20/2026 for blood sugar of 77 mg/dL; During an interview on 4/21/2026 at 4:49 PM, Staff CC, RN, stated she misread the physician order, held the insulin, and did not recall notifying the physician. During an interview on 4/22/2026 at 2:55 PM, the Director of Nursing (DON) stated, It is the expectation that nursing staff follow physician orders when administering medications. During an interview on 4/23/2026 at 11:10 AM, Medical Doctor 2 stated he did not recall being notified that the insulin was being held. 2) During an observation on 4/22/2026 at 8:58 AM, Staff A, Licensed Practical Nurse (LPN), was pouring medication for Resident #90. Staff A crushed Zunveyl Oral Tablet Delayed Release 10 mg (milligram). During an interview on 4/22/2026 at 8:58 AM, Staff A, LPN, was requested to clarify if the medication Zunveyl should be crushed for Resident #90. Staff A stated she would get clarification from the provider. Staff A administered the medication without obtaining clarification from the provider. During an interview on 4/22/2026 at approximately 1:20 PM, Staff A, LPN, stated I clarified the medication and it is a delayed release medication even though the blister pack do not say it. When asked if the medication should have been crushed, Staff A stated, It is not enteric coated, its delayed release. Review of Resident #90's physician order dated 2/16/2026 read, Medications to be started after delivery form pharmacy. May crush meds unless contraindicated and administer together. Review of Resident #90's physician order dated 2/26/2026 read, Zunveyl Oral Tablet Delayed Release 10 MG (Benzgalantamine Gluconate), Give 10 mg by mouth two times a day for Dementia. During an interview on 4/23/2026 at 6:51 AM, the DON stated, The nurse should not crush delayed release medication. They should first call pharmacy or the doctor to get clarification before giving the medication. The medication should not have been given. Review of the facility policy and procedures titled Medication Administration with the last date of 1/28/2026 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusal of medication by the resident. Procedure: 3. Medications should be administered in a timely manner and in accordance with physician's orders. 5. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director for further instructions. 3) During an observation on 4/20/2026 at 10:14 AM, Resident #112 was sitting up in bed. There was a dressing dated 4/16/2026 on the left side of her neck (Photographic evidence obtained). During an interview on 4/20/2026 at 10:14 AM, Resident #112 stated, Dermatology came to see me and decided to biopsy an area on my neck. During an observation on 4/21/2026 at 8:10 AM, Resident #112 was lying in bed. There was a dressing on the left side of the resident's neck dated 4/16/2026. During an interview on 4/21/2026 at 8:10 AM, Resident #112 stated, They have not changed my dressing. The nurse said she would change it today. Review of Resident #112's physician order dated 4/15/2026 read, Wound care left neck- wash with soap and water, pat dry, apply petroleum jelly, cover with nonstick bandage every day shift for biopsy site for 7 days. During an interview on 4/21/2026 at 4:36 PM, Staff W, RN, stated, I don't remember the date on the dressing. During an interview on 4/21/2026 at 4:46 PM, Staff V, LPN, stated, I didn't see orders for dressing changes. I know they were talking about a biopsy on her neck today. During an interview on 4/22/2026 at 8:04, Staff B, LPN Wound Care Nurse, stated, There was a lot going on Saturday [4/18/2026]. Normally when I do wound care, I wait to do it to check it off. I cannot recall what happened. 4) During an observation on 4/20/2026 at 10:16 AM, Resident #119 was sitting in his wheelchair. There was a dressing dated 4/16 on his right knee (Photographic evidence obtained). During an interview on 4/20/2026 at 10:16 AM, Resident #119 stated, He had fallen at home and had a wound on his right knee. Review of Resident #119's physician order dated 4/14/2026 read, Cleanse right knee with wound cleanser and apply Iodosorb gel and cover with border gauzes three times a week every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday]. During an interview on 4/22/2026 at 8:04 AM, Staff B, LPN Wound Care Nurse, stated, I did work on 4/18. I did not do his [Resident #119] dressing on Saturday [4/18/2026] because he was up. During an interview on 4/23/2026 at 6:37 AM, the DON stated, The staff should follow physician orders and do wound care as ordered. Review of the facility policy and procedures titled Wound Care with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care procedures and treatments should be performed according to physician orders.

Based on observation, interview, and record review, the facility failed to ensure residents with limited mobility received appropriate services to maintain or improve mobility for 1 of 4 residents reviewed for therapy services (Resident #16).Findings include:During an observation on 4/20/2026 at 10:33 AM, Resident #16 was sitting in a wheelchair next to his bed. The resident was not wearing a splint, or an AFO (Ankle Foot Orthoses).During an observation on 4/21/2026 at 11:05 AM, Resident #16 was sitting in a wheelchair at the nurses' station. The resident was not wearing an AFO.During an interview on 4/22/2026 at 2:52 AM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #16's name] is often up in his wheelchair when I come in at 7:00 AM and is not always wearing his AFO. Staff A was not able to provide any specific dates.During an observation on 4/22/2026 at 3:00 PM, Resident #16 was lying in bed. The resident was not wearing an AFO. There was an AFO stored on a shelf in the closet.Review of Resident #16's physician order dated 1/28/2026 read, Apply orthosis to right ankle following restorative nursing program. Monitor skin integrity when applying and removing. The order was discontinued on 4/2/2026.Review of Resident #16's physician order dated 4/2/2026 read, Apply R [right] ankle orthosis (AFO) during transfers and when OOB [out of bed] to improve positioning. Monitor for skin integrity.During an interview on 4/23/2026 at 10:00 AM, the Director of Rehab stated, [Resident #16's name] AFO is to be applied when he is getting up with the mechanical sit to stand, and remain on to stabilize the position [of his foot/lower leg]. [Resident #16's name] has been on physical therapy case load. In January, the [physical] therapist turned the AFO application over to the Restorative team.During an interview on 4/23/2026 at 10:15 AM, Staff H, LPN Unit Manager, stated, PT [Physical Therapy] gave their recommendations to the two restorative aids. If it is a new skill for applying splints for a resident, therapy will work with the restorative aids for training. The Unit Manager will then give approval for the task to be taken on independently by the Restorative Aids. Review of Resident #16's Task List or application of AFO for April 2026 showed X was documented from 4/2/2026 through 4/8/2026 and no entry on 4/20/2026 and 4/22/2026.During an interview on 4/23/2026 at 10:40 AM, Staff Q, Restorative Certified Nursing Assistant (CNA), stated that Restorative was not applying Resident #16's AFO; they were working with him and applying the carrot for his right hand. Resident #16 liked his foot brace and his carrot, and when he saw her, he would raise his leg or arm up indicating he wanted her to put on his AFO and his carrot. During an interview on 4/23/2026 at 11:05 AM, Staff R, CNA, stated that she knew Resident #16 was supposed to have his AFO on when transferring, but she sometimes took it off when he was sitting up in his wheelchair because she thought he did not like to wear it.Review of the facility policy and procedures titled Contracture Management with the last review date of 1/28/2026 [NAME], Policy: It will be the policy of this facility that the facility must ensure that a resident with a limited range of motion (ROM) receives appropriate treatment to increase range of motion and/or prevent further decrease in ROM. A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Procedure: 3. Treatment may include, restorative nursing programs, positioning or splinting to prevent further loss of ROM. 4. If splinting is used, a schedule for wearing the splint must be developed. 5. Application of devices should be documented in the clinical record and should be present in the plan of care.

Based on observation, record review, and interview, the facility failed to ensure a safe and hazard-free environment for 1 of 4 residents reviewed (Resident #39).Findings include: During an observation on 4/20/2026 at 10:15 AM, there was a disposable razor on the back of Resident #39's bathroom sink (Photographic evidence obtained). During an observation on 4/21/2026 at 1:25 PM, there was a black disposable razor on the sink in Resident #39's bathroom. During an interview on 4/21/2026 at 1:27 PM, Staff F, Certified Nursing Assistant (CNA), stated that Resident #39 was using the razor earlier that day, and Resident #39 was somewhat independent. During an interview on 4/21/2026 at 3:00 PM, Staff G, Licensed Practical Nurse (LPN), stated that Resident #39 was mostly independent, he was steady, he moved on his own, and he shaved himself. During an interview on 4/21/2026 at 3:13 PM, Staff H, LPN Unit Manager, stated that Resident #39 was mostly independent. Residents should be observed while shaving and the razor should be disposed of after the resident shaved. During an interview on 4/21/2026 at 4:45 PM, the Director of Nursing (DON) stated that Resident #39 should be observed while shaving. The CNA would have known he was shaving as she would have had to give the razor to Resident #39 and she should have picked it up after he was finished. During an interview on 4/22/2026 at 9:01 AM Resident #39 stated that he did not shave today and did not have a razor in his room. He had to obtain a razor from the CNAs. Staff did not observe him when he was shaving and did not always pick up the razor after he used it. His bathroom was shared with his roommate. Other residents did have access to the bathroom. Review of the facility policy and procedures titled Disposable Resident Care Product Utilization with the last review date of 1/28/2026 read, Policy: It is the policy of this facility to ensure products utilized for the provision of personalized resident care are available, utilized appropriately and discarded when no longer needed. Procedure: 6. When the disposable item is no longer needed it should be discarded in the appropriate receptacle. Razors must be discarded in the Sharps Container.

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate enteral feeding for 1 of 7 residents reviewed for nutrition and dining services (Resident #58).Findings include:During an observation on 4/20/2026 at 10:05 AM, Resident #58 was lying in bed. The resident's tube feeding pump was alarming. The bottle of enteral feeding was dated 4/18/2026, and the bag of water attached was dated 4/15/2026 (Photographic evidence obtained).During an interview on 4/22/2026 at 10:20 AM, Staff A, Licensed Practical Nurse (LPN), stated that more than likely when the bottle of enteral feeding was low, they would change the set-up. Changing [of the bottle and tubing] was based on what was left in the bottle. She thought the set-up was good for 24 hours. She would look at what time it was actually hung.During an observation on 4/22/2026 at 2:40 PM, Staff A, LPN, attached the tubing for the enteral feeding, set the feeding pump according to the order and started the pump. Staff A did not check for residual prior to the initiation of the enteral feeding.During an interview on 4/22/2026 at 2:50 PM, Staff A, LPN, stated that she did not check for residual for Resident #58's G-tube (Gastrostomy) prior to medication administration or prior to the initiation of her enteral feeding.During an interview on 4/22/2026 at approximately 4:00 PM, the Director of Nursing (DON) stated that tube feeding set-ups (tubing enteral feeding and water flush) should be changed every day. The expectation was that the nurse would confirm placement of the feeding tube which included checking for residual.Review of Resident #58's physician order dated 11/12/2025 read, Enteral Feed Order every shift Jevity 1.5 at 50 cc [cubic centimeter]/hour via feeding tube for 20 hours with autoflush at 50 cc/hour for 20 hours. On at 1400 [2:00 AM] and off at 1000 [10:00 AM].Review of Resident #58's physician order dated 3/29/2026 read, Check tube residual to verify placement prior to administration of feeding, prior to administration of medication, and prior to flush. If residual is 100 ML [milliliter] or more, hold feeding and notify physician every shift,Review of Resident #58's physician order dated 3/29/2026 read, May be off feeding tube/pump for short periods of time for ADL [Activities of Daily Living] care, activities, or appointmentsReview of the facility policy and procedures titled Enteral Tube Feeding with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to provide nourishment to the resident who is unable to obtain adequate nourishment orally via use of enteral tube feeding. Procedure: 3. Verify/obtain orders related to water flushes per shift for additional hydration, auto- flush for additional hydration, flushes prior to and after medication administration. Standard order for flushes prior to and after medication administration should be 30-50 mL or as ordered by physician. Flushes between medications administered are 5-10 mL or as ordered by physician. 7. Verify placement of feeding tube and gastric residual volumes per physician orders or as needed. 9. For residents receiving enteral tube feeding with the use of a pump or via gravity infusion - Replace infusion sets every 24 hours for open tube systems or 48 hours for closed tube feed systems or per manufacturer's guidelines.

Based on record review and interview, the facility failed to ensure the providers acted upon the pharmacist recommendations for 2 of 5 residents reviewed (Residents #66 and #67).Findings include: 1) Review of Resident #66's Consultant Pharmacist Recommendation to Physician dated 9/17/2025 read, This resident is receiving the antipsychotic agent Quetiapine 100 mg po [orally] QHS [every night at bedtime] (9/11/25) but lacks an allowable diagnosis to support its use. Please adjust the diagnosis code as clinically indicated. There was no response or signature from the provider. Review of Resident #66's Pharmacist Recommendations (DON/Medical Director Copy)for recommendations created between 10/1/2025 and 10/28/2025 read, This resident is using the following duplicate antidepressant therapy. Paroxetine HCl Tablet 10 MG, Give 2 tablet by mouth one time a day related to major depressant disorder. Active 09/18/2025. Trazodone HCl oral tablet 100 MG (Trazodone HCl), Give 1 tablet by mouth three times a day for depression. Active 09/18/2025. There was no response or signature from the provider. During an interview on 4/22/2026 at 12:43 PM, the Nursing Consultant stated that the Pharmacy Monthly consultations provided is all that there is. 2) Review of Resident #67's Consultant Pharmacist Recommendation to Physician dated 8/15/2025 read, A reference range for Keppra has not been well established. Most patients display optimal response to Keppra with serum levels 10-40 ug/ml [micrograms/milliliter]. Some patients may respond well outside this range or may display toxicity within the therapeutic range, thus interpretation should include clinical evaluation. Toxic levels have not been established. Therapeutic ranges are based on specimen drawn at trough. There was no response or signature from the provider. Review of Resident #67's Pharmacist Recommendations (DON [Director of Nursing]/Medical Director Copy) for recommendations created between 10/1/2025 and 10/28/2025 read, This resident is using the following duplicate antidepressant therapy: Sertraline HCl [hydrochloride] Tablet 50 MG [milligram], Give 2 tablet by mouth at bedtime for Depression. Active 10/12/2023. Trazodone HCl Oral Tablet 50 MG (Trazadone HCl), Give 2 tablet by mouth at bedtime related to Depression. Active 10/17/2024. There was no response or signature from the provider. Review of Resident #67's physician order dated 10/12/2023 read, Sertraline HCl Tablet 50 MG, Give 2 tablet by mouth at bedtime for Depression. Order Status: Active. Review of Resident #67's physician order dated 10/17/2024 read, Trazodone HCl Oral Tablet 50 MG (Trazadone HCl), Give 2 tablet by mouth at bedtime related to Depression. Order Status: Active. During an interview on 4/22/2026 at 5:21 PM, Medical Doctor #1 stated, I do admit I have gotten delayed. I get the recommendations in bulk. It is more on me than the pharmacy. During an interview on 4/23/2026 at 6:57 AM, the Director of Nursing stated, I review the recommendations and give them to each doctor. I will send them an email or put it in their book. [Medical Doctor #1's name] signs the recommendations and them and gives them back to us so we can out them in and that is a hit or miss. Review of the facility policy and procedures titled Pharmacist Recommendations with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines.

Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications for 2 of 8 residents reviewed (Residents #50 and #55).Findings include:1) Review of Resident #55's physician order dated 3/29/2026 read, Metoprolol Succinate ER [Extended Release] Oral Tablet Extended Release 24 Hour 50 MG [milligram] (Metoprolol Succinate), Give 1 tablet by mouth two times a day for HTN [hypertension], hold for SBP [Systolic Blood Pressure] less than 110 or DBP [Diastolic Blood Pressure] less than 60.Review of Resident #55's Medication Administration Record (MAR) for April 2026 for administration of Metoprolol Succinate showed the medication was administered on 4/7/2026 at 9:00 AM for blood pressure (BP) of 111/58 (SBP/DBP), 4/14/2026 at 9:00 PM for BP of 110/54, 4/15/2026 at 9:00 PM for BP of 93/51, 4/17/2026 at 9:00 PM for BP of 108/90, and 4/19/2026 at 9:00 PM for BP of 108/65.During an interview on 4/22/2026 at 1:28 PM, Staff J, Licensed Practical Nurse (LPN), stated, I administered the medication in error.2) Review of Resident #50's physician order dated 1/31/2026 read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical)), Apply to both hands topically two times a day for pain. The order was discontinued on 4/20/2026.Review of Resident #50's MAR for April 2026 for application of Voltaren Gel showed the medication was applied at 9:00 AM and 9:00 PM on 4/1/2026 through 4/12/2026 and on 4/14/2026 through 4/19/2026.During an interview on 4/22/2026 at 1:44 PM, Staff M, LPN, stated, When I administer the medication, I put on gloves and massage it into the resident's hands. I don't remember specifically how much I applied.During an interview on 4/22/2026 at 2:55 PM, the Director of Nursing (DON) stated, It is the expectation that nursing staff clarify incomplete or unclear medication orders with the provider and document the response, and that staff are expected to follow physician-ordered parameters when administering medications.During an interview on 4/22/2026 at 1:53 PM, Medical Doctor #1 stated, I am aware that residents [Residents #50 and #55] have received medications outside of ordered parameters. I have reviewed the residents and feel that the administrations did not result in any adverse events.Review of facility policy and procedures titled Medication Administration with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with accepted professional principles in 3 of 4 units.Findings include: 1) During an observation on 4/20/2026 at 9:59 AM, there were two vials of nebulizer treatment on top of Resident #137's drawer. During an observation on 4/21/2026 at 4:25 PM, there were two clear plastic ampules of nebulizer treatment on top of Resident #137's drawer. During an interview on 4/21/2026 at 4:58 PM, Staff W, Registered Nurse (RN), stated, [Resident #137's name] should not have medication at bedside. 2) During an observation on 4/20/2026 at 10:28 AM, there was zinc oxide ointment and packets of vitamin A and D ointment on top of Resident #59's drawer. During an interview on 4/20/2026 at 10:28 AM, Resident #59 stated, The nurses assist me to apply the ointment on my skin. During an interview on 4/21/2026 at 4:53 PM, Staff W, RN, stated, [Resident #59's name] should not have medications at bedside. 3) During an observation on 4/21/2026 at 11:00 AM, Resident #151 had a clear medication cup with clear gel like ointment and was applying it to hands. During an interview on 4/21/2026 at 11:00 AM, Resident #151 stated, I use this [clear gel ointment] on my dry skin. During an interview on 4/21/2026 at 4:50 PM, Staff W, RN, stated, [Resident #151's name] should not have medication at bedside. When I offered the ointment, he said he had his own, but I did not understand what he was referring to. I did not see it at bedside when I went in. 4) During an observation on 4/22/2026 at 9:21 AM, Resident #3 was lying in bed. There was a bottle of TUMS on top of her bedside table. During an interview on 4/22/2026 at 9:30 AM, Staff X, RN, confirm the bottle of TUMS was on the bedside table and stated, [Resident #3's name] is not able to self-administer medications and should not have medication at bedside. During an interview on 4/23/2026 at 6:36 AM, the Director of Nursing stated, Medication should not be left unattended at bedside. In order to self-administer medication, we would evaluate the resident and provide a lock box for them. 5) During an observation on 4/23/2026 at 10:15 AM, in memory care unit, the medication cart was unattended with a medication card pack on top of the cart turned upside down with no patient information visible. One of the blister bubbles remained sealed and a tablet was present in the package tablet #25 of Coreg 6.25 MG (milligrams) prescribed to Resident #54 for hypertension. During an interview on 4/23/2026 at 10:15 AM, the Assistant Director of Nursing stated, The nurse must have stepped away to the restroom and thought that card was empty. My expectation is for all meds to be secured. During an interview on 4/23/2026 at 10:17 AM, Staff E, LPN, stated, I thought it was empty and I was going to reorder it. Review of the facility policy and procedure titled Medication/Biological Storage with the last review date of 1/28/2026 read, Policy: It will be the policy of this facility to store medication, drugs and biologicals in a safe, secure, and orderly manner. Procedure: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurses view.

Based on observation, record review, and interview, the facility failed to ensure complete and accurate medical records for 2 of 4 residents reviewed for skin conditions (Residents #112 and #119).Findings include: 1) During an observation on 4/20/2026 at 10:14 AM, Resident #112 was sitting up in bed. There was a dressing dated 4/16/2026 on the left side of her neck (Photographic evidence obtained). During an interview on 4/20/2026 at 10:14 AM, Resident #112 stated, Dermatology came to see me and decided to biopsy an area on my neck. During an observation on 4/21/2026 at 8:10 AM, Resident #112 was lying in bed. There was a dressing on the left side of the resident's neck dated 4/16/2026. During an interview on 4/21/2026 at 8:10 AM, Resident #112 stated, They have not changed my dressing. The nurse said she would change it today. Review of Resident #112's physician order dated 4/15/2026 read, Wound care left neck- wash with soap and water, pat dry, apply petroleum jelly, cover with nonstick bandage every day shift for biopsy site for 7 days. Review of Resident #112's Treatment Administration Record for April 2026 for left neck wound care showed wound care was performed on 4/17/2026, 4/18/2026, and 4/20/2026. During an interview on 4/21/2026 at 4:36 PM, Staff W, Registered Nurse (RN), stated, I don't remember the date on the dressing when I changed it today [4/21/2026]. During an interview on 4/21/2026 at 4:46 PM, Staff V, Licensed Practical Nurse (LPN), stated, I didn't see orders for dressing changes. I know they were talking about a biopsy on her neck today. I am not sure why I checked it off it was probably a mistake. During an interview on 4/22/2026 at 8:04 AM, Staff B, LPN Wound Care Nurse, stated, There was a lot going on Saturday [4/18/2026]. Normally, when I do wound care, I wait to do it to check it off. I cannot recall what happened. 2) During an observation on 4/20/2026 at 10:16 AM, Resident #119 was sitting in his wheelchair. There was a dressing dated 4/16 on his right knee (Photographic evidence obtained). During an interview on 4/20/2026 at 10:16 AM, Resident #119 stated, He had fallen at home and had a wound on his right knee. Review of Resident #119's physician order dated 4/14/2026 read, Cleanse right knee with wound cleanser and apply Iodosorb gel and cover with border gauzes three times a week every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday]. Review of Resident #119's Treatment Administration Record for April 2026 for right knee wound care showed the wound care was provided on 4/18/2026. During an interview on 4/22/2026 at 8:04 AM, Staff B, LPN Wound Care Nurse, stated, I did work on 4/18. I did not do his dressing on Saturday [4/18/2026] because he was up. I am trying to think what happened. My days are blurred. I don't remember what happened on Friday. That was the day I had to wait to get relieved and do the dining room and there was a lot of things going on for me. During an interview on 4/23/2026 at 6:37 AM, the Director of Nursing stated, The staff's documentation should be accurate and not check off wound care as completed unless it is done. Review of the facility policy and procedures titled Charting and Documentation with the last review date of 1/28/2026 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical condition, shall be documented in the resident's clinical record as is needed.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 4 residents, Resident #1, reviewed for medication administration. Findings include: Review of Resident #1's physician order dated 11/16/2024 read, Acidophilus Capsule 100 mg [milligrams] (Lactobacillus) give 1 capsule by mouth two times a day for probiotic. Order status: Active. Start date: 11/16/2024.Review of Resident #1's MAR [Medication Administration Record] for December 2025 for the administration of Acidophilus Capsules showed no entry for 12/09/2025 at 1700 [5:00 PM].Review of Resident #1's physician order dated 11/16/2024 read, Ascorbic Acid (Vitamin C) Oral Tablet 500 mg (Ascorbic Acid) give 1 tablet by mouth two times a day for supplement. Order status: Active. Start date: 11/16/2024.Review of Resident #1's MAR for December 2025 for the administration of Ascorbic Acid tablet showed no entry for 12/09/2025 at 1700.Review of Resident #1's physician order dated 11/16/2024 read, Eliquis Oral Tablet 5 mg (Apixaban) (blood thinner) give 5 mg by mouth two times a day related to unspecified atrial flutter (irregular heart beat). Order status: Active. Start date: 11/16/2024.Review of Resident #1's MAR for December 2025 for administration of Eliquis Oral Tablet showed no entries at 12/09/2025 and 12/14/2025 at 1700.Review of Resident #1's physician order dated 11/16/2024 read, Famotidine (medication to decrease stomach acid production) Tablet 20 mg give 1 tablet by mouth two times a day related to gastro-esophageal reflux disease without esophagitis. Order status: Active. Start date: 11/16/2024.Review of Resident #1's MAR for December 2025 for administration of Famotidine Tablet showed no entry for 12/09/2025 at 1700.Review of Resident #1's physician order dated 12/25/2025 read, Insulin Glargine (long-acting insulin) Solution 100 Unit/ML (milliliter). Inject 35 unit subcutaneously (beneath the skin) two times a day for diabetes (0500 and 1700) (5:00 AM and 5:00 PM) dialysis patient. Order status: Active. Start date: 12/25/2025.Review of Resident #1's MAR for December 2025 for the administration of Insulin Glargine showed no entries for 12/09/2025 at 1630 and 12/14/2025 at 1630 [4:30 PM]Review of Resident #1's physician order dated 01/04/2025 read, Apidra SoloStar (rapid-acting insulin) 100 Unit/ML solution pen-injector. Inject 8 units subcutaneously before meals related to type 2 diabetes mellitus with other specified complication. Order status: Active. Start date: 01/06/2026.Review of Resident #1's MAR for December 2025 for the administration of Apidra Solostar showed no entries for 12/09/2025 for 16:30 and 12/14/2025 for 16:30.During an interview on 01/27/2026 at 1:16 PM Staff A, LPN (Licensed Practical Nurse) stated, [Resident #1's name] doesn't like [Staff B, LPN's name] and [Staff C, LPN's name], so when they are there, I take over his care. I gave [Resident #1's name]'s medications on December 9th. We do 12-hour shifts. I gave [Resident #1's name] all of his medications, and I expected [Staff B, LPN's name] to document that the medications were given. I told [Staff B, LPN's name] I gave the medications, and she was supposed to document them.During an interview on 01/27/2026 at 2:01 PM, Staff B, LPN stated, [Resident #1's name] doesn't like me. When I am working, we split the hallway and another nurse takes over his care, usually [Staff A, LPN's name]. [Staff A's name] gives the medications and I am supposed to document that the medications were given in that scenario. I must have forgotten to document that [Staff A, LPN's name] gave the meds to [Resident #1's name] for whatever reason.During an interview on 01/27/2026 at 2:21 PM Staff C, LPN stated, I worked 7a-7p on December 14th. I had [Resident #1's name] in my assigned group. Another nurse was giving the medications for [Resident #1's name]. I do not take care of [Resident #1's name] because he is verbally abusive to me, so on that day another nurse was giving his medications. I don't recall who the other nurse was on that day. I pulled the insulin for that nurse. If there is a blank space on the MAR for [Resident #1's name]'s medications on December 14th, I must have gotten distracted and forgot to document that the medications were given. I remember on that day I pulled the medications and verified with the other nurse that the medications were given. I must have just gotten distracted that day and forgot to sign off.During an interview on 01/27/2026 at 2:06 PM the Director of Nursing stated, I explained to the nurses going forward that whichever nurse gives the medication is going to need to sign off on it. My expectation is that whichever nurse gives the medication, they should document it. [Staff A's name] should have documented that [Resident #1's name] received his medications on December 9th.Review of policy and procedure titled, Charting and Documentation issued 04/01/2022 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be recorded in the resident's clinical records. 3. Entries into the clinical record should be made by the appropriate staff members. Staff providing care and services to the resident may contribute to the overall documentation in the clinical record in accordance with state and federal law.

Based on observations and interviews, the facility failed to ensure an orderly and sanitary environment in 4 (100, 200, 300, 400) of 4 hallways. Findings include: During a tour of the facility on 3/29/25 at 9:17 AM, a buildup of trash and debris was observed on all hallways [100, 200, 300 and 400]. No housekeeping carts were observed during the tour. During a tour of the facility on 3/29/25 at 9:20 AM, in the 100 hallway, close to the exit leading to the smoking patio, there was significant debris observed on the floor, which consisted primarily of leaves, grass, and some small pieces of trash. An interview on 3/29/25 at 10:00 AM, Resident #6 stated that he does not see housekeeping very often. An interview on 3/29/25 at 10:10 AM, Resident #7 stated that housekeeping could be better. An interview on 3/29/25 at 10:17 AM, Resident #8 stated housekeeping was a 'joke.' During a tour of the facility on 3/29/25 at 11:30 AM, debris and trash was still observed on the floors of 100, 200, 300, and 400 hallways. No housekeeping carts were observed during the tour. During an observation of the facility on 3/29/25 at 1:20 PM with the Administrator, trash and debris were observed on all hallways (100, 200, 300 and 400) throughout the facility. A large, uncovered cart was being brought out of the dirty utility room that was filled with bags of soiled linens and trash creating a lingering and foul odor. On the 100 hallway there was a brownish dried liquid on the wall from the handrail to the floor in two distinct wavy lines that were approximately 1/8 to 1/4 width in size. No housekeeping carts were observed during the tour with the Administrator. The Administrator confirmed the unclean and unsanitary environment. An interview on 3/29/25 at 1:30 PM, the Administrator stated that housekeeping follow a check list that they are supposed to turn in showing those rooms and common areas that were cleaned. The Administrator stated that his expectation was to follow checklist and that the daily cleaning schedule was not being followed. He verified there was no housekeeping personnel working the morning of 3/29/25.

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards when residents were served an inappropriate therapeutic diet for 1 (Resident #45) of 10 residents reviewed for nutrition. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F805, F835, and F867. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. Review of Resident #45's Speech Therapy SLP [Speech Language Pathology] Evaluation & Plan of Treatment dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months . Objective tests/measures & additional analysis . additional analysis: Other: [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia; however, resident is exhibiting a severe deficit with oral phase of swallow . Assessment Summary: Skilled Justification: Reason for Skilled services: Skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume least restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration and weight loss. Review of Resident #45's Speech Therapy Treatment Encounter Notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM Staff R, Speech Therapist stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person aspiration pneumonia and an increased risk of hospitalization . During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:40 PM, the Registered Dietitian #1, stated, I consider the staff giving the wrong diet order and identifying it was the wrong diet order and not doing anything to correct it would be considered a mistake. It was a clinical error. He was a mechanical soft diet at that time. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. Review of the written statement authored by Staff J, LPN, dated 10/15/2024 read, Assisting in the Dining Rm [room] for lunch. [Resident #45's initials] had the ravioli and string beans but was asking for an alternative. He requested a hot dog. I had gotten the hot dog from the kitchen and brought it to the table. Took the hot dog and added condiments as per his request. The CNA, then cut up the hot dog for him to eat. Resident had eaten the hot dog without any difficulties. He was not coughing. Resident had same meal as everyone else therefore, I thought that he had a regular meal also. I stayed to observe the table to make sure he had no swallowing issues and no signs or symptoms of aspiration. When I realized I had made a mistake I panicked and did not remove the resident's food because I saw the surveyor standing there watching me and I did not want to raise any red flags by taking his food back, I felt as though she would sense something was wrong and I would cause more harm than good. Review of the written statement authored by Staff J, LPN, dated 10/16/2024 read, Yesterday I was asked to assist in the dining room, due to the increase in the resident population during lunchtime. Resident observed a fell ow resident having a hot dog and decided that he would like to have one as well. I proceeded to the kitchen and requested a hot dog platter from the kitchen staff. I returned the plate to the residents' request; I then gave the resident condiments and the RN that was present pointed out that the resident was on a mechanical diet. Residents' meal was properly mechanicalized prior to him eating. Review of Employee Statement/ Interview Record authored by Staff I, RN, dated 10/16/2024 read, Date of Event 10/16/2024 . [Resident #45's name] requested alternative for lunch during lunch time in the dining room. Other LPN in dining room brought resident a full hot dog w/ [with] bun. Before she brought it to him and sat it in front of him. I told her [he] can't have it b/c [because] he is MS [Mechanical Soft] diet. She looked at me then looked at the state woman [State surveyor] standing in the corner and moved to grab a cart. I was running plates and assisting other residents upon returning to food counter [the] LPN began putting mustard on hot dog for resident [Resident #45's name] I said again he cannot have that he is mechanical soft you need to take it. LPN looked at me a slightly shrugged shoulder. I was called away again and when I returned a bite was taken out of [Resident #45's name] hot dog and he had it in his hands. LPN was gone resident [Resident #45's name] left dining room soon after. Review of the written statement authored by Staff Q, Cook, dated 10/16/2024 read, On October 15 between 12:30-12:45 pm I was serving the lunch line. A nurse came in saying she needed a hot dog. We asked who for? She said she needed it for the dining room. We asked what their diet was and she said she didn't know. I made the hot dog and then handed it to her. Review of the facility policy and procedure titled Accidents and Supervision with the last review date of 1/31/2024 read, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions . Hazards refers to elements of the resident environment that have the potential to cause injury or illness . Supervision/Adequate/Supervision refers to intervention and means of mitigating risk of an accident . Procedure: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility should make a reasonable effort to identify the hazards and risk factors for each resident . 5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders by 11/13/2024. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on accuracy of diets.

Based on observation, interview, and record review, the facility failed to serve food designed to meet individual needs for 1 (Resident #45) of 10 residents sampled who required mechanically altered diets. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant, cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the resident's needs led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on February 10, 2025, at 8:28 AM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F835, and F867. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. Review of Resident #45's Speech Therapy SLP [Speech Language Pathology] Evaluation & Plan of Treatment dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months . Objective tests/measures & additional analysis . additional analysis: Other: [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia; however, resident is exhibiting a severe deficit with oral phase of swallow . Assessment Summary: Skilled Justification: Reason for Skilled services: Skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume least restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration and weight loss. Review of Resident #45's Speech Therapy Treatment Encounter Notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM, Staff R, Speech Therapist, stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person, there is a risk of aspiration pneumonia and an increased risk of hospitalization . During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a [NAME] day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. Review of the written statement authored by Staff J, LPN, dated 10/15/2024 read, Assisting in the Dining Rm [room] for lunch. [Resident #45's initials] had the ravioli and string beans but was asking for an alternative. He requested a hot dog. I had gotten the hot dog from the kitchen and brought it to the table. Took the hot dog and added condiments as per his request. The CNA, then cut up the hot dog for him to eat. Resident had eaten the hot dog without any difficulties. He was not coughing. Resident had same meal as everyone else therefore, I thought that he had a regular meal also. I stayed to observe the table to make sure he had no swallowing issues and no signs or symptoms of aspiration. When I realized I had made a mistake I panicked and did not remove the resident's food because I saw the surveyor standing there watching me and I did not want to raise any red flags by taking his food back, I felt as though she would sense something was wrong and I would cause more harm than good. Review of the written statement authored by Staff J, LPN, dated 10/16/2024 read, Yesterday I was asked to assist in the dining room, due to the increase in the resident population during lunchtime. Resident observed a fell ow resident having a hot dog and decided that he would like to have one as well. I proceeded to the kitchen and requested a hot dog platter from the kitchen staff. I returned the plate to the residents' request; I then gave the resident condiments and the RN that was present pointed out that the resident was on a mechanical diet. Residents' meal was properly mechanicalized prior to him eating. Review of Employee Statement/ Interview Record authored by Staff I, RN, dated 10/16/2024 read, Date of Event 10/16/2024 . [Resident #45's name] requested alternative for lunch during lunch time in the dining room. Other LPN in dining room brought resident a full hot dog w/ [with] bun. Before she brought it to him and sat it in front of him. I told her [he] can't have it b/c [because] he is MS [Mechanical Soft] diet. She looked at me then looked at the state woman [State surveyor] standing in the corner and moved to grab a cart. I was running plates and assisting other residents upon returning to food counter [the] LPN began putting mustard on hot dog for resident [Resident #45's name] I said again he cannot have that he is mechanical soft you need to take it. LPN looked at me a slightly shrugged shoulder. I was called away again and when I returned a bite was taken out of [Resident #45's name] hot dog and he had it in his hands. LPN was gone resident [Resident #45's name] left dining room soon after. Review of the written statement authored by Staff Q, Cook, dated 10/16/2024 read, On October 15 between 12:30-12:45 pm I was serving the lunch line. A nurse came in saying she needed a hot dog. We asked who for? She said she needed it for the dining room. We asked what their diet was and she said she didn't know. I made the hot dog and then handed it to her. Review of the facility policy and procedure titled Provide Diet to Meet Needs of Each Resident with the last review date of 1/31/2024 read, Policy: The purpose of the food and nutrition services (FNS)/dietary department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances and personal, religious and cultural preferences, based on reasonable effort. Therapeutic diets will be served as prescribed by the attending physicians or their designee. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on accuracy of diets.

Based on observation, interview, and record review, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident by failing to implement policies and procedures related to therapeutic diets. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J, Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F805, and F867. Findings include: Review of the Job Description titled Administrator signed by the Administrator on 11/1/2024 read, Purpose of Your Job Position: The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Duties and Responsibilities: Administrative Functions . Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility . Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures. Review of the Job Description titled Director of Nursing Services signed by the Director of Nursing on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operations of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities. Review of the Job Description titled Dietitian signed by the Registered Dietitian #1 on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall clinical operation of the Food Services Department in accordance with current federal, state, and local standards guidelines, and regulations, that govern the Facility, and as may be directed by the Administrator, to assure the quality nutritional services are being provided on a daily basis . Duties and Responsibilities: Administrative Functions . Develop, implement, and maintain written departmental policies that apply to your area. Ensure staff is aware of and follows the established policies . Assist in planning regular and special diet menus as prescribed by the attending physician . Review therapeutic and regular diet plans and menus to assure they comply with physician orders. Review of the Job Description titled Food Service Supervisor signed by the Food Service Director on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop, and oversee the operations of the Nutritional Services/Food Services Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our Facility, and as may be directed by the Administrator or the Food Services Director to assure that quality nutritional services are provided on a daily basis and that the Nutritional Services/Food Department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities. Administrative Functions . Review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. Review of the Medical Director Retainer Agreement signed by the Medical Director on 2/23/2020 read, Consultant Responsibilities: Supervise the overall functions of our facility's medical services in that the medical director shall . Participate in the development of written policies, rules, and regulations to govern the nursing care and related medical and other health services provided. The medical director is responsible for seeing that these policies reflect an awareness of and have provisions for meeting the total needs of the residents. Ensure the residents receive adequate services appropriate to their needs. During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, muscle weakness (generalized), other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis and legal blindness. Review of Resident #45's Speech Theary SLP [Speech Language Pathologist] Evaluation & Plan dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months .Objective tests/measures & additional analysis: .additional analysis: other [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia however, resident is exhibiting a severe deficit with oral phase of swallow .Assessment Summary: Reason for skilled services: skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: due to the documented physical impairment and associated functional deficits, the patient is at risk for: aspiration and weight loss . Review of Resident #45's Speech Therapy Treatment encounter notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. Review of Resident #45 physician order dated 7/9/2024 read Physician ordered CCHO [Consistent Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45's name] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name [Residents #45's name]. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM Staff R, Speech Therapist stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person aspiration pneumonia and an increased risk of hospitalization . During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a [NAME] day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:12 PM with the Administrator, when asked if identifying the wrong diet order served and not removing the meal was neglectful behavior, the Administrator stated, We took it as both ways because no action happened. We worked the event as a near miss. During an interview on 11/12/2024 at 12:13 PM, the Regional Nursing Consultant stated, We worked it as a near miss like if someone had a medical error. If we reported every near miss med error or error, we would be doing that every day. This was a [NAME] employee. A nurse who failed to act. During an interview on 11/12/2024 at 12:40 PM, the Registered Dietitian #1, stated, Choosing the word neglect makes it hard to answer since it's a legal term. Would I consider this a mistake or not following the procedure, yes. I do not feel comfortable answering and using that kind of language. A mistake is anything that occurs that is outside the realm of norm, deviation from the norm. I consider the staff giving the wrong diet order and identifying it was the wrong diet order and not doing anything to correct it would be considered a mistake. It falls under the definition I gave you of a deviation from the norm. It was a clinical error. He was a mechanical soft diet at that time. During an interview on 11/12/2024 at 12:45 PM with the Food Service Director, when asked if not removing the food item after identifying it was wrong diet order would be considered neglectful behavior, The Food Service Director stated, I do not feel comfortable answering the question. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. When asked if the nurse's inaction after identifying the incorrect diet order and not removing the tray was neglectful, the Medical Director stated, I would consider this to be a situation with a nurse that needs to be suspended and educated. During an interview on 11/13/2024 at 9:57 AM, the Administrator stated, Part of the incident after looking at it, yes it was neglectful behavior. To me, neglect is the unwillingly action made against somebody. Since the staff was told twice, she should have removed it. During an interview on 11/13/2024 at 10:08 AM, the Medical Director stated, Neglect to me is to do something that would harm a patient on purpose. In this case, it was a request from a patient. Even if they have a lower BIMS [Brief Interview for Mental Status] than usual or dementia, but they understand they can ask and we have to respect them. We would consider those pleasure feed. Another staff tried to resolve the issue by cutting the hot dog. During an interview on 11/13/2024 at 12:01 AM, the DON, stated, Neglect is intentionally not taking care the patient. A dietary scenario that would be considered neglect would be not making sure that a patient got a meal. Referring to the two nurses not providing the best care for the patient, that would be neglect. We should have followed through. During an interview on 11/13/2024 at 12:20 PM, Food Service Director stated, The residents have the right to good and services. Basically, the situation that happened in the dining room with [Resident #45's name] and that nurse not removing the tray is considered neglect because it can possibly do harm to the resident. During an interview on 11/13/2024 at 12:26 PM, Registered Dietitian #1, stated, [Neglect is] the failure to provide goods and services as deemed medically necessary. I would consider the case you are here for neglect. I did not want to answer it yesterday until I was completely familiar with the situation and all the definitions. Review of the facility policy and procedure titled Nutrition and Hydration Assistance with the last review date of 1/31/2024 read, Policy: It will be the policy that this facility will provide the level of assistance required to the residents while maintain their highest practicable level of function and personal preferences. Staff will help ensure residents receive adequate assistance and provision of services for nourishment and hydration. Review of the facility policy and procedure titled Provide Diet to Meet Needs of Each Resident with the last review date of 1/31/2024 read, Policy: The purpose of the food and nutrition services (FNS)/dietary department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances and personal, religious and cultural preferences, based on reasonable effort. Therapeutic diets will be served as prescribed by the attending physicians or their designee. Review of the facility policy and procedure titled Accidents and Supervision with the last review date of 1/31/2024 read, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions . Hazards refers to elements of the resident environment that have the potential to cause injury or illness . Supervision/Adequate/Supervision refers to intervention and means of mitigating risk of an accident . Procedure: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility should make a reasonable effort to identify the hazards and risk factors for each resident . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024 and on 11/13/2024, residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, the facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements. On 11/12/2024, a performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin. On 11/13/2024, education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of the facility records showed the facility completed interviews and skin checks with all residents for identification of abuse/neglect on 10/16/2024 and 11/13/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders, and on abuse and neglect by 11/13/2024. Review of the education in-service attendance record dated 11/13/2024 showed the Administrator, Director of Nursing, Assistant Director of Nursing, and Registered Nursing Consultant received education by the Chief Nursing Officer on abuse and neglect, job description, monitoring of facility systems and 5 elements of QAPI. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on abuse/neglect and accuracy of diets. During interviews conducted on 11/13/2024, the Regional Nursing Consultant, the Administrator, and the DON verified having received education and verbalized understanding.

Based on interview, record review, and observation, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility identified policies and procedures were not implemented for modified consistency diets. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F805, and F835. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. Right now, when someone asks for something else, they have to show the dietary slip for the cook to release any food items. Every department involved got a disciplinary action and training. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a [NAME] day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:12 PM with the Administrator, when asked if identifying the wrong diet order served and not removing the meal was neglectful, the Administrator stated, We took it as both ways because no action happened. We work the event as a near miss. During an interview on 11/12/2024 at 12:13 PM, the Regional Nursing Consultant stated, We worked it as a near miss like if someone had a medical error. If we reported every near miss med error or error, we would be doing that every day. This was a [NAME] employee. A nurse who failed to act. During an interview on 11/13/2024 at 9:57 AM, the Administrator stated, Part of the incident after looking at it, yes it was neglectful behavior. To me, neglect is the unwillingly action made against somebody. Since the staff was told twice, she should have removed it. After yesterday, we had a meeting and analyzed the situation and called it what it is. We filed the reportable and reported the staff members. A request was made for the policy and procedures for QAPI. Review of the provided document titled QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home read, What is QAPI? QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). Both involve using information, but differ in the key ways: QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better . Why QAPI is important? Once QAPI is launched and sustained, many people report that is a rewarding and even an enjoyable way of working. The rewards of QAPI include: Competencies that equip you to solve quality problems and prevent their recurrences; Competencies that allow you to seize opportunities to achieve new goals; Fulfillment for caregivers, as they become active partners in performance improvement; and above all, better care and better quality of life for your residents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024 and on 11/13/2024, residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, the facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements. On 11/12/2024, a performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin. On 11/13/2024, education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of the facility records showed the facility completed interviews and skin checks with all residents for identification of abuse/neglect on 10/16/2024 and 11/13/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders, and on abuse and neglect by 11/13/2024. Review of the education in-service attendance record dated 11/13/2024 showed the Administrator, Director of Nursing, Assistant Director of Nursing, and Registered Nursing Consultant received education by the Chief Nursing Officer on abuse and neglect, job description, monitoring of facility systems and 5 elements of QAPI. Review of the facility records showed the facility held an Ad Hoc QAPI meeting on 10/17/2024 and conducted a root cause analysis for the concerns on accuracy of diets, held an Ad Hoc QAPI meeting on 11/12/2024 on accuracy of diets and abuse and neglect, and an Ad Hoc QAPI meeting 11/13/2024 on approval of removal plan and review of supervisor monitoring tool. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on abuse/neglect and accuracy of diets. During interviews conducted on 11/13/2024, the Regional Nursing Consultant, the Administrator, and the DON verified having received education and verbalized understanding.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from medical neglect when the staff failed to notify the physician of elevated blood sugars for 1 of 5 residents, Resident #13, and failed to follow physicians' orders for the administration of long-acting insulin for 3 of 5 residents, Residents #100, #4, and #5, reviewed for long-acting insulin administration. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing sever hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulins; long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MAR reflects appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP [performance improvement plan]. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I did not receive training prior to last night for insulin. We talked about calling and documenting accuchecks. I know I should not hold long-acting insulin without parameters now. I should not have held the insulin and not let the doctor know. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to notify the physician of changes in condition for 1 of 5 residents, Resident #13, and failed to follow physicians' orders for the administration of long-acting insulins for 3 of 5 residents, Residents #100, #4, and #5. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing sever hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulins; long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. I did not receive any training related to long-acting insulin. Today we discussed long term insulin administration and that we don't ever hold the insulin unless we call the doctor and they just put in new parameters that say below 80 call the doctor. During an interview on 9/1/2023 at 1:30 PM, Staff N, LPN stated, I was not trained on long- acting insulin until today. I just was given the information about long-acting insulin today. I was not trained on this two weeks ago. During an interview on 9/1/2023 at 1:45 PM, Staff O, LPN stated, Two weeks ago I did not get any training on the types of insulin or when they peak. We just got that today along with long- acting insulin that it doesn't get held. That we need to call doctors if we hold insulin or if it's high and on neglect. I do understand that I shouldn't hold long-acting insulin and that I have to follow doctors' orders when it comes to insulin. During an interview on 9/1/2023 at 2:15 PM, Staff P, RN stated, I was not given insulin administration education information before today. They did not talk to use about long-acting insulin until today. I did get training on neglect, change of condition, following doctors' orders, the new orders to call a doctor if blood glucose is less than eighty today. I do understand how long-acting insulin works and that I shouldn't hold it. During an interview on 9/1/2023 at 2:25 PM, Staff Q, LPN stated, We got some training like two weeks ago making sure orders were in if they had blood sugars below 60 and what to do, like give glucagon. I was not trained on the types of insulin until today. We went over a printout that had the types of insulin, when they begin to work, that we don't have parameters on Lantus and Levemir insulins only the short acting ones. That we don't hold long-acting insulin, they also talked about following doctors' orders, calling doctors when we need to report things like blood sugars to them. Review of the policy and procedure titled P&P Diabetes/Hypo/Hyperglycemia issued on 4/1/2022 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other condition requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to physician order . 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders. 13 . Report noncompliance with physician orders to the physician and/or resident representative, if applicable. 14. Document pertinent information, regarding medication administration, changes in condition, education, or interventions in clinical record. Review of the policy and procedure titled P&P Medication Errors issued on 4/1/2022 read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Procedure: 1. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturers specifications for use, dose, administration, duration, and monitoring of the medication. b. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences to the resident's physician, governing agencies, and resident representative, if applicable . 4. Staff will document appropriately detailed accounts of any incidents/events on an appropriate report form or electronic database system for quality assurance. Review of the policy and procedure titled Medication Administration issued on 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in a timely manner and in accordance with the physician's orders . 5. Should a dose seem excessive considering the residents age and medical condition, or medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director . 12. Should a drug be withheld, refused, or given other than the scheduled time, the individual administering the medication will document this in the clinical record. Review of the policy and procedure titled P&P Change in Condition issued on 4/1/2022 read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to resident wishes and physician's orders . 6. Contact the primary physician to update/him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, abuse, and change in condition notification. Interview with the Administrator on 9/1/2023 verified training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical wellbeing of each resident when not assuming full responsibility for the day-to-day operations of the facility and failing to effectively implement a QAPI/QAA plan. The administration failed to identify medication errors for residents who were not administered long-acting insulin as ordered by the physician and failed to ensure physician notification when medication orders were not followed and residents had change of condition for 4 of 7 residents, Resident #13, #100, #4, and #5. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: Cross Reference to F867- QAPI/QAA (Quality Assurance and Performance Improvement/Quality Assessment and Assurance) Improvement Activities under survey event RQJA12. Review of the job description for the Administrator read, Purpose of your job position: The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities: Administrative functions: Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Review deficiencies noted during the exit conference. Assist in developing plans of correction for cited deficiencies. Ensure such plans incorporate timetables and methods of monitoring to ensure such deficiencies do not recur. Committee functions: Serve on various committees of the facility (i.e., Infection control, Quality Assurance & Assessment, etc ., assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies, evaluate and implement recommendations from the facility's committees as necessary. Safety and Sanitation: Review accident and incident reports (e.g., falls, injuries of unknown source, abuse, etc.) Monitor to determine effectiveness of facility's risk management program. Review of the Job description for the Director of Nursing Services read, Purpose of your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator to ensure the highest degree of quality care is maintained at all times. Delegation of Authority: You are charged with carrying out the resident care policies established by this facility. Administrative functions: Plan, develop, organize, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day function of the nursing service department. Make written and oral recommendations to the administrator concerning the operation of the nursing service department. Develop, implement, and maintain an ongoing quality assurance program for the nursing service department. Assist in developing and implementing appropriate plans of action to correct identified deficiencies. Monitor the facility's QI [Quality Improvement], QM [Quality Management], and survey reports. Assist in developing plans of action to correct potential or identified problem areas. Committee functions: Serve on, participate in, and attend various committees of the facility as appointed by the administrator. Evaluate and implement recommendations from established committees as they may pertain to nursing services. Staff Development: Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department. Develop, implement, and maintain an effective orientation program that orients new employees to the department, its policies and procedures, and to his/her job position and title. Review of the contractual agreement for the Medical Director read, The responsibilities of the Medical Director shall be without limitation, to perform the following duties, such duties to be solely administrative in nature and not including any direct medical services: Coordinate medical care in the facility, provide clinical guidance and oversight regarding the implementation of patient care policies and make good faith efforts to assure adequate medical care for patients. Coordinate and collaborate with facility leadership, staff, other practitioners, and consultants, including any other facility medical directors to help develop, implement and evaluate patient care policies and procedures that reflect current standards of practice and regarding administrative requests and patient care initiatives as specified in the agreement. Assist facility to identify, evaluate, address, resolve medical and clinical concerns and issues that affect patient care, medical care or quality of life or are related to the provision of services by physicians and other licensed healthcare practitioners including medical care consistent with applicable current standards of care and monitoring of the performance and practices of healthcare practitioners generally. Provide clinical leadership through active participation in the facilities quality assurance committee and quality assurance program and participate in all other activities which may be designated by the executive director of the facility from time to time to facilitate the cost-effective delivery of services at the facility. Assurance of and participation in the delivery of regular in-service training sessions for all facility staff. Participate in such case management and risk management activities and programs as the executive director of the facility may request from time to time. 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 5/31/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 16 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 6/1/2023 through 6/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 7 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 7/1/2023 through 7/31/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 10 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 7 days. Cross Reference to F884- Quality of Care. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 5 days. Cross Reference to F884- Quality of Care. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 6 days. Cross Reference to F884- Quality of Care. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. Review of the policy and procedure titled P&P Diabetes/Hypo/Hyperglycemia issued on 4/1/2022 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other condition requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to physician order . 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders. 13 . Report noncompliance with physician orders to the physician and/or resident representative, if applicable. 14. Document pertinent information, regarding medication administration, changes in condition, education, or interventions in clinical record. Review of the policy and procedure titled P&P Medication Errors issued on 4/1/2022 read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Procedure: 1. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturers specifications for use, dose, administration, duration, and monitoring of the medication. b. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences to the resident's physician, governing agencies, and resident representative, if applicable . 4. Staff will document appropriately detailed accounts of any incidents/events on an appropriate report form or electronic database system for quality assurance. Review of the policy and procedure titled Medication Administration issued on 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in a timely manner and in accordance with the physician's orders . 5. Should a dose seem excessive considering the residents age and medical condition, or medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director . 12. Should a drug be withheld, refused, or given other than the scheduled time, the individual administering the medication will document this in the clinical record. Review of the policy and procedure titled P&P Change in Condition issued on 4/1/2022 read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to resident wishes and physician's orders . 6. Contact the primary physician to update/him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to take actions to fully implement a developed plan of correction and Performance Improvement Plan (PIP), which resulted in the facility's failure to identify licensed staff was not following physicians' orders for notification of elevated blood sugars for 1 of 5 residents, Resident #13, and failure to identify medication errors for 3 of 5 residents, Residents #100, #4 and #5, who were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. Review of the education provided to licensed staff dated 8/16/2023 read, F842 following physician orders and notifying physician of CIC [change in condition] as indicated. Ensure you complete all PCC [Point Click Care] documentation before the end of your shift. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to take actions to fully implement a developed plan of correction and Performance Improvement Plan (PIP), which resulted in the facility's failure to identify licensed staff was not following physicians' orders for notification of elevated blood sugars for 1 of 5 residents, Resident #13, and failure to identify medication errors for 3 of 5 residents, Residents #100, #4 and #5, who were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. Review of the education provided to licensed staff dated 8/16/2023 read, F842 following physician orders and notifying physician of CIC [change in condition] as indicated. Ensure you complete all PCC [Point Click Care] documentation before the end of your shift. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on record review, interview, and observation the facility failed to ensure its resources were used effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for 1 of 3 sampled residents (Resident #1) who was not provided adequate supervision outdoors to protect from heat-related illness, when the weather was 91 degrees Fahrenheit at midday. The staff found the [AGE] year-old resident after being outside for approximately two hours with a temperature of 102.8 degrees Fahrenheit, unresponsive, and was subsequently hospitalized for [REDACTED].#1 resulted in Immediate Jeopardy. This has the potential to affect 143 of 143 residents requiring supervision. The Administrator was informed of the existence of Immediate Jeopardy on 10/04/2019 at 8:10 PM. The Immediate Jeopardy began on 09/29/2019, was on-going at the time of the exit on 10/04/2019. Cross reference to F600 and F689. The findings included: Review of the Job Description for Administrator for the Department of Administration/Operations under the section titled Essential Job Functions, B. Facility Management it read Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of facility; moral of the staff; and ensures the resident needs are being addressed. Under Section H, it further read Review accident and incident reports and establish an effective prevention program. Under Other Job Functions, Section A it read Responds promptly and thoroughly when problems are reported. Plans, implements and monitors corrective action when problems including ethics, compliance and/or resident abuse, neglect are identified. Directs immediate and appropriate action concerning reports of abuse or neglect. The job description was signed on 9/5/18. Review of the Job Description for the Director of Nursing Services for the Department of Nursing Administration under the section titled Essential Job Functions, [NAME] Facility Management it read Conduct regular rounds to monitor delivery of service, operation of department, cleanliness and appearance of the facility and residents to assure nursing practices and delivery of nursing services provide a comfortable, clean and safe environment. Under Section H, it further read Demonstrate and monitor the use of safe practices in regards to resident's comfort and safety. Practice and promote adherence to facility safety policies. Under Section J it read Responds promptly and thoroughly when problems are reported. Plans, implements and monitors corrective action when problems including ethics and compliance and resident abuse or neglect are identified. Maintains compliance with reporting requirements. Review of the Facility Assessment with a completion date of 10/12/2019 revealed under Hazard and Vulnerability Assessment Tool Naturally Occurring Events revealed 0 probability and 0 percent risk listed for Temperature Extremes. An interview was conducted on 10/4/2019 at 12:00 PM with the Administrator he stated, I understand there is no formal procedure for the supervision on the patio. There is no documentation in the PIP (Performance Improvement Plan) for supervision on the patio. An interview was conducted on 10/4/2019 at 12:15 PM with the Regional Clinical Nurse she stated, I understand there is no formal procedure for supervision on the patio following the incident with (Resident #1's name). An interview was conducted on 10/4/2019 at 6:47 PM with the Administrator when asked regarding the Facility Assessment and Hazard and Vulnerability Assessment Tool Naturally Occurring Events related to extreme temperatures he stated, The facility assessment needs to be adjusted because it does not take into account the risk of the heat index and extreme temperatures of Florida. When asked whether anyone considered the hot weather to be a risk to residents who go outdoors and if that risk was communicated to nursing and administration he stated, I feel we consider the hot weather as a risk to the residents who go outside. The Administrator confirmed based on the Facility Assessment there was no risk assessment for extreme temperatures. When asked how he monitors care and services he stated, I conduct a risk assessment weekly for care and services. If we have an incident, I look at the cases and make sure we are following proper protocol. An interview was conducted on 10/4/2019 at 11:20 AM the DNS (Director of Nursing Services) stated, There is no policy for supervision of residents when outdoors. Prior to the incident with (Resident #1's name) residents were check as per standards of practice, which is every two hours, unless there was special instruction for more frequent checks. After the incident with (Resident #1's name) the monitoring of the patio remains the same. The DNS then stated, The restorative department is to check the patio every hour. An interview was conducted on 10/4/2019 at 7:21 PM the DNS confirmed the Facility Assessment needs to be looked at since we did not identify extreme temperatures as a concern. An interview was conducted with Staff M, CNA, on 10/2/19 at 3:00 PM. She stated, Some residents are rounded on every 15 minutes, others every two hours and sometimes assigned as one on one. An interview was conducted with Staff F, CNA, on 10/2/19 at 3:14 PM. When asked regarding resident rounding, she stated, I round every two hours unless they are on a specific check, like every 15 minutes. An interview was conducted with Staff G, CNA, on 10/2/19 at 3:22 PM. When asked about rounding on residents she stated, Every two hours we do rounding for our patients and some residents are on special checks. An interview was conducted with Staff L, CNA, on 10/3/19 at 11:32 AM. She stated, We check our residents every two hours. An interview was conducted with Staff I, CNA on 10/3/19 at 11:39 AM. She stated, I do resident rounding every two hours unless instructed otherwise. An interview was conducted with Staff J, Restorative CNA, on 10/3/19 at 11:47 AM. When asked regarding rounding of residents he stated, At a minimum of two-hour rounds. An interview was conducted on 10/2/2019 at 2:03 PM with Clinical Educator when asked the training that has been provided to staff regarding supervision, she provided the training material. A review of the content of the hydration education provided to the staff was dated 10/01/2019, post Resident #1's incident, and read Please ensure that you are frequently monitoring any resident you see especially if they're outside. Always encourage fluids. Always ask if they're ok if they need anything. Remember to hydrate, hydrate, hydrate! Remember always encourage residents to drink fluids. A review of the content of the education titled Continuing education for nursing staff dated 10/02/2019, post Resident #1's incident, read Rounding with residents no greater than every two hours unless otherwise noted to have more frequent rounds is very important. During these times we are to be offering fluids as well with residents. Do not forget to check if residents need to be assisted to the restroom, and always make sure call light is within reach. Please notify nurse supervisor for any noted change in condition. Review of the progress notes dated 09/29/2019 revealed: Weekend receptionist assisted Resident #1 outside to the courtyard patio. Resident #1 was brought in from outside for lunch and was found unresponsive with a temperature of 102.8 Fahrenheit. Resident #1 has Dementia and is rarely or never understood. Resident #1 was transferred to an acute care hospital due to sun burn and hyperthermia. Review of Resident #1's medical record revealed the patient was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. prostate (an abnormal growth that can grow uncontrolled and spread to other parts of the body), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), need for assistance of personal care. The resident was prescribed the medication, [MEDICATION NAME] (Calcium channel blocker). A review of the Minimum Data Set Comprehensive Quarterly assessment dated [DATE] revealed the resident could not complete the Brief Interview for Mental Status (BIMS) Assessment and he is rarely/never understood. Under Section C revealed, the resident has short term and long term memory problems and decision making is severely impaired. Resident #1 requires supervision and oversight for locomotion off the unit, (how resident moves to and returns from off-unit locations such as areas set aside for dining, activities or treatments). A review of the care tasks for (MONTH) 2019 for Resident #1 revealed the resident was on 'hourly rounds' for supervision. A review of the progress notes dated 9/29/19 at 2:21PM revealed Resident #1 was brought inside from courtyard for lunch after he had been outside for around 2 hours. Resident was brought into the restorative dining area where vital signs were obtained, blood pressure: 117/45 mmHg (millimeters of mercury), pulse: 90 beats per minute, respirations: 16 (rate of breathing), temperature: 102.8 Fahrenheit, blood sugar 200 mg/dL (milligrams per deciliter). Resident would not fully wake up and kept his eyes and mouth closed. We placed multiple ice packs around his body and took him back to his room. We then Hoyered (used a mechanical lift) to put him on to the bed and continued ice packs. Order from MD (medical doctor) to send out to ED (emergency department). An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/2/19 at 2:45 PM. Staff B stated that she gave Resident #1 his medication a little after 10:00 AM and he stayed by her cart for about 30 minutes. She then pushed him closer to the nursing station. She continued to see him there until a little after a 11:00 AM. At approximately 1:49 PM, Resident #1 had been brought into the restorative dining room and we took vitals. The RN (Registered Nurse) Supervisor said to get ice packs, we did sternal rubs on him. The doctor responded at 1:58 PM to a text I sent at 1:49 PM and said to send Resident #1 to the ED (Emergency Department). Staff B stated that the weekend receptionist had pushed the resident outside at about 11:30 AM. An interview was conducted with Staff C, Registered Nurse (RN), House Supervisor on the weekends, on 10/2/19 at 3:57 PM. Staff C stated that on the day of the incident with Resident #1, Sunday, 9/29/19 she was called over into the dining room, she didn't know the time. She stated she assessed Resident #1, got vitals and a blood sugar. Staff B, LPN, called the doctor and was instructed to send resident to the ED. An interview was conducted with Staff A, CNA (Certified Nursing Assistant) on 10/2/19 at 3:54 PM. Staff A stated an aide came to get her because Resident #1 had not eaten, and then she discovered that he was let outside. She went to get the nurse, they got vitals, got him into the bed, and worked at cooling him down. Then he went to the hospital. Normally, he is not very verbal, but he was unresponsive. The last time she saw him was right before lunch and she took him in for activities, this was at 11:00 AM. She peeked in the windows of the dining room while he was in activities about 11:30 AM, then the next time she saw him was when he was brought in from outside at around 1:30 PM. She was told that one of the aides told her that the weekend receptionist took him outside. When asked what she considered as neglect she stated it was when you are responsible for a person and don't take care of them or you know something is wrong and you fail to address it. What I will say, that if the person that let him out came to me and told me, then I would have been more aware of the need to check on him more frequently. An interview was conducted with Staff A, CNA on 10/3/19 at 9:25 AM to clarify her documentation. She confirmed that she checked on Resident #1 around 11:30 AM and then again when staff came to get her around 1:30 PM. Her documentation for hourly rounds at 12:00 PM and 1:00 PM were in error. She did not do hourly rounds for Resident #1 at 12:00 PM or 1:00 PM. An interview was conducted with the Director of Nursing Services (DNS) on 10/2/19 at 4:49 PM. She stated Resident #1 was supposed to be on hourly rounds. An interview was conducted with the DNS on 10/4/2019 at 11:20 AM she stated prior to the incident with Resident #1, Residents were checked as per standards of practice every two hours unless there were special instructions for more frequent checks. After the incident the monitoring of the patio was the same. The Restorative Department is supposed to check the patio every hour. An interview was conducted on 10/4/2019 at 11:30 AM with Staff K, Restorative Aide she stated, I don't check the patio every hour. I wasn't told to do that. An interview conducted on 10/4/2019 at 11:55 AM with Staff J, Restorative Aide he stated, I do check the patio, but sometimes not every hour. I get busy with my other job. I get busy in the rooms with the residents with the restorative program. A surveyor observed the patio on 10/2/2019 beginning at 11:00 AM to 12:30 PM. There were three residents observed. The temperature was 88 degrees Fahrenheit, 66% humidity, with scattered clouds. Staff J, Restorative Aide was not seen to come out on the patio and check on the residents. An interview was conducted with the DNS on 10/2/19 at 1:03 PM. She stated that Resident #1 could self propel his wheelchair however, he needed staff assistance to get over the threshold of the door to go out to the courtyard. A telephone interview was conducted with Staff D, Weekend Receptionist, on 10/3/19 at 10:13 AM. He stated on Sunday, 9/29/19, he saw Resident #1 stuck on the threshold of the door going out to the courtyard patio. Staff D stated he pushed Resident #1 out into the courtyard. Review of the written witness statement dated 9/29/19 by Staff B, LPN read, I was walking into the dining room to look for a resident when I was told by a group of CNAs that Resident #1 was hot and wasn't responding. This was around 2:00 PM. Myself, the Supervisor, and multiple CNAs started taking vital signs, applied ice packs, and then pushed him in his wheelchair back to his room to then be Hoyered (use of a mechanical lift) into bed. Upon asking the CNAs how long he was out there: They all responded with at least two hours or more. I sent vital signs to the physician and he requested that we send Resident #1 out to Emergency Department. I called his daughter and she was thankful for my call. Review of the written witness statement dated 10/01/19 by Staff A, CNA read I took Resident #1 into the dining room for activities around 10:00 AM. During lunch another aide came and got me saying that he wasn't eating. I went to check on him, and that's when I found out that he was let outside and had overheated. Right away, I and other staff took action to get him in and trying to get him cool down. Review of the written witness statement dated 9/29/19 by Staff C, RN read Called to assess Resident #1 in dining room who was unresponsive in his chair. Resident was not responding to noxious stimuli, noted resident felt extremely warm. Vitals obtained - stable except elevated temp, blood sugar 200. Instructed CNAs to apply ice to patient. Instructed primary nurse to call his doctor to update and obtain orders. Resident started to respond to sternal rub. Relocated resident to his room and used Hoyer lift to move resident from wheelchair to bed, he started being mildly combative while moving him. After in bed shortly became more responsive and opening eyes and making sound/grunting. During that time (Staff B, LPN's name) was instructed to send resident to emergency room , Emergency Medical Services (EMS) called. Arrived and transferred resident. Review of the written witness statement dated 10/2/19 by Staff D, Week-end Receptionist read At approximately 11:30 AM Resident #1 was stuck in the door by cafeteria near restorative area. I pushed him out. Review of the Hospital Emergency Department documentation dated 9/29/19 at 3:05 PM revealed for Resident #1, Chief Complaint: altered mental status. Review of the hospital notes read, The patient present by EMS (Emergency Medical Services) from rehab center. The patient reportedly unknown only when outside today into the sun and was out there for an unknown amount of time. The staff found the patient outside and reportedly he was unresponsive but also talking, he was also found to have a temperature of 101.4 F (Fahrenheit). He was sent to the emergency department. EMS (Emergency Medical Services) gave the patient 600 ml (milliliters) of reportedly cold normal saline. The patient is alert but not responsive and will only nod his head to questions but not in a reliable way to answer questions. Physical Exam: Skin: warm, dry, right [DIAGNOSES REDACTED] on patient's bilateral forearms and tops of feet. Re-Evaluation: Patient with a history of dementia who was outside in the sun for unknown period time and found questionably unresponsive, patient also has sunburn. Patient possibly had [MEDICAL CONDITION]. Patient received 600 ml IV (intravenous) fluids prior to arrival. Patient had hyperthermia of 101.4 prior to arrival that has resolved. Patient given 2 L (Liter) IV fluids here. Patient is being admitted to the hospital. Review of the hospital Radiology Chest report dated 09/29/2019 at 4:04 PM revealed Congestive failure/pulmonary [MEDICAL CONDITION]. (IV fluids may worsen congestive symptoms/IV fluid can cause [MEDICAL CONDITION] congestion as fluid shifts into the lungs). Review of hospital History of Present Illness dated 09/29/2019 at 6:21 PM revealed [AGE] year-old male. Additional medical history: CAD ([MEDICAL CONDITION]). Review of the Physical Exam revealed Extremities: [MEDICAL CONDITION] (swelling of the legs due to [MEDICAL CONDITION]) (1 + B/L, Bilateral). Review of the Impression/Plan: 1. Hyperthermic. 2. Mild [MEDICAL CONDITION] (occurs when the concentration of sodium in your blood is abnormally low). Gentle IV fluids. Monitor. A review of the Performance Improvement Plan (PIP) dated 9/30/19 and revised on 10/3/19 revealed: Facility received an allegation of neglect in the supervision of a resident when outside facility on the patio resulting in resident's transfer to hospital for unresponsiveness/lethargy. A medical review was completed. The facility responded with the development and examination of a PIP with concurrent investigation. PIP is executed to ensure the facility is following proper protocol and maintaining ongoing Quality Monitoring. Goal: Residents are closely supervised when outside facility on the patio. The following action steps were outlined: 1. Resident transferred to hospital secondary to lethargy and further medical evaluation, completed 10/1/19. 2. Resident #1 returned to facility 10/2/19. Continue one hour rounding; while Resident #1 is outside in courtyard offer fluids and monitor status; honor resident choice but encourage resident to return to inside facility for meals, activities and ADL (Activities of Daily Living) care and services, completed 10/2/19. 3. Medication reconciliation, completed 10/3/19. 4. Update Care Plan related to Care and Services around resident preference to be outside in courtyard, completed 10/2/19. 5. Quality review and audit conducted for current residents residing in the facility with a focus on identifying residents who require assistance to outside patio, completed 10/2/19. 6. Quality audit of current residents with intervention of increased supervision for documentation of interventions, completed 10/2/19 and continue weekly audits x 4 then weekly x 2 until substantial compliance. 7. Quality review audit conducted for residents who were transferred to the hospital focusing on unresponsiveness/lethargy related to overheating/change in condition, person responsible Director of Nursing, completed on 10/2/19. 8. Current Licensed Nursing Staff were re-educated on close supervision of residents who require assistance when outside on facility patio and identification of residents who require assistance when outside facility on patio, ANEMMI (Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injuries of unknown origin), process for resident rounding, education initiated on 9/29/19 and continues until all educated by 10/11/19. 9. Current CNAs re-educated on ANEMMI, resident rounding, offering fluids to residents in courtyard/patio, reporting any change of condition to nurse supervisor, initiated on 9/29/19 and continues until all educated by 10/11/19. 10. Current Facility Staff re-educated on ANEMMI, offering fluids to resident in courtyard/patio, residents requires assistance staff is to notify resident has been assisted out to courtyard, staff not permitted to work until above education is completed, above education included in new employee orientation, initiated on 9/29/19 and continues until all educated by 10/11/19. 11. Audit close supervision for resident who required assistance outside to facility patio. All units completed audit: 9 residents identified, these residents require assistance in and out of patio door, educate/remind staff that they need help. Initiated 10/3/19, completion not done. 12. Ad Hoc Quality Assurance meeting held on 10/1/19 and attended by Nursing Home Administrator, Director of Nursing, Medical Director via phone, Infection Control & Prevention Officer, Physical Therapy, Physical Plant, Social Services Director, Minimum Data Set Coordinator, Activities Director. On 09/29/2019, the outside temperature was 91 degrees Fahrenheit with 51% humidity and full sun. The resident was not provided with any hydration during that time, and needed assistance to receive hydration. The resident was not provided with any sun protection before he went out.

Based on record review, interview, and observation the facility failed to ensure 1 of 3 sampled residents (Resident #1) was provided adequate supervision outdoors to protect residents from heat-related illness, when the weather was 91 degrees Fahrenheit at midday. The staff found the [AGE] year-old resident after being outside for approximately two hours, without hydration and sun protection, with a temperature of 102.8 degrees Fahrenheit, unresponsive, and was subsequently hospitalized for [REDACTED]. The Administrator was informed of the existence of Immediate Jeopardy on 10/04/2019 at 8:10 PM. The Immediate Jeopardy began on 09/29/2019, was on-going at the time of the exit on 10/04/2019. This has the potential to affect 143 of 143 residents requiring supervision. Cross reference to F600 and F835. The findings included: Review of Resident #1's medical record revealed the patient was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. prostate (an abnormal growth that can grow uncontrolled and spread to other parts of the body), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), need for assistance of personal care. The resident was prescribed the medication, [MEDICATION NAME] (Calcium channel blocker). The resident was [AGE] years old. A review of the Minimum Data Set Comprehensive Quarterly assessment dated [DATE] revealed the resident could not complete the Brief Interview for Mental Status (BIMS) Assessment and he is rarely/never understood. Under Section C revealed, the resident has short term and long term memory problems and decision making is severely impaired. Resident #1 requires supervision and oversight for locomotion off the unit, (how resident moves to and returns from off-unit locations such as areas set aside for dining, activities or treatments). A review of the care tasks for (MONTH) 2019 for Resident #1 revealed the resident was on 'hourly rounds' for supervision. A review of the progress notes dated 9/29/19 at 2:21 PM revealed Resident #1 was brought inside from courtyard for lunch after he had been outside for around 2 hours. Resident was brought into the restorative dining area where vital signs were obtained, blood pressure: 117/45 mmHg (millimeters of mercury), pulse: 90 beats per minute, respirations: 16 (rate of breathing), temperature: 102.8 Fahrenheit, blood sugar 200 mg/dL (milligrams per deciliter). Resident would not fully wake up and kept his eyes and mouth closed. We placed multiple ice packs around his body and took him back to his room. We then Hoyered (used a mechanical lift) to put him on to the bed and continued ice packs. Order from MD (medical doctor) to send out to ED (emergency department). An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/2/19 at 2:45 PM. Staff B stated that she gave Resident #1 his medication a little after 10:00 AM and he stayed by her cart for about 30 minutes. She then pushed him closer to the nursing station. She continued to see him there until a little after a 11:00 AM. At approximately 1:49 PM, Resident #1 had been brought into the restorative dining room and we took vitals. The RN (Registered Nurse) Supervisor said to get ice packs, we did sternal rubs on him. The doctor responded at 1:58 PM to a text I sent at 1:49 PM and said to send Resident #1 to the ED (Emergency Department). Staff B stated that the weekend receptionist had pushed the resident outside at about 11:30 AM. An interview was conducted with Staff C, Registered Nurse (RN), House Supervisor on the weekends, on 10/2/19 at 3:57 PM. Staff C stated that on the day of the incident with Resident #1, Sunday, 9/29/19 she was called over into the dining room, she didn't know the time. She stated she assessed Resident #1, got vitals and a blood sugar. Staff B, LPN, called the doctor and was instructed to send resident to the ED. An interview was conducted with Staff A, CNA (Certified Nursing Assistant) on 10/2/19 at 3:54 PM. Staff A stated an aide came to get her because Resident #1 had not eaten, and then she discovered that he was let outside. She went to get the nurse, they got vitals, got him into the bed, and worked at cooling him down. Then he went to the hospital. Normally, he is not very verbal, but he was unresponsive. The last time she saw him was right before lunch and she took him in for activities, this was at 11:00 AM. She peeked in the windows of the dining room while he was in activities about 11:30 AM, then the next time she saw him was when he was brought in from outside at around 1:30 PM. She was told that one of the aides told her that the weekend receptionist took him outside. What I will say, that if the person that let him out came to me and told me, then I would have been more aware of the need to check on him more frequently. An interview was conducted with Staff A, CNA on 10/3/19 at 9:25 AM to clarify her documentation. She confirmed that she checked on Resident #1 around 11:30 AM and then again when staff came to get her around 1:30 PM. Her documentation for hourly rounds at 12:00 PM and 1:00 PM were in error. She did not do hourly rounds for Resident #1 at 12:00 PM or 1:00 PM. An interview was conducted with the Director of Nursing Services (DNS) on 10/2/19 at 4:49 PM. She stated Resident #1 was supposed to be on hourly rounds. An interview was conducted with the DNS on 10/4/2019 at 11:20 AM she stated prior to the incident with Resident #1, Residents were checked as per standards of practice every two hours unless there were special instructions for more frequent checks. After the incident the monitoring of the patio was the same. The Restorative Department is supposed to check the patio every hour. An interview was conducted on 10/4/2019 at 11:30 AM with Staff K, Restorative Aide she stated, I don't check the patio every hour. I wasn't told to do that. An interview conducted on 10/4/2019 at 11:55 AM with Staff J, Restorative Aide he stated, I do check the patio, but sometimes not every hour. I get busy with my other job. I get busy in the rooms with the residents with the restorative program. A surveyor observed the patio on 10/2/2019 beginning at 11:00 AM to 12:30 PM. There were three residents observed. The temperature was 88 degrees Fahrenheit, 66% humidity, with scattered clouds. Staff J, Restorative Aide was not seen to come out on the patio and check on the residents. An interview was conducted with the DNS on 10/2/19 at 1:03 PM. She stated that Resident #1 could self propel his wheelchair however, he needed staff assistance to get over the threshold of the door to go out to the courtyard. A telephone interview was conducted with Staff D, Weekend Receptionist, on 10/3/19 at 10:13 AM. He stated on Sunday, 9/29/19, he saw Resident #1 stuck on the threshold of the door going out to the courtyard patio. Staff D stated he pushed Resident #1 out into the courtyard. Review of the progress notes dated 09/29/2019 revealed, Weekend receptionist assisted Resident #1 outside to the courtyard patio. Resident #1 was brought in from outside for lunch and was found unresponsive with a temperature of 102.8 Fahrenheit. Resident #1 has Dementia and is rarely or never understood. Resident #1 was transferred to an acute care hospital due to sun burn and hyperthermia. Review of the written witness statement dated 9/29/19 by Staff B, LPN read, I was walking into the dining room to look for a resident when I was told by a group of CNAs that Resident #1 was hot and wasn't responding. This was around 2:00 PM. Myself, the Supervisor, and multiple CNAs started taking vital signs, applied ice packs, and then pushed him in his wheelchair back to his room to then be Hoyered (use of a mechanical lift) into bed. Upon asking the CNAs how long he was out there: They all responded with at least two hours or more. I sent vital signs to the physician and he requested that we send Resident #1 out to Emergency Department. I called his daughter and she was thankful for my call. Review of the written witness statement dated 10/01/19 by Staff A, CNA read I took Resident #1 into the dining room for activities around 10:00 AM. During lunch another aide came and got me saying that he wasn't eating. I went to check on him, and that's when I found out that he was let outside and had overheated. Right away, I and other staff took action to get him in and trying to get him cool down. Review of the written witness statement dated 9/29/19 by Staff C, RN read Called to assess Resident #1 in dining room who was unresponsive in his chair. Resident was not responding to noxious stimuli, noted resident felt extremely warm. Vitals obtained - stable except elevated temp, blood sugar 200. Instructed CNAs to apply ice to patient. Instructed primary nurse to call his doctor to update and obtain orders. Resident started to respond to sternal rub. Relocated resident to his room and used Hoyer lift to move resident from wheelchair to bed, he started being mildly combative while moving him. After in bed shortly became more responsive and opening eyes and making sound/grunting. During that time (Staff B, LPN's name) was instructed to send resident to emergency room , Emergency Medical Services (EMS) called. Arrived and transferred resident. Review of the written witness statement dated 10/2/19 by Staff D, Week-end Receptionist read At approximately 11:30 AM Resident #1 was stuck in the door by cafeteria near restorative area. I pushed him out. Review of the Hospital Emergency Department documentation dated 9/29/19 at 3:05 PM revealed for Resident #1, Chief Complaint: altered mental status. Review of the hospital notes read, The patient present by EMS (Emergency Medical Services) from rehab center. The patient reportedly unknown only when outside today into the sun and was out there for an unknown amount of time. The staff found the patient outside and reportedly he was unresponsive but also talking, he was also found to have a temperature of 101.4 F. He was sent to the emergency department. EMS (Emergency Medical Services) gave the patient 600 ml (milliliters) of reportedly cold normal saline. The patient is alert but not responsive and will only nod his head to questions but not in a reliable way to answer questions. Physical Exam: Skin: warm, dry, right [DIAGNOSES REDACTED] on patient's bilateral forearms and tops of feet. Re-Evaluation: Patient with a history of dementia who was outside in the sun for unknown period time and found questionably unresponsive, patient also has sunburn. Patient possibly had [MEDICAL CONDITION]. Patient received 600 ml IV (intravenous) fluids prior to arrival. Patient had hyperthermia of 101.4 prior to arrival that has resolved. Patient given 2 L (Liter) IV fluids here. Patient is being admitted to the hospital. Review of the hospital Radiology Chest report dated 09/29/2019 at 4:04 PM revealed Congestive failure/pulmonary [MEDICAL CONDITION]. (IV fluids may worsen congestive symptoms/IV fluid can cause [MEDICAL CONDITION] congestion as fluid shifts into the lungs). Review of hospital History of Present Illness dated 09/29/2019 at 6:21 PM revealed [AGE] year-old male. Additional medical history: CAD ([MEDICAL CONDITION]). Review of the Physical Exam revealed Extremities: [MEDICAL CONDITION] (swelling of the legs due to [MEDICAL CONDITION]) (1 + B/L, Bilateral). Review of the Impression/Plan: 1. Hyperthermic. 2. Mild [MEDICAL CONDITION] (occurs when the concentration of sodium in your blood is abnormally low). Gentle IV fluids. Monitor. Review of an article for by American Family Physician dated (MONTH) 1, 2002 revealed Physiology: the body's ability to regulate core temperature depends on both host (internal) and environmental (external) factors. Children and the elderly are particularly vulnerable. Heat exhaustion occurs both as water and sodium depleted types, with associated symptoms such as malaise, vomiting and confusion. In more serious cases, intravenous hydration may be necessary. If not treated promptly, heat exhaustion may evolve into heatstroke, a deadly form of heat illness. Fluid resuscitation is important but should be closely monitored. Pre-Existing Conditions That (MONTH) Contribute to Heat-Related Illness: [MEDICAL CONDITION], Extremes of age, Calcium channel blockers. Heat Exhaustion: Potentially dangerous clinical manifestations include circulatory collapse and excessive temperature. Core body temperature is usually higher than 100.4 degrees Fahrenheit but below the cutoff for heat-stroke, which is 104.0 degrees Fahrenheit. On 09/29/2019, the outside temperature was 91 degrees Fahrenheit with 51% humidity and full sun. The resident was not provided with any hydration during that time, and needed assistance to receive hydration. The resident was not provided with any sun protection before he went out. Review of the Facility Assessment with a completion date of 10/12/2019 revealed under Hazard and Vulnerability Assessment Tool Naturally Occurring Events revealed 0 probability and 0 percent risk listed for Temperature Extremes. An interview was conducted on 10/4/2019 at 12:00 PM with the Administrator he stated, I understand there is no formal procedure for the supervision on the patio. There is no documentation in the PIP (Performance Improvement Plan) for supervision on the patio.' An interview was conducted on 10/4/2019 at 12:15 PM with the Regional Clinical Nurse she stated, I understand there is no formal procedure for supervision on the patio following the incident with (Resident #1's name). An interview was conducted on 10/4/2019 at 6:47 PM with the Administrator when asked regarding the Facility Assessment and Hazard and Vulnerability Assessment Tool Naturally Occurring Events related to extreme temperatures he stated, The facility assessment needs to be adjusted because it does not take into account the risk of the heat index and extreme temperatures of Florida. When asked whether anyone considered the hot weather to be a risk to residents who go outdoors and if that risk was communicated to nursing and administration he stated, I feel we consider the hot weather as a risk to the residents who go outside. The Administrator confirmed based on the Facility Assessment there was no risk assessment for extreme temperatures. An interview was conducted on 10/4/2019 at 11:20 AM the DNS (Director of Nursing Services) stated, There is no policy for supervision of residents when outdoors. Prior to the incident with (Resident #1's name) residents were check as per standards of practice, which is every two hours, unless there was special instruction for more frequent checks. After the incident with (Resident #1's name) the monitoring of the patio remains the same. The DNS then stated, The restorative department is to check the patio every hour. An interview was conducted on 10/4/2019 at 7:21 PM the DNS confirmed the Facility Assessment needs to be looked at since we did not identify extreme temperatures as a concern. An interview was conducted with Staff M, CNA, on 10/2/19 at 3:00 PM. She stated, Some residents are rounded on every 15 minutes, others every two hours and sometimes assigned as one on one. An interview was conducted with Staff F, CNA, on 10/2/19 at 3:14 PM. When asked regarding resident rounding, she stated, I round every two hours unless they are on a specific check, like every 15 minutes. An interview was conducted with Staff G, CNA, on 10/2/19 at 3:22 PM. When asked about rounding on residents she stated, Every two hours we do rounding for our patients and some residents are on special checks. An interview was conducted with Staff L, CNA, on 10/3/19 at 11:32 AM. She stated, We check our residents every two hours. An interview was conducted with Staff I, CNA on 10/3/19 at 11:39 AM. She stated, I do resident rounding every two hours unless instructed otherwise. An interview was conducted with Staff J, Restorative CNA, on 10/3/19 at 11:47 AM. When asked regarding rounding of residents he stated, At a minimum of two-hour rounds. An interview was conducted on 10/2/2019 at 2:03 PM with Clinical Educator when asked the training that has been provided to staff regarding supervision, she provided the training material. A review of the content of the hydration education provided to the staff post Resident #1's incident read Please ensure that you are frequently monitoring any resident you see especially if they're outside. Always encourage fluids. Always ask if they're ok if they need anything. Remember to hydrate, hydrate, hydrate! Remember always encourage residents to drink fluids. A review of the content of the education titled Continuing education for nursing staff post Resident #1's incident read Rounding with residents no greater than every two hours unless otherwise noted to have more frequent rounds is very important. During these times we are to be offering fluids as well with residents. Do not forget to check if residents need to be assisted to the restroom, and always make sure call light is within reach. Please notify nurse supervisor for any noted change in condition. A review of the Performance Improvement Plan (PIP) dated 9/30/19 and revised on 10/3/19 revealed: Facility received an allegation of neglect in the supervision of a resident when outside facility on the patio resulting in resident's transfer to hospital for unresponsiveness/lethargy. A medical review was completed. The facility responded with the development and examination of a PIP with concurrent investigation. PIP is executed to ensure the facility is following proper protocol and maintaining ongoing Quality Monitoring. Goal: Residents are closely supervised when outside facility on the patio. The following action steps were outlined: 1. Resident transferred to hospital secondary to lethargy and further medical evaluation, completed 10/1/19. 2. Resident #1 returned to facility 10/2/19. Continue one hour rounding; while Resident #1 is outside in courtyard offer fluids and monitor status; honor resident choice but encourage resident to return to inside facility for meals, activities and ADL (Activities of Daily Living) care and services, completed 10/2/19. 3. Medication reconciliation, completed 10/3/19. 4. Update Care Plan related to Care and Services around resident preference to be outside in courtyard, completed 10/2/19. 5. Quality review and audit conducted for current residents residing in the facility with a focus on identifying residents who require assistance to outside patio, completed 10/2/19. 6. Quality audit of current residents with intervention of increased supervision for documentation of interventions, completed 10/2/19 and continue weekly audits x 4 then weekly x 2 until substantial compliance. 7. Quality review audit conducted for residents who were transferred to the hospital focusing on unresponsiveness/lethargy related to overheating/change in condition, person responsible Director of Nursing, completed on 10/2/19. 8. Current Licensed Nursing Staff were re-educated on close supervision of residents who require assistance when outside on facility patio and identification of residents who require assistance when outside facility on patio, ANEMMI (Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injuries of unknown origin), process for resident rounding, education initiated on 9/29/19 and continues until all educated by 10/11/19. 9. Current CNAs re-educated on ANEMMI, resident rounding, offering fluids to residents in courtyard/patio, reporting any change of condition to nurse supervisor, initiated on 9/29/19 and continues until all educated by 10/11/19. 10. Current Facility Staff re-educated on ANEMMI, offering fluids to resident in courtyard/patio, residents require assistance staff is to notify resident has been assisted out to courtyard, staff not permitted to work until above education is completed, above education included in new employee orientation, initiated on 9/29/19 and continues until all educated by 10/11/19. 11. Audit close supervision for resident who required assistance outside to facility patio. All units completed audit: 9 residents identified, these residents require assistance in and out of patio door, educate/remind staff that they need help. Initiated 10/3/19, completion not done. 12. Ad Hoc Quality Assurance meeting held on 10/1/19 and attended by Nursing Home Administrator, Director of Nursing, Medical Director via phone, Infection Control & Prevention Officer, Physical Therapy, Physical Plant, Social Services Director, Minimum Data Set Coordinator, Activities Director.

Based on record review, interview, and facility policy and procedure review the facility failed to ensure 1 of 3 sampled residents (Resident #1) was free from neglect by not providing supervision to protect residents from heat related illnesses when the weather was 91 degrees Fahrenheit at midday. The staff found the [AGE] year-old resident after being outside for approximately two hours without hydration and sun protection with a temperature of 102.8 degrees Fahrenheit unresponsive requiring transfer to the hospital. The Administrator was informed of the existence of Immediate Jeopardy on 10/04/2019 at 8:10 PM. The Immediate Jeopardy began on 09/29/2019, was on-going at the time of the exit on 10/04/2019. This has the potential to affect 143 of 143 residents requiring supervision. Cross reference to F689 and F835. The findings included: Review of Resident #1's medical record revealed the patient was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. prostate (an abnormal growth that can grow uncontrolled and spread to other parts of the body), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), need for assistance of personal care. The resident was prescribed the medication: [MEDICATION NAME] (Calcium channel blocker). The resident was [AGE] years old. A review of the Minimum Data Set Comprehensive Quarterly assessment dated [DATE] revealed the resident could not complete the Brief Interview for Mental Status (BIMS) Assessment and he is rarely/never understood. Under Section C it revealed the resident has short term and long term memory problems and decision making is severely impaired. Resident #1 requires supervision and oversight for locomotion off the unit, (how resident moves to and returns from off-unit locations such as areas set aside for dining, activities or treatments). A review of the care tasks for (MONTH) 2019 for Resident #1 revealed the resident was on hourly rounds for supervision. A review of the progress notes dated 9/29/19 at 2:21 PM revealed Resident #1 was brought inside from courtyard for lunch after he had been outside for around 2 hours. Resident was brought into the restorative dining area where vital signs were obtained, blood pressure: 117/45 mmHg (millimeters of mercury), pulse: 90 beats per minute, respirations: 16 (rate of breathing), temperature: 102.8 Fahrenheit, blood sugar 200 mg/dL (milligrams per deciliter). Resident would not fully wake up and kept his eyes and mouth closed. We placed multiple ice packs around his body and took him back to his room. We then Hoyered (used a mechanical lift) to put him on to the bed and continued ice packs. Order from MD (medical doctor) to send out to ED (emergency department). An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/2/19 at 2:45 PM. Staff B stated that she gave Resident #1 his medication a little after 10:00 AM and he stayed by her cart for about 30 minutes. She then pushed him closer to the nursing station. She continued to see him there until a little after a 11:00 AM. At approximately 1:49 PM, Resident #1 had been brought into the restorative dining room and we took vitals. The RN (Registered Nurse) Supervisor said to get ice packs, we did sternal rubs on him. The doctor responded at 1:58 PM to a text I sent at 1:49 PM and said to send Resident #1 to the ED (Emergency Department). Staff B stated that the weekend receptionist had pushed the resident outside at about 11:30 AM. An interview was conducted with Staff C, Registered Nurse (RN), House Supervisor on the weekends, on 10/2/19 at 3:57 PM. Staff C stated that on the day of the incident with Resident #1, Sunday, 9/29/19 she was called over into the dining room, she didn't know the time. She stated she assessed Resident #1, got vitals and a blood sugar. Staff B, LPN, called the doctor and was instructed to send resident to the ED. An interview was conducted with Staff A, CNA (Certified Nursing Assistant) on 10/2/19 at 3:54 PM. Staff A stated an aide came to get her because Resident #1 had not eaten, and then she discovered that he was let outside. She went to get the nurse, they got vitals, got him into the bed, and worked at cooling him down. Then he went to the hospital. Normally, he is not very verbal, but he was unresponsive. The last time she saw him was right before lunch and she took him in for activities, this was at 11:00 AM. She peeked in the windows of the dining room while he was in activities about 11:30 AM, then the next time she saw him was when he was brought in from outside at around 1:30 PM. She was told that one of the aides told her that the weekend receptionist took him outside. When asked what she considered as neglect she stated it was when you are responsible for a person and don't take care of them or you know something is wrong and you fail to address it. What I will say, that if the person that let him out came to me and told me, then I would have been more aware of the need to check on him more frequently. An interview was conducted with Staff A, CNA on 10/3/19 at 9:25 AM to clarify her documentation. She confirmed that she checked on Resident #1 around 11:30 AM and then again when staff came to get her around 1:30 PM. Her documentation for hourly rounds at 12:00 PM and 1:00 PM were in error. She did not do hourly rounds for Resident #1 at 12:00 PM or 1:00 PM. An interview was conducted with the Director of Nursing Services (DNS) on 10/2/19 at 4:49 PM. She stated Resident #1 was supposed to be on hourly rounds. An interview was conducted with the DNS on 10/2/19 at 1:03 PM. She stated that Resident #1 could self propel his wheelchair however, he needed staff assistance to get over the threshold of the door to go out to the courtyard. An interview was conducted with the DNS on 10/4/2019 at 11:20 AM she stated prior to the incident with Resident #1, Residents were checked as per standards of practice every two hours unless there were special instructions for more frequent checks. A telephone interview was conducted with Staff D, Weekend Receptionist, on 10/3/19 at 10:13 AM. He stated on Sunday, 9/29/19, he saw Resident #1 stuck on the threshold of the door going out to the courtyard patio. Staff D stated he pushed Resident #1 out into the courtyard. Review of the ANE (Abuse, Neglect, Exploitation) and Investigations Policy #12.09.009, revised 11/1/2010 read Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the written witness statement dated 9/29/19 by Staff B, LPN read, I was walking into the dining room to look for a resident when I was told by a group of CNAs that Resident #1 was hot and wasn't responding. This was around 2:00 PM. Myself, the Supervisor, and multiple CNAs started taking vital signs, applied ice packs, and then pushed him in his wheelchair back to his room to then be Hoyered (use of a mechanical lift) into bed. Upon asking the CNAs how long he was out there: They all responded with at least two hours or more. I sent vital signs to the physician and he requested that we send Resident #1 out to Emergency Department. I called his daughter and she was thankful for my call. Review of the written witness statement dated 10/01/19 by Staff A, CNA read I took Resident #1 into the dining room for activities around 10:00 AM. During lunch another aide came and got me saying that he wasn't eating. I went to check on him, and that's when I found out that he was let outside and had overheated. Right away, I and other staff took action to get him in and trying to get him cool down. Review of the written witness statement dated 9/29/19 by Staff C, RN read Called to assess Resident #1 in dining room who was unresponsive in his chair. Resident was not responding to noxious stimuli, noted resident felt extremely warm. Vitals obtained - stable except elevated temp, blood sugar 200. Instructed CNAs to apply ice to patient. Instructed primary nurse to call his doctor to update and obtain orders. Resident started to respond to sternal rub. Relocated resident to his room and used Hoyer lift to move resident from wheelchair to bed, he started being mildly combative while moving him. After in bed shortly became more responsive and opening eyes and making sound/grunting. During that time (Staff B, LPN's name) was instructed to send resident to emergency room , Emergency Medical Services (EMS) called. Arrived and transferred resident. Review of the written witness statement dated 10/2/19 by Staff D, Week-end Receptionist read At approximately 11:30 AM Resident #1 was stuck in the door by cafeteria near restorative area. I pushed him out. Review of the Hospital Emergency Department documentation dated 9/29/19 at 3:05 PM revealed for Resident #1, Chief Complaint: altered mental status. Review of the hospital notes read, The patient present by EMS (Emergency Medical Services) from rehab center. The patient reportedly unknown only when outside today into the sun and was out there for an unknown amount of time. The staff found the patient outside and reportedly he was unresponsive but also talking, he was also found to have a temperature of 101.4 F (Fahrenheit) . He was sent to the emergency department. EMS (Emergency Medical Services) gave the patient 600 ml (milliliters) of reportedly cold normal saline. The patient is alert but not responsive and will only nod his head to questions but not in a reliable way to answer questions. Physical Exam: Skin: warm, dry, right [DIAGNOSES REDACTED] on patient's bilateral forearms and tops of feet. Re-Evaluation: Patient with a history of dementia who was outside in the sun for unknown period time and found questionably unresponsive, patient also has sunburn. Patient possibly had [MEDICAL CONDITION]. Patient received 600 ml IV (intravenous) fluids prior to arrival. Patient had hyperthermia of 101.4 prior to arrival that has resolved. Patient given 2 L (Liter) IV fluids here. Patient is being admitted to the hospital. Review of the hospital Radiology Chest report dated 09/29/2019 at 4:04 PM revealed Congestive failure/pulmonary [MEDICAL CONDITION]. (IV fluids may worsen congestive symptoms/IV fluid can cause [MEDICAL CONDITION] congestion as fluid shifts into the lungs.) Review of hospital History of Present Illness dated 09/29/2019 at 6:21 PM revealed [AGE] year-old male. Additional medical history: CAD ([MEDICAL CONDITION]). Review of the Physical Exam revealed Extremities: [MEDICAL CONDITION] (swelling of the legs due to [MEDICAL CONDITION]) (1 + B/L, Bilateral). Review of the Impression/Plan: 1. Hyperthermic (condition where a person's temperature is elevated beyond normal, most common causes include heat stroke. Heat stroke is an acute temperature elevation caused by exposure to excessive heat). 2. Mild [MEDICAL CONDITION] (occurs when the concentration of sodium in your blood is abnormally low). Gentle IV fluids. Monitor. Review of an article for by American Family Physician dated (MONTH) 1, 2002 revealed Physiology: the body's ability to regulate core temperature depends on both host (internal) and environmental (external) factors. Children and the elderly are particularly vulnerable. Heat exhaustion occurs both as water and sodium depleted types, with associated symptoms such as malaise, vomiting and confusion. In more serious cases, intravenous hydration may be necessary. If not treated promptly, heat exhaustion may evolve into heatstroke, a deadly form of heat illness. Fluid resuscitation is important but should be closely monitored. Pre-Existing Conditions That (MONTH) Contribute to Heat-Related Illness: [MEDICAL CONDITION], Extremes of age, Calcium channel blockers. Heat Exhaustion: Potentially dangerous clinical manifestations include circulatory collapse and excessive temperature. Core body temperature is usually higher than 100.4 degrees Fahrenheit but below the cutoff for heat-stroke, which is 104.0 degrees Fahrenheit. On 09/29/2019, the outside temperature was 91 degrees Fahrenheit with 51% humidity and full sun. The resident was not provided with any hydration during that time and needed assistance to receive hydration. The resident was not provided with any sun protection before he went out.