Every finding on record at Perry Creek Health and Rehabilitation Center

Based on record review and interviews with staff and Physician, the facility failed to consult with the physician when a resident was unable to swallow his medications. This was for 1 of 3 sampled residents reviewed for medical care during acute illness (Resident # 1).The findings included:Resident # 1 was admitted to the facility on [DATE] after being hospitalized for altered mental status which was partially attributed to multifocal stroke (a stroke affecting multiple areas of the brain). According to the 2/20/26 hospital Discharge summary, dated [DATE], the resident also had additional diagnoses of multiple myeloma (cancer of the bone marrow plasma cells), atrial fibrillation, chronic pain, and depression.On 2/20/26 at 5:58 PM, Nurse # 1 documented Resident # 1 was admitted to the facility at 5:45 PM and was alert but confused.On 2/20/26 the following medication orders were entered into Resident # 1's record:Calcium 600 + D3 Plus minerals tablet by mouth every day.Cyanocobalamin tablet 1000 micrograms every day (A form of B12).Pantoprazole Sodium Delayed Release 40 mg every day (used for gastroesophageal reflux disease).Apixaban 5 mg every twelve hours for atrial fibrillation (Apixaban is an anticoagulant used to prevent clot formation which can occur with atrial fibrillation when blood pools in the heart). On 2/20/26 Resident # 1's physician documented he saw Resident # 1 and in addition to having a history of stroke, the physician noted the resident had a history of dysphagia.Review of Resident # 1's February 2026 Medication Administration Record (MAR) revealed Resident # 1's medications were initialed as administered on 2/21/26 as ordered.Medication Aide # 1, who initialed she administered morning medications on 2/21/26, was interviewed on 2/25/26 at 5:02 PM and reported she had crushed Resident # 1's medications, placed them in applesauce, and the resident took them without difficulty.Nurse # 3, who initialed she administered evening medications on 2/21/26, was interviewed on 2/25/26 at 1:25 PM and reported the resident took his medications without problems. Nurse # 3 did not specify if the resident took the medications whole or crushed.On 2/22/26 Nurse # 2 documented on the February 2026 MAR that Resident # 1's Calcium, Cyanocobalamin, Pantoprazole and Apixaban were not administered at 9:00 AM when they were scheduled to have been administered.On 2/22/26 at 7:52 PM, Nurse # 2 documented in a progress note that Resident # 1 had refused all his medications due to difficulty swallowing.Nurse # 2 was interviewed on 2/26/26 at 9:05 AM and reported the following information. She had cared for Resident # 1 from 7:00 AM to 7:00 PM on 2/22/26. In the morning, Resident # 1 could not take his medication. Resident # 1's RP (Responsible Party) was present that morning and Resident # 1 drank from a straw for the RP. The RP also pointed to an empty blue bowl and reported Resident # 1 had eaten some dry cereal. She (Nurse # 2) tried to give him his medication, but he would hold the water in his mouth and not swallow. The water seemed to pool in his mouth. The RP wanted her (Nurse # 2) to try giving the medications in applesauce and she also tried that, but he held the applesauce in his cheek and would not swallow. She spent a long time at the bedside talking to the RP and trying to see if the resident would swallow, but he would not. Eventually, they (she and the RP) turned his head, and she (the nurse) wiped the medications out of his mouth, and he spit also to remove them. She was not sure if it was a behavioral issue or if he just could not swallow. Nurse #2 indicated she held his medication all day and she did not call the provider and consult with the provider about the missed medications or swallowing difficulty.Review of Resident # 1's February 2026 MAR revealed Resident # 1's evening medications were initialed as given. One of the medications administered on the evening of 2/22/26 was the resident's evening dose of Apixaban.On 2/25/26 at 8:37 PM Nurse # 4, who had initialed the administration of evening medications on 2/22/26, was interviewed and reported the following information. She crushed the resident's medications and gave them in applesauce. It took some time to get him to swallow the medications, but she went slow and he was able to swallow the medications. She also gave him sips of water which he was able to drink.On 2/23/26 (Monday) Unit Manager # 1 made a late entry notation at 10:10 AM in Resident # 1's medical record noting Resident # 1 appeared restless, was not eating, drinking or taking his morning medications. The physician had been consulted and an order obtained on 2/23/26 to transfer the resident to the hospital.The DON (Director of Nursing) was not available for interview during the survey.The facility's corporate Nurse Consultant was interviewed on 2/26/26 at 3:45 PM regarding whether the physician should be notified if a resident could not swallow medications and reported that the physician should have been contacted on 2/22/26 about the missed medications.On 3/3/26 at 11:28 PM, Resident # 1's physician was interviewed and reported the staff should have consulted him when the resident could not swallow his medications. The physician reported that the resident was not harmed by the facility's failure to call him. The Physician reported he reviewed an EKG (Electrocardiogram) which was completed the following day on 2/23/26 for Resident # 1 and the resident had a normal heart rhythm. The physician reported it was his opinion that one dose of a missed anticoagulant had not led to further problems with atrial fibrillation or stroke. The physician also reported the resident had both dementia and a history of strokes and it was anticipated that he might wax and wane at times.

Based on record review, and interviews with staff, Nurse Practitioner (NP), and contracted lab company, the facility failed to ensure labs to check the resident's medical condition following a hospitalization stay within the last month were completed as ordered by the provider. This was for 1 of 3 sampled residents reviewed for medical care following acute illness (Resident #4).The findings included:Record review revealed Resident # 4 was initially admitted to the facility on [DATE]. Resident # 4 had diagnoses of chronic kidney disease, diabetes, anemia, polyneuropathy, and congestive heart failure. Review of Resident # 4's record revealed she was most recently readmitted to the facility on [DATE] after a hospitalization and followed by a health care group who provided primary oversight and care for medical issues in addition to the resident's physician.On 2/16/26 Resident # 4 had an annual Minimum Data Set assessment completed noting she was cognitively intact.On 2/20/26 the NP documented a clinic note noting that she had received a call from a nurse who reported Resident # 4 was short of breath without hypoxia (low levels of oxygen in the body's tissues) and had a feeling of abdominal fullness. She was functionally at her baseline. Medication changes were made and labs were ordered.A review of orders, which were entered in the resident's record on 2/20/26, included: CBC (complete blood count) with differentialBMP (basic metabolic panel) BNP/NT proBNP (B-type Natriuretic Peptide which measures hormones released by the heart when stressed) During an interview on 2/27/26 at 11:17 AM with Resident # 4's NP the NP reported the lab work had been ordered to help plan Resident # 4's care, monitor the resident's kidney function, anemia, and risk for infection. She had expected the lab work to be completed the next routine blood draw after she ordered it on 2/20/26. The Risk Manager for the facility's lab company was interviewed on 2/26/26 at 3:29 PM and again on 3/2/26 at 2:25 PM and reported the following information. The lab company provided routine lab services six days per week. The only day they did not provide routine lab drawings was on Sunday morning. For an order that was given on a Friday (such as for Resident # 4's 2/20/26 order) the lab phlebotomist should have drawn it on Saturday morning if the requisition was in the book for it to be drawn. The phlebotomist arrived sometime after midnight on lab days and drew blood in the early morning hours. There was one notation which was entered by the Unit Manager on 2/24/26 at 8:59 AM noting the labs were unable to be obtained. The NP was notified and the labs would be done the next lab draw. Resident # 4 was interviewed on 2/25/26 at 9:05 AM and reported the following. She had recently returned from the hospital due to a new diagnosis of congestive heart failure. She was dealing with being more short of breath and was very tired. While hospitalized she had required blood and they were supposed to have drawn labs recently, but they had not been done. One of the nurses told her that she had refused the blood work on the morning of 2/24/26 when she was asleep. She may have done so in her sleep but did not recall. The next morning (2/25/26) one of the nurses had told her that she was glad they got her blood work done. She had looked at her arms, saw no cotton balls to indicate she had a lab stick, and did not recall a blood draw in the early morning hours. During a follow up interview with Resident # 4 on 2/26/26 at 2:15 PM, Resident # 4 reported she still had no lab work drawn. Resident # 4's Unit Manager (Unit Manager # 2) was interviewed on 2/26/26 at 2:25 PM and reported on the morning of 2/24/26 the phlebotomist had noted she was not able to obtain the labs. On the morning of 2/25/26 the phlebotomist had signed off she had drawn the blood work, and they thought it had been done. The Phlebotomist was not available for interview during the investigation. During the interviews with the Risk Manager for the facility's lab company on 2/26/26 at 3:29 PM and again on 3/2/26 at 2:25 PM the Risk Manager further reported the following information. If a phlebotomist was unable to draw blood from a resident two days in a row, then the phlebotomist was to notify a nurse and also notify their lead team phlebotomist so a second phlebotomist could go out. The phlebotomist, who was designated for Resident # 4's facility, was not available for interview. She (the Lab Company's Risk Manager) was not sure why the blood had not been drawn and the phlebotomist who had been responsible for drawing the labs could not be interviewed by her at the current time. When the phlebotomist was at the facility it was the procedure that the phlebotomist checked the facility's lab book which had requisitions under a tab for the date they were due. There was also a lab sheet at the front of each day's lab requisitions. The phlebotomist was to sign that she had drawn the labs on the lab sheet. During the interview on 2/26/26 at 3:29 PM the Lab Risk Manager reported the lab would get the blood work done that day (2/26/26). On 3/2/26 the Administrator provided copies of lab sheets/logs which had been left for the phlebotomist. A review of a lab tracking form dated 2/21/26 (Saturday) revealed Resident # 4's name appeared on the form with her room number along with other residents listed on the form/log which needed labs collected. Resident # 4's name and room number were the only information on the form about Resident # 4. There was no notation by Resident # 4's name noting Resident # 4 had refused or the phlebotomist had been unable to draw the labs. The phlebotomist had initialed at the top of the form under the date of 2/21/26. Review of a lab tracking form dated 2/24/26 (Tuesday) revealed Resident # 4's room number, name, and labs to be drawn were listed along with other residents on the log who had scheduled labs for that morning (2/24/26). There was one notation which read, unable by Resident # 4's name and no further explanation. The lab phlebotomist signed her initials and the date of 2/24/26 at the top of this form. On 2/25/25 (Wednesday) Resident # 4's name and labs to be drawn again appeared on the lab tracking form with the Phlebotomist's initials at the top of the page. There was no notation that the resident had refused or the labs were not drawn. During a follow-up interview with Resident # 4's Unit Manager (Unit Manager # 2) on 3/2/26 at 3:00 PM the Unit Manager reported the following information. When the phlebotomist signs at the top of the page and makes no notation that the labs were not done by their name, then this indicates that the labs were done. The labs had not been done prior to 2/26/26. Residents, who were under the care of the provider's group, were visited daily by a nurse within the provider's group. Each day when the labs did not come back the facility had alerted this nurse who in turn alerted the NP about the delay. The Director of Nursing was not available for interview during the survey. The Administrator and the Nurse Consultant were interviewed on 3/3/26 at 3:58 PM and reported the following information. The Administrator reported that he expected labs to be done timely and did not offer a timeframe he considered to be timely. He pointed out that the facility lab sheets indicated the labs were done excluding on one date on which the resident refused. The Nurse Consultant reported that the clinical team reviewed labs daily to make sure they were done, and this had been being done for Resident # 4. By their system which required the phlebotomist to put her initials at the top of the lab sheets, it was indicated to them that the labs had been drawn on 2/21/26 and 2/25/25. If the resident had refused or the phlebotomist could not draw the blood for a reason, there should have been a notation by her name. According to the Nurse Consultant, each day the NP had been notified. During the interview with Resident # 4's NP on 2/27/26 at 11:17 AM, the NP reported when the labs, which were ordered on 2/20/26, were completed on 2/26/26, they were stable and the resident had not been harmed in any way by the delay in obtaining the labs.

Based on observations, record review, and interviews with resident, responsible party, and staff, the facility failed to treat residents with dignity and respect when Nurse Aide #1 was watching a video on her cell phone while assisting Resident #72 with eating and Resident #106's clothes were not provided to her for a 3 day period after they were sent to the laundry resulting in the resident having to wear a hospital gown, feeling annoyed, and causing her not to leave her room. A reasonable person would expect Resident #72's caregiver to be focused on them during the provision of care. This deficient practice affected 2 of 4 residents reviewed for dignity (Resident #72 and Resident #106).Findings included: 1. Resident #72 was admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit and muscle weakness. Resident #72's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was assessed as severely cognitively impaired, required supervision or touching assistance with eating, was able to make herself understood, and she understood others. During observation on 2/11/26 at 9:12 AM Nurse Aide #1 was observed assisting Resident #72 with her breakfast. The nurse aide was sitting next to Resident #72 at the head of the bed with the bedside table in front of her. The bedside table was perpendicular to the resident's bed, and a cell phone was observed on the bedside table, out of view of the resident. A video was playing on the cell phone with closed captioning on and no sound. Nurse Aide #1 was observed watching the video on her phone while she offered the resident bites of food. The nurse aide was glancing back and forth between the video on her phone and the resident. During an interview on 2/11/26 at 9:13 AM Nurse Aide #1 stated no one had indicated she could not watch a show on her phone while providing assistance to residents with their meals. She stated she was watching a series on vampires. During an interview on 2/12/26 at 10:15 AM Resident #72's Responsible Party (RP), he stated it was a disgrace that his family member would be provided assistance with her meal by a nurse aide whose attention was divided between the nurse aide's own entertainment and his mother's care. He stated that when a nurse aide was providing Resident #72 assistance, the nurse aide should be present and 100% involved with the care his family member needed because she was reliant on the other person to ensure her needs were met. He expressed that the nurse aide should not be focused on their own entertainment while assisting the resident. During an interview on 2/11/26 at 9:28 AM the Regional Director of Clinical Services stated she was not sure if Resident #72 was able to respond to the nurse aide or not. She was also unsure if watching a video while assisting a resident with a meal was a dignity concern, however she did prefer nurse aides engage with residents while assisting with meals. She concluded the facility did not have a policy regarding staff cell phone use. During an interview on 2/11/26 at 9:30 AM the Administrator stated he would not recommend nurse aides watch a show on their cell phone while providing assistance to a resident with their meals, however he would need to check their cell phone policy to know if a nurse aide would be able to watch a show while assisting residents with meals. He stated he was unsure if a nurse aide watching a show while assisting residents with meals would be a dignity concern but watching a video while assisting a resident with their meal would not be something he recommended. 2. Resident #106 was admitted to the facility on [DATE]. The Minimum Data Set admission assessment dated [DATE] revealed Resident #106 was cognitively intact and she demonstrated no behaviors. During an observation and interview on 02/09/26 at 11:15 AM with Resident #106, she was observed in her room wearing a hospital gown. Resident #106 reported that she had 4 house coats (a loose lightweight robe) that were brought to the laundry department on Friday 02/05/26. She stated the facility was responsible for doing her laundry and the laundry was picked up on Fridays and returned back to her clean on the same day. Resident #106 stated a nurse aide picked up her laundry on Friday morning on 02/05/26 and as of today (02/09/26) the laundry had not been returned. Resident #106 stated she had been in a hospital gown since Friday 02/05/26. Resident #106 stated she was annoyed that she could not get dressed and had to wear a hospital gown for 3 days. Resident #106 added that she was not comfortable leaving her room while wearing a hospital gown, so she had remained in her room since her clothes were taken to the laundry on 02/05/26. Resident #106 stated she only brought 4 house coats to the facility and she and had no other clothes to wear. During an observation and interview on 02/10/26 at 3:25 PM with Resident #106, she was observed wearing a house coat. She revealed the staff brought back her 4 house coats late in the afternoon on 02/09/26. An interview was conducted with Housekeeper #1 on 02/12/26 at 10:00 AM. Housekeeper #1 stated that she and Housekeeper #2 were assigned to collect the laundry for the 500 hall each Friday. Housekeeper #1 stated once she brought the laundry and linens to the laundry department on Fridays; the laundry staff would launder the 500 hall's items and were supposed to return the clothing the same day. Housekeeper #1 stated the laundry was returned the same day on the 500 - hall because these residents were at the facility for rehabilitation services and they were discharged quicker than residents on other halls. Housekeeper #1 stated she did not work on Friday 02/05/26 so she did not pick up Resident #106's laundry. An interview with the Housekeeping Director on 02/12/26 at 10:30 AM revealed she had picked up the laundry from Resident #106's room on Friday 02/05/26 and returned the clean laundry the same day. The Housekeeping Director stated she returned the folded clothing items and left them in Resident #106's room to be put away on 02/05/26. A follow-up interview was conducted with the Housekeeping Director on 02/12/26 at 12:32 PM. The Housekeeping Director stated she did not bring Resident #106's clothes back to her room on Friday 02/05/26 like she had indicated in her previous interview. The Housekeeping Director stated she had confused Resident #106's room with another room on the same hall. The Housekeeping Director stated she recalled staff coming to her on Saturday 02/06/26 looking for Resident #106's clothes but they had not been laundered yet. She stated she worked all weekend in the laundry department due to being short staffed and got the laundry caught up. The Housekeeping Director stated there was usually one person assigned to the laundry room on day shift and one person on 2nd shift and that was enough staff to be able to keep up with the laundry. The Housekeeping Director stated she was familiar with the laundry process and on Fridays the 500-hall laundry would be picked up by the housekeeping department and washed and returned the same day. An interview was conducted with Nurse Aide #2 on 02/12/26 at 11:29 AM. Nurse Aide #2 stated she worked on Friday 02/05/26, Saturday 02/06/26, and Sunday 02/07/26. Nurse Aide #2 stated she brought Resident #106's laundry to the laundry department on Friday 02/05/26. Nurse Aide #2 reported Resident #106 did not have any clothes to wear all weekend. Nurse Aide #2 stated Resident #106 got out of bed and did therapy over the weekend in her room, but the resident did not leave her room because she said she had no clothes to wear. Nurse Aide #2 stated Resident #106 did not have any of her own clothes to wear all weekend and she (Nurse Aide #2) went to the laundry department on Saturday 02/06/26 and Sunday 02/07/26 and the Housekeeping Director kept saying we are working on it. Nurse Aide #2 stated when she returned on Monday 02/09/26, Resident #106 still did not have her clothes and she (Nurse Aide #2) went to the laundry department on Monday afternoon and Resident #106's 4 house coats were ready, so she brought them to Resident #106's room. An interview was conducted with the Administrator on 02/12/26 at 3:45 PM. The Administrator stated he expected the laundry to be completed on the day it was scheduled. He reported that the laundry on Resident #106's hall was scheduled to be done on Fridays. He indicated it should have been done that day so that Resident #106 had her own clothing to wear.

Based on record review and staff interviews, the facility failed to accurately code a resident's Minimum Data Set (MDS) assessment for 2 of 30 MDS assessments reviewed (Resident #3, Resident #59).Findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her active diagnoses included anemia, heart failure and diabetes mellitus. Review of Resident #3's Election of Benefits for Hospice dated 1/19/26 revealed she elected hospice and services were started for her on this date. Review of Resident #3's admission Minimum Data Set assessment dated [DATE] did not indicate she received hospice care. During an interview on 2/11/25 at 8:19 AM the MDS Coordinator stated he used the census report while completing the MDS assessment which had not been updated to reflect the hospice admission for Resident #3. The MDS Coordinator explained Resident #3's MDS assessment dated [DATE] did not capture her hospice status and it should have. During an interview on 2/11/25 at 9:34 AM the Administrator stated MDS assessments should accurately reflect resident's hospice status. 2. Resident #59 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM 2). A physician's order for Resident #59 dated 10/31/25 revealed Ozempic (0.25 or 0.5 milligram (MG/DOSE) subcutaneous (beneath the skin) Solution Pen-injector 2 MG/1.5 milliliter (ML) (Semaglutide) Inject 0.5 mg subcutaneously one time a day every 7day(s) for DM2 0.5 mg once every week. Resident #59's medical record did not reveal any physician's orders for Resident #59 to receive insulin in October 2025 or November 2025. Resident #59's October 2025 and November 2025 Medication Administration Record (MAR) did not reveal any documentation indicating insulin was administered to Resident #59. Resident #59's November 2025 MAR revealed documentation indicating Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-injector 2 MG/1.5ML (Semaglutide) Inject 0.5 mg subcutaneously was administered to her on 11/1/25 at 9:00 AM. Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 received one insulin injection in the last 7 days. On 2/11/26 at 12:59 PM an interview with MDS Nurse #1 indicated she coded the Medications section of Resident #59's 11/5/25 MDS assessment to indicate Resident #59 received one (1) insulin injection in the 7-day look-back period which included 10/30/25 through 11/5/25 because of the documentation on Resident #59's November 2025 MAR indicating Resident #59 received an Ozempic injection subcutaneously on 11/1/25. She reported that she thought because the medication was ordered for Resident #59's DM 2, it was to be coded as an insulin injection. On 2/11/26 at 1:08 PM an interview with the MDS Director revealed that although Ozempic was ordered for Resident #59's DM 2, it was not an insulin and should not be coded as insulin on MDS assessments. The facility's Director of Nursing was not present in the facility during the investigation and was unavailable for telephone interview. On 2/12/26 at 3:51 PM an interview with the Administrator indicated MDS assessments should be coded to accurately reflect the medication residents received.

Based on observations and staff interviews, the facility failed to secure a medication cart when the cart was left unattended for 1 of 4 medication carts observed for medication storage (500 Hall medication cart). Findings included: A continuous observation was conducted on 02/11/26 at 8:35 AM through 8:38 AM and revealed a medication cart on the 500 hall was left unattended and unsecured. The medication cart was noted to have 3 drawers containing prescription medications that were pulled open and medications were exposed. Additionally, the medication cart was noted to be unlocked with the keys hanging from the lock. The medication cart was facing the hallway and there were no staff or residents visible on the 500 - hall near or around the medication cart during the observation. Nurse #3 exited a resident's room and approached the unsecured cart. An interview was conducted with Nurse #3 on 02/11/26 at 8:38 AM when she returned to the medication cart. Nurse #3 stated she had her eyes on the cart the whole time. Nurse #3 then reported that she was assisting a resident to his room and did not have her eyes on the medication cart. Nurse #3 stated she knew the cart should not have been left unattended and unsecured with drawers' open and the keys left in the lock. Nurse #3 stated she was rushing and did not realize she left the drawers open or that she kept the key in the lock. An interview was conducted with the Administrator on 02/13/26 at 3:40 PM. The Administrator stated he expected his nursing staff to ensure the medications carts were secured at all times whenever the nursing staff stepped away from their cart. He stated it was important to keep the medications carts secured while unattended to prevent any residents or staff from taking medications from the cart who were not issued access to the medication cart.

Based on record reviews, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations for 4 of 5 residents (Resident #37, #67, #98, and #118) and offer annual influenza vaccine for 1 of 5 (Resident #118) residents reviewed for immunizations.The findings included:The facility policy for Pneumococcal Vaccination with the effective date 8/4/2023 read in part Vaccinations against pneumonia will be offered to center patients as indicated. Contraindications for receiving a pneumococcal vaccination were severe allergy to any component of the vaccine. Patient pneumococcal vaccine tracking will be maintained by the Infection Preventionist using the Immunization Tracking in the electronic medical record.The facility policy for Influenza Vaccination with the effective date 5/1/2023 read in part Influenza vaccine should be offered annually. The optimal time to administer influenza vaccine is in late September or early October of each year. The center will check the immunization status of patients admitted during flu season. Those who have not had a flu vaccine will be offered one upon admission unless contraindicated. The patient influenza vaccine tracking will be maintained by the Infection Preventionist using the Immunization Tracking in the electronic medical records.1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis and gout.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact and was coded as being offered and declining the pneumococcal vaccine.Review of Resident #37's immunization record revealed no documentation that he had been offered, given, or refused the pneumococcal vaccine. An interview was completed on 8/7/2025 at 10:30 am with Resident #37. Resident #37 stated he was unable to recall if he was offered the pneumococcal vaccine by the facility and declined it. An interview was completed on 8/7/2025 at 2:05 pm with the Quality Assurance Nurse. The Nurse verified she was responsible for ensuring facility residents were offered and received the pneumococcal and influenza vaccine. The Quality Assurance Nurse revealed she began working at the facility approximately 1 1/2 months ago. The Nurse stated she audited all residents' medical records to verify who had not been offered or received the influenza and pneumococcal vaccinations. The Quality Assurance Nurse revealed she contacted all residents and their responsible parties that had no documentation of vaccinations in their medical record to obtain their consent or refusals for them. The Nurse stated she was now at the point of obtaining Physician orders to administer the vaccinations. An interview was completed on 8/7/2025 at 3:33 pm with the Administrator. The Administrator stated there had been a recent change in leadership that contributed to residents not being offered and receiving vaccinations timely. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included arthritis and asthma. The annual MDS assessment dated [DATE] revealed Resident #67 was cognitively intact and was coded as not receiving her pneumococcal vaccination. Review of Resident #67's immunization record revealed no documentation that she had been offered, given, or refused the pneumococcal vaccine. An interview was completed on 8/7/2025 at 2:05 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she was responsible for ensuring facility residents were offered and received the pneumococcal and influenza vaccine. The Quality Assurance Nurse revealed she began working at the facility approximately 1 1/2 months ago. The Nurse stated she audited all residents' medical records to verify who had not been offered or received the influenza and pneumococcal vaccinations. The Quality Assurance Nurse revealed she contacted all residents and their responsible parties that had no documentation of vaccinations in their medical record to obtain their consent or refusals for them. The Nurse stated she was now at the point of obtaining Physician orders to administer the vaccinations. An interview was completed on 8/7/2025 at 3:33 pm with the Administrator. The Administrator stated there had been a recent change in leadership that contributed to residents not being offered and receiving vaccinations timely. 3. Resident #98 was admitted to the facility on [DATE] with diagnoses that included asthma and congestive heart failure. The annual MDS assessment dated [DATE] revealed Resident #98 was cognitively intact and was coded as being offered and declining the pneumococcal vaccination. Review of Resident #98's immunization record revealed no documentation that she had been offered, given, or refused the pneumococcal vaccine. An interview was completed on 8/7/2025 at 10:40 am with Resident #98. Resident #98 stated she was unable to recall if she was offered the pneumococcal vaccine by the facility and declined it. An interview was completed on 8/7/2025 at 2:05 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she was responsible for ensuring facility residents were offered and received the pneumococcal and influenza vaccine. The Quality Assurance Nurse revealed she began working at the facility approximately 1 1/2 months ago. The Nurse stated she audited all residents' medical records to verify who had not been offered or received the influenza and pneumococcal vaccinations. The Quality Assurance Nurse revealed she contacted all residents and their responsible parties that had no documentation of vaccinations in their medical record to obtain their consent or refusals for them. The Nurse stated she was now at the point of obtaining Physician orders to administer the vaccinations. An interview was completed on 8/7/2025 at 3:33 pm with the Administrator. The Administrator stated there had been a recent change in leadership that contributed to residents not being offered and receiving vaccinations timely. 4. Resident #118 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke. The quarterly MDS assessment dated [DATE] revealed Resident #118 was severely cognitively impaired and was coded as not being offered nor receiving the pneumococcal or influenza vaccination. Review of Resident #118's immunization record revealed no documentation that she had been offered, given, or refused the pneumococcal vaccine. The review also revealed she was documented as not being eligible to receive the influenza vaccination. Multiple attempts made to interview the Resident Representative were unsuccessful. Review of Resident #118's medical record revealed no contraindications to receiving the influenza vaccination. An interview was completed on 8/7/2025 at 2:05 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she was responsible for ensuring facility residents were offered and received the pneumococcal and influenza vaccine. The Quality Assurance Nurse revealed she began working at the facility approximately 1 1/2 months ago. The Nurse stated she audited all residents' medical records to verify who had not been offered or received the influenza and pneumococcal vaccinations. The Quality Assurance Nurse revealed she contacted all residents and their responsible parties that had no documentation of vaccinations in their medical record to obtain their consent or refusals for them. The Nurse stated she was now at the point of obtaining Physician orders to administer the vaccinations. The Quality Assurance Nurse stated she was unable to state why Resident #118 was documented as not being eligible to receive the influenza vaccination. An interview was completed on 8/7/2025 at 3:33 pm with the Administrator. The Administrator stated there had been a recent change in leadership that contributed to residents not being offered and receiving vaccinations timely. The facility provided the following corrective action plan with a completion date of 8/1/2025. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.The facility failed to document and/or administer immunizations and/or vaccinations for residents in the electronic medical record (EMR). 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On July 8, 2025, the Infection Preventionist (IP) reviewed all residents' EMR for immunizations and/or vaccinations. Out of the 114 residents in-house, 33 were vaccinated, 29 refused, 23 received partial vaccination, 24 consented and had not yet received the vaccinations, 3 voicemail messages were left for consent from the Resident Representative with no return call, and 2 unable to reach the guardian for the COVID vaccination. Out of the 114 in-house residents, 37 refused, 40 were vaccinated, 4 voicemail messages were for consent from the Resident Representative with no return call, 2 have consented, and 31 were not eligible based on their admission date and/or received prior to admission the Influenza vaccination. Out of the 114 in-house residents, 40 refused, 24 were vaccinated, 41 have consented, and 9 voicemail messages were left for consent from the Resident Representative with no return call for the Pneumococcal vaccination. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The Staff Development Coordinator Nurse initiated education on July 8, 2025, to all licensed nurses to document available immunizations and/or vaccinations upon admission and was completed on July 31, 2025. Any that has not received the education by July 31,2025, will be educated prior to the start of his/her next scheduled shift. All newly licensed nurses will be educated during orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Include dates when corrective action will be completed.On July 8, 2025, the newly hired Infection Preventionist (IP) was educated by the Regional Director of Clinical Services on immunization/vaccination requirements and documentation standards. The Infection Preventionist (IP) will review each new admission and administer the vaccination and/or immunization per the consent and document the administration in the EMR. The Infection Preventionist (IP) will audit all new admissions for immunization/vaccination documentation and/or administration daily, Monday through Friday for 12 weeks. Monitoring began on July 8, 2025, and initial results of these audits were reviewed on July 31, 2025, during the facility's Quality Assurance Performance Improvement (QAPI) meeting. The continued audits will be reviewed at the Quarterly QAPI meeting for 3 meetings for further problem resolution if needed. The Administrator will review the results of the weekly audits to ensure any issues are identified and corrected. Alleged date of compliance: 8/1/2025Onsite validation was completed on 8/7/2025 through staff interviews and record reviews. Inservice education was confirmed to be provided on immunization/vaccination requirements and documentation standards. Staff were interviewed to validate the in-service education was completed. Review of education conducted with Infection Preventionist regarding immunization/vaccination requirements and documentation standards was completed. Audits were reviewed with no concerns noted.An interview was completed on 8/7/2025 at 2:35 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she received education regarding vaccination requirements and documentation. The Nurse stated she reviewed new admissions daily for vaccinations.An interview was completed on 8/7/2025 at 2:57 pm with Unit Manager #2. The Unit Manager #2 verified she received education regarding the documentation of prior vaccinations residents had upon admission to the facility.The facility's corrective action plan completion date of 8/1/2025 was validated.

Based on record reviews and interviews with staff, the facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for 1 of 3 residents reviewed for MDS assessments (Resident #89).The findings included: Resident #89 was readmitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke). An admission MDS assessment with an Assessment Reference Date (ARD) of 8/6/25 was noted to be in process when reviewed on 8/20/25. In an interview on 8/20/25 at 2:03 PM, the MDS Coordinator stated the MDS assessment should have been done within 14 days after admission. He stated the MDS was not completed due to the volume of MDS assessments the facility had pending and they were trying to hire another full time MDS nurse. In an interview on 8/20/25 at 3:34 PM, the Administrator stated Resident #89's MDS assessment should have been completed on time. She stated because they were needing another full time MDS nurse, the corporate office had been helping part-time and another part-time employee had been hired, but not all the assessments were up to date yet.

Based on record review and facility staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for Antipsychotic Medication Review for 1 of 5 residents reviewed for unnecessary medications (Resident #117).The findings included: Resident #117 was admitted to the facility on [DATE] with diagnoses which included dementia with delusions. A review of Resident #117's July 2025 Medication Administration Record (MAR) documented Quetiapine Fumarate 0.5 milligrams (mg) was administered 7/7/25, 7/8/25 and 7/10/25 through 7/30/25. A review of Resident #117's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed she received antipsychotic medications. The Antipsychotic Medication Review was coded as not receiving antipsychotics on a scheduled or routine basis. During an interview with the Regional MDS Consultant on 8/6/25 at 10:30 a.m., she stated the MDS should have indicated Resident #117 had received antipsychotic medications on a regular basis, and this had been an error. She verified the Minimum Data Set Assessment was inaccurate and that antipsychotic use should have been coded correctly. During an interview with the Administrator on 8/7/25 at 2:00 pm, she stated the MDS assessments should have been coded accurately to reflect the use of antipsychotics.

Based on observations and staff interviews, the facility failed to remove a box which contained 40 bisacodyl (a laxative) suppositories that were expired in 1 of 3 medication storage rooms (Unit 2 Medication Storage Room) reviewed for medication storage and labeling. The findings included: An observation of Unit 2 Medication Storage Room on 8/7/25 at 9:49 am revealed an opened box of bisacodyl suppositories, originally containing 40 suppositories, with an expiration date of 4/2025. In an interview with the Unit Manager #2 on 8/7/25 at 9:49 am, she stated the opened box of expired bisacodyl suppositories should have been discarded in April 2025. During an interview with the interim Director of Nursing (DON) on 8/7/25 at 2:00 pm, she stated the nursing staff was responsible for regularly checking the medication storage rooms and removing expired medications. The Administrator was interviewed on 8/7/25 at 2:00 pm and she indicated all nursing staff were responsible for regularly checking the medication storage rooms and removing expired medications.

Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse #1 failed to apply all the required Personal Protective Equipment (PPE) before entering a room with a resident on contact precautions. This occurred for 1 of 7 staff observed for infection control practices.The findings included:The facility's Infection Prevention and Control Program policy last revised on 2/6/2020 read in part: for patients documented as suspected to be infected with highly transmissible important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission, contact precautions may be utilized for diseases that have multiple routes of transmission that can be transmitted by direct contact or when performing patient care activities that require touching the resident.Review of the facility's contact precautions signage read in part: All healthcare personnel must: Clean hands before entering and when leaving room. Wear gloves when entering room and remove before leaving room. Wear a gown when entering room and remove before leaving.A review of Resident #89's physician order dated 8/5/25 revealed an order for contact isolation precautions related to conjunctivitis (an inflammation of the conjunctiva, the thin, transparent membrane covering the white part of the eye and the inner surface of the eyelids) for 10 days.An observation on 8/5/25 at 9:13 am of Resident #89's room revealed a sign posted on the right side of the door Contact Precautions. A storage cart was located outside the resident's room beside his door containing PPE to include gloves and gowns.An observation was conducted on 8/5/25 at 2:57 pm of Nurse #1. Nurse #1 was observed administering medications to Resident #89 via gastrostomy tube (a tube inserted in the abdomen to provide nutrition and medications) with no gloves or gown on for contact precautions. During an interview on 8/5/25 at 3:11 pm with Nurse #1, she stated she did not realize Resident #89 was on contact precautions. Nurse #1 indicated she was busy on the unit; however, she knew she was supposed to wear PPE for a resident on contact precautions. In an interview with Unit Manager #1 on 8/5/25 at 3:00 pm, she stated Nurse #1 should have had her PPE on going in to Resident #89's room.The Staff Development Coordinator (SDC) nurse was interviewed on 8/5/25 at 3:01 pm. The SDC nurse stated the facility had on-going in-services for infection control prevention on transmission-based precautions (TBP).During an interview on 8/7/25 at 2:00 pm with the interim Director of Nursing (DON), she stated Nurse #1 had been in-serviced on this day on infection control prevention and PPE usage. The interim DON further stated Nurse #1 should have had her PPE on for a resident on contact precautions.In an interview on 8/7/25 at 2:00 pm with the Administrator, she stated her expectations were the nursing staff to read the signs on the residents' doors prior to entering the rooms and use the appropriate PPE supplies indicated by the signage posted.

Based on record reviews, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccinations for 1 of 5 residents (Resident #67) reviewed for immunizations.The findings included:The facility policy for COVID-19 vaccination with the effective date 3/11/2024 read in part Vaccinations against COVID-19 will be offered to center patients as indicated. Contraindications for receiving the COVID-19 vaccination include severe allergic reaction to any component of the vaccine. COVID-19 vaccination tracking will be maintained by the Infection Preventionist or designee.Resident #67 was admitted to the facility on [DATE] with diagnoses that included arthritis and asthma. The annual MDS assessment dated [DATE] revealed Resident #67 was cognitively intact and was coded as not being up to date for the COVID-19 vaccination. Review of Resident #67's immunization record revealed no documentation that she had been offered, given, or refused the COVID-19 vaccination. An interview was completed on 8/6/2025 at 12:07 pm with Resident #67. The Resident revealed she was unable to recall being offered the COVID-19 vaccination. An interview was completed on 8/7/2025 at 2:05 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she was responsible for ensuring facility residents were offered and received the COVID-19 vaccination. The Quality Assurance Nurse revealed she began working at the facility approximately 1 1/2 months ago. The Nurse stated she audited all residents' medical records to verify who had not been offered or received the COVID-19 vaccination. The Quality Assurance Nurse revealed she contacted all residents and their responsible parties that had no documentation of the vaccination in their medical record to obtain their consent or refusals for them. The Nurse stated she was now at the point of obtaining Physician orders to administer the vaccinations. An interview was completed on 8/7/2025 at 3:33 pm with the Administrator. The Administrator stated there had been a recent change in leadership that contributed to residents not being offered and receiving vaccinations timely. The facility provided the following corrective action plan with a completion date of 8/1/2025.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.The facility failed to document and/or administer immunizations and/or vaccinations for residents in the electronic medical record (EMR). 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On July 8, 2025, the Infection Preventionist (IP) reviewed all residents' EMR for immunizations and/or vaccinations. Out of the 114 residents in-house, 33 were vaccinated, 29 refused, 23 received partial vaccination, 24 consented and had not yet received the vaccination, 3 voicemail messages were left for consent from the Resident Representative with no return call, and 2 unable to reach the guardian for the COVID vaccination. Out of the 114 in-house residents, 37 refused, 40 were vaccinated, 4 voicemail messages were for consent from the Resident Representative with no return call, 2 have consented, and 31 were not eligible based on their admission date and/or received prior to admission the Influenza vaccination. Out of the 114 in-house residents, 40 refused, 24 were vaccinated, 41 have consented, and 9 voicemail messages were left for consent from the Resident Representative with no return call for the Pneumococcal vaccination. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The Staff Development Coordinator Nurse initiated education on July 8, 2025, to all licensed nurses to document available immunizations and/or vaccinations upon admission and was completed on July 31, 2025. Any that has not received the education by July 31,2025, will be educated prior to the start of his/her next scheduled shift. All newly licensed nurses will be educated during orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Include dates when corrective action will be completed.On July 8, 2025, the newly hired Infection Preventionist (IP) was educated by the Regional Director of Clinical Services on immunization/vaccination requirements and documentation standards. The Infection Preventionist (IP) will review each new admission and administer the vaccination and/or immunization per the consent and document the administration in the EMR. The Infection Preventionist (IP) will audit all new admissions for immunization/vaccination documentation and/or administration daily, Monday through Friday for 12 weeks. Monitoring began on July 8, 2025, and initial results of these audits were reviewed on July 31, 2025, during the facility's Quality Assurance Performance Improvement (QAPI) meeting. The continued audits will be reviewed at the Quarterly QAPI meeting for 3 meetings for further problem resolution if needed. The Administrator will review the results of the weekly audits to ensure any issues are identified and corrected. Alleged date of compliance: 8/1/2025Onsite validation was completed on 8/7/2025 through staff interviews and record reviews. Inservice education was confirmed to be provided on immunization/vaccination requirements and documentation standards. Staff were interviewed to validate the in-service education was completed. Review of education conducted with Infection Preventionist regarding immunization/vaccination requirements and documentation standards was completed. Audits were reviewed with no concerns noted.An interview was completed on 8/7/2025 at 2:35 pm with the Quality Assurance Nurse/Infection Preventionist. The Nurse verified she received education regarding vaccination requirements and documentation. The Nurse stated she reviewed new admissions daily for vaccinations.An interview was completed on 8/7/2025 at 2:57 pm with Unit Manager #2. The Unit Manager #2 verified she received education regarding the documentation of prior vaccinations residents had upon admission to the facility.The facility's corrective action plan completion date of 8/1/2025 was validated.

Based on record review, observation, and staff and Medical Director interviews, the facility failed to ensure nursing staff were competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer when Nurse #1 was observed not disinfecting a shared glucometer (Resident #35). Also, Medication Aide #1 (an agency staff member) failed to clean and disinfect an individually assigned glucometer using the approved disinfectant wipes according to manufacturer's recommendations for Resident #32 who was observed having a blood glucose level checked. This occurred for 2 of 7 nursing staff members (Nurse #1 and Medication Aide #1) reviewed for competency. Immediate jeopardy began on 2/17/25 when Nurse #1 failed to demonstrate competency through her failure to disinfect a shared glucometer per manufacturer's instructions. Immediate jeopardy was removed on 2/19/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: 1. The skills validation record for Nurse #1 dated 5/7/2024 included the use of equipment that included glucometers. The former Assistant Director of Nursing signed the validation form on 5/7/2024. An educational in-service roster dated 9/11/2024 and 9/12/2024 on cleaning glucometers between patients every time for infection control practices stated to allow the glucometer to air dry 2 minutes after wiping with purple wipes and place on a clean surface to dry. Nurse #1's signature was not included on the roster to indicate she had received the education. On 2/17/2025 at 5:50 am in preparation to check Resident #35's blood glucose, Nurse #1 was observed searching for Resident #35's glucometer. Nurse #1 stated each resident had their individually assigned glucometer to check blood glucose levels. Nurse #1 was observed opening the top drawer of the 100-hall medication cart flipping three glucometer pouches labeled with Resident #66's, Resident #33's and Resident # 93's name and room number upward toward Nurse #1. Nurse #1 was observed locking the 100-hall medication cart and walking to the 200-hall medication cart before returning to the 100-hall medication cart and reopening the top drawer. Nurse #1 reflipped Resident #66's, Resident #33's and Resident # 93's labeled glucometer pouches upward toward her and picked up Resident #33's glucometer pouch. There was an unlabeled glucometer not in a labeled glucometer pouch observed underneath Resident #33's glucometer pouch. Nurse #1 stated the unlabeled glucometer was Resident #35's glucometer and was observed not disinfecting the glucometer before performing a blood glucose test on Resident #35 on 2/17/2025 at 5:56 am. Nurse #1 was observed returning the used unlabeled glucometer to the top drawer of the 100-hall medication cart without disinfecting the glucometer. On 2/17/2025 at 6:00 am in an interview with Nurse #1, she stated Resident #35 did not have a labeled glucometer pouch and the reason she did not disinfect the glucometer before performing the blood glucose was because the staff member who used the glucometer before she used it should have disinfected the glucometer. Nurse #1 stated she did not think about disinfecting the glucometer after performing the blood glucose test. Nurse #1 was observed removing an alcohol pad from the top drawer of the 100-hall medication cart and wiping the unlabeled glucometer without an resident identified glucometer pouch with the alcohol pad and returning the unlabeled glucometer to the top drawer of the 100-hall medication cart. She stated she always disinfected glucometers with alcohol pads and Resident #35 was the only blood glucose monitoring she had to perform. In an interview with Nurse #2 on 2/18/2025 at 10:08 am, she identified the unlabeled / unidentified glucometer not stored in a pouch with a resident's name and room number as a shared glucometer. She stated the Resident #35 and Resident #31 who resided on the 100 hall did not have individually assigned glucometers and shared the unlabeled / unidentified glucometer. She also stated a disinfectant wipe was used to clean glucometers after each use on a resident. On 2/18/2025 at 10:42 am in a follow up phone interview with Nurse #1, she stated she thought the unlabeled glucometer that was not in a pouch labeled with a resident's name and room number on the 100-hall medication cart was Resident #35's glucometer on 2/17/2025 when performing the blood glucose monitoring. She stated Resident #31 also received blood glucose monitoring and did not have an individually assigned glucometer, and she had forgotten Resident #35 and Resident #31 shared the unlabeled glucometer not in a labeled pouch. Nurse #1 stated she was trained on how to use and disinfect a glucometer with employment orientation and was unable to recall the instructions on how to use the disinfectant wipes at the facility. She reported there were no disinfectant wipes on the 100-hall medication cart to clean the glucometer on the morning of 2/17/2025. On 2/17/2025 at 6:50 am in an interview with the Director of Nursing (DON), she stated the facility did not have a glucometer for every resident receiving blood glucose monitoring, and some of the glucometers on the medication carts were shared between residents. The DON stated Nurse #1 was to clean the glucometer that was shared between residents with the facility's EPA-disinfected wipes and allow the glucometer to dry for two minutes before storing in the resident's labeled glucometer pouch. The DON stated since starting at the facility five weeks ago, she had seen documentation that the nursing staff had received an educational in-services on cleaning and disinfecting glucometers. There was no documentation provided by the facility that recorded educational in-services were conducted on cleaning and disinfecting glucometers since 9/12/2024. The facility's Administrator was informed of the immediate jeopardy (IJ) on 2/18/2025 at 2:00 pm. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure Nurse #1 was trained and competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer and on knowing how to distinguish an individually assigned resident glucometer from a shared glucometer. Nurse #1 failed to ensure an unlabeled / unidentified glucometer that was shared between Resident #35 and Resident #31 on the 100-hall medication cart was cleaned and disinfected prior to and after use. (Resident #35) Nurse #1 thought the glucometer was individually assigned to Resident #35 and had forgotten that the unlabeled / unidentified glucometer was also used on Resident #31. Nurse #1 indicated the glucometer used for Resident #35 was individually assigned. She stated she did not think about cleaning and disinfecting the unlabeled / unidentified glucometer after performing Resident #35's blood glucose and stated she always cleaned residents' glucometer with alcohol wipes. The Director of Nursing stated the facility did not have a glucometer for every resident receiving blood glucose monitoring and some of the glucometers on the medication carts were shared between residents. The DON stated glucometers were to be cleansed with an approved disinfectant. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared glucometer potentially exposes residents to the spread of blood borne infections. Six residents within the facility were identified as having a diagnosis which included one or more blood borne pathogens. Nurse # 1 was removed from the schedule on 2/17/2025 and will be educated with a competency prior to returning to work. This will be completed by the Director of Nursing. Current residents that receive finger stick blood sugar checks are at risk. Forty residents require FSBS and all forty have been provided their individual glucometer. The Assistant Director of Nursing completed an audit on 2/18/2025. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container. The was completed by the Director of Nursing and the Assistant Director of Nursing on 2/18/2025. Education was started by the Director of Nursing on 2/18/2025 to current licensed nursing staff, including agency staff, on proper procedure for cleaning glucometers and for proper storage of glucometers. Employees not receiving this education will not be allowed to work until the education is received. The Director of Nursing will track the education to ensure that current staff have received. Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart. Education also includes the proper cleaning technique as recommended by the manufacturer guidelines. The cleaning product will be kept on each medication cart. The Director of Nursing or charge nurse will check the med carts daily to ensure that the cleaning product is present on each med cart. The Director of Nursing educated the charge nurses on 2/18/2025. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. Current Licensed Nurses will complete a skills return demonstration on glucometer cleaning and storage. This will be completed by the Director of Nursing. Any licensed nurse will not be allowed to work until return demonstration has been completed. The Director of Nursing will track the education to ensure that current staff have received. The Director of Nursing or charge nurse is responsible for ensuring new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The charge nurses are educated on this process by the Director of Nursing on 02/18/2025. New licensed nurses will receive this education and verify competencies during the orientation process by the Director of Nursing or charge nurse. Agency nurses will receive this education and competencies prior to the start of their shift. The charge nurses were educated on this responsibility by the Director of Nursing on 02/18/2025. The Director of Nursing will assign the charge nurse to complete this task when needed. Immediate Jeopardy removal date 2/19/2025. The facility's credible allegation of immediate jeopardy removal was validated on 2/22/25. A phone interview with the medical director on 2/18/2025 validated the facility had notified the physician of the deficient practice and the facility was implementing new practices that included an individual glucometer per resident and educating the nursing staff on how to disinfect the glucometer after use on a resident. Observation of the 43 residents' (40 plus 3 admissions since 2/18/2025) individually assigned glucometers who currently resided in the facility on 2/22/2025 validated each resident receiving blood glucose monitoring had an individually assigned glucometer in a glucometer pouch labeled with their name and room number. Medication aides reported during interviews that blood glucose monitoring was performed by licensed nursing staff in the facility and medications aides did not conduct blood glucose monitoring in the facility. Interviews with licensed nursing staff on each hallway and on all shifts validated in-service training was conducted in regard to the use of individually assigned glucometers for resident blood glucose monitoring and the infection control practices for the disinfection of glucometers. All licensed nursing staff who were interviewed reported they had received the required in-service training on 2/18/2025 or prior to beginning their next assigned shift after 2/18/2025. The educational in-services stressed using individually assigned glucometers for each resident requiring blood glucose monitoring and storing each individual assigned glucometer in an individually labeled glucometer pouch with resident's name and room number. The in-service training also included a review of the manufacturer's instructions for the facility's glucometers and disinfectant wipes related to disinfection of the glucometer and completion of a returned demonstration of the proper procedure for effective glucometer disinfection. Nurse observation in conducting a blood glucose check and subsequent glucometer disinfection completed the task without difficulty. Individually assigned resident glucometers were observed stored on the medication carts in closed labeled pouches with resident's name and room number. Each medication cart was observed with a canister of EPA disinfectant wipes. The nursing staff were recording verification of individually assigned glucometers and EPA disinfectant wipes on each medication cart at the change of shift. There was an unused unlabeled new glucometer observed on each medication cart that licensed nursing staff validated through interviews the new unused glucometers were available for new admissions, replacement of a resident's individually assigned glucometer or in an emergency as needed. To prevent the likelihood of a new glucometer used as a shared glucometer, the facility removed the new, unused glucometers from each medication cart and relocated the storage of the new unused glucometer into the medication storage rooms on each unit. There were no further concerns identified during either the interviews or observations. The immediate jeopardy removal date of 2/19/25 was validated. 2. The manufacturer's operator manual revised 10/2019 for Resident #32's assigned glucometer provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed after each use. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting procedure for Resident #32's individually assigned glucometer included in part: Step 5: using one EPA disinfectant towelette to wipe the entire surface of the glucometer horizontally and vertically to remove bloodborne pathogens and Step 6: Treated surface must remain wet for the recommended contact time. Do not wrap the meter in a towelette. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/18/2025 at 7:51 am, Medication Aide #1 (agency) was observed performing blood glucose monitoring using an individually assigned glucometer for Resident #32. After obtaining a blood glucose level, Medication Aide #1 was observed cleaning Resident #32's individually assigned glucometer with alcohol wipes. On 2/18/2025 at 7:57am in an interview with Medication Aide #1, she explained Resident #32's glucometer needed to be disinfected after use and she cleaned the glucometer with an alcohol pad because she did not have any disinfected wipes on the 300-hall medication cart. On 2/18/2025 at 10:25 am in a follow up interview with Medication Aide #1, she stated she received training less than a month ago at the facility on using disinfectant wipes to clean glucometers after use. She stated there were disinfectant wipes on the 300-hall medication cart, and she did not know the disinfectant wipes were on the 300-hall medication cart because she had not checked the 300-hall medication cart. On 2/18/2025 at 11:50 am when interviewing Medication Aide #1 regarding her training in cleaning and disinfecting glucometers after resident use, she reported she had been informed on 2/18/2025 medication aides were not allowed to perform blood glucose monitoring at the facility and stated she would get a nurse to perform blood glucose monitoring. She explained she was in nursing school and had received training in performing blood glucose monitoring and had attended an educational in-service at the facility. On 2/18/2025 at 12:22 pm in an interview with the Administrator, she stated medication aides could perform blood glucose monitoring if training and competency were documented. She explained Medication Aide #1 had received training from the agency company and was currently in nursing school where she received training. On 2/18/2025 at 12:30 pm in an interview with the Director of Nursing, she stated in the last five weeks of employment she had not seen an orientation/competency form that agency staff completed for the facility. On 2/18/2025 at 5:10 pm in follow up interview with the Director of Nursing, she stated Resident #32's individually assigned glucometer needed to be disinfected after each use using a disinfectant wipe and medications aides did not perform blood glucose monitoring at the facility. She stated blood glucose monitoring was completed by licensed nurses in the facility and not medication aides. A skills competency rating dated 9/30/2024 from the agency company indicated Medication Aide #1 performed glucose monitoring daily to weekly and was proficient in the task. An educational in-service roster dated 9/11/2024 and 9/12/2024 on cleaning glucometers between patients every time for infection control practices stated to allow the glucometer to air dry 2 minutes after wiping with purple wipes and place on a clean surface to dry. Medication Aide #1 signature was included on the roster to indicate she had received the education.

Based on record review, observation and staff interview, the facility failed to implement infection control policies and procedures when staff failed to: (1) disinfect an unlabeled glucometer (a blood glucose meter) that was shared between residents for 1 of 2 residents (Resident #35) observed to have a blood glucose level checked. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer's instructions for the glucometer potentially exposes residents to the spread of bloodborne infections. This occurred with six residents in the facility identified as having a diagnosis that included one or more bloodborne pathogens; (2) disinfect an individually assigned glucometer stored outside of the resident's room with an EPA-registered disinfectant in accordance with the manufacturer's instructions of the glucometer (Resident #32); (3) don necessary personal protective equipment (PPE) before entering a COVID isolation room and remove PPE before exiting the room; (4) evidence and documentation of annual review of infection control policies and procedures; and (5) cover the linen on linen carts located in the hallway to reduce the risk of accidental contamination.The uncovered linen carts were observed on 2 of 5 halls (300 and 400 halls). These deficient practices affected 3 of 127 residents residing in the facility (Residents #35, #32 and #230). Immediate jeopardy began on 2/17/2025 at 5:50 am when Nurse #1 was observed performing a blood glucose test on Resident #35 using shared glucometer and not disinfecting the glucometer before and after performing the blood glucose test. Immediate jeopardy was removed on 2/19/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not immediate jeopardy) for findings #2, #3, #4, and #5 for the facility's completion of employee and agency nursing staff training with blood glucose monitoring to ensure effective interventions were implemented. The findings included: 1. The glucometer manufacturer's operator manual dated 2016 provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: all parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting step-by-step instructions included, in part: Step 3: inspect for blood, debris, dust or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4: Clean the meter using a moist lint-free cloth dampened with a mild detergent and wiping all external areas of the meter including the front and back surfaces until visibly clean. Step 5: Disinfect the meter, cleaning the surface with an approved disinfectant wipe and wiping all external areas of the meter including front and back surface until visibly wet. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/17/2025 at 5:50 am in preparation to check Resident #35's blood glucose, Nurse #1 was observed searching for Resident #35's glucometer. Nurse #1 stated each resident had their individually assigned glucometer to check blood glucose levels. Nurse #1 was observed opening the top drawer of the 100-hall medication cart flipping three glucometer pouches labeled with Resident #66's, Resident #33's and Resident # 93's name and room number upward toward Nurse #1. Nurse #1 was observed locking the 100-hall medication cart and walking to the 200-hall medication cart before returning to the 100-hall medication cart and reopening the top drawer. Nurse #1 reflipped Resident #66's, Resident #33's and Resident # 93's labeled glucometer pouches upward toward her and picked up Resident #33's glucometer pouch. There was an unlabeled glucometer not in a labeled glucometer pouch observed underneath Resident #33's glucometer pouch. Nurse #1 stated the unlabeled glucometer was Resident #35's glucometer and was observed not disinfecting the glucometer before performing a blood glucose test on Resident #35 on 2/17/2025 at 5:56 am. Nurse #1 was observed returning the used unlabeled glucometer to the top drawer of the 100-hall medication cart without disinfecting the glucometer. On 2/17/2025 at 6:00 am in an interview with Nurse #1, she stated Resident #35 did not have a labeled glucometer pouch and there were two glucometers in Resident #66's pouch earlier, and the glucometer that was not found in a glucometer pouch, must have fallen out of the unzipped glucometer pouch of Resident #66. The glucometer in Resident #66's pouch was observed unlabeled. Nurse #1 stated she did not know which glucometer was Resident #35's and grabbed the unlabeled glucometer that was not in a labeled glucometer pouch to perform Resident #35's blood glucose. Nurse #1 stated the reason she did not disinfect the glucometer before performing the blood glucose was because the staff member who used the glucometer before she used it should have disinfected the glucometer. Nurse #1 stated she did not think about disinfecting the glucometer after performing the blood glucose test. Nurse #1 was observed removing an alcohol pad from the top drawer of the 100-hall medication cart and wiping the unlabeled glucometer without an resident identified glucometer pouch with the alcohol pad and returning the unlabeled glucometer to the top drawer of the 100-hall medication cart. She stated she always disinfected glucometers with alcohol pads and Resident #35 was the only blood glucose monitoring she had to perform. On 2/18/2025 at 10:08 am in an interview with Nurse #2 she stated due to Medication Aide #5 being assigned to the 100-hall medication cart on 2/16/2025 for the 7:00 am to 7:00 pm shift, she performed Resident #35's blood glucose monitoring. She stated Resident #35 did not have an individually assigned glucometer and when performing Resident #35's blood glucose monitoring, the unlabeled glucometer that was not stored in a labeled pouch with resident's name and room number on the 100-hall medication cart was used for Resident #35 and Resident #31, who also did not have an individually assigned glucometer. She stated she used disinfectant wipes on the 100-hall medication cart to disinfect the unlabeled glucometer after each use. On 2/18/2025 at 10:42 am in a follow up phone interview with Nurse #1, she stated she thought the unlabeled glucometer that was not in a pouch labeled with a resident's name and room number on the 100-hall medication cart was Resident #35's glucometer on 2/17/2025 when performing the blood glucose monitoring. She stated Resident #31 also received blood glucose monitoring and did not have an individually assigned glucometer, and she had forgotten Resident #35 and Resident #31 shared the unlabeled glucometer not in a labeled pouch. Nurse #1 stated she was trained on how to use and disinfect a glucometer with employment orientation and was unable to recall the instructions on how to use the disinfectant wipes at the facility. She reported there were no disinfectant wipes on the 100-hall medication cart to clean the glucometer on the morning of 2/17/2025. On 2/18/2025 at 10:30 am in an interview with the Central Supply, she reported there were no disinfectant wipes in the central supply room. She stated she restocked the 100-hall medication cart with disinfectant wipes on the morning of 2/17/2025 upon reporting to work for the 7:00am to 3:00pm shift. On 2/17/2025 at 6:50 am in an interview with the Director of Nursing (DON), she stated the facility did not have an individually assigned glucometer for every resident receiving blood glucose monitoring, and there were glucometers on the medication carts that were shared between residents. The DON stated Nurse #1 should have disinfected the glucometer that was shared between the residents with the facility's EPA-disinfectant wipes and allow the glucometer to dry for two minutes before storing in resident's labeled glucometer pouch. The Regional Director of Clinical Services indicated via email on 2/18/2025 at 5:26 pm that there were six current residents in the facility identified as having a diagnosis that included one or more bloodborne pathogens. The Administrator was informed of the immediate jeopardy (IJ) on 2/18/2025 at 2:00 pm. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Nurse #1 failed to ensure an unlabeled / unidentified glucometer that was shared between Resident #35 and Resident #31 on the 100-hall medication cart was cleaned and disinfected prior to and after use. (Resident #35). Nurse #1 thought the glucometer was individually assigned to Resident #35 and had forgotten that the unlabeled / unidentified glucometer was also used on Resident #31. Nurse #1 indicated the glucometer used for Resident #35 was individually assigned. She stated she did not think about cleaning and disinfecting the unlabeled / unidentified glucometer after performing Resident #35's blood glucose and stated she always cleaned residents' glucometer with alcohol wipes. The Director of Nursing stated the facility did not have a glucometer for every resident receiving blood glucose monitoring and some of the glucometers on the medication carts were shared between residents. The DON stated glucometers were to be cleansed with an approved disinfectant. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared glucometer potentially exposes residents to the spread of blood borne infections. There are six current residents within the facility identified as having a diagnosis which included one or more blood borne pathogens. The following immediate actions were taken for affected residents: The facility Medical Director was notified by the Administrator of the facility on 2/18/2025 of the deficient practice for Resident #35 and of the new process of each resident having their own designated glucometer. He is in agreement with the current process for cleaning and storage of glucometers with no further recommendation. No recommendations were provided for Resident #35. The local county Health Department Communicable Disease Coordinator was notified by the facility Administrator on 2/18/2025 with no further recommendations at this time. Current residents that receive finger stick blood sugar checks are at risk. Forty residents require FSBS and all forty have been provided their individual glucometer. The Assistant Director of Nursing completed an audit on 2/18/2025. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container. The was completed by the Director of Nursing and the Assistant Director of Nursing on 2/18/2025. Education was started by the Director of Nursing on 2/18/2025 to current licensed nursing staff, including agency staff, on proper procedure for cleaning/disinfecting glucometers and for proper storage of glucometers. Employees not receiving this education will not be allowed to work until the education is received. The Director of Nursing will track the education to ensure that current staff have received. Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart. Education also includes the proper cleaning technique as recommended by the manufacturer guidelines. The cleaning product will be kept on each medication cart. The Director of Nursing or charge nurse will check the med carts daily to ensure that the cleaning product is present on each med cart. The Director of Nursing educated the charge nurses on 2/18/2025. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The Director of Nursing or charge nurse is responsible for ensuring new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The charge nurses are educated on this process by the Director of Nursing on 02/18/2025. New licensed nurses will receive this education during the orientation process by the Director of Nursing or charge nurse on 02/18/2025. Agency nurses will receive this education prior to the start of their shift. The charge nurses were educated on this process on 02/18/2025 by the Director of Nurse. The Director of Nursing will assign the charge nurse to complete this task when needed. Immediate Jeopardy Removal Date: 2/19/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/22/25. A phone interview with the medical director on 2/18/2025 validated the facility had notified the physician of the deficient practice and the facility was implementing new practices that included an individual glucometer per resident and educating the nursing staff on how to disinfect the glucometer after use on a resident. Observation of the 43 residents' (40 plus 3 admissions since 2/18/2025) individually assigned glucometers who currently resided in the facility on 2/22/2025 validated each resident receiving blood glucose monitoring had an individually assigned glucometer in a glucometer pouch labeled with their name and room number. Interviews with licensed nursing staff on each hallway and on all shifts validated in-service training was conducted in regard to the use of individually assigned glucometers for resident blood glucose monitoring and the infection control practices for the disinfection of glucometers. All licensed nursing staff who were interviewed reported they had received the required in-service training on 2/18/2025 or prior to beginning their next assigned shift after 2/18/2025. The educational in-services stressed using individually assigned glucometers for each resident requiring blood glucose monitoring and storing each individual assigned glucometer in an individually labeled glucometer pouch with resident's name and room number. The in-service training also included a review of the manufacturer's instructions for the facility's glucometers and disinfectant wipes related to disinfection of the glucometer and completion of a returned demonstration of the proper procedure for effective glucometer disinfection. Nurse observation in conducting a blood glucose check and subsequent glucometer disinfection completed the task without difficulty. Individually assigned resident glucometers were observed stored on the medication carts in closed labeled pouches with resident's name and room number. Each medication cart was observed with a canister of EPA disinfectant wipes. There was an unused unlabeled new glucometer observed on each medication cart that licensed nursing staff validated through interviews the new unused glucometers were available for new admissions, replacement of a resident's individually assigned glucometer or in an emergency as needed. To prevent the likelihood of a new glucometer used as a shared glucometer, the facility removed the new, unused glucometers from each medication cart and relocated the storage of the new unused glucometer into the medication storage rooms on each unit. There were no further concerns identified during either the interviews or observations. The immediate jeopardy removal date of 2/19/2025 was validated. 2. The manufacturer's operator manual revised 10/2019 for Resident #32's assigned glucometer provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed after each use. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting procedure for Resident #32's individually assigned glucometer included in part: Step 5: using one EPA disinfectant towelette to wipe the entire surface of the glucometer horizontally and vertically to remove bloodborne pathogens and Step 6: Treated surface must remain wet for the recommended contact time. Do not wrap the meter in a towelette. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/18/2025 at 7:51 am, Medication Aide #1 (agency) was observed performing blood glucose monitoring using an individually assigned glucometer for Resident #32. After obtaining a blood glucose level, Medication Aide #1 was observed cleaning Resident #32's individually assigned glucometer with alcohol wipes. On 2/18/2025 at 7:57am in an interview with Medication Aide #1, she explained Resident #32's glucometer needed to be disinfected after use and she cleaned the glucometer with an alcohol pad because she did not have any disinfectant wipes on the 300-hall medication cart. On 2/18/2025 at 10:25 am in a follow up interview with Medication Aide #1, she stated she received training less than a month ago at the facility on using disinfectant wipes to clean glucometers after use. She stated there were disinfectant wipes on the 300-hall medication cart, and she did not know the disinfectant wipes were on the 300-hall medication cart because she had not checked the 300-hall medication cart. On 2/18/2025 at 5:10 pm in an interview with the Director of Nursing, she stated Resident #32's individually assigned glucometer needed to be disinfected after each use using a disinfectant wipe. 3. The facility's policy for COVID-19 dated 10/24/2024 stated in part: to implement Special Droplet-Contract Precautions until patient meets the Center of Disease Control and Prevention criteria for discontinuation of transmission -based precautions. The facility's policy Transmission Based Precautions-General Practice dated 12/1/2021 stated in part: to maintain transmission based precautions before entering the patient's room and fundamental protective measures: hand washing, use of mask, eye protection, gowns and gloves. Supplies are kept near the entrance and large trash can for general trash placed inside the room. When donning the protective attire: wash hands, put on gown, apply mask, put on goggles or face shield if required. Removing of protective attire in the patient's room in the trach can: gloves, goggles or face shield, gown and mask. On 2/17/2025 at 4:20 am, Nurse #5 was observed applying an isolation gown, gloves and N-95 mask before entering Resident #230' room. On 2/17/2025 at 4:22 am, there was a droplet precautions sign observed posted on Resident #230's door. A three-drawer container was observed outside Resident #230's door and contained gowns, face mask, N-95 mask, gloves and eye protection. Nurse #5 was observed inside Resident #230's room preparing to obtain Resident #230 vital signs not wearing eye protection. On 2/17/2025 at 4:27 am, Nurse #5 was observed exiting Resident #230's room into the hallway and removing the isolation gown, gloves and N-95 and discarding the personal protective equipment (PPE) into one of two large trash cans observed located in the hallway outside of Resident #230's room. On 2/17/2025 at 4:29 am in an interview with Nurse #5, she stated Resident #230 was on isolation for COVID-19 that required contact and droplet precautions. She stated she did not place the droplet precautions signage on Resident #230's door. She stated eye protection was available to wear and stated she did not need to wear eye protection to enter Resident #230's room because she was fully vaccinated against COVID-19. She explained she removed the PPE (gown, gloves and N-95 mask) after exiting Resident #230's room because of the large grey trash cans were located outside Resident #230's room and she didn't want to contaminate herself inside the room. Nurse #5 stated she was an agency nurse and had received infection control training from the agency. She stated she had worked at the facility for one week and had not received COVID-19 and PPE training from the facility. On 2/18/2025 at 5:28 pm in an interview with Unit Manager #1, she stated she had made an error and placed the wrong isolation signage for droplet precautions on Resident #230's door. She stated the droplet precautions signage did not include the use of a N-95 mask, gown or eye protection to enter Resident #230 room and the posted signage on Resident #230's door should have been special droplet and contact precautions. She stated the required PPE (gown, gloves, N-95 mask and face shield for eye protection) were placed outside Resident #230's door for the staff to use and the trash cans should have been inside Resident #230's room for Nurse #5 to remove the PPE inside Resident #230's room before exiting the room. On 2/18/2025 at 5:10 pm in an interview with the Director of Nursing (DON), she stated Resident #230 was admitted with COVID-19 and she did not know exactly which isolation signage was to be posted on Resident #230's door. She explained Unit Manager #1 was responsible for posting the isolation precaution signage on Resident #230 door. The DON stated Nurse #5 should have worn eye protection before entering Resident #230's room to provide resident care and should have removed the PPE before exiting Resident #230's room. The DON reported that when she started five weeks ago at the facility she was informed that infection control was her responsibility also, and she had not performed any tasks (training, reports) related to infection control. 49502 4. Review of the facility's Infection Prevention and Control Policies and Procedures revealed an Infection Prevention and Control Manual with an effective date of 2/6/20 with no evidence of annual review. During an interview with the Director of Nursing (DON) #1 on 2/17/25 at 5:06 pm, she stated she was responsible for the Infection Prevention and Control program. The DON #1 further stated she had been in the DON position for 5 weeks and had been unable to review the Infection Prevention and Control Policies. In an interview with Corporate Nurse Consultant #1 on 2/22/25 at 5:00 pm, she stated the facility was currently working on their Infection Prevention and Control program. The Corporate Nurse Consultant #1 did not have documentation of annual review and signed Infection Prevention and Control policies and procedures. 5. Review of the facility's Infection Prevention and Control policy and procedures for linen read, Clean towels will be kept covered and available for individual use. The clean linen cart on the 300 hall was observed on 2/17/25 at 3:28 pm with the front cover pulled up and resting on the top of the mesh covered plastic pipe line cart. During an interview with Unit Manager #1 on 2/17/25 at 3:30 pm, she stated all linen carts should be covered for infection control purposes. Unit Manager #1 placed the covering correctly on the linen cart. A continuous observation was made on 2/18/25 from 9:03 am until 9:10 am of the linen cart on the 400 hall. The front cover was pulled up and was resting on the top of the mesh covered plastic pipe linen cart. Clean gowns, towels, wash clothes, and blankets were observed on the cart. The maintenance staff was observed walking by pulling furniture at 9:05 am and Physical Therapy staff was observed walking by at 9:06 am. A NA was observed walking by with bagged trash in hand at 9:09 am. Another NA with a plate and cup in hand was observed walking by at 9:09 am. The linen cart front covered was closed by a NA at 9:10 am. During an interview on 2/28/25 at 9:35 am with NA #5, she stated the linen carts should be covered after retrieving the items needed for resident care for infection control prevention. The clean linen cart on the 300 hall was observed for a second time on 2/21/25 at 12:29 pm with the front covering on top of the linen cart. During an interview with Nursing Assistant (NA) #3 on 2/21/25 at 12:39 pm, she stated the linen carts are supposed to be covered when not in use due to infection control prevention. She immediately placed the covering on the linen cart correctly. During an interview with the Housekeeping Manager on 2/18/25 at 3:00 pm, she indicated the linen carts on the hall ways held clean gowns, towels, wash clothes, and blankets for the residents. She further indicated the linen carts should be covered when not in use by the staff. In an interview with the Administrator and Corporate Nurse Consultant #1 on 2/22/25 at 5:00 pm, the Administrator stated she expected the linen carts to be covered when the nursing staff were not using them. The Corporate Nurse Consultant #1 indicated they were working on the infection control program at the facility.

Based on record review, and staff, family member, and home health agency staff interviews, the facility failed to implement an effective discharge planning process and to ensure a resident had home health services arranged prior to discharge for 1 of 3 resident reviewed for discharge (Resident #181). The findings included: Resident #181 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and malnutrition. Resident #181's admission Minimum Data Set assessment dated [DATE] coded him as being cognitively intact, requiring limited assistance for most activities of daily living, required a feeding tube and having the expectation to be discharged to the community. Review of Resident #181's record revealed he was discharged home on 8/29/24. A discharge note dated 8/29/24 written by the physician assistant revealed Resident #181 had tolerated meals with 50% of intake and the g-tube was clamped off. The g-tube was placed during his hospitalization prior to his admission to the facility. Record review revealed there was no mention of discharge planning for Resident #181 from the time of admission [DATE]) through the date of his discharge home (8/29/24). Resident #181 was not care-planned for discharge. Review of Resident #181's Discharge summary dated [DATE] revealed home health services were arranged with a local home health agency for nurse aide services, physical and occupational therapy. The discharge summary provided the local home health agency name and contact number for reference. The discharge summary had no instructions for use of or care of the feeding tube. The discharge instructions stated he received a mechanically altered diabetic diet with nectar thickened liquids. An interview was conducted with Resident #181's family member on 2/17/25 at 12:25 PM who reported Resident #181 was not referred to home health prior to discharge from the facility. She reported she coordinated with Resident #181's insurance and primary care provider to get his home health arranged. The family member stated Resident #181's insurance coverage had ended which led to his discharge on [DATE]. Resident #181's family member stated care for him was difficult because he came home with a feeding tube, however they did the best they could to care for Resident #181 before home health was involved. She reported that when the home health agency came to assess him 9/12/24 he was transferred to the local hospital. He was kept overnight for observation. Resident #181 returned home after his hospitalization and the family was able to care for his feeding tube with the assistance of home health. A review of hospital records indicated on 9/12/2024 Resident #181 was dysphagic (difficulty in swallowing), his blood glucose was 327 (normal blood sugar levels are considered to be between 70 milligrams per deciliter [mg/dL] to 100mg/dL), and he had not been using the g-tube that was inserted on 8/13/2024 because the patient did not know how to use the g-tube and home health did not start until 9/12/2024. The hospital records stated Resident #181 reported he was never given instructions on how to use the g-tube at home. The hospital records indicated Resident #181 had lost 19.2 pounds since the hospital discharge on [DATE]. The hospital records stated Resident #181 reported the g-tube was for supplemental feedings and was not used while at the nursing home. Resident #181 reported only receiving oral intake at the nursing home and was not provided g-tube supplemental feeding. Resident #181 reported attempting oral liquids and becoming weaker since discharge from the nursing home. The hospital record listed Resident #181 on sliding scale insulin and insulin before meals and at night. Resident #181 was diagnosed with a urinary tract infection, acute kidney failure and hyperglycemia (a medical condition in which the body's blood glucose level is higher than normal) and admitted to the hospital. During hospitalization, he was seen by a Speech Language Pathologist who recommended continued use of the g-tube as primary means of nutrition, hydration, and medication administration. The Discharge summary dated [DATE] included the diagnoses of severe protein-calorie malnutrition, failure to thrive, chronic dysphagia, and diabetes mellitus. The outpatient follow up items included bolus tube feed regimen and insulin regimen. He was discharged with home health services. During an interview with a staff member from the same local home health agency listed on Resident #181's discharge summary on 2/22/25 at 3:25 PM the staff member stated Resident #181 was referred to their office by his primary care provider on 9/11/24. She reported there was no referral from the skilled nursing facility. On 2/22/25 at 3:36 PM an interview was conducted with the facility Social Worker who stated she was not employed at the facility at the time of Resident #181's discharge. She stated she had checked the social work office and could find no mention of his stay at the facility. The facility Social Worker stated the process that should have been followed was Resident #181's home health services should have been arranged prior to discharge. She stated she documented all discharge coordination in progress notes and on the discharge summary. Attempts to contact the former facility Social Worker were unsuccessful. Calls to the former Administrator were not returned. An interview was conducted with the Administrator who stated the Social Worker was responsible for ensuring services were in place for residents at the time of discharge. She reported neither she nor the current Social Worker were employed with the facility at the time of Resident #181's discharge.

Based on observations, staff interviews, and record review, the facility failed to designate a full-time qualified director of food and nutrition services or Dietary Manager (DM). The findings included: Review of the complete staffing list of employees provided by the facility on 2/17/25 revealed that there was a designated Dietary Manager (DM) at the facility. During observations throughout the survey from 2/17/25 through 2/22/25, the facility DM was noted to be scheduled to work at the facility full-time and was observed as the staff member responsible for day-to-day operations in the kitchen. During an interview on 2/18/25 at 12:04 PM, the Regional Dietary Manager said he came to the facility several times a week to support and oversee the facility Dietary Manager. During an interview on 2/22/25 at 12:56 PM, the facility DM said he was in school to become a certified DM but was not certified yet, but the Regional DM was certified and managed the department while he was in school and would come several times a week. During an interview on 2/22/25 at 6:34 PM, the Administrator confirmed that the DM did not have certification as a dietary manager and that he was in school and due to complete his studies in June. She said the Regional Dietary Manager managed the kitchen for the time being, coming to the facility several times a week.

Based on facility policy review, record review and staff interviews the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 127 of 127 residents in the facility. The findings included: Review of the facility's policy titled, Antibiotic Stewardship Program, effective date 10/24/22 revealed the following: The Antibiotic Stewardship Program is designed to promote the appropriate use of antibiotics, monitoring, and management of clinical antimicrobial outcomes, reduce antibiotic resistance, to the extent possible. During an interview with the Director of Nursing (DON) #1 on 2/17/25 at 5:06 pm, she stated she was responsible for the Infection Prevention and Control program. The DON #1 further stated she had been in the DON position for 5 weeks and there was not an Antibiotic Stewardship Program, and she had not had the time to start one. When asked had the facility been monitoring and tracking infections within the facility, she replied no. She indicated she had just learned there was a software program for Antibiotic Stewardship on the computer, but she had not used it. In an interview with Corporate Nurse Consultant #1 on 2/22/25 at 5:00 pm, she stated the facility was currently working on their infection control program which included the Antibiotic Stewardship Program. The department heads in their morning meetings had discussions about the residents and the antibiotics used in the facility. She indicated an infection control program was on their computer and worked as long nursing input the information concerning resident antibiotic use and infections within the facility. The Corporate Nurse Consultant #1 did not have documentation on the tracking or trending of infection within the facility.

Based on observations, interviews with Resident Council members and staff, and review of the Resident Council minutes, the facility failed to communicate the facility's efforts to address concerns voiced by the Resident Council members and to resolve repeat concerns in 3 of 3 months reviewed (November 2024, December 2024, and January 2025) and to maintain evidence that demonstrated the facility's response to grievances/recommendations made by the Resident Council from December 2023 through October of 2024. The findings included: On 2/18/25 at 8:49 AM, the Administrator revealed the facility had no record of Resident Council minutes from prior to November 2024. The Administrator indicated due to staff turnover they were unable to locate those minutes. Additionally, they had no documented evidence to demonstrate their responses and rationale for such responses for any grievances and recommendations made by the Resident Council prior to November 2024. Resident Council minutes dated 11/5/24 indicated residents voiced concerns call lights not being answered timely. The administration resolution section, where the facility's attempts to resolve the concerns from the previous meeting would be documented, was blank. There was no indication of who recorded the meeting minutes. A Service Concern Report dated 11/5/24 documented the concerns of the Resident Council related to call light response. The concern form noted nursing staff were educated on answering call bells in a timely manner. The Report noted on 11/6/24 that the status of the concern was complete. There was no entry in the Disposition by Administration section which would document the follow up on the department manager's response to the grievance and indicate if the resolution of the concerns was ongoing or if the concern was resolved. There was no indication of who completed the Service Concern Report. Resident Council minutes dated 12/19/24 revealed call lights not being answered was resolved from the last meeting, but an entry under nursing services noted the repeat concern with call bells being answered timely. Nursing services concerns also noted residents expressed concerns over trouble getting their medications. The minutes also noted dietary concerns of cold food. The administration resolution section was blank. There was no indication of who recorded the meeting minutes. A Service Concern Report dated 12/19/24 documented the concerns of the Resident Council related to call light response and cold food. The concern form noted nurse aides were educated on answering call bells in a timely manner and customer service and that the dietary department would improve their time management. The Resident Council's concerns regarding their medications was not addressed on the concern form. The Report noted on 12/21/24 that the status of the concern was complete. There was no entry in the Disposition by Administration section indicating if the resolution of the concerns was ongoing or if the concern was resolved. There was no indication of who completed the Service Concern Report. Resident Council Minutes dated 1/28/25 completed by the Activity Director noted the council expressed repeat concerns related medications being administered late and call bells not being answered in a timely manner. An interview was conducted on 2/18/25 at 10:30 AM with the facility's Resident Council. There were 11 residents present. During the meeting, residents expressed concern with the resolution of grievances discussed during the Resident Council meetings. The residents in the meeting reported not all grievances were acted on promptly by the facility and there was no explanation as to why the grievances were not resolved. The residents stated at each meeting they discussed the same concerns. Residents stated the Activity Director was present at the Resident Council meetings and communicated their concerns to the Administration but said they had never heard back from anyone about measures attempted by the facility to resolve their grievances and believed no one was listening to them. Residents stated they continued to have concerns about dietary and food palatability, nurse aide response times, and had requested multiple times for the Administrator and other department heads to come to the meetings themselves and none had come. The residents stated the former Administrator would not meet with residents to discuss any of their concerns and they had the same concerns repeatedly since before the summer of 2024. The residents said the new Administrator was more attentive to the residents but their concerns were still not being addressed. In an interview on 2/22/25 at 3:31 PM, the Activity Director said when the Resident Council had concerns, a copy of the minutes would be given to the Social Worker. The resolution to the concerns would be communicated back to the council by the Activity Director. She said the call light response time had been an issue for a while but she was unsure what was being done about the issue and she had not reported a resolution to the council because she had not heard of the measures being taken to resolve their concerns. . In an interview on 2/22/25 at 3:03 PM, the Social Worker and the Social Services Assistant said when the Resident Council had concerns, the Activity Director would let the Social Worker know and the Social Worker would write up a grievance concern form. The Social Worker would then let each department know of the concerns for them to follow up and resolve. An interview was conducted with the Administrator on 2/22/25 at 6:34 PM who stated since she started in the facility in December 2024, any concerns or grievances from the Resident Council would be reported by the Activity Director to the Social Worker, who would review the next morning in the morning meeting of department heads. Each department head would have 72 hours to resolve and give the resolution back to the Social Worker. The Social Worker or Activity Director would then share the information/resolution at the next Resident Council meeting verbally.

Based on observations and resident and staff interviews, the facility failed to maintain shower floor tiles in good condition on 1 of 3 shower rooms (100-hallway shower room). Findings included: During a tour of the 100-hallway shower room on 2/16/25 at 3:48 PM, broken floor tiles were observed in the 1st and 2nd shower stalls on the left side of the shower room. Resident #70 was present. He reported he could bathe himself once he was assisted to the shower room. He stated he pulled himself up with the grab bar in the shower which placed him with his feet directly on the broken shower tiles. Resident #70 stated he had expressed concerns to staff with no results. He stated he could not remember the last time he reported it or to whom. An observation was made of the 100-hall shower room [ROOM NUMBER]/16/25 at 4:47 PM. In shower stall #1 there was 11 inches by 14 inches of broken tile below the temperature control and the handrail. In shower stall #2 there was 2 inches by 2 inches of broken tile at the center of the shower under the handrail and shower head. An interview was conducted with the Regional Maintenance Consultant on 2/18/25 at 11:41 AM who stated the shower tiles needed to be replaced, and they were a potential hazard to residents when showering. He stated the facility was in the process of hiring a Maintenance Supervisor. During an interview with the Regional Housekeeping Consultant on 2/18/25 at 2:06 PM he stated he was unaware of the broken tiles in the 100-hall shower room and none of his staff had mentioned it. An interview was conducted with Nurse Aide (NA) #15 on 2/18/25 at 2:42 PM she stated she had not noticed the broken tile in the showers. She reported that there were residents that come into the shower room to take their own shower. NA #15 stated residents who were taking their own shower would likely use the front left side of the shower where the broken tile was located. She stated the facility has not had a maintenance staff member for a few weeks. During an interview with NA #16 on 2/18/25 at 5:23 PM stated she was aware of the broken tiles and had reported it to maintenance staff a few weeks ago. She stated she reported her concern to the maintenance supervisor prior to the last one. An interview was conducted with the Director of Nursing (DON) on 2/18/25 at 4:52 PM. She stated she was not aware of the broken tiles in the shower room and none of the staff had advised her. Attempts to contact the former Maintenance Director were not successful. The Administrator was interviewed on 2/22/23 at 6:26 PM. She stated she was not aware of the broken tiles in 100-hall shower room. The Administrator stated she expected staff to notify maintenance staff of any maintenance concerns.

Based on record reviews, observations, and staff, Pharmacist and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled medications. In [DATE], this affected six residents reviewed for misappropriation of property (Resident #232, Resident #109, Resident #87, Resident #81, Resident #16 and Resident #14) and on [DATE], Resident #14's discontinued controlled medications were removed from 300-hall medication cart and not returned to the pharmacy. The findings included: 1. a. Resident #232 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone HCL (an opioid) 5 milligrams(mg) every 4 hours as needed for pain. Pharmacy's control medication report recorded Resident #232 was dispensed two separate orders for 90 tablets of Oxycodone HCL 5mg tablet on [DATE]. The [DATE] Medication Administration Record indicated Resident #232's last dose of Oxycodone HCL 5mg was administered on [DATE] at 4:00 pm by Nurse #10. Resident #232 expired on [DATE] in the facility. The facility's controlled substance count sheet for medication cart 300-hall recorded 35 controlled substance sheets on [DATE] at 7:00am when Nurse #8 and Nurse #10 counted at the change of shift. Nurse #10 recorded removal of a total of four controlled substance sheets and listed two controlled substance sheets (didn't include the name of the controlled medications) removed for Resident #232 with Nurse #14 co-sign signature. The number of controlled substance sheets was recorded as 31 for the 300-hall medication cart on [DATE] at 7:00pm at shift change for Nurse #10 and Nurse #11. b. Resident #109 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone HCL 5 milligrams(mg) every 4 hours for pain as needed. Resident #109 was not listed on the pharmacy's control medication report as having received any controlled substances in [DATE]. The [DATE] Medication Administration Record indicated Resident #109 received doses of Oxycodone HCL 5mg on the following dates: -[DATE] at 1:20 pm -[DATE] at 1:00 pm -[DATE] at 9:07am -[DATE] at 12:34 pm -[DATE] at 9:32 am -[DATE] at 11:50 pm -[DATE] at 1:08 pm -[DATE] at 12:54 pm There was no documentation on Resident #109's controlled drug receipt record/disposition form for Oxycodone 5mg of the above medications removed for administration to Resident #109. Resident #109's control drug receipt record/disposition form for Oxycodone HCL 5mg indicated 60 tablets were accounted for by Nurse #8 and the form stated each dose signed for here requires charting on the medication record. There were 17 tablets recorded removed from the Oxycodone 5mg medication card from [DATE] through [DATE] and there were only 4 tablets recorded as administered to Resident #109 on Resident 109's [DATE] MAR from [DATE] through [DATE]. A photo of Resident #109's Oxycodone HCL 5mg medication card dated dispensed [DATE] displayed 50 tablets and bubble slots ,d+[DATE] empty on the medication card. On the back side to the Oxycodone HCl 5mg medication card, slots number 10 and 27 were observed as opened and recovered. c. Resident #87 was admitted to the facility on [DATE]. Resident #87's physician orders dated [DATE] included Oxycodone HCL milligrams (mg) tablet take one to two tablets every four hours for pain. Pharmacy's control medication report recorded Resident #87 was dispensed 30 tablets of Oxycodone HCL 5mg tablet on [DATE]. A photo of Resident #87's Oxycodone HCL 5mg medication card dated dispensed [DATE] displayed 30 tablets and bubble slots 30 empty and reported bubble slot number 5 empty/missing on the medication card. On the back side to the Oxycodone HCl 5mg medication card, slot number 30 was opened and number 5 was recovered. Resident #87's control drug receipt record/disposition form for Oxycodone HCL 5mg indicated 30 tablets were accounted for and the form stated each dose signed for here requires charting on the medication record. There was one tablet recorded removed from the Oxycodone 5mg medication card on [DATE]. Resident #87's [DATE] Medication Administration Record (MAR) recorded three doses of Oxycodone HCL 10mg were administered to Resident #87 on [DATE], [DATE] and [DATE]. There was no documentation on the [DATE] MAR that Resident #87 received a dose of Oxycodone HCL 5mg on [DATE]. d. Resident #81 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone HCL 5 milligram (mg) every six hours as needed for pain. A photo of Resident #81's Oxycodone HCL 5mg medication card dated dispensed [DATE] displayed 57 tablets and bubble slots ,d+[DATE] empty and reported bubble slot number 27 and 18 as empty/missing on the medication card. On the back side to the Oxycodone HCl 5mg medication card, slot number 18 and 37 were recovered. Resident #81's control drug receipt record/disposition form for Oxycodone HCL 5mg indicated 50 tablets were accounted for on [DATE] and the form stated each dose signed for here requires charting on the medication record. There were 40 tablets total recorded removed from the Oxycodone 5mg medication card with a zero balance on [DATE]. There were 10 Oxycodone 5mg tablets unaccounted for on Resident #81's control drug receipt record/disposition form. Resident #81's [DATE] Medication Administration Record (MAR) recorded 22 doses of Oxycodone HCL 5mg were administered to Resident #87 from [DATE] through [DATE]. There was 10 doses not recorded on the [DATE] MAR documented as removed from Resident #81's control drug receipt record/disposition form for Oxycodone HCL 5mg. There were three doses recorded as given on the [DATE] MAR that were not documented as a removal on Resident #81's control drug receipt record/disposition form for Oxycodone HCL 5mg. e. Resident # 16 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone 5 mg every six hours as needed for pain. A photo of Resident #16's Oxycodone HCL 5mg medication card dated dispensed [DATE] displayed 18 tablets and bubble slots ,d+[DATE] empty and reported bubble slot number 4 and 14 as empty/missing on the medication card. On the back side to the Oxycodone HCl 5mg medication card, slot number 4 and 14 were recovered. Resident #16's control drug receipt record/disposition form for Oxycodone HCL 5mg indicated 30 tablets were accounted for on [DATE] and the form stated each dose signed for here requires charting on the medication record. There were 12 tablets total recorded removed from the Oxycodone 5mg medication card with 18 as the balance on [DATE]. Resident #16's [DATE] Medication Administration Record (MAR) recorded a total of 2 doses of Oxycodone HCL 5mg were administered to Resident #87 on [DATE] (1 dose) and [DATE] (1 dose). There was 10 doses not recorded on the [DATE] MAR that were documented as removed from Resident #16's control drug receipt record/disposition form for Oxycodone HCL 5mg. f. Resident #14 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone HCL 5 milligram (mg) tablets one every six hours as needed for pain. A photo of Resident #14's Oxycodone HCL 5mg medication card dated dispensed [DATE] displayed 18 tablets and bubble slots ,d+[DATE] empty and reported bubble slot number 4 and 14 as empty/missing on the medication card. On the back side to the Oxycodone HCl 5mg medication card, slot number 4 and 14 were recovered. Resident #14's control drug receipt record/disposition form for Oxycodone HCL 5mg indicated 90 tablets were accounted for on [DATE] and the form stated each dose signed for here requires charting on the medication record. There were 58 tablets total recorded removed from the Oxycodone 5mg medication card with 32 as the balance on [DATE]. Resident #14's [DATE] Medication Administration Record (MAR) recorded a total of 2 doses of Oxycodone HCL 5mg were administered to Resident #14 on [DATE] (1 dose) and [DATE] (1 dose). There were 26 doses not recorded on the [DATE] MAR that were documented as removed from Resident #14's control drug receipt record/disposition form for Oxycodone HCL 5mg. Resident #14's [DATE] Medication Administration Record (MAR) recorded a total of 7 doses of Oxycodone HCL 5mg were administered to Resident #14 on [DATE] through [DATE]. There were 25 doses not recorded on the [DATE] MAR that were documented as removed from Resident #14's control drug receipt record/disposition form for Oxycodone HCL 5mg. The facility submitted an initial allegation report dated [DATE] signed by the former Administrator reporting a diversion of facility drugs to the state agency. The initial allegation report stated the facility became aware of the incident on [DATE] at 2:40 pm and reported the incident occurred between [DATE] and [DATE]. The initial allegation report stated during a shift change an in-coming licensed nurse identified that Oxycodone 5mg (an opioid/pain medication) medication cards for three different residents were tampered with. The Oxycodone tablets in the medications cards had been replaced with a different medication that resembled oxycodone to make the count deem correct. The total of 27 tablets of oxycodone 5mg were missing. All three residents have no signs of pain or discomfort. The facility reported that the local police department was notified of the incident on [DATE] at 2:40 pm. The facility's investigation summary completed on [DATE] by the former Administrator reported that on [DATE], the facility's Director of Nursing (DON) and the Unit Coordinator inspected the controlled medications cards in all the medication carts in the facility to identify any other medications cards that were tampered with. Two other residents' controlled medication cards were identified as having been tampered with, with three tablets of Oxycodone replaced with another tablet that resembled oxycodone 5 mg. The total of oxycodone 5mg tablets missing was identified as 30 tablets. On [DATE], the DON reviewed the controlled medications that were to be returned to the pharmacy for disposal and identified two oxycodone 5mg medication cards for Resident #232 were missing. When the DON contacted Nurse #8 who removed the missing cards from the medication cart to return to the DON, Nurse #8 told the DON she misplaced the medication and did not know where she put them. A review of the controlled substance count sheet indicated Nurse #8 signed the two medication cards out of the medication cart and was co-signed by the weekend supervisor Nurse #12. The DON interviewed Nurse #12, who stated she did not co-sign with Nurse #8. When the DON showed Nurse #12 the signature on the controlled substance count sheet and Nurse #12 disputed that she did not sign the form and indicated that the signature was created by another person. Narcotic count sheets indicated Nurse #8 worked on both medication carts with tampered medications cards and missing medication cards. The tampered medication cards were for oxycodone 5 mg, the same medication that Nurse #8 lost the two medication cards for Resident # 232 and forged a co-signature. The DON contacted Nurse #8 about the tampered medication and forged signature on [DATE] and [DATE]. Nurse #8 refused to be interviewed and chose not to respond when asked to report to the facility for a drug screening. Nurse #8 was an agency employee who periodically worked in the facility from [DATE] to [DATE]. Nurse #8 will no longer be allowed to work at the facility. The facility concluded based on circumstantial evidence (forged signature, missing oxycodone 5mg medication cards and tampered of the oxycodone medication cards) there was reasonable suspicion that Nurse #8 diverted Oxycodone 5mg tablets for 6 residents (Resident #232, Resident #109, Resident #87, Resident #81, Resident #16 and Resident #14). The facility reported Nurse #8 to the North Carolina Board of Nursing on [DATE]. Licensed nurses and medication aides were re-educated on the importance of inspecting the medication cards to ensure they were not tampered with. The facility's investigation report dated [DATE] signed by the former Administrator was submitted to the state agency. The investigation report recorded the Department of Social Services (DSS) was notified on [DATE] with no on-site visit from DSS and there were no charges filed against the accused individual. On [DATE], the facility's folder for [DATE] misappropriation of controlled medications was reviewed. There was documentation of sixteen nurses on [DATE] attending an educational in-service conducted by the former DON on inspection of controlled medication card and destruction of controlled medications in the dry drug buster requiring two nurse witness and signage. There was no documentation of resident assessments related to pain management with confirmed tampering of controlled medications. There was no documentation of the nursing staff education on the changes in adding and removing controlled medications from the medication carts and the DON returning controlled medications to the pharmacy. There was documentation of random weekly control medication audits conducted on one resident one controlled medication per week by the former DON on [DATE], [DATE], [DATE], [DATE]. There were no missing tablets on the controlled medication cards. There was missing entries on the controlled medication sheet on [DATE] (CF) and crossed out and/or changed entries on [DATE], [DATE] and [DATE] for 2 residents. The [DATE] audits were marked as reviewed in QAPI on [DATE]. Unit Manager #1 conducted random audits in [DATE] ([DATE], [DATE], [DATE], [DATE] and [DATE]) one resident per day audited with no missing entries on controlled medication sheet, crossed out or changed entries or missing tablets on medication card. The [DATE] audits were not signed as reviewed in QAPI. On [DATE] at 5:30 pm, when asked if there was a corrective action plan, the facility provided corrective action plan for the misappropriation of controlled medications. On [DATE] at 9:09 am in an interview with Nurse #13, she stated she could not recall the exact date in [DATE] when counting controlled medications at the change of shift with Nurse #8. She stated Nurse #8 brought it to her attention the tablets in a medication card of oxycodone didn't look right. When the medication card was removed, there were tablets that look similar but not exactly like the controlled medication and there was tape observed on the back of the medication card over some of the bubble slots of the medication card. She stated the acting Administrator was notified. She stated when all residents' controlled medication cards were checked for tampering, correct count and correct medication, there were more residents' medication cards observed with tampering and/or missing controlled medications. Nurse #13 was unable to recall the names of the residents who controlled medication cards were affected. She stated the facility change the process of counting and removing controlled medications from the medications cart after the incident in [DATE]. She explained the changes as: (1) when counting controlled medications inspect the back of the medication cards and tablets for suspicion of tampering, (2) adding and/or removing controlled medications to a medication cart required another nurse to count and sign with the nurse and (3) discontinued controlled medications were to remain on the medication cart and when the Director of Nursing removed the controlled medications to return to pharmacy, a nurse would count and sign with the DON. On [DATE] at 4:17 am in a phone interview with Nurse #8, she stated prior to [DATE] the night nurses returned discontinued controlled medications to the pharmacy by completing return to pharmacy form, place in pharmacy tote, secure with zip tie and return to pharmacy when medications were delivered at night. Nurse #8 stated she was not given Resident #232's controlled medications to return to the pharmacy in [DATE]. She stated since [DATE], the process to receive and return controlled medications had changed. She explained two nurses have to count and sign controlled medications when added to the medications cart and/or removed to return to pharmacy. She stated nurses on the medications carts let the DON know when there were discontinued medications on the medication carts and DON was responsible for returning medications to the pharmacy now. On [DATE] at 10:26 am in a phone interview with Nurse #8, she recalled in [DATE] while counting controlled mediations with another nurse (unable to recall name), the back of a controlled medications card was observed tampered with. She described the tampering as a tiny slit that had been made in the back of the bubble slot on the controlled medication card, there was a tablet in the bubble slot and a piece of tape was covering area where the slit was made. She stated the tablet inside looked similar to the controlled medication and questioned the medication because there was a number on the tablet. She stated the acting Administrator was at the facility and informed. She stated all controlled medications were counted for accuracy and assessed for tampering and drug test were performed on nursing staff. She explained after [DATE], two nurses counted and signed when adding controlled medications to the medications cart and the DON was the only person that could remove controlled medications from the medication cart to return controlled medications to the pharmacy. On [DATE] at 5:44 pm in an interview with Nurse #14, she explained she was the weekend supervisor and had worked at the facility since February 2018. She stated controlled medications were stored in a double locked drawer on the medications carts and two nurses were to count and sign the controlled medications records when adding controlled medications to the medication cart. She stated controlled medications were counted by two nursing staff at the change of the shift and when controlled medications counts were not correct the supervisor was notified to determine the reason the count was incorrect and notified the DON if unable to determine why the controlled medication was inaccurate. She stated she did not recall in [DATE] reports of inaccurate controlled medication counts. She explained she rarely worked during the week and in [DATE] when there was a concern with controlled medications on the medication carts. She recalled receiving a call from the former DON asking where the controlled medications for Resident #232 were located. She stated she remembered Resident #232 dying on a weekend (unsure of the date) and Nurse #10 having Resident #232's three controlled medications cards that consisted of two controlled medications cards for oxycodone and one controlled medication card for Lorazepam asking her what she needed to do with Resident #232's controlled medications cards. She stated she verified the count on the controlled medications sheets and the controlled medication cards with Nurse #10, and the controlled medication sheet was marked with an x symbol. She stated she informed Nurse #10 to give the controlled medications to the night nurse to return the medications to the pharmacy. She explained discontinued controlled medications remained on the medication cart and were counted at the change of each shift until returned to the pharmacy. She said on [DATE] the former DON called inquiring where Resident #232's controlled medications were located because Nurse #10 had signed the controlled substance count sheet recording Resident #232 controlled medications had been given to her (Nurse #14). She stated she told the former DON Nurse #10 had been informed to give the discontinued controlled medications to the night nurse to return to the pharmacy and she (Nurse #14) had not signed a controlled substance sheet or received Resident #232's controlled medications. She stated she reviewed the signed controlled substance count sheet and that was not her signature on [DATE] when Resident #232's controlled medications were documented removed from the 300-hall medication cart. Attempts to interview Nurse #10 were unsuccessful. On [DATE] at 4:12 pm in a phone interview with Unit Manager #1, she stated she was unable to recall the date and recalled reporting to work that morning and at nursing station #2 controlled medications were observed tampered with when counting the controlled medications and the former DON was notified. She stated the acting Administrator was present and the nurses who had worked at nursing station #2 were drug tested . She stated the facility did not drug test everyone. She stated she and the acting Administrator checked all the controlled medications on the medications carts for accurate count and tampering of controlled medications. She reported the controlled medication, Oxycodone, for Resident #232 was not located. She explained that the nursing staff were not sending residents' controlled medications back to the pharmacy and controlled medications were remaining on the medication carts long after discontinuation of the controlled medications. She stated on [DATE] when she and the former DON conducted a facility wide audit on the controlled medications, tampering was observed with Resident #87' controlled medications and the controlled medications were replaced by the pharmacy. She stated the residents affected with tampering of the controlled medications were assessed by the former DON and nurses. She stated the nursing staff was educated on the changes in the controlled medication sheet, documenting all controlled medications administered and non-controlled scheduled medications in the electronic MAR and documenting controlled medications removed on the controlled medication sheet. She stated the nursing staff were further educated on the changes that two nurses were required to count and sign when controlled medications were added and/or removed from the medication carts and the DON would be responsible for returning controlled medications to the pharmacy. On [DATE] at 5:25 pm in a phone interview with Pharmacist #1 and Pharmacist Consultant #1, they stated the Pharmacy Director of Clinical Services worked with the facility in [DATE] related to misappropriation of controlled medications and the person in that position no longer worked at the pharmacy. Pharmacist #1 stated there was no record in the pharmacy that Resident #232 controlled medication, Oxycodone, was returned to the pharmacy. On [DATE] at 9:29 am in a phone interview with the Pharmacist Consultant #1, she stated due to the turnover in the Director of Nursing position, the pharmacy consultants had been providing education to the DON on the process of returning controlled medications using the return to pharmacy triple form to list the controlled medications and using the red pharmacy totes to return controlled medications to the pharmacy. She stated on [DATE] a medication inspection was performed at the facility and there were no controlled medications observed to return to the pharmacy. On [DATE] at 1:56 pm in a phone interview with the former Director of Nursing, she remembered receiving a call about tampered controlled medication cards discovered by Nurse #13. Unit Manager #1, who was at the facility, conducted an audit on all controlled medications on the medication carts and removed all the tampered controlled medications cards off the medications carts and were replaced by the pharmacy. She stated the controlled medications for Resident #232 were not located. She stated nurses were drug tested with negative results reported and one nurse did not return for a drug test or work and was reported to the N.C. Board of Nursing. She stated residents' assessments for pain management was completed and the nursing staff received education on accuracy accounting for controlled medications when receiving and removing controlled medications for the medication carts. She stated it was changed to the DON would be responsible in returning controlled medications to the pharmacy and stated controlled medications were to be returned within ,d+[DATE] hours and not remain in the facility. She stated the nursing staff receiving educational training on two nurses counting and signing for controlled medications when adding and removing controlled medications to the medication carts and counting the number of controlled medications cards and the actual number of tablets in each controlled medication card sheet at the change of the shift. She stated another audit of all controlled medications on the medication carts were conducted a week later and further tampering of resident controlled medications. She stated there were ongoing audits conducted on controlled medications on the medication carts conducted and the information was discussed in Quality Assurance and Performance Improvement (QAPI) meetings. On [DATE] at 1:33 pm in a phone interview with the former Administrator, she stated when a concern with misappropriation of controlled medications was identified by Nurse #13, all controlled medications on the medication carts were audited and further discovering of tampering of controlled medications were identified. Residents' controlled medications were replaced and nursing staff were educations of the changing in adding and removing controlled medications to the medication cart. Residents were interviewed with no negative findings related to pain. She explained there was a plan of correction and should be in the QAPI minutes for [DATE]. She stated the Assistant Administrator in [DATE] would have more information on the plan of correction. On [DATE] at 2:32 pm in a phone interview with the former Assistant Administrator, she stated she was left the facility in [DATE] after the incident with misappropriation of controlled medications. She stated the Administrator and Regional Clinical Consultant addressed the concern. She stated she was not sure there was a plan of correction. On [DATE] at 10:50 pm in a phone interview with Regional Clinical Consultant, he explained due to the facility's history with diversion of controlled medications there had been a plan of correction in place and the facility continued with the plan of correction in [DATE] when controlled medications cards were found at the change of shift tampered with. He explained that the facility was only counting the number of controlled medication cards and were not actually counting the number of pilling in the controlled medication cards. New practices included counting the number of controlled medication cards and the actual count for each controlled medication card on the medication cart at the change of each shift, inspecting the back of the controlled medications cards and controlled medication sheet for each medication cart required two nurses to count and sign when controlled medications were added and removed from the medication cart. He stated the DON only was to remove controlled medications from the medication carts to return controlled medications to the pharmacy Monday through Friday. He stated controlled medications that remained on the medication carts were counted at the change of the shift on the weekends to be returned to the pharmacy by the DON on Monday. He stated when tampering with controlled medications were identified on [DATE], all medications carts where audited, nurse staff were educated on counting controlled medications and the process for removing controlled medications from the medication cart. He stated Nurse #10 was reported to the North [NAME] Board of Nursing due to suspicion of misappropriation of controlled medications and audits were conducted on the new process for controlled medications and reviewed in Quality Assurance and Performance Improvement (QAPI) meetings. On [DATE] at 1:10 pm, when asked for a second time, the facility was unable to provide a corrective action plan for misappropriation of property related to controlled medications. 2. Resident #14 was admitted to the facility on [DATE]. Resident #14 died on [DATE]. Physician orders dated [DATE] at 5:48 pm included oxycodone HCL (an opioid) 10 milligrams(mg) tablets; take two tablets every six hours as needed for pain. There was a previous order dated [DATE] for oxycodone HCL 10mg one tablet every six hours for pain as needed that was discontinued on [DATE]. Physician orders also included the controlled medications: Morphine sulfate concentrate solution (an opioid) 100mg per 5 milliliters with instructions to give 0.25 milliliters every three hours as needed for moderate to severe pain or shortness of breath on [DATE] and Lorazepam (antianxiety medication) 0.5mg every six hours as needed for anxiety. A review of the February 2025 Medication Administration Record indicated Resident #14 received Oxycodone 10mg two tablets on [DATE] and [DATE]. Oxycodone 10mg was administered on for a total of eleven doses from [DATE] to [DATE]. On [DATE] at 7:17 am, an interview and observation was conducted. Medication aide #4 and Nurse #15 were observed counting the controlled medications at the change of shift narcotic count for the 300-hall medication cart. The following controlled medications were on the 300-hall medication for Resident #14: one Oxycodone 10mg controlled medication card with 35 tablets verified with the controlled medication sheet, oxycodone 5mg controlled medication card with 20 tablets verified with the controlled medication sheet, Lorazepam 0.5mg controlled medication card with 3 tablets verified with the controlled medication sheet and a bottle of Morphine Sulfate solution with 13.5 milliliters verified with the controlled medication sheet. Medication Aide #4 stated controlled medications were returned to the pharmacy at night and the pharmacy did not deliver medications on Sunday ([DATE]). She stated the unit managers removed the controlled medications off the medication carts and completed the return to pharmacy form to return controlled medications to the pharmacy. A review of the controlled substance count sheet for 300-hall medication cart on [DATE] recorded three controlled medication cards for Resident #14 were removed on [DATE]: Oxycodone 5mg, Oxycodone 10mg and Lorazepam 0.5mg and the initials of the Director of Nursing (DON) as the person that removed the controlled medications. On [DATE] at 4:30 pm an interview was conducted with the DON, who resigned on [DATE]. During the interview the DON informed the surveyor there were controlled medications in a filing cabinet behind the locked door of the DON's office. No further information was obtained in the interview. On [DATE] at 4:10 pm in a phone interview with Interim Director of Nursing, she stated she had not received Resident #14's oxycodone medication card from the 300-hall medication cart from any nursing staff. She stated she understood unit managers were removing controlled medications off the medication carts and giving them to the DON, who was responsible for ensuring controlled medications were returned to the pharmacy. The Interim DON stated Resident #14's controlled medications should have been removed from the 300-hall medication cart and returned to the pharmacy immediately after Resident #14's death. On [DATE] at 4:14 pm and interview and observation was conducted with Nurse #4. Nurse #4, who was assigned the 300-hall medication cart, stated Resident #14's Oxycodone and Lorazepam controlled medication cards were not on the medications cart and the DON would have removed the [TRUNCATED]

Based on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Pre-Admission Screening and Resident Review (PASARR) (Resident #17, Resident 67, and Resident #4), use of opioid pain medication (Resident #14), schizophrenia (Resident #41) and anticoagulants (Resident #10) for 6 of 54 residents whose MDS assessments were reviewed. Findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included depression and dementia. Resident #17's care plan included a focus for dementia and PASARR. Interventions included administering medications as ordered. Resident #17's medical record revealed a level II PASARR determination date of 8/17/23. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was not currently considered by the state level II PASARR process to have a serious mental illness. On 2/21/25 at 2:08 PM in an interview with MDS Coordinator #1, he stated the 7/6/24 MDS for Resident #17 should have been coded as having a Level II PASARR determination. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and depression. Resident #67's care plan included a focus for the use of psychotropic medications and behaviors. Interventions included administering medications as ordered. Resident #67's medical record revealed a level II PASARR determination date of 2/7/23. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was not currently considered by the state level II PASARR process to have a serious mental illness. On 2/21/25 at 2:08 PM in an interview with MDS Coordinator #1, he stated the 4/5/24 MDS for Resident #67 should have been coded as having a Level II PASARR determination. 3. Resident #4 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Resident #4's care plan included a focus for behaviors such as refusal of care. Resident #4's medical record revealed a level II PASARR determination date of 4/23/19. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was not currently considered by the state level II PASARR process to have a serious mental illness. On 2/21/25 at 2:08 PM in an interview with MDS Coordinator #1, he stated the 12/10/24 MDS for Resident #4 should have been coded as having a Level II PASARR determination. 41387 4. Resident #14 was admitted to the facility on [DATE] with diagnoses including osteoarthritis to both knees and partial intestinal obstruction. Resident #14's care plan included a focus for pain related to arthritis and bowel (intestinal) blockage. Interventions included administering medications as ordered. Physician orders dated 11/7/2024 for Resident #14 included Oxycodone (an opioid analgesic used to treat moderate to severe pain) 5 milligrams one tablet as needed for pain. Resident #14's December 2024 Medication Administration Record MAR recorded Resident #14 received Oxycodone daily on the following dates: 12/1/2024 to 12/8/2024, 12/10/2024 to 12/14/2024, 12/16/2024 to 2/18/2024 and 12/20/2024 to 12/31/2024. Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was cognitively intact and was not coded for Resident #14 receiving opioid pain medication. On 2/22/2025 at 8:30 p.m. in an interview with the MDS Coordinator #2, she stated Resident #14's December 2024 MAR recorded Resident #14 receiving opioid pain medication in the 7-day look back period for the MDS dated [DATE], and Resident #14's MDS should have been coded for receiving opioid pain medication. On 2/22/2025 at 8:42 p.m. in an interview with the Administrator, she stated Resident #14's MDS assessment should reflect Resident #14's information correctly. 5. Resident #41 was admitted to the facility on [DATE] with diagnoses including major depressive disorder. Physician's orders dated 12/11/2024 included Risperidone (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) 2 milligrams (mg) one tablet a day for anxiety, and Sertraline (a medication used for depression, panic disorders and social anxiety disorders) 50 mg one time a day for depression. The psychiatric physician note dated 1/23/2025 recorded Resident #41 was receiving Risperidone 2 mg at night for management of schizophrenia. The psychiatric physician note also reported there was no increase in symptoms of anxiety or depression and staff reported no behavioral concerns suggesting the current medication was effective in managing Resident #41's schizophrenia. Resident #41's February Medication Administration Record recorded Resident #41 received Risperidone 2mg daily from 2/1/2025 to 2/22/2025. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 was moderately cognitively impaired and had displayed no behaviors in the 7-day look back period. Resident #41's MDS was coded for receiving antipsychotic medication on a daily basis and was not coded for schizophrenia. On 2/22/2025 at 8:27 p.m. in an interview with MDS Coordinator #2, she stated Resident #41's MDS dated [DATE] was not coded for schizophrenia due to not finding supportive evidence to validate the diagnosis of schizophrenia. She stated the psychiatric physician note was not enough evidence to support coding Resident #4's MDS for schizophrenia. On 2/22/2025 at 8:41 p.m. in an interview with Corporate Nurse Consultant #1, she stated coding Resident #41 as Schizophrenia triggers an audit and Resident #41's medical record may need to include more than the psychiatric physician note to code the MDS for schizophrenia. 50234 6. Resident #10 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), peripheral artery disease, and coronary artery disease. Resident #10's physician orders noted orders dated 1/14/25 for Plavix (an antiplatelet) 75 milligrams (mg) one tablet daily and Aspirin Chewable (an antiplatelet) 81mg one tablet daily. There were no orders for an anticoagulant. Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] indicated he was severely cognitively impaired. The MDS indicated he was taking anticoagulants (prevent or reduce blood clotting) and antiplatelets (prevents platelets from clumping together and forming blood clots). In an interview with the MDS Coordinator on 2/22/25 at 4:13 PM, she said the MDS was miscoded and Resident #10 was not on any anticoagulants. In an interview with the Administrator on 2/22/25 at 6:34 PM, she said the MDS assessments were expected to be accurate.

Based on observations, staff and physician interviews and record review, the facility failed to provide care safely to (Resident (R) 5 and R8) resulting in the residents sustaining injury. On 10/7/24 during the provision of incontinence care to R5 by Certified Nurse Aide (CNA) 1, the CNA utilized the draw sheet to pull the resident toward her resulting in the resident rolling in the opposite direction and onto the floor. R5 sustained a right hip fracture requiring surgical repair. On 9/19/24, R8, a resident who was dependent on staff assistance and was at high risk for injury related to a history of osteoporosis, was identified with bruising to her left leg and her feet. An x-ray revealed a probable fracture of the fifth toe on her left foot. Additionally, the facility failed to investigate and analyze R8's unwitnessed fall that occurred on 9/24/24 to determine causative factors. This deficient practice affected 2 of 2 residents reviewed for accidents. Findings included: 1.Review of R5's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, muscle weakness, and communication deficit. R5 was discharged from the facility on 10/08/24. Review of R5's Quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/16/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R5 was cognitively intact. The MDS indicated R5 had an impairment on both sides of their lower extremities. Review of R5's Care Plan, dated 08/08/24, located in the Care Plan tab of the EMR, indicated, The resident is at risk for falls. Intervention in place included, Non-skid socks while out of bed (initiated 08/08/24); Place bed in lowest position while residents in bed (Initiated 08/08/24); Place common items within reach of the resident (Initiated 08/08/24); Remind resident to use call light to ask for assistance with ADLs [Activities of Daily Living] (Initiated 08/08/24); and Send to ER [emergency room ] for evaluation and treatment (Initiated on 10/09/24). The resident also had a Care Plan which indicated, The resident requires assistance with ADLs, initiated on 08/08/24 which indicated, Refer to skilled therapy as needed. Review of R5's undated CNA Kardex (a care guide for CNAs), located in the Tasks of the EMR, indicated, Bed mobility-one person assist. R5's toileting ability did not indicate how many staff were needed for assistance. Review of the facility's document titled, Corrective Action, dated 10/07/24, accompanied a statement by CNA1 which indicated, On the night of the patient accident. I walked in the room to give patient care. Patient was on her back sleeping on her right side. Head of bed in the up position. I let the head of patient down for the change [sic]. Walk to the dresser for a new brief. With pull sheet, pulled patient to me before the care was completed, and the patient rolled off the bed. No guard rail for patient support from rolling off bed to floor. I, as the caregiver, couldn't and had no time to stop the fall of patient. The nurse came with another CNA. Interview with the CNA1 on 10/29/24 at 5:09 PM, CNA1 stated on 10/07/24 I walked in the room and grabbed the 'diaper' and began care. I was standing at the resident's bedside between the two beds. I used the draw sheet to pull the resident towards me. As I pulled the draw sheet the resident rolled in the opposite direction. I then yelled for help and a nurse, and another aide came to assist with the resident. When asked if the resident required a mechanical lift, CNA1 stated she had never seen the resident outside of bed. She stated she reviewed the Kardex and spoke to nursing and the resident who ensured the resident one person assist. Review of R5's Progress Notes found in the Progress Notes tab of the EMR documented by Licensed Practical Nurse (LPN)1 effective date, 10/08/24 at 7:45 AM indicated on 10/07/24, Resident was observed on her right side on the floor between her bed and the wall with her back towards the wall. Her right arm pinned beneath her, facing the bed with her head towards the head of the bed and her feet towards the foot of the bed at 8:53PM. Resident was moaning and complaining of a lot of pain to her right hip. Resident reported that she had struck her head on the wall and wanted staff to call her daughter as well as send her to the hospital Call placed to 911 [10/07/24] at 8:57PM. EMS arrived at facility at 9:06PM. Review of the Witnessed Fall documentation provided by the facility dated 10/08/24, indicated on 10/07/24, Resident observed on her right side of the floor between her bed and the wall with her back towards the wall, her right arm is pinned beneath her, facing the bed with her head towards the head of the bed and her feet towards the foot of the bed. Patient stated that while being changed, she was being rolled over for incontinence care and rolled off the bed. Review of the [Hospital] Emergency Department [ED] Provider Note provided by the State Agency (SA), dated 10/08/24, listed date of service as 10/07/24. The note indicated, Patient was laying in the bed, she is not ambulatory, was being changed by nursing facility and rolled off the bed, hit the right side of her head as well as her right hip only complaint of pain of the right hip. On exam, her right leg is shortened and externally rotated . Will obtain X-Ray of hip . Further review revealed, ED Course . right hip fracture .surgery tomorrow. Interview with LPN1 on 10/29/24 at 1:56 PM revealed CNA1 was working with the resident alone when the resident rolled out of bed. LPN1 stated the resident called for staff to come to assist. LPN1 stated R5 had always been one person assist with care and had no concerns with CNA1 assisting the resident alone. During an interview with the MDS Coordinator on 10/29/24 at 5:18 PM, he stated, I go and assess the resident myself. If there is a change on the resident status I then write up a care plan. I would notify the DON and change it on the Kardex so CNAs can do their charting. Interview with the Medical Director on 10/29/24 at 7:29PM, the Medical Director stated he was aware that R5 sustained a fall but stated he did not know all the details of the fall. He stated R5 was sent out to the hospital and from his knowledge sustained a fracture. Interview on 10/29/24 at 7:48 PM, the DON stated that instead of pulling the resident back, CNA1 proceeded to roll the resident to clean her. R5 rolled in the opposite direction. The DON stated she was not aware if R5 was a two person assist. The DON stated R5 probably should have been a two-person assist but agreed the Kardex indicated one person assist. 2. Review of R8's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, muscle wasting and atrophy, osteoarthritis, and other lack of coordination. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/30/24, located in the EMR under the MDS tab, revealed a brief interview for mental status (BIMS) score of two out of 15 which indicated R8 was severely cognitively impaired. The MDS assessed R8 with an impairment on one side of the lower extremity and was dependent on staff for transfers from bed to chair. Review of R8's comprehensive Care Plan, dated 09/11/24, located in the EMR under the Care Plan tab, revealed a focus area of R8 required assistance with activities of daily living (ADLs) with an intervention for one-person assistance with transfers. 2a) Review of R8's Nursing Progress Notes, dated 09/19/24, located in the EMR under the Prog Note tab, revealed, Change of Condition: Resident had bruising on L/T [left] leg black, blue, yellow in color and bruising on the feet. Golf ball sized knot in the left calf, MD [physician] made aware and gave orders for doppler and x-ray. Review of R8's Complaint Intake and Health Personnel Investigations Report, dated 09/19/24, provided by the facility, revealed the former Administrator reported, R8 had bruising of unknown origin on left leg. This bruising was found to have occurred from the transfer from the bed to the shower chair in the resident's room. R8 had a history of osteoporosis. The bruising was a result of the toe being broken during the transfer. CNA6 was the only witness. Staff were educated on properly transferring residents . Staff was transferring R8 properly, but due to osteoarthritis diagnosis, R8 was at risk for fractures. R8 would be transferred with extra care and therapy would evaluate if R8 needed a different modality of transferring. An interview was attempted with CNA6 on 11/01/24 but unsuccessful. CNA6 did not return the phone calls. An interview was attempted with the former Administrator on 11/01/24 but was unsuccessful because he was out of the country. Review of R8's Radiology Report, dated 09/20/24, located in the EMR under the Results tab revealed, . LEFT FOOT . Impression: 1. There is a probable non-displaced fracture of the distal fifth metatarsal (bones located between the toes and the ankle) of indeterminate age . Review of R8's Physicians Orders, dated 09/21/24, located in the EMR under the Orders tab revealed an order to Tape 5th and 4th metatarsal together for stability for one month. Change tape every seven days/PRN [as needed if] soiled. Monitor every shift. During an interview on 10/30/24 at 11:56 AM, Physical Therapy Assistant (PTA) stated R8's physical therapy notes indicated no transfer assessment prior to 09/24/24 could be found. The PTA stated R8 slept in a hook lying position in bed, and that she could not locate any transfer recommendations prior to 09/24/24. During an interview on 10/30/24 at 12:15 PM, Family Member (F)1 stated that R8 could not bear weight on her feet, laid in a fetal position for the last six months, and her knees were contracted. During an interview on 10/30/24 at 1:08 PM, the Medical Director confirmed R8 could not stand, bear weight on her feet, was bed bound, lay in bed in a fetal position, and had knee contractures. The Medical Director stated it would not be safe for one staff person to transfer R8 from the bed to the chair and it caused a fracture to her toe and bruises on her legs. During an interview on 10/30/24 at 2:52 PM, CNA5 stated she was assigned to R8 when she worked at the facility for the last three or four months of R8's stay at the facility. R8's Kardex stated she required physical assistance of one-person for transfers dated 09/11/24, but she [CNA5] asked for assistance from another person when she transferred her due to her contracted knees and not being able to bear weight on her feet. During an interview on 10/30/24 at 4:45 PM, CNA7 revealed she was assigned to R8 in August and September 2024 and that R8 could not straighten her legs fully and could not bear weight on her feet. CNA7 stated R8 required two staff to transfer her safely. CNA7 also stated she [CNA7] placed her arm under R8's arm on one side and the other staff member did the same on the other side and then lifted R8 off the bed and placed her in the chair. b) Review of R8's SBAR (Situation Background Assessment) Recommendation, dated 09/24/24, located in the EMR under the Prog Note tab, revealed Situation: The Change In Condition/s reported on this Evaluation are/were: Falls Other change in condition . Functional Status Evaluation: Fall . Pain Status Evaluation: Does the resident/patient have pain? Yes . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER [emergency room ] for eval [evaluation] B. New Testing Orders: - Other - Send to ER for eval C. New Intervention Orders: - Other - Fall mats and wedges to prevent fall/further injury. Review of R8's Skin Assessment, dated 09/24/24, located in the EMR under the Prog Notes tab revealed R8 had bruising to the right temple. Review of R8's Physical Therapy Progress Notes, dated 09/24/24, provided by the facility, revealed this assessment was conducted in response to R8 falling out of the bed on 09/24/24. The progress note stated the Physical Therapist (PT) educated the CNA on use of a lift for patient transfers. During an interview on 10/30/24 at 11:06 AM, the Director of Nursing (DON) indicated she expected the nurse to complete an incident report, interview the nurse aide that reported the fall to the nurse and get a statement, and complete a progress note in the EMR when fall occurred in the facility. The DON verified a post fall investigation, incident report and interviews with staff were not completed for R8's 09/24/24 fall. During an interview on 10/30/24 at 11:41 AM, LPN1 stated an aide found R8 on the right side of the bed when she was making rounds on the residents on 09/24/24 in the AM. LPN1 also stated she assessed the resident and stayed with her because she struck her head on the floor and was bleeding from her right temple. LPN1 indicated when a fall occurred a post fall investigation was completed which would determine the root cause of the fall. LPN1 confirmed she did not complete the post fall investigation because she thought the nurse supervisor was going to do it. The facility provided corrective action plans dated 10/09/24 which included the following: Immediate Action Implemented: R5 is currently in the hospital no other action taken for R5. On 10/09/24, the DON completed CNA1's competence evaluation on providing incontinent care residents in bed. The emphasis was on ensuring the resident is centered in bed when care is provided. ADL care plan interventions, located on the Kardex, are followed including the number of staff required for bed mobility, and the importance of pulling the resident towards an employee when one person assistance is provided per care plan. Identification of Other Residents who Might Be Affected: DON, Director of Nursing, Unit Coordinator, and/or designated nurse #1 completed bed mobility assessment of all current residents in the facility on 10/09/24 to identify the appropriate number of staff required for bed mobility. Findings of this audit are documented on the bed mobility assessment tool located in the facility Quality Assurance and Performance Improvement (QAPI) binder. 100% audit of current resident care plans completed by MDSC on 10/10/24, to assure each resident has an ADL care plan that indicates the amount of assistance required during ADL care and ensure the Kardex is updated with such information. Findings of this audit are documented on a care plan and ADL audit tool located in the facility QAPI binder. 100% audit of resident records for the last 30 days for all residents in the facility completed by the Regional Director of Clinical services on 10/10/24 and 10/11/24 to identify any other resident with an accident with staff presence. No other resident identified with a fall during care. During the audit of residents' records, one resident identified with a fall from bed. R8 rolled out of bed to the floor on 09/23/24. No incident report noted in the system for R8. Systemic Changes and Modification: Effective 10/10/24, all new residents will have a bed mobility assessment completed on admission, quarterly, and with any changes in their bed mobility status, by the licensed nurse on duty. This will be reviewed in the daily clinical meeting and documented on the facility medical records under ADL care plan. Moving forward, residents' ADL assistance needs will be added on the Kardex located electronically in the Kiosks. Effective 10/10/24 any resident with an incident/accident will have an incident report completed in EMR with a detailed incident investigation. The investigation will indicate the root cause of the incident, and the care plan will be updated timely. This will be reviewed in the daily clinical meeting and documented on the facility medical records under ADL care plan. Effective 10/10/2024, all residents will be centered in bed before being turned from one side to side during care. This will be accomplished by ensuring staff members who provide care to a dependent resident are centered in bed before turning from one side to the other during care. Staff members will also use appropriate number of staff based on resident's care plan effective 10/10/24. Effective 10/10/24, the Regional Director of Clinical services in collaboration with the facility clinical team to include the DON, ADON and Unit Coordinator #1 revised the process of reviewing all new admits/readmits in a daily clinical meeting and included the provision for bed mobility assessment to ensure it is completed and documented in electronic medical records. Any discrepancies identified will be corrected promptly. Any negative Findings of this systemic change is documented on the daily clinical meeting homework sheet located on the daily clinical meeting binder. 100% education of all current Licensed nursing staff to include full time, part time, and as needed nursing employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, 2). The emphasis of this education includes but is not limited to, the importance of completing incident report after each incident, completing incident investigation, bed mobility assessment on admission, quarterly and with changes of bed mobility status. This education will be completed by 10/14/2024. Any Licensed nursing staff members (Registered nurses, and/or Licensed practical nurses, not educated by 10/14/2024, will not be allowed to work until educated. This education will be provided annually and will be added to the new hire orientation for all new nursing employees effective 10/10/2024. This education will be provided by the Director of nursing and/or Staff development Coordinator effective 10/10/2024 100% education of all current nursing staff to include full-time, part-time, and as needed employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators. The emphasis of this education includes but is not limited to the importance of ensuring residents' care provided in bed is rendered in a safe manner, ensure residents are centered in bed during bed mobility, and appropriate number of staff is used during care per resident's individual plan of care. This education also emphasized the importance of turning a resident towards the care giver if one person is providing care in bed per resident's plan of care. This education will be completed by 10/14/2024. Any nursing staff members (Registered nurses, Licensed practical nurses, Medication aides, and/or Certified nurse aides not educated by 10/14/2024, will not be allowed to work until educated. This education will be provided annually and will be added to the new hire orientation for all new nursing employees effective 10/10/2024. This education will be provided by the Director of nursing and/or Staff development Coordinator effective 10/10/2024 This education will be completed by 10/14/2024. Any nursing staff members (Registered nurses, LPNs, Medication aides, and/or CNAs not educated by 10/14/2024, will not be allowed to work until educated. This education will be provided annually and will be added to the new hire orientation for all new nursing employees effective 10/10/2024. Quality Assurance and Performance Improvement (QAPI). Monitoring Process Implemented: Effective 10/10/24, the DON,, ADON, MDSC and/or Unit Coordinators (1, 2) will complete incident/accident monitoring process. This monitoring process will be accomplished by reviewing 24 hours report from electronic health records to ensure an incident report is completed, and detail investigation contains root cause analysis. This monitoring process will be completed daily (Monday through Friday) for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings will be addressed by the DON promptly. This monitoring process will be documented on an accommodation of needs monitoring tool located in the facility QAPI binder. Effective 10/10/24, the DON, ADON, MDSC and/or Unit Coordinators (1, 2) will complete incident/accident monitoring process. This monitoring process will be accomplished by observing residents to ensure employees are providing services in the facility that assure an environment that is free from accidents and hazards. The monitoring process will be accomplished by observing three randomly selected staff members and residents. The observer will focus on observing ADL care specifically pertaining to bed mobility and ensure staff members keep residents at the center of the bed before turning from one side to another. The observer will also ensure an appropriate number of staff based on individual resident's care plan is adhered. This monitoring process will be completed daily (Monday through Friday) for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings will be addressed by the DON promptly. This monitoring process will be documented on an accommodation of needs monitoring tool located in the facility QAPI binder. Effective 10/10/24, the DON, ADON, and/or Unit Coordinators (1, 2) will review all new admissions for the last 24 hours or from last clinical meeting to ensure that a bed mobility assessment has been completed. Any negative findings will be corrected promptly. This monitoring process will be completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the bed mobility assessment tool for new residents located in the facility QAPI binder. Effective 10/10/24, the DON and/or ADON will report the findings of this monitoring process to the facility's QAPI, for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Compliance date 10/14/24 Resident #8 is no longer in the facility, no other actions taken for resident #8. Identification of Other Residents who Might Be Affected: Director of Nursing, Unit coordinator #1, and/or designated nurse #1 completed resident transfer assessments of all current residents in the facility on 10/09/24 to identify the appropriate methodology to safely transfer the resident from one location to the other. The audit also focused on identifying residents with non-weight bearing status. Findings of this audit are documented on a resident transfer assessment tool located in the facility QAPI binder. 100% audit of current resident's care plans completed by MDS coordinator on 10/10/24, to assure each resident has an ADL care plan that indicates the amount of assistance required during ADL care, with specification of modality of transfer to include (Mechanical lift, one person. And/or two people assist and ensure the Kardex is updated with such information. The audit also ensured that residents who have a non-weight bearing status have a care plan that reflects so, and Kardex updated with such information. Findings of this audit are documented on a care plan ADL audit tool located in the facility QAPI binder. 100% audit of resident records for the last 30 days completed for all residents in the facility completed by the Regional Director of Clinical services on 10/10/24 and 10/11/24 to identify any other resident with an accident with a staff presence. No other resident identified with a fall during care. Systemic Changes and Modification: Effective 10/10/24, all new residents will have a transfer assessment completed on admission quarterly, and with any changes in their transfer status, by the licensed nurse on duty. This will be reviewed in the daily clinical meeting and documented on the facility medical records under ADL care plan. Moving forward, residents, ADL assistance needs will be added on the Kardex located electronically in the Kiosks. Effective 10/10/24, the therapy department will screen on admission quarterly and with any changes with any transfer status to ensure the transfer status assessed by nursing is appropriate for patient safe transfer. Therapy screen will be documented in each resident's electronic clinical records. Any discrepancies on transfer status between nursing and therapy will be corrected promptly by licensed nurse on duty and/or therapy employee who completes the screening. Effective 10/10/24, any resident with a non-weight bearing status has a care plan indicating their non weight bearing status in resident's medical records. The non-weight status will be included in each resident's Kardex. This will be reviewed in the daily clinical meeting and documented on the facility medical records under ADL care plan. Effective 10/10/2024, the Regional Director of Clinical services in collaboration with the facility clinical team to include the Director of Nursing, and Unit coordinator #1 revised the process of reviewing all new admits/readmits in a daily clinical meeting and include the provision for non-weight bearing status and transfer status to ensure it is completed and documented in electronic medical records. Any discrepancies identified will be corrected promptly. Any negative Findings of this systemic change is documented on the daily clinical meeting homework sheet located on the daily clinical meeting binder. 100% education of all current licensed nursing staff (LPN, and RNs) to include full time, part time, and as needed nursing employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, 2). The emphasis of this education includes but is not limited to, the importance of completing transfer assessment and adding non weight bearing status to each resident's care plan and Kardex on admission, quarterly and with changes of transfer status. This education will be completed by 10/14/2024. Any nursing staff members (Registered nurses, Licensed practical nurses, Medication aides, and/or Certified nurse aides not educated by 10/14/2024, will not be allowed to work until educated. This education will be provided annually and will be added to the new hire orientation for all new nursing employees effective 10/10/2024. This education will be provided by the Director of nursing and/or Staff development Coordinator. 100% education of all current nursing staff (LPN, RNs, and nurse aides) to include full-time, part-time, and as needed employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators. The emphasis of this education includes but is not limited to the importance of ensuring residents are transferred appropriately based on individualized care plan as indicated on the Kardex. This education will be completed by 10/14/2024. Any nursing staff members (Registered nurses, Licensed practical nurses, Medication aides, and/or Certified nurse aides not educated by 10/14/2024, will not be allowed to work until educated. This education will be provided annually and will be added to the new hire orientation for all new nursing employees effective 10/10/2024. This education will be provided by the Director of nursing and/or Staff development Coordinator effective 10/10/2024. Monitoring Process Implemented: Effective 10/10/2024, the Director of Nursing, Assistant Director of Nursing, MDS coordinators and/or Unit Coordinators (1, 2) will complete incident/accident monitoring process. This monitoring process will be accomplished by observing residents to ensure employees are providing services in the facility that assure an environment that is free from accidents and hazards. The monitoring process will be accomplished by observing three randomly selected staff members and residents. The observer will focus on observing ADL care specifically pertaining to resident's transfer and ensure staff members transfer resident based on resident's plan of care. The observer will also ensure an appropriate number of staff based on individual resident's care plan is adhered, and non-weight bearing status is adhered (if any). This monitoring process will be completed daily (Monday through Friday) for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings will be addressed by the Director of nursing promptly. This monitoring process will be documented on an accommodation of needs monitoring tool located in the facility QAPI binder. Effective 10/10/2024, the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (1, 2) will review all new admissions for the last 24 hours or from last clinical meeting to ensure that a transfer assessment has been completed. Any negative findings will be corrected promptly. This monitoring process will be completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the bed mobility assessment tool for new residents located in the facility QAPI binder. Effective 10/10/2024, the Director of Nursing and/or Assistant Director of Nursing will report the findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Compliance date 10/14/2024. The facility's corrective action plans for example #1 (R5) and example #2 (R8) were verified on 11/07/24 by the following: Interviews and record review verified the DON completed CNA1's competence evaluation on 10/09/24; bed mobility assessments, transfer assessments, care plan audits, kardex review, and record review of all residents for the last 30 days were completed as indicated. Staff interviews verified the systemic changes were implemented as noted related to new admissions/readmissions bed mobility assessments and transfer assessments with review in the daily clinical meeting. Additionally, staff were aware of the systemic change for the therapy department to complete screens on admission. Record review confirmed ADL assistance needs as specified in the corrective action plans were on the kardex and care plan; incident reports were completed with investigations and root cause analysis for incidents/accidents; and care plans were updated as needed. Interviews and review of inservice logs revealed education was completed related to the following: the systemic changes; completing incident report and investigation after each incident; completing bed mobility assessments and transfer assessments on admission, quarterly and with changes of bed mobility/transfer status; completing transfer assessments and adding non-weight bearing status to care plan and kardex; ensuring resident care provided in bed is rendered in a safe manner with residents centered in the bed during bed mobility, turning a resident towards the care giver if one person is providing care in bed, and using the appropriate number of staff during care (to include transfers) per resident's individual plan of care and kardex. The education was added to new hire orientation. An observation of resident care revealed no concerns with the provision of care in accordance with the care plan and kardex. Record review of the facility's monitoring documentation for each corrective action plan verified all monitoring has been implemented as specified. The compliance date of 10/14/24 was validated.

Based on record review, staff interviews, Emergency Medical Services (EMS) interview, family interview, and physician interviews, pharmacy interviews the facility staff were made aware Resident #21 had a blood glucose level of 33 milligrams/deciliter (mg/dL); the facility failed to administer Glucagon (Glucagon is a manmade version of a hormone made by the pancreas that raises blood glucose levels) per standing orders; and failed to effectively respond to a medical emergency of hypoglycemia. Upon EMS arrival Resident #21 had a blood glucose level of 38 and was unresponsive. The hospital records indicated Resident #21 was profoundly hypoglycemic. (Hypoglycemia is a medical condition in which the body's blood glucose level falls too low for bodily functions to continue. Severe hypoglycemia may trigger loss of consciousness or seizures.) Additionally, Resident #22 had a blood glucose level registering over 400 mg/dL over two days; the facility failed to assess and monitor the resident in order that a physician who oversaw the resident's care be accurately appraised of her medical status; and the facility failed to effectively respond to a medical emergency when Resident #22 was found to be nonresponsive by a physical therapy staff member hours before EMS was called. Resident #22 was found with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. At the time of ED (emergency department) physician assessment, Resident # 22 was diagnosed with sepsis and hyperglycemia. (Hyperglycemia is a medical condition in which the body's blood glucose level is higher than normal. High blood glucose happens when the body has too little insulin or when the body can't use insulin properly.) The facility failed to implement physician ordered laboratory tests and obtain weights used to assess Resident #16's medical condition. This was for three (Resident #21, #22, and #16) of five residents reviewed for a change in medical condition. Immediate jeopardy began on 6/28/2024 when Resident #21 was identified as having a blood glucose reading of 33 mg/dL and the facility failed to administer Glucagon per physician standing orders. Immediate jeopardy began on 7/10/2024 when Resident #22 was identified as having a blood glucose reading of over 400 mg/dL and the facility failed to effectively assess and implement interventions. Immediate Jeopardy was removed on 9/9/2024 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Example #3 for Resident #16 will be cited at a lower scope and severity level of D. Findings included: 1. Resident #22 was originally admitted to the facility on [DATE] with multiple diagnoses some of which included dementia, type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, and hypertension. Resident #22 was readmitted to the facility on [DATE] after a hospitalization for the diagnoses of sepsis, urinary tract infection, and hydronephrosis. (Hydronephrosis is a medical condition characterized by excess fluid in a kidney due to blockage in the tube that connects the kidney to the bladder.) Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 was assessed as having adequate hearing and vision with clear speech. Documentation on the same assessment indicated Resident #22 was usually understood and usually had the ability to understand others. Resident #22 was coded as having the diagnosis of type 2 diabetes mellitus and received insulin injections for 7 days of the assessment period. Documentation on the care plan initiated on 6/22/2024 revealed a care plan description of Resident #22's risk for hypo/hyperglycemia and a diagnosis of diabetic retinopathy relative to a diagnosis of diabetes mellitus. One of the interventions was to observe signs and symptoms of hypo/hyperglycemia such as sweating, tremor, pallor, nervousness, headache, double vision, confusion, and or lack of coordination. Additional interventions were to perform blood glucose monitoring and medication/insulin as ordered. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (applied under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units; greater than 400 call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive 5 units of Semglee insulin solution to be injected subcutaneously one time a day at 8:00 PM for hyperglycemia. Semglee is a long-acting insulin used to treat high blood glucose levels for people with diabetes. Documentation on the July Medication Administration Record (MAR) for Resident #22 revealed on 7/9/2024 the blood glucose level was 399 and Medication Aide (Med Aide) #5 administered ten units of insulin at 6:22 PM. Med Aide #5, an agency employee, was interviewed on 9/5/2024 at 1:08 PM and revealed the following information. Med Aide #5 confirmed she did take the blood glucose reading of 399 on 7/9/2024 and that she did not administer insulin to Resident #22. Med Aide #5 did not recall who the licensed nurse was who was assigned to help her perform medication administration tasks out of her scope of practice on 7/9/2024. Med Aide #5 explained when she put the blood glucose reading into the electronic MAR, the administration of the insulin would also incorrectly go under her name. Med Aide #5 indicated she had to trust that the licensed nurse, to whom she reported the blood glucose level of Resident #22, would administer the correct insulin dose, document the administration, and notify a physician of any concerns if needed. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/9/2024 at 8: 24 PM. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or received Novolog insulin as ordered at 8:00 AM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. On the morning of 7/10/24 she was assigned for the 7:00 AM to 7:00 PM shift to the hallway which Resident #22 resided. Med Aide #4 was told Nurse #4 took care of administering medications for several people during the 7:00 PM to 7:00 AM shift ending on 7/10/2024. Resident #22 was one of those people who Nurse #4 told Med Aide #4 she had already administered the morning medications to. Med Aide #4 stated she expected Nurse #4 to document on the MAR the medications she was told had already been administered as an explanation for why there was no documentation of the Novolog insulin for Resident #22 at 8:00 AM on 7/10/2024. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered 10 units of Novolog insulin on 7/10/2024 at 1:43 PM to Resident #22, one hour and 43 minutes after the scheduled administration time. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 4:00 PM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 relayed the following information. Med Aide #4 explained that she could not remember which licensed nurse was assisting her on 7/10/2024 and confirmed she did not administer Novolog insulin to Resident #22 on 7/10/2024 at 1:43 PM. Med Aide #4 thought the licensed nurse, assisting her on 7/10/24, was Unit Manager #2. On 7/10/2024 the blood glucose level for Resident #22 read as HI or above 400 on the glucose monitor. (A reading of HI on a glucometer means the reading is above the level readable by the glucometer.) The licensed nurse who was assisting Med Aide #4 was told the blood glucose monitor was reading above 400 and the physician needed to be called. The licensed nurse told Med Aide #4 the physician ordered 12 units of Novolog insulin to be administered to Resident #22 and to keep checking the blood glucose level every hour. Med Aide #4 kept checking the blood glucose level every hour and reported to the licensed nurse the reading was still registering as above 400 mg/dL. Med Aide #4 thought the licensed nurse was going to document everything and take care of the 4:00 PM scheduled Novolog insulin administration on 7/10/2024 because of the blood glucose readings that were over 400 mg/dL, requiring a physician to be involved. Unit Manager #2 was interviewed on 9/10/2024 at 8:21 AM. Unit Manager #2 revealed the following information. Unit Manager #2 did recall Med Aide #4 contacting her about an elevated glucose level for Resident #22 on 7/10/2024. Unit Manager #2 revealed she assessed Resident #22 and thought she was dehydrated but was arousable and able to drink fluids. Unit Manager #2 stated she was very busy on 7/10/24, in addition to being the unit manager, the only registered nurse in the building, doing wound care, and admitting multiple residents, leaving her with little time for adequate coverage of the Med Aides in the building. Unit Manager #2 revealed she thought she sent a text to the physician for Resident #22 informing him of the elevated blood glucose levels on 7/10/2024. Unit Manager #2 stated she trusted the judgement of Med Aide #4 and felt she communicated effectively if she needed any assistance. Unit Manager #2 could not recall specifically what interventions were put in place on 7/10/2024 other than administration of insulin and fluids but would trust the recollections of Med Aide #4. Unit Manager #2 revealed she kept a small notebook with notes on which residents she had to go back and complete documentation on as a late entry. Unit Manager #2 thought perhaps Resident #22 having elevated blood sugars was one of those residents and she forgot to go back and document. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/10/2024 at 10:56 PM. There was no documentation in the electronic medical record of Resident #22 that any additional interventions were taken for the elevated blood glucose reading on 7/10/2024. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 8:00 AM on 7/11/2024. The facility nursing schedule dated 7/11/2024 indicated Nurse #7 was assigned to the hallway for which Resident #22 resided for the 12 hour day shift (7:00 AM to 7:00 PM). Nurse #7 was interviewed on 9/5/2024 at 2:37 PM. Nurse #7 stated she was an agency nurse who only worked at the facility on one occasion and that was 7/11/2024. Nurse #7 stated she did not recall what hall she was assigned to. Nurse #7 stated when she arrived at 7:00 AM on 7/11/2024, the scheduler handed her a stack of paper MARs and told her to go to the hall to begin the medication pass. Nurse #7 explained she was told she would not have access to the electronic medical record system. Nurse #7 revealed it was chaos, but she stayed. Nurse #7 further explained that at 2:30 PM she was approached by the Interim Director of Nursing (DON) with the electronic medical record system login information she needed and another stack of papers for a new admission she was expected to process. Nurse #7 said she handed the new admission paperwork back to the Interim DON and told her she wasn't doing it. Nurse #7 revealed she had never returned to the facility. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 stated she was assigned on 7/11/2024 for the 7:00 AM to 7:00 PM shift to another hall next to the hall which Resident #22 resided. Med Aide #4 revealed everything was a mess on the hallway which Resident #22 resided because there was an agency nurse (Nurse #7) who was trying to figure out the paper MAR and she was not giving medications. Med Aide #4 revealed the agency nurse (Nurse #7) left and was put on the do not return list. Documentation on the July MAR revealed Med Aide #4 obtained a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 11:47AM to Resident #22. Documentation on a physical therapy treatment encounter note for Resident #22 written by Physical Therapy Assistant (PTA) #1 on 7/11/2024 at 3:58 PM revealed, PTA facilitated that [Resident #22] get [out of bed] for the purpose of attempting goals. [Resident #22] responded [by demonstrating] extreme lethargy, incoherent mumbling, [nonresponsive] pupils/eye movement to bright light. PTA attempted to have [Resident #22] sit [on edge of bed] with [Resident #22 [demonstrating] inability to arise from sleep/difficulty to hold head. Nursing [Med Aide #4], DON, [Physical Therapist/Occupational Therapist] notified regarding [Resident #22's] decrease in status. Continue [with plan of care.] An interview was conducted with PTA #1 on 9/6/2024 at 4:45 PM. PTA #1 revealed the following information. PTA #1 stated she did not recall the exact time she went to see Resident #22 on 7/11/2024. PTA #1 confirmed she found Resident #22 in a nonresponsive condition on that day, so she went to the Med Aide on the hall, the interim DON, the Physical Therapist, and Occupational therapist to let them know of her concern for Resident #22. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 4:51 PM. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 confirmed she took the blood glucose readings for Resident #22 on 7/11/2024 at 11:47 AM and 4:51 PM. Med Aide #4 revealed that some of the blood glucose readings for Resident #22 were actually registering as HI or over 400 mg/dL while at least one of the readings she documented on the MAR on 7/11/2024 was actually 400 mg/dL. Med Aide #4 revealed the MAR did not allow Novolog insulin to be checked off as administered unless an actual number was entered into the MAR for the blood glucose reading. Med Aide #4 stated she had to put in 400 mg/dL although the reading may have been over 400 mg/dL. Med Aide #4 confirmed she told the licensed nurse who was assisting her on 7/11/2024 for the 12:00 PM and 4:00 PM administration time for the Novolog insulin, that the blood glucose levels were continuously HI. Med Aide #4 explained the licensed nurses were going into the MAR after she documented the blood glucose reading and using her login credentials to document the administration of insulin. Med Aide #4 was told by the licensed nurse on 7/11/2024 the physician had been contacted and ordered for Resident #22 to be monitored. Med Aide #4 did not recall who the licensed nurse was. Med Aide #4 confirmed PTA #1 informed her of concerns of the lack of response from Resident #22. Med Aide #4 stated she did tell the licensed nurse of what PTA #1 had said. Med Aide #4 stated she informed Unit Manager #2 and sent a text message to the interim DON about the continued blood glucose readings of over 400 mg/dL for Resident #22. Med Aide #4 stated she got a text message back from the interim DON that she would take care of it. Med Aide #4 stated that in report at the end of her shift on 7/10/24 and 7/11/24 she let Nurse #4 know Resident #22 was continually having blood glucose readings of over 400 mg/dL. Med Aide #4 indicated Nurse #4 did not seem to care, telling her that on the shift, 7:00 PM to 7:00 AM, when Nurse #4 worked, the blood glucose readings for Resident #22 were in the 200's mg/dL. Med Aide #4 stated, It just didn't make any sense to me but only the nurses can call the doctor. An interview was conducted with the responsible party (RP) for Resident #22 on 9/3/2024 at 3:42 PM and the following information was provided. On 7/8/2024 the RP checked on Resident #22 before going out of town and she was okay. The RP heard nothing all week from the facility. On 7/11/24 around 7:30 PM to 8:00 PM she saw she had several missed calls on her phone. She then picked up on the next one. It was from a private number. The person on the phone did not identify themselves but told the RP, You need to come now and check on your mother. It is an emergency. She needs to be sent out. The RP did not know what was going on because the facility did not notify her that Resident #22 was sick. The RP called another family member who was local to the facility and asked him to go to the facility to see Resident #22. The family member arrived at the facility around 8:30 to 8:45 PM to find Resident #22 was not responding. Nurse #4 walked into the room with a blood glucose monitor and said the doctor ordered Resident #22 to receive insulin, to monitor her blood glucose level, and call the doctor back in two hours. Since Resident #22 was not responding the family member insisted that Resident #22 be sent to the emergency room and finally Nurse #4 called emergency medical services (EMS). Later that night the interim DON called the RP wanting to know who had called her from the facility to let her know Resident #22 was not well. The RP stated she did not know who the anonymous phone caller was, but she was grateful she was contacted as it may have saved the life of Resident #22. The RP talked to the (former) Administrator about her concerns and the (former) Administrator informed the RP that the facility had learned that a physical therapy staff member had noted a change in the resident earlier that day. The (former) Administrator maintained that they did not have to let the family know if Resident #22 had elevated blood glucose levels, which did not make sense to her. If she had known that Resident #22's blood glucose levels were running high for several days she would have wanted her sent to the hospital to be checked. Documentation in the physician orders revealed an order dated 7/11/2024 at 7:00 PM for Resident #22 to be administered ten units of Humalog insulin solution to be injected subcutaneously one time only for a blood glucose exceeding 400 mg/dL and contact the physician in two hours. Humalog insulin is a fast-acting insulin which is absorbed quickly and starts working in about 15 minutes after injection to lower blood glucose levels. There was no documentation on the July MAR that the order for Humalog insulin was administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin to Resident #4 on 7/11/2024 at 8:58 PM. Documentation in the physician orders revealed an order dated 7/11/2024 at 9:00 PM for Resident #22 to be administered ten units of Novolog insulin solution subcutaneously one time for blood glucose exceeding 400 mg/dL and contact the physician in two hours. There was no documentation on the July MAR that the one-time order for Novolog insulin was ever administered to Resident #22 on 7/11/2024 after 7:00 PM. There was no other documentation in the electronic medical record of any vital signs taken of Resident #22 on 7/11/2024. Documentation in the nursing notes for Resident #22 dated 7/12/2024 at 9:48 AM by Nurse #4 revealed, Physician contacted due to blood glucose exceeding 400 [mg/dL] and order received from physician to administer 10 [units] of Humalog or Novolog and report back after 2 hours. After 2 hours, resident blood [glucose] reading still exceeded 400 [mg/dL] and physician made aware of results. Family arrived and RP requested for resident to be sent to [emergency room ] for evaluation. Physician made aware and order received to send resident to [emergency room ]. DON made aware. An interview was conducted with Nurse #4 on 9/5/2024 at 6:04 PM. Nurse #4 relayed the following information and timeline of events for Resident #22 on the evening of 7/11/2024. Nurse #4 started her 7:00 PM to 7:00 AM shift at 7:00 PM on 7/11/2024. Nurse #4 received the information in a nursing report from Med Aide #4 that the blood glucose level of Resident #22 was above 400 mg/dL on the 4:00 PM medication pass. Nurse #4 denied she had any knowledge of the blood glucose level of Resident #22 being at or above 400 mg/dL for several shifts. Nurse #4 stated she assessed Resident #22 and took her vital signs at the start of her shift. Nurse #4 revealed the blood glucose level of Resident #22 was registering as HI or over 400 mg/dL on the glucometer, a device to measure blood glucose levels. Nurse #4 revealed the vital signs of Resident #22 were fine, so she called the on-call physician. Nurse #4 stated she received an order from the physician to administer 10 units of fast acting insulin to Resident #22 and call the physician back in two hours. Nurse #4 stated she went back to check on Resident #22 again at 9:00 PM and all her vital signs were fine. Resident #22 did not have a temperature, elevated blood pressure, or an elevated heart rate. Nurse #4 stated her blood glucose level was still registering as HI or above 400 mg/dL on the glucometer. Nurse #4 was adamant Resident #22 was fine and was responsive. Nurse #4 related that when she pricked the finger of Resident #22 with the lancet, the resident looked at her and rolled her eyes. Nurse #4 stated the family of Resident #22 arrived at the facility stating they received a phone call from an unknown caller telling them something was wrong with Resident #22, and she needed to be sent to the emergency room . The family of Resident #22 looked at Resident #22 and demanded she be sent to the emergency room . Nurse #4 stated she did not know who called the family because the breathing and vital signs for Resident #22 were normal. Nurse #4 reported she was about ready to call the physician because of the elevated blood glucose reading, so she called the physician, and the physician agreed Resident #22 could be sent out per the family wishes. Nurse #4 relayed that she did all her documentation for the residents at the end of her shift so that all the events of the shift for each resident could be documented, for an explanation for why her nursing note for Resident #22 was dated 7/12/2024, the day after Resident #22 discharged from the facility. An interview was conducted with the interim DON on 9/5/2024 at 1:58 PM. The interim DON stated she was not made aware of any concerns with the blood glucose levels of Resident #22 until the RP called her on the evening of 7/11/2024 at approximately 8:00 PM or 8:30 PM. The interim DON was told by the RP of a phone call she received from a facility staff member telling her Resident #22 was very ill and needed to be sent to the hospital. The interim DON relayed she called Nurse #4 and was told Resident #22 was still at the facility and was fine. The interim DON further revealed Nurse #4 had explained the following interventions for Resident #22. An assessment had been completed by Nurse #4 revealing an elevated blood glucose level, lethargy, vital signs were fine, the physician was called for orders, and Resident #22 was responsive. The interim DON stated she knew the blood glucose level of Resident #22 was high in the moment on the evening of 7/11/2024 but she was not aware the blood glucose level had been HI over several shifts. An interview was conducted with MD #2, the physician for Resident #22, on 9/9/2024 at 1:12 PM. MD #2 stated he could not recall if he was notified of the elevated blood glucose levels of Resident #22 on 7/9/2024, 7/10/2024, or 7/11/2024. MD #2 explained that if he had been notified of elevated blood glucose levels for Resident #22 during normal business hours, he would have ordered a change in the amount of fast-acting insulin to be administered and requested a call back if there was no change after continuous monitoring of the resident. MD #2 indicated that if those orders did not exist on 7/10/2024 or 7/11/2024 during the day shift then it was likely he was not notified. MD #2 stated he did not recall receiving a phone call on the evening of 7/11/2024 from Nurse #4, but he received phone calls of that type routinely making it difficult to recall a specific phone call of that type for a resident. MD #2 stated that a blood glucose level of 400 mg/dL was not good, but having a blood glucose level of 400 mg/dL was an isolated event for this resident making it likely an underlying medical condition was occurring for which he would have had to figure out. Documentation on an Emergency Medical Services (EMS) report dated 7/11/2024 revealed 911 was called at 9:17 PM and arrived at room of Resident #22 at 9:37 PM. The following information was revealed in the EMS report. Upon arriving at the scene, the facility staff stated Resident #22 had been having an elevated blood glucose level all day and had been alert but not acting like herself. The facility staff also told EMS they had been giving Resident #22 insulin as instructed by the resident's physician with no changes in the reading level of HI on the glucose monitor. EMS noted Resident #22 had a glucose reading of HI on their glucose monitor as well. EMS documented Resident #22 as having a heart rate of 140 with respirations in the 40s. Once in the ambulance, Resident #22 remained unresponsive. Documentation on a hospital record dated for a 7/11/2024 admission revealed Resident #22 was diagnosed with sepsis, hyperglycemia, altered mental status, acute renal failure, dehydration, and a urinary tract infection in the emergency room . Resident #22 was discharged from the hospital on 7/24/2024 into the care of the RP with home health services, per the RP's request. 13289 2. Resident # 21 was originally admitted to the facility on [DATE]. The resident's diagnoses included in part a diagnosis of diabetes, dementia, and a history of heart attack and cancer. Review of Resident # 21's 4/12/24 quarterly Minimum Data Set assessment revealed the resident was cognitively impaired. He was able to clearly speak and make himself understood. He was also able to eat with supervision only. The resident was also coded to be a diabetic and had required insulin for seven days in the assessment period. Review of June 2024 monthly orders and the June 2024 MAR (medication administration record) revealed the following: Resident # 21 had an order, which originated on 3/25/23, for Humalog 100 units/ml give 5 units under the skin with breakfast. (Humalog is a fast-acting insulin). Resident # 21 had an order, which originated on 11/16/23, for Humalog 100 units/ml give 10 units under the skin every day at 12 PM. Resident # 21 had an order, which originated on 11/16/23, for Humalog 100 units/ml give 7 units under the skin every day at 4:30 PM. Resident # 21 had an order, which originated on 4/18/24, for Levemir 70 units every hour of sleep. (Levemir is a long acting insulin). Additionally Resident # 21 had orders for blood glucose checks and sliding scale insulin coverage with Humalog Insulin four times per day. The sliding scale insulin dosage was noted be as follows: 201-250 4 units; 251-300 6 units; 301-350 8 units; 351 to 400 10 units; call MD for greater than 400. According to the June 2024 MAR the blood glucose checks were scheduled for 6:00 AM; 11:30 AM; 4:30 PM; and 9:00 PM. The resident's MAR was blank for the reading on 6/28/24 at 6:00 AM. Resident # 21 also had an order to follow standing orders. Review of standing orders revealed emergency measures would be initiated by a licensed nurse immediately when either a routine or stat (right away) CBG (capillary blood glucose) indicates hypoglycemia (low blood glucose). The standing orders further directed for a blood glucose less than 60 the following should be done: If the resident had no renal failure and could take oral food, the resident would be given 15 grams simple carbohydrate (1 tube instant glucose (buccal) or 1 AMP (ampule) Glucagon IM (intramuscularly). Then the resident was to be given protein (4 ounces of milk or 1 tablespoon of peanut butter) and carbohydrate (6 saltines or 3 graham crackers). The blood glucose was to then be checked again in 15 minutes and if the response was inadequate the treatment was to be repeated. On 6/28/24 at 9:54 AM Nurse # 4 documented the following entry. Resident was alert and responding normally per his baseline at HS (hour of sleep). Resident was hot to the touch and vital signs measured. Resident noted to have temperature of 99.8. Resident received PRN (as needed) Tylenol with scheduled medications and during follow up resident's temperature had fallen to 98.8. At 0600 (6:00 AM) resident's temperature remained within normal ranges. On 6/28/24 at 1:19 PM Unit Manager # 2 documented the following late entry which indicated when she was called to the room on that date emergency medical staff were with the resident. The entry did not note the time she had been called to the room. The nursing entry read, Late entry for 06/28/2024. Nurse called to resident's room at this time because staff noted resident not responsive and difficult to arouse. EMT (Emergency Medical Technician) present and resident noted in bed with eyes closed and lethargic. VS (vital signs) 97.6-81-16 98/60 82% oxygenation on room air. Resident given IV glucose prior to transport and now being sent to ER for evaluation. Physician notified at this time. The day following the resident's 6/28/24 transfer to the hospital Nurse # 4 also entered a nursing entry. Specifically, on 6/29/24 at 9:31 AM Nurse # 4 documented the following nursing entry. This writer was made aware that residents blood glucose was measured at 33 by med aides on duty. Upon entering the room, resident was noted to be pale and lethargic. Resident unable to drink orange juice at that time but tolerated sugar mixed in applesauce. Resident blood glucose measured again and read 56. RN Unit Manager on duty arrived to room to assess resident. EMS arrived 9:06 AM and was received report from RN Unit Manager on duty. Review of EMS (emergency medical system) records revealed the following information. EMS was called on 6/28/24 at 8:56 AM, on the scene at 9:05 AM, and at Resident # 21's side at 9:07 AM. At 9:11 AM the EMS records showed the resident was unresponsive upon their arrival and he had a blood glucose level of 38. Once an IV with dextrose was begun the resident became alert and talking. They were unable to obtain his temperature reading. The resident was transferred to the hospital for evaluation. Review of Resident # 21's hospital admission history and physical, dated 6/28/24, revealed the physician noted the EMS crew had been summoned to the facility when the resident was found to be profoundly hypoglycemia with a blood glucose reading of 30. The history and physical noted the resident was found to have lactic acidosis related possibly to liver disease or hypoglycemia. (Lactic acidosis is a build- up of lactate acid in the bloodstream which is normally metabolized and can contribute to organ dysfunction). Following hospitalization and treatment, Resident # 21 returned to the facility on [DATE]. On 9/3/24 at 10:55 AM MA (Medication Aide) # 3 was interviewed and reported the following. On 6/28/24 she arrived at work during the morning. MA # 4 had asked for help as she (MA # 3) was coming on duty. MA # 4 informed her that the assigned Nurse Aide had let her (MA # 4) know that Resident # 21 was gurgling and everything and she needed help. She (MA # 3) went immediately, and she checked the resident's blood glucose. It was 33. She called the ADON (Assistant Director of Nursing) who told her to call 911. As a medication aide, she thought she could not call 911. Therefore, she ran to get Nurse # 4, who was the night shift nurse and still at work. She told Nurse # 4 t[TRUNCATED]

Based on record review, and staff, family, and physician interview, the facility to provide accurate notification to the physician of repeated episodes of Resident 22's blood glucose level registering greater than 400 milligrams per deciliter (mg/dL) (normal blood glucose level are considered to be between 70 mg/dL to 100 mg/dL) over two days and to notify the resident's physician and family when Resident #22 was found to be nonresponsive by a physical therapy staff member hours before Emergency Medical Services (EMS) was called. Resident #22 was found with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. At the time of ED (emergency department) physician assessment, Resident # 22 was diagnosed with sepsis (a life-threatening complication of an infection) and hyperglycemia. (Hyperglycemia is the technical term for high blood glucose levels that occurs due to the body having too little insulin or when the body can't use insulin properly.) This was for one (Resident #22) of three residents reviewed for notification of physician for a change in medical condition. Immediate jeopardy began on 7/10/2024 when Resident #22 was identified as having a blood glucose reading of over 400 mg/dL and the physician was not notified. Immediate Jeopardy was removed on 9/9/2024 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses which included type 2 diabetes mellitus. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 mg/dL to 250 mg/dL administer 4 units; 251 mg/dL to 300 mg/dL administer 6 units; 301 mg/dL to 350 mg/dL administer 8 units; 351 mg/dL to 400 mg/dL administer 10 units; greater than 400 mg/dL call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. There was no documentation on the July (Medication Administration Record) (MAR) Resident #22 had a blood glucose level taken or received Novolog insulin as ordered at 8:00 AM on 7/10/2024. Documentation on the July MAR revealed Medication Aide (Med Aide) #4 took a blood glucose level of 400 mg/dL and administered 10 units of Novolog insulin on 7/10/2024 at 1:43 PM to Resident #22. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 4:00 PM on 7/10/2024. There was no documentation in the electronic medical record of Resident #22 that any additional interventions were taken for the elevated blood glucose reading on 7/10/2024 at 1:43 PM. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. On the morning of 7/10/24 Med Aide #4 was assigned for the 7:00 AM to 7:00 PM shift to the hallway which Resident #22 resided. Nurse #4 relayed to Med Aide #4 that she had already administered the morning medications to include insulin administration for Resident #22 on the 7:00 PM to 7:00 AM shift that ended on 7/10/2024. Med Aide #4 indicated she did not know what the blood glucose level of Resident #22 was at 8:00 AM. Med Aide #4 explained that she could not remember which licensed nurse was assisting her on 7/10/2024 at the 12:00 PM administration time but she thought it was Unit Manager #2. Med Aide #4 confirmed she did not administer Novolog insulin to Resident #22 on 7/10/2024 at 1:43 PM, because she was not allowed to administer insulin to residents under her scope of practice as a medication aide. According to Med Aide #4 on 7/10/2024 the blood glucose level for Resident #22 read as HI or above 400 mg/dL on the glucose monitor and Unit Manager #2 was made aware. (A reading of HI on a glucometer means the reading is above the level readable by the glucometer.) She revealed the MAR did not allow Novolog insulin to be checked off as administered unless an actual number was entered into the MAR for the blood glucose reading. Med Aide #4 stated she had to put in 400 mg/dL although the reading may have been over 400 mg/dL. Med Aide #4 indicated she was told by Unit Manager #2 the physician for Resident #22 was called and had ordered 12 units of Novolog insulin to be administered to Resident #22 and to keep checking the blood glucose level every hour. Med Aide #4 kept checking the blood glucose level every hour and reported to Unit Manager #2 the glucose reading was still registering as above 400 mg/dL. Med Aide #4 thought Unit Manager #2 was going to document everything and take care of the 4:00 PM scheduled Novolog insulin administration on 7/10/2024 because of the blood glucose readings that were over 400 mg/dL, requiring a physician to be notified. Unit Manager #2 was interviewed on 9/10/2024 at 8:21 AM. Unit Manager #2 revealed the following information. Unit Manager #2 did recall Med Aide #4 contacting her about an elevated glucose level for Resident #22 on 7/10/2024. Unit Manager #2 revealed she assessed Resident #22 and thought she was dehydrated but was arousable and able to drink fluids. Unit Manager #2 revealed she thought she sent a text to the physician for Resident #22 informing him of the elevated blood glucose levels on 7/10/2024 but, she could not recall specifically if she had done so. There was no documentation on the July MAR Resident #22 had a blood glucose reading taken or was administered Novolog insulin as ordered at 8:00 AM on 7/11/2024. The facility nursing schedule dated 7/11/2024 indicated Nurse #7 was assigned to the hallway for which Resident #22 resided for the 12 hour day shift (7:00 AM to 7:00 PM). Nurse #7 was interviewed on 9/5/2024 at 2:37 PM. Nurse #7 stated she was an agency nurse who only worked at the facility on one occasion and that was 7/11/2024 for the 7:00 AM to 7:00 PM shift. Nurse #7 revealed when she arrived at the facility, she was not given login information for the electronic medical record system and was given paper MARs to work with for documentation of administration of the medications for residents on the hallway she was assigned. Nurse #7 revealed she was unable to recall what residents she took blood glucose levels for, but she would have documented calling the physician for an elevated blood glucose if that had been required of her. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 11:47AM to Resident #22. Documentation on a physical therapy treatment encounter note for Resident #22 written by Physical Therapy Assistant (PTA) #1 on 7/11/2024 at 3:58 PM revealed, PTA facilitated that [Resident #22] get [out of bed] for the purpose of attempting goals. [Resident #22] responded [by demonstrating] extreme lethargy, incoherent mumbling, [nonresponsive] pupils/eye movement to bright light. PTA attempted to have [Resident #22] sit [on edge of bed] with [Resident #22 [demonstrating] inability to arise from sleep/difficulty to hold head. Nursing [Med Aide #4], DON (Director of Nursing), [Physical Therapist/Occupational Therapist] notified regarding [Resident #22's] decrease in status. Continue [with plan of care.] An interview was conducted with PTA #1 on 9/6/2024 at 4:45 PM. PTA #1 revealed the following information. PTA #1 stated she did not recall the exact time she went to see Resident #22 on 7/11/2024. PTA #1 confirmed she found Resident #22 in a nonresponsive condition on that day, so she went to the Med Aide on the hall, the interim DON, the Physical Therapist, and Occupational therapist to let them know of her concern for Resident #22. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 4:51 PM. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. Med Aide #4 confirmed she took the blood sugar readings for Resident #22 on 7/11/2024 at 11:47 AM and 4:51 PM. Med Aide #4 revealed that some of the blood glucose readings for Resident #22 were registering as HI or over 400 mg/dL while at least one of the readings she documented on the MAR on 7/11/2024 was actually 400 mg/dL. Med Aide #4 confirmed she told the licensed nurse who was assisting her on 7/11/2024 for the 12:00 PM and 4:00 PM administration time for the Novolog insulin, that the blood glucose levels were continuously registering as HI. Med Aide #4 was told by the licensed nurse on 7/11/2024 the physician had been contacted and ordered for Resident #22 to be monitored. Med Aide #4 did not recall who the licensed nurse was. Med Aide #4 confirmed PTA #1 informed her of concerns of the lack of response from Resident #22. Med Aide #4 stated she did tell the licensed nurse of what PTA #1 had said. Med Aide #4 stated she informed Unit Manager #2 and sent a text message to the interim DON about the continued blood glucose readings of over 400 mg/dL for Resident #22. Med Aide #4 stated she got a text message back from the interim DON that she would take care of it. Med Aide #4 stated that in report at the end of her shift on 7/10/24 and 7/11/24 she let Nurse #4 know Resident #22 was continually having blood glucose readings of over 400 mg/dL. Med Aide #4 indicated Nurse #4 did not seem to care, telling her that on the shift, 7:00 PM to 7:00 AM, when Nurse #4 worked, the blood glucose readings for Resident #22 were in the 200's mg/dL. Med Aide #4 stated, It just didn't make any sense to me but only the nurses can call the doctor. Documentation in the physician orders revealed an order dated 7/11/2024 at 7:00 PM for Resident #22 to be administered ten units of Humalog insulin solution to be injected subcutaneously one time only for a blood glucose exceeding 400 mg/dL and contact the physician in two hours. Humalog insulin is a fast-acting insulin which is absorbed quickly and starts working in about 15 minutes after injection to lower blood glucose levels. There was no documentation on the July MAR that the order for Humalog insulin was administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation in the physician orders revealed an order dated 7/11/2024 at 9:00 PM for Resident #22 to be administered ten units of Novolog insulin solution subcutaneously one time for blood glucose exceeding 400 mg/dL and contact the physician in two hours. There was no documentation on the July MAR that the one-time order for Novolog insulin was ever administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation in the nursing notes for Resident #22 dated 7/12/2024 at 9:48 AM by Nurse #4 revealed, Physician contacted due to blood glucose exceeding 400 (mg/dL) and order received from physician to administer 10 [units] of Humalog or Novolog and report back after 2 hours. After 2 hours, resident blood [glucose] reading still exceeded 400 (mg/dL) and physician made aware of results. Family arrived and RP (Responsible Party) requested for resident to be sent to [emergency room ] for evaluation. Physician made aware and order received to send resident to [emergency room ]. DON made aware. An interview was conducted with Nurse #4 on 9/5/2024 at 6:04 PM. Nurse #4 relayed the following information and timeline of events for Resident #22 on the evening of 7/11/2024. Nurse #4 started her 7:00 PM to 7:00 AM shift at 7:00 PM on 7/11/2024. Nurse #4 received the information in a nursing report from Med Aide #4 that the blood glucose level of Resident #22 was above 400 mg/dL on the 4:00 PM medication pass. Nurse #4 denied she had any knowledge of the blood glucose level of Resident #22 being at or above 400 for several shifts. Nurse #4 stated she assessed Resident #22 and took her vital signs at the start of her shift. Nurse #4 revealed the blood glucose level of Resident #22 was registering as High or over 400 on the glucometer, a device to measure blood glucose levels. Nurse #4 revealed the vital signs of Resident #22 were fine, so she called the on-call physician. Nurse #4 stated she received an order from the physician to administer 10 units of fast acting insulin to Resident #22 and call the physician back in two hours. Nurse #4 stated she went back to check on Resident #22 again at 9:00 PM and all her vital signs were fine. Resident #22 did not have a temperature, elevated blood pressure, or an elevated heart rate. Nurse #4 stated her blood glucose level was still registering as High or above 400 mg/dL on the glucometer. Nurse #4 was adamant Resident #22 was fine and was responsive. Nurse #4 related that when she pricked the finger of Resident #22 with the lancet, the resident looked at her and rolled her eyes. Nurse #4 stated the family of Resident #22 arrived at the facility stating they received a phone call from an unknown caller telling them something was wrong with Resident #22, and she needed to be sent to the emergency room . The family of Resident #22 looked at Resident #22 and demanded she be sent to the emergency room . Nurse #4 stated she did not know who called the family because the breathing and vital signs for Resident #22 were normal. Nurse #4 reported she was about ready to call the physician because of the elevated blood glucose reading, so she called the physician, and the physician agreed Resident #22 could be sent out per the family wishes. An interview was conducted with the responsible party (RP) for Resident #22 on 9/3/2024 at 3:42 PM and the following information was provided. On 7/8/2024 the RP checked on Resident #22 before going out of town and she was okay. The RP heard nothing all week from the facility. On 7/11/24 around 7:30 PM to 8:00 PM she saw she had several missed calls on her phone. She then picked up on the next one. It was from a private number. The person on the phone did not identify themselves but told the RP, You need to come now and check on your mother. It is an emergency. She needs to be sent out. The RP did not know what was going on because the facility did not notify her that Resident #22 was sick. The RP called another family member who was local to the facility and asked him to go to the facility to see Resident #22. The family member arrived at the facility around 8:30 to 8:45 PM to find Resident #22 was not responding. Nurse #4 walked into the room with a blood glucose monitor and said the doctor ordered Resident #22 to receive 10 units of insulin, to monitor her blood glucose level, and call the doctor back in two hours. Since Resident #22 was not responding the family member insisted that Resident #22 be sent to the emergency room and finally Nurse #4 called emergency medical services (EMS). The RP talked to the (former) Administrator about her concerns and the (former) Administrator informed the RP that the facility had learned that a physical therapy staff member had noted a change in the resident earlier that day (7/11/2024). The (former) Administrator maintained that they did not have to let the family know if Resident #22 had elevated blood glucose levels, which did not make sense to her. If she had known that Resident #22's blood glucose levels were running high for several days she would have wanted her sent to the hospital to be checked. An interview was conducted with the interim DON on 9/5/2024 at 1:58 PM. The interim DON stated she was not made aware of any concerns with the blood glucose levels of Resident #22 until the RP called her on the evening of 7/11/2024 at approximately 8:00 PM or 8:30 PM. The interim DON was told by the RP of a phone call she received from a facility staff member telling her Resident #22 was very ill and needed to be sent to the hospital. The interim DON relayed she called Nurse #4 and was told Resident #22 was still at the facility and was fine. The interim DON further revealed Nurse #4 had explained the following interventions for Resident #22. An assessment had been completed by Nurse #4 revealing an elevated blood glucose level, lethargy, vital signs were fine, the physician was called for orders, and Resident #22 was responsive. The interim DON stated she knew the blood glucose level of Resident #22 was high in the moment on the evening of 7/11/2024 but she was not aware the blood glucose level had been high over several shifts. Documentation on an Emergency Medical Services (EMS) report dated 7/11/2024 revealed 911 was called at 9:17 PM and arrived at room of Resident #22 at 9:37 PM. The following information was revealed in the EMS report. Upon arriving at the scene, the facility staff stated Resident #22 had been having an elevated blood glucose level all day and had been alert but not acting like herself. The facility staff also told EMS they had been giving Resident #22 insulin as instructed by the resident's physician with no changes in the reading level of HI on the glucose monitor. EMS noted Resident #22 had a glucose reading of High on their glucose monitor as well. EMS documented Resident #22 as having a heart rate of 140 with respirations in the 40s. Once in the ambulance, Resident #22 remained unresponsive. Documentation on a hospital record dated for a 7/11/2024 admission revealed Resident #22 was diagnosed with sepsis, hyperglycemia, altered mental status, acute renal failure, dehydration, and a urinary tract infection in the emergency room . An interview was conducted with Medical Doctor (MD) #2, the physician for Resident #22, on 9/9/2024 at 1:12 PM. MD #22 stated he could not recall if he was notified of the elevated blood glucose levels of Resident #22 on 7/9/2024, 7/10/2024, or 7/11/2024. MD #2 explained that if he had been notified of elevated blood glucose levels for Resident #22 during normal business hours, he would have ordered a change in the amount of fast-acting insulin to be administered and requested a call back if there was no change after continuous monitoring of the resident. MD #2 indicated that if those orders did not exist on 7/10/2024 or 7/11/2024 during the day shift then it was likely he was not notified. MD #2 stated he did not recall receiving a phone call on the evening of 7/11/2024 from Nurse #4, but he received phone calls of that type routinely making it difficult to recall a specific phone call of that type for a resident. MD #2 stated that a blood glucose level of 400 mg/dL was not good, but having a blood glucose level of 400 mg/dL was an isolated event for this resident making it likely an underlying medical condition was occurring for which he would have had to figure out. On 9/9/24 at 5:04 PM the facility Administrator and Corporate Nurse Consultant were notified of Immediate Jeopardy. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #22 was admitted to the facility on [DATE] and discharged on [DATE]. Between the original admission and discharge, she was readmitted on [DATE]. The most recent readmission, she was readmitted with diagnoses that included: Type 2 diabetes with diabetic retinopathy without macular edema (a complication of diabetes that can cause vision loss and blindness), schizoaffective disorder, dementia, chronic embolism (long-term condition where one or more blood clots block the pulmonary arteries), and thrombosis of distal lower extremity (a blood clot condition that forms within the deep veins, usually of the leg, but can occur in the arms). Review of Resident #22's Medication Administration Records (MAR), indicates; on 7/10/24 at 1:43pm the medication aide (MA #4) notified Unit Manager #2 that Resident #22 had blood glucose levels registering over 400. No evidence that the physician was notified. Resident #22's MAR indicates that Resident #22 received 10 units of Novolog insulin at 1:43pm. Further review of Resident #22's MAR indicates; on 7/11/2024, at 11:47 am, Resident #22's blood glucose was documented to be 400. No evidence that the physician was notified, and 10 units of fast-acting insulin were administered. Review of the Physical Therapy Assistant documentation on 7/11/24 at 3:38 PM indicated the resident was non-responsive, and the Director of Nursing was notified. No documentation of actions taken. The Director of Nursing who was informed is no longer working at the facility. No evidence that the physician was notified. On 7/11/24 at 4:51pm blood glucose documented by MA #4 to be 400. The MAR indicates Resident #22 received 10 units of Novolog insulin. No evidence that the physician was notified, no indication that anything else was done. Review of progress notes documented on 7/12/2024 (late entry for 7/11/2024), in Resident #22's medical records indicate (in part); Nurse #4 contacted physician due to Resident #22's blood glucose exceeding 400. An order was received from the physician to administer ten units of Humalog or Novolog and report back after 2 hours. After two hours, Resident #22's blood glucose reading still exceeded 400 and the physician made aware of results, the note added. Resident #22's family arrived and requested that Resident #22 to be sent to the hospital for evaluation. The physician made aware, and the order received to send resident to hospital, documentation concluded. A phone interview was conducted on 09/07/2024 by the Assistant Director of Nursing. Nurse #4 indicated; she contacted the physician around 7:10pm on 7/11/2024 due to Resident #22's blood glucose exceeding 400. Nurse #4 added she received an order to administer ten units of Humalog or Novolog and report back after 2 hours. Nurse #4 indicated that she recalled administering 10 units of Novolog to Resident #22 per physician order. Nurse #4 further added that, at approximately 9:00pm, she rechecked Resident #22's blood glucose, the reading still exceeded 400. She added the physician was made aware of the results at approximately 9:03pm. Per Nurse #4, Resident #22's family arrived at approximately 9:05pm and requested for Resident #22 be sent to the hospital. The physician was made aware of the request at approximately 9:10pm, and the order was received to send the resident to hospital, Nurse # 4 contacted EMS at 9:17pm, interview concluded. EMS arrived on scene at 9:32pm. Resident #22 was still non-responsive when EMS arrived. Per EMS report, Resident #22 was found with an elevated heart rate of 140, respirations in the 40s, and with a continued reading of a blood sugar in excess of 400 at time of transport. Resident #22 was sent to the hospital for further evaluation and treatment, Resident #22 left the facility at approximately 9:53pm. Resident #22 is no longer in the facility. No other actions taken. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 09/06/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. For Resident #22, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice to inform the attending physician of the elevated blood glucose levels that were sustained over a two-day time frame and over multiple shifts for Resident #22. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. Clinical assessments of all current residents in the facility were completed on 09/07/24 by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator (#1 or #2) to identify any other resident with the change condition that require medical attention and/or notification to the physician. The clinical assessment focused on resident's vital signs to include, blood pressure reading, pulse, respiration rate, temperature, and/or presence of pain. The assessment also includes measuring blood glucose for the residents with diagnosis of diabetes with orders for blood glucose check. The attending physician will be informed by the Director of Nursing, Assistant Director of Nursing and/or Unit Coordinator #1 or #2) on any identified findings of a change in condition and appropriate measures to include, but not limited to activating emergency medical services if indicated. 100% audit of all current resident's blood glucose reading documented from 6/28/2024 to 09/07/2024 completed on 09/07/2024 and 09/08/2024, by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator (#1 or #2) to identify any other documentation of a resident with episodes of hypoglycemia and/or hyperglycemia to ensure notification to the attending physician was made. Any resident(s) identified with a change in condition, the Director of nursing will inform the physician for appropriate measures and or interventions and implement the interventions as ordered. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 09/07/2024, facility employees will ensure significant changes, to include hypoglycemia and/or hyperglycemia, were reported to the physician for appropriate intervention. This systemic modification will be accomplished by implementing the following measures: Effective 09/09/2024, licensed nurse on duty will inform the resident; consult with the resident's physician; and notify, the resident representative when there is; an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment), and/or a decision to transfer or discharge the resident from the facility, to including when resident's blood glucose is excessive high or low blood glucose. This notification will be documented on each resident's electronic medical records by the licensed nurse on duty. Effective 09/09/2024, the facilities nursing administrative team, which includes the DON, ADON, Unit coordinators (#1, #2), and/or wound nurse, incorporated the process for reviewing clinical documentation for the last 24 hours and physician orders written in the last 24 hours, or from the last clinical meeting to ensure any needed notification of changes to the physician, and/or responsible party was done in a timely manner. This systemic process will take place Monday through Friday. Any identified issues will be addressed promptly. This process will be incorporated into the daily clinical meeting. The nursing administrative team will review the clinical documentation and physician orders written on Friday and/or Saturday on the next clinical meeting on the following Monday. Effective 09/07/2024, for residents with orders for blood glucose check; certified medication aides will obtain and document blood glucose reading in each resident's medical records, and inform a Nurse on duty immediately, on any blood glucose level less than 60, greater than 200 or based on the physician order. Facility licensed nurses on duty will assess the resident blood glucose level and provide appropriate intervention including notifying the physician in a timely manner. 100% education of all licensed nurses to include full time, part time, and as needed licensed nurses will be completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Coordinators (#1, #2). The emphasis of this education will be the importance of notifying physician and the responsible party in a timely manner for any change in condition, change of treatment/intervention, and/or incidents of sustained elevated blood glucose. This education will be completed by 9/09/2024, any licensed nurses not educated by 09/09/24 will not be allowed to work until educated. This education will also be implemented in new hire orientation. Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1, #2) will monitor and track the completion of this education and will complete this education for any newly hired licensed nurses during the new hire orientation effective 09/09/2024. Alleged immediate jeopardy removal date: 09/09/2024. On 9/12/24 the following was done to validate the facility's immediate jeopardy removal plan: Review of records revealed documentation confirming the completion of audits and in-service training per the facility's removal plan. A review of staffing schedules revealed that there was a designation on the schedule noting which licensed nurse was assigned to cover for any Medication Aide so that physician notification could take place when needed. Beginning at 9:45 AM on 9/12/24 multiple staff members were interviewed regarding in-service training the facility had provided. Staff were able to report details of their training and validated they attended. Staff were also interviewed regarding whether they had witnessed any resident go without medical care during the past week for failure of assessment and notification of the physician of changes. There were no reports of a lack of medical care for acutely ill residents due to a lack of physician notification. A random interview was conducted on 9/12/24 at 1:35 PM with an alert and oriented diabetic resident regarding her medical care. The resident reported no problems with her diabetic care due to staff not communicating with the physician. The facility's immediate jeopardy removal, date of 9/9/24, was validated.

Based on record review, staff interviews, family interview, and physician interview the facility failed to protect a resident's right to be free from neglect when they failed to comprehensively assess and effectively monitor a resident with blood glucose levels registering over 400 milligrams per deciliter (mg/dL) (normal blood sugar levels are considered to be between 70mg/dL to 100 mg/dL) over two days, accurately notify the physician of the resident's medical status to ensure necessary care and services were implemented to treat the resident, and to identify the seriousness of the resident's change in medical status and the need to immediately initiate emergency medical services (EMS) when the resident was identified as nonresponsive. EMS was not notified until hours after the resident was first observed as nonresponsive by a physical therapy staff member. Resident #22 was assessed by EMS with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. An Emergency Department (ED) physician assessment indicated Resident #22 was diagnosed with sepsis (a life-threatening complication of an infection) briefly explain and hyperglycemia. (Hyperglycemia is a medical condition in which the body's blood glucose level is higher than normal. High blood glucose happens when the body has too little insulin or when the body can't use insulin properly.) This was for one (Resident #22) of five residents reviewed for neglect. Immediate jeopardy began on 7/10/2024 when staff neglected to provide the necessary care and services to Resident #22 when she was identified as having a blood glucose reading of over 400 mg/dL. Immediate Jeopardy was removed on 9/9/2024 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #22 was originally admitted to the facility on [DATE] with multiple diagnoses some of which included dementia, type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, and hypertension. Resident #22 was readmitted to the facility on [DATE] after a hospitalization for the diagnoses of sepsis, urinary tract infection, and hydronephrosis. (Hydronephrosis is a medical condition characterized by excess fluid in a kidney due to blockage in the tube that connects the kidney to the bladder.) Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 was assessed as having adequate hearing and vision with clear speech. Documentation on the same assessment indicated Resident #22 was usually understood and usually had the ability to understand others. Resident #22 was coded as having the diagnosis of type 2 diabetes mellitus and received insulin injections for 7 days of the assessment period. Documentation on the care plan initiated on 6/22/2024 revealed a care plan description of Resident #22's risk for hypo/hyperglycemia and a diagnosis of diabetic retinopathy relative to a diagnosis of diabetes mellitus. One of the interventions was to observe signs and symptoms of hypo/hyperglycemia such as sweating, tremor, pallor, nervousness, headache, double vision, confusion, and or lack of coordination. Additional interventions were to perform blood glucose monitoring and medication/insulin as ordered. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (applied under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units; greater than 400 call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive 5 units of Semglee insulin solution to be injected subcutaneously one time a day at 8:00 PM for hyperglycemia. Semglee is a long-acting insulin used to treat high blood glucose levels for people with diabetes. Documentation on the July Medication Administration Record (MAR) for Resident #22 revealed on 7/9/2024 the blood glucose level was 399 and Medication Aide (Med Aide) #5 administered ten units of insulin at 6:22 PM. Med Aide #5, an agency employee, was interviewed on 9/5/2024 at 1:08 PM and revealed the following information. Med Aide #5 confirmed she did take the blood glucose reading of 399 on 7/9/2024 and that she did not administer insulin to Resident #22. Med Aide #5 did not recall who the licensed nurse was who was assigned to help her perform medication administration tasks out of her scope of practice on 7/9/2024. Med Aide #5 explained when she put the blood glucose reading into the electronic MAR, the administration of the insulin would also incorrectly go under her name. Med Aide #5 indicated she had to trust that the licensed nurse, to whom she reported the blood glucose level of Resident #22, would administer the correct insulin dose, document the administration, and notify a physician of any concerns if needed. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/9/2024 at 8: 24 PM. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or received Novolog insulin as ordered at 8:00 AM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. On the morning of 7/10/24 she was assigned for the 7:00 AM to 7:00 PM shift to the hallway which Resident #22 resided. Med Aide #4 was told Nurse #4 took care of administering medications for several people during the 7:00 PM to 7:00 AM shift ending on 7/10/2024. Resident #22 was one of those people who Nurse #4 told Med Aide #4 she had already administered the morning medications to. Med Aide #4 stated she expected Nurse #4 to document on the MAR the medications she was told had already been administered as an explanation for why there was no documentation of the Novolog insulin for Resident #22 at 8:00 AM on 7/10/2024. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered 10 units of Novolog insulin on 7/10/2024 at 1:43 PM to Resident #22, one hour and 43 minutes after the scheduled administration time. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 4:00 PM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 relayed the following information. Med Aide #4 explained that she could not remember which licensed nurse was assisting her on 7/10/2024 and confirmed she did not administer Novolog insulin to Resident #22 on 7/10/2024 at 1:43 PM. Med Aide #4 thought the licensed nurse, assisting her on 7/10/24, was Unit Manager #2. On 7/10/2024 the blood glucose level for Resident #22 read as HI or above 400 on the glucose monitor. (A reading of HI on a glucometer means the reading is above the level readable by the glucometer.) The licensed nurse who was assisting Med Aide #4 was told the blood glucose monitor was reading above 400 and the physician needed to be called. The licensed nurse told Med Aide #4 the physician ordered 12 units of Novolog insulin to be administered to Resident #22 and to keep checking the blood glucose level every hour. Med Aide #4 kept checking the blood glucose level every hour and reported to the licensed nurse the reading was still registering as above 400 mg/dL. Med Aide #4 thought the licensed nurse was going to document everything and take care of the 4:00 PM scheduled Novolog insulin administration on 7/10/2024 because of the blood glucose readings that were over 400 mg/dL, requiring a physician to be notified. Unit Manager #2 was interviewed on 9/10/2024 at 8:21 AM. Unit Manager #2 revealed the following information. Unit Manager #2 did recall Med Aide #4 contacting her about an elevated glucose level for Resident #22 on 7/10/2024. Unit Manager #2 revealed she assessed Resident #22 and thought she was dehydrated but was arousable and able to drink fluids. Unit Manager #2 stated she was very busy on 7/10/24, in addition to being the unit manager, the only registered nurse in the building, doing wound care, and admitting multiple residents, leaving her with little time for adequate coverage of the Med Aides in the building. Unit Manager #2 revealed she thought she sent a text to the physician for Resident #22 informing him of the elevated blood glucose levels on 7/10/2024. Unit Manager #2 stated she trusted the judgement of Med Aide #4 and felt she communicated effectively if she needed any assistance. Unit Manager #2 could not recall specifically what interventions were put in place on 7/10/2024 other than administration of insulin and fluids but would trust the recollections of Med Aide #4. Unit Manager #2 revealed she kept a small notebook with notes on which residents she had to go back and complete documentation on as a late entry. Unit Manager #2 thought perhaps Resident #22 having elevated blood sugars was one of those residents and she forgot to go back and document. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/10/2024 at 10:56 PM. There was no documentation in the electronic medical record of Resident #22 that any additional interventions were taken for the elevated blood glucose reading on 7/10/2024. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 8:00 AM on 7/11/2024. The facility nursing schedule dated 7/11/2024 indicated Nurse #7 was assigned to the hallway for which Resident #22 resided for the 12 hour day shift (7:00 AM to 7:00 PM). Nurse #7 was interviewed on 9/5/2024 at 2:37 PM. Nurse #7 stated she was an agency nurse who only worked at the facility on one occasion and that was 7/11/2024. Nurse #7 stated she did not recall what hall she was assigned to. Nurse #7 stated when she arrived at 7:00 AM on 7/11/2024, the scheduler handed her a stack of paper MARs and told her to go to the hall to begin the medication pass. Nurse #7 explained she was told she would not have access to the electronic medical record system. Nurse #7 revealed it was chaos, but she stayed. Nurse #7 further explained that at 2:30 PM she was approached by the Interim Director of Nursing (DON) with the electronic medical record system login information she needed and another stack of papers for a new admission she was expected to process. Nurse #7 said she handed the new admission paperwork back to the Interim DON and told her she wasn't doing it. Nurse #7 revealed she had never returned to the facility. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 stated she was assigned on 7/11/2024 for the 7:00 AM to 7:00 PM shift to another hall next to the hall which Resident #22 resided. Med Aide #4 revealed everything was a mess on the hallway which Resident #22 resided because there was an agency nurse (Nurse #7) who was trying to figure out the paper MAR and she was not giving medications. Med Aide #4 revealed the agency nurse (Nurse #7) left and was put on the do not return list. Documentation on the July MAR revealed Med Aide #4 obtained a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 11:47AM to Resident #22. Documentation on a physical therapy treatment encounter note for Resident #22 written by Physical Therapy Assistant (PTA) #1 on 7/11/2024 at 3:58 PM revealed, PTA facilitated that [Resident #22] get [out of bed] for the purpose of attempting goals. [Resident #22] responded [by demonstrating] extreme lethargy, incoherent mumbling, [nonresponsive] pupils/eye movement to bright light. PTA attempted to have [Resident #22] sit [on edge of bed] with [Resident #22 [demonstrating] inability to arise from sleep/difficulty to hold head. Nursing [Med Aide #4], DON, [Physical Therapist/Occupational Therapist] notified regarding [Resident #22's] decrease in status. Continue [with plan of care.] An interview was conducted with PTA #1 on 9/6/2024 at 4:45 PM. PTA #1 revealed the following information. PTA #1 stated she did not recall the exact time she went to see Resident #22 on 7/11/2024. PTA #1 confirmed she found Resident #22 in a nonresponsive condition on that day, so she went to the Med Aide on the hall, the interim DON, the Physical Therapist, and Occupational therapist to let them know of her concern for Resident #22. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 4:51 PM. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 confirmed she took the blood glucose readings for Resident #22 on 7/11/2024 at 11:47 AM and 4:51 PM. Med Aide #4 revealed that some of the blood glucose readings for Resident #22 were actually registering as HI or over 400 mg/dL while at least one of the readings she documented on the MAR on 7/11/2024 was actually 400 mg/dL. Med Aide #4 revealed the MAR did not allow Novolog insulin to be checked off as administered unless an actual number was entered into the MAR for the blood glucose reading. Med Aide #4 stated she had to put in 400 mg/dL although the reading may have been over 400 mg/dL. Med Aide #4 confirmed she told the licensed nurse who was assisting her on 7/11/2024 for the 12:00 PM and 4:00 PM administration time for the Novolog insulin, that the blood glucose levels were continuously HI. Med Aide #4 explained the licensed nurses were going into the MAR after she documented the blood glucose reading and using her login credentials to document the administration of insulin. Med Aide #4 was told by the licensed nurse on 7/11/2024 the physician had been contacted and ordered for Resident #22 to be monitored. Med Aide #4 did not recall who the licensed nurse was. Med Aide #4 confirmed PTA #1 informed her of concerns of the lack of response from Resident #22. Med Aide #4 stated she did tell the licensed nurse of what PTA #1 had said. Med Aide #4 stated she informed Unit Manager #2 and sent a text message to the interim DON about the continued blood glucose readings of over 400 mg/dL for Resident #22. Med Aide #4 stated she got a text message back from the interim DON that she would take care of it. Med Aide #4 stated that in report at the end of her shift on 7/10/24 and 7/11/24 she let Nurse #4 know Resident #22 was continually having blood glucose readings of over 400 mg/dL. Med Aide #4 indicated Nurse #4 did not seem to care, telling her that on the shift, 7:00 PM to 7:00 AM, when Nurse #4 worked, the blood glucose readings for Resident #22 were in the 200's mg/dL. Med Aide #4 stated, It just didn't make any sense to me but only the nurses can call the doctor. An interview was conducted with the responsible party (RP) for Resident #22 on 9/3/2024 at 3:42 PM and the following information was provided. On 7/8/2024 the RP checked on Resident #22 before going out of town and she was okay. The RP heard nothing all week from the facility. On 7/11/24 around 7:30 PM to 8:00 PM she saw she had several missed calls on her phone. She then picked up on the next one. It was from a private number. The person on the phone did not identify themselves but told the RP, You need to come now and check on your mother. It is an emergency. She needs to be sent out. The RP did not know what was going on because the facility did not notify her that Resident #22 was sick. The RP called another family member who was local to the facility and asked him to go to the facility to see Resident #22. The family member arrived at the facility around 8:30 to 8:45 PM to find Resident #22 was not responding. Nurse #4 walked into the room with a blood glucose monitor and said the doctor ordered Resident #22 to receive insulin, to monitor her blood glucose level, and call the doctor back in two hours. Since Resident #22 was not responding the family member insisted that Resident #22 be sent to the emergency room and finally Nurse #4 called emergency medical services (EMS). Later that night the interim DON called the RP wanting to know who had called her from the facility to let her know Resident #22 was not well. The RP stated she did not know who the anonymous phone caller was, but she was grateful she was contacted as it may have saved the life of Resident #22. The RP talked to the (former) Administrator about her concerns and the (former) Administrator informed the RP that the facility had learned that a physical therapy staff member had noted a change in the resident earlier that day. The (former) Administrator maintained that they did not have to let the family know if Resident #22 had elevated blood glucose levels, which did not make sense to her. If she had known that Resident #22's blood glucose levels were running high for several days she would have wanted her sent to the hospital to be checked. The RP felt the resident had been neglected and she had talked to the (former) Administrator about all her concerns. Documentation in the physician orders revealed an order dated 7/11/2024 at 7:00 PM for Resident #22 to be administered ten units of Humalog insulin solution to be injected subcutaneously one time only for a blood glucose exceeding 400 mg/dL and contact the physician in two hours. Humalog insulin is a fast-acting insulin which is absorbed quickly and starts working in about 15 minutes after injection to lower blood glucose levels. There was no documentation on the July MAR that the order for Humalog insulin was administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin to Resident #4 on 7/11/2024 at 8:58 PM. Documentation in the physician orders revealed an order dated 7/11/2024 at 9:00 PM for Resident #22 to be administered ten units of Novolog insulin solution subcutaneously one time for blood glucose exceeding 400 mg/dL and contact the physician in two hours. There was no documentation on the July MAR that the one-time order for Novolog insulin was ever administered to Resident #22 on 7/11/2024 after 7:00 PM. There was no other documentation in the electronic medical record of any vital signs taken of Resident #22 on 7/11/2024. Documentation in the nursing notes for Resident #22 dated 7/12/2024 at 9:48 AM by Nurse #4 revealed, Physician contacted due to blood glucose exceeding 400 [mg/dL] and order received from physician to administer 10 [units] of Humalog or Novolog and report back after 2 hours. After 2 hours, resident blood [glucose] reading still exceeded 400 [mg/dL] and physician made aware of results. Family arrived and RP requested for resident to be sent to [emergency room ] for evaluation. Physician made aware and order received to send resident to [emergency room ]. [Director of Nursing] made aware. An interview was conducted with Nurse #4 on 9/5/2024 at 6:04 PM. Nurse #4 relayed the following information and timeline of events for Resident #22 on the evening of 7/11/2024. Nurse #4 started her 7:00 PM to 7:00 AM shift at 7:00 PM on 7/11/2024. Nurse #4 received the information in a nursing report from Med Aide #4 that the blood glucose level of Resident #22 was above 400 mg/dL on the 4:00 PM medication pass. Nurse #4 denied she had any knowledge of the blood glucose level of Resident #22 being at or above 400 mg/dL for several shifts. Nurse #4 stated she assessed Resident #22 and took her vital signs at the start of her shift. Nurse #4 revealed the blood glucose level of Resident #22 was registering as HI or over 400 mg/dL on the glucometer, a device to measure blood glucose levels. Nurse #4 revealed the vital signs of Resident #22 were fine, so she called the on-call physician. Nurse #4 stated she received an order from the physician to administer 10 units of fast acting insulin to Resident #22 and call the physician back in two hours. Nurse #4 stated she went back to check on Resident #22 again at 9:00 PM and all her vital signs were fine. Resident #22 did not have a temperature, elevated blood pressure, or an elevated heart rate. Nurse #4 stated her blood glucose level was still registering as HI or above 400 mg/dL on the glucometer. Nurse #4 was adamant Resident #22 was fine and was responsive. Nurse #4 related that when she pricked the finger of Resident #22 with the lancet, the resident looked at her and rolled her eyes. Nurse #4 stated the family of Resident #22 arrived at the facility stating they received a phone call from an unknown caller telling them something was wrong with Resident #22, and she needed to be sent to the emergency room . The family of Resident #22 looked at Resident #22 and demanded she be sent to the emergency room . Nurse #4 stated she did not know who called the family because the breathing and vital signs for Resident #22 were normal. Nurse #4 reported she was about ready to call the physician because of the elevated blood glucose reading, so she called the physician, and the physician agreed Resident #22 could be sent out per the family wishes. Nurse #4 relayed that she did all her documentation for the residents at the end of her shift so that all the events of the shift for each resident could be documented, for an explanation for why her nursing note for Resident #22 was dated 7/12/2024, the day after Resident #22 discharged from the facility. An interview was conducted with the interim DON on 9/5/2024 at 1:58 PM. The interim DON stated she was not made aware of any concerns with the blood glucose levels of Resident #22 until the RP called her on the evening of 7/11/2024 at approximately 8:00 PM or 8:30 PM. The interim DON was told by the RP of a phone call she received from a facility staff member telling her Resident #22 was very ill and needed to be sent to the hospital. The interim DON relayed she called Nurse #4 and was told Resident #22 was still at the facility and was fine. The interim DON further revealed Nurse #4 had explained the following interventions for Resident #22. An assessment had been completed by Nurse #4 revealing an elevated blood glucose level, lethargy, vital signs were fine, the physician was called for orders, and Resident #22 was responsive. The interim DON stated she knew the blood glucose level of Resident #22 was high in the moment on the evening of 7/11/2024 but she was not aware the blood glucose level had been HI over several shifts. Documentation on an Emergency Medical Services (EMS) report dated 7/11/2024 revealed 911 was called at 9:17 PM and arrived at room of Resident #22 at 9:37 PM. The following information was revealed in the EMS report. Upon arriving at the scene, the facility staff stated Resident #22 had been having an elevated blood glucose level all day and had been alert but not acting like herself. The facility staff also told EMS they had been giving Resident #22 insulin as instructed by the resident's physician with no changes in the reading level of HI on the glucose monitor. EMS noted Resident #22 had a glucose reading of HI on their glucose monitor as well. EMS documented Resident #22 as having a heart rate of 140 with respirations in the 40s. Once in the ambulance, Resident #22 remained unresponsive. Documentation on a hospital record dated for a 7/11/2024 admission revealed Resident #22 was diagnosed with sepsis, hyperglycemia, altered mental status, acute renal failure, dehydration, and a urinary tract infection in the emergency room . Resident #22 was discharged from the hospital on 7/24/2024 into the care of the RP with home health services, per the RP's request. An interview was conducted with MD #2, the physician for Resident #22, on 9/9/2024 at 1:12 PM. MD #2 stated he could not recall if he was notified of the elevated blood glucose levels of Resident #22 on 7/9/2024, 7/10/2024, or 7/11/2024. MD #2 explained that if he had been notified of elevated blood glucose levels for Resident #22 during normal business hours, he would have ordered a change in the amount of fast-acting insulin to be administered and requested a call back if there was no change after continuous monitoring of the resident. MD #2 indicated that if those orders did not exist on 7/10/2024 or 7/11/2024 during the day shift then it was likely he was not notified. MD #2 stated he did not recall receiving a phone call on the evening of 7/11/2024 from Nurse #4, but he received phone calls of that type routinely making it difficult to recall a specific phone call of that type for a resident. MD #2 stated that a blood glucose level of 400 mg/dL was not good, but having a blood glucose level of 400 mg/dL was an isolated event for this resident making it likely an underlying medical condition was occurring for which he would have had to figure out. The facility's medical director was interviewed on 9/9/24 at 4:19 PM and details of how the staff had failed to respond to Resident # 22's multiple readings of high blood glucose readings and unresponsiveness prior to EMS transport were discussed with the medical director. The medical director reported facility staff had not shared with him any incidents which would indicate Resident # 22 had been neglected and he was unaware of what had transpired with Resident # 22. On 9/9/24 at 5:04 PM the facility Administrator and Corporate Nurse Consultant were notified of Immediate Jeopardy based on findings related to Resident # 22. On 9/10/24 the facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #22 was admitted to the facility on [DATE] and discharged on [DATE]. Between the original admission and discharge, she was readmitted on [DATE]. The most recent readmission, she was readmitted with diagnoses that included: Type 2 diabetes with diabetic retinopathy without macular edema (a complication of diabetes that can cause vision loss and blindness), schizoaffective disorder, dementia, chronic embolism (long-term condition where one or more blood clots block the pulmonary arteries), and thrombosis of distal lower extremity (a blood clot condition that forms within the deep veins, usually of the leg, but can occur in the arms). Review of Resident #22's Medication Administration Records (MAR), indicates; on 7/10/24 at 1:43pm the medication aide (MA #4) notified Unit Manager #2 that Resident #22 had blood glucose levels registering over 400. No evidence that the physician was notified. Resident #22's MAR indicates that Resident #22 received 10 units of Novolog insulin at 1:43pm. Further review of Resident #22's MAR indicates; on 7/11/2024, at 11:47 am, Resident #22's blood glucose was documented to be 400 and 10 units of fast-acting insulin were administered, no evidence that the physician was notified. Review of the Physical Therapy Assistant documentation on 7/11/24 at 3:38 PM indicated the resident was non-responsive, and the Director of Nursing was notified. No documentation of actions taken, no evidence that the physician was notified. The Director of Nursing who was informed is no longer working at the facility. On 7/11/24 at 4:51pm blood glucose documented by MA #4 to be 400. The MAR indicates Resident #22 received 10 units of Novolog insulin. No indication that the physician was notified, or anything else was done. Review of progress notes documented on 7/12/2024 (late entry for 7/11/2024), in Resident #22's medical records indicate (in part); Nurse #4 contacted physician due to Resident #22 blood glucose exceeding 400. An order was received from the physician to administer ten units of Humalog or Novolog and report back after 2 hours. After two hours, Resident #22's blood glucose reading still exceeded 400 and the physician made aware of results, the note added. Resident #22's family arrived and requested that Resident #22 to be sent to the hospital for evaluation. The physician made aware, and the order received to send resident to hospital, documentation concluded. A phone interview was conducted on 09/07/2024 by the Assistant Director of Nursing. Nurse #4 indicated; she contacted physician around 7:10pm on 7/11/2024 due to Resident #22's blood glucose exceeding 400. Nurse #4 added she received an order to administer ten units of Humalog or Novolog and report back after 2 hours. Nurse #4 indicated that she recalled Administering 10units of Novolog to Resident #22 per physician order. Nurse #4 further added that, at approximately 9:00pm, she rechecked Resident #22's blood glucose, the reading still exceeded 400. She added the physician was made aware of the results at approximately 9:03pm. Per Nurse #4, Resident #22's family arrived at approximately 9:05pm and requested for Resident #22 be sent to the hospital. The physician was made aware of the request at approximately 9:10pm, and the order was received to send the resident to hospital, Nurse # 4 contacted EMS at 9:17pm, interview concluded. EMS arrived on scene at 9:32pm. Resident #22 was still non-responsive when EMS arrived. Per EMS report, Resident #22 was found with an elevated heart rate of 140, respirations in the 40s, and with a continued reading of a blood sugar in excess of 400 at time of transport. Resident #22 was sent to the hospital for further evaluation and treatment, Resident #22 left the facility at approximately 9:53pm. Resident #22 is no longer in the facility. No other actions taken. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 09/06/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. For Resident #22, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice on managing repeated episodes of hyperglycemia for Resident #22 who was non-responsive on 7/11/2024. The RCA further identified that the facility failed to have a system in place medication aides to be informed of the licensed nurse responsible to oversee them while on duty. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. On 7/11/2024, the former Administrator completed an initial report to the State agency and completed the investigation on 7/15/2024 for Resident #22. The allegation was unsubstantiated. Per investigation report completed on 7/15/2024, the allegation for Resident #22 was not reported to law enforcement and Adult Protective Services (APS). The former Administrator is no longer employed at the facility. On 09/09/2024 the new Administrator has been educated by the [NAME] President of Operation on reporting requirements to include reporting to Law enforcement and APS. Clinical assessments of all current residents in the facility were completed on 09/07/24 by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator (#1 or #2) to identify any other resident with the change condition that require medical attention. The clinical assessment focused on resident's vital signs to include, blood pressure reading, pulse, respiration rate, temperature, and/or presence [TRUNCATED]

Based on observation, record review, and interviews with resident, staff, and Nurse Practitioner the facility failed to ensure Resident # 1 was afforded dignity while residing in the facility. Resident # 1, who was documented to be a bedbound resident, was found with multiple maggots located in her bed, under her breast, and within her contracted hand. Prior to the maggots being found on Resident # 1, staff had observed multiple flies in the resident's room, landing on the resident, and in other parts of the facility. This was for one (Resident # 1) of five residents reviewed for respectful treatment by staff. (Resident # 1 had mental illness and was unable to express harm a reasonable person would express if they had multiple maggots located on them while relying on others for care. Therefore, the reasonable person concept was applied in determining severity to this citation). The findings included: Resident # 1 was admitted to the facility on [DATE] and had diagnoses in part which included a degenerative neuromuscular disease and bipolar disorder with psychotic features. Resident # 1's quarterly Minimum Data Set assessment, dated 6/19/24, coded Resident # 1 as cognitively intact and as being totally dependent on staff for bathing, dressing, hygiene, and bed mobility. Review of nursing notes revealed an entry by Nurse # 1, dated 8/11/24 (Sunday) at 5:57 PM, noting a new order for Resident # 1's care. The nurse documented, Noted right hand contracture below the fingers cleanse with wound cleanser Xerofoam drsg (dressing) apply then cover with dry dressing change Tuesday, Thursday, Saturday and PRN (as needed). Nurse #1 also noted the resident's family was called and notified. The note did not signify the problem with the hand other than the resident had a contracture. On 8/13/24 (Tuesday) Nurse Practitioner # 1 documented she saw Resident # 1 and noted the following information. The resident was grimacing when her hand was touched. She was a bedbound resident and was being seen for follow up after living larvae had been identified in her right hand/fingers and manually removed. Hygiene care had been provided and an antibiotic ointment applied. Oral antibiotics had been initiated also. At the time NP # 1 saw the resident the resident had no agitation or anxiety and was at her baseline. There was mild swelling of her right hand fingers, and fingers 3 to 4 were tender to touch. There was no drainage or redness. Nurse # 1 was interviewed on 8/30/24 at 5:45 PM and reported the following. During the weekend prior to Resident # 1 being seen by the NP on 8/13/24 (Tuesday), the resident had been complaining of her hand hurting. She had a contracted hand. She (Nurse # 1) soaked the resident's hand and did the best to clean the hand. Resident # 1 had a carrot device that she was to keep in the hand for the contracture, but the resident did not always keep the carrot in her hand. The Nurse Aides said the resident would refuse care at times. At the time she saw Resident # 1 on the weekend, there were no maggots in her hand. The weekend Treatment Nurse was interviewed on 8/31/24 at 9:30 AM and reported the following information. On 8/11/24 MA (Medication Aide) # 1 told her Resident # 1 had some dried blood on her hand. The weekend Treatment Nurse also knew that on 8/10/24 (Saturday) Nurse # 1 said that therapy had been working with the resident and her hand was bleeding. Resident # 1 had a carrot device to keep in her hand for her contracture. On Saturday, Nurse # 1 took care of the resident's hand because she (the weekend treatment nurse) had been busy. When she (the weekend treatment nurse) saw Resident # 1's hand on 8/11/24 (Sunday) there was no active bleeding. In her right contracted hand, the resident had fragile skin where she had previous skin breakdown. Within the fragile skin the resident appeared as if she had a very small puncture wound from her fingernails being against the palm of her skin. She (the weekend treatment nurse) used a cotton tipped swab to clean the wound and she applied a dressing. At the time she did not see any signs of maggots in the resident's hand or wound. The resident had refused to have her nails trimmed and cared for. She had seen flies in Resident # 1's room and she had also seen flies in other parts of the facility landing on people. MA # 1 was interviewed on 8/29/24 at 2:38 PM and reported the following information. She had cared for Resident # 1 both on 8/10/24 (Saturday) and 8/11/24 (Sunday). On 8/10/24 (Saturday) Resident # 1's Nurse Aide (NA) had told her that it appeared as Resident # 1's hand was bleeding. She told Nurse # 1. On 8/10/24 (Saturday) there were a lot of flies in Resident # 1's room. MA # 1 estimated there were about 12 or so flies in the room on that date. She (MA # 1) was swishing, swishing, swishing trying to get them away from the resident and out of her room to the best of her ability. Flies would land on the resident, who tended to keep food items resting on her chest as she ate in the bed. MA # 1 also was aware blood from the resident's hand might attract the flies to her. The Maintenance Director was aware flies were in the facility. It was her understanding that the problem with flies had been added to the maintenance log and he had been told multiple times. She (MA #1) could not go to the nursing desk and sit down without flies following her. On Sunday 8/11/24, she knew the weekend Treatment Nurse had cared for Resident # 1's hand and cleaned it well. She (MA # 1) never saw maggots on Resident # 1 during the weekend. According to staffing records, Nurse # 8 had cared for Resident # 1 on the shift which began at 11:00 PM on 8/11/24 (Sunday night). Nurse # 8 was interviewed on 8/29/24 at 7:56 PM and reported she had not seen maggots on Resident # 1 during her Sunday night shift which began on 8/11/24. She had not seen flies in the room. MA # 2 was interviewed on 8/29/24 at 3:21 PM and reported the following information. She had been assigned to care for Resident # 1 on 8/12/24 (Monday) when the maggots were found on Resident # 1. She had started her medication pass when Resident # 1's Nurse Aide #2 came to her and reported Resident # 1 had maggots on her. She (MA # 2) alerted a nurse who also alerted the former DON (Director of Nursing). On 8/12/24 MA # 2 had seen a fly in Resident # 1's room. MA # 2 reported the room did not appear to be infested with flies when she was there. Nurse Aide # 2, who had been assigned to care for Resident # 1 on 8/12/24 (Monday), was interviewed on 8/29/24 at 7:47 PM and reported the following information. On 8/12/24 she was turning and providing a bath for Resident # 1 when she saw maggots in the bed. She went to Unit Manager # 1 to report the issue and they both looked and saw the maggots. Then the ADON (Assistant Director of Nursing) and former DON (Director of Nursing) were asked to come and help. At the time NA # 2 recalled seeing at least three in the resident's bed and at least one on her body. The DON picked the maggots off the resident. The resident's hand was contracted at the time and the resident was holding a gauze pad in her hand. She (Nurse Aide #2) had not seen the maggots in her hand. The resident had pain in her hand and did not want staff to do anything with the hand on that day. Prior to 8/12/24, the resident would at times refuse care to her hand if she did not know the staff member well who was trying to provide care. She (Nurse Aide # 2) left at 3:00 PM on 8/12/24 and did not know what happened with the resident' s hand after that. She did see flies everywhere in the facility and had seen them at times land on residents. Nurse Aide # 1 was interviewed on 8/29/24 at 4:40 PM and reported the following information. She had been working on 8/12/24 and had helped Nurse Aide # 2 with Resident # 1. She knew NA # 2 had been told to clean the resident's bed and body. She (NA #1) saw multiple maggots on the resident and in her bed as she was helping care for the resident. It was her understanding the maggots had crawled out from the resident's hand. The higher ups (including the former DON) had been present in the room to deal with the maggots. Flies had been a problem in the facility. She (NA # 1) saw them daily and they would at times land on residents. Unit Manager # 1 was interviewed on 8/31/24 at 10:38 AM and reported the following information. She had heard about the maggots being on Resident # 1, and the former DON had dealt with the maggots. When she was called into the room, she (Unit Manager # 1) pulled back the covers but did not personally see them. NA # 3, who at times cared for Resident # 1, was interviewed on 8/29/24 at 12:40 PM and reported the following information. She had never witnessed maggots in Resident # 1's hand. She did know the resident's hand hurt at times and she would not allow the staff to care for the hand at times. She (NA # 3) did see flies in the facility. She saw flies all the time and she was aware residents complained about them. The ADON (Assistant Director of Nursing) was interviewed on 8/29/24 at 11:30 AM and reported the following information. It was her understanding that the maggots had been found when the resident was being given a bath one day. The former DON (Director of Nursing) had dealt with the issue and given direction to the wound nurse to assess and clean the resident's hand. The facility's weekday treatment nurse was interviewed on 8/30/24 at 5:15 PM and reported the following information. She (the weekday treatment nurse) had been told the resident had maggots in her hand on 8/12/24 (Monday). She had not personally seen them. She had not witnessed flies landing on Resident # 1, but she had seen flies in her room. She had also seen them in the facility on a daily basis. Resident # 1 was interviewed and observed on 8/29/24 at 8:20 AM. At the time she was observed to have a right hand contracture. When interviewed about her care in general, the resident did not initially bring up the maggots during conversation. She tended to wander in her conversation from topic to topic. While talking about something else, she abruptly mentioned she had neuropathy in her hand and at one time had maggots in her hand. She then went off topic again and did not expound further. Interview with the Maintenance Director on 8/29/24 at 4:20 PM revealed he had been employed at the facility for about a month. He had not been aware there had been a problem with a specific resident having any medical issues related to flies in their room. He was aware there were flies in the facility and he had called a pest control company, and the company's technician had not visited that month as of 8/29/24. The former DON, who had reportedly removed the maggots, was not available for interview during the survey. Nurse Practitioner # 1 (NP#1) was interviewed on 9/5/24 at 8:55 AM and reported the following information. She had been called on 8/12/24 and told the resident had maggots on her. She had been informed that there had been approximately 26 maggots removed from her. At the time she was called, she was told that the resident's hand had been cleaned with soap and water, a triple antibiotic topical cream had been applied to her hand, and the resident was not in distress. On 8/13/24 she saw the resident for evaluation. The resident was placed on an antibiotic to prevent any problems. The resident was considered to be cognitively intact but also had some mental illness. The resident tended to talk to non-existent people at times and when she (NP # 1) tried to talk to Resident # 1 on 8/13/24 the resident was doing so. The resident also had some short term memory problems. During the 8/13/24 assessment, there was a disruption of the resident's nail bed on fingers three and four of her right hand. She (NP #1) could tell the maggots had been under the nails and in the nail bed. There was some slight inflammation around the nail beds and no wound in the palm of her hand at the time of assessment. The resident had not been aware the maggots had been in her hand before they were identified on 8/12/24. Due to the resident's medical diagnoses, the resident did not have the sensation in the hand to detect that they had been in her hand, and she did not have the mobility to move away from flies. The resident tended to keep snacks in her room. If she had gotten some food in her hand without adequate hygiene, then flies could have landed on her hand and laid eggs. It did not take long for a fly to do this. When she assessed Resident # 1's hand on 8/13/24 there was some warmth around her hand which involved her wrist and palm as well. This appeared to have come from the maggots being in her hand and the NP estimated from the amount of inflammation in the hand, she felt the maggots had been in her nail beds and under her fingers for at least 24 to 48 hours prior to being removed. She did have some routine pain in her contracted hand but some of the pain she was reporting at time of assessment on 8/13/24 was also due to the maggots being in her hand. The resident tended to not be trusting of staff if she did not know them due to her mental illness. If she had refused care, her distrust of some new staff members may have contributed to refusal of hygiene. The NP felt the staff should be patient and try to build a trusting relationship with the resident so she would consistently accept hygiene assistance. The facility's corporate Nurse Consultant was interviewed on 8/30/24 at 6:00 PM. According to the Corporate Nurse Consultant the former DON had not informed the Administrator or corporate employees of any problems with the resident having maggots in her bed and on her. If the former DON had done so, the issue of flies in the building would have been addressed and a plan to prevent the problem from reoccurring would have been initiated. He had learned that day that the facility did not have a pest control contract with a service provider. When the facility recently underwent new ownership, there had been miscommunication with the pest control company and the service contract had not been extended. The facility had not had pest control services since 5/15/24.

Based on observation, record review, and interviews with residents, staff, family, and a pest control technician the facility failed to ensure they maintained routine and as needed pest control services for the entire facility. Two of twenty-seven sampled residents were affected by flies. Resident # 24 was observed trying to eat while four flies kept landing on her food. Resident # 1 was found by staff to have multiple maggots on her and in her bed during the timeframe during which the facility was without a service contract and during which time staff members, residents, and family were observing multiple flies in the facility. (Resident # 1 had mental illness and was unable to express harm a reasonable person would express if they had multiple maggots located on them while relying on others for care. Therefore, the reasonable person concept was applied in determining severity to this citation). The findings included: 1. Resident # 1 was admitted to the facility on [DATE] and had diagnoses in part which included a degenerative neuromuscular disease and bipolar disorder with psychotic features. Resident # 1's quarterly Minimum Data Set assessment, dated 6/19/24, coded Resident # 1 as cognitively intact and as being totally dependent on staff for bathing, dressing, hygiene, and bed mobility. On 8/13/24 Nurse Practitioner # 1 documented she was seeing the resident, who was bedbound, because living larvae had been identified on the resident and removed. Nurse Practitioner # 1 (NP#1) was interviewed on 9/5/24 at 8:55 AM and reported the following information. She had been called on 8/12/24 and told Resident had approximately 26 maggots on her, which facility staff removed. On 8/13/24 she assessed the resident and found she had some signs of inflammation in her hand because of the maggots. From her assessment, she could tell that the maggots had been in the resident's nailbed and underneath her fingernails. She tried to talk to the resident on 8/13/24 but the resident had mental illness and was talking to nonexistent people at the time of her assessment. The resident had not been aware the maggots had been in her hand before they were identified on 8/12/24. Due to the resident's medical diagnoses, the resident did not have the sensation in the hand to detect that they had been in her hand, and she did not have the mobility to move away from flies. The resident tended to keep snacks in her room. If she had gotten some food in her hand without adequate hygiene, then flies could have landed on her hand and laid eggs. It did not take long for a fly to do this. The weekend treatment nurse was interviewed on 8/31/24 at 9:30 AM and reported the following information. On 8/11/24 MA (Medication Aide) # 1 told her Resident # 1 had some dried blood on her hand. The weekend treatment nurse also knew that on 8/10/24 (Saturday) Nurse # 1 said that therapy had been working with the resident and her hand was bleeding. On Saturday, Nurse # 1 took care of the resident's hand because she (the weekend treatment nurse) had been busy. When she (the weekend treatment nurse) saw Resident # 1's hand on 8/11/24 (Sunday) there was no active bleeding. In her right contracted hand, the resident had fragile skin where she had previous skin breakdown. Within the fragile skin the resident appeared as if she had a very small puncture wound from her fingernails being against the palm of her skin. She (the weekend treatment nurse) used a cotton tipped swab to clean the wound and she applied a dressing. At the time she did not see any signs of maggots in the resident's hand or wound. She had seen flies in Resident # 1's room and she had also seen flies in other parts of the facility landing on people. MA # 1 was interviewed on 8/29/24 at 2:38 PM and reported the following information. She had cared for Resident # 1 both on 8/10/24 (Saturday) and 8/11/24 (Sunday). On 8/10/24 (Saturday) Resident # 1's Nurse Aide (NA) had told her that it appeared as Resident # 1's hand was bleeding. She told Nurse # 1. On 8/10/24 (Saturday) there were a lot of flies in Resident # 1's room. MA # 1 estimated there were about 12 or so flies in the room on that date. She (MA # 1) was swishing, swishing, swishing trying to get them away from the resident and out of her room to the best of her ability. Flies would land on the resident, who tended to keep food items resting on her chest as she ate in the bed. MA # 1 also was aware blood from the resident's hand might attract the flies to her. The maintenance director was aware flies were in the facility. It was her understanding that the problem with flies had been added to the maintenance log and he had been told multiple times. She (MA #1) could not go to the nursing desk and sit down without flies following her. On Sunday 8/11/24, she knew the weekend treatment nurse had cared for Resident # 1's hand and cleaned it well. She (MA # 1) never saw maggots on Resident # 1 during the weekend. MA # 2 was interviewed on 8/29/24 at 3:21 PM and reported the following information. She had been assigned to care for Resident # 1 on 8/12/24 (Monday) when the maggots were found on Resident # 1. She had started her medication pass when Resident # 1's Nurse Aide came to her and reported Resident # 1 had maggots on her. She (MA # 2) alerted a nurse who also alerted the former DON (Director of Nursing). On 8/12/24 MA # 2 had seen a fly in Resident # 1's room. Nurse Aide # 2, who had been assigned to care for Resident # 1 on 8/12/24 (Monday), was interviewed on 8/29/24 at 7:47 PM and reported she had found maggots on Resident # 1 while she was providing care. She saw flies everywhere in the facility and had seen them at times land on residents. Nurse Aide # 1 was interviewed on 8/29/24 at 4:40 PM and reported the following information. She had been working on 8/12/24 and had helped Nurse Aide # 2 with Resident # 1. She (NA # 2) saw multiple maggots on the resident and in her bed as she was helping care for the resident. It was her understanding the maggots had crawled out from the resident's hand. The higher ups (including the former DON) had been present in the room to deal with the maggots. Flies had been a problem in the facility. She (NA # 1) saw them daily and they would at times land on residents. NA # 3, who at times cared for Resident # 1, was interviewed on 8/29/24 at 12:40 PM and reported the following information. She had never witnessed maggots on Resident # 1. She saw flies all the time in the facility and she was aware residents complained about them. The facility's weekday treatment nurse was interviewed on 8/30/24 at 5:15 PM and reported the following information. She (the weekday treatment nurse) had been told the resident had maggots in her hand on 8/12/24 (Monday). She had not personally seen the maggots. She had not witnessed flies landing on Resident # 1, but she had seen flies in her room. She had also seen them in the facility on a daily basis. Resident # 1 was interviewed on 8/29/24 at 8:20 AM. At the time she was observed to have a right hand contracture. When interviewed about her care in general, the resident did not initially bring up the maggots during conversation. She tended to wander in her conversation from topic to topic. While talking about something else, she abruptly mentioned she had neuropathy in her hand and at one time had maggots in her hand. She then went off topic again and did not expound further. The former DON, who had reportedly removed the maggots, was not available for interview during the survey. On 8/29/24 at 1:10 PM an interview was conducted with a randomly interviewed family member of a resident (Resident # 25). This resident also resided on the unit where Resident # 1 resided. The family member reported she visited often and saw flies all the time. She further commented they would land on the resident and on the resident's food and she was constantly fanning the resident's food to keep them away. During a random observation made on a different unit (Station 2) other than the unit on which Resident # 1 resided, it was observed on 8/31/24 at 8:10 AM that a fly was hovering over the meal tray carts waiting to be served to residents on the hall. Interview with the Maintenance Director on 8/29/24 at 4:20 PM revealed he had been employed at the facility for about a month. He had not been aware there had been a problem with a specific resident having any medical issues related to flies in their room. He was aware there were flies in the facility and he had called a pest control company, and the company's technician had not visited that month as of 8/29/24. The Maintenance Director named the company he had called and indicated they would be out the next week. The Maintenance Director was interviewed about current strategies to keep flies out of the facility and reported he thought there were fly curtains (heavy duty fans that blast air away from doors which lead outside) on two to three doors. The maintenance director was accompanied as the exit doors in the facility were observed. There was one door observed to have a working fly curtain leading to the exit. There were no fly curtains on exit doors leading to the inner courtyard or on the front door of the facility. The facility's corporate Nurse Consultant was interviewed on 8/30/24 at 6:00 PM. According to the Corporate Nurse Consultant the former DON had not informed the Administrator or corporate employees of any problems with the resident having maggots in her bed and on her. If the former DON had done so, the issue of flies in the building would have been addressed and a plan to prevent the problem from reoccurring would have been initiated. He had learned that day that the facility did not have a pest control contract with a service provider. When the facility recently underwent new ownership, there had been miscommunication with the pest control company and the service contract had not been extended. The facility had not had pest control services since 5/15/24 in the facility. They had called that day (8/30/24) to set services up again. The corporate Nurse Consultant reported the Maintenance Director may have called someone to come out who did not have a contract with them, while not recognizing that the contract needed to be reset with the previous company. A technician for the pest control company, which had a contract with the facility up until May 2024, was interviewed on 9/4/24 at 1:50 PM. The technician reported the following information. One of the most important things to do in controlling flies in the facility was to inspect where flies were coming from and try to eliminate a source of problems. That was part of his job when he went to facilities. Given he had not been to the facility in recent months, he was not aware from where the problem might be originating. In general, when he did go to facilities, in addition to finding and eliminating the source, he tried to install fly lights and glue boards which might bait and trap flies that might make their way into the facility. There were different kinds of flies, and at times he also considered taking a sample to differentiate what kind of fly was causing problems. 13030 2. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses one of which included mild cognitive impairment. Documentation on a skilled daily nursing documentation form dated 8/28/2024 revealed Resident #24 was assessed as oriented to person and place with a cognitive status that varied. The following observation and interview were conducted with Resident #24 on 8/28/2024 at 1:18 PM. Resident #24 was observed to be sitting up in bed with her lunch meal in a Styrofoam container in front of her on her bedside table. Resident #24 stated, There are always flies in here 24 hours a day, 7 days a week. Resident #24 was observed attempting to put a fork full of food into her mouth as four flies were landing on and flying around her lunch meal. Resident #24 attempted to brush the flies off her food with her hand, but the flies continued to land on her food intermittently.

Based on record review, staff, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #3 refused to assist Resident #2 with eating her meal at lunch time and then yelled at Resident #2 when her lunch tray fell on the floor. Nurse #2 observed the resident shaking and crying after the incident with NA #3. This occurred for 1 of 2 residents reviewed for dignity and respect. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness, arthritis in the right shoulder, and post left shoulder surgery. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was moderately cognitively impaired and required substantial to maximal assistance with eating. There were no behaviors documented on the MDS. The facility's initial allegation report dated 1-2-24 for an incident occurring on 1-1-24 documented Resident #2 reported NA #3 had refused to feed her after Resident #2 had requested help with eating and that NA #3 spoke in a loud voice to Resident #2. The allegation report also documented Resident #2 had shoulder surgery and that Resident #2 had stated she had difficulty feeding herself. Resident #2 was interviewed on 1-10-24 at 11:45am. Resident #2 explained on 1-1-24 NA #3 had brought her lunch tray and sat the tray on her table. The resident stated she told NA #3 that she needed to have help eating and she said NA #3 had told her No you can feed yourself. The resident stated NA #3 left the room and when she tried to feed herself, she accidentally knocked her tray on the floor before she was able to eat any of her lunch. Resident #2 stated when NA #3 answered her call light, NA #3 told her You did it on purpose and began screaming at her. The resident said she told NA #3 to leave her room because she did not want to be screamed at and NA #3 left the room. The resident explained Nurse #2 came in later and cleaned up the spilled lunch tray, brought her a new lunch tray, and assisted her in eating. Resident #2 stated a couple of days later NA #3 came to her room to help her eat her soup. She said NA #3 said to her I don't want a hissy fit anymore. The resident discussed taking a couple of spoonful's of soup and then told NA #3 she was done because she was afraid the NA may do something. Resident #2 stated when the incident on 1-1-24 occurred, she was upset and crying. Nurse #2 was interviewed on 1-10-24 at 12:05pm. The nurse confirmed she had been assigned to Resident #2 on 1-1-24. Nurse #2 discussed not being aware of the incident with NA #3 until a short time later when she entered Resident #2's room and found her shaking and crying. She said Resident #2 had told her NA #3 had refused to help her eat and then yelled at her when she accidentally knocked her tray on the floor. The nurse stated Resident #2 told her she had not received another lunch tray and was hungry, so the nurse said she had obtained a lunch tray for Resident #2 and assisted her in eating. Nurse #2 stated Resident #3 had never showed any behaviors and had not had any incidences with any other NA. Nurse #2 stated she had reported the incident to the Director of Nursing (DON) as soon as she was finished assisting Resident #2 and was told by the DON to educate NA #3 on customer service. The nurse discussed not providing the education to NA #3 because she kept walking away from me. She explained when Resident #2 was admitted , she needed assistance in eating due to her shoulder surgery and the NAs were aware through the staff's morning report that Resident #2 needed assistance. Nurse #2 also explained Resident #2 needed assistance with eating up until a week and a half ago when the resident had progressed in her treatment and could now feed herself. A telephone interview occurred with NA #3 on 1-10-24 at 1:40pm. NA #3 confirmed she had been assigned to Resident #2 on 1-1-24. The NA explained she had brought Resident #2 her lunch tray and the resident had asked her to help feed her. NA #3 said she told the resident No because Resident #2 could feed herself. The NA stated right after she walked out of Resident #2's room she heard a noise, so she went back into the room and saw Resident #2's lunch tray on the floor. NA #3 stated Resident #2 told her See I told you I can not feed myself. The NA explained she started cleaning up the lunch tray from the floor and Resident #2 began yelling and cussing at me and then asked me to leave. NA #3 said she had reported the incident to Nuse #2. The NA stated she had been assigned to Resident #2 prior to the incident on 1-1-24 and did not have any issues. NA #2 was interviewed on 1-10-24 at 12:28pm. NA #2 stated she was familiar with Resident #2 and aware the resident required assistance in eating until 1.5 weeks ago when Resident #2 had progressed well enough to feed herself. She stated she was made aware of the requirement to assist Resident #2 in eating during the staff's morning report. The NA discussed not working on 1-1-24 but stated she had never heard of Resident #2 throwing her meal tray on the floor or yelling at any staff member. During an interview with the Administrator and DON on 1-10-24 at 1:29pm, the DON discussed speaking with NA #3 on 1-2-24 and the NA had told her Resident #2 had refused to allow NA #3 to assist her with her meal and then the resident threw her lunch tray on the floor. The DON also stated NA #3 told her she had not raised her voice at Resident #2. The Administrator discussed training being provided to all staff on dignity/respect and customer service prior to the incident and did not know why the incident occurred as NA #3 had not had any issues with customer service prior to the incident on 1-1-24.

Based on observations, record review and staff interviews the facility failed to treat a resident in a dignified manner when staff used a racial slur and vulgar hand gesture when interacting with a resident (Resident #97) for 1 of 1 resident reviewed for dignity. The findings included: Resident #97 was admitted to the facility on [DATE]. Resident #97's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no behaviors documented. During an interview on 11/27/23 at 1:06 PM Resident #97 stated his son came to visit the day before Thanksgiving. He heard that his son did something to a door by the nursing station and staff were walking him out and a nurse and his son exchanged words and an altercation ensued in which his son hit a nurse. The next day, Nurse #2 came to his room, opened the door, and asked him why he let his son come in and do what he did. Then she said, you white cracker in a conversational tone to conceal it, and stuck her middle finger up at him. After that, she left. He stated it made him feel like shit because she asked why he let his son up here when he was stuck in bed after having a stroke. The Administrator came to him the next morning, 11/24/23, to ask him about the incident. He told her about the incident, and she told him he did not need to worry about his safety and that she was going to take care of it. She then got a statement from him. During an interview on 11/28/23 at 10:19 AM Nurse #2 stated on 11/23/23 she was out in the hallway talking on the phone by Resident #97's room and she was speaking with her daughter and assisting two other staff members passing trays some time before 8 PM. She could not recall who the staff members were. The residents were getting potatoes and chili. Because she was running late for Thanksgiving, her daughter asked her what she was going to eat and what the residents were eating because sometimes she got a plate and brought it home to eat. This was why her daughter was asking what the residents were having for dinner. Nurse #2 was helping pass the trays while on the phone with her daughter outside of Resident #97's room. She told her daughter over the phone, they are having potatoes and chili but no crackers. She stated two other nurse aides were in the hallway assisting with meals and she hung up her phone when she finished speaking with her daughter. She could not remember who the nurse aides were. Two minutes later the nurse aides started talking about the fact that Resident #97's son came to the facility and hit an employee. She stated she told the other employees she was glad she was not there when it happened. She concluded that was all that was said and occurred that night, 11/23/23, and nothing was said to her until the next day about Resident #97's complaint. The next day the Director of Nursing called her at home and told her the resident had stated she had stuck her middle finger up at the resident and called him a cracker. She was informed by the Director of Nursing that she was suspended and could not come back to work. She concluded that was the last she had heard and that she did not return to work after this allegation was made known to the facility. During an interview on 11/28/23 at 12:54 PM the Regional Nurse Consultant stated it was reported to her by the Director of Nursing that Nurse #2 approached Resident #97 and said, why did you let your son hit my friend? She did not know what Resident #97 replied. Resident #97 alleged that Nurse #2 then called him white trash and, flew her middle finger up at him. She stated his roommate, Resident #71 had the curtain pulled and did not see anything but heard the word, cracker. During an interview on 11/28/23 at 1:06 PM Resident #71 (per 9/4/23 MDS his cognition was intact) stated he had been in the bathroom the day before Thanksgiving (11/23/23) and came out to his side of the room and the curtain was drawn between the two beds and he was on the window side. Because of this he could not see who was at the door. He heard the door open, and he heard Nurse #2 say, why did you let your son jump my friend? He stated he recognized her voice. He stated he and Nurse #2 usually talked in passing on the hall when he was going out to visit other residents. She was also their nurse that day over their medication aide. His roommate was quiet and then he heard Nurse #2 say in conversational tone, white cracker. He then heard the door close, and his roommate then said, she just called me a white cracker and flipped me the middle finger. The roommate came around the curtain to inform his roommate that he had overheard her call him that. Resident #71 then wanted to confirm he knew who it was and went to the door and looked down both ways of the hall. The only staff member in the hall was Nurse #2 walking back to her medication cart at the nurse's station. He stated he came back in the room and let Resident #97 know he also confirmed it was Nurse #2. They talked about the incident, and it made his roommate very mad and so he told his roommate to tell someone in the facility. During observation on 11/28/23 at 3:55 PM Resident #97's room was observed with the door closed while staff were speaking in the hallway. The surveyor was able to hear some voices in the hallway but unable to distinguish words or specific voices. During an interview on 11/29/23 at 10:19 AM the Director of Nursing stated she was unable to identify two nurse aides who could corroborate Nurse #2 statement that there were two nurse aide staff members with Nurse #2 outside of Resident #97's room at the time of the incident. The Director of Nursing stated when she called Nurse #2 to inform her she was suspended, Nurse #2 stated to the Director of Nursing at that time that she walked up to medication cart in the hallway outside Resident #97's room around dinner time and joined a conversation about what happened the day before with Resident #97's son. Nurse #2 did not remember what she said, stated she never said or did anything Resident #97 was saying she did, and then began to cry. The Director of Nursing stated that concluded the interview with the nurse. During an interview on 11/28/23 at 1:27 PM the Administrator stated Friday morning (11/24/23) the Medical Records Director told her that a resident informed her that Nurse #2 came in his room and asked him why he let his son hit her friend. As she (Nurse #2) was leaving, she called him a white cracker and stuck her middle finger up at Resident #97. She immediately went down to Resident #97's room and asked him about the incident. He told her the exact same story and described Nurse #2 to a T but did not know her name. She asked Resident #97's roommate, Resident #71, what had occurred, and he informed her he did not see anything but heard the word cracker and corroborated Resident #97's story. The roommate also confirmed the nurse was Nurse #2. Resident #97 and Resident #71 were cognitively intact and reliable witnesses. She told the Director of Nursing to suspend Nurse #2 until they investigated the incident. The investigation was currently ongoing and due to the incident having a reliable witness, it was doubtful the nurse would be allowed to return. She concluded it was her expectation that staff treat residents with dignity and respect, and the interaction described and corroborated with a reliable witness indicated this interaction was not acceptable.

Based on observation, resident, staff, nurse practitioner, dentist, and Medical Director interview the facility failed to ensure a resident's well-being when necessary oral care was not provided resulting in unresolved dental pain for 1 of 3 residents reviewed for oral care needs (Resident #67). Additionally, the resident's diet consistency was not re-evaluated when he expressed difficulty chewing his regular textured diet due to the unresolved dental pain. Resident #67 was ordered a dental consult on 10/31/21 and was not seen for the consult until 3/23/22 at which time a recommendation was given for the extraction of his remaining teeth and upper and lower denture fittings. The dental recommendations were not completed, and the resident experienced a tooth infection treated with antibiotics, chronic inflammation, mouth pain ranging from an 8 to 9 out of 10 (10 being the worst pain), and difficulty chewing. Additionally, the facility failed to ensure medications on the hospital discharge orders were available for 1 of 2 residents reviewed for pharmacy services which resulted in the resident not receiving any medications and being readmitted to the hospital (Resident #401). Immediate Jeopardy began on 3/5/22 when Resident #67 experienced tooth and mouth pain resulting from chronic gum inflammation that had not been addressed due to the facility's failure to obtain a dental consult as ordered by the physician on 10/31/21. Immediate jeopardy was removed on 8/7/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and level G (actual harm that is not immediate jeopardy) for example #2. The findings included: 1. Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #67's cognition was intact, and he had no pain. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's care plan initiated 11/2/21 revealed that he was at risk for pain. The care plan was not specific with the location of the pain. The interventions included assess pain daily using 1-10 scale, administer pain medication as needed, monitor for worsening of pain symptoms, and notify the physician of changes. Review of the medical record 11/1/21 through 3/4/22 revealed no dental consult was obtained as ordered on 10/31/21. Review of a physician's progress note dated 3/5/22 revealed that Resident #67 complained of tooth and mouth pain. The progress note revealed a referral for a dental consult. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing noted dated 3/22/22 revealed Resident #67 was scheduled for a dental visit on 3/23/22 at 9:30 AM. Review of the recommendations from Resident #67's dental appointment on 3/23/22 revealed a plan to extract all his remaining teeth due to inflammation and decay. Resident #67 was to be fitted for upper and bottom dentures. An interview was conducted with the Outpatient Dentist on 8/4/22 at 1:49 PM. He stated that Resident #67 last saw him in March, and he had a couple of missing teeth and his remaining teeth needed to be removed due to the inflammation. The Dentist stated that the resident had a large amount of bone loss, his teeth were decayed with gum inflammation and really needed to come out. He stated that he had sent a plan with the resident to have the remaining teeth removed and have upper and lower dentures. He stated that with the chronic inflammation it would further affect the resident's oral health and could cause further bone loss or an abscess. The Dentist stated that the Resident #67's chronic dental issues could become quite painful and interfere with his ability to eat. The Dentist stated that when inflammation or infection enters the blood stream it can cause issues with other organ systems. He indicated that he wanted to help Resident #67 with his dental needs and had hoped he could assist him in the future. Review of a nursing note completed by Nurse #13 dated 5/26/22 revealed that Resident #67 complained of constant tooth pain on the right side and further stated that he had been in pain for more than a week. A phone interview was attempted with Nurse #13 (an agency nurse) on 8/3/22 at 11:10 AM. She was unable to be reached. A review of a social worker progress note dated 6/1/22 indicated that Resident #67 would be put on the list to be seen by the inhouse dental clinic on 7/1/22. A physician's progress note dated 6/3/22 indicated that Resident #67 had a toothache, and he was prescribed [MEDICATION(S)] (a medication used for oral pain relief) and ibuprofen. The order indicated Resident #67 was to see the inpatient dentist his next visit. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurses note dated 6/7/22 revealed the nurse practitioner was advised of Resident #67's tooth pain and that he was already on an antibiotic. Resident # 67 was on an antibiotic for [CONDITION(S)] of the arm. The nurse practitioner referred resident for dental consult. Nursing note dated 6/8/22 completed by Nurse #4 revealed that the medical doctor was notified that the resident had increased mouth pain. The physician gave no new orders but referred resident to dentist. An interview was conducted with Nurse #4 on 8/5/22 at 1:10 PM. Nurse #4 stated that she had worked with Resident #67 and was familiar with his care. Nurse #4 stated Resident #4 had a lot of issues with his mouth hurting. She stated that she recalled Resident #67 having increased pain the end of May into June. Nurse #4 stated that she notified the physician and was told that the resident needed to see a dentist. She reported that she worked with Resident #67 about 2 to 3 times per week and that his pain was bad. Nurse #4 stated that she did not recall if Resident #67 told her he had trouble eating. She added that his meal plate would be untouched during the dinner meal when she worked with him. The medical record revealed no evidence Resident #67 saw the inhouse dental provider on 7/1/22 as indicated in the SW note. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated that it was painful when the resident ate, and all his teeth were in poor health. The progress note stated the resident had some swollen gums and a dental referral would be entered. The medical record revealed no dental referral for Resident #67 as indicated in the 7/3/22 physician's progress note. Resident #67's active orders revealed he was on a regular diet since admission. The medical record revealed no evidence of Resident #67's diet order being re-evaluated following his complaints of pain when eating. An observation and interview were conducted with Resident #67 on 7/31/22 at 1:30 PM. Resident #67 was laying on the bed. He stated that his mouth was hurting, and he was supposed to have gotten his teeth pulled. Resident #67 stated that he only received acetaminophen and ibuprofen for his mouth pain and neither helped. He further stated that the nurse had tried [MEDICATION(S)] on his teeth and gums and he did not get any relief. An observation and interview were conducted with Resident #67 on 8/1/22 at 8:05 AM. Resident #67 was ambulating in the hallway and stated that his mouth was hurting. Resident #67 rated his pain 8 out of 10. An observation and interview were conducted with Resident #67 on 8/2/22 at 8:53 AM and he stated that he had been suffering with a toothache for 4 months. Resident #67 stated that he was supposed to have had all his teeth pulled and have dentures. He further stated that he had a difficult time with trying to chew his food due to the pain. Resident #67 stated that he received ibuprofen and acetaminophen for pain but had no relief. Resident #67 stated that he had talked with multiple staff about not being able to chew the food on his plate. An observation was conducted of Resident #67's breakfast plate and he pointed out that he was unable to chew the bacon on the plate and did not like his grits cold. Resident #67 stated that he was only able to eat soft food or had to swallow his food whole because it hurt him to chew. He indicated that he had been on a regular diet since admission, and he had not been offered a change in diet or re-evaluated for a change in diet when he expressed pain with chewing. Resident #67 stated that he did not see the inhouse dentist on 7/1/22 because he did not have a payor source. An interview was conducted with Nurse #6 on 8/2/22 at 11:14 AM. Nurse #6 stated that she had worked with Resident #67 often and he always complained about his mouth and rated the pain at 8 to 9/10. Nurse #6 stated the Resident #67 had been complaining of mouth pain since she started working in March. She indicated pain was monitored three times daily for Resident #67, but the pain level was not recorded. She explained that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with Nursing Assistant (NA) #9 on 8/3/21 at 11:46 AM. NA #9 stated that she was familiar with Resident #67's care. NA #9 stated Resident #67 had been complaining of mouth pain when he chewed for months. NA #9 stated she had reported it to the nurse she was working with. An interview was conducted with Nurse Practitioner #1 8/3/22 at 5:51 PM. She stated she was aware of the mouth pain for Resident #67, he had reported it on multiple occasions. She stated she had written multiple consults for dental and pain but was told by the facility that he did not have insurance and the facility was trying to find a dental office that would accept him as a patient. She stated it was the nurses/unit manager that told her about him not having insurance and needing to find a dentist that would take him without insurance. She ordered him PRN pain medications and [MEDICATION(S)] and other items to help him with the pain. She stated from what she was told by the facility that he did see a dentist and was prescribed antibiotics she believed for infection of the gums so she assumed that the dentist would continue to care for the resident and follow-up with him but was unable to recall the time frame this information was given regarding seeing the dentist. An interview was conducted with Physician #1 (the Medical Director) on 8/4/22 at 10:15 AM. Physician #1 stated that he had seen Resident #67 a couple of times and prescribed antibiotics for his teeth pain. Physician #1 stated that he had made multiple dental consults for outpatient dental services and the facility had a difficult time getting Resident #67 in to see a dentist because he had no payor source. Physician #1 stated that when he went to see Resident #67, he continued to complain of pain. He indicated that acetaminophen and ibuprofen were provided for pain management and that he felt this was adequate. He stated Resident #67 did not have the best dentition indicated that he had several missing teeth. He stated that he had given Resident #67 an antibiotic because of the mouth pain but the antibiotic was only temporary. Physician #1 stated that Resident #67 was at risk for deterioration in his dental health. An interview was conducted with the Administrator on 8/4/22 at 2:55 PM. Resident #67 did not have a payor source so it was hard to find a dentist that would see him. The Administrator stated that she reached out to a private organization to help with the cost of Resident #67s dental care because the estimate that she received was about $8000.00. The Administrator stated that she did ask the social worker to cancel the appointment for Resident #67 on 6/9/22 because the dental office was asking for a large amount of money upfront. The Administrator further stated that she and the dietary manager had offered to change Resident #67's diet to mechanical soft or pureed texture in March and he refused. She acknowledged the medical record included no evidence that Resident #67 was offered a change in his dietary orders. The Administrator was notified of immediate jeopardy on 8/4/22 at 4:21PM. On 8/8/22 the facility provided the following allegation of Immediate Jeopardy removal. The Credible Allegation of removal indicated: On 8/5/2022 the Assistant Director of Nursing and Unit Managers conducted a Dental Questionnaire for current residents to see if they were having any dental issues/concerns: 1) Are you having any issues with your teeth 2) Are you having dental pain 3) Are you having trouble eating. Any identified issues or concerns will be addressed, and dental consultations will be initiated to ensure residents are treated appropriately utilizing access dental services if recommended by our physician. Physician will be notified of any residents that are having moderate to severe dental pain; to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain assessments will be conducted by the Director of Nursing, Assistant Director of Nursing, and/or Unit Managers to ensure there is not a need for emergent dental services; until seen by Access Dental Services. If there are residents that does not have a payor source; Corporate will be notified immediately by the Administrator. Once notified Administrator will notify Corporate to ensure residents with discomfort receive treatment. Our Company medical director will then be contacted to see what the facilities next course of treatment will be. This includes, but not limited to, scheduling services with an Emergency Dental provider and/or sending to ER. Current residents who are not edentulous have been interviewed for mouth pain and to ensure residents are not having difficulty eating due to the consistency of their diet. Those residents who are not able to be interviewed will have the oral cavity exam. These exams were started on 8/4/22 and completed on 8/5/22. The exams and interviews were conducted by the Director of Nursing, Assistant Director of Nursing and Unit Manager. Physician will be notified of any residents identified in need of dental services or having mouth pain; will be added to the next contracted dental visit by Access Dental Service by the Director of Nursing, Assistant Director of Nursing and/or Unit Manager. Consultation orders, to include dental, will be entered into the resident's electronic medical record. Consultation for Registered Dietician and Speech Therapy will be discussed during the clinical meeting daily, 5 days a week. The Director of Nursing, Assistant Director of Nursing or Unit Manager will notify Speech Therapy and/or Registered Dietician of the consultation order during clinical meeting and/or when the order is written. On 8/5/22 education was provided by the Regional Nurse Consultant to the Administrative Team to include Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Social Worker, Dietary Manager and Unit Managers regarding the importance of timely follow up with physician consults and a process that will ensure continued compliance. On 8/5/22 the Regional Nurse Consultant also provided education to the Administrative Team to include Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Social Worker, Dietary Manager and Unit Managers regarding the importance of following up post dental consultations to ensure the prescribed diet is tolerated by the resident. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This review will take place during the morning clinical meeting. Consultation orders will be followed up by the Director of Nursing with the person designated to schedule appointments to ensure appointments have been made/scheduled with the designated provider. Follow up on consultations and the date of the appointment will be discussed with the Interdisciplinary Team the following day during the clinical meeting. Any residents in need of a dental consultation, will also be assessed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Managers for pain; until resident can be seen by Access Dental Services. Physician will be notified if assessment reveals; a patient is having dental discomfort. Following resident's consultation, the Registered Dietician will review the resident during the next scheduled visit to ensure the resident is tolerating the prescribed diet. Registered Dietician recommendations will be reviewed with the Director of Nursing and copy provided to the Administrator upon the Registered Dietician's exit of the facility. The recommendations will be provided to the physician by the Director of Nursing, Assistant Director of Nursing or Unit Manager for approval within 48 hours of the recommendation Once approved by the physician, the Director of Nursing, Assistant Director of Nursing or Unit Manager will input a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Director of Nursing and Administrator will review the Registered Dietician's recommendations and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This review will be conducted within 72 hours of Registered Dieticians visit. The facility alleges compliance with Immediate Jeopardy removal on 8/7/22. On 8/11/22, the facility's corrective action plan with the correction date of 8/7/22 was validated onsite by record review, and staff interviews. On 8/11/22 interviews with administrative staff revealed they had received recent education regarding oral care, assessment, resident complaint of pain and reporting of problems. Documentation review included staff education, resident screening, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident screening documentation was dated 8/4/22 and 8/5/22. Questions answered indicating resident concerns were then referred to Speech Therapy (ST) for chewing and swallowing evaluation, to the Registered Dietician (RD) for diet review and placed on a list to be seen by the dentist. Review of facility documentation revealed the Regional Nurse Consultant had educated the administrative team on 8/5/22 regarding physician referrals for consults and follow up orders including diets. Reviewed facility documentation of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed documentation for residents identified with concerns or potential concerns had orders written to have a dental consult and pain medication as needed. Immediate jeopardy was validated as removed on 8/7/22. 2. Record review of hospital discharge record dated 6/17/22 revealed Resident #401 was discharged to the facility with discharge orders which included the following: Tylenol 650 milligram (mg) suppository every 6 hours as needed for pain or fever. Tylenol 325 mg tablet take 650 mg by mouth every 6 hours as needed for pain or fever. [MEDICATION(S)] 10 mg tablet every 6 hours as needed for muscle spasms. [MEDICATION(S)] 0.25 mg disintegrating tablet three times a day for seizures. [MEDICATION(S)] 40mg inject under the skin every 12 hours for prevention of blood clots. [MEDICATION(S)] 300 mg/6 milliliters (mL) by mouth three times a day for seizures. Insulin [MEDICATION(S)] inject daily with breakfast per sliding scale for blood sugar management. Loperamide 1 mg/7.5 mL liquid; take 12 mL by mouth every 4 hours for diarrhea. Loratadine 10 mg tablet; take 10 mg daily by mouth for allergy symptoms. [MEDICATION(S)] 4 mg disintegrating tablet every 6 hours as needed for nausea. [MEDICATION(S)] Tincture ([MEDICATION(S)]) 10mg/mL; take by mouth 0.6 ml every 6 hours for pain. [MEDICATION(S)] 5 mg immediate release tablet every 12 hours for pain. [MEDICATION(S)] 5 mg tablet every six hours as needed for moderate pain. [MEDICATION(S)] 12.5 mg tablet every six hours as needed for nausea. [MEDICATION(S)] 100 mg tablet by mouth daily for depression. Total [MEDICATION(S)] Nutrition (TPN) Electrolytes IV Infuse daily 167 ml/hour to start at 9:00 pm for nutritional management. Resident #401 arrived at the facility on 6/17/22. No admission assessment, written physician medication orders, or Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #401 ' s Face Sheet revealed the only information listed was address, social security number, payer information, phone number, and personal contact information. The face sheet did not have a date of admission, no bed location, no reason for stay, no discharge date , discharge status, or discharge location. Record review of the Record of Immunizations dated June 2022 revealed Nurse #2 administered 1 dose of the Mantoux (PPD) injection in the left forearm of Resident #401 on 6/18/22. Record review of the paper nursing progress note dated 6/18/22 at 8:00 am Nurse #2 revealed Resident #401 was admitted to the facility and was alert and oriented. The nursing assessment was documented tube feed was documented as started at 40 ml/hr. Nurse #2 stated TPN was ordered but the facility did not have an IV pump to administer. Physician #2 was notified, and a verbal order was obtained to start the TPN when the pump arrived. Nurse #2 medicated Resident #401 x 1 dose of Tylenol for report of general pain. Medication delivery pending. Record review of the paper nursing progress note dated 6/18/22 at 10:30 am Nurse #3 revealed Resident #401 was transported by ambulance and taken to the hospital. Record review of the hospital emergency record dated 6/18/22 revealed Resident #401 presented from the facility with abdominal distention, nausea, drainage from abdominal wound, and pain. He reported he had two episodes of nausea and pain while at the facility and did not receive any medications or TPN from the facility. Resident #401 was administered IV fluids, pain medication, and nausea medication. Resident #401 was admitted to the hospital on 6/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/02/22 at 12:13 pm Nurse #3 revealed she was assigned to Resident #401 on 6/18/22 and that she contacted Physician #2 to notify him the facility did not have the IV pump for the TPN and had not received his medications from the pharmacy. Nurse #3 stated Resident #401 was not entered into the system as an admission and the facility was not prepared to provide the care he required. During a telephone interview on 8/02/22 at 3:55 pm Nurse #2 revealed she was the nurse assigned to Resident #401 on 6/17/22 for the 7:00 pm to 7:00 am shift. She stated Resident #401 was not entered in the electronic health system, and she stated she was unable to enter the admission assessment or medications that were ordered during her shift. Nurse #2 stated she faxed the hospital discharge orders to the pharmacy but did not receive any of the ordered medications on her shift for Resident #401. Nurse #2 reported she was unable to remember if she gave any medication to Resident #401 but if medication was administered, it was Tylenol because it was available. She stated she started the tube feed as ordered but was unable to start the TPN because the facility did not have the IV pump from pharmacy. Nurse #2 stated she did not have a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/02/22 at 4:11 pm Unit Manager (UM) #2 revealed she was in the facility on 6/17/22 and she faxed the discharge medication list for Resident #401 to the pharmacy in advance of his arrival. UM #2 stated once Resident #401 was at the facility the nurse was responsible to change the status to active so the pharmacy would know to send the medications. During an interview on 8/02/22 at 4:26 pm the Director of Nursing (DON) revealed that Resident #401 was never activated in the electronic health system by nursing which resulted in no electronic record of his admission. He stated the nurse was responsible to activate Resident #401 when he arrived at the facility but was unable to state why he was not moved to active status. He stated the Business Office Manager did not enter Resident #401 in the system because she notified him, the Resident was not in the facility long enough to be billed. During an interview on 8/03/22 at 3:55 pm the Pharmacy Manager revealed the pharmacy received a discharge medication list for Resident #401 on 6/17/22 at 5:00 pm and again on 6/18/22 at 1:18 am. He stated the pharmacy was unable to register Resident #401 in the electronic health record in order to send any medications because he was not showing in the system as either an active or inactive admission. The Pharmacy Manager stated the hospital discharge medication list would remain in waiting for the facility to change Resident #401 to active and then medications and any pharmacy supplies would be delivered once the pharmacy was aware he was in the facility. The Pharmacy Manager stated the facility had not updated the status of Resident #401 to date so no medications would be sent for the admission. During an interview on 8/03/22 the Business Office Manager (BOM) revealed she was notified by nursing that Resident #401 did not remain in the facility, so she did not enter him into the system when she returned to work on the next business day. The BOM did not further investigate how long Resident #401 remained in the facility to determine if he needed to be added into the system for billing purposes because nursing notified her Resident #401 was not in the facility for a midnight stay. During a telephone interview on 8/04/22 at 10:24 am Physician #1 revealed he was notified by UM #2 that Resident #401 was admitted to the facility on [DATE]. Physician #1 reported he was not aware Resident #401 did not have medications available when he signed off to Physician #2 for the weekend. Physician #1 stated the discharge from hospital and acceptance of admission was a poor decision but did not feel a negative outcome was a concern for the short time Resident #401 was in the facility. During an interview on 8/04/22 at 11:10 am Physician #2 revealed he was the physician scheduled to cover the facility on 6/18/22. Physician #2 stated he was notified by Nurse #3 in the morning on 6/18/22, that Resident #401 arrived at the facility on 6/17/22 and the facility did not have medications or other required supplies to provide care, so he gave the direction to send Resident #401 to the hospital at that time. Physician #2 stated he did not observe Resident #401 on 6/18/22, but he did recall being notified that Resident #401 was not entered in the electronic health system. During an interview on 8/05/22 at 3:59 pm the Administrator revealed that the Admissions Director was responsible to enter the admission and place in preadmission status and the nurse was expected to move to active status once at the facility. The Administrator was unable to state why Resident #401 was not activated when he entered the facility so the medications would be sent from the pharmacy.

Based on observation, record reviews, Nurse Practitioner (NP), Medical Director (MD), Outpatient Dentist, Dental Office Manager, staff, and resident interviews the facility failed to obtain necessary dental services for 1 of 3 residents reviewed for dental care. Resident #67 was ordered a dental consult on 10/31/21 and was not seen for the consult until 3/23/22 at which time a recommendation was given for the extraction of his remaining teeth and upper and lower denture fittings. The facility failed to obtain these recommended dental services. The resident experienced chronic inflammation that resulted in mouth pain, difficulty chewing, and was treated with an antibiotic for a tooth infection. The delay in dental services put the resident at risk for further bone loss, an abscess, and [CONDITION(S)]. Immediate Jeopardy began on 3/5/22 when Resident #67 experienced tooth and mouth pain resulting from chronic gum inflammation that had not been addressed due to the facility's failure to obtain a dental consult as ordered by the physician on 10/31/21 for a tooth infection. Immediate jeopardy was removed on 8/7/22 when the facility implemented a credible allegation of Immediate Jeopardy removal The facility will remain out of compliance at a lower scope and level E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring systems are put in place and to complete employee in-service. The findings included: Resident #67 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #67's cognition was intact, and he had no pain. He was coded as no oral or dental issues. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record 11/1/21 through 3/4/22 revealed no dental consult was obtained as ordered on 10/31/21. Review of a physician's progress note dated 3/5/22 revealed that Resident #67 complained of tooth and mouth pain. The progress note revealed a referral for a dental consult. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing noted dated 3/22/22 revealed Resident #67 was scheduled for a dental visit on 3/23/22 at 9:30 AM. Review of the recommendations from Resident #67's dental appointment on 3/23/22 revealed a plan to extract all his remaining teeth due to inflammation and decay. Resident #67 was to be fitted for upper and bottom dentures. An interview was conducted with the Outpatient Dentist on 8/4/22 at 1:49 PM. He stated that Resident #67 last saw him in March, and he had a couple of missing teeth and his remaining teeth needed to be removed due to the inflammation. The Dentist stated that the resident had a large amount of bone loss, his teeth were decayed with gum inflammation and really needed to come out. He stated that he had sent a plan with the resident to have the remaining teeth removed and have upper and lower dentures. He stated that with the chronic inflammation it would further affect the resident's oral health and could cause further bone loss or an abscess. The Dentist stated that the Resident #67's chronic dental issues could become quite painful and interfere with his ability to eat. The Dentist stated that when inflammation or infection enters the blood stream it can cause issues with other organ systems. He indicated that he wanted to help Resident #67 with his dental needs and had hoped he could assist him in the future. Review of the quarterly MDS assessment dated [DATE] indicated Resident #67 had no oral or dental issues. Review of a nursing note dated 5/26/22 revealed that Resident #67 complained of constant tooth pain on the right side and further stated that he had been in pain for more than a week. A review of a social worker progress note dated 6/1/22 indicated that Resident #67 would be put on the list to be seen by the inhouse dental clinic on 7/1/22. A physician's progress note dated 6/3/22 indicated that Resident #67 had a toothache, and he was prescribed [MEDICATION(S)] (a medication used for oral pain relief) and ibuprofen. The order indicated Resident #67 was to see the inpatient dentist his next visit. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #67 related to [CONDITION(S)]. Review of a nurses note dated 6/7/22 revealed the Nurse Practitioner was advised of Resident #67's tooth pain and that he was already on an antibiotic. The nurse practitioner referred resident for dental consult. Nursing note dated 6/8/22 completed by Nurse #4 revealed that the medical doctor was notified that the resident had increased mouth pain. The physician gave no new orders but referred resident to dentist. A review of a nursing progress note completed by Nurse #4 dated 6/8/22 revealed that an appointment was set up for Resident #67 to see the dentist on 6/9/22. A social worker note completed by Social Worker #1 and dated 6/9/22 revealed that the dental appointment was canceled. An interview was conducted with Social Worker #1 on 8/2/22 at 4:27 PM. Social Worker #1 stated that Resident #67 needed some in-depth dental work and she had scheduled an appointment and transportation for 6/9/22 using her own credit card. She stated that she had called several dentist offices to get Resident #67 seen as soon as possible since the weekend was approaching. She stated that she was able to get an appointment with an outpatient dental provider after explaining the severity of the mouth pain. She stated that she did not know that Resident #67 did not have insurance until the next day when she went to the business office. She explained that she went to the Administrator on 6/8/22 because Resident #67 was in a lot of pain and had an emergent situation. Social Worker #1 stated that she was told by the Administrator to cancel the appointment because she had something else in mind. Social Worker #1 stated that she discussed with the Administrator that Resident #67 needed to have something done immediately because he had showed her the puffiness in his gums and was crying due to his pain. Social Worker #1 stated that she reluctantly canceled the dental appointment scheduled on 6/9/22. A nursing note dated 6/13/22 completed by Nurse #4 revealed that the Administrator had scheduled an emergency appointment with a dental clinic for 6/14/22 because Resident #67 complained of increased tooth and mouth pain. Review of the medical record revealed no documented evidence Resident #67 attended an emergency dental appointment on 6/14/22. An interview was conducted with the Administrator on 8/4/22 at 2:55 PM and she stated Resident #67 was sent to the emergency dental appointment on 6/14/22 and the dental office did X rays. She stated the resident had X-rays taken but no treatment was initiated. The Administrator was unable to produce any documentation from the actual visit and could not say how the resident was transported to the appointment. The Administrator stated that the inhouse dentist would not see Resident #67 due to his no payor status. A telephone interview conducted on 8/4/22 at 11:13 AM with the Office Manager of the dental office the Administrator indicated the resident went to on 6/14/22. The office manager stated they had no record of Resident #67 being seen at their establishment. An interview was conducted with the Transportation Aide on 8/4/22 at 12:10 PM. The Transportation Aide stated that he was responsible for scheduling resident appointments and transporting residents to appointments. He stated that he had not transported Resident #67 to a dental appointment in June. The Transportation Aide stated that in his absence a unit manager or a social worker made the appointments and set up transport. Review of the most recent quarterly MDS assessment dated [DATE] did not address Resident #67's oral or dental issues. The medical record revealed no evidence Resident #67 saw the inhouse dental provider on 7/1/22 as indicated in the 6/1/22 social work note. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated that it was painful when the resident ate, and all his teeth were in poor health. The progress note stated the resident had some swollen gums and a dental referral would be entered. The medical record revealed no evidence a dental referral was made as indicated in the 7/3/22 physician note. An observation and interview were conducted with Resident #67 on 7/31/22 at 1:30 PM. Resident #67 was laying on the bed. He stated that his mouth was hurting, and he was supposed to have gotten his teeth pulled. An observation was conducted of Resident #67 on 8/1/22 at 8:05 AM. Resident #67 was ambulating in the hallway and stated that his mouth was hurting. Resident #67 rated his pain 8 out of 10. An observation and interview were conducted with Resident #67 on 8/2/22 at 8:53 AM and he stated that he had been suffering with a toothache for 4 months. Resident #67 stated that he was supposed to have had all his teeth pulled and have dentures. He further stated that he had a difficult time with trying to chew his food due to the pain. Resident #67 stated that he received ibuprofen and acetaminophen for pain but had no relief. Resident #67 was sitting up on the side of the bed holding the left side of his face. He stated his mouth was still hurting and he had not been able to get his teeth pulled because of issues with his insurance. An interview was conducted with Nurse #6 on 8/2/22 at 11:14 AM. Nurse #6 stated that she had worked with Resident #67 often and he always rated his mouth pain at 8 to 9/10. An interview was conducted with Social Worker #1 on 8/2/22 at 4:27 PM. She reported that she was not responsible for scheduling dental appointments that the Transportation Aide did the scheduling of resident appointments. An interview was conducted with Social Worker #2 on 8/4/22 at 1:49 PM. Social Worker #2 stated that Resident #67 complained of tooth pain around February or March. The social worker stated she contacted the dentist that visited the facility in March, and they had her take pictures of Resident #67's teeth and mouth. She stated that she got an approval to send Resident #67 to an outside dental office in March. The social worker stated she was unaware that Resident #67's Medicaid was in pending status. Social Worker #2 stated that the facility was supposed to send Resident #67 to the emergency department (ED) because his Medicaid was pending, and he needed to be seen right away. Social Worker #2 stated that it was the company's protocol to send the resident to the emergency department when there was no payor source and that did not happen. The social worker further stated Resident #67 had issues with his mouth from March to April that had not been resolved when she left her employment with the facility in April. Social Worker #2 stated she notified the Director of Nursing (DON) and Administrator in March that Resident #67 was having issues with his gums, teeth and a lot of pain. An interview was conducted with Nurse Practitioner #1 on 8/3/22 at 5:51 PM. She stated she was aware of the mouth pain for Resident #67, he had reported it on multiple occasions. She stated she had written multiple consults for dental because of mouth pain but was told by the facility that he did not have insurance and the facility was trying to find a dental office that would accept him as a patient. She stated it was the nurses/unit manager that told her about him not having insurance and needing to find a dentist that would take him without insurance. She ordered him as needed (PRN) pain medications and [MEDICATION(S)] and other items to help him with the pain. She stated from what she was told by the facility he did see a dentist and was prescribed antibiotics she believed for infection of the gums so she assumed that the dentist would continue to care for the resident and follow-up with him but was unable to recall the time frame this information was given regarding seeing the dentist. An interview was conducted with Physician #1 on 8/4/22 at 10:15 AM. Physician #1 stated that he had seen Resident #67 a couple of times and prescribed antibiotics for his teeth pain and gum inflammation. Physician #1 stated that he had made multiple orders for dental consults for an outpatient dentist and the facility had a difficult time getting Resident #67 in to see a dentist because he had no payor source. Physician #1 stated he had visited Resident #67 on multiple occasions and he continued to complain of mouth and tooth pain. The physician stated Resident #67 did not have the best dentition. He stated that he had given Resident #67 an antibiotic because of the pain but the antibiotic was only temporary. Physician #1 stated that Resident #67 was at risk for deterioration in his dental health and it could affect other areas if the inflammation was left untreated. An interview was conducted with the Administrator on 8/4/22 at 2:55 PM. The Administrator stated Resident #67 did not have a payor source so it was hard to find a dentist that would see him. The Administrator stated that she reached out to a private organization to help with the cost of Resident #67s dental care because the estimate that she received was about $8000.00. The Administrator stated that she did ask the social worker to cancel the appointment for Resident #67 on 6/9/22 because the dental office was asking for a large amount of money upfront. The Administrator was asked if the facility had considered sending the resident to the emergency department for immediate assessment as indicated in Social Worker #2's interview. The Administrator verified she had not sent Resident #67 out for immediate assessment at the emergency department. The Administrator was notified of immediate jeopardy on 8/4/22 at 3:58 PM. On 8/8/22 the facility provided the following allegation of Immediate Jeopardy removal: On 8/5/2022 the Assistant Director of Nursing and Unit Managers conducted a Dental Questionnaire for current residents to see if they were having any dental issues/concerns: 1) Are you having any issues with your teeth 2) Are you having dental pain 3) Are you having trouble eating. Any identified issues or concerns will be addressed, and dental consultations will be initiated to ensure residents are treated appropriately utilizing access dental services if recommended by our physician. If there are residents that do not have a payor source; Corporate will be notified immediately by the Administrator. Once notified Administrator will notify Corporate to ensure residents with discomfort receive treatment. Our Company medical director will then be contacted to see what the facility's next course of treatment will be. This includes, but not limited to, scheduling services with an Emergency Dental provider and/or sending to ER. On 8/5/22 the in-house provider, Access Dental Service, was contacted by the corporate representative regarding resident #67 and the need for emergency dental services. The in-house dental provider, Access Dental Service, will conduct an on-site evaluation and treatment plan on 8/5/22. Resident has an appointment on Wednesday with Access Dental Service to have extractions completed. As of 8/5/22 the Director of Nursing, Assistant Director of Nursing and the Unit Manager were educated by the Regional Nurse Consultant regarding the responsibility of physician notification regarding the results of the dental questionnaires. On 8/5/22 the Director of Nursing determined the Unit Manager would be accountable for physician notification. The physician will determine if emergent dental consultation is needed, or routine dental services are sufficient. As of 8/6/22 the Unit Manager is accountable for inputting the order for consultation into the electronic medical record and to schedule emergent dental consultations. Emergent dental consultations will be sent to Access Dental Services. On 8/5 and 8/6/22 the Director of Nursing, Assistant Director of Nursing and Unit Manager provided education to nurses and nursing assistants, including contract nursing staff, to complete oral cavity observations for red swollen gums, foul odor, and/or other abnormal teeth issues on admission, during routine care, and with residents that complain of mouth pain. Any identified concerns will be reported to the Director of Nursing, Assistant Director of Nursing or Unit Manager. Assessments completed with any identified issues will be reported to our physician for further recommendations to treat. Employees who have not received training from the Director of Nursing, Assistant Director of Nursing or Unit Manager/designee will not be permitted to work until education has been completed. The Administrator will validate current employees and agency staff have been educated on 8/4/22, 8/5/22 and 8/6/22. The Administrator will also validate all clinical employees, including agency staff, are educated prior to working. As of 8/5/22 Regional Nurse Consultant also completed education with the Interdisciplinary Team to include, Administrator, Director of Nursing, Assistant Director of Nursing and Unit Manager, related to their responsibility to review Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 8/6/22, the Director of Nursing, Assistant Director of Nursing or designee will validate by phone/email the consultations have been addressed and the appointments have been scheduled with the dental provider. This validation of appointments will be brought to the clinical meeting by the Director of Nursing, Assistant Director of Nursing for review. The facility alleges full compliance with this immediate jeopardy removal on 8/7/22. On 8/11/22, the facility's corrective action plan with the correction date of 8/7/22 was validated onsite by record review, resident, and staff interviews. Resident screening documentation was dated 8/4/22 and 8/5/22. Questions answered indicating resident concerns were then referred to Speech Therapy (ST) for chewing and swallowing evaluation, to the Registered Dietician (RD) for diet review and placed on a list to be seen by the dentist. Review of facility documentation revealed the Regional Nurse Consultant had educated the administrative team on 8/5/22 regarding physician notification, referrals for consults and follow up orders including diets. Review of facility documentation revealed nurse and nurse aide in-services had been conducted and were ongoing for staff who had not worked. Interviews with nurse and nurse aide staff revealed they had recently attended in-services regarding oral care, assessment, and reporting. Reviewed facility documentation of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate jeopardy was validated as removed on 8/7/22.

Based on observation, record review, medical doctor, nurse practitioner, dentist, resident, and staff the Administration failed to provide leadership and oversight to the facility staff to ensure: 1) dental consultations were obtained as ordered, recommendations from the dentist for extractions and denture fittings were completed, and re-evaluation of a resident's diet consistency was conducted when the resident reported difficulty chewing as a result of unresolved dental pain; 2) medications were available; and 3) food and nutrition services met the needs of the residents. The Administration also failed to have an effective process that involved the interdisciplinary team and explored all options to ensure needed care and services were provided for residents. This deficient practice affected 1 of 3 residents (Resident #67) reviewed for dental and oral care, 1 of 2 residents (Resident #401) reviewed for pharmacy services, and had the potential to affect all residents who received food from the kitchen. Immediate Jeopardy began on 3/5/22 when the facility failed to have systems in place to obtain necessary dental services for Resident #67 who experienced tooth and mouth pain resulting from chronic gum inflammation. Immediate jeopardy was removed on 8/8/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and level G (actual harm that is not Immediate Jeopardy) related to example #1a. The facility was also cited at scope and severity F (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for examples #2a, 2b, 2c, 2d, and 2e. The findings included: This tag is cross referenced to: 1a. F684: Based on observation, resident, staff, nurse practitioner, dentist, and Medical Director interview the facility failed to ensure a resident's well-being when necessary oral care was not provided resulting in unresolved dental pain for 1 of 3 residents reviewed for oral care needs (Resident #67). Additionally, the resident's diet consistency was not re-evaluated when he expressed difficulty chewing his regular textured diet due to the unresolved dental pain. Resident #67 was ordered a dental consult on 10/31/21 and was not seen for the consult until 3/23/22 at which time a recommendation was given for the extraction of his remaining teeth and upper and lower denture fittings. The dental recommendations were not completed, and the resident experienced a tooth infection treated with antibiotics, chronic inflammation, mouth pain ranging from an 8 to 9 out of 10 (10 being the worst pain), and difficulty chewing. Additionally, the facility failed to ensure medications from the hospital discharge orders were available for 1 of 2 residents reviewed for pharmacy services which resulted in the resident not receiving any medications and being readmitted to the hospital (Resident #401). 1b: F791 Based on observation, record reviews, Nurse Practitioner (NP), Medical Director (MD), dentist, staff, and resident interviews the facility failed to obtain necessary dental services for 1 of 3 residents reviewed for dental care. Resident #67 was ordered a dental consult on 10/31/21 and was not seen for the consult until 3/23/22 at which time a recommendation was given for the extraction of his remaining teeth and upper and lower denture fittings. The facility failed to obtain these recommended dental services. The resident experienced chronic inflammation that resulted in mouth pain, difficulty chewing, and was treated with an antibiotic for a tooth infection. The delay in dental services put the resident at risk for further bone loss, an abscess, and [CONDITION(S)]. The Administrator was notified of Immediate Jeopardy on 8/4/22 at 4:23 PM. On 8/8/22 the facility provided the following allegation of Immediate Jeopardy removal: The Credible Allegation of removal indicated. All residents have the potential to be affected. Morning meeting will be held daily to ensure all systems are effective by following our policies and procedures. Every department will discuss issues and/or concerns in their department. If it is found that systems need to be implemented, the Executive Director will provide effective leadership to ensure this happens. On 8/7/22, the Regional Director of Operations educated the Executive Director on the importance of holding Accountability meetings to ensure managers are supported. The Interdisciplinary Team (IDT) will be responsible for reviewing information prior to meetings. Information will be reviewed from the previous day and new issues, or concerns will be discussed that need to be resolved. The Executive Director was hired on 10/21/2021 to manage and supervise the facilities' daily operations. The executive director is restructuring the facility management staff by hiring qualified personnel to manage the departments in the facility to ensure quality outcomes. The executive director hired a Social Services Director on 08/01/2022, Director of Nursing Services 6/7/2022, Activity Director in February and Dietary Manager on 7/2022. The new Executive Director is leading the team towards systematically identifying and addressing quality deficits. She has implemented systems and processes to improve facility operations. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This review will take place during the morning clinical meeting. Executive Director and Director of Nursing will follow up to ensure all orders are carried out effectively. On 8/4/22 education was provided by the Regional Nurse Consultant to the Administrative Team to include Executive Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Social Worker, Dietary Manager and Unit Managers regarding the importance of following up with physician consults and a process that will prevent deficient practice going forward. On 8/4/22 the Regional Nurse Consultant also provided education to the Administrative Team to include Executive Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Social Worker, Dietary Manager and Unit Managers regarding the importance of following up post dental consultations to ensure the prescribed diet is tolerated by the resident. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This review will take place during the morning clinical meeting. The Executive Director will ensure all members of the Interdisciplinary Team are strictly following this process. Administrative team will be held accountable if this process is not followed. Any identified areas of concerns will be corrected immediately by the Executive Director. The consultation review and appointment schedule validation audit will be brought to the monthly Quality Assurance Performance Improvement (QAPI) meeting by the Executive Director and/or Director of Nursing for review by the QAPI Committee. Negative findings will be addressed by the committee if noted and additional interventions to be developed and implemented by the QAPI Committee. The facility alleges compliance with Immediate Jeopardy removal on 8/8/22. On 8/11/22, the facility's corrective action plan with the completion date of 8/8/22 was validated onsite by record review, and staff interviews. An interview with the Administrator revealed she had received recent education regarding supervision of management and daily operations of the facility. Review of facility documentation revealed the Regional Director of Operations had educated the Administrator on 8/7/22 regarding supervision and management of daily operations. Facility documentation revealed daily clinical meetings were conducted with administrative staff. Documentation of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation revealed the Regional Nurse Consultant had educated the administrative team on 8/5/22 regarding physician referrals for consults and follow up orders including diets. Immediate jeopardy was validated as removed on 8/8/22. 2a. F802: Based on observations, resident and staff interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact residents who received meals from the kitchen. 2b. F803: Based on observation, review of the planned menus, resident and staff interviews the facility failed to serve the menu as planned for 3 of 3 meal observations. 2c. F804: Based on record review, resident, family and staff interviews, and test tray evaluation, the facility failed to ensure food was palatable and served at an appetizing temperature for 4 of 5 halls. (100, 200, 300, 400 Halls.) 2d. F806: Based on record reviews, observations, staff and resident interviews the facility failed to obtain and honor food preferences for 2 of 2 residents reviewed for nutrition (Resident #357 and #356). 2e. F809: Based on record review, observation, resident, and staff interviews the facility failed to serve meals on time and failed to provide snacks to residents. This was for 7 out of 35 residents interviewed (Resident #98, #6, #50, #84, #39, #40 and #26).

Based on observations, record reviews, resident and staff interviews, the facility failed to provide pants for 1 of 3 residents reviewed for dignity. Resident #42 stated he was embarrassed, felt bad and didn't like it. Finding included: Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #42's quarterly minimum data set (MDS) dated [DATE] indicated the resident had no short/long term memory loss. Cognitive skills for daily decision-making was coded as being independent with some difficulty in new situations only. The resident needed extensive one-person assistance with dressing. A review of Resident #42's care plan dated 12/17/20 indicated he needed assistance with bed mobility, transfers, walking, dressing, toilet use and bathing. Interventions included staff to give verbal cues to help prompt the resident. The care plan did not identify Resident #42 refused care and treatment or would remove clothing. During an interview with Resident #42 on 03/22/21 at 12:10 pm, Resident #42 indicated his only concern at the facility was he had no clothes and the resident indicated he was embarrassed to talk to the surveyor because he only had on a shirt and adult brief. Resident #42 stated he was not able to go to the laundry department and get his clothes like some of the other residents. He added this really made him feel bad that his clothes were in the laundry and he didn't like not having any pants on. He indicated this had been going on for days and he had reported this but unsure what staff he told. During this interview Resident #42 gave surveyor permission to look in his closet which revealed one shirt. A second closet in the room revealed nothing was in it. No pants were observed on Resident #42 during the interview. Resident#42 was observed in his room with the door slightly open on 3/22/21 at 12:10 pm with a shirt and an adult brief on; his lap was not covered. Resident #42 indicated that he was embarrassed to talk with surveyor, but he wanted his clothes. Resident #42 had no roommate. Resident #42 was observed at 2:30pm on 03/22/21 asleep in his wheelchair; his door was still slightly open. The resident had on a shirt and adult brief and his lap was not covered. During an interview with Nursing Assistant (NA) #8 on 03/23/21 at 9:30 am she indicated she had been working on the same hall for months and provided care for Resident #42. NA #8 stated the resident was able to provide most of his activities of daily living and was not aware of any concerns. NA #8 indicated nothing about Resident #42's clothing. During an interview with the Administrator on 03/24/21 at 2:30pm, she indicated no knowledge of Resident #42 missing clothes. The Administrator stated she would investigate the situation. She stated she expected the staff would treat all residents with dignity and ensure residents needs were provided for them. During an interview with Laundry Manager (LM) on 03/30/21 at 2:34 pm he indicated the concerns regarding Resident #42's clothes were reported to him on 3/24/21. The LM stated he went to the laundry department on 03/24/21 and brought the residents clothes to his room two days after the observations.

Based on record reviews and interviews with Adult Protective Services Worker, Medical Doctor, Ombudsman, Transportation Company Staff, Home Health Agency Worker, Emergency Medical Technician, former and current facility staff members and former resident the facility failed to provide 1 of 4 sampled residents (Resident #12) who were reviewed for discharge with a safe discharge planning process that included discharge goals, needs and caregiver support for Resident #12. The facility failed to ensure 1 of 4 sample residents (Resident #12) discharge to have a safe place to go to after leaving the facility. The facility failed to assess Resident #12's medical condition and complete a home assessment to identify possible barriers for a safe discharge home. Immediate jeopardy began on 12/13/2018 when the facility failed to provide and document sufficient preparation and orientation to Resident #12 to ensure safe and orderly discharge from the facility. The facility failed to train and orient the resident and or family representative on administering medications, checking blood sugar and self-administration of insulin or any other medical treatment. The facility failed to have a discussion with the resident the safety of the home environment in relation to the resident's physical condition and ability to maneuver at home, the resident's basic needs of food, water, electricity and heat and medical care needs. Immediate Jeopardy was removed on 02/01/19 at 3:45pm based on the allegation of compliance that was provided. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective related to training of facility staff regarding the discharge planning process. The Findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 5/23/18 revealed Resident #12 was found at home in her bathtub by Emergency Medical Services (EMS). The patient reported she had called out for several days for help and her neighbors had called EMS because they had not heard from the patient for several days. EMS noted that the patient's home was knee-deep with trash that was full of rats and roaches. The patient was found to have a blood sugar of 690 milligrams per deciliter (mg/dl). Record review of a social service progress note dated 5/29/18 for Resident #12 stated Adult Protective Services (APS) was working with the resident and identified the resident's home would need to be cleaned before she could return home. The resident planned to return home after she completed therapy, stabilized her medical condition and had her home cleaned. Record review of a care plan for Resident #12 dated 6/15/18 revealed the resident desired to return home with a goal identified that she would return home with supportive services. Interventions included the facility would evaluate the resident's home for possible barriers, schedule a family meeting to discuss post change needs, assist the resident with obtaining community resources for discharge, notify the residents physician to discuss concerns and obtain orders for discharge supplies. Record review of a social service progress note dated 7/6/18 for Resident #12 stated the Social Worker (SW) had informed the resident her last day of Medicare coverage was 7/11/18. The SW explained the non-coverage letter, advanced beneficiary notice letter and appeal process and rights to the resident. Resident #12 expressed to the SW that she was not ready to return home and may have to get her lawyer involved if the facility was going to throw her out. The SW explained to the resident that the facility was not throwing her out but providing this information per protocol and Medicare guidelines. After continued discussion with the resident she decided she would appeal the decision and a follow-up meeting was planned after notification of the appeal decision. Record review of a quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #12 revealed her cognition was intact and an active discharge plan was in place for the resident to return to the community. She required extensive two-person assistance with bed mobility, transfers, personal hygiene and extensive one-person assistance with dressing, toilet use and bathing. She was incontinent of bowel and bladder. Review of MDS dated [DATE] indicated that Resident #12's weight was 389 pounds and her height was 71 inches tall. Record review of a transfer / discharge notice for Resident #12 dated 11/15/18 from the facility Administrator stated the date of discharge was 12/15/18. The reason for the transfer / discharge was Resident #12 after having received reasonable and appropriate notice failed to pay (or have paid under Medicare / Medicaid) for her stay at the facility. This information was given to Resident #12 and the Ombudsman on 11/15/2018. Record review of a social service progress note dated 11/15/18 for Resident #12 stated discharge plans were discussed with the resident and she would like to discharge back to her home. The resident requested home health services upon discharge. The writer inquired about transfers as well as assistance needed with toileting and the resident stated she would like continued supervision with her activities of daily living (ADLs) until discharge to ensure her balance and stability for transfers using the sliding board. The resident was currently working with therapy and the writer informed the therapy team of resident's request for assistance with transfers. The discharge paperwork was reviewed with the resident including her right to appeal. The resident stated appealing was a waste of time and she would like to go home. The writer would prepare the resident to return home and set up assistance closer to her discharge date . Record review of a social services progress note dated 12/12/18 for Resident #12 stated discharge plans were reviewed again with the resident to ensure she was prepared for her transfer home on 12/13/18. The resident will discharge to her home per her choice. She was provided with options for independent living and assisted living facilities on numerous occasions, but the resident declined. The resident will transport home and receive home care services with the home health company of her choice. Her motorized wheelchair was in place as well as a bedside commode that was ordered by the facility. The resident expressed that her family and friends will assist her with the transition and check in on her periodically. There were no concerns brought to the attention of this writer by the resident. Record review of the discharge summary for Resident #12 dated 12/12/18 at 1:19 pm revealed her physical home address, physicians name and number, discharge notes to the Ombudsman and home health services phone number and allergies [REDACTED]. Attached to the discharge summary was a list of the residents' medications and her care plan. Record review of a departmental note dated 12/13/18 for Resident #12 revealed the resident was alert and oriented, able to make needs know. No acute distress noted. The resident required assistance with ADLs, 2 person assist using mechanical lift with transfers. The resident took her meds without any problems, she was incontinent of bowel and bladder, breathing was even and unlabored. Blood sugar was checked, and insulin coverage provided. Record review of a social service progress note dated 12/13/18 revealed APS was informed of the resident's choice to return home verses transfer to an independent or assisted living facility. Home health services were set up per request of the resident. The writer spoke with APS to alert case worker that the resident was being discharged home with home health services. Record review revealed Resident #12 was transported home on 12/13/18 2:30pm by a transportation company that was paid for by the facility. An EMS report dated 12/13/18 7pm revealed EMS was dispatched to Resident #12's home for a sick call. A [AGE] year-old female complained of sitting in her motorized wheelchair. She reported she had been discharged home from the nursing home this afternoon after staying there for 7 months. She reported she arrived home about 2:00 pm today and was unable to transfer from her wheelchair to the toilet. The patient reported she was not able to complete her rehab while at the facility. Review of the hospital records dated 12/13/18 for Resident #12 identified her chief complaint was generalized weakness and unable to take care of herself. The patient had a history of [REDACTED]. She had been at a skilled nursing facility for the past 7 months and was unable to take care of her bill, so she was discharged home this morning. She was unable to walk and used a motorized wheelchair. She had to go to the bathroom but was not able to get to the bedside commode, so she called EMS. EMS found the resident covered in urine and stool. The patient admitted to dysuria for the past couple days and a work up in the emergency room revealed a urinary tract infection and received 1 dose or [MEDICATION NAME] (an antibiotic). The patient was discharged from the hospital to a skilled nursing facility on 12/19/18. An interview with the former Social Worker (SW) on 1/25/2018 at 11:00am revealed she discharged Resident #12 on 12/13/2018. The SW indicated the resident wanted to go home and indicated she had neighbors to help her. The SW stated there were no family members present with the resident when she was discharged on [DATE]. She added the facility arranged for the transportation company that took the resident home. She explained she had contacted APS and informed them that Resident #12 was being transferred home. The SW added that Resident #12 did not want to go to another facility and she only wanted to go home. SW also indicated she never made a home visit to Resident #12's home. SW indicated she had no knowledge of another cleaning up Resident #12's home. An interview with the physical therapy staff member on 1/25/19 at 11:30 am revealed they had worked with Resident #12 prior to being discharged . The staff member stated the resident had not completed her goals and would not have been able to care for herself at home alone. She added Resident #12 would have had a hard time trying to transfer herself from her wheelchair to the toilet without assistance. An interview with Nursing Aide #1 (NA) on 1/25/19 at 11:45 am who worked with Resident #12 during her stay at the facility revealed the resident needed assistance with all her ADLs, however she could feed herself. NA # 1 added the resident wanted to go home. An interview with the Director of Nursing (DON) on 1/25/2019 at 11:00 am revealed she had no knowledge of Resident #12's discharge. DON indicated that the former Social Worker handled that discharged . An interview with the Administrator on 1/25/2019 at 1:00 pm revealed the SW completed the discharge for Resident #12 and she was unaware that the facility paid for this resident to be transported home. She stated she did not know if someone had made a home visit prior to Resident #12's discharge. Pre phone interview on 1/25/19 at 1:30 pm with a staff member of the skilled nursing facility that Resident #12 was currently residing at revealed the resident was admitted on [DATE] and required extensive to total assistance with her ADL's except she could feed herself with staff set-up. During an interview with Resident #12 on 1/26/2019 at 2:00 pm revealed she was at the former facility for 8 months. She stated she told the facility she wanted to go home however she knew that she could not take care of herself. Resident #12 added the facility kicked her out because she had not paid them. She stated she had completed the Medicaid applications to get help but never but she never heard back. Resident #12 stated she did want to go home but with services in place. She added the facility knew she didn't have any family or support to help her at home. She stated she felt very bad once she got home and had no one to help her go to the bathroom. She added there was no food at her home. Resident #12 stated the facility told her that home health would be visiting her, so she would have what she needed once she got home. Resident #12 explained she had been home for several hours and could not get herself up to get on the toilet, so she called 911. She added she had felt bad all day, and no one had checked on her except to give her medications on the day she was discharged . Pre phone interview on 1/27/19 at 2pm with a home health company staff member #1 revealed they had received a referral for Resident #12 from the facility on 12/13/18. The staff member stated the records she was looking at indicated the referral was denied and they provided no services for the resident in (MONTH) (YEAR). Pre phone interview with the medical doctor (MD) on 1/28/19 10:30am revealed that he last saw Resident #12 sometime in December. He stated the resident knew her medications and would be able to take her medication without assistance. The MD added we would need to talk to physical therapy about her transfer ability. Pre phone interview with an APS worker on 1/28/19 at 11:00 am revealed he had received a call from the facility SW on 12/13/18 to let him know Resident #12 was being discharged home. The APS worker explained they were called in (MONTH) (YEAR) about the condition of the resident's home. He added because the resident was placed in the nursing facility they had not been further involved with the resident's case. The APS worker explained the last communication he had with the facility SW was that Resident #12 was going to remain at the facility due to her health and didn't have any family to help take care of her. APS worker indicated that Resident #12 history indicated that someone need to clean up Resident #12's home before her return home. APS indicated that this information was indicated in Resident #12 history with APS. Review of statement from the Business office on 1/28/19 at 11:10am dated 10/10/2018 indicated that staff talked to resident she did not have a Medicaid application on file. Staff also explained to her that would be responsible for patient liability which consist of social security check minus $30.00. She completed her Medicaid application and told staff that she understood how it went: but did have any money to pay anything because she was paying for her trailer and other bills so she could go back home (however she paid 1,000.00 for October). An interview with Business Office Manager (BOM) on 1/28/2019 at 11:30am revealed she indicated that she went to see Resident #12 to pick up her monthly payment and Resident #12 indicated she was not paying anything here. BOM stated that Resident #12 told her to give her 30 day notice and Resident #12 indicated so she can go back home. Resident #12 stated I owe everybody and other nursing facilities too and they are not getting anything either, what are they going to do: Nothing'. Resident #12 also stated that she was not going to spend down her money nor give any information on her life insurance either. An interview with facility SW #2 on 1/28/19 at 3:00 pm revealed she was a witness to the conversation on 7/6/2018 with the previous facility SW. She stated during this meeting the previous SW explained to Resident #12 that her last day of coverage would be 7/11/2018. Resident #12 stated during that meeting that she wanted to stay at the facility. Pre phone interview on 1/29/19 at 10:45 am was conducted with the van driver from the transportation company that transported Resident #12 home. He stated he picked up the resident from the facility midday and transported her home. The van driver stated he did know the condition of her home. He explained he just dropped her off and kept it moving. Pre phone interview on 1/29/19 at 11:17 am with the facility Ombudsman revealed she was not aware of Resident #12's discharge. Ombudsman indicated he had not received any information on this resident's discharge. An interview on 1/29/19 at 11:30 am with Nursing Aide (NA) #5 revealed she had provided care for Resident #12 when she was at the facility. She stated the resident was able to make her needs known. The resident would let the staff know if she needed to use the bedside commode, but the resident also choose to wear a brief. NA #5 added the resident required extensive one to two-person assistance with all her ADLs except she was able to feed herself. An interview on 1/29/19 at 11:50 am with NA #2 revealed she was familiar with Resident #12 and that the resident had been discharged sometime in December. NA #2 explained she had worked with the resident on the day she was discharged , and the resident told her she would have an aide coming to help her when she got home. NA #2 stated the resident could do some for herself, but she was unsure if the resident would be able to clean herself up after having a bowel movement. She added the resident was able to make her needs known. NA #2 stated she had no knowledge if the facility hade made a home visit before the resident was discharged . An interview on 1/29/19 at 1:00 pm with Nurse #2 revealed she had been the nurse for Resident #12 during her stay at the facility. She stated the resident didn't have any issues with taking her medications and that the resident had told her that when she was at home she had administered her own medications. Nurse #2 explained she discharged Resident #12 on 12/13/18 but she was unsure of the time. She added she had reviewed and instructed the resident on how to take her medications. She added the resident knew how to check her blood sugar and administer her insulin but stated she had never actually observed her doing this. Nurse #2 revealed she was not able to find the discharge paperwork for Resident #12. Pre phone interview on 1/30/19 at 3:45 pm with a staff member #2 from a home health agency revealed the referral for services for Resident #12 was denied on 12/13/18. The staff member explained they had not received a referral from the facility but from a third party. Pre phone interview with EMS Worker #1 on 1/31/19 at 11:00 am revealed he remembered Resident #12 and he had been at her home earlier in the year when the resident was stuck in the bathtub. He stated the resident lived in a trailer that had a horrible odor and was very nasty. EMS Worker #1 added he didn't know how the resident even got around in her wheelchair because there was so much clutter. He explained when he responded to the call on 12/13/18 Resident #12 met them at the door. He added the resident would not let them in the house, but he could see that there was clutter, boxes and papers all over the floor and there was a horrible odor. Pre phone interview on 1/31/19 at 12:38 pm with EMS Worker #2 revealed a call was received by 911 and dispatched to them as a sick call to Resident #12's home. Worker #2 indicated the resident had a history with EMS and they had observed the resident's home cluttered with trash up to the ceiling and the home had a very bad odor. He stated on this call the resident wouldn't let them in the house, but he could observe the clutter was still present. He explained they rolled the resident out of the home to her driveway and the fire department assisted them with getting the resident on a stretcher. Worker #2 indicated you could smell the odor from the house down to driveway. EMS Worker #2 added the resident was very weak and had urine and had stool on herself. During a second interview with the Van Driver on 1/31/19 at 3pm VD indicated that it is not his responsibility to assess the Residents home but everyone knew that Resident #12's situation that he had to make a path in her house just to stack her boxes. VD also indicated that her home was clutter, nasty and had horrible odor. The Administrator was notified of immediate jeopardy on 1/30/2019 at 11:30am. The facility provided a credible allegation of compliance on 2/1/2019 at 10:52am. The credible allegation was amended on 3/1/19 to as follow: The creation of this Letter of Credible allegation constitutes a written allegation of compliance. Preparation and submission of this letter does not constitute an admission or agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth by the survey agency. This letter is solely prepared because of requirement under state and federal law, and to demonstrate the good faith attempts by the provider to improve the quality of life of each resident. As of 3/1/19 changes have been made to the original Allegation of Compliance that was accepted by the State survey team on 1/30/19. We are making these changes under the direction that CMS has requested the changes and we are assured that those changes will not impact the date the IJ was lifted for F 624. Date: 1/30/2019 Corrective action accomplished for those residents found to have been affected by the deficient practice. During the Survey the State alleged that; the facility failed to provide and document sufficient preparation and orientation to resident #12 to ensure safe and orderly discharge from the facility. The facility failed to train and orient the resident and or family representative on administering medications, checking blood sugar and self-administration of insulin or any other medical treatment. The facility failed to have a discussion with the resident and or family representative to address the safety of the home environment in relation to the resident's physical condition and ability to maneuver at home, the resident's basic needs of food, water, electricity and heat and medical care needs. The facility failed to discuss with the resident and or family representative the level and type of support the resident needed from her family, significant others, the community, home health agencies, and any other government agencies and how the facility will assist the resident in getting the support and assistance she needed. Resident #12 was given a 30 day notice on 11/15/2018 for nonpayment. Social Worker notes from 11/15/18 and 12/12/18 reflect discharge planning discussions with Resident #12 including that resident indicated she had family support at home On 12/13/18 Resident #12 was transferred home at her request by the facility with Home care services in place. Resident #12 was transferred to the hospital for generalized weakness on 12/13/2018 from her private home. At the time of the survey allegations it was identified that the resident was residing in another skilled nursing facility, no other corrective action was needed as a result of Resident #12's location. On 1/30/19; Chief Clinical Officer from the Management and consulting company contracted by the facility, conducted the root cause analysis for this alleged noncompliance. The analysis concluded the alleged noncompliance resulted from the facility's failure to ensure that the facility management team that consist of the department supervisors understand the center's Abuse Prohibition and policies and procedures, specifically related to unsafe discharging of a resident that can be considered neglect. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. Audits of 100% of residents' discharge documentation in the last 90 days were completed by the Director of Nursing, assistant Director of nursing, Staff Development coordinator and/or unit manager on 1/30/19 to identify if any other resident was discharged without sufficient preparation and orientation to ensure safe and orderly discharge from the facility. This audit would have included identifying any involuntary discharge. No other resident was identified to be affected by this alleged noncompliance. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective 1/30/2019 the Director of Nursing, Director of Rehabilitation Center, Staff Development coordinator and/or Director of Social services will be responsible to initiate and train/provide the needed education to either resident and/or resident representative, or will train the designated licensed nurse who will then train the resident and/or resident representative. This education/training will take place at least three days before resident is discharged from the facility. Staff members who will be responsible to educate residents or resident's representative include; Director of Nursing, Director of Rehabilitation Center, Staff Development coordinator, Director of social services #1 or #2. And/or discharging nurse. The education will be intended to train and orient the resident and or family representative on the resident's medical care needs including but not limited to administering medications, checking blood sugar, self-administration of insulin or any other medical treatment. The facility will have a discussion with the resident and or family representative to address the resident's safety including but not limited to home environment in relation to the resident's physical condition and ability to maneuver at home, the resident's basic needs of food, water, electricity and heat and medical care needs or any other issues that are relevant to the safety of the resident. The facility will discuss with the resident and or family representative the level and type of support the resident needed from her family, significant others, the community, home health agencies, and any other government agencies and how the facility will assist the resident in getting the support and assistance she needed. The facility will discuss with the resident and or family representative any other issues the facility can help the resident to have a safe and orderly discharge as identified in the resident's discharge planning on the comprehensive care plan. Effective 1/30/19 the facility will conduct a weekly Case Management meeting chaired by the facility Administrator, MDS nurse, Director of Rehabilitation and/or Director of Nursing. Residents with pending discharges will be discussed in this meeting at least a week in advance to allow the Director of Social Services #1 and/or #2 at least seven days to make necessary arrangements to ensure sufficient preparation and orientation for safe and orderly discharge from the facility in a form and manner that the resident will understand. During this meeting the person who is going to orient the resident will be assigned. Effective 1/30/19 and moving forward the facility will conduct home visits as deemed appropriate and necessary by the facility licensed therapist and/or director of nursing to ensure resident's home is safe for the resident. Each resident will receive appropriate preparation, orientation and education individualized based on the findings from home visit before the discharge to ensure resident has a safe and orderly discharge. The education and home visits will be conducted prior to resident's discharge. The home visit will be documented on the home visit checklist form and maintained in resident's medical records. The facility will validate orientation was provided in a form and manner that the resident will understand. In the instance where the resident is unable to understand, resident's representative will be educated and/or Adult protective services will be notified effective 1/30/2019 Effective 1/30/19 the facility will conduct a discharge meeting and work with the resident and/or resident representative, if applicable, to develop interventions to meet each resident's discharge goals and to ensure a sufficient preparation and orientation for safe and orderly discharge from the facility in a form and manner that the resident will understand. Any identified barriers will be addressed before the resident is discharged from the facility and hence reduce factors leading to preventable readmissions to the hospital. This review will take place daily Monday through Friday effective 1/30/19. Effective 1/30/2019 the director of social services will be ultimately responsible to coordinate all discharge meetings in the facility. The facility will not discharge any resident from the facility until the facility validates that all services are arranged and the resident is safe to be discharged effective 1/30/2019 Effective 1/30/19 and moving forward the facility director of social services #1 or #2 and/or discharging licensed nurse will provide and document sufficient preparation and orientation to residents and/or resident representative if applicable to ensure safe and orderly transfer or discharge. This orientation will be provided in a form and manner that the resident can understand. This education will be documented in resident's medical records. Regional Clinical Consultant from the contracted Management and consulting company conducted re-education for current facility interdisciplinary team involved on discharge planning to include the Administrator, Director of Nursing, Director of Social services #1 and #2, Activity Director, Director of Rehabilitation services, MDS nurse and staff development coordinator on 1/30/19. This education emphasized on the importance of providing sufficient preparation and orientation for safe and orderly discharge from the facility in a form and manner that the resident will understand before discharge to ensure each resident have a safe discharge from the facility. The education will involve the resident, resident's representative if applicable and will include information such as post discharge services from home health agencies, and/or Adult protective services (if applicable). This education will be completed by 1/30/19, any department head not educated by 1/30/19 will not be allowed to work until educated. Effective 1/30/19 this education will be added on new hires education and provided annually for all new facility department heads. The Facility Director of Nursing (DON), Assistant Director of Nursing and/or staff development coordinator will complete 100% education on the importance of providing sufficient preparation and orientation for safe and orderly discharge from the facility in a form and manner that the resident will understand before discharge to ensure each resident have a safe discharge from the facility. The education will involve the resident, resident's representative if applicable and will include information such as post discharge services from home health agencies, and/or Adult protective services (if applicable). This education will be provided for all licensed nurses, to include full time, part time and as needed licensed nursing staff. This education will be completed by 1/30/19. The education will involve the resident, resident's representative if applicable and will include information such as post discharge services from home health agencies, Adult protective services (if applicable), Medication reconciliation, and will be documented on the each resident's discharge records acknowledged by the resident and/or representative of their understanding. Any licensed nurse not educated by 1/30/19 will not be allowed to work until educated. This education will also be added on the new hire orientation process for all new licensed nurses effective 1/30/19, and will also be provided annually. The facility plans to monitor its performance to make sure that solutions are sustained. Effective 1/30/19 the Facility Administrator, Director of Nursing, Assistant Director and/or Nursing, RN supervisors will review all planned discharges to the community in the next 72 hours to ensure that each resident receive sufficient preparation and orientation for safe and orderly discharge from the facility in a form and manner that the resident understood before discha

Based on record reviews and interviews with Adult Protective Services Worker, Medical Doctor, Ombudsman, Transportation Company Staff, Home Health Agency Worker, Emergency Medical Technician, former and current facility staff members and former resident the facility failed to provide 1 of 4 sampled residents (Resident #12) with a safe discharge planning process that included discharge goals, needs and caregiver support for Resident #12. The facility failed to assess Resident #12's medical condition and complete a home assessment to identify possible barriers for a safe discharge home. Immediate jeopardy began on 12/13/2018 when Resident #12 was transported to her home without any assessment, preparation, home assessment and caregiver in place. There was no evidence that the facility conducted a home evaluation before resident #12 was discharged on [DATE]. Immediate Jeopardy was removed on 1/30/19 based on the allegation of compliance that was provided. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective related to training of facility staff regarding the discharge planning process. The Findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 5/23/18 revealed Resident #12 was found at home in her bathtub by Emergency Medical Services (EMS). The patient reported she had called out for several days for help and her neighbors had called EMS because they had not heard from the patient for several days. EMS noted that the patient's home was knee-deep with trash that was full of rats and roaches. The patient was found to have a blood sugar of 690 milligrams per deciliter (mg/dl). Review of a social service progress note dated 5/29/18 for Resident #12 stated Adult Protective Services (APS) was working with the resident and identified the resident's home would need to be cleaned before she could return home. The resident planned to return home after she completed therapy, stabilized her medical condition and had her home cleaned. Review of a care plan for Resident #12 dated 6/15/18 revealed the resident desired to return home with a goal identified that she would return home with supportive services. Interventions included the facility would evaluate the resident's home for possible barriers, schedule a family meeting to discuss post change needs, assist the resident with obtaining community resources for discharge, notify the residents physician to discuss concerns and obtain orders for discharge supplies. Review of a social service progress note dated 7/6/18 for Resident #12 stated the Social Worker (SW) had informed the resident her last day of Medicare coverage was 7/11/18. The SW explained the non-coverage letter, advanced beneficiary notice letter and appeal process and rights to the resident. Resident #12 expressed to the SW that she was not ready to return home and may have to get her lawyer involved if the facility was going to throw her out. The SW explained to the resident that the facility was not throwing her out but providing this information per protocol and Medicare guidelines. After continued discussion with the resident she decided she would appeal the decision and a follow-up meeting was planned after notification of the appeal decision. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #12 revealed her cognition was intact and an active discharge plan was in place for the resident to return to the community. She required extensive two-person assistance with bed mobility, transfers, personal hygiene and extensive one-person assistance with dressing, toilet use and bathing. She was incontinent of bowel and bladder. Review of MDS dated [DATE] indicated that Resident #12's weight was 389 pounds and her height was 71 inches tall. Review of a transfer / discharge notice for Resident #12 dated 11/15/18 from the facility Administrator stated the date of discharge was 12/15/18. The reason for the transfer / discharge was Resident #12 after having received reasonable and appropriate notice failed to pay (or have paid under Medicare / Medicaid) for her stay at the facility. This information was given to Resident #12 and the Ombudsman on 11/15/2018. Review of a social service progress note dated 11/15/18 for Resident #12 stated discharge plans were discussed with the resident and she would like to discharge back to her home. The resident requested home health services upon discharge. The writer inquired about transfers as well as assistance needed with toileting and the resident stated she would like continued supervision with her activities of daily living (ADLs) until discharge to ensure her balance and stability for transfers using the sliding board. The resident was currently working with therapy and the writer informed the therapy team of resident's request for assistance with transfers. The discharge paperwork was reviewed with the resident including her right to appeal. The resident stated appealing was a waste of time and she would like to go home. The writer would prepare the resident to return home and set up assistance closer to her discharge date . Review of a social services progress note dated 12/12/18 for Resident #12 stated discharge plans were reviewed again with the resident to ensure she was prepared for her transfer home on 12/13/18. The resident will discharge to her home per her choice. She was provided with options for independent living and assisted living facilities on numerous occasions, but the resident declined. The resident will transport home and receive home care services with the home health company of her choice. Her motorized wheelchair was in place as well as a bedside commode that was ordered by the facility. The resident expressed that her family and friends will assist her with the transition and check in on her periodically. There were no concerns brought to the attention of this writer by the resident. Review of the discharge summary for Resident #12 dated 12/12/18 at 1:19 pm revealed her physical home address, physicians name and number, discharge notes to the Ombudsman and home health services phone number and allergies [REDACTED]. Attached to the discharge summary was a list of the residents' medications and her care plan. Review of a departmental note dated 12/13/18 for Resident #12 revealed the resident was alert and oriented, able to make needs know. No acute distress noted. The resident required assistance with ADLs, 2 person assist using mechanical lift with transfers. The resident took her meds without any problems, she was incontinent of bowel and bladder, breathing was even and unlabored. Blood sugar was checked, and insulin coverage provided. Review of a social service progress note dated 12/13/18 revealed APS was informed of the resident's choice to return home verses transfer to an independent or assisted living facility. Home health services were set up per request of the resident. The writer spoke with APS to alert case worker that the resident was being discharged home with home health services. Record review revealed Resident #12 was transported home on 12/13/18 2:30 pm by a transportation company that was paid for by the facility. An EMS report dated 12/13/18 7pm revealed EMS was dispatched to Resident #12's home for a sick call. A [AGE] year-old female complained of sitting in her motorized wheelchair. She reported she had been discharged home from the nursing home this afternoon after staying there for 7 months. She reported she arrived home about 2:00 pm today and was unable to transfer from her wheelchair to the toilet. The patient reported she was not able to complete her rehab while at the facility. Review of the hospital records dated 12/13/18 for Resident #12 identified her chief complaint was generalized weakness and unable to take care of herself. The patient had a history of [REDACTED]. She had been at a skilled nursing facility for the past 7 months and was unable to take care of her bill, so she was discharged home this morning. She was unable to walk and used a motorized wheelchair. She had to go to the bathroom but was not able to get to the bedside commode, so she called EMS. EMS found the resident covered in urine and stool. The patient admitted to dysuria for the past couple days and a work up in the emergency room revealed a urinary tract infection and received 1 dose or [MEDICATION NAME] (an antibiotic). The patient was discharged from the hospital to a skilled nursing facility on 12/19/18. An interview with the former Social Worker (SW) on 1/25/19 at 11:00 am revealed she discharged Resident #12 on 12/13/2018. The SW indicated the resident wanted to go home and indicated she had neighbors to help her. The SW stated there were no family members present with the resident when she was discharged on [DATE]. She added the facility arranged for the transportation company that took the resident home. She explained she had contacted APS and informed them that Resident #12 was being transferred home. The SW added that Resident #12 did not want to go to another facility and she only wanted to go home. An interview with the physical therapy staff member on 1/25/19 at 11:30 am revealed they had worked with Resident #12 prior to being discharged . The staff member stated the resident had not completed her goals and would not have been able to care for herself at home alone. She added Resident #12 would have had a hard time trying to transfer herself from her wheelchair to the toilet without assistance. An interview with Nursing Aide #1 (NA) on 1/25/19 at 11:45 am who worked with Resident #12 during her stay at the facility revealed the resident needed assistance with all her ADLs, however she could feed herself. NA # 1 added the resident wanted to go home. An interview with the Director of Nursing (DON) on 1/25/2019 at 11:00 am revealed she had no knowledge of Resident #12's discharge. An interview with the Administrator on 1/25/2019 at 1:00 pm revealed the SW completed the discharge for Resident #12 and she was unaware that the facility paid for this resident to be transported home. She stated she did not know if someone had made a home visit prior to Resident #12's discharge. Pre phone interview on 1/25/19 at 1:30 pm with a staff member of the skilled nursing facility that Resident #12 was currently residing at revealed the resident was admitted on [DATE] and required extensive to total assistance with her ADL's except she could feed herself with staff set-up. An interview with Resident #12 on 1/26/2019 at 2:00 pm revealed she was at the former facility for 8 months. She stated she told the facility she wanted to go home however she knew that she could not take care of herself. Resident #12 added the facility kicked her out because she had not paid them. She stated she had completed the Medicaid applications to get help but never but she never heard back. Resident #12 stated she did want to go home but with services in place. She added the facility knew she didn't have any family or support to help her at home. She stated she felt very bad once she got home and had no one to help her go to the bathroom. She added there was no food at her home. Resident #12 stated the facility told her that home health would be visiting her, so she would have what she needed once she got home. Resident #12 explained she had been home for several hours and could not get herself up to get on the toilet, so she called 911. She added she had felt bad all day, and no one had checked on her except to give her medications on the day she was discharged . Pre phone interview on 1/27/19 at 2pm with a home health company staff member #1 revealed they had received a referral for Resident #12 from the facility on 12/13/18. The staff member stated the records she was looking at indicated the referral was denied and they provided no services for the resident in (MONTH) (YEAR). Pre phone interview with the medical doctor (MD) on 1/28/19 10:30am revealed that he last saw Resident #12 sometime in December. He stated the resident knew her medications and would be able to take her medication without assistance. The MD added we would need to talk to physical therapy about her transfer ability. Pre phone interview with an APS worker on 1/28/19 at 11:00 am revealed she had received a call from the facility SW on 12/13/18 to let her know Resident #12 was being discharged home. The APS worker explained they were called in (MONTH) (YEAR) about the condition of the resident's home. He added because the resident was placed in the nursing facility they had not been further involved with the resident's case. The APS worker explained the last communication he had with the facility SW was that Resident #12 was going to remain at the facility due to her health and didn't have any family to help take care of her. Review of statement from the Business office on 1/28/19 at 11:10am dated 10/10/2018 indicated that staff talked to resident she did not have a Medicaid application on file. Staff also explained to her that would be responsible for patient liability which consist of social security check minus $30.00. She completed her Medicaid application and told staff that she understood how it went: but did have any money to pay anything because she was paying for her trailer and other bills so she could go back home (however she paid 1,000.00 for October). An interview with Business Office Manager (BOM) on 1/28/2019 at 11:30am revealed she indicated that she went to see Resident #12 to pick up her monthly payment and Resident #12 indicated she was not paying anything here. BOM stated that Resident #12 told her to give her 30 day notice and Resident #12 indicated so she can go back home. Resident #12 stated I owe everybody and other nursing facilities too and they are not getting anything either, what are they going to do: Nothing'. Resident #12 also stated that she was not going to spend down her money nor give any information on her life insurance either. An interview with facility SW #2 on 1/28/19 at 3:00 pm revealed she was a witness to the conversation on 7/6/2018 with the previous facility SW. She stated during this meeting the previous SW explained to Resident #12 that her last day of coverage would be 7/11/2018. Resident #12 stated during that meeting that she wanted to stay at the facility. Pre phone interview on 1/29/19 at 10:45 am was conducted with the van driver from the transportation company that transported Resident #12 home. He stated he picked up the resident from the facility midday and transported her home. The van driver stated he did know the condition of her home. He explained he just dropped her off and kept it moving. Pre phone interview on 1/29/19 at 11:17 am with the facility Ombudsman revealed she was not aware of Resident #12's discharge. An interview on 1/29/19 at 11:30 am with Nursing Aide (NA) #5 revealed she had provided care for Resident #12 when she was at the facility. She stated the resident was able to make her needs known. The resident would let the staff know if she needed to use the bedside commode, but the resident also choose to wear a brief. NA #5 added the resident required extensive one to two-person assistance with all her ADLs except she was able to feed herself. An interview on 1/29/19 at 11:50 am with NA #2 revealed she was familiar with Resident #12 and that the resident had been discharged sometime in December. NA #2 explained she had worked with the resident on the day she was discharged , and the resident told her she would have an aide coming to help her when she got home. NA #2 stated the resident could do some for herself, but she was unsure if the resident would be able to clean herself up after having a bowel movement. She added the resident was able to make her needs known. NA #2 stated she had no knowledge if the facility hade made a home visit before the resident was discharged . An interview on 1/29/19 at 1:00 pm with Nurse #2 revealed she had been the nurse for Resident #12 during her stay at the facility. She stated the resident didn't have any issues with taking her medications and that the resident had told her that when she was at home she had administered her own medications. Nurse #2 explained she discharged Resident #12 on 12/13/18 but she was unsure of the time. She added she had reviewed and instructed the resident on how to take her medications. She added the resident knew how to check her blood sugar and administer her insulin but stated she had never actually observed her doing this. Nurse #2 revealed she was not able to find the discharge paperwork for Resident #12. Pre phone interview on 1/30/19 at 3:45 pm with a staff member #2 from a home health agency revealed the referral for services for Resident #12 was denied on 12/13/18. The staff member explained they had not received a referral from the facility but from a third party. Pre phone interview with EMS Worker #1 on 1/31/19 at 11:00 am revealed he remembered Resident #12 and he had been at her home earlier in the year when the resident was stuck in the bathtub. He stated the resident lived in a trailer that had a horrible odor and was very nasty. EMS Worker #1 added he didn't know how the resident even got around in her wheelchair because there was so much clutter. He explained when he responded to the call on 12/13/18 Resident #12 met them at the door. He added the resident would not let them in the house, but he could see that there was clutter, boxes and papers all over the floor and there was a horrible odor. Pre phone interview on 1/31/19 at 12:38 pm with EMS Worker #2 revealed a call was received by 911 and dispatched to them as a sick call to Resident #12's home. Worker #2 indicated the resident had a history with EMS and they had observed the resident's home cluttered with trash up to the ceiling and the home had a very bad odor. He stated on this call the resident wouldn't let them in the house, but he could observe the clutter was still present. He explained they rolled the resident out of the home to her driveway and the fire department assisted them with getting the resident on a stretcher. Worker #2 indicated you could smell the odor from the house down to driveway. EMS Worker #2 added the resident was very weak and had urine and had stool on herself. During a second interview with the Van Driver on 1/31/19 at 3pm VD indicated that it is not his responsibility to assess the Residents home but everyone knew that Resident #12's situation that he had to make a path in her house just to stack her boxes. VD also indicated that her home was clutter, nasty and had horrible odor. The Administrator was notified of immediate jeopardy on 1/28/2019 at 1:32pm The facility provided a credible allegation of compliance on 1/30/2019 at 6pm. The credible allegation was amended on 3/1/19 to as follow: The creation of this Letter of Credible allegation constitutes a written allegation of compliance. Preparation and submission of this letter does not constitute an admission or agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth by the survey agency. This letter is solely prepared because of requirement under state and federal law, and to demonstrate the good faith attempts by the provider to improve the quality of life of each resident. As of 3/1/19 changes have been made to the original Allegation of Compliance that was accepted by the State survey team on 1/30/19. We are making these changes under the direction that CMS has requested the changes and we are assured that those changes will not impact the date the IJ was lifted for F 660. Date: 1/30/2019 Corrective action accomplished for those residents found to have been affected by the deficient practice. During the Survey the State alleged that the facility failed to ensure the post-discharge planned destination and continuing care was validated to meet resident #12 needs. Resident #12 was transferred to the hospital for generalized weakness on 12/13/2018 from her private home. Hospital records indicated resident #12 was unable to take care of herself at her home. Resident #12 is no longer in the facility, no further actions warranted at this time. Resident #12 was given a 30 day notice on 11/15/2018 for nonpayment. Social Worker notes from 11/15/18 and 12/12/18 reflect discharge planning discussions with Resident #12 including that resident indicated she had family support at home On 12/13/18 Resident #12 was transferred home at her request by the facility with Home care services in place. Resident #12 was transferred to the hospital for generalized weakness on 12/13/2018 from her private home. At the time of the survey allegations it was identified that the resident was residing in another skilled nursing facility, no other corrective action was needed as a result of Resident #12's location. On 1/30/19; Chief Clinical Officer from the Management and consulting company contracted by the facility, conducted the root cause analysis for this alleged noncompliance. The analysis concluded the alleged noncompliance resulted from the facility's failure to ensure that the facility management team that consist of the department supervisors understand the center's Abuse Prohibition and policies and procedures, specifically related to unsafe discharging of a resident that can be considered neglect. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. Audits of 100% of residents' comprehensive care plan and/or baseline care plan were completed by the Minimum Data Set (MDS) nurse on 1/30/19 to identify whether a resident centered discharge plan was in place. The audit concluded there were no other residents identified without a resident centered care plan necessary to ensure safe and orderly discharge from the facility. 100% of comprehensive care plan and/or baseline care plan audits for all residents discharged to the community in the last 90 days were completed by the facility Director of Social Services #1 and/or #2 on 1/30/19 to identify any other resident discharged unsafely, and/or discharged without following a resident's discharge plan of care. There were no other residents identified as having an unsafe discharge in the last 90 days. The audit validated that each resident discharged from the facility to their private home in the last 90 days had a resident centered discharge planning in place and their discharge from the facility was safe and orderly except for resident #12. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective 1/30/19 each resident will have an individualized discharge care plan created on admission and become part of each resident's comprehensive care plan. Each resident's discharge care plan will be reviewed and revised at least quarterly and with significant change of resident condition by the facility MDS nurse or designated licensed nursing staff. The care plan revision will include, but not limited to, the inputs from the resident, resident representative, if applicable and/or interested family member as permitted by the resident. Effective 1/30/19 and moving forward all newly admitted resident have a care plan for discharge planning that include the following criteria's; arranging and securing services (home health, adult protective services from other government agencies and the community. These items will be included in each resident's individualized discharge care plan as appropriate. Effective 1/30/19 and moving forward the facility will conduct home visits as deemed appropriate and necessary by the facility licensed therapist and/or director of nursing to ensure resident's home is safe for the resident. During the home visit the facility representative who is conducting the visit will make sure the resident have food, medicine and needed equipment's necessary. These items will be included in each resident's individualized discharge care plan as appropriate. The home visits will be conducted prior to resident's discharge. The home visit will be documented on the home visit checklist form and maintained in resident's medical records. Effective 1/30/2019 the facility will train the resident and/or family or significant other, regarding medication administration and/or any other procedures the resident needs before resident is discharged from the facility. This education will be documented in resident's medical records by the facility director of social services #1 or #2 and/or discharging licensed nurse. Effective 1/30/19 the facility will conduct a weekly Case Management meeting chaired by the facility Administrator, MDS nurse, Director of Rehabilitation and/or Director of Nursing. Residents with pending discharges will be discussed in this meeting at least a week in advance to allow the Director of Social Services #1 and/or #2 at least seven days to make necessary arrangements so that the resident discharge was safe and orderly. Member of facility management will alert the interdisciplinary team during the daily stand up meeting for any resident with imminent discharge effective 1/30/2019. Effective 1/30/19 the facility will conduct a discharge meeting and work with the resident and/or resident representative, if applicable, to develop interventions to meet each resident's discharge goals and to ensure a smooth and safe transition from the facility to the post-discharge setting. The discharge meetings will be led by the facility's Director of social services #1 and/or #2 and take place at least three days prior to resident is discharged from the facility, unless the resident stay is less than 3 days, effective 1/30/19. Any identified barriers will be addressed before the resident is discharged from the facility and hence reduce factors leading to preventable readmissions to the hospital. This review will take place daily Monday through Friday effective 1/30/19. Effective 1/30/2019 the director of social services will be ultimately responsible to coordinate all discharge meetings in the facility. The facility will not discharge any resident from the facility until the facility validates that all services are arranged and the resident is safe to be discharged effective 1/30/2019 Effective 1/30/19 and moving forward the facility will provide and document sufficient preparation and orientation to residents and/or resident representative if applicable to ensure safe and orderly transfer or discharge. This orientation will be provided in a form and manner that the resident can understand. This education will be documented in resident's medical records by the facility director of social services #1 or #2 and/or discharging licensed nurse. Effective 1/30/19 and moving forward the facility's administrative team, which includes Administrator, Director of nursing, Nurse supervisors, Director of Social Services #1 and #2, added the review of discharge process for all new admits to an existing process of reviewing new admits for the last 24 hours. By adding the review of residents' discharge planning during daily department heads meetings, it will assure an effective discharge planning process that focuses on the resident's discharge goals, prepare residents for effectively transition, and ensure post-discharge care is appropriately arranged. Effective 1/30/19 and moving forward the weekend Registered Nurse supervisor and/or designated licensed nurse will review new admissions for the last 24 hours to ensure that they have a discharge care plan in place developed on admission. This process with take place every Saturday and Sunday effective 1/30/19. The result of this systemic process will be documented on the weekend supervisor report form maintained in the Daily Stand up meeting binder. Findings from this systemic changes will be discussed in the daily 'stand up meeting daily Monday through Friday effective 1/30/19 Regional Clinical Consultant from the contracted Management and consulting company conducted re-education for current facility interdisciplinary team involved on discharge planning to include the Administrator, Director of Nursing, Director of Social services #1 and #2, Activity Director, Director of Rehabilitation services, MDS nurse and staff development coordinator on 1/30/19. This education emphasized on the importance of developing, implementing, and evaluating each resident's discharge planning at least 3 days before discharge to ensure each resident have a safe discharge from the facility. The education will involve the resident, resident's representative if applicable and will include information such as post discharge services from home health agencies, and/or Adult protective services (if applicable). The education will also include making sure each resident has an individualized discharge care plan created on admission; reviewed and revised at least quarterly and with significant change of resident condition; and at least 3 days prior to discharge to make sure the services are arranged and assured before the resident is discharged . The education also emphasized on the importance of assuring resident have food, medicine and needed equipment's necessary. These items will be included in each resident's individualized discharge care plan as appropriate. This education will be completed by 1/30/19, any department head not educated by 1/30/19 will not be allowed to work until educated. Effective 1/30/19 this education will be added on new hires education and provided annually for all new facility department heads. The Facility Director of Nursing (DON), Assistant Director of Nursing and/or staff development coordinator will complete 100% education on the importance of developing discharge planning beginning on admission and completed immediately and/or within 48 hours of admission. This education emphasized the documentation requirements for all residents discharged to the community to include but no limited to physician orders, discharge education, and interdisciplinary team discussion. This education will be provided for all licensed nurses, to include full time, part time and as needed licensed nursing staff. This education will be completed by 1/30/19. The education will involve the resident, resident's representative if applicable and will include information such as post discharge services from home health agencies, Adult protective services (if applicable), Medication reconciliation, and will be documented on the each resident's discharge records acknowledged by the resident and/or representative of their understanding. Any licensed nurse not educated by 1/30/19 will not be allowed to work until educated. This education will also be added on the new hire orientation process for all new licensed nurses effective 1/30/19, and will also be provided annually. The facility plans to monitor its performance to make sure that solutions are sustained. Effective 1/30/19 the Facility Administrator, Director of Nursing, Assistant Director and/or Nursing, RN supervisors will review all planned discharges to the community in the last 24 hours to ensure that each resident's discharge goals and plan of care was implemented appropriately. (This review is intended to evaluate the systemic changes implemented that discuss resident's discharges at least three days prior to discharge). Any issues identified during this monitoring process will be addressed promptly. Findings from this monitoring process will be documented on a daily Stand up report form and filed in stand up meeting binder after proper follow-ups are completed. This monitoring process will take place daily for 4 weeks, weekly x 2 more

Based on record review, staff interviews, and physician (MD) interview, the facility failed to provide supervision to prevent a totally dependent resident from falling out of bed for 1 of 4 sampled residents reviewed for accidents. Resident #13 fell out of bed which was in the high position when the staff member left the resident unattended in bed. Additionally, the staff member moved the resident from the floor back to bed by herself before the resident was assessed for any injuries. As a result of the fall, the resident sustained [REDACTED]. Resident #13 expired later the same day of the fall. Findings included: Resident #13 was readmitted in the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had a gastrostomy (stomach) tube placed for her nutrition, fluids and medications. The Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and stated that the resident cannot communicate her needs or had no ability to make herself be understood. It was coded that the resident needed extensive assistance with bed mobility, transfer and dressing with two person assistance. The care plan for Resident #13 last updated by the facility on [DATE] was reviewed. The resident required a total assistance with Activities of Daily Living (ADL). The goal was to have no evidence for further ADL decline through the next review. The approaches included extensive to total care for aspects of ADL. The Hospice Nurse visiting notes from [DATE] to [DATE] showed no changes from the previous months. There were no signs of any respiratory issues for the resident and the resident needed no oxygen (O2) treatment. The O2 saturation (O2 Sat - (blood oxygen level)) from the assessment ranges from 95% to 99% with room air (Normal range is 94% to 99%). There was no skin bruising noted in their assessments. An investigation report for the incident written on [DATE] at 11:15 AM by the Administrator stated the Nursing Assistant (NA) #1 was providing care on [DATE] and raised the resident's bed. NA#1 turned the resident on her side and stepped away from the bed, to the door to alert the nurse of a status change regarding the resident's eye. When NA #1 turned her back she heard a noise. And when she turned around the resident was on the floor, she ran to the door again to get the nurse. She was unable to locate the nurse and turned around back in the room and felt the resident was uncomfortable on the floor because the resident was tangled in the feeding tube and catheter. The Administrator's report further stated that the resident fell out of bed from a high position. The NA panicked, lowered the bed, pulled the resident back to bed. After putting the resident to bed, the NA ran out and got the nurse. Several phone calls were attempted to NA #1 during the survey but these attempts were unsuccessful to conduct an interview with her. A nurses' notes on [DATE] written by Nurse #1 revealed that NA #1 called the nurse to the room of Resident #13 at 11:30 AM. The NA showed the nurse some bruises on the resident's right side. The note stated that there was a skin tear and scratch on resident's right buttocks area with some discoloration on right side of the rib cage. An interview with Nurse #1 was conducted on [DATE] at 10:40 AM. The nurse stated that on [DATE] she immediately notified unit supervisor and the Assistant Director of Nursing (ADON) of the bruising and skin tear. Nurse #1 also notified the family member, the hospice nurse and the Medical Doctor (MD) of the bruising and skin tear. The MD ordered chest x-ray and monitoring the resident for any distress. She further stated that the family member came to the facility and stayed with the resident. The chest x-ray was never performed due to the resident's passing away later that day. Another interview with Nurse #1 on [DATE] at 2:14 PM she stated she assessed the resident when she was called in the room at 11:30 AM on [DATE] including monitoring her vital signs which were within normal limits and the resident's respiration increased with signs of anxiety. She stated that an [MEDICATION NAME] 0.5mg was given as requested by the family member and to help the resident calm down. Nurse #1 also stated that NA #1 originally denied any knowledge of what caused the bruises from the resident. Nurse #1 also stated the bruising on the right rib and right buttock were like a hand/finger marks. The nurse stated that NA #1 came back about 30 minutes later and admitted that she knew what had happened to the resident. The NA revealed that she walked away from the resident while doing morning care to get the nurse to assess resident's eye and when she turned around, the resident was sliding off the bed. The NA stated that she intercepted the fall. Nurse #1 stated that the resident was monitored for any distress several times on [DATE] to make sure the resident was in stable condition. She stated that the resident was resting in bed and the family member was in the room the whole time. The nurse said they didn't do a neuro checks because there was no report at that time that the resident fell out of bed and there were no signs of any head injury. The family member was there so they checked the resident visually for any distress. A hospice nurses' notes on [DATE] at 5:37 PM indicated a large hematoma extending from right mid back down across the flank. An abrasion on the right buttock was also written in her assessment. An interview with the Hospice Nurse was conducted on [DATE] at 3:41 PM. The Hospice Nurse stated that she observed Resident # 13 on [DATE]. She explained that the resident's hematoma (bruise) was located at the right mid rib and flank down to her right buttock. She stated that there was also an abrasion in the resident's right middle buttock. A nurses' notes on [DATE] at 7:04 PM written by the ADON indicated the resident went on distress at 2:40 PM and the O2 saturation recorded was at 60% and the pulse rate was 76 Beats Per Minute (BPM) (Normal pulse rate is 60 to 100). The note indicated that the head of the bed was elevated, and O2 was started at 5 liters per minute via a face mask. The O2 Sat was rechecked after 15 minutes and it went up to 78% after the continuous O2 treatment. She stated in the note that the MD and the Hospice Nurse was notified right around 2:40 PM. The Hospice Nurse stated during her interview on [DATE] at 3:41 PM that she came in the door after 3:00 PM and saw the resident in bed with her head of the bed in high position with oxygen mask. The Hospice Nurse stated that the resident already expired when she got in the resident's room. She further stated that she pronounced the resident expired at 3:45 PM. The ADON was interviewed on ,[DATE]/ 19 at 11:35 AM. She stated that NA #1 confessed the following day on [DATE] with the facility administration that the resident rolled out of bed to the floor during her ADL care. The NA admitted that she assisted the resident to bed alone without alerting the nurse of the fall. An interview with a Nursing Assistant (NA) #4 was conducted on [DATE] at 9:45 AM. The NA stated that the resident was a total care and the resident was unable to move by herself due to her contractures of her hands and her legs. NA #4 stated that Resident #13 was very stiff and solid that needed two persons assist with ADL care. NA #3 was interviewed on [DATE] at 2:44 PM and she stated Resident #13 cannot move herself independently and the resident needed two persons assist during ADL care. An interview with Nurse #1 was conducted on [DATE] at 10:40 AM. The Nurse stated the resident had contractures on her upper and lower extremities. She also stated the resident cannot move by herself and the resident was somewhat in fetal position all the time. Nurse #1 also stated the resident only open her eyes with verbal stimulation and moans at times. Interview with the Unit Coordinator on [DATE] at 11:17 AM she stated the resident needed 2 persons assist with bed mobility and transfers. Interview with the ADON on [DATE] at 11:35 AM the ADON stated that the resident needed 2 persons assist with bed mobility and transfers. Interview with MDS Coordinator on [DATE] at 3:15 PM she stated that the resident needed 2 persons assist with bed mobility and transfers. Interview with the MD was conducted on [DATE] at 4:01 PM. The MD stated that the resident was with no brain function and on hospice for her declining health status. He stated the hospice was ordered for the resident who could die in the next 6 months. The MD did not know about the fall up until the next day on [DATE] when he was informed by the facility staff. The MD stated that he didn't believe the fall caused the death of the resident. The MD stated that the order to monitor was for any distress the resident might have. Review of the resident's death certificate indicated the resident died of [MEDICAL CONDITIONS] disease and adult failure to thrive. An interview with the Chief Clinical Officer (CCO) was conducted on [DATE] at 4:35 PM. The CCO stated that they have investigated this incident and the NA no longer worked for the company. The written investigation showed by the CCO specified that on [DATE] at 11:30 AM, NA #1 left Resident #13 unattended while positioned on the side of the bed with the bed in the high position and resident fell from bed to the floor and experienced injuries which included bruising from her right mid ribs down to her right buttocks. Skin tear was also noted on the right buttocks. He also stated that they implemented a corrective action plan for this incident and provided a binder for their plan of correction. The facility plan of correction: The facility provided the following plan of corrections that had been completed on [DATE]. Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #13 was admitted to the facility on [DATE] for long term care services. On [DATE] resident #13 was admitted on Hospice services while in the facility and coded on section O of MDS with ARD [DATE]. Review of facility most recent minimum data set, with Assessment reference date [DATE] section G indicated Resident #13 requires extensive assistance with bed mobility with two assists, transfer with one assistance, and toileting with one assistance. Resident #13 coded in section J. to have no falls since the entry/re-entry and/or last assessment. Review of fall incident log from [DATE] up to [DATE] indicated Resident #13 had one fall dated [DATE]. On [DATE] during AM care resident #13 rolled off the bed onto the floor. The nursing aide providing care had turned the resident on her side and stepped to the door to alert the nurse of a status charge regarding's right eye. Before the nursing aide exited the room, resident #13 fell from bed to the floor while the bed was in high position. C.N.A. failed to report timely and accurately. C.N.A. failed to lower bed to lowest position prior to leaving bed side. C.N.A moved resident before resident was assessment by a licensed nurse. C.N.A. failed to position resident properly and safely on the bed. Nurse aide #1 assisted resident from the floor back to bed without alerting a nurse to assess the resident which is contrary to the facility standards and expectation. Nurse aide number one then exited the room and notified a nurse of the right ribs discoloration and right buttock skin tear with a scratch and claimed that she noticed those injuries when she was turning resident #13 in bed. Nurse aide #1 also reported to licensed nurse #1 the discoloration Licensed nurse #1 walked to resident room and assessed the resident while in bed and noticed right rib discoloration and right buttock skin tear a scratch. Licensed nurse #1 notified unit supervisor who walked to resident's room with the licensed nurse #1 and reassessed resident #13. Unit supervisor indicated that resident shown no signs or symptoms of destress. Nurse aide #1 who was providing care for resident #13 was suspended on [DATE] pending investigation as she did not report resident fall. Attending physician, attending physician called the facility within 30 minutes and ordered X-rays to be completed. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. 100% of residents care cards audit completed on [DATE] by the facility unit manager #1 and Unit manager #2 to ensure each resident means of transfer is documented in a care card. Any resident identified without directives was re-assessed and means of transfer added on the care. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective [DATE] nursing assistants will review resident's care card before providing care for any resident to ensure appropriate number of staff is used during ADL care as indicated on each resident's care card. Nursing assistants will utilize the appropriate number of staff during care and hence ensure resident safety. Effective [DATE] nursing assistants will not move any resident from the floor when a resident experience any fall until the resident is assessed by the trained personnel, specifically licensed nurses. Nursing assistant should make all attempts possible to make resident comfortable while waiting for assistance to arrive. Facility Administrator, and/or Director of Nursing conducted re-education for current nursing assistants' onsite on [DATE]. This education included, importance of ensuring resident is not moved from the floor until proper assessments are completed by the appropriate, trained personnel (licensed nurse) and the importance of following resident's level of assistance needed by reviewing each resident's care cards. This education will be completed by [DATE], any nursing assistant not educated by [DATE] will not be allowed to work until educated on this requirement. Effective [DATE] this education will be added on new hires orientation education for all new facility nursing assistants. This education will also be provided annually for all facility staff to include nursing assistants. The facility plans to monitor its performance to make sure that solutions are sustained. Effective [DATE] the Director of Nursing (DON), Assistant Director of Nursing (ADON), RN supervisors and/or Staff Development Coordinator (SDC) initiated a process to review residents' transfer capabilities on admission/readmission and/or with resident's change of condition and update resident's care card immediately. By updating the care card, it will ensure each resident has a correct transfer method in place and hence receive appropriate services to attain and maintain highest practicable wellbeing. Effective [DATE], Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor the accuracy and updates of each resident's care card by conducting clinical meeting daily (M-F), this meeting covers any change of resident condition that occurred from the prior daily clinical meeting, any admission/readmission occurred from the last clinical meeting and/or any incidents or accidents occurred from the prior clinical meeting, and validated whether resident's care card was updated . Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in clinical meeting binder in Director of Nursing office after proper follow ups are done. Director of Nursing will review the completion of daily clinical report daily (M-F) X4 weeks, weekly x 4 weeks, then monthly x 3 months. Effective [DATE], Residents will be audited after ADL care bed is in the lowest position and resident is positioned correctly and safely in bed. DON/ADON/Unit Managers,,[DATE] Supervisor and Weekend Supervisor. Audits will include 15 residents daily x 2 weeks, 5 days x 1 weeks, and monthly x 3 months Effective [DATE], Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly X3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. The title of the person responsible for implementing the acceptable plan of correction. Effective [DATE] the facility Administrator and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. On [DATE] at 5:48 PM, the plan of correction of the facility was validated. The survey team confirmed the facility addressed the resident involved and acted to mitigate the risk of the other residents. The facility re-educated all staff of safety transfers and the education included the policy to call and report to the nurse for assessment before moving any resident from fall. The facility implemented an audit to update all care card. The facility initiated a process to review resident's transfer capabilities and update the care card of all residents including the new admission. The facility also implemented the monitoring process and to be included in the Quality Assurance and Performance Improvement Committee meeting. The facility's plan of date of correction of [DATE] was validated.

Based on record review, observation, physician and staff interviews the facility failed to monitor the administration of tube feeding formula and water flushes as ordered by the physician for a resident that experienced a significant weight loss and dehydration. This was evident for 1 of 7 residents that was reviewed for nutrition (Resident #422). Findings Included: Resident #422 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of physician's order [REDACTED].#422 revealed an order for [REDACTED]. Review of a nutrition note completed by the Registered Dietitian (RD) dated 2/27/18 for Resident #422 stated diet was brand name tube feeding formula that provided 1.2 calories per ml at 80 ml per hour. NPO due to silent aspiration. Height was 72 inches and weight was 147 lbs. (hospital weight). Ideal body weight (IBW) range 172 lbs. to 182 lbs. and body mass index (BMI) was 19.8. Resident at 84% of his IBW. Estimated nutritional needs based on weight of 154 lbs. were 1747 to 2070 calories, 62 to 69 grams of protein and 1747 to 2070 ccs of fluid. Tube feeding provided 1920 ml, 2034 calories, 115 grams of protein, 1555 ml free water. Nutritional needs were being met with current tube feeding order. Recommended 150 ml free water flush every 6 hours to provide a total of 2155 ml water. Continue to monitor weight, skin and labs for further recommendations. An admission minimum data set (MDS) for Resident #422 dated 3/2/18 identified he had a feeding tube that provided 51% or more of his total daily caloric intake and provided an average daily fluid intake of 501 cc ' s or more. His height was 72 inches, weight was 143 pounds (lbs.) and his cognition was moderately impaired. The MDS did not identify any behaviors related to rejection of care. A care plan dated 3/2/18 for Resident #422 stated he was at risk for complications related to feeding tube. Interventions included to keep head of bed elevated, to administer tube feeding and water flushes per physician orders, to document intake and output, notify physician as needed, weigh resident per facility protocol, RD to review dietary regimen, check placement and residual per facility protocol and observe for any complications such as aspiration, weight loss, nausea/vomiting, etc. A care plan dated 3/2/18 for Resident #422 stated he was at risk for dehydration related to [DEVICE]. The goal was he would have no signs / symptoms of dehydration. Interventions included to obtain lab works as ordered, weigh per facility protocol, observe for signs / symptoms of dehydration, notify physician as needed and administer tube feeding and water flushes per order. Review of the (MONTH) (YEAR) medication administration record (MAR) for Resident #422 revealed an order to flush the [DEVICE] with 100 ccs of water every 4 hours. The start date was 2/23/18 and discontinue date was 3/6/18. The water flush was signed off with a check mark as being administered at 5:00 am, 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm from 2/23/18 through 2/28/18. There was no order on the (MONTH) (YEAR) MAR to administer the tube feeding formula. Review of the (MONTH) (YEAR) MAR for Resident #422 revealed an order to flush the [DEVICE] with 150 ml water every 6 hours with a start date of 3/1/18 and a discontinue date of 3/26/18. The water flush was signed off with a check mark as being administered at 12:00 am, 6:00 am, 12:00 pm and 6:00 pm from 3/1/18 through 3/26/18 with two entries that resident refused. The (MONTH) (YEAR) MAR revealed an order for [REDACTED]. The order had a start date of 3/31/18 and was initialed with a check mark as being administered once on 3/31/18 at 9:00 pm. There was no order on the (MONTH) (YEAR) MAR to administer tube feeding formula from 3/1/18 through 3/30/18. Review of a nursing note entry on 3/12/18 for Resident #422 stated resident would not let this writer give him his medications or flush his [DEVICE]. Review of a nursing note entry dated 3/18/18 for Resident #422 stated resident with abdominal binder on at all times, still noted to take feeding out of [DEVICE] and let it run onto the floor. Review of a nursing note entry dated 3/22/18 for Resident #422 stated resident refused 3 times for this writer to give him medications in his [DEVICE] and refused tube feeding at this time. He used his left hand to push this writers hand away and shook head no. Earlier this shift resident took feeding tube out of his [DEVICE] and hung it on the pole and let the feeding run out on the floor. Resident has been off the tube feeding for approximately two hours as this point and still refused to let this writer reapply feeding. New feeding container and fresh water hung and ready for insertion into [DEVICE]. Review of a RD note dated 3/25/18 for Resident #422 stated he was NPO and received a brand name tube feeding formula that provided 1.2 calories per ml at 80 ml an hour and 100 ml water flush every 4 hours. Weight was 137.2 lbs. (3/25/28). Nursing staff reported the resident would push the call button if he was full and if they didn ' t turn off the feeding pump he would disconnect the tube feeding and let it run on the floor. The nurse informed me they would let the feeding pump stay off for several hours before turning the feeding pump back on. The resident was very thin and weak. Will not increase tube feeding due to tolerance issues. Recommend decreasing flushes to 100 ml every 6 hours to help alleviate feeling of fullness. Will continue to monitor weight, skin and labs but expect further weight loss. Review of a nursing note entry dated 3/26/18 for Resident #422 stated the tube feeding was noted to be going at 150 ml per hour instead of 80 ml per hour. Resident with stomach not distended, but complained of feeling very full. Resident given a few hours of feeding. A physician's order [REDACTED].#422 stated to have the RD assist with transition to bolus feedings via his [DEVICE]. Review of a physician order [REDACTED].#422 stated to discontinue continuous [DEVICE] feedings and flushes. Start a brand name tube feeding formula that provided 1.2 calories per ml, 480 ccs at 8:00 am, 12:00 pm and 9:00 pm, 240 ccs at 5:00 pm and 150 ml water every 6 hours via [DEVICE]. Review of the weights recorded in the electronic medical record (EMR) for Resident #422 revealed weight was 137.2 lbs. on 3/20/18, 135.4 lbs. on 5/6/18 and 134 lbs. on 6/6/18. Review of a hand- written list of weights for Resident #422 provided by the RD revealed a weight of 139.6 lbs. on 3/13/18, 137.2 lbs. on 3/20/18 and 131 lbs. on 4/4/18. This reflected an 8.6 lb. / 6.1% significant weight loss in 22 days. An interview with the RD on 6/13/18 at 11:55 am revealed the first weight she had for Resident #422 was on 3/13/18 and she had used the hospital weight for her initial nutritional assessment. An observation on 6/13/18 at 12:30 pm of Resident #422 revealed he was in his room eating his lunch meal. He had received a Mechanical Soft diet with nectar thickened liquids. He could feed himself and consumed all of his food and fluids. Review of a physician's order [REDACTED].#422 stated to start a brand name tube feeding formula that provided 1.5 calories per ml, 225 ml at 8:00 am and 12:00 pm, 150 ml water flush at 8:00 am, 12:00 pm, 5:00 pm and 9:00 pm, from 10:00 pm until 4:00 am run continuous feeding at 110 ml per hour with 65 ml water every hour. Review of nursing note entries on 4/14/18 from 6:14 pm until 11:53 pm for Resident #422 revealed a change in the resident ' s condition and he was sent out to the emergency room at 11:50 pm. Review of the hospital record dated 4/15/18 for Resident #422 stated resident was found to be dehydrated with acute [MEDICAL CONDITION]. Admission BUN (blood urea nitrogen) was 84 milligrams per deciliter (mg/dl) and improved to 34 mg/dl on 4/16/18 after administration of intravenous fluids. The normal reference range for BUN was identified as 7 to 25 mg/dl. Review of hospital nutritional assessment dated [DATE] for Resident #422 stated per hospital records residents weight had decreased from 72 kilograms (kg) (158.4 lbs.) on 3/6/18 to 59.6 kg (131.1 lbs.) on 4/15/18. An approximate 17% weight loss in 5 weeks. Review of a nursing note dated 4/16/18 for Resident #422 stated resident readmitted to the facility at 6:25 pm. Review of a physician's order [REDACTED].#422 stated to administer a brand name tube feeding formula that provided 1.5 calories per ml, 250 ml at 6:00 am, 12:00 pm, 6:00 pm and 12:00 am and 150 ml water flush at the same times via [DEVICE]. An interview on 6/14/18 at 10:54 am with the RD revealed the weight used for Resident #422 ' s nutritional assessment dated [DATE] was 142 lbs. She stated the Dietary Manager (DM) had obtained the weight from a nursing assistant (NA) report and it was never entered into the EMR. She added all of the resident ' s weights should be in the EMR and she didn ' t know why they weren ' t entered. The RD stated the facility weight protocol was to weigh all new admissions weekly for 4 weeks. She explained she had spoken to the nurses and the resident ' s family members about Resident #422 being underweight and options for his tube feedings. She added the nurses would tell her the resident was disconnecting his tube feeding. The RD stated she had assumed that the resident ' s tube feeding was being administered according to the physician's order [REDACTED]. She added she had changed his tube feedings from continuous to bolus feedings on 3/31/18 at the request of the physician in preparation of the resident being discharged home. The RD added the resident was not discharged and she changed his tube feeding on 4/10/18 to one with a higher caloric density. She stated she hadn ' t considered changing the formula prior to that date even though she acknowledged the resident had experienced a significant weight loss. The RD added she did not believe there had been any lab work completed on the resident and she had not recommended any labs to better assess the resident ' s nutritional status. An interview on 6/14/18 at 7:03 pm with Nurse #5 revealed she had been the nurse for Resident #422 on the evening shift (7:00 pm to 7:00 am). She stated the resident did receive tube feeding and he didn ' t have any tolerance issues on her shift. She added other nurses had reported to her that the resident would disconnect the tube feeding and let it run on the floor. Nurse #5 explained she followed the orders on the MAR and would initial the MAR that the tube feeding was given. She stated they did not record the exact amount of tube feeding or water flushes that were administered on their shift. An interview on 6/16/18 at 7:15 pm with the Assistant Director of Nursing (ADON) revealed she was familiar with Resident #422. She stated the resident did not tolerate his tube feedings well and he would pull the feedings off and let them run on the floor. The ADON explained the resident had been referred to the RD because of the issues with his tube feeding. She stated the nurses were responsible to sign off on the MAR to reflect that the tube feeding was administered. The ADON added they did not typically document the exact number of ccs of formula or water that the resident received. The tube feeding care plan intervention that stated to monitor intake and output for Resident #422 was reviewed with the ADON and she stated she would interpret this as meaning the total cc ' s / volume of tube feeding and water that the resident received should have been documented. The (MONTH) and (MONTH) (YEAR) MARs were reviewed with her and she stated she was not aware that the tube feeding formula was not on the MARs for these months and she didn ' t know why his tube feeding had not been documented as being administered. An interview on 6/15/18 at 9:52 am with Nurse #7 revealed she had cared for Resident #422. She stated the resident would refuse the tube feedings at times by pushing her hand away when she tried to administer it or he would disconnect the tube feeding and let it run on the floor. She stated they did not document the exact amount of tube feeding formula or water the resident received; she would just initial the MAR if it was given or write a N if refused. Nurse #7 added she would initial the MAR that the tube feeding was administered even if she was only able to administer a partial amount. She stated she was not aware of the care plan intervention to monitor intake and output on the Resident #422. She was also not aware that the tube feeding formula was not on the (MONTH) or (MONTH) (YEAR) MARs. Nurse #7 stated she had notified the physician and the RD of the resident ' s behaviors with his tube feeding. She added she was not aware the resident had a significant weight loss. A phone interview on 5/15/18 at 12:19 pm with the physician for Resident #422 revealed the resident was NPO and received tube feeding for his nutritional intake. He added the resident was eating by mouth now. The physician stated he believed the facility had notified him that the resident had disconnected his feeding tube and refused his tube feeding at times. He added he could not confirm if he had been notified of his significant weight loss. The physician added the facility probably should have been monitoring the exact amount of tube feeding formula and water flushes he was receiving because of his behaviors of refusing and disconnecting the tube feeding. He stated the resident ' s actual intake would have been more accurately assessed if they were doing that. The physician explained the dehydration identified when the resident was hospitalized was likely associated with his insufficient fluid intake from his tube feeding. An interview with the Director of Nursing (DON) on 6/15/18 at 5:01 pm revealed he expected physician's order [REDACTED]. He stated the facility should have implemented additional monitoring to ensure the resident ' s nutritional status was maintained.

Based on medical record review, staff and resident interviews it was determined that facility staff failed to treat 1 of 1 sampled resident's with dignity while providing care; talking down to the resident and snatching pillow from under the residents head (Resident #16). Findings included: Resident # 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) revealed that the resident scored 13 on the brief interview of mental indicating that the resident had good memory. The resident did not have disorganized thinking or altered level of consciousness. The resident was not exhibiting behavioral symptoms per the MDS. The resident was coded as requiring extensive two person assistance for bed mobility, transfer and toilet use. He was coded as requiring extensive one person assistance for eating, dressing and personal hygiene. Interview with the resident's family member on 4/14/18 at 1:10 PM revealed that she had video evidence of Resident #16 being abused. She stated the resident told her that staff threw him in the bed, they talked down to him and that they treated him horrible at the facility. She reported installing a recording device because she thought the resident was exaggerating his treatment. She said that one night she came in and the resident's television was on full blast, his phone was across the room and his call bell was dropped over the night staff. Both items were out of the resident's reach. She stated that the resident is able to use the telephone and the call bell. She reported that there was no need for the television to be on full blast and she had spoken to staff about it. During interview with the resident at 1:54 PM on 4/14/17 he stated that the staff are mean all the time; mostly at night. He said, One girl picks me up and flips me around like I'm a rag doll. He reported staff used the lift to get him up sometimes. He said one girl told him he needed a longer leash. Review of a video recorded on 4/9/18 during 3rd shift (am of the 10th) at 3:00 on 4/14/18 revealed a staff member enter the resident's room during 3rd shift and state aww you stink. Another staff member entered the room and appeared to be cleaning the resident up while he lay on the floor. Neither resident #16 nor the floor could be seen from the camera angle. Another staff member entered the room and the resident was placed on the bed by the 3 staff. One staff exited the room while two remained in the room. The NA (later identified); then dropped the resident's legs onto the bed. The same nursing assistant was then observed snatching the pillow from underneath the resident's head without informing the resident of what she was doing. Review of the recording revealed the NA stating, How old are you? U should be enjoying your retirement; pooping on yourself-shame on u. The nurse #4 was observed in the room at this time giving the resident a tube feeding. Per the video it appeared she Nurse #4 responded, 1 when the NA asked Resident #16 how old he was. Interview with NA at 1:31 PM on 4/15/18 revealed that she found Resident #16 on the floor and reported it to the nurse. She stated that she asked the resident if he was ok and told him to wait a minute. She stated the resident was lying on the mat. He had taken off his brief and had bowel movement all over. She said she asked him if he could stay in bed so he wouldn't fall again when she was in the room. The nursing assistant denied telling the resident that he should be ashamed of himself. She stated that maybe she asked him how old he was because he tried to touch her. The NA said that the resident did not ring his bell to go to the bathroom. She said she gave him the call bell but he tried to rip it from the wall. She did not want him to get hurt so she put it to the other side and moved the table because he kept reaching for the phone. She stated that she did not want him to get hurt reaching because them he goes to the floor. During interview on 04/15/18 at approximately 5:20 PM with Resident #16 he stated he felt like hell on the day when the Nursing assistant and nurses got him up off the floor and back into bed. Stated he did not like the way he was treated and talked to, that he felt very depressed about it. Stated he does not care what happens to him anymore. Interview via telephone on 4/15/18 at 2:45 PM with nurse #4 who was present on 3rd shift revealed that the NA (nursing assistant) reported that when she went to change Resident #16 he put his feet off the bed. The NA said she saw him roll off the bed. Nurse #4 stated she went to the room but did not go inside immediately because she needed help to get him up. The nurse stated that she, another nurse and the NA went into the room where the resident was lying on the mat. She reported that she did not see any injuries. She said that the Resident was very heavy, so they lifted him up. She stated she thought they were gentle enough with him. NA stated, You keep falling and it is hurting our backs. She said she could not remember the details about the conversation. NA said you are breaking our backs. The nurse said she did remember NA saying shame on you for pooping on yourself. She said the resident would say some things. The nurse stated she talked to the nursing assistant and told her not to go overboard with what she was saying to him. Nurse #4 said she also remembered someone saying .aww you stink! During interview with the social worker at 4:25 PM on 4/14/18 she reported that she, the rehabilitation manager and the resident's family member had a care plan meeting in 4/12/18. She said that she asked about concerns at the end of the meeting. Resident #16's family member said that the resident complained about staff being rude on 3rd shift. The social worker wrote the concerns up on a grievance form. Per review of the grievance form dated 4/12/18; the concern was addressed in the interdisciplinary team meeting on 4/12/18. Social worker planned to follow up with the resident's family member on Monday 4/17/18.

Based on medical record review, staff, family and resident interviews it was determined that facility staff failed to notify the physician and family of a fall for 1 of 2 sampled residents (#16) with falls. Findings included: Resident # 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) revealed that the resident scored 13 on the brief interview of mental indicating that the resident had good memory. The resident did not have disorganized thinking or altered level of consciousness. The resident was not exhibiting behavioral symptoms per the MDS. The resident was coded as requiring extensive two person assistance for bed mobility, transfer and toilet use. He was coded as requiring extensive one person assistance for eating, dressing and personal hygiene. Review of the medical record 4/14/18 revealed a nursing note (Nurse #4)4/11/18 4:51 am which stated, 4/10/18 at 7:45 PM patient noted to be hanging almost off the bed. Patient assisted back to bed 8:10 PM. One of the (family) members alerted this nurse that he had observed patient using his bed control to high position and was almost sliding off the bed. Patient observed way up hanging the bed. Patient continue to hang off the bed, restless throughout the night. Unable to redirect. Will continue to monitor. Therapy note 4/11/18 1:22 PM stated, Patient reports recent fall, but unclear about details and number of falls. Interview with the resident's family member on 4/14/18 at 1:10 PM revealed that the resident was telling her every time he had a fall. She stated that he had goose egg on his head. She said that she had not been notified by the facility that Resident #16 had any falls. She stated that the rehabilitation manager and the social worker admitted that the resident had 6 falls during a care plan meeting. Review of a video recorded on 4/9/18 during 3rd shift (am of the 10th) at 3:00 on 4/14/18 revealed a shot of the resident's unoccupied bed. Staff was seen entering the room and talking to someone below the bed on the other side. A staff member entered the room and appeared to be cleaning the resident up while he lay on the floor. Neither resident #16 nor the floor could be seen from the camera angle. Interview with the administrator at 3:53 PM on 4/14/18 revealed that if a resident has a fall the nurse will assess for injury, the MD and family are notified and the incident is available for review in clinical rounds. Falls are investigated as needed. During interview with the social worker at 4:25 PM on 4/14/18 she reported that she, the rehabilitation manager and the resident's family member had a care plan meeting in 4/12/18. She said that she asked about concerns at the end of the meeting. Resident #16's family member said that the resident complained about staff being rude on 3rd shift. The social worker wrote the concerns up on a grievance form. Per review of the grievance form dated 4/12/18; the concern was addressed in the interdisciplinary team meeting on 4/12/18. The attachment to the grievance form stated 4/1/18 (fall). Social worker planned to follow up with the resident's family member on Monday 4/17/18. During interview with the rehabilitation manager on 4/15/18 at 2:20 PM, he stated that he did not remember the family member saying anything about falls during the care plan meeting. He reported that the falls log indicated that the resident had 2 falls per the incident log, one fall occurred on (MONTH) 1st. Interview with a nursing assistant on 4/15/18 at 1:31 PM revealed that she found the Resident #16 on the floor and reported it to the nurse. She stated they tried to transfer him to bed because the lift could not go down to the floor. They got a 3rd person to help because it was so hard and it was killing their back. The NA said she did not report the fall to the nurse because the nurse was there. Interview via telephone on 4/15/18 at 2:45 PM with Nurse #4 who was present on 3rd shift revealed that the NA (nursing assistant) reported to her that when she went to change Resident #16 he put his feet off the bed. The NA said she saw him roll off the bed. Nurse#4 stated she went to the room but did not go inside immediately because she needed help to get him up. Nurse #4 stated that she, another nurse and the NA #1 went into the room the resident was laying on the mat. She reported that she did not see any injuries. She said that the Resident was very heavy, so they lifted him up. She further stated that the night he fell it was documented. Put in electronic chart under notes. Review of facility records revealed no documentation of the incident. There was no indication that the family or the resident's physician had been notified of the fall.

Based on medical record review, staff and resident interviews it was determined that facility staff spoke to 1 of 1 sampled resident's in a verbally abusive manner (Resident #16). Findings included: Resident # 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) revealed that the resident scored 13 on the brief interview of mental indicating that the resident had good memory. The resident did not have disorganized thinking or altered level of consciousness. The resident was not exhibiting behavioral symptoms per the MDS. The resident was coded as requiring extensive two person assistance for bed mobility, transfer and toilet use. He was coded as requiring extensive one person assistance for eating, dressing and personal hygiene. Interview with the resident's family member on 4/14/18 at 1:10 PM revealed that she had video evidence of Resident #16 being abused. She stated the resident told her that staff threw him in the bed, they talked down to him and that they treated him horrible at the facility. She reported installing a recording device because she thought the resident was exaggerating his treatment. The resident's family member stated that on her recording she saw a staff member enter the resident's room on 3rd shift; look at the resident then leave. She reported that no one returned to the room for 12-15 minutes. During interview with the resident at 1:54 PM on 4/14/17 he stated that the staff are mean all the time; mostly at night. He said, One girl picks me up and flips me around like I'm a rag doll. He reported staff used the lift to get him up sometimes. He said one girl told him he needed a longer leash. Review of a video recorded on 4/9/18 during 3rd shift (am of the 10th) at 3:00 on 4/14/18 revealed a staff member enter the resident's room during 3rd shift and state aww you stink. Another staff member entered the room and appeared to be cleaning the resident up while he lay on the floor. Neither resident #16 nor the floor could be seen from the camera angle. Another staff member entered the room and the resident was placed on the bed by the 3 staff members. One staff exited the room while two remained in the room. The NA (later identified); then dropped the resident's legs onto the bed. The same nursing assistant was then observed snatching the pillow from underneath the resident's head without informing the resident of what she was doing. Review of the recording revealed the NA #1 stating, How old are you? You should be enjoying your retirement; pooping on yourself-shame on you. Nurse #4 was observed in the room at this time giving the resident a tube feeding. It appeared that she responded, 1 when the NA asked Resident #16 how old he was. During interview on 04/15/18 at approximately 5:20 PM with Resident #16 he stated he felt like hell on the day when the Nursing assistant and nurses got him up off the floor and back into bed. Stated he did not like the way he was treated and talked to, that he felt very depressed about it. Stated he does not care what happens to him anymore. Interview with a nursing assistant at 1:31 PM on 4/15/18 revealed that she found Resident #16 on the floor and reported it to the nurse #4. She stated that she asked the resident if he was ok and told him to wait a minute. She stated the resident was lying on the mat. He had taken off his brief and had bowel movement all over. She said she asked him if he could stay in bed so he wouldn't fall again. The nursing assistant denied telling the resident that he should be ashamed of himself. She stated that maybe she asked him how old he was because he tried to touch her. Interview with the Administrator at 2:26 PM on 4/15/18 revealed that she learned about the incident from the Resident's family member on 4/14/17. She reported that staff members involved in the incident were identified from the video. The staff was placed on leave pending investigation. She filed a 24hour with the Division of Health Service regulation and made a police report. Resident's on the hall were interviewed by the social worker regarding staff treatment. Interview via telephone on 4/15/18 at 2:45 PM with nurse #4 who was present on 3rd shift revealed that the NA (nursing assistant) reported that when she went to change Resident #16 he put his feet off the bed. The NA said she saw him roll off the bed. Nurse #4 stated she went to the room but did not go inside immediately because she needed help to get him up. Nurse #4 stated that she, another nurse and the NA went into the room where the resident was lying on the mat. She reported that she did not see any injuries. She said that the Resident was very heavy, so they lifted him up. She stated she thought they were gentle enough with him. The resident kept talking about doctors made him stay at the facility. He always gives this story when you talk to him. NA stated, You keep falling and it is hurting our backs. She said she could not remember the details about the conversation. NA said you are breaking our backs. Nurse #4 said she did remember NA saying shame on you for pooping on yourself. She said the resident would say some things. The nurse stated she talked to the nursing assistant and told her not to go overboard with what she was saying to him. The nurse said she also remembered someone saying .aww you stink! Nurse #4 further stated, now that she thought about it, it was probably verbal abuse, but at the time, she did not think of it that way. She talked to NA later and told her she should avoid saying things like this to the resident. She did not have NA leave the room when she said them. She stated the NA continued to talk to resident while she him gave the tube feeding. During interview at 3:01 PM on 4/15/18 with 3rd staff member (nurse #2), she stated that she just went in to help get him off the floor. She stated that she had worked with the NA when she worked the 400 hall sometimes. She stated that she had seen the NA talk to residents in the am and she talked to them so well. She reported no complaints from residents regarding the nursing assistant. Interview with the Administrator on 4/15/18 at 3:30 PM - The administrator stated that the video spoke for itself and that verbal abuse was clear. The administrator stated that resident was not handled in a dignified manner when found on floor and transferred back to bed. She stated she was following steps to report the abuse and that she was following the facility abuse protocol.

Based on record review and staff interviews, the facility failed to update a care plan for a 1 of 3 sampled residents (Resident #5), high risk for falls; resulting in a fracture, once it was determined that she needed two staff to safely transfer her. The findings included: Resident #5 was admitted to the facility on [DATE] with the following diagnoses, senile dementia, functional [MEDICAL CONDITION], anxiety plus a history of falls and subdural hemorrhage. On 2/25/14 she was readmitted to the facility after sustaining a fractured left tibia and fibula. Resident #5's chart was reviewed and revealed that a care plan was developed for her on 11/12/13 to address the potentials for falls due to short and long term memory deficits, visional deficits, use of anti-depressant and anti-hypertension medications as well as incontinence of bowel and bladder. She required assistance from staff for all transfers and with mobility. The written goal assured that she would not experience any injuries from falls through the next review. Approaches to be used included monitoring her condition that might warrant increased supervision and assistance. Both physical and occupational therapy referrals would be made as needed. A quarterly fall risk assessment, would be performed, per policy. An Initial Assessment report from physical therapy (PT) dated 11/27/13 revealed that Resident #5 needed to be evaluated due to a change in her abilities to transfer to/from her wheelchair and bed. A PT Daily Treatment Note on 12/4/13 recorded that a nurse aide reported to Physical Therapist (PT #1) that Resident #5 was inconsistent with transfers depending on level of alertness. She was unable to follow directions to weight bear on both feet. At times, she would thrust posteriorly and extended both knees, require total assist for transfer and bed positioning. During an observation it was noted that Resident #5 was able to stand up but unable to pivot and needed total assist for turning and for sitting to supine positions. A quarterly Minimum Data Set (MDS) performed on 12/6/13 determined that she was cognitively impaired and needed the extensive assistance of one person for bed mobility and the extensive assistance of two persons during transfers. Resident #5 was noted to be unsteady with her balance and non-ambulatory. She was assessed to have no limitations with range of motion on her upper and lower extremities. On the PT Therapist Progress and Discharge Summary, 12/11/13, PT #1 recorded that clinically, Resident #5 would require a two person transfer for safety of patient and staff from bed and/or wheelchair, due to her decreased stand tolerance. The Nursing Instructions report was revised on 2/25/14 to require a mechanical lift for mobility and two staff to assist with positioning. Her care plan was revised on 2/27/14 to include a floor mat while in bed as a new approach to prevent injuries from fall but did not include language about using two staff to transfer. On 5/29/14 at 9:25 am, Physical Therapist #1 (PT #1) was interviewed. She shared that she initially got involved with Resident #5 last year in November to help her with transfers from bed to the wheelchair. She stated that Resident #5 was dependent on staff for her mode of transfer and that two persons were required. Administrative staff #3 was interviewed on 5/29/14 at 10:08 am. She shared that she was a new employee and only became involved with Resident #5's care plan in February. She explained that the nurse who originally did the assessment was no longer employed at the facility, but the expectation would be for the care plan to be updated to reflect the changes that therapy had made, regarding a safer mode of transfer.

Based on record review, resident and staff interviews, the facility failed to safely transfer 2 of 3 residents (Residents #1 and #5) who required extensive assistance, resulting in a serious injury for Resident #5. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with the following diagnoses, senile dementia, functional quadriplegia, anxiety plus a history of falls and subdural hemorrhage. On [DATE] she was readmitted to the facility after sustaining a fractured left tibia and fibula. Resident #5's chart was reviewed and revealed that a care plan was developed for her on [DATE] to address the potentials for falls due to short and long term memory deficits, visional deficits, use of anti-depressant and anti-hypertension medications as well as incontinence of bowel and bladder. She required assistance from staff for all transfers and with mobility. The written goal assured that she would not experience any injuries from falls through the next review. Approaches to be used included monitoring her condition that might warrant increased supervision and assistance. Both physical and occupational therapy referrals would be made as needed. A quarterly fall risk assessment, would be performed, per policy. An Initial Assessment report from physical therapy (PT) dated [DATE] revealed that Resident #5 needed to be evaluated due to a change in her abilities to transfer to/from her wheelchair and bed. A PT Daily Treatment Note on [DATE] recorded that a nurse aide reported to Physical Therapist (PT #1) that Resident #5 was inconsistent with transfers depending on level of alertness. She was unable to follow directions to weight bear on both feet. At times, she would thrust posteriorly and extended both knees, require total assist for transfer and bed positioning. During an observation it was noted that Resident #5 was able to stand up but unable to pivot and needed total assist for turning and for sitting to supine positions. A quarterly Minimum Data Set (MDS) performed on [DATE] determined that she was cognitively impaired and needed the extensive assistance of one person for bed mobility and the extensive assistance of two persons during transfers. Resident #5 was noted to be unsteady with her balance and non-ambulatory. She was assessed to have no limitations with range of motion on her upper and lower extremities. On the PT Therapist Progress and Discharge Summary, [DATE], PT #1 recorded that clinically, Resident #5 would require a two person transfer for safety of patient and staff from bed and/or wheelchair, due to her decreased stand tolerance. The chart review did not contain an updated Kardex (nursing instructions form) or Care Plan, to reflect the change in transfer mode for Resident #5. A Physician Exam Summary on [DATE] remarked that Resident #5 needed maximum assistance for all of the activities of daily living. She was non-ambulatory and had a bed to chair existence. It was noted that she had been more confused recently. The musculoskeletal assessment indicated that she had partial limitations to her upper and lower motor abilities. On [DATE] at 12:09 am, Nurse #1 recorded in her notes that (on [DATE]) at 7:00 pm, she was called to Resident #5's room by a nurse aide. Upon entering, she heard Resident #5 say, "My leg, it hurts." She found her lying in bed with left leg slightly swollen. The leg was turned outward in the shin area and a bruise was forming. The palpitation of the leg found a movable bump in the shin area. She noted that Resident #5 was lifting her leg to cross over the other leg, saying, "Please help me, my leg hurts." The left leg was immobilized and the nursing supervisor was notified. Her vital signs were recorded and a call was made to the physician's office. An order was written for an x-ray, then the family was notified. The x-ray was taken around 8:40 pm, with the results posting at 11:20 pm. A new order was made by the physician to send Resident #5 out to the emergency room . She was taken to the emergency room at 12:25 am. A Report of Resident Other Event (defined as an out of the ordinary occurrence), dated [DATE] was reviewed. Within the report, it mentioned that Resident #4 was lying in bed, saying "My leg." The left leg was noted with small amount of swelling to shin area and slight deformity of leg noted. Leg was turned outward at shin area with bruise forming. The event location took place in the resident's room with her sustaining a major injury. The report indicated that a new plan of care/intervention had been completed to prevent further events. The Hospital's Transfer Summary, dated [DATE] was reviewed. It indicated that Resident #5 was brought to the emergency room with pain in her left leg following a fall. She was found to have a fracture of the tibia and fibula. On [DATE], her leg was surgically repaired, using an open reduction and internal fixation, but not placed in a cast. At the request of her family, she was placed on palliative care. She returned to the facility on [DATE]. The Nursing Instructions report was revised on [DATE] to require a mechanical lift for mobility and two staff to assist with positioning. Her care plan was revised on [DATE] to include a floor mat while in bed as a new approach to prevent injuries from fall but did not include language about using two staff to transfer. A Physician's Monthly Note, [DATE], recorded that Resident #5 had remained stable since her return from the hospital and did not have complications due to her surgery. She was noted to have continual weight loss due to chronic diseases and expired at the facility a week later. On [DATE] at 4:08 pm, Administrative Staff #1 was interviewed. She commented that Resident #4 was injured during an event, sustaining a fracture, which prompted the facility to develop an Action Plan to prevent reoccurrence. She then explained that nurse aide #1 was transferring Resident #5 from her wheelchair to her bed, when her leg got caught in her recliner, thus fracturing her leg. She presented the Action Plan, [DATE], which revealed that Nurse Aide #1 was assigned to Resident #5 routinely, who had just received a new recliner chair, which was placed in her room, at bedside. She shared that there was about a space of 4 inches between the bed and recliner. She acknowledged that their Nursing Instructions report had still indicated that Resident #5 only needed a one person transfer. It did not reflect that therapy no longer felt that Resident #5 was safe for a one person transfer, when she was evaluated in December, 2013. Recommendations followed and included: all nursing assistants were in-serviced on proper transfers and gait belt usage. They were also educated on when they should stop and re-evaluate a transfer technique needs and seek additional assistance or therapy advisement. A DOT system was developed and shared with all nursing assistants. Colored dots would be placed by the resident's door outside their door symbolizing their mode of transfer or need for additional help. A red dot meant that staff needed some mode of help to transfer the resident. The Nursing Instructions report should be checked to verify the mode of transfer. Nurse Aide #1 received follow up training on [DATE] and was required to be involved in all training, moving forward. Kardexes (nursing instructions reports) were reviewed to ensure that all residents have the correct transfer assist needs listed. Kardex would be completed on admission and updated with changes by Unit Managers, Therapy and Nursing Assistants. All rooms were checked for significant clutter on [DATE]. All staff would check rooms daily for clutter. Staff would receive transfer training in orientation and quarterly. The Staff Development Coordinator, Therapy and Nursing would be responsible for training staff, with return demonstrations required. The Plans completion date was [DATE] and ongoing. Administrative staff #2 was interviewed on [DATE] at 4:20 pm. She explained that each resident had a Nursing Instructions report completed at the time of admission, detailing the activities of daily living skills needed. However, the charge nurse usually revised the form, whenever a change occurred. She discussed that the facility had started to implement a new DOT system, about two months ago. It entailed placing a dot outside the resident's door, so that it was viewed before entering. A green not meant that the resident needed supervision by staff for transfers. A yellow dot meant that staff should be cautious and offer a 1 person assist. The red dot, meant that the staff should stop and get equipment or another person to help with transfer. On [DATE] at 9:25 am, Physical Therapist #1 (PT #1) was interviewed. She shared that she initially got involved with Resident #5 last year in November to help her with transfers from bed to the wheelchair. She stated that Resident #5 was dependent on staff for her mode of transfer and that two persons were required. A written statement from Nurse Aide #1, dated [DATE] was attached to the Action Plan. She indicated that she was putting Resident #5 back to bed when she noticed that her leg was caught between the chair and bed. She stated, "I get it out the best I could." I put her to bed and got the nurse. Nurse Aide #1 was interviewed on [DATE] at 6:23 pm. She stated that Resident #5 was her permanent assignment and she worked with her during the evenings. She shared that Resident #5 could not make her needs known and that she would usually have to transfer her from her bed to the wheelchair, when taking her down to dinner, or after dinner, transferring her back to bed. She stated that before the fracture, Resident #5 was not a two person transfer. The day of the incident she explained that Resident #5 was sitting in her wheelchair and she was getting ready to undress her for bed. She removed her shirt, placed her gown over her head, and then intended to transfer her bed, to remove her pants. She went on to explain how she set up the transfer that evening to the bed. Resident #5 was placed in her wheelchair, which was next to her bed, facing the new recliner. Nurse Aide #1 stood between the recliner and the wheelchair. She removed the leg rests off the wheelchair and noted that Resident #5's legs were still bent. Nurse Aide #1 commented that although Resident #5 was taller than her, she wasn't heavy to transfer because she had been losing weight. She stated that she always felt comfortable moving her. Nurse Aide #1 asked Resident #5 to place her arms around her and grab onto her gait belt, as the aide leaned forward. She held onto Resident #4, lifting her bottom off of the chair cushion and noticed that Resident #4 wasn't really grasping her waist so she was really doing all of the lifting. She shared that Resident #5 wasn't completely standing when she heard a funny noise. Then she turned, holding Resident #5, to put her to bed, continuing with her movements. Resident #5 did not cry out, but afterwards, Nurse Aide #1 could feel her bone moving, so she went to get the nurse, after she placed her in bed. She shared that while lifting Resident #5, she believed that the resident extended her left leg, which was not something that she usually did. When she heard the popping sound, she realized then that the knee was out, while she transferred her. She also commented that she felt that Resident #5's room was too crowded. Resident #5 was in an average size semi-private room, placed near the window. Next to her bed, she remembered that the new recliner was placed, without removing the visitor chair, so the area seemed cluttered. A follow up conversation with Administrative Staff #1 took place on [DATE] at 12:15 pm. She stated that Nurse Aide #1 did not use the proper technique to transfer Resident #5. When she investigated the incident, Nurse Aide #1 was forthright and told her that she always transferred her independently. She also didn't place her gait belt on the residents. Administrative Staff #1 felt it was important to re-counsel Nurse Aide #1 on her techniques and pulled her from her assignments until she could get a transfer specialist like therapy to come in the following day and in-service and train her. Nurse Aide #1 had to do a return demonstration of transfer techniques with one physically dependent resident and one alert and oriented resident. They were satisfied that she could use the proper techniques before she was returned to the floor. Next, they went ahead and retrained all of the nursing assistants. Training on gait belt usage and transfers took place on [DATE]- [DATE] and [DATE]-[DATE]. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] revealed resident #1 was assessed as needing extensive assistance with the staff providing weight bearing support during transfers. The resident was assessed as being cognitively intact. A review of the Hospital Discharge/Transfer Summary dated [DATE] revealed resident #1 was limited to toe-touch weight bearing on her right leg. A review of the physician's orders [REDACTED]. " A review of the Nursing Instructions Card for resident #1 was conducted. The special care instructions dated [DATE] stated the resident was touch toe weight bearing. A review of the Care Plans dated [DATE] revealed the resident was assessed as being at risk for falls related to de conditioning and weakness. The plan of care dated [DATE] indicated the resident experienced an assisted fall to the floor in the shower room. The resident was non weight bearing at that time. A review of the Report of Resident Fall dated [DATE] revealed resident #1 sustained an intercepted fall in which the resident was lowered to the floor by a staff member while in the shower room on [DATE]. There was no injury observed. A review of a written statement from Nursing Assistant (NA) #2 dated [DATE] was conducted. NA #2 stated on [DATE] she assisted resident #1 to the shower room for her scheduled shower. She had the resident stand and hold on to the rail. NA #2 took her shorts and underwear off of her right leg first. When she attempted to remove her shorts and underwear off of her left leg, the right leg became weak and she started to fall to the floor. NA #2 stated she caught her underneath her arms and assisted her to the floor. An interview was conducted with NA #2 on [DATE] at 3:26 PM. NA #2 stated she took resident #1 to the shower room in her wheelchair. She assisted the resident to stand. The resident grabbed the safety rail and lifted her right leg. NA #2 removed her underwear and shorts from her right leg. The resident lifted her left leg and then began to fall. NA #2 stated she put her arms around the resident and assisted her to the floor. NA #2 stated she believed the resident was allowed to bear weight on her legs at the time of the fall on [DATE]. NA #2 stated she had not been informed the resident was toe touch weight bearing on her right leg. NA #2 stated the Nursing Instructions Card was kept at the nurse's station. She stated she would review the Nursing Instructions Card for new admissions, readmissions and periodically for any changes in resident care. An interview was conducted with resident #1 on [DATE] at 5:38 PM. The resident stated [DATE] was the first time NA #2 assisted her to the shower room. She stated she stood up, lifted her leg and fell . NA #2 caught her and assisted her to the floor. She was unsure if it was the left leg she lifted prior to the fall. The resident stated she hit her right knee on the floor when she fell . An interview was conducted with Physical Therapist (PT) #2 on [DATE] at 9:26 AM. PT #2 stated resident #1 was toe touch weight bearing on her right leg at the time of the fall in the shower room. He stated toe touch weight bearing meant the resident would have been capable of sitting and resting her right foot on the floor with her toes touching the floor. PT #2 stated he expected the resident to be assisted by two staff members in the shower room. He stated the resident fell as a result of supporting her total body weight on her right leg when she lifted her left leg to remove her clothing. PT #2 stated once a resident has been evaluated by the physical therapy department, he would go and verbally communicate therapy instructions to the nurses and the nursing assistants. Therapy instructions included transfers and weight bearing status. An interview was conducted with Administrative Staff #1 on [DATE] at 11:15 AM. She stated she expected resident #1 to have been assisted by two staff members in the shower room. She stated NA #2 should have assisted the resident to a sitting position before removing her clothes from her left leg. She stated the physical therapists have routinely talked to the nurses and nursing assistants directly regarding therapy instructions for individual residents. Administrative Staff #1 stated an x-ray of the right leg was done on [DATE] and no further injury to the resident' s right leg was observed.