Every finding on record at Premier Health Care Center

Based on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 2 (Resident #34, and Resident #43) of 4 residents reviewed for medication administration. The facility failed to ensure the medication rate (10.34 %) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Findings included: Resident #34Record review Resident #34's face sheet dated 05/21/2026 revealed a [AGE] year-old female with an admission date of 09/12/2024. She had an active diagnosis of Asthma (a chronic respiratory condition that causes airways to swell, narrow, and fill with excess mucus and makes breathing difficult) and Chronic Obstructive Pulmonary Disease (a chronic obstructive lung disease that makes it difficult to breath and progressively gets worse over time). Record review of Resident #34's physician orders dated 05/21/2026 documented the following order: Brovana Inhalation Nebulization Solution 15 MCG/2ML (Arformoterol Tartrate) 1 inhalation inhale orally via nebulizer two times a day for the diagnosis of Chronic Obstructive Pulmonary Disease, and Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation) 1 inhalation inhale orally via nebulizer two times a day for Chronic Obstructive Pulmonary disease. Nebulizer treatment in room. During an observation and an interview on 05/19/2026 at 3:50 PM. Resident # 34 was observed in her room alone with her nebulizer treatment running. Resident #34 stated the nurses change her tubing on her nebulizer one time a week and they always left her medication for the nebulizer treatment in the room for her to finish and she turns the machine off when she was done. Stated she got 4-5 nebulizer treatments a day. During an observation on 05/20/2026 at 9:09 AM LVN B gave Resident #34 Brovana Inhalation Nebulization Solution 15 MCG/2ML vial (Arformoterol Tartrate) via nebulizer for the diagnosis of Chronic Obstructive Pulmonary Disease and Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation) 1 vial for inhalation inhale orally. LVN B left 1 vial of medication in the room with Resident #34 for the resident to administer to herself at a later time. LVN B did not stay in the room to see that Resident #34 took the medication. LVN B documented both medications as given and completed on Resident #34's electronic medication administration record. Resident #49Record review on 05/21/2026 of Resident # 49's face sheet dated 05/21/2026 revealed a [AGE] year-old female with an admission date of 08/03/2023. She had a diagnoses of Chronic Atrial Fibrillation, (a chronic abnormal rhythm of the heart causing the blood to pool in the heart and potentially cause blood clots) and Acute Upper Respiratory Infection. Record review of Resident #49's physician orders dated 05/20/26 revealed an order for Eliquis Oral Tablet 5 MG (Apixaban). Give 1 tablet by mouth one time a day related to CHRONIC ATRIAL FIBRILLATION, the medication was not in the medication cart. There was still an order on the MAR. LVN B stated that she thought the medication was discontinued while she was in the hospital and that was why is was not there in the cart. The medication was not given the physician was notified and the order was revised on 5/20/26 to restart the medication on 05/21/2026. During an observation on 5/20/25 at 8:00 a.m. LVN B was unable to find the Eliquis ordered for Resident #49 on the med cart and stated the medication was not available for administration. The med was not given as ordered. During the same observation on 5/20/26 8:00 AM, LVN B gave 1 vial of Ipratropium Bromide/Albuterol Sulfate 3 mL via nebulizer, returned to her medication cart and documented the Albuterol as completed and left the medication in the room with the resident without waiting to see that the medication was taken. In an interview on 05/20/26 at 9:30 AM with the LVN B, she said medication should be given as ordered and the nurses should remain with the resident until the medication was completed to ensure that the correct dose of the medication was given to the correct resident. She stated a negative outcome of leaving a medication in a resident's room for them to take unobserved would be that the correct dose might not be taken and the resident would not benefit from the intended therapeutic effect of the medicine. She stated medications should be ordered before the supply was exhausted and to be available for administration at the time it was due to be administered. She stated that an order should be written for any medication that was on hold or discontinued. In an interview on 05/20/26 at 2:00 PM with the DON, she said she expected medication to be given as ordered and for the nurses to remain with the resident until the medication was completed to ensure that the correct dose of the medication was given to the correct resident. She stated a negative outcome of leaving a medication in a resident's room for them to take unobserved would be that the correct dose might not be taken and the resident would not benefit from the intended therapeutic effect of the medicine. She stated she expected medications to be ordered before the supply was exhausted and to be available for administration at the time it was due to be administered. She stated she was not aware until now that the nurses were leaving the residents to administer their own nebulizer treatments. Record review of facility policy titled Administering Medications dated revised, April 2019, revealed the following in part: Medications are administered according to the physicians orders. If a drug is withheld or ungiven at times other than the scheduled time the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The medication is initialed by the nurse after the medication is taken.

Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter was not used unless there was valid medical justification for catheterization and that a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 3 of 16 residents (Resident #25, Resident #12, and Resident #49) reviewed for indwelling catheters. The facility failed to ensure that Resident #25 had a physician's order for an indwelling catheter and for monitoring and maintenance of an indwelling catheter. The facility failed to ensure that Resident #12 had a physician's order for an indwelling catheter and for monitoring and maintenance of an indwelling catheter. The facility failed to ensure that Resident #49 had a physician's order for an indwelling catheter and for monitoring and maintenance of an indwelling catheter. These failures could place residents with catheters at risk of not receiving continuity of catheter care and could place residents at risk of infection.Findings included: Resident #25 Record review of Resident #25's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: upper respiratory infection, femur fracture, and neuromuscular dysfunction of bladder (nerves that control the bladder are not working). Record review of Resident #25's Significant Change MDS assessment, dated 05/13/2026, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review of MDS revealed the resident had an indwelling catheter. Record review of Resident #25's care plan, revised on 05/19/2026, revealed, Focus: The resident has a 16fr indwelling foley catheter.Interventions: Change 16fr catheter 1 x month. Monitor and document intake and output as per facility policy. Monitor/record/report to MD for signs and symptoms of urinary tract infection pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #25's electronic physicians orders revealed no evidence of an order for an indwelling catheter, monitor output, monitor for s/sx of UTI, or catheter care. Record review of Resident #25's electronic record revealed no evidence of foley catheter care or monitoring. Observation and interview on 05/19/2026 1:52 PM, revealed Resident #25 resting in bed with catheter bag hanging with no kinks in tubing. Urine clear yellow in color. Resident #25 stated she was recently in the hospital because she fell and broke her hip. She stated she has had the catheter since then. Resident #12 Record review of Resident #12's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: neuromuscular dysfunction of bladder (nerves that control the bladder are not working) and prostatic hyperplasia (enlargement of prostate gland). Record review of Resident #12's Quarterly MDS assessment, dated 03/20/2026, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review revealed the resident had an indwelling catheter. Record review of Resident #12's care plan, last revised on 03/25/2026, revealed: Focus: Supra pubic catheter r/t neurogenic bladder .Interventions: Change monthly. Indwelling Foley Catheter to bedside drainage: 16- 20g 15-30 balloon silicone coated, Position catheter bag and tubing below the level of the bladder and away from entrance door. or place bag in a blue bag, Monitor and document intake and output as per facility policy, and Monitor/record/report to MD for signs and symptoms UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.[sic] Record review of Resident #12's electronic physician orders revealed no evidence of an order for an indwelling catheter, monitor output, monitor for s/sx of UTI, or catheter care. Record review of Resident #12's electronic record revealed no evidence of foley catheter care or monitoring. Observation and interview on 05/19/2026 2:10 PM, revealed Resident #5 in electric wheelchair with catheter bag full of clear yellow urine with no privacy bag. He stated he used to have a privacy bag on his catheter bag but for some reason the night shift always removed it. He stated he had had a catheter for years. Resident #49 Record review of Resident #49's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: retention of urine, Chronic Obstructive Pulmonary Disease (disease where lungs are damaged and inflamed), and neuromuscular dysfunction of bladder (nerves that control the bladder are not working). Record review of Resident #49's Significant Change MDS assessment, dated 03/25/2026, revealed a BIMS score of 09, which indicated moderate cognitive impairment. Further review revealed the resident had an indwelling catheter. Record review of Resident #49's care plan, revised on 03/26/2026, revealed: Focus: The resident has 16g indwelling Foley catheter attached to bedside drainage R/T urinary retention R/T neurogenic bladder due to neurogenic bladder .Interventions: The resident has a supra pubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. [sic] Record review of Resident #49's electronic physician's order revealed, Change catheter once a month, date 02/01/2026 and no evidence or order for foley catheter, monitoring for foley catheter, or care of foley catheter. Record review of Resident #49's electronic record revealed no evidence of foley catheter care or monitoring. Observation on 05/19/2026 at 3:00 PM revealed Resident #49 resting in bed call light in reach. Foley hanging with no kinks in tubing draining clear yellow urine. During an interview on 05/20/2026 at 8:45 AM, LVN B stated she was aware that Resident #25, Resident #12, and Resident #49 had catheters. She stated she assumed they had orders for them. She stated she did not monitor output and that foley care was performed by the aides. She stated a negative outcome for not performing care could have been infection. She stated not monitoring output could lead to missed decrease in urine or possible obstructions. During an interview on 05/21/2026 at 11:00 AM, the DON stated her expectation was that all catheters have a physician order with a proper diagnosis. She stated catheter care should be provided each shift and output should have been monitored. She stated she was not aware that these residents did not have the appropriate orders. She stated it was her responsibility as DON to monitor. During an interview on 05/21/2026 at 11:33 AM, the ADON stated all catheters should have an order for the catheter and for maintenance and monitoring. She stated Resident #25 had come back from the hospital with the catheter and the order was just missed. She stated Resident #12 and Resident #49 had a catheter for a long time and that there was no good reason as to why they did not have orders. Record review of the facility's policy titled, Urinary Catheter Care Procedure, not dated, revealed in part, Policy: The facility will provide catheter care using aseptic and infection control practices to reduce the risk of infection, trauma, and complications associated with urinary catheters. Catheter care shall be completed routinely. Indwelling urinary catheters shall only be used when medically necessary and with physicians' orders.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Resident #25, Resident #5, and Resident #49) of 16 residents reviewed for respiratory care. The facility failed to ensure Resident #25's nebulizer (used to receive medications by breathing in mist through the mouth) for breathing treatment was properly stored when not in use and failed to ensure an oxygen sign was in place. The facility failed to ensure Resident #5's nebulizer for breathing treatment was properly stored when not in use and changed out weekly per orders. The facility failed to ensure Resident #49's nebulizer for breathing treatment was properly stored when not in use. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Resident #25 Record review of Resident #25's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: upper respiratory infection, and femur fracture. Record review of Resident #25's Significant Change MDS assessment, dated 05/13/2026, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review of MDS revealed the use of oxygen. Record review of Resident #25's care plan, revised on 05/19/2026, revealed no evidence of the use of oxygen or breathing treatments. Record review of Resident #25's physicians order dated 05/14/2026, revealed, Ipratropium bromide/Albuterol sulfate 3ML 1 inhalation orally four times a day. Further review revealed physicians order dated 08/04/2023, O2 at 2-4 LPM via NC as needed for shortness of breath. Observation and interview on 05/19/2026 1:52 PM, revealed Resident #25 resting in bed, oxygen on at 3LPM via nasal cannula with no date on tubing, nebulizer laying on nightstand with no date and not in a bag, and no oxygen sign outside of door. Resident #25 stated she has worn oxygen for years and that she usually just removed the nebulizer mask when the treatment finished and laid it on the table. Resident #5 Record review of Resident #5's electronic face sheet, accessed on 05/20/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: wheezing, upper respiratory infection, and shortness of breath. Record review of Resident #5's Quarterly MDS assessment, dated 03/06/2026, revealed a BIMS score of 05, which indicated severe cognitive impairment. Further review of MDS revealed no use of oxygen or respiratory treatments. Record review of Resident #5's care plan, revised on 03/05/2023, revealed: Focus: The resident has altered respiratory status/difficulty breathing . Interventions: O2 tubing to be changed weekly and prn if falls on the floor. All staff to help in monitoring when O2 or HHN not being used, it will be in a plastic bag. Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Remind him when O2 and/or nebulizer are not in use they must be in a bag to maintain cleanliness and assist as needed. Record review of Resident #5's physician's order dated 05/29/2025, revealed, Ipratropium-Albuterol inhalation solution 0.5-2.5MG/3ML- 3ml inhale orally every 4 hours as needed for wheezing. Further review revealed physician's order dated 02/08/2022, 02, H20, and HHN tubing checked and dated within 1 week, is off the floor and bagged if not using.[sic] Observation on 05/19/2026 at 2:00 PM revealed Resident #5's nebulizer laying on the bedside table, dated 04/24/2026, and not bagged. Resident #49 Record review of Resident #49's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: retention of urine, Chronic Obstructive Pulmonary Disease (disease where lungs are damaged and inflamed), and neuromuscular dysfunction of bladder (nerves that control the bladder are not working). Record review of Resident #49's Significant Change MDS assessment, dated 03/25/2026, revealed a BIMS score of 09, which indicated moderate cognitive impairment. Further review revealed the use of oxygen. Record review of Resident #49's care plan, revised on 03/26/2026, revealed: Focus: The resident has shortness of breath (SOB) r/t respiratory failure. Albuterol nebulizer treatment . Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects, Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring, and Use UNIVERSAL PRECAUTIONS as appropriate. Record review of Resident #49's electronic physicians ordered revealed, Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial inhale orally via nebulizer three times a day, dated 03/25/2026 and Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 2 ml inhale orally two times a day, dated 11/10/2025. Observation on 05/19/2026 at 3:00 PM revealed Resident #49 resting in bed with call light in reach. Oxygen was in place with no date on the nasal cannula. Nebulizer mask lying on nightstand no date and not in a bag. During an interview on 05/20/2026 at 8:45 AM, LVN B stated nebulizers were to be changed out weekly and kept in a plastic bag when not in use. She stated a negative outcome for failing to keep the nebulizer and tubing clean, covered, and changed out would be infection. During an interview on 05/21/2026 at 11:00 AM, the DON stated her expectation was to keep nebulizers covered when not in use and to clean the nebulizer after each treatment. She stated she was unaware that the LVNs were not doing those things. She stated it was her responsibility as DON to monitor. During an interview on 05/21/2026 at 11:33 AM, the ADON stated all nebulizers should be cleaned after use and placed in a plastic bag. She stated nebulizers are to be changed out weekly and dated. She stated not bagging the nebulizers could lead to infection. She stated the staff just know that they are supposed to change them on night shift every week even if there is not an order in the chart. Record review of the facility's policy titled, Hand-Held Nebulizer Operating Instructions, not dated, revealed in part, .B. Equipment is cleaned after each treatment as follows.4.) Wash the nebulizer in warm water with mild soap and rinse thoroughly. %.) When completely dry, reassemble and place in a storage compartment. Record review of the facility's policy titled, Respiratory Care Services and Oxygen Safety Policy, not dated, revealed in part, Policy: Facility will provide respiratory care services to residents based upon physicians' orders, resident assessment, individual care plans, and applicable standards of care. Respiratory services shall include oxygen administration, monitoring, equipment maintenance, infection prevention practices, and emergency preparedness measures.4. Oxygen Safety Requirements.Oxygen in Use signage shall be posted.8. Infection Control. Respiratory equipment shall be cleaned and disinfected per manufacture recommendations and facility infection control policies.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and , for 4 of 16 residents (Resident #3, Resident #4, Resident #6, and Resident #43) reviewed for care plans. 1. The facility failed to ensure Resident #3's care plan objectives or goals were measurable. 2. The facility failed to ensure Resident #4's care plan objectives or goals were measurable. 3. The facility failed to ensure Resident #6's care plan objectives or goals were measurable. 4. The facility failed to ensure Resident #43's care plan objectives or goals were measurable. These failures could place residents at risk of not receiving individualized care and services to meet their needs.The findings include: 1. Record review of Resident #3's electronic face sheet, dated 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had medical diagnoses which included paranoid schizophrenia (a chronic mental disorder characterized by intense paranoia, delusions of persecution, and auditory hallucinations), schizoaffective disorder (a chronic mental health disorder that combines symptoms of schizophrenia with a mood disorder), high blood pressure, repeated falls, and pain. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. Record review of Resident #3's Comprehensive Care Plan, dated 12/27/2025, revealed Focus: Victim of emotional abuse by intimate partner. Goal: No known psychological abuse. 2. Record review of Resident #4's electronic face sheet, dated 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had medical diagnoses which included anxiety, heart failure, high blood pressure, and obesity. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Record review of Resident #4's Comprehensive Care Plan, dated 05/09/2026, revealed Focus: Resident will maintain current weight and feel better about diet and meals provided. Goal: Residents health will be maintained. 3. Record review of Resident #6's electronic face sheet, dated 05/20/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had medical diagnoses which included anxiety, Alzheimer's disease, chronic pain, and high blood pressure. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Record review of Resident #6's Comprehensive Care Plan, dated 04/13/2026, revealed Focus: colace for constipation. Goal: Resident will have less constipation .Focus: Admit to Hospice. Goal: Resident will feel comfortable . with Hospice.Focus: Mechanical soft diet weight to be stable. Goal: Resident will be able to eat more food easier .Focus: Remeron for agitation. Goal: Medication will be administered for agitation and dementia outbreaks. 4. Record review of Resident #43's electronic face sheet, dated 05/20/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had medical diagnoses which included anxiety, depression, and dementia. Record review of Resident #43's Medicare 5-day MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Record review of Resident #43's Comprehensive Care Plan, dated 03/22/2026, revealed Focus: Psychiatric evaluation for hollering out every 2-3min. Goal: Resident will have less hollering out throughout the review period. Interventions/Tasks: Resident will have less outbursts throughout the review period. Resident will push the call light instead of screaming or hollering. During an interview on 05/21/2026 at 12:43 PM, the DON stated goals should be measurable. She stated measuring the goals allowed the staff and other disciplines to see progress positively or negatively and evaluate the effectiveness of the interventions. The DON stated she had not received formal training on care plans. She explained she was told to read other care plans and learn from them. She stated care plans were reviewed frequently and revised if there was any change in the residents' care.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #34, #37, and #49) of 6 residents reviewed for infection control. LVN A failed to sanitize the shared glucometer before and after use on Resident #37 LVN B failed to sanitize the shared blood pressure cuff between Residents #34 and #49 and perform hand hygiene after touching residents during medication administration. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Resident #34 Record review Resident #34's face sheet dated 05/21/2026 revealed a [AGE] year-old female with an admission date of 09/12/2024. She had an active diagnosis of Asthma (a chronic respiratory condition that causes airways to swell, narrow, and fill with excess mucus and makes breathing difficult) an Chronic Obstructive Pulmonary Disease (a chronic obstructive lung disease that makes it difficult to breath and progressively gets worse over time). Record review of Resident 34's Quarterly MDS dated [DATE], indicated the resident had a BIMS score of 10 which indicated moderate cognitive impairment. During an observation on 05/20/2026 at 9:09 AM, LVN B obtained a blood pressure reading with a wrist cuff and administered a nebulizer treatment to Resident #34 without sanitizing the blood pressure cuff prior to use and without performing hand hygiene before or after touching Resident #34. Resident # 37 Record review of Resident #37's face sheet dated 05/21/2026 revealed a [AGE] year-old female with an admission date of 02/19/2026. She had a diagnosis of Insulin Dependent Diabetes. Record review of Resident #37's Entry MDS dated [DATE] revealed the resident did not have a BIMS score completed but documented that she had no problems with memory recall. During an observation and an interview on 05/19/2026 LVN B performed a fingerstick blood sugar with a shared glucometer device. He used an alcohol wipe to clean the shared glucometer before and after use. He stated that he used alcohol wipes and another disinfectant wipe with a purple top, but he stated they were low on the disinfectant wipes right now and there were none on his cart, so he used the alcohol pad to clean the glucometer before and after obtaining a FSBS on Resident #37 . Her fingerstick blood sugar was 121. She did not require insulin according to her physician orders and her sliding scale. LVN B stated that failure to disinfect a glucometer with the proper disinfectant could have a negative impact on a resident by spreading germs. He stated that he did not know for sure if the alcohol swab that he used was effective in killing blood borne pathogens. Resident #49 Record review on 05/21/2026 of Resident #49's face sheet dated 05/21/2026 revealed a [AGE] year-old female with an admission date of 08/03/2023. She had a diagnoses of Chronic Atrial Fibrillation (a chronic abnormal rhythm of the heart causing the blood to pool in the heart and potentially cause blood clots) and Acute Upper Respiratory Infection. Record review of Resident #49's Entry MDS dated [DATE] revealed the resident did not have a BIMS completed but documented that she had no problems with memory recall. During an observation on 5/20/25 at 8:00 a.m. LVN B obtained a blood pressure reading with a wrist cuff and administered a nebulizer treatment to Resident #49 without sanitizing the blood pressure cuff prior to use and without performing hand hygiene before or after touching Resident #49. During an interview on 05/20/26 at 9:30 AM with the LVN B, she said she should have sanitized the blood pressure cuff before each use on the residents, and she should have performed hand hygiene with alcohol-based hand rub or soap and water after touching residents. She stated that failure to perform hand hygiene after resident contact could negatively affect a resident by spreading infection. In an interview on 05/21/2026 at 9:45 AM, the DON said it was her expectation for the staff to perform hand hygiene and to use the purple top disinfectant wipe provided by the facility. She stated ADON was in charge of ordering supplies and there were plenty of disinfecting wipes in the supply closet. She stated a negative outcome of not using proper

Tag: F921/N4888 S/S=E Surveyor Name(s): Reisha Horn, RNImmediate Supervisor: [NAME], LBSWBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, environment for residents, staff, and the public for 1 of 4 hallways reviewed, for physical environment. The facility failed to ensure the carpet was free of tears and stains in the back hallway on 05/20/2026. This failure place residents at risk of injury, and a diminished quality of life due to the lack of a well-kept and clean environment.Findings included: In an observation of the facility on 05/20/2026 at 11:00 AM, the carpet in the back hallway of the facility was ripped and soiled with visible stains. In an interview with the maintenance director on 05/20/2026, he stated he stated the tear had been in the carpet for a long time and that the carpet stains remained even after they were cleaned. In an interview with the DON on 05/20/2026 at 11:40 AM she stated it was her expectation for carpets to be intact and clean. She stated the torn carpet could be an accident hazard for the residents, staff and visitors. She stated she tripped on the torn carpet, and it caused her to fall last week. In an interview with the Administrator on 05/21/2026 at 9:15 AM, she said potential negative outcomes of the ripped carpet could be a fall hazard. She stated the carpet needed to be repaired or replaced. Record review of the facility policy provided titled Clean and Safe Environment Policy and Procedure, not dated, revealed the following [in part]: It is the policy of Ranger Care Center to provide and maintain a clean, sanitary, comfortable orderly, and safe environment for all residents, staff, visitors, and vendors. The facility will ensure that environmental conditions promote resident dignity, infection prevention, accident prevention, and compliance with all federal, state, and local regulations. Ranger Care Center is committed to maintaining a homelike environment free from hazards, unsafe conditions, offensive odors clutter, sanitation concerns, and environmental risks that could negatively impact resident health safety and quality of life. Hazards shall be identified and corrected immediately. The environment shall remain free from trip and fall hazards.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes needed t provide effective and person-centered care of the resident that meet professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #13) reviewed for base line care plan completion. The facility failed to include Resident # 13's catheter in the baseline care plan within the required 48-hour time limit. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings include: Record review of Resident #13's electronic face sheet, dated 05/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: Urinary Tract Infection, Neuromuscular dysfunction of the bladder (a condition where the brain, spinal cord, or nerve pathways cannot properly communicate with the bladder muscles and disrupts the normal process of holding and releasing urine) and Benign Prostatic Hypertrophy (an enlargement of the prostate gland that makes it difficult to pass urine). Record review of Resident #13's electronic medical record revealed there was no baseline care plan initiated within 48 hours of admission for his suprapubic catheter which was present at the time of his admission on [DATE]. The catheter was not added to his Care plan until 03/21/2026. During an interview on 05/21/2026 at 10:51 AM, the DON stated she was responsible for completing baseline care plans. The DON stated, she was not aware of the 48-hour requirement for a baseline care plan to be initiated on each resident. She stated she was aware of the requirement now, and her expectation was for the baseline care plan to be completed within 48 hours and address the basic needs to care for each resident until the MDS assessment and the comprehensive care plan was completed. The DON stated there was no negative outcome for Resident #13, a possible negative outcome would be a resident would not receive needed care. During an interview on 05/21/2026 at 11:29 AM, the administrator said the DON was responsible for completing base line care plans. The ADMN stated her expectation was that base care plans were completed within 48 hours of admission and included all of the residents' immediate care needs. Record review of the facility's, undated, policy titled; Baseline Care Plan revealed The facility will develop a person-centered baseline Care Plan for each resident with 48 hours of admission. The Baseline Care Plan will include instructions needed to provide effective and person-centered care that meets the resident's immediate needs and preferences. The facility will ensure the Baseline Care Plan is communicated to direct care staff and interdisciplinary team members responsible for the resident's care and services.Purpose: To ensure Immediate resident care needs are identified and addressed upon admission, staff have clear instructions for providing safe and effective care, residents preferences and goals are honored, risks are identified early to prevent adverse outcomes.

Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening residents diagnosed with mental illness were provided with a PASARR Level II Screening for 1 of 1 residents (Resident #16) reviewed for PASARR Level 1 screenings. The facility failed to correctly identify Resident #16 as having a mental illness and did not complete a new PASARR Level One Screening. This failure could place residents at risk of not receiving needed services and care. The findings were: Record review of Resident #16's PASRR Level One Screening Forms, dated 02/19/2026, revealed she did not have a primary diagnosis of dementia. It revealed she was negative for mental illness, intellectual disability, or developmental disability. The form had not been updated. Record review of Resident #16's Care Plan, dated 03/12/2026, revealed the resident received antidepressant medication. Record review of Resident #16's face sheet, dated 05/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11's had a diagnosis which included Schizoaffective Disorder Bipolar Type (a chronic mental condition combining schizophrenia symptoms [like delusions or hallucinations with severe mood swings of mania and depression. Treatment requires a lifelong mix of medication and therapy]). Record review of Resident #16's Physician Orders, dated 05/21/2026, revealed orders for Zoloft Oral Tablet 25 mg (Sertraline Give 75 mg by mouth one time a day related to Major Depressive Disorder single episode. In an interview on 05/21/2026 at approximately 9:45 AM, the DON revealed she was not familiar with the PASRR process. She stated the ADON had been doing the PASSR's in February 2026 when Resident # 16 was admitted from another facility. She stated the Administrator asked the former ADON to come back to the facility and assume responsibility for the PASRR's and assist with the Care plans and MDS until she was adequately trained. In an interview on 05/21/2026 at approximately 11:10 AM, the MDS Coordinator said that given the diagnosis (schizoaffective disorder) of Resident #16 a PL new 1 reflecting Mental Illness should have been completed. She stated she would be submitting the corrected forms at her earliest convenience. She stated she did not complete the form, she only submitted it and stated she did not know why the form was not completed incorrectly. Record review of the facility's, undated, policy titled PASSR Policy and Procedure stated in part: It is the policy of the facility to comply with all Federal and Texas Health and Human Services Commission requirements regarding the pre-admission screening and resident review process. The facility will ensure that all individuals admitted to the facility have appropriate PASSR documentation completed prior to admission, when required, and that all PASSR recommendations are implemented and maintained throughout the residents stay. The facility will not admit any residents requiring PASSR screening without the appropriate authorization and documentation and accordance with Medicaid, CMS and Health and Human Services regulations. Pre-admission screening requirements:Prior to admission, admission staff or a designee will obtain and review Level 1 screening, verify PASRR status, and confirm all required documentation is present and ensure Medicaid eligibility requirements are met. If an applicant is identified as PASRR positive, the facility must ensure a PASRR Level 2 evaluation is completed when required. admission authorization is obtained and specialized service recommendations accompany admission documentation The facility will not admit individuals lacking required PASSR clearance unless permitted under an exempted hospital discharge.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #43) whose assessments were reviewed for assessments. The facility failed to ensure Resident #43's quarterly MDS assessment did not correctly document the resident as having an unhealed pressure ulcer. This failure could place residents at risk for inadequate care.The findings include: Record review of Resident #43's electronic face sheet, dated 05/20/2026, revealed a female who was admitted to the facility on [DATE]. Resident #43 had medical diagnoses which included a closed fracture of her left femur (upper thigh bone), dementia, anxiety, major depressive disorder, and rheumatoid arthritis (a disorder that causes the immune system to attack the lining of the joints). Record review of Resident #43's Medicare 5-day MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 4 out of 15, which indicated severe cognitive impairment. Section M - Skin Conditions, subsection M0210 Unhealed Pressure Ulcers/Injuries, Does this resident have one or more unhealed pressure ulcers/injuries? 1. Yes was entered. Subsection M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, E. Unstageable (inability to determine a wounds depth due to dead tissue on the wound bed)- non-removable dressing/device: Know but not stageable due to non-removable dressing/device, 1 was entered which indicated the number of unstageable pressure ulcers/injuries due to non-removable dressing/device was selected. F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar, 1 was entered which indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough (moist, sticky dead tissue) and/or eschar(a thick, dry, and leathery layer of dead tissue that forms over a deep wound or severe burn). Record review of Resident #43's physician orders, dated 03/12/2026, revealed Skin tears/abrasions, may cleanse with sterile NS (normal saline) pat dry with 4 X 4 may apply steri-strips (adhesive strips used to close minor skin openings) as indicated. No order for treatment of a pressure ulcer or diagnosis of a pressure ulcer was included in the physician's orders. Record review of Resident #43's skin assessment, dated 03/13/2026, revealed in the Notes section redness from sutures and pressure from lying on her side due to r hip sx. Resident #43's skin assessment, dated 03/16/2026, revealed in the Notes section skin issues only to bottom that is resolving from admission time. Resident #43's skin assessment, dated 03/31/2026, revealed in the Notes section resident had unwitnessed fall no new areas found. Record review of Resident #43's Comprehensive Care Plan, dated 03/13/2026, reviewed/revised 03/18/2026, revealed no current skin issues or risk for skin issues addressed. During an interview on 05/21/2026 at 12:38 PM, the ADON stated the DON was responsible for care plans. She stated wounds should be addressed on the care plan. The ADON stated she was not sure who was responsible for the accuracy of the MDS's or care plans. During an interview on 05/21/2026 at 12:43 PM, the DON stated the wound claimed on Resident #43's MDS was most likely selected in error. She stated the charge nurses were responsible for conducting and documenting skin assessments. She stated she was responsible for monitoring the completion of skin assessments. She stated failure to accurately assess and document could result in improper care and/or additional injury. The DON stated her expectations were for all MDS's and care plans to be accurate. During an interview on 05/21/2026 at 2:12 PM, the MDS Coordinator stated the DON was responsible for entering data in Section M - Skin Conditions on the MDS. She stated the DON was responsible for monitoring the accuracy of the MDS's. Record review of the facility's policy titled Comprehensive Assessment and the Care Delivery Process , revised December 2016, revealed Comprehensive assessments will be conducted to assist in developing person-centered care plans.6. Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals.

Based on interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 of 16 residents (Resident #43) reviewed for comprehensive care plans. The facility added an indwelling urinary catheter to Resident #43's care plan three days before receiving a verbal physician's order to place an indwelling urinary catheter. This failure could place residents at risk of not receiving individualized care and services to meet their needs. The findings include: Record review of Resident #43's electronic face sheet, dated 05/20/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had medical diagnoses which included anxiety, Alzheimer's disease, high blood pressure, neurogenic dysfunction of bladder (a condition where nerve damage disrupts the communication between the brain and bladder, leading to a loss of bladder control), and chronic pain. Record review of Resident #43's Comprehensive Care Plan, dated 03/18/2026, revealed Focus: Risk for Impaired Urinary Elimination r/t cognitive inability to urinate. Placement of catheter. Goal: Resident Will Have Normal Urinary Elimination Pattern. Interventions/Tasks: Insert 16fr (a unit of measure indicating the diameter of the drainage tubing) foley (a fixed tube placed in the urinary bladder to drain urine) catheter per Dr. [name] orders and remain in place. Record review of Resident #43's Quarterly MDS, dated [DATE], revealed in Section C – Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Section H – Bladder and Bowel, subsection H0100. Appliances, Z. None of the Above was selected. Record review of Resident #43'a physician orders, dated 03/21/2026, revealed Orders to place 16fr foley catheter r/t abdominal distention. Order to collect urine and if it is more than 600ml leave the catheter in place. 1500ml drained. catheter to remain til Doctor states otherwise. During an interview on 05/21/2026 at 12:43 PM, the DON stated the care plan should be reviewed frequently and if there were any changes to the resident's status. She stated she revised the care plans when she did her assessments and completed the MDS's. She stated she did not know how long to leave the care plan focused on a prior problem. The DON explained every discipline involved in an individual's care provided input for the care plan. She stated PT, RT, OT, shift nurses, ADON, DON, and CNAs were all involved. The DON stated she had not had formal care plan training when she was hired. The DON explained she was told to look at other care plans and learn from them. [NAME], [NAME] (37) Horn, Reisha (41944) - Care Planning No Notes [NAME], [NAME] (37) Horn, Reisha (41944) - RESIDENT NOTE No Notes

Based on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 (Resident #25) of 16 residents reviewed for unnecessary medications. The facility failed to have an adequate diagnosis and indication for the use of the medication Clonazepam for Resident #25. The facility failed to have an adequate diagnosis and indication for the use of the medication Diazepam for Resident #25. The facility failed to monitor the side effects of Clonazepam and Diazepam medications for Resident #25. These failures could place residents at risk for adverse consequences and decline in health.Findings included: Record review of Resident #25's electronic face sheet, accessed on 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: upper respiratory infection, and femur fracture. Review revealed no evidence of a diagnosis related to anxiety. Record review of Resident #25's Significant Change MDS assessment, dated 05/13/2026, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review of MDS revealed the use of antianxiety medications. Record review of Resident #25's care plan, revised on 05/19/2026, revealed no evidence of anxiety or antianxiety medications. Record review of Resident #25's electronic physicians orders revealed, Diazepam (medication used to treat anxiety) 10mg/ml gel give 1ml Apply to inner wrist topically every 4 hours as needed for Prophylaxis with no diagnoses entered, dated 05/14/2026, entered by ADON, Clonazepam (medication used to treat anxiety) Oral Tablet Disintegrating 0.25 MG Give 1 tablet by mouth at bedtime for Prophylaxis related to COGNITIVE COMMUNICATION DEFICIT, dated 05/14/2026, entered by LVN D, and Clonazepam Oral Tablet Disintegrating 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Prophylaxis with no diagnoses entered, dated 05/14/2026, entered by ADON. Further review revealed no evidence of orders to monitor for side-effects related to the use of Clonazepam and Diazepam. Record review of Resident #25's electronic MAR for May 2026, revealed Clonazepam had been administered at 8:00 pm on 05/14/26, 05/15/26, 05/17/26, 05/18/26, 05/19/26, 05/20/26, and 05/21/26 and administered at 9:26 am on 05/22/26. Further review of MAR revealed no doses of Diazepam had been administered. Observation and interview on 05/19/2026 1:52 PM, revealed Resident #25 resting in bed, oxygen on at 3LPM via nasal cannula. Resident #25 stated she was recently in the hospital because she fell and broke her hip. During an interview on 05/21/2026 at 11:00 AM, the DON stated her expectation was for all psychotropic medications to have proper diagnosis and indications. She stated she did not know why these orders were entered inappropriately. She stated side-effect monitoring orders should have been in place. She stated it was her responsibility as DON to monitor. During an interview on 05/21/2026 at 11:33 AM, the ADON stated the order had been entered by the floor nurse and that she had edited the orders to add a stop date but had not noticed that the diagnoses and indications were incorrect. She stated prophylaxis was not an appropriate diagnosis or indication for an antianxiety medication. Record review of the facility's policy titled, Psychotropic Medication Policy and Procedure not dated, revealed in part, Policy: The facility will ensure residents are free from unnecessary psychotropic medications and that each resident's drug regimen is free from unnecessary medications unless clinically indicated to treat a diagnosed condition with adequate monitoring and documentation.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1, who was transported via the facility van, was secured with the proper utilization of the 5-seatbelt restraint system, required when transporting residents in a van, which resulted in injury and hospitalization on 01/08/2026. An Immediate Jeopardy (IJ) situation was identified on 01/13/2026. While the IJ was removed on 01/13/2026, the facility remained out of compliance at a scope of an isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, hospitalization or death.Findings include: Record review of Resident #1's face sheet, accessed on 01/09/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: fracture of left femur, anxiety, and depression. Record review of Resident #1's admission MDS assessment, dated 11/24/2025, revealed a BIMS of 10, which indicated moderate cognitive impairment. Further review revealed sit to stand position and car transfer required substantial/maximal assistance and walking was not attempted due to medical condition. Record review of Resident #1's care plan, initiated on 11/04/2025, revealed: Focus: The resident has limited physical mobility related to fracture hip.Interventions: The resident requires assistance by one staff to walk. Record review of facility's incident report, dated 01/08/2026, revealed in part: CNA-A was doing transport to orthopedic surgeon for Resident #1. CNA-A has officially been the transporting aide in the past. She reports that she went to the South office and was supposed to be at the North location, when in route to North side, the van started spewing fluid and instrument panel now showing the van is running hot. She was pulling over to stop when she looked back, she could no longer see Resident #1 in her rearview mirror. The resident was now at the back of the van on the floor rolled forward from the waist.Her front safety belt was unclamped. The remaining safety belts were all intact. A good Samaritan stopped to help and called 911.The ambulance arrived, put a neck brace on Resident #1 and she was taken to the hospital. Record review of hospital records, dated 1/12/2026, revealed Resident #1 was admitted to the hospital on [DATE] with an admitting diagnosis of acute subdural hematoma and cervical fracture status post fall from wheelchair while being transported in a van. Observation and Interview on 01/11/2026 at 12:30 PM, revealed Resident #1 was lying in bed at the hospital. Resident #1 had a cervical collar in place. Resident #1 stated all she remembered was CNA-A hit the brakes and the wheelchair flipped. She stated she did not know if all of the straps were fastened. She stated that she had not unfasted any of the safety belts. During an interview on 01/09/2026 at 1:35 PM, the Office Manager stated CNA A was the previous transportation aide, and NA-K was the current transportation aide. She stated transportation aides were trained regarding transportation safety and proper wheelchair securement and safety belt placement prior to ever transporting residents. She stated both CNA-A and NA-K had proven competency in those areas when hired prior to transporting any residents. She stated no residents had been transported since the incident and there were no plans to transport any residents over the weekend. She later stated she did not have any evidence of training or competencies for CNA-A or NA-K. During an interview on 01/09/2026 at 3:20 PM, the Administrator stated CNA-A told her the seat belts were all secured prior to driving the van. She stated the van was worked on after the incident regarding the overheating issue. She stated there had been no other incidents in the van regarding resident injuries or accidents. The Administrator stated there were no logs for maintenance on the van or routine checks regarding van maintenance or safety checks. She stated the van was not inspected routinely. During an observation and interview on 01/09/2026 at 3:30 PM, the Office Manager and the Administrator performed a test with an empty wheelchair in the van to ensure all 5 safety belts worked correctly and were secure. Observed 4 belt straps secured. 2 in the front and 2 in the back. Observed lap belt secured. Observed the Office Manager attempt to flip the wheelchair, and the chair did not budge. The Office Manager removed the lap belt, and the chair still would not budge. The Office manager refastened the lap belt and unlatched one front strap and the chair would not budge. The Office Manager then unfasted both front straps and with pressure to the back of the chair the wheelchair was able to flip backwards. The administrator stated the only way the chair could have flipped was if the 2 front safety belts were not fastened. During an interview on 01/09/2026 at 4:15 PM, CNA-A stated on 01/08/26 prior to the incident she arrived at a doctor's office with Resident #1 and wheeled the resident in. She was then told they were at the wrong office. She stated the other office stated they would see the resident if they got there quickly. She stated she pushed Resident #1 up the wheelchair ramp in the van, locked her wheelchair wheels, and fastened the 2 rear seatbelts. She stated she then climbed into the driver's seat and climbed behind in front of Resident #1. She stated she fastened the other 3 seatbelts. She stated the van began to overheat and she was in a construction zone with nowhere to exit. She stated she called the maintenance man on the phone, then she looked up and saw a yellow light and began slowing down. She stated that she heard a noise behind her, looked back, and saw Resident #1's wheelchair flipped backwards. She stated that she stopped the van and climbed back to help Resident #1. She stated she had to unbuckle the lap belt to move the wheelchair to get to the resident. She did not say anything regarding the 4 other safety belts. She stated she did not recall if the other safety belts were still intact but insisted, she secured them prior to transportation. She called 911 and EMS arrived and transported Resident #1 to the hospital. She stated the van had a 5-seatbelt restraint system. There were 2 safety belts behind the wheelchair that secured the wheelchair to the floor. There were 2 more safety belts in front of the wheelchair that secured the wheelchair to the floor. There was a lap belt that went through the arms of the wheelchair and over the resident's lap to secure the resident into the wheelchair. She stated when she started transporting residents, she was oriented by the previous transportation aide for a week. She stated she had not read any policies and had not received any computer training regarding seatbelt securement or safe transportation. She stated she never performed competency or was observed or check-off on wheelchair security. CNA-A stated she had never had any issues with wheelchair securement, and she had transported many residents. During an interview on 01/09/2026 at 4:45 PM, NA-K stated she had not completed any transportation or wheelchair securement training. She stated she had never been checked off regarding competency of wheelchair securement. She stated she always fastened all 5 safety belts, and she did not see any way a wheelchair could flip if secured appropriately. She stated she had never had any issues with wheelchair securement and she had transported many residents. Record review of the facility's, undated, policy titled Wheelchair Securement in Facility Transportation Van, revealed in part: Staff responsible for transportation must be trained and demonstrate competency in wheelchair securement procedures. Staff involved in resident transportation must receive initial and ongoing training on wheelchair securement. Competency must be documented prior to independent transport duties. Record review of CNA A's personnel files revealed a hire date of 08/08/2025, and no evidence of training related to transportation safety or wheelchair securement. Record review of NA-K's personnel files revealed a hire date of 09/10/2025, and no evidence of training related to transportation safety or wheelchair securement. This was determined to be an Immediate Jeopardy (IJ) on 01/13/2026 at 3:00 PM. The Administration was notified. The Administrator was provided with the IJ template on 01/13/2026 at 3:00 PM. The following Plan of Removal was accepted on 01/15/2026 at 4:55 PM: 1. Immediate Cessation of Immediate JeopardyAction Taken: Effective 01/13/2026, upon receipt of the IJ, the facility ceased all resident transportation via van and wheelchair transfers requiring safety restraint usage. All other facility transports were ceased, unless staff were trained by nursing staff who have been trained in transporting residents safely using proper safety restraints.A licensed nursing staff trained in transport is available at the facility 24/7. Every resident who utilizes a wheelchair has been identified as a potential for wheelchair transport utilizing the facility van. The facility now requires verification that safety restraints are applied correctly, and staff supervision is present prior to movement. A check sheet for each transport is located at the nurses station. All transport staff have been trained on the proper use of the transport checklist. How Harm Is Prevented From Occurring or Recurring:No resident is permitted to be transported or transferred using the facility van until safety checks are completed and documented. All transport staff have signed an in-service for the training and notification of safety checks. A licensed nursing staff that has been trained on van safety transportation will provide supervisory oversight as a requirement for all transfers involving wheelchairs.Date Completed: 01/15/2026Responsible Party: Administrator / Director of Nursing (DON)2. Identification of Residents Who Have Suffered or Are Likely to Suffer HarmAffected Resident(s):The resident involved in the incident resulting in hospitalization.Residents Likely to Be Affected:All residents who:Are transported outside the facility (hospital, clinic, hospice)35 residents have been identified as likely to be affected, due to the use wheelchairs, and 9 residents do not. Action Taken:A 100% audit of all residents meeting the above criteria was completed immediately.Any resident identified as high risk had care plans updated and additional supervision implemented.Date Completed: Completion by 01/15/2026Responsible Party: DON3. Determination of the Underlying CauseRoot Cause Identified:Failure to consistently ensure wheelchair brakes and restraints were engaged prior to transport.Lack of a standardized transportation and wheelchair restraint checklist.Inadequate staff competency validation related to wheelchair transportation safety.The facility will establish a standardized maintenance checklist that will be reported monthly in QAPI meetings with the IDT. Date Completed: Completion by 01/14/20264. Specific Corrective Actions to Address NoncomplianceAction 1: Standardized Transportation Safety ProcessImplemented a Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist for all Nursing Staff.Date Competed: 01/15/2026Responsible Party: DON / Transportation DesigneeAction 2: Staff Education and Competency ValidationAll staff involved in resident transfers and transportation (nurses, CNAs, drivers) will receive education training before their next work day:Wheelchair brake lockingProper restraint useSupervision requirementsCompetency validation completed prior to staff resuming transport duties through a return demonstration for a supervisor. If the staff is not competent, they are not able to drive, supervise transports, and must have a competently trained staff in the facility to work with them. All nurses will be trained on proper procedure for transports with a wheelchair by prior to their next work day, immediately over the phone, upon hire, and annually. A nurse is available at the facility 24/7.Date Completed 01/15/2026Responsible Party: DON Action 3: Care Plan and Policy RevisionsCare plans updated to clearly identify supervision and transport requirements.Transportation and accident prevention policy created that includes training requirements, safety checklist, transportation safety, and restraint checklist.Date Completed: Completed by 01/15/2026Responsible Party: DON / Interdisciplinary Team5. Systemic Changes to Prevent RecurrenceFacility adopted a zero tolerance policy for noncompliance with transportation safety procedures through an in-service for staff currently at the facility and is mandatory for staff before starting their first shift. Supervisory sign off required for all external transports.Preventive maintenance checks for wheelchairs and restraints conducted weekly.Date Completed: 01/13/2026Responsible Party: Administrator / DON6. Monitoring and OversightDON/designee conducts daily audits of transportation documentation for 7 days, then weekly for 4 weeks.Findings reviewed during QAPI meetings.Any identified non compliance results in immediate corrective action.Date Completed: 01/13/2026 and ongoingResponsible Party: DON / QAPI Committee7. Sustainability PlanTransportation safety training incorporated into new hire orientation.Annual competency validation required for all applicable staff.Ongoing QAPI monitoring to ensure sustained compliance.Date Completed: 01/13/2026 and ongoing Monitoring of the facility's Plan of Removal revealed the following: Interview on 01/14/2025 at 4:45 pm, with the Administrator, ADON, and Office Manager revealed only 4 residents were transported since the IJ was called on 01/13/2026, none of which were transported it the van or in a wheelchair. Verified residents were transported via facility car, by NA-B who had been trained in transportation safety and wheelchair securement on 01/09/2026 by the Office Manager. Interview and observation on 01/14/2026 at 5:00 PM, NA-B (6am-2pm shift) stated she was observed properly securing a wheelchair in the van and showed competency. She stated she was trained on the new checklist and was aware all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. Observed NA-B properly secure a wheelchair into the van. Interview and observation on 01/14/2026 at 5:15 PM, NA-C (6am-2pm shift) stated she had been observed properly securing a wheelchair in the van and showed competency. She stated she had been trained on the new checklist and was aware that all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. Observed NA-C properly secure a wheelchair into the van. Interview on 01/14/2026 at 5:25 PM, CNA-A (8-5 PM shift) stated she was trained in transportation safety and proper wheelchair securement. She stated she was observed properly securing a wheelchair in the van and showed competency. She stated she had been trained on the new checklist and was aware all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. During interviews on 01/14/2026 from 5:00 PM- 6:00 PM, LVN-D, CNA-E, and NA-F (2pm-10pm shift) stated they were trained in transportation safety and proper wheelchair securement. They stated they were observed properly securing a wheelchair in the van and showed competency. They stated they were trained on the new checklist and were aware all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. During telephone interviews on 01/15/2026 from 11:00 AM- 12:30 PM, LVN-G, CNA-H, and NA-I (10pm-6am shift) stated they were trained in transportation safety and proper wheelchair securement. They stated they were observed properly securing a wheelchair in the van and showed competency. They stated they were trained on the new checklist and were aware that all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. During an interview on 01/15/2026 at 12:35 PM, LVN-J (6am-2pm shift) stated he was trained in transportation safety and proper wheelchair securement. He stated he was observed properly securing a wheelchair in the van and showed competency. He stated he was trained on the new checklist and was aware all transports must have a nurse verify proper wheelchair securement, and the checklist must be completed prior to every transport. Record review of completed safety checklist, completed by ADON prior to each of the four residents being transported with no concerns noted. Record review of Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist reflected it was completed on 01/09/2026 by NA-B. Record review of Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist reflected it was completed on 01/09/2026 by NA-C. Record review of Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist completed for LVN-D, CNA-E, NA-F, LVN-G, CNA-H, NA-I, CNA-C, and LVN J. Record review list of 35 residents identified at risk as wheelchair transfers and verified all 35 resident care plans were updated. Record review of the facility document, dated 01/14/2026, titled Weekly Preventative Maintenance Log,' revealed safety check completed on all 4 wheelchair straps in the van and all 35 residents' wheelchairs. The Administrator was informed the Immediate Jeopardy was removed on 01/15/2026 at 6:00 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for minimum harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure an individual working in the facility as a nurse aide for more than 4 months, on a full-time basis was competent to provide nursing and nursing related services, completed a training and competency evaluation program approved by the State as meeting requirements and that individual was deemed or determined competent as provided for 5 of 9 nurse aides (NA-C, NA-F, NA-I, NA-K, and NA-L) reviewed for nursing services. The facility failed to ensure NA-C, NA-F, NA-I, NA-K, and NA-L were certified within 4 months of being hired. This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known. Findings include: Record review of NA-F's employee file revealed a hire date of 04/19/2024 and worked full time. An employability status check dated 04/09/2025 indicated NA-F had no CNA certification. Record review of NA-I's employee filed revealed a hire date of 06/23/2025 and worked full time. An employability status check dated 06/14/2025 indicated NA-I had no CNA certification. Record review of NA-K's employee file revealed a hire date of 09/10/2025 and worked full time. An employability status check dated 09/10/2025 indicated NA-K had no CNA certification. Record review of NA-L's employee file revealed a hire date of 11/21/2024 and worked full time. An employability status check dated 01/14/2026 indicated NA-L had no CNA certification. During an interview on 01/14/2026 at 3:45 PM, the Office Manager stated NAs must be certified within 4 months of hire. She stated she was aware that many of the NA were past that deadline. She stated the facility was waiting for approval to have the nurse aide class. During an interview on 01/14/2026 at 4:00 PM, the Administrator stated she was aware many of her NAs were past the deadline of 4 months. She stated it was very hard to get people certified and it was very hard to find CNAs in a rural area. She stated the facility had just gotten certified to have a CNA class but was not sure if they would be able to have class due to the IJ that was called, and she did not know what she was going to do. Record review of the, undated, document provided by the Administrator titled Job Description for Nurse Aide, revealed in part: Qualifications: 1. Has completed a training and competency evaluation program or a competency evaluation approved by the state and holds a current certificate from the state. 2. must be enrolled in a competency training program approved by the state and performs only services of any type for which he or she has demonstrated competence.

Based on observation and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition of 1 of 1 van reviewed. The facility failed to ensure the facility van was maintained. This failure could place residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, hospitalization or death.The findings include:During an interview on 01/09/2026 at 3:20 PM, the Administrator stated there were no logs for maintenance on the van or routine checks regarding van maintenance or safety checks. She stated the van was not inspected routinely. During an interview on 01/09/2026 at 4:15 PM, CNA-A stated on 01/08/26 while transporting a resident the van began to overheat and she was in a construction zone with nowhere to exit. She stated she called the maintenance man on the phone, then she looked up and saw a yellow light and began slowing down.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage. The facility failed to ensure foods were sealed and/or labeled properly in dry storage. This failure could place residents at risk for foodborne illnesses. Findings include: During an observation of dry storage on [DATE] at 09:10 AM revealed the following: *,d+[DATE] bag of 35-ounce toasted oats not sealed *,d+[DATE] packaged cornbread mix opened with no open date or expiration dates. *1 plastic container with dry round cereal with no used by dates. Container was approximately ,d+[DATE] filled. *1 plastic container with what appeared to be dry oatmeal with no labels or dates. *1 plastic container of dry white substance with no label or dates *1 open box of dried beans not sealed, no labels or dates. *,d+[DATE] bag 26-ounce mashed potatoes open not sealed and no label with dates. During an interview on [DATE] at 09:25 dietary cook A stated products are supposed to be dated with date arrived, and date open. [NAME] stated they use the expiration date on the cans, package food came in. Dietary [NAME] A stated she did not know why everything was not labeled and dated. Dietary [NAME] A stated expired food could cause illness and leaving a bag or box unsealed could cause the food to go bad. During an interview on [DATE] at 01:45 PM The DM stated her expectations for storage and labeling in the kitchen was everything off the truck should be labeled and dated as it was stored. Any product opened should have ship date, open date and used by date. The DM stated if food was not stored properly, it could cause a food-borne illness and make residents sick. The DM stated the failure occurred due to her being out sick and she was the one that dated and labeled all the products in the kitchen. During an interview on [DATE] at 02:05 PM. The AMD stated her expectations are the kitchen staff would follow facility policy on storage and labeling food products. The ADM stated the harm to residents could be if food products were moldy or any product not stored properly could cause food-borne illness. The ADM stated this failure occurred due to DM being out sick and no one in the kitchen checking to see that everything was labeled and stored properly. The ADM stated she conducts spot checks in the kitchen at least 2 times a month. Review of facility's policy titled: Food Storage and Labeling Policy for Long-Term Care Facilities. Effective Date [DATE] revealed Purpose To establish guidelines for the proper storage, labeling, handling of food in long-term care facilities to ensure food safety, prevent contamination, and comply with state and federal health regulations Procedures 1. Labeling Requirements o All food items must be clearly labeled with the following information: o Name of the food item o Date received or prepared. o Expiration or use-by date o Initials of the staff member labeling the item . Food Code 2022 ,d+[DATE].11 Food labels

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practice, that were complete and accurate for 1 of 8 (Resident #10) residents reviewed for resident records. The facility failed to ensure Resident #10's physician orders were accurate and reflected Resident #10's current hospice. This failure could place residents at risk of having errors with their care and treatment. Findings included: Record review of Resident #10's electronic face sheet dated 03/05/2025 revealed a [AGE] year-old female admitted on [DATE] with the following medical diagnoses dementia, heart disease, high blood pressure, and malnutrition. Record review of Resident #10's Significant Change MDS dated [DATE] revealed Section C - Cognitive Patterns, Resident # 10's BIMS score of 3 indicating severe cognitive impairment. Section O-Special Treatments, Procedures, and Programs revealed Resident #10 received hospice care. Record review of Resident #10's hospice discharge revealed Resident #10 discharged from Hospice E on 02/11/2025. Record review of Resident #10's physician orders revealed Resident #10 admitted to Hospice E on 12/17/2024. Further review revealed no evidence of an order to discharge from hospice E or an order to admit to Hospice F. During an observation and interview on 03/05/2025 at 11:00 AM, Resident #10 was in her room with her Family Representative. Resident #10's Family Representative stated Resident #10 had discharged from Hospice E and admitted to Hospice F. During an interview on 03/05/2025 at 3:45 the DON stated her expectation was that resident orders she be current and accurate a reflect the current care received by patients. The DON stated orders should be entered by the receiving charge nurse and she and the ADON were responsible to monitor to ensure orders were accurate. The DON stated she monitored by reviewing resident charts periodically. The DON stated the effect on residents' orders not being accurate could affect the Resident's care. The DON stated when Resident #10 discharged from Hospice E there should have been an order to admit to Hospice F. The DON stated Resident #10's care could have been affected because staff would have been calling the wrong hospice and Resident #10 could have received delayed care. The DON stated she was not sure why the orders had not been changed and what led to failure of the orders not be accurate was oversight by staff. During exit conference on 03/05/2025 at 5:30 PM, the facility did not provide requested policies on accurate records at the time of exit when requested from the DON.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which must include, at a minimum, standard and transmission-based precautions to be followed to prevent spread of infections, for 7 of 41residents reviewed (Resident #4, Resident #11, Resident #15, Resident #28, Resident #191, Resident #192, and Resident #241) for infection control and prevention. 1. The facility failed to ensure Resident #4 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care due to Resident #4's suprapubic urinary catheter. 2. The facility failed to ensure Resident #11 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care due to Resident #11's open wounds on both lower legs. 3. The facility failed to make Personal Protective Equipment readily available for use when entering Resident #15's room designated for isolation due to Resident #15's positive COVID-19 test. 4. The facility failed to ensure Resident #28 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care due to Resident #28's indwelling urinary catheter. 5. The facility failed to make Personal Protective Equipment readily available for use when entering Resident #191's room designated for isolation due to Resident #191's positive COVID-19 test. 6. The facility failed to make Personal Protective Equipment readily available for use when entering Resident #192's room designated for isolation due to Resident #192's positive COVID-19 test. 7. The facility failed to make Personal Protective Equipment readily available for use when entering Resident #241's room designated for isolation due to a positive COVID-19 test. The failures could place residents at risk for infection, illness, and a decline in quality of life. The findings included: Resident #4 A record review of Resident #4's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of shortness of breath, history of urinary tract infections, prostate cancer, an enlarged prostate, mini strokes, and high blood pressure. A record review of Resident #4's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #4 scored 5 out of 15 indicating severe cognitive impairment. Section J Bladder and Bowel, subsection H0100 Appliances, A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was selected. A record review of Resident #4's physician's orders dated 10/12/2023 revealed Change S/P (suprapubic) Cath (a tube inserted into the urinary bladder through the lower abdominal wall to drain urine from the bladder). QM every day shift every 30 day(s) ., physician's orders date 10/19/2022 revealed 30mL flush of catheter BID two times a day for prevention of sediment build up. Furthr review revealed no evidende of orders for Enhanced Barrier Precautions. During an observation on 03/03/2025 at 09:04 AM, no EBP signage on Resident #4's door to indicate additional protection required when providing care to the resident due to Resident #4's suprapubic urinary catheter. Resident #11 A record review of Resident #11's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of cellulitis and wounds on both heels, enlarged prostate, and recurrent urinary tract infections. A record review of Resident #11's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #11 scored 11 out of 15 indicating moderate cognitive impairment. Section M - Skin Conditions, subsection M1200 Skin and Ulcer/Injury Treatments, item E. Pressure ulcer/injury care was selected, item F. Surgical wound care was selected, item H. Application of ointments/medications other than to feet was selected, and item I. Application of dressing to feet (with or without topical medications) was selected. A record review of Resident #11's physician's orders dated 11/01/2024 revealed wound care left heal: cleanse with wound cleanser, pat dry, apply calcium alginate with silver (a gel-forming substance containing silver particles used to treat wounds), cover with absorbent dressing, secure with [sterile cotton gauze dressing] and tape every day shift every Mon, Wed, Fri for wound care, wound care right heal: cleanse area with wound cleanser, pat dry, apply [povidone-iodine], leave open to air every day shift every Mon, Wed, Fri for wound care, wound care RLE and LLE: cleanse with wound cleanser, pat dry, apply [a gel used to inhibit the growth of bacteria and fungi and absorb wound drainage], cover, secure with [sterile cotton gauze dressing] and tape every day shift every Mon, Wed, Fri for wound care, Furthr review revealed no evidende of orders for Enhanced Barrier Precautions. During an observation on 03/03/2025 at 09:30 AM, no EBP signage on Resident #11's door to indicate additional protection required when providing care to the resident due to open wounds on both lower legs. Resident #15 A record review of Resident #15's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of COVID-19, major depression, Type 2 diabetes, history of breast cancer, scoliosis (a condition characterized by an abnormal sideways curvature of the spine), anxiety, high blood pressure, fainting, weakness, and arthrogryposis multiplex congenita (a rare group of disorders characterized by multiple joint contractures, permanent shortening or tightening of muscles, tendons, ligaments, or skin, which restricts movement in a joint or body part, present at birth). A record review of Resident #15's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #15 scored 13 out of 15 indicating moderate cognitive impairment. A record review of Resident #15's physician's orders dated 03/03/2025 revealed an order Place on COVID isolation. During an observation on 03/03/2025 at 09:11 AM of Resident #15's closed door revealed a sign with Isolation printed on it. No additional information or instructions was posted. No PPE was available outside Resident #15's door. Resident #28 A record review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of anxiety, obesity, high blood pressure, heart disease, an irregular heartbeat, diseased veins in her legs, emphysema (a chronic lung disease that causes permanent damage to the air sacs in the lungs), COPD (a group of lung diseases that cause ongoing breathing problems), and a history of cervical (the lower part of the uterus) cancer. A record review of Resident #28's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #28 scored 10 out of 15 indicating moderate cognitive impairment. Section H - Bladder and Bowel, subsection H0100 Appliances, A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was selected. A record review of Resident #28's physician's orders dated 12/02/2024 revealed Insert 16 fr with 10-30 cc bulb foley catheter due to neurogenic bladder. Furthr review revealed no evidende of orders for Enhanced Barrier Precautions. During an observation on 03/04/2025 at 06:42 AM, no EBP signage on Resident #28's door to indicate additional protection required when providing care to the resident due Resident #28's indwelling urinary catheter. During an interview on 03/04/2025 at 11:43 AM, Resident # 28 stated she had the indwelling catheter for a couple of months. She denied issues with the catheter. Resident #28 stated staff emptied the collection bag regularly and had come in, emptied it, and hung it under the bed after she received her medications this morning. She stated she was not bothered by the bag not hanging under her bed. During an interview on 03/05/2025 at 02:07 PM, NA C stated administration was responsible for monitoring training compliance. He stated the DON and ADON provided the infection control and catheter care training. NA C stated he was not trained on EBP. He stated the failure could cause the resident to get an infection. Resident #191 A record review of Resident #191's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of mini strokes, asthma, anxiety, high blood pressure, and irregular heartbeat. A record review of Resident #191's Admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #191 scored 14 out of 15 indicating intact cognition. A record review of Resident #191's physician's orders dated 03/03/2025 revealed an order Place on COVID isolation. During an observation on 03/04/2025 at 11:25 AM of Resident #191's closed door revealed a sign with Isolation printed on it. No additional information or instructions was posted. No PPE was available outside Resident #191's door. Resident #192 A record review of Resident #192's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of vertebral disc disorder (a breakdown of the spinal discs). A record review of Resident #192's Admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #192 scored 14 out of 15 indicating intact cognition. A record review of Resident #192's physician's orders dated 03/03/2025 revealed an order Place on COVID isolation. During an observation on 03/04/2025 at 11:25 AM of Resident #192's closed door revealed a sign with Isolation printed on it. No additional information or instructions was posted. No PPE was available outside Resident #192's door. Resident #241 A record review of Resident #241's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood pressure, irregular heartbeat, enlarged prostate, weakness, and stroke. A record review of Resident #241's Admission MDS dated [DATE], revealed Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score was not completed. A record review of Resident #241's physician's orders dated 03/03/2025 revealed an order Place on COVID isolation. During an observation on 03/03/2025 at 09:24 AM of Resident #241's closed door revealed a sign with Isolation printed on it. No additional information or instructions was posted. No PPE was available outside Resident #241's door. During an interview on 03/03/2025 at 10:09 AM, the DON stated she was responsible for ensuring signage and PPE were available and we just haven't got them put up yet referring to instruction signage on isolation room doors. The DON explained her expectation of staff before entering an isolation room was to put on a gown in the hall and the rest of the PPE was in the resident's room. She explained before exiting, the gown was removed and hung in the resident's room. She stated staff are the only ones to enter the room, so they knew how to identify which gown was theirs. During the conversation with the DON, NA D approached the DON and asked what she needed to put on before entering an isolation room. The DON replied, PPE is in the room. The DON then turned and walked to the nurse's station. During an interview on 03/05/2025 at 01:56 PM, the Administrator stated the staff had not been trained on EBP. She stated she was aware of the requirement but had been too busy the past 4 months with audits and not paying attention to other tasks. The Administrator stated infection control training was provided during orientation and monthly by the DON. She stated her expectation when providing care for residents in isolation rooms was for PPE to be available outside each room. She stated the DON was responsible for training and monitoring the staff on infection control policy and practice. The Administrator stated her expectation of information given to visitors of residents in isolation was for the nurse on duty to explain the purpose of PPE was to prevent spread of infection. She stated the effect on residents of failing to have an EBP program in place would be a possible increase in infections. During an interview on 03/05/2025 at 02:25 PM, the DON stated implementing the EBP program was in process of being in process. She could not explain why the process had not been implemented. The DON stated her expectation was for PPE to be available outside the isolation rooms. The DON stated the facility was using one PPE cart for residents on 300 and 400 halls because it was on wheels and could be moved from room to room. She stated the ADON was responsible for infection control training. The DON stated consequences of failing to have an EBP program in place could be the spread of infection. During an interview on 03/05/2025 at 02:52 PM, the ADON stated she was in process of completing IP training but could not estimate a completion date. She stated LVN B was a certified IP but only worked part-time. The ADON stated PPE should be outside the door of each isolation room and staff was expected to wear the proper PPE. She stated the reason for the failure was because the DON set up one PPE cart to use since it was on wheels. The ADON stated she was not aware of the EBP regulation. The ADON stated failure to implement an EBP program would be cross contamination from one resident to the next. The ADON stated the DON was responsible for in-services and training. Review of the facility policy titled COVID-19 Positive Area in Facility effective 11/28/2022 and updated 05/09/2023 revealed Per most recent CDC Guidelines for COVID-19, resident who test positive for COVID-19 can be quarantined to their rooms. An isolation cart/table will be set up outside the room of the resident with the proper PPE listed below. 9. N-95 Masks, 10. Face Shields, 11. Goggles, 12. Shoe Covers, 13. Gloves, 14. Bio-Hazard Bags (Red), 15. Laundry Bags (Yellow), 16. Hand Sanitizer Review of the facility policy titled Enhanced Barrier Precautions in Nursing Homes, dated 06/01/2024, revealed 1. Resident Requiring Enhanced Barrier Precautions. EBP will be implemented for residents who: * Have indwelling medical devices (e.g., central lies, urinary catheters, feeding tubes, tracheostomies). 2. Personal Protective Equipment (PPE) . Healthcare personnel must wear: * Gloves and gowns when performing high-contact care activities (e.g., dressing changes, device care, bathing, toileting, wound care).

Based on interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessmen of diagnosis of Diebeates Mellitus, Goutt for 1 of 16 residents reviewed (Resident #34) residents reviewed for comprehensive care plans. The facility failed to implement care plan for Resident #34 that included Diabetes Mellitus and Gout These failures could place residents at risk of not having preferences and needed care for residents. Findings included: Record review of Resident #34' electronic face sheet revealed an [AGE] year-old female admitted [DATE]. Diagnoses include Hypothyroidism (abnormally low activity of thyroid gland), Type 1 Diabetes Mellitus (pancreas makes little to no insulin) , Obesity( excess accumulation of body fat), Hypertension (high blood pressure), Gout (a type of arthritis that causes joint pain and swelling), Paroxysmal Atrial Fibrillation(a type of irregular heart beat that starts and stops suddenly) Right Upper quadrant pain, Shortness of breath, Osteoarthritis (degeneration of joint cartilage and the underlying bone) . Record review of Resident #34's Comprehensive Care Plan dated 01/29/2025 revealed no problem, interventions, goals for diagnosis of Paroxysmal Atrial Fibrillation, Gout, Type I Diabetes Mellitus, Obesity, Right Upper quadrant pain, Shortness of breath, Osteoarthritis, Sleeping in recliner. Record review of Resident #34's Admission MDS dated [DATE] revealed Section C - Cognitive Patterns-C0500 BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). Section I-Active Diagnoses I0100 Cancer, I0300 Atrial Fibrillation, I0700 Hypertension, I2900 Diabetes Mellitus, I3300 Hyperlipidemia, I3400 Thyroid Disorder, I3700 Arthritis, I8000 Additional active diagnoses Obesity unspecified. Record review of Resident 34's Physician orders dated 03/01/2025 revealed the resident received the following medications: *Metoprolol Tartrate for hypertension, *Losartan for hypertension, *Potassium for low potassium levels *Tylenol 8-hour Arthritis Pain, *Allopurinol for Gout, *Metformin HCL for diabetes, *Levothyroxine for Hypothyroidism, *Empagliflozin for Diabetes, *Celecoxib for arthritis, *O2 (oxygen)at 2-4 LPM (liters per minute) via N/C (nasal canula). During an interview on 03/05/2025 at 01:55 PM, the DON stated comprehensive care plans should address all diagnosis, medications and anything revealed from admission assessments, such as falls, smoker, skin impairment. The DON stated care plans should be updated with any significant change for resident and every 3 months. The DON stated if a care plan was not updated the care may not be provided. The DON stated the staff informed her of any changes and she updates the care plan as needed. Review of facility's policy titled: Comprehensive Care Plan Policy Effective Date: 05/05/2024 revealed: Purpose To establish guidelines for the development, implementation, and evaluation of comprehensive care plans for residents in long-term care facilities, ensuring person-centered care that meets regulatory requirements and promotes resident well-being 1. Development of the Comprehensive Care Plan . A full comprehensive care plan must be completed within 7 days after the completion of the resident's initial [NAME] Data Set (MDS) assessment, which occurs within 14 days of admission. The care plan must be: Resident-centered and reflect the individual's goals, preferences, and strengths. Based on a comprehensive assessment, including physical and emotional, cognitive, and social aspects of care. Developed with input from the resident and/or their legal representative. Documented in the resident's medical record Care plans should include measurable goals and specific interventions tailored to the resident's needs

Based on interview and record review, the facility failed to revise the resident's care plan for use of firgure eight binder and recent fall. 1 of 16 residents (Resident #33) reviewed for comprehensive care plans. The IDT team failed to revise Resident #33's care plan to include the updated fall with injury, left distal clavicle fracture and physician order for figure eight binder.(Clavicle support brace). These failures could affect residents by placing them at risk of not having their individual needs met. The findings include: Record review of Resident #33's electronic face sheet revealed [AGE] year-old male admitted [DATE] with diagnoses Nonrheumatic Aortic valve Stenosis, Congestive Heart Failure, (heart disease) Nicotine Dependence, Epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures), Hypertension (high blood pressure, Chronic Obstructive Pulmonary Disease (Lung disease). Record review of Resident #33's Quarterly MDS dated [DATE] revealed Section C-Cognitive Patterns-C0500 BIMS Score 05 (severely impaired cognitive function), Section GG0120 Mobility Devices Walker Record review of Resident #33's Care Plan date initiated 08/08/2023 revealed Resident #33's care plan did not address the injury on 2/23/2025or the intervention of figure eight binder (clavicle support binder) for fracture of left distal clavicle fracture. Record review of Resident #33's Physician orders dated 02/26/2025 revealed order for figure eight binder. During an interview on 03/05/2025 at 01:55 PM, the DON stated care plans should be updated with any significant change for resident and every 3 months. The DON stated if care plan was not updated the care may not be provided. The DON stated the staff informed her of any changes and she updated the care plan as needed. The DON stated she did not know what caused this failure. Review of facility's policy titled: Comprehensive Care Plan Policy Effective Date: 05/05/2024 revealed: Purpose To establish guidelines for the development, implementation, and evaluation of comprehensive care plans for residents in long-term care facilities, ensuring person-centered care that meets regulatory requirements and promotes resident well-being 4. Care Plan Review and Updates Care plans must be reviewed at least quarterly and with any significant change in the resident's condition. Revision must be made promptly to reflect changes in: *Medical Status * Functional ability * Psychosocial needs * Resident preferences and goals .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #28) reviewed for catheter care. The facility failed to ensure Resident #28's indwelling urinary catheter collection bag was secured off the floor. This failure placed residents at risk for infection. Findings included: A record review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of anxiety, obesity, high blood pressure, heart disease, an irregular heartbeat, diseased veins in her legs, emphysema (a chronic lung disease that causes permanent damage to the air sacs in the lungs), COPD (a group of lung diseases that cause ongoing breathing problems), and a history of cervical (the lower part of the uterus) cancer. A record review of Resident #28's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 - BIMS Summary Score, Resident #28 scored 10 out of 15 indicating moderate cognitive impairment. Section H - Bladder and Bowel, subsection H0100 Appliances, A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was selected. A record review of Resident #28's physician's orders dated 12/02/2024 revealed Insert 16 fr with 10-30 cc bulb foley catheter due to neurogenic bladder. During an observation on 03/04/2025 at 06:42 AM, Resident #28's urine collection bag was lying on the floor and visible from the doorway. During an interview on 03/04/2025 at 06:50 AM, LVN A stated a urinary catheter collection bag should be hung from the bed frame and not left lying on the floor. She stated the effect on a resident of the urinary catheter collection bag lying on the floor would be an increased risk for urinary infection. During an interview on 03/04/2025 at 11:43 AM, Resident # 28 stated she had the indwelling catheter for a couple of months. She denied issues with the catheter. Resident #28 stated staff emptied the collection bag regularly and had come in, emptied it, and hung it under the bed after she received her medications this morning. She stated she was not bothered by the bag not hanging under her bed. During an interview on 03/05/2025 at 02:07 PM, NA C stated a urine collection bag should be hanging below bladder level and under the bed, not lying on the floor. He stated administration was responsible for monitoring training compliance. He stated the DON and ADON provided the infection control and catheter care training. NA C was not able to explain why Resident #28's urine collection bag was lying on the floor. He stated the failure could cause the resident to get an infection. During an interview on 03/05/2025 at 01:56 PM, the Administrator stated infection control training was provided during orientation and monthly by the DON. She stated the DON was responsible for training and monitoring the staff on infection control policy and practice. The Administrator stated urine collection bags should not be on the floor. Her expectation was for them to be properly placed. The Administrator was unable to provide an explanation of the failure to place urine collection bags in a privacy cover and hang off the floor. During an interview on 03/05/2025 at 02:25 PM, the DON stated the urine collection bag found on the floor in a resident's room should not have happened. She explained a leg bag used during the day and a big bag used at night. She stated Resident # 28 who had a residential full-size bed there was not a good way to hang the collection bag. Stated she had tried to place the hook between the mattress and box springs, but it did not hold well. She stated the ADON was responsible for infection control training. The DON stated the effective of failing to keep the collection bag off the floor would be risk for infection. During an interview on 03/05/2025 at 02:52 PM, the ADON stated a urine collection bag should never be on the floor. The ADON stated the DON was responsible for in-services and training. She explained the consequence to a resident with an indwelling urinary catheter collection bag lying on the floor visible from the door would be demeaning and embarrassing. Review of the facility policy titled Catheter Care, Urinary, revised September 2014, revealed Infection Control . b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review the facility failed to ensure adequate supervision to prevent accidents for 3 of 5 (Resident #s 1, 2 and 3) residents reviewed for smoking. a. On 04/05/20 at approximately 5:30 PM Resident #1 was severely burned while lighting a cigarette unsupervised. Staff reported he was at a hospital in another city on a ventilator [MEDICAL CONDITION] 45% of his body. b. There was not a system in place to communicate to staff which residents smoked, and which residents required supervision while smoking. c. Residents #2 and #3 said they had kept lighters in their possession (Note: The facility policy stated all lighters were to be kept at the nurse's station) prior to 04/05/20. d. Residents #1 and #3 did not have smoking safety assessments. An Immediate Jeopardy (IJ) was identified on 04/09/20. While the IJ was removed on 04/10/20, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could result in resident injury or death. The findings included: Review of Resident #1's Admission Record dated 04/06/20 revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE]. He was [AGE] years of age. His [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS dated [DATE] revealed he was documented as a tobacco user. Review of a Behavior Note dated 11/9/2019 revealed Resident #1 was observed picking up cigarette butts out of the public ashtrays outside. His wife was called and said she could not afford to buy him cigarettes. Review of Resident #1's computerized record revealed he was discharged from his 10/22/19 admission on 11/22/19. Review of the Nursing Admission Screening/History for his latest admitted d 03/12/20 noted he was a current smoker and dipped snuff. Review of Resident #1's Admission MDS dated [DATE] revealed he was not documented as a tobacco user. His BIMs was 14 indicating intact mental status. Review of Resident #1's Care Plan dated 03/12/20 revealed it did not address the use of tobacco. Review of Resident #1's electronic health record revealed no smoking safety assessment prior to his accident (04/05/20); however, there was an assessment dated [DATE] completed by the DON. The assessment documented that Resident #1 was safe to smoke with supervision. In an interview with the DON on 04/09/20 at 11:50 AM, that she knew Resident #1 was dipping snuff, but did not know he had been smoking. However, she said that cigarette butts had been found in his room. She said they had two residents that could pick up their lighter from the nurse and go smoke unsupervised. She confirmed a smoking safety assessment had not been done for Resident #1 prior to his accident. She stated she should have not completed a smoking safety assessment on Resident #1 after the accident, but she had been trying to cover all the bases. Review of a facility Provider Investigation Report dated 04/07/20 revealed that on 04/05/20 at 5:30 PM, Resident #1 was found in the central courtyard/smoking area on fire. Review of an Incident Note dated 04/05/20 at 6:34 PM revealed that a CNA had notified LVN A that a resident had caught himself on fire and had been put out with a fire extinguisher. LVN A assessed Resident #1 outside on the interior courtyard/smoking area patio and [MEDICAL CONDITION] the resident's upper arms, legs (including the residents left above the knee amputation stump), buttocks, upper and lower back, chest, and neck with singed hair on the resident's head and face. Resident #1's was alert and oriented. Resident #1 told the nurse that it was windy outside, so he put his head and a lighter inside his shirt to light a cigarette and that his shirt caught on fire and he started to yell for help. In an interview with Resident #2 on 04/09/20 at 2:20 PM, she said she had been out on the patio with Resident #1, he had already been out there, sitting at the picnic table, when she went out to smoke. She did not see Resident #1 smoking at that time. She lit her cigarette and Resident #1 started banging on the window and the door. The cook came out of the kitchen and that was when she noticed that Resident #1 had a bunch of fire that just blew up all over him. In an interview with Cook A on 04/09/20 at 1:45 PM, he said that he had gone out with the residents who smoke in the past. He said residents didn't have lighters and he would have to light the cigarettes for them. He said that Resident #1 had been out in the designated smoking area every time Resident #1 had a chance and had seen Resident #1 smoking once or twice this visit. He said on the day of the accident (04/05/20) he had seen him going through the ashtrays. He said he had seen him do the same thing during his previous stay. Cook A said that at the time of the accident, he heard pounding on the window and door and when he looked he saw Resident #1 outside on the patio on fire. He rushed out and started putting out the flames with his shirt and then a CNA came with a fire extinguisher and they were able to get the flames out. In an interview with LVN A on 04/09/20 at 1:55 PM she said that on 04/05/20 just after evening meal time, she was in a resident room when she heard staff yelling emergency. She had staff call emergency services and went out to the patio, where she found the resident on the ground [MEDICAL CONDITION] most of his body. Resident #1 said he had put his head and a lighter under his shirt to light a cigarette because it was windy. She began to assess the resident, when the ambulance arrived. In an interview with the DON on 04/09/20 at 11:38 AM, that Resident #1's wife had notified them that the resident was at a hospital in another city in a medically induced coma [MEDICAL CONDITION] 45% of his body. In an interview with the Administrator on 04/10/20 at 10:50 AM she said Resident #1's wife had said he was at a hospital in another city on a ventilator, in medically induced coma, with 45% body of his body burned. He would need several surgeries, but that they were not confident he would survive surgery. In an interview with CNA A on 04/09/20 at 10:47 AM, he said that he had seen Resident #1 outside smoking for a couple of days prior to the resident's accident. He said he thought the resident could have his own lighter. CNA A said that they were usually just told which residents needed to be supervised while smoking. He said residents were not supposed to have a lighter; but could get one from the nurse and light their own cigarettes. In an interview with CNA B on 04/09/20 at 11:03 AM, she said that Resident #1 dipped snuff and smoked sometimes, but that she had not seen him out smoking during this admission. She said residents were supposed to get the lighter from the nurse. In an interview with CNA C on 04/09/20 at 11:12 AM, she said that staff were verbally told when a resident was admitted if they needed to be supervised while smoking. She said that they were verbally told which residents needed to be supervised to smoke. She said residents could keep their cigarettes but were not supposed to have a lighter. In an interview with LVN B on 04/09/20 at 11:20 AM, he said that he was aware that Resident #1 had a history of [REDACTED]. He did not think he had been smoking this visit. In an interview with LVN C on 04/09/20 at 11:28 AM, she said that she had seen Resident #1 out smoking for a couple of days prior to his accident. She said residents were supposed to be assessed for smoking safety on admission, and if they were assessed as being safe could smoke unsupervised. In an interview with the Administrator on 04/09/20 at 12:00 Noon, she said that residents were assessed for smoking safety on admission, quarterly and as needed. She said that staff would light resident's cigarettes but would not stay outside monitoring the residents if they had been assessed as being able to smoke safely without supervision. She said they had not had any residents who could not smoke without supervision in a long while. The Administrator also said that it was her expectation that staff would have completed a smoking safety assessment on Resident #1 to see if he could smoke without being supervised. She said that if staff had seen him outside smoking she would expect the staff to say something to their supervisor, so action could be taken. In an interview with LVN D on 04/09/20 at 1:36 PM she said that they only had four residents who smoked and that staff just know who can smoke by themselves. She said that she had seen Resident #1 after the fire was out and that he said he had lit a cigarette under his shirt. In an interview with LVN A on 04/09/20 at 1:55 PM, she said she was not aware that Resident #1 smoked but knew that he had been dipping snuff. Resident #2 Review of Resident #2 computerized medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years of age. Her [DIAGNOSES REDACTED]. Review of Resident #2 Annual MDS dated [DATE] revealed she used tobacco and had a BIMS of 15 indicating intact mental status. Review of Resident #2 Smoking Safety screenings dated 08/09/19, 11/07/19, and 01/30/20 indicated she was safe to smoke without supervision and was able to use her own lighter to light cigarettes. (Note: facility policy stated residents were to get lighters from the nurse's station.) In an interview with Resident #2 on 04/09/20 at 2:20 PM, she said that prior to the accident, she had kept her lighter in the side pocket of her purse with her cigarettes. Resident #3 Review of Resident #3's computerized medical record revealed he was admitted to the facility on [DATE]. He was [AGE] years of age. His [DIAGNOSES REDACTED]. Review of Resident #3's Admission MDS dated [DATE] indicated he was a current tobacco user. Review of Resident #3's Care Plan last updated 01/27/20 revealed a problem initiated 10/17/19 He is a smoker. Review of Resident #3's computerized assessments revealed no Smoking-Safety Screens from admission on 10/14/19 until 04/08/20. In an interview with the DON on 04/09/20 at 5:05 PM she confirmed that there was not a smoking assessment prior to 04/08/20 for Resident #3. In an interview with Resident #3 on 04/09/20 at 2:15 PM, he said that before the accident he could keep his lighter with him. He said that Resident #1 had been out smoking several times. In an interview with the Administrator on 04/10/20 at 10:50 AM, said she felt the failure that caused this accident was a communication failure with the staff and that the DON should have known the resident had been smoking. She said staff should have reported seeing the resident smoke to the DON. In an interview with the ADON on 04/10/20 at 11:33 AM she said that it had become normal for staff to expect Resident #1 to be non-compliant. She said that she had found cigarette butts in his room during this stay and had spoken with Resident #1 and thought it was taken care of. She felt there was a failure of communication between the shifts. In an interview with the DON on 04/10/20 at 11:58 AM, she said she knew Resident #1 was non-compliant, she had believed him when he said he was not smoking, but, that in hindsight, it was her responsibility to assess all the residents. Review of the facility Smoking Policy dated 02/29/15 revealed the following: It is the policy of (facility name) to ensure the safety of all the residents. Residents, visitors, and employees may only smoke in the designated smoking area, which is the courtyard located in the center of the facility. Resident's will be assessed every six months and as needed to determine the need for supervision to smoke. All resident's that are able to smoke without supervision are allowed to keep their cigarettes. All resident lighters are to be kept at the nurse's station. A metal container with a self-closing lid to empty/dump ashes will be provided at all times in designated smoking area(s). Noncombustible ashtrays will be provided for residents, visitors, and employees to use in areas where smoking is permitted. Absolutely no smoking is allowed in any rooms, wards, or compartment where flammable liquids, combustible gases, or oxygen or inhalation therapy equipment is used or stored. The safety of our residents is of the utmost importance. We ask your consideration in abiding by this policy. The Administrator, Director of Nurses (DON) were informed of the identification of an immediate jeopardy situation on 04/09/20 at 5:05 p.m. The Administrator was provided the IJ template. Review of the facility's Plan of Removal dated 04/09/20 documented: The smoking/tobacco assessment has been revised so that every resident who is admitted into the facility will have a smoking/tobacco assessment completed. This assessment will be done on admission, quarterly and as needed. This assessment has been added to the new admission check list to ensure compliance. When unknown tobacco user is discovered smoking or digging through ashtrays, staff will either stay with resident to ensure safety while they are smoking or remove the resident from the smoking area. Staff will confiscate tobacco paraphernalia and give to supervisor. Once inside the facility the staff member will immediately report it to the supervisor. The supervisor will report to the Director of Nursing. The DON will assess resident for tobacco usage. Resident will be educated on facility smoking policy and if lighter is found, it will be taken to the charge nurse per policy. DON will update care plan to reflect tobacco usage. Incident will be documented in residents chart. Smoking information sticker will be added to residents information located on their door name plate. This change will be added to the nursing 24 hour report and will be reported on all shift reports. Ashtrays will be emptied after every use in the red fire proof receptacle. Staff will be in-serviced of this new policy as they pick up their paycheck 04/10/2020. Any staff that are not available on 04/10/20 will be trained/in-serviced prior to beginning work on their next shift. The smoking/tobacco policy has been revised to include all smoking residents will be supervised while smoking. Staff will be in-serviced and trained as they pick up their paycheck on 04/10/20. Any staff member that is not available on 04/10/20 will be trained/in-serviced prior to working their next shift. The facility utilizes a sticker system on the residents name plate as a way of communication. A smoking sticker (bear) has been added to all smokers. All staff have been given access to the residents Care Profile, which includes such information as Smoking Status. Staff will be in-serviced and trained as they pick up their paycheck on 04/10/2020. Any staff member that is not available on 04/10/20 will be trained/in-serviced prior to working their next shift. Smoking aprons have been ordered and will be utilized per assessment. We have included a smoking/tobacco statement in the New Admission packet. This includes our policy as well as informing family not to bring lighters to the resident or in the facility. Responsible party will be notified and notification will be documented. The smoking/tobacco policy has been added to the new hire packet. Employee will sign that they understand and it will stay in employee file. All residents in the facility have a current smoking assessment completed and a revised care plan to include supervised smoking. All residents who are able will sign the new policy stating that they have been informed of the revisions. The following residents are our current smokers: (Resident Id #s 2, 3, 4 and 5) These residents have a new smoking assessment, a revised care plan to include smoking supervision and have been informed of our new policy. The surveyor verified the completion of the Plan of Removal as follows: In-services were conducted on 04/09/20 and 04/10/20 by the Administrator and Business Office Manager regarding the new smoking policy, procedures and rules regarding smoking and having a lighter in the facility and the new sticker identification system. Interviews with staff on the day and evening shift: 2 nurses, 3 aides, and 2 other personnel revealed the staff understood the content and answered questions appropriately. Interviews with Residents 2, 3 and 5 revealed they had been instructed on the new smoking policy. They were not to go smoke without staff and they were no longer to keep their lighters. Resident #4 refused to be interviewed. Residents were observed on 04/09/20 and 04/10/20 with staff while smoking in the designated smoking area. The new smoking assessment was reviewed and all current residents were assessed. Resident #s 2,3, 4 and 5's records were reviewed for current smoking safety assessments and their care plans were updated. Bear stickers were noted on the resident door for those who smoke. Smoking Apron order receipt was reviewed. Interview on 04/10/20 at 3:25 PM the Administrator and DON were informed the IJ was lifted but the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to notify the resident's physician of the resident's condition or as ordered when the resident experienced a change in condition and/ or extreme blood sugar levels for four (Residents #1, #2, #3, and #4) of seven residents reviewed for notification of changes in condition. A. Resident #2 had orders for routine and sliding scale insulin, but did not have parameters that established when the physician should be notified of her blood sugar (BS) level or when Resident #2's insulin should be held due to low blood sugar. Resident #2 had multiple incidents during September and October 2017 during which she had either dangerously high or low blood sugar levels. B. Resident #3 had orders for her physician to be notified if her blood sugar level was above 400. There were 22 incidents in October 2017 where her blood sugar was over 400, but her physician was not notified. C. Resident #4 had order for her blood sugar to be recheck within one hour if her blood sugar level was above 400, and if the level remained above 400 when rechecked the physician was to be notified. There were 22 incidents in September and October 2017 where Resident #4's blood sugar measured above 400, but her level was not rechecked and her physician was not notified. D. Resident #1 began displaying signs of pain to her leg on September 8, 2017 and on 09/09/17 Resident #1's family member requested from LVN A that Resident #1 receive an x-ray due to her pain. LVN A did not notify the physician of Resident #1's displays of pain or the family's request. Resident #1 continued to display signs of pain on 09/10/17, but an x-ray was not requested until 09/11/17. The x-ray revealed Resident #1 had a displaced fracture of her toe on her right foot. Resident #1 did not receive any pain medication from 09/08/17 through 09/10/17 despite indications of pain. This deficient practice resulted in an Immediate Jeopardy (IJ) on 11/03/17. While the IJ was removed on 11/07/17, the facility remained out of compliance at a level of pattern, with potential for more than minimal harm that was not IJ due to the facility's need to continue to monitor the effectiveness of the Plan of Removal. This failure could all 41 residents in the facility, and could place them at risk for not being adequately treated for [REDACTED]. in condition. This could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: A. Resident #2 Record review of Resident #2's Admission Record, dated 11/02/17, revealed she was an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's Admission Record identified her primary care physician as Physician A. Record review of Resident #2's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #2's MDS revealed she required the physical assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. The MDS also revealed Resident #2's active [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan, undated, revealed the following: Focus: She has diabetes mellitus. (Date Initiated: 09/14/16) Goal: She will be free from any s/sx (signs or symptoms) of [MEDICAL CONDITION] through the review date. (Date Initiated: 09/14/16) She will be free from an s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 09/14/16) Interventions: . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 09/14/16). Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/14/16) . Monitor/document/report PRN (as needed) any s/sx of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breath, [MEDICATION NAME] breath (smells fruity), stupor, coma (Date Initiated: 09/14/16 ) Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, slurred speech, lack of coordination, staggering gait (Date Initiated: 09/14/16) . Focus: She has [MEDICAL CONDITION] r/t (related to) uncontrolled diabetes (Date Initiated: 09/27/16) Goal: She will have no complications from [MEDICAL CONDITION] through the review date. (Date Initiated: 09/27/16) Interventions: Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/27/16 Monitor compliance with diet and document any problems. (Date Initiated: 09/27/16) Monitor/document/report PRN (as needed) any s/sx of [MEDICAL CONDITION] . (Date Initiated: 09/27/16) Record review of Resident #2's Order Summary Report, dated 11/03/17, revealed there were no orders for blood sugar checks, but did identify the following orders: Humalog Solution 100 unit/ML (milliliter) (Insulin [MEDICATION NAME]) Inject per sliding scale: if 0-349 = 0; 350-400 = 3; 401-450 = 5; 451-500 = 6 Recheck 2 hours after admin (administration) of 6 units; 501+ = 8 Recheck 2 hours after admin of 8 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . Order Date: 04/30/17. Continued review of Order Summary Report revealed there was no parameters as to when Resident #2's physician should be notified for high and/or low blood sugars. Glucose Gel 15 GM/33 GM (grams) Give 1 packet by mouth as needed for BS (Blood Sugar) below 70 MG/DL (Milligram/Deciliter) related to Type 2 Diabetes Mellitus . Adm (Administer) 15 gm into mouth and swallow, if no response in 15 min (minutes) repeat dosage, if no response in 30 min contact PCP. Order Date: 10/13/17 According to the U.S. National Library of Medicine Humalog (generic name: Insulin [MEDICATION NAME]) is used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. Insulin [MEDICATION NAME] is a short-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 1.html According to the National Institute of Diabetes and Digestive and Kidney Diseases, Glucose Gel is pure glucose (type of sugar) in gel form used for treating [DIAGNOSES REDACTED]. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-[DIAGNOSES REDACTED] Record review of Resident #2's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] Solution (generic name: Insulin Detemir) is used to treat people with type 2 diabetes . who need insulin to control their diabetes. Insulin detemir is a long-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 2.html Record review of Resident #2's MAR for September 2017 revealed on the following dates Resident #2's blood sugar was below 54 at 6:30 AM, but there was no documentation that indicated staff provided interventions to address the low blood sugar, rechecked her blood sugar, or notified a physician of potentially dangerous BS levels. Resident #2's blood sugar was not rechecked, she did not receive the available Glucose Gel, and her PCP was not notified. On the identified dates Resident #2 also received her [MEDICATION NAME] at 8:00 AM despite the low blood sugar levels. 09/06/17 8:59 AM BS 52 LVN H 09/13/17 5:43 AM BS 50 LVN I 09/22/17 6:51 AM BS 46 LVN C Record review of Resident #2's MAR for September 2017 revealed on 09/26/17 at 6:56 AM her blood sugar measured 53. LVN A documented in Resident #2's nurses' notes on 09/26/17 at 6:56 AM he gave juice and would recheck Resident #2's blood sugar in 30 minutes. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for September 2017 revealed she received her [MEDICATION NAME] at 8:00 AM on 09/26/17 despite a blood sugar of 53 at 6:56 AM. Record review of Resident #2's MAR for October 2017 revealed on 10/03/17 at 7:25 AM her blood sugar measured 37. LVN A documented in Resident #2's nurses' notes on 10/03/17 at 7:25 AM juice given at this time. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for October 2017 revealed she received her [MEDICATION NAME] at 8:00 AM on 10/03/17 despite a blood sugar of 37 at 7:25 AM. Observation and interview on 10/13/17 at 4:00 PM revealed Resident #2 was appropriately dressed and groom. She was observed laying on her bed in room while watching television. Resident #2 stated she had fallen recently, but was feeling better. Resident #2 was alert, oriented, and able to converse appropriately. In an interview on 11/03/17 at 1:50 PM LVN A confirmed he took Resident #2's blood sugar on 09/26/17 and 10/03/17. LVN A confirmed what the actions he documented in relation to those dates where the only actions that he took. LVN A stated he should have notified the physician of those blood sugars levels. According to the U.S. National Library of Medicine Low blood sugar is a condition that occurs when your blood sugar (glucose) is lower than normal. Low blood sugar may occur in people with diabetes who are taking insulin or certain other medicines to control their diabetes. Low blood sugar can cause dangerous symptoms. Low blood sugar is called [DIAGNOSES REDACTED]. A blood sugar level below 70 mg/dL . is low and can harm you. A blood sugar level below 54 mg/dL . is cause for immediate action. Record review of Resident #2's MAR for September and October 2017 revealed on the following dates and times her blood sugar was above 450, but there was no documentation that her blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/09/17 4:48 PM BS 552 LVN D 09/11/17 8:19 PM BS 497 LVN D 09/14/17 8:08 PM BS 490 LVN F 09/27/17 4:00 PM BS 471 LVN F 09/28/17 4:31 PM BS 502 LVN E 10/04/17 7:34 PM BS 516 LVN E 10/07/17 4:08 PM BS 510 LVN F 10/08/17 10:51 AM BS 491 LVN A 10/08/17 6:02 PM BS 546 LVN G 10/12/17 4:05 PM BS 529 LVN E 10/13/17 4:19 PM BS 479 LVN G 10/14/17 7:10 PM BS 559 LVN F 10/16/17 11:14 AM BS 452 LVN B 10/22/17 12:28 PM BS 457 LVN A 10/29/17 7:00 PM BS 555 LVN G 10/30/17 4:20 PM BS 578 LVN E Record review of Resident #2's MAR for September and October 2017 revealed on the following dates Resident #2's blood sugar was documented as 600. On the identified dates there was no documentation that indicated Resident #2's blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/11/17 4:40 PM BS 600 LVN D 09/30/17 4:17 PM BS 600 LVN D 10/05/17 8:22 PM BS 600 LVN G 10/06/17 4:24 PM BS 600 LVN E 10/11/17 7:25 AM BS 600 LVN C 10/11/17 4:46 PM BS 600 LVN D 10/17/17 6:37 AM BS 600 LVN A Record review of Resident #2's clinical record revealed results from a local lab, dated 10/17/17, revealed on 10/17/17 at 4:09 AM Resident #2's blood sample was collected, and at 3:37 PM the lab reported Resident #2's blood sugar measured 748 mg/dL. The lab identified this level as a critically high level, with a reference range of 65-105 mg/dL. According to the Mayo Clinic if your blood sugar level tops 600 milligrams per deciliter (mg/dL) . the condition is known as diabetic hyperosmolar syndrome. When your blood sugar gets this high, your blood becomes thick and syrupy. The excess sugar passes from your blood into your urine, which triggers a filtering process that draws tremendous amounts of fluid from your body. Left untreated, diabetic hyperosmolar syndrome can cause life-threatening dehydration and a diabetic coma. Diabetic hyperosmolar syndrome is most common in middle-aged and older adults who have type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/diabetic-coma/basics/causes/con- 691 (accessed on 11/14/17) Record review of Resident #2's Nurses' Notes revealed Resident #2 experienced a sharp drop in blood sugar and displayed symptoms of a change in condition after her blood sugar was measured at 600 on the following dates: 10/06/17 7:00 PM (approximately 2.5 hours after a blood sugar over 600) Res (resident) lethargic, cold clammy, and pale Accu check (glucometer) 283. BP (blood pressure), 88/52, P (pulse) 62, T (temperature) 96.7. C/O (complaints of) nausea. Res transferred (sp) to (local hospital) by ambulance . ADON informed. Signed by LVN E 10/07/17 12:15 AM Resident returned to facility via ambulance at approximately 2240 (10:40 PM) Resident has no new orders resume previous NH (nursing home) orders and meds. Call light and H20 within reach. WCTM (will continue to monitor). Signed by LVN B (No further nurses' notes related the change of condition Resident #2 experienced on 10/06/17) 10/11/17 9:49 AM (approximately 2 hours after a blood sugar over 600) Called into resident's room by (CNA A) upon entering resident's bathroom noted resident sitting on toilet having a loose BM (bowel movement). Resident was pale in color, clammy, with slow response to questions asked. BS checked 362. BP checked and read 88/46 pulse 78. Contacted PCP and made aware of situation N/O (new order) received to encourage fluids, check BP TID (three times a day) x (times) 2 days and send BP results to PCP on 10/13/17. WCTM call light with in reach. Signed by LVN C (No additional nurses' notes between 9:49 AM and 8:32 PM on 10/11/17 that addressed Resident #2's change in condition or Resident #2's second blood sugar over 600 taken at 4:46 PM on 10/11/17) 10/11/17 8:32 PM Resident resting in bed watching tv (television), alert and confused per self. No further episodes of loose stools. Resident has responded appropriately this shift with no further incidents. Call light and H20 in easy reach. Signed by LVN D In an interview on 11/02/17 at 4:45 PM Physician A's nurse stated the only notification the office had received related to Resident #2's blood sugar was at the end of September and 10/13/17. The nurse stated Physician A had been monitoring Resident #2's insulin and blood sugar for quite a while and trying to find what works. She stated Resident #2 was a brittle diabetic, however the facility should still notify the physician about extreme blood sugars. In an interview on 11/02/17 at 8:00 PM Physician A confirmed he was the primary care physician for Resident #2. He stated Resident #2 was a brittle diabetic and he had been monitoring her blood sugar levels and tweaking her insulin for some time. Physician A stated he was not aware that Resident #2 had been experiencing blood sugar levels of 600. He stated he would have expected for the facility to notify him of any extreme blood sugar levels, high or low. Physician A stated that he was aware of two incidents were Resident #2 became cold, clammy, and confused. He stated he was not aware these incidents occurred within two to three hours of Resident #2's blood sugar being identified as 600. Physician A stated a sharp drop in blood sugar in a short period of time could cause symptoms like those Resident #2 displayed. Physician A stated if he had been aware that Resident #2 was experiencing such high and low blood sugars he could have tweaked her insulin doses to help address the issue. B. Resident #3 Record review of Resident #3's Admission Record, dated 11/05/17, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #3's PCP as Physician B. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #3 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #3's active [DIAGNOSES REDACTED]. Record review of Resident #3's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated: 05/30/17) Goal: She will have no complications related to diabetes through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of [MEDICAL CONDITION] through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 05/30/17) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 05/30/17) . Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 05/30/17). Monitor/document/report PRN any s/sx of [MEDICAL CONDITION]. (Date Initiated: 05/30/17) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED]. (Date Initiated: 05/30/17) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 05/30/17). Record review of Resident #3's Order Summary Report, dated 10/01/17, revealed the following orders: Cont (continue) to check BS 3 x day. Notify (Physician B) if BS < (less than) 100 or > (greater than) 400 (Order Date: 08/29/17) Humalog Solution 100 Unit/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 0 - 150 = 0 if below 100 notify md (medical doctor); 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 9 units if over 400 notify md; 351 - 400 = 11 units; 401 + = 13 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . (Order Date: 09/29/17) Record review of Resident #3's MAR for October 2017 revealed on the following 22 dates and times Resident #3's blood sugar was above 400, but there was no documentation that indicated staff rechecked her blood sugar, provided interventions, or notified a physician of potentially dangerous blood sugar levels: 10/01/17 8:00 PM BS 417 LVN D 10/02/17 11:00 AM BS 442 LVN A 10/03/17 6:30 AM BS 434 LVN I 10/04/17 8:00 PM BS 416 LVN E 10/05/17 5:00 PM BS 449 LVN E 10/06/17 5:00 PM BS 405 LVN G 10/07/17 8:00 PM BS 415 LVN G 10/08/17 5:00 PM BS 444 LVN D 10/09/17 8:00 PM BS 478 LVN D 10/10/17 8:00 PM BS 433 LVN E 10/13/17 6:30 AM BS 401 LVN I 10/14/17 5:00 PM BS 502 LVN G 10/14/17 8:00 PM BS 469 LVN G 10/17/17 8:00 PM BS 437 LVN D 10/19/17 6:30 AM BS 424 LVN C 10/19/17 5:00 PM BS 427 LVN G 10/19/17 8:00 PM BS 410 LVN G 10/20/17 6:30 AM BS 404 LVN I 10/21/17 8:00 PM BS 419 LVN E 10/28/17 5:00 PM BS 483 ADON 10/29/17 5:00 PM BS 442 LVN E 10/29/17 8:00 PM BS 451 LVN E Record review of Resident #3's clinical record including Nurses' Notes and Vitals for October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/07/17 at 4:00 PM the ADON confirmed she did not contact the physician on 10/28/17 at 5:00 PM when Resident #3's blood sugar was 483 because she was not aware there were parameters that required notification. The ADON stated she did notify the physician several hours later when Resident #3's blood sugar remained above 400. C. Resident #4 Record review of Resident #4's Admission Record, dated 11/04/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #4's PCP as Physician B. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #4 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #4's active [DIAGNOSES REDACTED]. Record review of Resident #4's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated 03/19/13) Goal: She will have complications related to diabetes through the review date. (Date Initiated: 03/19/13) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated 03/19/13) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Keep glucose injection in facility for rapid use when FSBS (fasting serum blood sugar) (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of [MEDICAL CONDITION] . (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED] . (Date Initiated: 03/19/13) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 03/19/13) . Perform FSBS as ordered by physician and treat accordingly. Notify DR when FSBS over . sliding scale coverage (Date Initiate: 12/16/14). Record review of Resident #4's MAR for September and October 2017 revealed the following order: Humalog Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scales: if 0 - 150 = 0 give OJ (orange juice); 51 - 150 = 0; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; 401+ = 14 units, subcutaneously before meals related to Type 2 Diabetes Mellitus . If FSBS > 400 recheck in 1 hour if FSBS if still > 400 Notify Dr. (Start Date: 08/26/17) Record review of Resident #4's MAR for September and October 2017 revealed on the following 22 dates and times Resident #4's blood sugar was over 400, but there was no documentation that indicated staff had rechecked her blood sugar, provided interventions, or notified a physician of her potentially dangerous blood sugar levels: 09/01/17 5:00 PM BS 498 LVN G 09/02/17 5:00 PM BS 490 LVN D 09/10/17 11:00 AM BS 411 LVN A 09/10/17 5:00 PM BS 518 LVN D 09/12/17 11:00 AM BS 468 LVN I 09/14/17 5:00 PM BS 508 LVN G 09/15/17 5:00 PM BS 509 LVN F 09/19/17 5:00 PM BS 427 LVN D 09/21/17 5:00 PM BS 474 LVN F 09/25/17 5:00 PM BS 519 LVN D 09/28/17 5:00 PM BS 433 LVN F 09/29/17 5:00 PM BS 510 ADON 09/30/17 5:00 PM BS 433 LVN E 10/01/17 5:00 PM BS 418 LVN D 10/08/17 5:00 PM BS 450 LVN D 10/09/17 5:00 PM BS 439 LVN D 10/14/17 7:00 AM BS 406 LVN A 10/15/17 5:00 PM BS 466 LVN F 10/19/17 5:00 PM BS 405 LVN G 10/21/17 11:00 AM BS 407 LVN A 10/26/17 5:00 PM BS 456 LVN G 10/28/17 5:00 PM BS 506 ADON Record review of Resident #4's clinical record including Nurses' Notes and Vitals for September and October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/03/17 at 1:50 PM LVN A stated there should be parameters on the MAR for each resident with insulin, but confirmed the majority of the residents on insulin did not have parameters. LVN A defined parameters as instructions of when to notify the physician and when to hold the medication. LVN A stated with a blood sugar in the 50's or lower he should have notified the physician and should have followed up on the blood sugar. LVN A stated he was not sure what the facility policy was regarding when to notify a physician about a low blood sugar. He stated his nursing judgment would be to notify a physician for anything lower than 60 to 70. LVN A stated nurses' document 600 on the MAR indicated [REDACTED]. He stated the glucometer does not register above 600 and only reads as high when over 600. LVN A stated when the glucometer reads high they do not actually know the BS level. LVN A stated there was a sheet in with the glucometer copied from the manufacturers' instruction booklet that said when the glucometer reads high it was above 600. LVN A stated the nurses document 600 because the electronic MAR indicated [REDACTED]. LVN A stated he was not instructed to document in the nurses' notes when the glucometer reads high. In an interview on 11/03/17 at 2:23 PM LVN C stated within the last month each resident on insulin got new orders to allow the nurse to administer glucose when residents have low blood sugar. LVN C stated prior to those orders she would give the resident a glass of orange juice. LVN C stated she would recheck the resident's blood sugar and if it did not come up within 15 minutes she would use her nursing judgement to decide if the physician should be notified. LVN C stated if a resident's blood sugar was between 70 and 80 then she was comfortable with that level. LVN C stated she would then wait until after breakfast to administer the resident's long acting insulin. LVN C stated some residents had parameters on their sliding scale, but she confirmed some did not. LVN C stated if a residents' blood sugar measures as high on the glucometer she would notify the physician. LVN C stated she would use her nursing judgement to decide if she would contact the physician for low or high blood sugar levels. LVN C stated any time notification to the physician occurred it should be documented in the resident's chart. In an interview on 11/03/17 at 2:57 PM the DON stated when a resident was admitted their medication was reviewed by the DON, ADON, and the charge nurse. The DON stated if there was any question about the medications one of them will seek clarification about the orders. The DON stated the residents' physicians set up parameters for medications if the physician wants them. The DON stated that if a physician did not order/ set parameters for a medication, then the staff do not seek any type of clarification. The DON stated if a resident showed signs or symptoms of a hypoglycemic or hyperglycemic episode then she would expect staff to notify the physician. The DON confirmed their glucometers did not register above 600, and if the resident's blood sugar was above 600 the machine would just read high. The DON stated she was aware staff just entered 600 on the MAR indicated [REDACTED]. The DON stated staff should obtain a second blood sugar as ordered, and that the second blood sugar should be documented in the resident's clinical record. The DON stated if a resident was not displaying signs of a change in condition with blood sugars then she did not feel it was necessary for staff to necessarily notify the physician of either low or high blood sugars. The DON stated the nurses should use their nursing judgement when they decided if a physician should be notified. In an interview on 11/07/17 at 3:11 PM LVN F stated she has been working at the facility for approximately 2 months. She confirmed in the early part of October she did not contact Resident #4's physician when Resident #4' blood sugar was above 400 because she was not aware there were parameters for some residents' insulin. LVN F stated toward the end of October 2017 she was shown by the ADON how to expand the order on the electronic MAR indicated [REDACTED]. LVN F stated prior to that she was not aware she needed to notify the physician due to a resident's high or low blood sugar. LVN F stated she felt there were a lot of medications that she second guessed herself if it needed to be administered. LVN F stated had to use her own judgement to determine if a medication, including insulin, should be held or administered because there were no established parameters. In an interview on 11/07/17 at 4:27 PM LVN D stated prior to the last couple of days if a resident didn't have parameters and they had a high blood sugar she would recheck the resident's blood sugar in a couple of hours to see if it had come down. LVN D stated she believed in the past she did notify the physicians if a blood sugar was high, but just forgot to document. LVN D stated she would have documented notification of the physician in the resident's progress notes because she was not aware there was a way to put it into the vitals section until recently. LVN D stated she would typically notify the physician for blood sugars over 400, under 80, or if they were showing symptoms. LVN D stated any notification to the physician should be documented in the resident' progress notes. D. Resident #1 Record review of Resident #1's Admission Record, dated 11/02/17, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Admission Record identified Physician A as her primary care physician (PCP) Record review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS also revealed Resident #1 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Record review of Resident #1's Care Plan, undated, revealed the following areas of concern: Focus: She has communication problem r/t (related to) neurological symptoms. Revised on 06/20/17 Goal: She will be able to make basic needs known on a daily basis . Revised on 06/20/17 Interventions: Anticipate and meet needs . She is able to: (say yes or no) . Monitor for/record confounding problems . Focus: She is on pain medication therapy (Tylenol) . Initiated on 12/16/16 and Revised on 09/20/17 Goal: She will be free of any discomfort or adverse side effects from pain medication . Initiated on 12/16/16 and Revised on 06/20/17 Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (each) shift . Initiated on 12/16/16 and Revised on 06/20/17 Record review of Resident #1's Nurses' Notes revealed the following: (no Nurses' Notes on 09/08/17) 9/9/2017 (Saturday) 1:00 PM (Family Member A) approached me asking if I would fax the Dr (doctor). Monday morning asking for an x-ray to right leg. (Family Member A) stated that when mother leg is moved she cries out. Noted + (plus) 1 [MEDICAL CONDITION] to right hand and leg from knee to foot. Fax prepared to send to (Physician A). Signed by LVN A (Nurses' Note did not contain any documentation of the physician being notified by phone) 9/10/2017 3:57 AM Resident with no c/o (complaints of) pain to r (right) leg. Call light and h2o (water) within reach. WCTM (will continue to monitor). Signed by LVN B 9/10/2017 9:09 AM (CNA A) and (CNA B) reported to this nurse that while trying to assist with putting on sock to right foot resident kicked out at them and hollered. Assessed right foot, 3+ [MEDICAL CONDITION] noted to right lower extremity below the knee with big greater toe nail half way detached from nail bed. No bruising or discoloration noted to site, no indication of pain/discomfort unless right foot is repositioned (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for three (Residents #2, #3, and #4) of four residents reviewed for insulin use. A. Resident #2 had orders for routine and sliding scale insulin, but did not have parameters that established when the physician should be notified of her blood sugar (BS) level or when Resident #2's insulin should be held due to low blood sugar. Resident #2 had multiple incidents during September and October 2017 during which she had either dangerously high or low blood sugar levels. B. Resident #3 had orders for her physician to be notified if her blood sugar level was above 400. There were 22 incidents in October 2017 where her blood sugar was over 400, but her physician was not notified. C. Resident #4 had order for her blood sugar to be recheck within one hour if her blood sugar level was above 400, and if the level remained above 400 when rechecked the physician was to be notified. There were 22 incidents in September and October 2017 where Resident #4's blood sugar measured above 400, but her level was not rechecked and her physician was not notified. This deficient practice resulted in an Immediate Jeopardy (IJ) on 11/03/17. While the IJ was removed on 11/07/17, the facility remained out of compliance at a level of pattern, with potential for more than minimal harm that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place all 8 residents that receive insulin at risk for delay in treatment, not receiving medications as ordered, not receiving appropriate medical intervention, serious complications and /or death. The findings included: A. Resident #2 Record review of Resident #2's Admission Record, dated 11/02/17, revealed she was an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's Admission Record identified her primary care physician as Physician A. Record review of Resident #2's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #2's MDS revealed she required the physical assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. The MDS also revealed Resident #2's active [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan, undated, revealed the following: Focus: She has diabetes mellitus. (Date Initiated: 09/14/16) Goal: She will be free from any s/sx (signs or symptoms) of [MEDICAL CONDITION] through the review date. (Date Initiated: 09/14/16) She will be free from an s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 09/14/16) Interventions: . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 09/14/16). Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/14/16) . Monitor/document/report PRN (as needed) any s/sx of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breath, [MEDICATION NAME] breath (smells fruity), stupor, coma (Date Initiated: 09/14/16 ) Montior/document/report PRN any s/sx of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, slurred speech, lack of coordination, staggering gait (Date Initiated: 09/14/16) . Focus: She has [MEDICAL CONDITION] r/t (related to) uncontrolled diabetes (Date Initiated: 09/27/16) Goal: She will have no complications from [MEDICAL CONDITION] through the review date. (Date Initiated: 09/27/16) Interventions: Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/27/16 Monitor compliance with diet and document any problems. (Date Initiated: 09/27/16) Monitor/document/report PRN (as needed) any s/sx of [MEDICAL CONDITION] . (Date Initiated: 09/27/16) Record review of Resident #2's Order Summary Report, dated 11/03/17, revealed there were no orders for blood sugar checks, but did identify the following orders: Humalog Solution 100 unit/ML (milliliter) (Insulin [MEDICATION NAME]) Inject per sliding scale: if 0-349 = 0; 350-400 = 3; 401-450 = 5; 451-500 = 6 Recheck 2 hours after admin (administration) of 6 units; 501+ = 8 Recheck 2 hours after admin of 8 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . Order Date: 04/30/17. Continued review of Order Summary Report revealed there was no parameters as to when Resident #2's physician should be notified for high and/or low blood sugars. Glucose Gel 15 GM/33 GM (grams) Give 1 packet by mouth as needed for BS (Blood Sugar) below 70 MG/DL (Milligram/Deciliter) related to Type 2 Diabetes Mellitus . Adm (Administer) 15 gm into mouth and swallow, if no response in 15 min (minutes) repeat dosage, if no response in 30 min contact PCP. Order Date: 10/13/17 According to the U.S. National Library of Medicine Humalog (generic name: Insulin [MEDICATION NAME]) is used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. Insulin [MEDICATION NAME] is a short-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 1.html According to the National Institute of Diabetes and Digestive and Kidney Diseases, Glucose Gel is pure glucose (type of sugar) in gel form used for treating [DIAGNOSES REDACTED]. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-[DIAGNOSES REDACTED] Record review of Resident #2's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] Solution (generic name: Insulin Detemir) is used to treat people with type 2 diabetes . who need insulin to control their diabetes. Insulin detemir is a long-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 2.html Record review of Resident #2's MAR for September 2017 revealed on the following dates Resident #2's blood sugar was below 54 at 6:30 AM, but there was no documentation that indicated staff provided interventions to address the low blood sugar, rechecked her blood sugar, or notified a physician of potentially dangerous BS levels. Resident #2's blood sugar was not rechecked, she did not receive the available Glucose Gel, and her PCP was not notified. On the identified dates Resident #2 also received her [MEDICATION NAME] at 8:00 AM despite the low blood sugar levels. 09/06/17 8:59 AM BS 52 LVN H 09/13/17 5:43 AM BS 50 LVN I 09/22/17 6:51 AM BS 46 LVN C Record review of Resident #2's MAR for September 2017 revealed on 09/26/17 at 6:56 AM her blood sugar measured 53. LVN A documented in Resident #2's nurses' notes on 09/26/17 at 6:56 AM he gave juice and would recheck Resident #2's blood sugar in 30 minutes. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for September 2017 revealed she received her [MEDICATION NAME] at 8:00 AM on 09/26/17 despite a blood sugar of 53 at 6:56 AM. Record review of Resident #2's MAR for October 2017 revealed on 10/03/17 at 7:25 AM her blood sugar measured 37. LVN A documented in Resident #2's nurses' notes on 10/03/17 at 7:25 AM juice given at this time. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for October 2017 revealed she received her [MEDICATION NAME] at 8:00 AM on 10/03/17 despite a blood sugar of 37 at 7:25 AM. Observation and interview on 10/13/17 at 4:00 PM revealed Resident #2 was appropriately dressed and groom. She was observed laying on her bed in room while watching television. Resident #2 stated she had fallen recently, but was feeling better. Resident #2 was alert, oriented, and able to converse appropriately. In an interview on 11/03/17 at 1:50 PM LVN A confirmed he took Resident #2's blood sugar on 09/26/17 and 10/03/17. LVN A confirmed what the actions he documented in relation to those dates where the only actions that he took. LVN A stated he should have notified the physician of those blood sugars levels. According to the U.S. National Library of Medicine Low blood sugar is a condition that occurs when your blood sugar (glucose) is lower than normal. Low blood sugar may occur in people with diabetes who are taking insulin or certain other medicines to control their diabetes. Low blood sugar can cause dangerous symptoms. Low blood sugar is called [DIAGNOSES REDACTED]. A blood sugar level below 70 mg/dL . is low and can harm you. A blood sugar level below 54 mg/dL . is cause for immediate action. Record review of Resident #2's MAR for September and October 2017 revealed on the following dates and times her blood sugar was above 450, but there was no documentation that her blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/09/17 4:48 PM BS 552 LVN D 09/11/17 8:19 PM BS 497 LVN D 09/14/17 8:08 PM BS 490 LVN F 09/27/17 4:00 PM BS 471 LVN F 09/28/17 4:31 PM BS 502 LVN E 10/04/17 7:34 PM BS 516 LVN E 10/07/17 4:08 PM BS 510 LVN F 10/08/17 10:51 AM BS 491 LVN A 10/08/17 6:02 PM BS 546 LVN G 10/12/17 4:05 PM BS 529 LVN E 10/13/17 4:19 PM BS 479 LVN G 10/14/17 7:10 PM BS 559 LVN F 10/16/17 11:14 AM BS 452 LVN B 10/22/17 12:28 PM BS 457 LVN A 10/29/17 7:00 PM BS 555 LVN G 10/30/17 4:20 PM BS 578 LVN E Record review of Resident #2's MAR for September and October 2017 revealed on the following dates Resident #2's blood sugar was documented as 600. On the identified dates there was no documentation that indicated Resident #2's blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/11/17 4:40 PM BS 600 LVN D 09/30/17 4:17 PM BS 600 LVN D 10/05/17 8:22 PM BS 600 LVN G 10/06/17 4:24 PM BS 600 LVN E 10/11/17 7:25 AM BS 600 LVN C 10/11/17 4:46 PM BS 600 LVN D 10/17/17 6:37 AM BS 600 LVN A Record review of Resident #2's clinical record revealed results from a local lab, dated 10/17/17, revealed on 10/17/17at 4:09 AM Resident #2's blood sample was collected, and at 3:37 PM the lab reported Resident #2's blood sugar measured 748 mg/dL. The lab identified this level as a critically high level, with a reference range of 65-105 mg/dL. According to the Mayo Clinic if your blood sugar level tops 600 milligrams per deciliter (mg/dL) . the condition is known as diabetic hyperosmolar syndrome. When your blood sugar gets this high, your blood becomes thick and syrupy. The excess sugar passes from your blood into your urine, which triggers a filtering process that draws tremendous amounts of fluid from your body. Left untreated, diabetic hyperosmolar syndrome can cause life-threatening dehydration and a diabetic coma. Diabetic hyperosmolar syndrome is most common in middle-aged and older adults who have type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/diabetic-coma/basics/causes/con- 691 (accessed on 11/14/17) Record review of Resident #2's Nurses' Notes revealed Resident #2 experienced a sharp drop in blood sugar and displayed symptoms of a change in condition after her blood sugar was measured at 600 on the following dates: 10/06/17 7:00 PM (approximately 2.5 hours after a blood sugar over 600) Res (resident) lethargic, cold clammy, and pale Accu check (glucometer) 283. BP (blood pressure), 88/52, P (pulse) 62, T (temperature) 96.7. C/O (complaints of) nausea. Res transfered (sp) to (local hospital) by ambulance . ADON informed. Signed by LVN E 10/07/17 12:15 AM Resident returned to facility via ambulance at approximately 2240 (10:40 PM) Resident has no new orders resume previous NH (nursing home) orders and meds. Call light and H20 within reach. WCTM (will continue to monitor). Signed by LVN B (No further nurses' notes related the change of condition Resident #2 experienced on 10/06/17) 10/11/17 9:49 AM (approximately 2 hours after a blood sugar over 600) Called into resident's room by (CNA A) upon entering resident's bathroom noted resident sitting on toilet having a loose BM (bowel movement). Resident was pale in color, clammy, with slow response to questions asked. BS checked 362. BP checked and read 88/46 pulse 78. Contacted PCP and made aware of situation N/O (new order) received to encourage fluids, check BP TID (three times a day) x (times) 2 days and send BP results to PCP on 10/13/17. WCTM call light with in reach. Signed by LVN C (No additional nurses' notes between 9:49 AM and 8:32 PM on 10/11/17 that addressed Resident #2's change in condition or Resident #2's second blood sugar over 600 taken at 4:46 PM on 10/11/17) 10/11/17 8:32 PM Resident resting in bed watching tv (television), alert and confused per self. No further episodes of loose stools. Resident has responded appropriately this shift with no further incidents. Call light and H20 in easy reach. Signed by LVN D In an interview on 11/02/17 at 4:45 PM Physician A's nurse stated the only notification the office had received related to Resident #2's blood sugar was at the end of September and 10/13/17. The nurse stated Physician A had been monitoring Resident #2's insulin and blood sugar for quite a while and trying to find what works. She stated Resident #2 was a brittle diabetic, however the facility should still notify the physician about extreme blood sugars. In an interview on 11/02/17 at 8:00 PM Physician A confirmed he was the primary care physician for Resident #2. He stated Resident #2 was a brittle diabetic and he had been monitoring her blood sugar levels and tweaking her insulin for some time. Physician A stated he was not aware that Resident #2 had been experiencing blood sugar levels of 600. He stated he would have expected for the facility to notify him of any extreme blood sugar levels, high or low. Physician A stated that he was aware of two incidents were Resident #2 became cold, clammy, and confused. He stated he was not aware these incidents occurred within two to three hours of Resident #2's blood sugar being identified as 600. Physician A stated a sharp drop in blood sugar in a short period of time could cause symptoms like those Resident #2 displayed. Physician A stated if he had been aware that Resident #2 was experiencing such high and low blood sugars he could have tweaked her insulin doses to help address the issue. B. Resident #3 Record review of Resident #3's Admission Record, dated 11/05/17, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #3's PCP as Physician B. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #3 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #3's active [DIAGNOSES REDACTED]. Record review of Resident #3's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated: 05/30/17) Goal: She will have no complications related to diabetes through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of [MEDICAL CONDITION] through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 05/30/17) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 05/30/17) . Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 05/30/17). Monitor/document/report PRN any s/sx of [MEDICAL CONDITION]. (Date Initiated: 05/30/17) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED]. (Date Initiated: 05/30/17) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 05/30/17). Record review of Resident #3's Order Summary Report, dated 10/01/17, revealed the following orders: Cont (continue) to check BS 3 x day. Notify (Physician B) if BS < (less than) 100 or > (greater than) 400 (Order Date: 08/29/17) Humalog Solution 100 Unit/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 0 - 150 = 0 if below 100 notify md (medical doctor); 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 9 units if over 400 notify md; 351 - 400 = 11 units; 401 + = 13 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . (Order Date: 09/29/17) Record review of Resident #3's MAR for October 2017 revealed on the following 22 dates and times Resident #3's blood sugar was above 400, but there was no documentation that indicated staff rechecked her blood sugar, provided interventions, or notified a physician of potentially dangerous blood sugar levels: 10/01/17 8:00 PM BS 417 LVN D 10/02/17 11:00 AM BS 442 LVN A 10/03/17 6:30 AM BS 434 LVN I 10/04/17 8:00 PM BS 416 LVN E 10/05/17 5:00 PM BS 449 LVN E 10/06/17 5:00 PM BS 405 LVN G 10/07/17 8:00 PM BS 415 LVN G 10/08/17 5:00 PM BS 444 LVN D 10/09/17 8:00 PM BS 478 LVN D 10/10/17 8:00 PM BS 433 LVN E 10/13/17 6:30 AM BS 401 LVN I 10/14/17 5:00 PM BS 502 LVN G 10/14/17 8:00 PM BS 469 LVN G 10/17/17 8:00 PM BS 437 LVN D 10/19/17 6:30 AM BS 424 LVN C 10/19/17 5:00 PM BS 427 LVN G 10/19/17 8:00 PM BS 410 LVN G 10/20/17 6:30 AM BS 404 LVN I 10/21/17 8:00 PM BS 419 LVN E 10/28/17 5:00 PM BS 483 ADON 10/29/17 5:00 PM BS 442 LVN E 10/29/17 8:00 PM BS 451 LVN E Record review of Resident #3's clinical record including Nurses' Notes and Vitals for October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/07/17 at 4:00 PM the ADON confirmed she did not contact the physician on 10/28/17 at 5:00 PM when Resident #3's blood sugar was 483 because she was not aware there were parameters that required notification. The ADON stated she did notify the physician several hours later when Resident #3's blood sugar remained above 400. C. Resident #4 Record review of Resident #4's Admission Record, dated 11/04/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #4's PCP as Physician B. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #4 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #4's active [DIAGNOSES REDACTED]. Record review of Resident #4's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated 03/19/13) Goal: She will have complications related to diabetes through the review date. (Date Initiated: 03/19/13) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated 03/19/13) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Keep glucose injection in facility for rapid use when FSBS (fasting serum blood sugar) (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of [MEDICAL CONDITION] . (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED] . (Date Initiated: 03/19/13) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 03/19/13) . Perform FSBS as ordered by physician and treat accordingly. Notify DR when FSBS over . sliding scale coverage (Date Initiate: 12/16/14). Record review of Resident #4's MAR for September and October 2017 revealed the following order: Humalog Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scales: if 0 - 150 = 0 give OJ (orange juice); 51 - 150 = 0; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; 401+ = 14 units, subcutaneously before meals related to Type 2 Diabetes Mellitus . If FSBS > 400 recheck in 1 hour if FSBS if still > 400 Notify Dr. (Start Date: 08/26/17) Record review of Resident #4's MAR for September and October 2017 revealed on the following 22 dates and times Resident #4's blood sugar was over 400, but there was no documentation that indicated staff had rechecked her blood sugar, provided interventions, or notified a physician of her potentially dangerous blood sugar levels: 09/01/17 5:00 PM BS 498 LVN G 09/02/17 5:00 PM BS 490 LVN D 09/10/17 11:00 AM BS 411 LVN A 09/10/17 5:00 PM BS 518 LVN D 09/12/17 11:00 AM BS 468 LVN I 09/14/17 5:00 PM BS 508 LVN G 09/15/17 5:00 PM BS 509 LVN F 09/19/17 5:00 PM BS 427 LVN D 09/21/17 5:00 PM BS 474 LVN F 09/25/17 5:00 PM BS 519 LVN D 09/28/17 5:00 PM BS 433 LVN F 09/29/17 5:00 PM BS 510 ADON 09/30/17 5:00 PM BS 433 LVN E 10/01/17 5:00 PM BS 418 LVN D 10/08/17 5:00 PM BS 450 LVN D 10/09/17 5:00 PM BS 439 LVN D 10/14/17 7:00 AM BS 406 LVN A 10/15/17 5:00 PM BS 466 LVN F 10/19/17 5:00 PM BS 405 LVN G 10/21/17 11:00 AM BS 407 LVN A 10/26/17 5:00 PM BS 456 LVN G 10/28/17 5:00 PM BS 506 ADON Record review of Resident #4's clinical record including Nurses' Notes and Vitals for September and October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/03/17 at 1:50 PM LVN A stated there should be parameters on the MAR for each resident with insulin, but confirmed the majority of the residents on insulin did not have parameters. LVN A defined parameters as instructions of when to notify the physician and when to hold the medication. LVN A stated with a blood sugar in the 50's or lower he should have notified the physician and should have followed up on the blood sugar. LVN A stated he was not sure what the facility policy was regarding when to notify a physician about a low blood sugar. He stated his nursing judgment would be to notify a physician for anything lower than 60 to 70. LVN A stated nurses' document 600 on the MAR indicated [REDACTED]. He stated the glucometer does not register above 600 and only reads as high when over 600. LVN A stated when the glucometer reads high they do not actually know the BS level. LVN A stated there was a sheet in with the glucometer copied from the manufacturers' instruction booklet that said when the glucometer reads high it was above 600. LVN A stated the nurses document 600 because the electronic MAR indicated [REDACTED]. LVN A stated he was not instructed to document in the nurses' notes when the glucometer reads high. In an interview on 11/03/17 at 2:23 PM LVN C stated within the last month each resident on insulin got new orders to allow the nurse to administer glucose when residents have low blood sugar. LVN C stated prior to those orders she would give the resident a glass of orange juice. LVN C stated she would recheck the resident's blood sugar and if it did not come up within 15 minutes she would use her nursing judgement to decide if the physician should be notified. LVN C stated if a resident's blood sugar was between 70 and 80 then she was comfortable with that level. LVN C stated she would then wait until after breakfast to administer the resident's long acting insulin. LVN C stated some residents had parameters on their sliding scale, but she confirmed some did not. LVN C stated if a residents' blood sugar measures as high on the glucometer she would notify the physician. LVN C stated she would use her nursing judgement to decide if she would contact the physician for low or high blood sugar levels. LVN C stated any time notification to the physician occurred it should be documented in the resident's chart. In an interview on 11/03/17 at 2:57 PM the DON stated when a resident was admitted their medication was reviewed by the DON, ADON, and the charge nurse. The DON stated if there was any question about the medications one of them will seek clarification about the orders. The DON stated the residents' physicians set up parameters for medications if the physician wants them. The DON stated that if a physician did not order/ set parameters for a medication, then the staff do not seek any type of clarification. The DON stated if a resident showed signs or symptoms of a hypoglycemic or hyperglycemic episode then she would expect staff to notify the physician. The DON confirmed their glucometers did not register above 600, and if the resident's blood sugar was above 600 the machine would just read high. The DON stated she was aware staff just entered 600 on the MAR indicated [REDACTED]. The DON stated staff should obtain a second blood sugar as ordered, and that the second blood sugar should be documented in the resident's clinical record. The DON stated if a resident was not displaying signs of a change in condition with blood sugars then she did not feel it was necessary for staff to necessarily notify the physician of either low or high blood sugars. The DON stated the nurses should use their nursing judgement when they decided if a physician should be notified. In an interview on 11/07/17 at 3:11 PM LVN F stated she has been working at the facility for approximately 2 months. She confirmed in the early part of October she did not contact Resident #4's physician when Resident #4' blood sugar was above 400 because she was not aware there were parameters for some residents' insulin. LVN F stated toward the end of October 2017 she was shown by the ADON how to expand the order on the electronic MAR indicated [REDACTED]. LVN F stated prior to that she was not aware she needed to notify the physician due to a resident's high or low blood sugar. LVN F stated she felt there were a lot of medications that she second guessed herself if it needed to be administered. LVN F stated had to use her own judgement to determine if a medication, including insulin, should be held or administered because there were no established parameters. In an interview on 11/07/17 at 4:27 PM LVN D stated prior to the last couple of days if a resident didn't have parameters and they had a high blood sugar she would recheck the resident's blood sugar in a couple of hours to see if it had come down. LVN D stated she believed in the past she did notify the physicians if a blood sugar was high, but just forgot to document. LVN D stated she would have documented notification of the physician in the resident's progress notes because she was not aware there was a way to put it into the vitals section until recently. LVN D stated she would typically notify the physician for blood sugars over 400, under 80, or if they were showing symptoms. LVN D stated any notification to the physician should be documented in the resident' progress notes. Record review of the facility's policy entitled Medication Administration-General Guidelines, undated revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Medications are administered in accordance with written orders of the attending physician. The individual who administers the medication dose records the administration on the resident's MAR indicated [REDACTED]. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Record review of the facility's policy entitled Diabetes Mellitus Resident, Nursing Care of Adult, undated, revealed the following: . Responsibility: Licensed nurse and certified nurse assistant . PURPOSE 1. Assist the resident to establish a balance between diet, exercise, and insulin. 2. Restore carbohydrate utilization, correct electrolyte imbalance and prevent recurrence in the resident with diabetic ketoacidosis. 3. Quickly restore normal cerebral function and prevent recurrence of [DIAGNOSES REDACTED]. 4. Recognize and assist in the treatment of [REDACTED]. D(NAME)UMENTATION 1. Vital signs as ordered . 15. Pertinent laboratory studies: . c. Blood sugar (fasting, postprandial). 17. Pattern and time of adverse reactions: a. [MEDICAL CONDITION] (diabetic acidosis): . a) Nausea, vomiting. b) Drowsiness, prostration. c) Labored, rapid, increasingly deep respirations (kussmaul) . b. [DIAGNOSES REDACTED] (insulin reaction) . 3) Weakness, nervousness . 5) Skin-pallid, cool, diaphoretic . c) Thick speech. i) Unconsciousness or convulsions. Record review of the facility's policy entitled Physician, Contacting, undated, revealed the following: When the physician is notified about resident change in condition, certain information is vital. The licensed personnel must be able to convey the situation over the telephone in a concise and complete manner. Remember: The physician is being asked to make a [DIAGNOSES REDACTED]. Therefore, before placing a call to a physician to report a change in condition or status update have on hand: 1. A complete set of vital signs (i.e., TPR, BP) 2. Chief complaint of resident (i.e., signs, symptoms) 3. Nursing assessment . It is not acceptable to leave a message on the physician's answering machine when a prompt response is indicated. When using an answering service to contact a physician, indicated. When using an answering service to contact a physician, indicate how urgent the situation is. Do not hesitate to call an alternate if response time is too long (the nurse must use own judgement here). Record review of the facility policy entitled Pain Management Protocol, dated 01/18/15, revealed the following: . The assessment will address verbal and nonverbal expressions of pain as well as severity of pain and response to pain medication. (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services , including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs three (Residents #2, #3, and #4) of four residents reviewed for pharmacy services. A. Resident #2 had orders for routine and sliding scale insulin, but did not have parameters that established when the physician should be notified of her blood sugar (BS) level or when Resident #2's insulin should be held due to low blood sugar. Resident #2 had multiple incidents during September and October 2017 during which she had either dangerously high or low blood sugar levels. B. Resident #3 had orders for her physician to be notified if her blood sugar level was above 400. There were 22 incidents in October 2017 where her blood sugar was over 400, but her physician was not notified. C. Resident #4 had order for her blood sugar to be recheck within one hour if her blood sugar level was above 400, and if the level remained above 400 when rechecked the physician was to be notified. There were 22 incidents in September and October 2017 where Resident #4's blood sugar measured above 400, but her level was not rechecked and her physician was not notified. This deficient practice resulted in an Immediate Jeopardy (IJ) on 11/03/17. While the IJ was removed on 11/07/17, the facility remained out of compliance at a level of pattern, with potential for more than minimal harm that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. These failures to provide appropriate and accurate pharmaceutical services could affect the 8 residents who receive insulin, and place them at risk for a change in their condition, exacerbation of current health issues, development of new health issues, delayed healing time and the possibility of hospitalization . The findings included: A. Resident #2 Record review of Resident #2's Admission Record, dated 11/02/17, revealed she was an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's Admission Record identified her primary care physician as Physician A. Record review of Resident #2's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #2's MDS revealed she required the physical assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. The MDS also revealed Resident #2's active [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan, undated, revealed the following: Focus: She has diabetes mellitus. (Date Initiated: 09/14/16) Goal: She will be free from any s/sx (signs or symptoms) of hyperglycemia through the review date. (Date Initiated: 09/14/16) She will be free from an s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 09/14/16) Interventions: . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 09/14/16). Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/14/16) . Monitor/document/report PRN (as needed) any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breath, acetone breath (smells fruity), stupor, coma (Date Initiated: 09/14/16 ) Montior/document/report PRN any s/sx of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, staggering gait (Date Initiated: 09/14/16) . Focus: She has hyperglycemia r/t (related to) uncontrolled diabetes (Date Initiated: 09/27/16) Goal: She will have no complications from hyperglycemia through the review date. (Date Initiated: 09/27/16) Interventions: Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 09/27/16 Monitor compliance with diet and document any problems. (Date Initiated: 09/27/16) Monitor/document/report PRN (as needed) any s/sx of hyperglycemia . (Date Initiated: 09/27/16) Record review of Resident #2's Order Summary Report, dated 11/03/17, revealed there were no orders for blood sugar checks, but did identify the following orders: Humalog Solution 100 unit/ML (milliliter) (Insulin Lispro) Inject per sliding scale: if 0-349 = 0; 350-400 = 3; 401-450 = 5; 451-500 = 6 Recheck 2 hours after admin (administration) of 6 units; 501+ = 8 Recheck 2 hours after admin of 8 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . Order Date: 04/30/17. Continued review of Order Summary Report revealed there was no parameters as to when Resident #2's physician should be notified for high and/or low blood sugars. Glucose Gel 15 GM/33 GM (grams) Give 1 packet by mouth as needed for BS (Blood Sugar) below 70 MG/DL (Milligram/Deciliter) related to Type 2 Diabetes Mellitus . Adm (Administer) 15 gm into mouth and swallow, if no response in 15 min (minutes) repeat dosage, if no response in 30 min contact PCP. Order Date: 10/13/17 According to the U.S. National Library of Medicine Humalog (generic name: Insulin Lispro) is used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. Insulin lispro is a short-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 1.html According to the National Institute of Diabetes and Digestive and Kidney Diseases, Glucose Gel is pure glucose (type of sugar) in gel form used for treating [DIAGNOSES REDACTED]. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-[DIAGNOSES REDACTED] Record review of Resident #2's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. According to the U.S. National Library of Medicine Levemir Solution (generic name: Insulin Detemir) is used to treat people with type 2 diabetes . who need insulin to control their diabetes. Insulin detemir is a long-acting, man-made version of human insulin. https://medlineplus.gov/druginfo/meds/a 2.html Record review of Resident #2's MAR for September 2017 revealed on the following dates Resident #2's blood sugar was below 54 at 6:30 AM, but there was no documentation that indicated staff provided interventions to address the low blood sugar, rechecked her blood sugar, or notified a physician of potentially dangerous BS levels. Resident #2's blood sugar was not rechecked, she did not receive the available Glucose Gel, and her PCP was not notified. On the identified dates Resident #2 also received her Levemir at 8:00 AM despite the low blood sugar levels. 09/06/17 8:59 AM BS 52 LVN H 09/13/17 5:43 AM BS 50 LVN I 09/22/17 6:51 AM BS 46 LVN C Record review of Resident #2's MAR for September 2017 revealed on 09/26/17 at 6:56 AM her blood sugar measured 53. LVN A documented in Resident #2's nurses' notes on 09/26/17 at 6:56 AM he gave juice and would recheck Resident #2's blood sugar in 30 minutes. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for September 2017 revealed she received her Levemir at 8:00 AM on 09/26/17 despite a blood sugar of 53 at 6:56 AM. Record review of Resident #2's MAR for October 2017 revealed on 10/03/17 at 7:25 AM her blood sugar measured 37. LVN A documented in Resident #2's nurses' notes on 10/03/17 at 7:25 AM juice given at this time. Resident #2's blood sugar was not rechecked and her PCP was not notified. Review of Resident #2's MAR for October 2017 revealed she received her Levemir at 8:00 AM on 10/03/17 despite a blood sugar of 37 at 7:25 AM. Observation and interview on 10/13/17 at 4:00 PM revealed Resident #2 was appropriately dressed and groom. She was observed laying on her bed in room while watching television. Resident #2 stated she had fallen recently, but was feeling better. Resident #2 was alert, oriented, and able to converse appropriately. In an interview on 11/03/17 at 1:50 PM LVN A confirmed he took Resident #2's blood sugar on 09/26/17 and 10/03/17. LVN A confirmed what the actions he documented in relation to those dates where the only actions that he took. LVN A stated he should have notified the physician of those blood sugars levels. According to the U.S. National Library of Medicine Low blood sugar is a condition that occurs when your blood sugar (glucose) is lower than normal. Low blood sugar may occur in people with diabetes who are taking insulin or certain other medicines to control their diabetes. Low blood sugar can cause dangerous symptoms. Low blood sugar is called [DIAGNOSES REDACTED]. A blood sugar level below 70 mg/dL . is low and can harm you. A blood sugar level below 54 mg/dL . is cause for immediate action. Record review of Resident #2's MAR for September and October 2017 revealed on the following dates and times her blood sugar was above 450, but there was no documentation that her blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/09/17 4:48 PM BS 552 LVN D 09/11/17 8:19 PM BS 497 LVN D 09/14/17 8:08 PM BS 490 LVN F 09/27/17 4:00 PM BS 471 LVN F 09/28/17 4:31 PM BS 502 LVN E 10/04/17 7:34 PM BS 516 LVN E 10/07/17 4:08 PM BS 510 LVN F 10/08/17 10:51 AM BS 491 LVN A 10/08/17 6:02 PM BS 546 LVN G 10/12/17 4:05 PM BS 529 LVN E 10/13/17 4:19 PM BS 479 LVN G 10/14/17 7:10 PM BS 559 LVN F 10/16/17 11:14 AM BS 452 LVN B 10/22/17 12:28 PM BS 457 LVN A 10/29/17 7:00 PM BS 555 LVN G 10/30/17 4:20 PM BS 578 LVN E Record review of Resident #2's MAR for September and October 2017 revealed on the following dates Resident #2's blood sugar was documented as 600. On the identified dates there was no documentation that indicated Resident #2's blood sugar was rechecked as ordered or that her physician was notified about a potentially dangerous blood sugar level. 09/11/17 4:40 PM BS 600 LVN D 09/30/17 4:17 PM BS 600 LVN D 10/05/17 8:22 PM BS 600 LVN G 10/06/17 4:24 PM BS 600 LVN E 10/11/17 7:25 AM BS 600 LVN C 10/11/17 4:46 PM BS 600 LVN D 10/17/17 6:37 AM BS 600 LVN A Record review of Resident #2's clinical record revealed results from a local lab, dated 10/17/17, revealed on 10/17/17at 4:09 AM Resident #2's blood sample was collected, and at 3:37 PM the lab reported Resident #2's blood sugar measured 748 mg/dL. The lab identified this level as a critically high level, with a reference range of 65-105 mg/dL. According to the Mayo Clinic if your blood sugar level tops 600 milligrams per deciliter (mg/dL) . the condition is known as diabetic hyperosmolar syndrome. When your blood sugar gets this high, your blood becomes thick and syrupy. The excess sugar passes from your blood into your urine, which triggers a filtering process that draws tremendous amounts of fluid from your body. Left untreated, diabetic hyperosmolar syndrome can cause life-threatening dehydration and a diabetic coma. Diabetic hyperosmolar syndrome is most common in middle-aged and older adults who have type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/diabetic-coma/basics/causes/con- 691 (accessed on 11/14/17) Record review of Resident #2's Nurses' Notes revealed Resident #2 experienced a sharp drop in blood sugar and displayed symptoms of a change in condition after her blood sugar was measured at 600 on the following dates: 10/06/17 7:00 PM (approximately 2.5 hours after a blood sugar over 600) Res (resident) lethargic, cold clammy, and pale Accu check (glucometer) 283. BP (blood pressure), 88/52, P (pulse) 62, T (temperature) 96.7. C/O (complaints of) nausea. Res transfered (sp) to (local hospital) by ambulance . ADON informed. Signed by LVN E 10/07/17 12:15 AM Resident returned to facility via ambulance at approximately 2240 (10:40 PM) Resident has no new orders resume previous NH (nursing home) orders and meds. Call light and H20 within reach. WCTM (will continue to monitor). Signed by LVN B (No further nurses' notes related the change of condition Resident #2 experienced on 10/06/17) 10/11/17 9:49 AM (approximately 2 hours after a blood sugar over 600) Called into resident's room by (CNA A) upon entering resident's bathroom noted resident sitting on toilet having a loose BM (bowel movement). Resident was pale in color, clammy, with slow response to questions asked. BS checked 362. BP checked and read 88/46 pulse 78. Contacted PCP and made aware of situation N/O (new order) received to encourage fluids, check BP TID (three times a day) x (times) 2 days and send BP results to PCP on 10/13/17. WCTM call light with in reach. Signed by LVN C (No additional nurses' notes between 9:49 AM and 8:32 PM on 10/11/17 that addressed Resident #2's change in condition or Resident #2's second blood sugar over 600 taken at 4:46 PM on 10/11/17) 10/11/17 8:32 PM Resident resting in bed watching tv (television), alert and confused per self. No further episodes of loose stools. Resident has responded appropriately this shift with no further incidents. Call light and H20 in easy reach. Signed by LVN D In an interview on 11/02/17 at 4:45 PM Physician A's nurse stated the only notification the office had received related to Resident #2's blood sugar was at the end of September and 10/13/17. The nurse stated Physician A had been monitoring Resident #2's insulin and blood sugar for quite a while and trying to find what works. She stated Resident #2 was a brittle diabetic, however the facility should still notify the physician about extreme blood sugars. In an interview on 11/02/17 at 8:00 PM Physician A confirmed he was the primary care physician for Resident #2. He stated Resident #2 was a brittle diabetic and he had been monitoring her blood sugar levels and tweaking her insulin for some time. Physician A stated he was not aware that Resident #2 had been experiencing blood sugar levels of 600. He stated he would have expected for the facility to notify him of any extreme blood sugar levels, high or low. Physician A stated that he was aware of two incidents were Resident #2 became cold, clammy, and confused. He stated he was not aware these incidents occurred within two to three hours of Resident #2's blood sugar being identified as 600. Physician A stated a sharp drop in blood sugar in a short period of time could cause symptoms like those Resident #2 displayed. Physician A stated if he had been aware that Resident #2 was experiencing such high and low blood sugars he could have tweaked her insulin doses to help address the issue. B. Resident #3 Record review of Resident #3's Admission Record, dated 11/05/17, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #3's PCP as Physician B. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #3 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #3's active [DIAGNOSES REDACTED]. Record review of Resident #3's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated: 05/30/17) Goal: She will have no complications related to diabetes through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of hyperglycemia through the review date. (Date Initiated: 05/30/17) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated: 05/30/17) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness (Date Initiated: 05/30/17) . Fasting Serum Blood Sugar as ordered by doctor (Date Initiated: 05/30/17). Monitor/document/report PRN any s/sx of hyperglycemia. (Date Initiated: 05/30/17) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED]. (Date Initiated: 05/30/17) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 05/30/17). Record review of Resident #3's Order Summary Report, dated 10/01/17, revealed the following orders: Cont (continue) to check BS 3 x day. Notify (Physician B) if BS < (less than) 100 or > (greater than) 400 (Order Date: 08/29/17) Humalog Solution 100 Unit/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 if below 100 notify md (medical doctor); 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 9 units if over 400 notify md; 351 - 400 = 11 units; 401 + = 13 units, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus . (Order Date: 09/29/17) Record review of Resident #3's MAR for October 2017 revealed on the following 22 dates and times Resident #3's blood sugar was above 400, but there was no documentation that indicated staff rechecked her blood sugar, provided interventions, or notified a physician of potentially dangerous blood sugar levels: 10/01/17 8:00 PM BS 417 LVN D 10/02/17 11:00 AM BS 442 LVN A 10/03/17 6:30 AM BS 434 LVN I 10/04/17 8:00 PM BS 416 LVN E 10/05/17 5:00 PM BS 449 LVN E 10/06/17 5:00 PM BS 405 LVN G 10/07/17 8:00 PM BS 415 LVN G 10/08/17 5:00 PM BS 444 LVN D 10/09/17 8:00 PM BS 478 LVN D 10/10/17 8:00 PM BS 433 LVN E 10/13/17 6:30 AM BS 401 LVN I 10/14/17 5:00 PM BS 502 LVN G 10/14/17 8:00 PM BS 469 LVN G 10/17/17 8:00 PM BS 437 LVN D 10/19/17 6:30 AM BS 424 LVN C 10/19/17 5:00 PM BS 427 LVN G 10/19/17 8:00 PM BS 410 LVN G 10/20/17 6:30 AM BS 404 LVN I 10/21/17 8:00 PM BS 419 LVN E 10/28/17 5:00 PM BS 483 ADON 10/29/17 5:00 PM BS 442 LVN E 10/29/17 8:00 PM BS 451 LVN E Record review of Resident #3's clinical record including Nurses' Notes and Vitals for October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/07/17 at 4:00 PM the ADON confirmed she did not contact the physician on 10/28/17 at 5:00 PM when Resident #3's blood sugar was 483 because she was not aware there were parameters that required notification. The ADON stated she did notify the physician several hours later when Resident #3's blood sugar remained above 400. C. Resident #4 Record review of Resident #4's Admission Record, dated 11/04/17, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Resident #4's PCP as Physician B. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15. The MDS revealed Resident #4 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also revealed one of Resident #4's active [DIAGNOSES REDACTED]. Record review of Resident #4's Care Plan, undated, revealed the following: Focus: She has Diabetes Mellitus (Date Initiated 03/19/13) Goal: She will have complications related to diabetes through the review date. (Date Initiated: 03/19/13) She will be free from any s/sx of [DIAGNOSES REDACTED] through the review date. (Date Initiated 03/19/13) Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Keep glucose injection in facility for rapid use when FSBS (fasting serum blood sugar) (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of hyperglycemia . (Date Initiated: 03/19/13) . Monitor/document/report PRN any s/sx of [DIAGNOSES REDACTED] . (Date Initiated: 03/19/13) . Monitor/document/report PRN compliance with diet and document any problems (Date Initiated: 03/19/13) . Perform FSBS as ordered by physician and treat accordingly. Notify DR when FSBS over . sliding scale coverage (Date Initiate: 12/16/14). Record review of Resident #4's MAR for September and October 2017 revealed the following order: Humalog Solution (Insulin Lispro (Human)) Inject as per sliding scales: if 0 - 150 = 0 give OJ (orange juice); 51 - 150 = 0; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units; 401+ = 14 units, subcutaneously before meals related to Type 2 Diabetes Mellitus . If FSBS > 400 recheck in 1 hour if FSBS if still > 400 Notify Dr. (Start Date: 08/26/17) Record review of Resident #4's MAR for September and October 2017 revealed on the following 22 dates and times Resident #4's blood sugar was over 400, but there was no documentation that indicated staff had rechecked her blood sugar, provided interventions, or notified a physician of her potentially dangerous blood sugar levels: 09/01/17 5:00 PM BS 498 LVN G 09/02/17 5:00 PM BS 490 LVN D 09/10/17 11:00 AM BS 411 LVN A 09/10/17 5:00 PM BS 518 LVN D 09/12/17 11:00 AM BS 468 LVN I 09/14/17 5:00 PM BS 508 LVN G 09/15/17 5:00 PM BS 509 LVN F 09/19/17 5:00 PM BS 427 LVN D 09/21/17 5:00 PM BS 474 LVN F 09/25/17 5:00 PM BS 519 LVN D 09/28/17 5:00 PM BS 433 LVN F 09/29/17 5:00 PM BS 510 ADON 09/30/17 5:00 PM BS 433 LVN E 10/01/17 5:00 PM BS 418 LVN D 10/08/17 5:00 PM BS 450 LVN D 10/09/17 5:00 PM BS 439 LVN D 10/14/17 7:00 AM BS 406 LVN A 10/15/17 5:00 PM BS 466 LVN F 10/19/17 5:00 PM BS 405 LVN G 10/21/17 11:00 AM BS 407 LVN A 10/26/17 5:00 PM BS 456 LVN G 10/28/17 5:00 PM BS 506 ADON Record review of Resident #4's clinical record including Nurses' Notes and Vitals for September and October 2017 revealed no documentation related to her high blood sugars on the dates identified above. In an interview on 11/03/17 at 1:50 PM LVN A stated there should be parameters on the MAR for each resident with insulin, but confirmed the majority of the residents on insulin did not have parameters. LVN A defined parameters as instructions of when to notify the physician and when to hold the medication. LVN A stated with a blood sugar in the 50's or lower he should have notified the physician and should have followed up on the blood sugar. LVN A stated he was not sure what the facility policy was regarding when to notify a physician about a low blood sugar. He stated his nursing judgment would be to notify a physician for anything lower than 60 to 70. LVN A stated nurses' document 600 on the MAR indicated [REDACTED]. He stated the glucometer does not register above 600 and only reads as high when over 600. LVN A stated when the glucometer reads high they do not actually know the BS level. LVN A stated there was a sheet in with the glucometer copied from the manufacturers' instruction booklet that said when the glucometer reads high it was above 600. LVN A stated the nurses document 600 because the electronic MAR indicated [REDACTED]. LVN A stated he was not instructed to document in the nurses' notes when the glucometer reads high. In an interview on 11/03/17 at 2:23 PM LVN C stated within the last month each resident on insulin got new orders to allow the nurse to administer glucose when residents have low blood sugar. LVN C stated prior to those orders she would give the resident a glass of orange juice. LVN C stated she would recheck the resident's blood sugar and if it did not come up within 15 minutes she would use her nursing judgement to decide if the physician should be notified. LVN C stated if a resident's blood sugar was between 70 and 80 then she was comfortable with that level. LVN C stated she would then wait until after breakfast to administer the resident's long acting insulin. LVN C stated some residents had parameters on their sliding scale, but she confirmed some did not. LVN C stated if a residents' blood sugar measures as high on the glucometer she would notify the physician. LVN C stated she would use her nursing judgement to decide if she would contact the physician for low or high blood sugar levels. LVN C stated any time notification to the physician occurred it should be documented in the resident's chart. In an interview on 11/03/17 at 2:57 PM the DON stated when a resident was admitted their medication was reviewed by the DON, ADON, and the charge nurse. The DON stated if there was any question about the medications one of them will seek clarification about the orders. The DON stated the residents' physicians set up parameters for medications if the physician wants them. The DON stated that if a physician did not order/ set parameters for a medication, then the staff do not seek any type of clarification. The DON stated if a resident showed signs or symptoms of a hypoglycemic or hyperglycemic episode then she would expect staff to notify the physician. The DON confirmed their glucometers did not register above 600, and if the resident's blood sugar was above 600 the machine would just read high. The DON stated she was aware staff just entered 600 on the MAR indicated [REDACTED]. The DON stated staff should obtain a second blood sugar as ordered, and that the second blood sugar should be documented in the resident's clinical record. The DON stated if a resident was not displaying signs of a change in condition with blood sugars then she did not feel it was necessary for staff to necessarily notify the physician of either low or high blood sugars. The DON stated the nurses should use their nursing judgement when they decided if a physician should be notified. In an interview on 11/07/17 at 3:11 PM LVN F stated she has been working at the facility for approximately 2 months. She confirmed in the early part of October she did not contact Resident #4's physician when Resident #4' blood sugar was above 400 because she was not aware there were parameters for some residents' insulin. LVN F stated toward the end of October 2017 she was shown by the ADON how to expand the order on the electronic MAR indicated [REDACTED]. LVN F stated prior to that she was not aware she needed to notify the physician due to a resident's high or low blood sugar. LVN F stated she felt there were a lot of medications that she second guessed herself if it needed to be administered. LVN F stated had to use her own judgement to determine if a medication, including insulin, should be held or administered because there were no established parameters. In an interview on 11/07/17 at 4:27 PM LVN D stated prior to the last couple of days if a resident didn't have parameters and they had a high blood sugar she would recheck the resident's blood sugar in a couple of hours to see if it had come down. LVN D stated she believed in the past she did notify the physicians if a blood sugar was high, but just forgot to document. LVN D stated she would have documented notification of the physician in the resident's progress notes because she was not aware there was a way to put it into the vitals section until recently. LVN D stated she would typically notify the physician for blood sugars over 400, under 80, or if they were showing symptoms. LVN D stated any notification to the physician should be documented in the resident' progress notes. Record review of the facility's policy entitled Medication Administration-General Guidelines, undated revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Medications are administered in accordance with written orders of the attending physician. The individual who administers the medication dose records the administration on the resident's MAR indicated [REDACTED]. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Record review of the facility's policy entitled Diabetes Mellitus Resident, Nursing Care of Adult, undated, revealed the following: . Responsibility: Licensed nurse and certified nurse assistant . PURPOSE 1. Assist the resident to establish a balance between diet, exercise, and insulin. 2. Restore carbohydrate utilization, correct electrolyte imbalance and prevent recurrence in the resident with diabetic ketoacidosis. 3. Quickly restore normal cerebral function and prevent recurrence of [DIAGNOSES REDACTED]. 4. Recognize and assist in the treatment of [REDACTED]. D(NAME)UMENTATION 1. Vital signs as ordered . 15. Pertinent laboratory studies: . c. Blood sugar (fasting, postprandial). 17. Pattern and time of adverse reactions: a. Hyperglycemia (diabetic acidosis): . a) Nausea, vomiting. b) Drowsiness, prostration. c) Labored, rapid, increasingly deep respirations (kussmaul) . b. [DIAGNOSES REDACTED] (insulin reaction) . 3) Weakness, nervousness . 5) Skin-pallid, cool, diaphoretic . c) Thick speech. i) Unconsciousness or convulsions. Record review of the facility's policy entitled Physician, Contacting, undated, revealed the following: When the physician is notified about resident change in condition, certain information is vital. The licensed personnel must be able to convey the situation over the telephone in a concise and complete manner. Remember: The physician is being asked to make a [DIAGNOSES REDACTED]. Therefore, before placing a call to a physician to report a change in condition or status update have on hand: 1. A complete set of vital signs (i.e., TPR, BP) 2. Chief complaint of resident (i.e., signs, symptoms) 3. Nursing assessment . It is not acceptable to leave a message on the physician's answering machine when a prompt response is indicated. When using an answering service to contact a physician, indicated. When using an answering service to contact a physician, indicate how urgent the situation is. Do not hesitate to call an alternate if response time is too long (the nurse must use own judgement here). Record review of the facility policy entitled Pain Management Protocol, dated 01/18/15, revealed the following: . The assessment will address verbal and nonv(TRUNCATED)

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 2 (resident # 4 and 5) of 5 residents reviewed for accidents, hazards and supervision. A. Resident # 4, who was a two person transfer and totally dependent on two persons during toileting activities, fell from the bedside commode on 8/11/16 at 3:30 PM. Resident # 4 was transferred to the commode by CNA A. When CNA A was cleaning resident # 4, CNA A instructed resident # 4 to lean forward and resident # 4 fell from the commode. CNA A then picked resident # 4 up from the floor and placed resident # 4 in the recliner, before getting the nurse to assess resident # 4 for injuries. Resident # 4 was transferred to the hospital on [DATE] and admitted for the [DIAGNOSES REDACTED]. B. Therapy Tech C transferred resident # 5 from the w/c to the recliner alone on 10/18/16, resident # 5 was a two person transfer. This failure by the facility could place any of the facilities 22 residents, who required the assistance of 2 staff for transfers, at risk of falls and possible injuries. The finding included: Resident # 4: Review of resident # 4 ' s Admission Record , dated 10/18/16 documented resident # 4 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] documented an unscheduled, end of therapy MDS dated [DATE] for resident # 4. In Section G - Functional Status of said assessment documented resident # 4 was totally dependent on 2 or more persons for physical assistance with transfers and toileting. , resident # 1 required the extensive physical assistance of 1 person for bathing. Section C resident # 4 had a BIMS (Brief Interview for Mental Status) score of 8, decreased cognitive ability. Record review of resident # 4 ' s ADL care plan dated 7/12/16, documented resident # 4 ' s physical condition was impaired, making resident # 4 totally dependent on the assistance of 2 staff for all transfer and toileting activities. Record review of the nursing progress note dated 8/11/16 at 9:07 PM documented LVN B was called to resident # 4 ' s room because CNA A reported resident # 4 had fell off the bedside commode. The note documented resident # 4 was in the recliner when LVN B entered the room and CNA A stated he just reacted to resident # 4 being face down in the floor. Resident # 4 was assessed and complained of pain in the right knee. Resident # 4 was transferred to the ER and then admitted to the hospital. Record review of the hospital radiology report dated 8/11/16 at 4:44 PM documented resident # 4 an oblique distal femoral fracture of the right knee and a chronic right humeral (elbow) fracture. In an interview on 10/17/16 at 3:00 PM the Administrator said CNA A went into resident # 4 ' s room alone, he had resident # 4 leaned forward on the bedside commode to clean resident # 4 and resident # 4 fell forward face first into the floor. The Administrator said CNA A reacted and picked resident # 4 up and put her in the recliner before getting the nurse. CNA A was terminated, resident # 4 did have a fractured knee. In an observation and interview on 10/17/16 at 3:24 PM resident # 4 was in the recliner and resident # 4 ' s legs were drawn up against the recliner. Resident # 4 was alert and oriented to place, herself and her needs. Resident # 4 said she did not remember any fall, but knew her leg hurt some. Resident # 4 said it had always taken 2 people to move her. Resident # 4 said she was not sure who but there was one person who did transfer her alone. Resident # 4 said she did not remember anyone being rough or mistreating her. Resident # 4 ' s door had two bugs on the name plate indicating resident # 4 required two persons for transfers. In a telephone interview on 10/18/16 at 10:08 AM CNA A said he did transfer resident # 4 to the bedside commode alone and when he had resident # 4 lean forward to clean her resident # 4 fell forward into the floor face first. CNA A said he just reacted and picked resident # 4 up, placed resident # 4 into the recliner and got the nurse to check resident # 4. CNA A said resident # 4 did not complain of pain until the nurse checked her. CNA A said he knew resident # 4 required two persons to transfer her, he just did it alone and CNA A said he knew not to move an injured resident until the nurse checked them, he just reacted to see her lying there in the floor. Resident # 5: Record review of the Admission Record for resident # 5 documented a [AGE] year old admitted the facility on 8/27/16 with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] documented in Section C (cognitive assessment) resident # 5 had a BIMS score of 7. Section G (functional status) documented resident # 5 required the extensive assistance of two or more persons for bed mobility and transfers. Review of the care plan dated as ' overdue ' documented resident # 5 was totally dependent on two person for walking and transfers. The care plan documented resident #5 was at risk for falls, was to have 2 person assistance with walking, transfers and was to have a chair alarm in place. Observation of resident # 5 on 10/18/16 at 10:22 AM, resident # 5 was standing in front of the recliner, Therapy Tech D was assisting resident # 5 into the recliner with a w/c to the side and back of them. Therapy Tech D was holding onto resident # 5 and instructing resident # 5 to sit, resident # 5 then sat down in the recliner, roughly and grunted as he sat down hard. Resident # 5 ' s door had two bugs on the name plate indicating resident # 5 required two person to assist with transfers. Resident # 5 was observed to be tall and Therapy Tech D was considerably shorter that resident # 5. In an interview on 10/18/16 at 10:50 AM resident # 5 said usually two people helped him transfer and it was more difficult with one person. Resident # 5 said when one person helped him transfer it made him feel afraid that he would fall and sitting down so hard hurt some. Resident # 5 moved his hand to his upper legs and nodded toward them indicating it hurt there and would shake himself while saying afraid, yes . In an interview on 10/18 16 at 2:50 PM Therapy Tech D said she did transfer resident # 5 alone that morning. Therapy Tech D said she had forgotten resident # 5 had been changed to a two person transfer and therapy tech D said no, she did not check resident # 5's door before doing the transfer. Resident care plans also document how many people were needed to transfer a resident. In an interview on 10/17/16 at 4:02 PM CNA C said the name plates on resident doors have bugs on them, the number of bugs indicate the number of people that resident requires for transfers. CNA C said they had to report anyone who did a one person transfer for anyone who required two persons. In a confidential interview on 10/17/16 at 4:04 PM it was said CNA A did transfer residents that required two person by himself. The interview revealed CNA A had not been reported until the incident with resident # 4 occurred. In a confidential interview on 10/18/16 at 3:37 PM it was said CNA A did do two person transfers by himself, it had not been reported until the incident occurred. Record review of the facility Inservice Training for Employees dated 4/25/16 documented the training of employees about transfers: one person, two person and gait belt. The facility transfers Policy and the facility Abuse, neglect and exploitation policy was reviewed in the training. CNA A was documented to have attended the training. Record review of the Transfer Policy revised on 4/25/16 documented the name plate procedure with the residents name plates on the room door and the number of bugs indicating the # of persons required for transfers and a star to indicate fall risk. A copy of this information was placed on the back of each employee name tag. In an interview on 10/17/16 at 4:50 PM LVN B said resident # 4 was a two person transfer and was difficult to transfer anyway. LVN B said resident was in the recliner, CNA A said he just reacted and picked her up. LVN B said resident # 4 was sent to the hospital and did have a fracture. LVN B said the door name plates had bugs that indicated how many people were needed to transfer that person, the staff had a copy of the policy on the back of their badges. In an interview on 10/18/16 at 3:00 p.m. The Administrator and DON identified 22 resident in the facility required two person transfers.

Based on observation, interview and record review the facility failed to ensure that the nurses aides were demonstrating compentecy in their skills and techniques as necessary to provide care to residents as identified in their assessments and plan of care for 1 (resident # 4 ) of 5 residents reviewed for accidents, neglect and transfers. Resident # 4 was transferred to the commode by CNA A on 8/11/16 at 3:30 PM. When CNA A told resident # 4 to lean forward, so CNA A could clean resident # 4, resident # 4 fell forward into the floor. CNA A then picked resident # 4 up from the floor and placed resident # 4 in the recliner, before getting the LVN to assess resident # 4 for injuries. Resident # 4 was transferred to the hospital and admitted for pain treatment due to a fractured lower left femur (lower left leg). This failure by the facility could place any of the facilities 22 residents, who required the assistance of 2 staff for transfers, at risk of falls and possible injuries. The finding included: Resident # 4: Review of resident # 4 ' s Admission Record , dated 10/18/16 documented resident # 4 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] documented an unscheduled, end of therapy MDS dated [DATE] for resident # 4. In Section G - Functional Status of said assessment documented resident # 4 was totally dependent on 2 or more persons for physical assistance with transfers and toileting. , resident # 1 required the extensive physical assistance of 1 person for bathing. Section C resident # 4 ' s had a BIMS (Brief Interview for Mental Status) score of 8, decreased cognitive ability. Record review of resident # 4 ' s ADL care plan dated 7/12/16, documented resident # 4 ' s physical condition was impaired, making resident # 4 totally dependent on the assistance of 2 staff for all transfer and toileting activities. Record review of the nursing progress note dated 8/11/16 at 9:07 PM documented LVN B was called to resident # 4 ' s room because CNA A reported resident # 4 had fell off the bedside commode. The note documented resident # 4 was in the recliner when LVN B entered the room and CNA A stated he just reacted to resident # 4 being face down in the floor. Resident # 4 was assessed and complained of pain in the right knee. Resident # 4 was transferred to the ER and then admitted to the hospital. Record review of the hospital radiology report dated 8/11/16 at 4:44 PM documented resident # 4 an oblique distal femoral [MEDICAL CONDITION] knee and a chronic right humeral (elbow) fracture. In an observation and interview on 10/17/16 at 3:24 PM resident # 4 was in the recliner and resident # 4 ' s legs were drawn up against the recliner. Resident # 4 was alert and oriented to place, herself and her needs Resident # 4 said she did not remember any fall, but knew her leg hurt some. Resident # 4 said it had always taken 2 people to move her. Resident # 4 said she was not sure who but there was one person who did transfer her alone. Resident # 4 said she did not remember anyone being rough or mistreating her. Resident # 4 ' s door had two bugs on the name plate indicating resident # 4 required two persons for transfers. In an interview on 10/17/16 at 3:00 PM the Administrator said CNA A went into resident # 4 ' s room alone, he had resident # 4 leaned forward on the bedside commode to clean resident # 4 and resident # 4 fell forward face first into the floor. The Administrator said CNA A reacted and picked resident # 4 up and put her in the recliner before getting the nurse. CNA A was terminated, resident # 4 did have a fractured knee. Observation and interview on 10/17/16 at 3:32 PM resident # 1 was in the recliner in her room. Resident # 1 was alert and oriented. Resident # 1said two people transfer her but there was one staff would do it alone, but resident # 1 did not know his name. Resident # 1 had two bugs on the door name plate indicating resident # 1 required two person for transfers. In an interview on 10/17/16 at 4:02 PM CNA C said the name plates on resident doors have bugs on them, the number of bugs indicate the number of people that resident requires for transfers. CNA C said they had to report anyone who did a one person transfer for anyone who required two persons. In an interview on 10/17/16 at 4:50 PM LVN B said resident # 4 was a two person transfer and was difficult to transfer anyway. LVN B said resident was in the recliner, CNA A said he just reacted and picked her up. LVN B said resident # 4 was sent to the hospital and did have a fracture. LVN B said the door name plates had bugs that indicated how many people were needed to transfer that person, the staff had a copy of the policy on the back of their badges. In a confidential interview on 10/17/16 at 4:04 PM it was said CNA A di transfer residents that required two person by himself. The interview revealed CNA A had not been reported until the incident with resident # 4 occurred. In a confidential interview on 10/18/16 at 3:37 PM it was said CNA A did do two person transfers by himself, it had not been reported until the incident occurred. In an interview on 10/17/16 at 4:50 PM LVN B said resident # 4 was a two person transfer and was difficult to transfer anyway. LVN B said resident was in the recliner, CNA A said he just reacted and picked her up. LVN B said resident # 4 was sent to the hospital and did have a fracture. LVN B said the door name plates had bugs that indicated how many people were needed to transfer that person, the staff had a copy of the policy on the back of their badges. In a telephone interview on 10/18/16 at 10:08 AM CNA A said he did transfer resident # 4 to the bedside commode alone and when he had resident # 4 lean forward to clean her resident # 4 fell forward into the floor face first. CNA A said he just reacted and picked resident # 4 up, placed resident # 4 into the recliner and got the nurse to check resident # 4. CNA A said resident # 4 did not complain of pain until the nurse checked her. CNA A said he knew resident # 4 required two persons to transfer her, he just did it alone and CNA A said he knew not to move an injured resident until the nurse checked them, he just reacted to see her lying there in the floor. Record review of the facility Inservice Training for Employees dated 4/25/16 documented the training of employees about transfers: one person, two person and gait belt. The facility transfers Policy and the facility Abuse, neglect and exploitation policy was reviewed in the training. CNA A was documented to have attended this training. Record review of the Transfer Policy revised on 4/25/16 documented the name plate procedure with the residents name plates on the room door and the number of bugs indicating the # of persons required for transfers and a star to indicate fall risk. A copy of this information was placed on the back of each employee name tag. In an interview on 10/18/16 at 3:00 p.m. The Administrator and DON identified 22 residents in the facility required two person transfers.

Based on interviews, observation and record review the facility failed to provide assistant devices for 1 out of 5 sampled residents reviewed for accidents, (Resident ID #1). The facility failed to: a) provide handrails or a raised toilet seat for Resident ID #1, as the family had requested on admission. b) adequately assess and review the resident's fall status and provide a proper intervention that would prevent future falls. This deficient practice caused an avoidable accident for Resident #1. The resident had actual harm resulting in a fracture to the posterior right 8th rib. This deficient practice could place 35 high risk residents for falls, injuries or repeated falls if assistance devices were needed and not utilized. The findings included: 1. Review of Resident ID #1's admission face sheet and physician orders [REDACTED]. [DIAGNOSES REDACTED]. The resident was to be admitted under skilled nursing to receive OT and PT. 2. Review of a history and physical dated [DATE] from Resident ID #1's physician revealed the resident had been living alone at home and was being seen by home health services daily. The resident began to wander the neighborhood and Adult Protective Services was called and the resident was sent to the medical clinic for evaluation. The resident was admitted to the hospital once she left the clinic for further care and treatment. 3. Review of the nursing facility admission assessment dated [DATE] revealed the resident was a one person assist with transfers and ambulation. The form stated the resident was continent and capable of using the toilet or bedside commode with assistance. 4. Review of Resident ID #1's MDS dated [DATE] revealed the resident was continent of bowel and bladder and independent with transfers and ambulation. The resident was also documented to have an unsteady gait. 5. Review of the incident/accident report dated [DATE] revealed the resident was found at 12:38 AM on the bathroom floor in a puddle of liquid. The resident had a swollen area on her mid-back and left side. The report stated the resident was confused and that the facility would start a toileting program. The fall investigation form dated [DATE] stated the resident was ordered an x-ray on [DATE] at 7:00 AM due to pain to the right side of her back. The x-ray revealed a fracture to the 8th right rib. The facility's intervention at that time included placing a potty chair over the toilet in the bathroom so that the resident would have rails to use during toileting. The physician gave new orders for pain medication (Lortab) due to the pain the resident continued to have after the fall. 6. Nurses notes dated [DATE] revealed the resident was alert but confused and needs assistance with transfers due to an unsteady gait and can propel herself in the wheelchair. The nurse's note documented that the resident was complaining of pain to the posterior ribs and was scheduled to see the physician on the next day. Pain medication was given PRN. 7. Review of another incident/accident report dated [DATE] revealed the resident was found on the bathroom floor at 5:10 AM. The report stated the resident was confused. Post fall assessment dated [DATE] revealed the intervention would be that the resident would call for assistance prior to toileting. 8. Review of the resident's care plans dated [DATE] revealed the resident was unsteady and had a history of [REDACTED]. The approach plan stated that the resident would have a 1 person assist with showers, personal care and toileting. 9. Interview with a family member on [DATE] at 1:45 PM revealed she was with the resident when she was admitted to the facility on [DATE]. The family member stated she stayed with the resident a few days before she had to return home. The family member stated she was adamant about either having the resident have a raised toilet seat or handrails due to the fact the resident had problems getting up and down. The family member stated she told them she had a raised toilet seat at home and the family member went and got it to try to make it work on the nursing facility's toilet. The seat would not fit properly so they could not use it. The family member stated she told them several times before the resident fell on [DATE] that it was unsafe for her mother to use the toilet without the handrails or raised toilet seat. The family member stated by the time she left to go home the facility had not provided a raised seat nor handrails. 10. Interview with another family member on [DATE] at 1:15 PM revealed she lived closest to Resident ID#1 and checked on her frequently at her residence. The family member stated she required a raised seat at home and the family member stated they were very unhappy when they tried to fit her raised commode seat on the facility's seat and it did not work. The family member stated they requested that she at least have hand rails to help her on and off the toilet. The facility staff told her that they wanted the resident close to the nurses station and the room they put her in did not have rails. The facility never installed rails according to the family member and this resulted in Resident ID #1 having two falls, the first one with a fracture to the ribs. 11. Observation on [DATE] at 8:50 AM revealed the restroom that Resident ID #1 had used did not have handrails attached to the wall. 12. Interview on [DATE] at 9:20 AM with therapy personnel who worked with Resident ID #1 five days a week revealed Resident ID #1 was unsteady on her feet and agreed that the resident did have problems getting up and down from the sitting and standing positions. 13. Interview with the administrator on [DATE] at 1:10 PM revealed she knew nothing of Resident ID #1 needing a raised toilet seat or handrails. The administrator stated no one had come to her and requested that. She stated that the DON did not know anything about it either. Interview with the DON on [DATE] at 1:50 PM confirmed that the DON knew nothing about the resident needing handrails or a raised seat. 14. Interview with the former ADON on [DATE] at 10:00 AM revealed she did remember the family was very adamant about wanting a raised seat for the toilet when she was admitted . She stated they eventually did get a potty chair over her toilet. The former ADON stated when the resident was admitted she was a one person assist to and from the restroom. The former ADON stated she had been admitted awhile back due to she fell at home and had a fractured wrist so we knew she was a risk for falls. 15. Review of a faxed order to the physician dated [DATE] it was revealed the facility received orders for a bed alarm and a wheelchair alarm due to the resident getting up unassisted. 16. Confidential interviews with direct care staff during the course of the investigation revealed the resident would remove the alarm clip from her clothing and would ambulate without assistance. The staff stated they would try to educate her on using the call light system but did not feel like she comprehended. 17. Interview with the Administrator and DON on [DATE] at 1:40 PM agreed if the resident was ambulating and the alarm tab was not effective that another intervention should have been considered. 18. Interview with a family member on [DATE] at 1:15 PM revealed she came to see the resident almost daily and after the fractured was noticed the resident had pain to the ribs that was relieved by pain medication. The family member stated the resident became more incontinent and less active due to the pain. The family member stated she noticed the resident slept more and was less alert due to the medication for pain. The family member stated that she also the resident had " gone down hill" after the fracture. 19. Record review of Resident ID #1 revealed was sent to the hospital on [DATE] by ambulance and died enroute. Review of the death certificate revealed the resident died of a myocardial infarction. 20. Interview with the DON revealed there were 35 residents with high risk for falls.