Every finding on record at Ridgecrest Rehab & Skilled Nursing Center

Based on staff interviews, record review, and review of the policy titled Care Plan Policy, the facility failed to develop a care plan for one resident (R) (R19) related to psychotropic/antianxiety medication use. The sample size was 25 residents. Findings include:A review of the facility policy titled Care Plans, last reviewed September 2025, revealed that the facility would ensure timely reviews of residents' statuses and any changes in their needs. A further review revealed that the Director of Nursing (DON) was responsible for ensuring that care was provided in accordance with the care plan.A review of the Minimum Data Set (MDS) OBRA Quarterly Assessment, dated 9/24/2025, revealed that Section N (Medications) revealed that psychotropic medications were administered and prescribed for R19 during the look-back period.A review of the physician's orders for R19, dated 2/27/2025, revealed an order for lorazepam 0.5 milligrams (mg) orally (PO) daily at bedtime for generalized anxiety disorder.A review of the care plan for R19 revealed no care plan area for psychotropic/antianxiety medication.During an interview with the Director of Nursing (DON) on 12/6/2025 at 10:25 am, she stated R19 was admitted to the facility on [DATE] and was prescribed lorazepam 0.5 mg daily on 2/27/2025. She confirmed that the R19 did not have a care plan addressing the use of psychotropic or antianxiety medications. Additionally, she stated that it was her and the Unit Manager's responsibility to audit the residents' care plan to ensure that all care areas were updated to reflect the residents' care and treatment. She acknowledged that the oversight was an error.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Self-Administered Medications, Treatments, the facility failed to ensure one of 27 sampled residents (R) (R438) was assessed to determine if the practice of self-administration of medications would be safe, that physician's orders were obtained, and that medications were safely secured. The deficient practice had the potential to result in medication errors and to allow access to medications otherwise not prescribed by a physician to other residents. Findings included: Review of the facility's policy titled, Self-Administered Medications, Treatments dated October 2020, revealed under the policy statement, Self-administered medications and treatments must be carefully monitored and recorded in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Self-administration of medications or treatments by residents is permitted by a physician order that includes dosage, route, and any special instructions. All medications and treatments will be kept with the resident or in a locked drawer in the resident's room. 1. The RN Manager assesses resident competency to self-administer mediations and documents the resident's wishes in the nursing note with consideration of the following: a. Ability to receive information from the surrounding environment. b. Capacity to remember information received. c. Ability to make a decision and give reason for it. d. Ability to use relevant information in making decisions. e. Ability to appropriately asses relevant information. 2. A decision to permit self-administration is made by the Interdisciplinary Team Members in convert with the resident. 3. Obtain an order from the physician. Record in MAR and nursing notes. 4. Explain the procedure to the resident. 10. Update Resident Care Plan as needed. Record review revealed R438 was admitted to the facility on [DATE] with diagnoses of but not limited to spondylosis with myelopathy cervical region, type two diabetes mellitus with diabetic chronic kidney disease, and dysthymic disorder. Record review revealed a Minimum Data Set (MDS) assessment was not completed due to resident was a new admit. Review of R438's active orders dated December 3, 2024, lacked orders for medications of any kind to be self-administered. Review of progress notes and documents in the electronic record lacked documented evidence that R438 was evaluated for self-administration of medications. Review of R438's care plan with a start date of 11/26/2024 lacked documented evidence of interventions for self-administration of medications. Observation and interview on 12/4/2024 at 9:27 am revealed R438 sitting on the bedside doing a word search. A medication cup was on the bedside table filled with pills. R438 revealed they were her morning medications. Observation and interview on 12/4/2024 at 10:10 am with Licensed Practical Nurse (LPN) AA revealed that she watched R438 swallow her morning medications. LPN AA then observed and acknowledged the pills sitting in the disposable medication cup and said she left the pills with R438 because R438 asked for syrup, and LPN AA got distracted. LPN AA revealed it was not normal practice to leave medications at the bedside and the risk would be R438 missing her medication. Interview on 12/4/2024 at 10:17 am with the Director of Nursing (DON) revealed that LPN AA notified her that LPN AA had left medications at the bedside. The DON stated that she felt LPN AA was distracted and that she would have normally watched R438 take the medications or would have taken the medication with her. DON revealed it was her expectation that nurses watch the resident swallow the medications or if an issue arises, the nurse should take the medications and not leave them with the resident.

Based on resident and staff interviews, record review, review of the facility's Admission Packet, and review of the facility's policy titled, Advance Directive Policy, the facility failed to provide residents and/or their representatives written information with options regarding the right to accept or refuse medical or surgical treatment for three of 33 residents (R) (R437, R438, and R25). This failure denied the residents and/or representatives the opportunity to have choices and preferences with their health care decisions and formulating an Advance Directive. Findings included: Review of the facility's policy titled, Advance Directive Policy dated 1/1/2017, revealed under policy statement, Each resident with decision-making capacity has the right to make their own decisions related to his/her medical care. An integral component of self-determination is the right to make choices pertaining to one's health, including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment, refuse to participate in experimental research and to formulate advance directives. Further review revealed under section titled Informing resident and/or representative of rights/options: 4. The Advance Directive Checklist form (Appendix B) will be completed and filed on the resident's Chart. This form documents that written information was provided. Review of the facility's Admission Packet revealed it did not contain language that pertained to the facility's provision of written information about the resident/representative's right to accept or refuse medical or surgical treatment. 1. Review of the medical record revealed R437 was admitted to the facility on [DATE] with diagnoses of but not limited to chronic respiratory failure whether with hypoxia or hypercapnia, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, dependence on supplemental oxygen. Review of the Admission Minimum Data Set (MDS) assessment revealed it was not completed due to the resident being newly admitted on [DATE]. Interview on 12/3/2024 at 11:16 am with R437 revealed that she had an advanced directive but didn't remember the facility discussing or providing her anything in writing regarding her right to either accept or deny consent for medical or surgical treatment. 2. Record review revealed R438 was admitted to the facility on [DATE] with diagnoses of but not limited to spondylosis with myelopathy cervical region, type two diabetes mellitus with diabetic chronic kidney disease, and dysthymic disorder. Review of the Admission MDS assessment revealed it was not completed due to the resident being newly admitted on [DATE]. Interview on 12/4/2024 at 9:27 am with R438 revealed she was not provided anything in writing regarding her right to either accept or refuse medical and surgical treatment. 3. R25 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with behavioral disturbance, mood (affective) disorder, major depressive disorder, recurrent severe with psychotic symptoms, and anxiety. Review of the Significant Change MDS assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Interview on 12/4/2024 at 1:57 pm with R25 revealed she was not given anything in writing about her right to either refuse or accept medical or surgical treatment. Interview on 12/4/2024 at 10:40 am with the Social Services Director (SSD) revealed she was responsible for providing information to residents about advanced directives. The SSD revealed that she had never heard of a consent for either the acceptance or denial for medical and surgical treatment.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to follow the care plan for oxygen therapy for two of eight residents (R) (R437 and R28). Specifically, the facility failed to follow the care plan for R437 and R28 to ensure the oxygen flow rate was set based on the physician order. The deficient practice had the potential to place the residents at risk for medical complications and a diminished quality of life. Findings included: Review of the facility policy titled, Care Plan, dated 10/20/2020, revealed 10. The care plan team will include participation by CNA's (Certified Nursing Assistant)'s, Licensed Charge Nurses, Registered Nurse Supervisors (including the Director of Nursing), Social Services Worker, Activities Staff Member, and a Dietary Representative as deemed appropriate for the conference being held that day. These staff members will be invited to assure a comprehensive review of the resident's current status and needs. 1. Review of the medical record revealed R437 was admitted to the facility on [DATE] with diagnoses of but not limited to chronic respiratory failure, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, dependence on supplemental oxygen. Record review revealed the Admission Minimum Data Set (MDS) assessment was not completed due to the resident being newly admitted on [DATE]. Review of active orders included an order for oxygen dated 11/26/2024, Oxygen at 2/LPM (liters per minute) via (by) nasal cannula (NC) to keep O2 sat (saturation) greater than 90% (percent) as needed. Review of the care plan initiated on 11/26/2024, revealed, [R437] has diagnosis of chronic respiratory failure. Oxygen setting O2 via NC as ordered by provider and as indicated. Observation on 12/3/2024 at 9:43 am revealed R437 with oxygen being administered at a rate of 3/LPM via N/C. Observations on 12/4/2024 at 10:05 am and 1:45 pm revealed R437 with oxygen being administered at a rate of 2.5/LPM via N/C. Interview and observation on 12/4/2024 at 2:17 pm with the Director of Nursing (DON) confirmed photos of oxygen captured during observations not set at prescribed rate. The DON revealed that when nurses came on duty, they should check residents on oxygen and check the rate to ensure it was set at rate the physician ordered. 50877 2. Review of the electronic record revealed R28 was admitted with diagnoses and a history of chronic respiratory failure and congestive heart failure. Review of the Admission Minimum Data Set (MDS) assessment dated on 11/26/2024 assessed a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Record review of R28's electronic records revealed there were no Physician orders for oxygen to be administered. Observation on 12/3/2024 at 9:47 am revealed R28 with oxygen being administered at a rate of 2/LPM via N/C. Interview on 12/5/2024 at 9:48 am with the MDS Coordinator revealed that she was contracted to complete care plans for the facility. She revealed that each department was responsible for completing their section. She revealed that she was responsible for the nursing section and was working on making the care plans more individualized. She revealed that a resident's care plan would not include specific oxygen rates (LPM), rather it would be generic stating oxygen as ordered because she doesn't have time to update the care plan every time the order was changed. She revealed all nurses were responsible for looking at the care plan and assuring all interventions were implemented. Interview on 12/5/2024 at 11:35 am the DON confirmed that orders, care plan, and MDS did not sync for the care of R28. She also confirmed that the care plan was not specific to R28.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Therapy Guidelines, the facility failed to ensure oxygen (O2) was administered according to the physician order for two of eight residents (R) (R28 and R437) receiving oxygen. The deficit practice had the potential to place R28 and R437 at risk for medical complications and a diminished quality of life. Findings included: Review of the facility's policy Oxygen Therapy Guidelines with review/revision date of 6/21/2023, under Clinical Responsibilities revealed, Changes in O2 therapy may be adjusted by RRT (Registered Respiratory Therapist) or nurse, while maintaining SPO2 >88 (oxygen saturation above 88 percent) (oxygen saturation is a measurement of how much oxygen your blood is carrying as a percentage) or as ordered by physician . Pulse oximetry will be checked every shift. MAR (Medication Administration Record) documentation must include whether or not oxygen is in use (on/off), liter flow, delivery device, (i.e. 2 liters nasal cannula), and the patient's SpO2 reading. 1. Review of the electronic record revealed R28 was admitted on [DATE] with diagnoses of but not limited to chronic respiratory failure and congestive heart failure. Review of R28's active orders revealed there were no physician order documented for oxygen (O2) to be administered. Review of the Admission Minimum Data Set (MDS) assessment dated on 11/26/2024 for R28 assessed a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Observation on 12/3/2024 at 9:47 am revealed R28 with oxygen being administered at 2 LPM (liters per minute) via (by) nasal cannula (N/C). Interview on 12/5/2024 at 11:35 am the Director of Nursing (DON) revealed that all standing orders for oxygen was 2/LPM. If it was continuous, it required a provider order and check vital signs every shift. The DON confirmed there were no specified orders for oxygen. 49675 2. Review of the medical record revealed R437 was admitted to the facility on [DATE] with diagnoses of but not limited to chronic respiratory failure, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, and dependence on supplemental oxygen. Record review revealed there was not a completed MDS assessment due to the resident being newly admitted . Review of the active orders included an order for oxygen dated 11/26/2024, oxygen at 2 LPM via NC to keep O2 sat (saturation) greater than 90% as needed. Review of the care plan initiated on 11/26/2024, revealed, [R437] has diagnosis of chronic respiratory failure. Oxygen setting O2 via NC as ordered by provider and as indicated. Observation on 12/3/2024 at 9:43 am revealed R437 with oxygen running at a rate of 3/LPM via N/C. Observations on 12/4/2024 at 10:05 am and 1:45 pm revealed R437 with oxygen running at a rate of 2.5/LPM via N/C. Interview on 12/4/2024 at 2:17 pm with the DON, she observed photos of R437's oxygen being administered at flow rates of 2.5 and 3/LPM, and confirmed the flow rates were incorrect. The DON revealed that when nurses come on duty, they should check residents on oxygen and check the rate to ensure it was set at the rate the physician ordered. The DON confirmed the oxygen order was not increased. The DON revealed she was unsure why the rate would be set on the incorrect rate. Interview on 12/4/2024 at 2:38 pm with Licensed Practical Nurse (LPN) AA revealed she had not called the doctor or anyone else regarding R437's oxygen. Interview on 12/4/2024 at 2:46 pm with the DON revealed that she spoke with LPN AA and she had contacted the physician this morning about R437's oxygen and he advised to increase it. The DON revealed that LPN AA had not had time to document. Interview on 12/5/2024 at 12:10 pm with the Respiratory Therapist revealed he expected all oxygen orders, PRN (as needed) and continuous, to be followed to ensure oxygen saturation levels were within defined limits. Providers/nurses input orders to be followed.

Based on staff interviews, record review, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) beyond 14 days, and/or failed to indicate a stop date for the extension for psychotropic medication for one of 27 sampled residents (R) (R25). Findings included: Review of the policy titled Psychotropic Medications with a reviewed/revised date of October 2017 under Procedural Guideline revealed, D. PRN (as needed) orders for psychotropic drugs are limited to 14 days. 1. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the patient's medical record and indicate the duration for the PRN order. Review of the clinical record revealed R25 was admitted to the facility with diagnoses of but not limited to dementia with behavioral disturbance mood (affective) disorder, major depressive disorder, recurrent, severe with psychotic symptoms, and anxiety. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. Section N (medications) reported the resident was receiving antipsychotics, antidepressants, and antianxiety medications. Review of the electronic medical record (EMR) revealed physician's orders for R25 included but was not limited to lorazepam oral tablet, a medication used to relieve anxiety. The dosage ordered was 0.5 milligram (mg) give one tablet by mouth every two hours as needed for anxiety; agitation or restlessness. The last ordered date was 10/10/2024, and end date was indefinite. Interview on 12/4/2024 at 3:52 pm with Licensed Practical Nurse (LPN) AA revealed since R25 was on hospice she did not require a stop date for the antianxiety medication. Interview on 12/4/2024 at 3:53 pm with the Director of Nursing (DON) revealed that all residents whether they are on hospice or not, required a stop or end date for PRN psychotropic medications including antianxiety medications. The DON confirmed there was no stop or end date for the lorazepam order. Interview on 12/4/2024 at 3:55 pm with Registered Nurse (RN) BB revealed that hospice entered orders, but the facility went in and approved the hospice orders. She revealed that the order for the antianxiety medication should have had an end or stop date and confirmed R25 did not have a stop or end date for the prescribed lorazepam.

Based on observations, staff interviews, and review of the facility policy titled, Receiving & Storing Perishable, Non-Perishable Foods, Dry Storage, the facility failed to label, and date opened food items and properly thaw frozen foods. The deficient practice had the potential to promote foodborne illnesses associated with bacterial growth for 27 of 28 residents consuming an oral diet. Findings include: Review of the undated policy titled, Receiving & Storing Perishable, Non-Perishable Foods, Dry Storage revealed products requiring thawing will be handled in the following manner, frozen meats may also be submerged under cold running water to thaw. Products will be labeled the day they are received, and stock will be rotated. FIFO (First in, First out). Each item will be labeled with the month, day, and year. Observation on 7/28/2023 at 8:33 a.m. of the reach-in refrigerator by the smoker revealed a cooked sweet potato wrapped in plastic wrap with no label or date. During an interview on 7/28/2023 at 8:33 a.m. with the Dietary Cook II (DC II) confirmed that the cooked sweet potato wrapped in plastic wrap did not have a label or date. DC II revealed that staff are to date items for refrigeration but did not label/date the sweet potatoes because it was going to be used today at lunch. Observation on 7/28/2023 at 8:37 a.m. of the reach-in freezer near the fryer revealed open bags of tater tots, french fries, breaded patties, and bread fish squares with no open date. Observation on 7/28/2023 at 8:40 a.m. of a rolling storage bin containing panko breadcrumbs, flour, and corn meal revealed the bins were labeled but no open dates or date when product was placed in the bins. Continued observation revealed a large white storage bin on wheels containing sugar with no open date. Observation on 7/28/2023 at 8:45 a.m. of the food prep sink revealed frozen fish filets in a colander with running water from the faucet. The fish filets were not submerged in water and the water from the faucet was only making direct contact with a few fish filets. Observation on 7/28/2023 at 8:46 a.m. of the walk-in refrigerator revealed a sign posted outside by the door that stated, Do not put anything in the cooler or freezer without proper date. Continued observation of a shelf containing produce items revealed an opened bag of cut celery wrapped in plastic wrap with no label or date, open bag of broccoli pieces wrapped in plastic wrap with no label or date, and a peeled onion wrapped in plastic wrap with no label or date. On a shelf near the door revealed an opened five-pound bag of shredded mozzarella cheese with no open date, an opened five-pound bag of shredded cheddar cheese with no open date, a five-pound container of cottage cheese with no open date, a five-pound container of pimento cheese spread with no open date, and a five-pound container of egg salad with no open date. During an interview on 7/28/2023 at 8:55 a.m. with DC II confirmed that the frozen fish filets were being thawed in the sink and not submerged in water. DC II revealed that having the running water over the fish filets was enough since he had been stirring the filets while the faucet water was running. DC II stated that he would sometimes completely submerge frozen food items in water to thaw. During an interview on 7/28/2023 at 9:05 a.m. the Dietary Manager (DM) confirmed that the shredded cheese, cottage cheese, and pimento cheese spread had been opened and had no date. The DM stated that staff are to date any refrigerated food item after it has been opened. Observation on 7/28/2023 at 9:10 a.m. of the dry storage area revealed a large bag of bow tie pasta that had been opened with no date. During an interview on 7/28/2023 at 9:10 a.m. with the DM revealed that staff do not need to date opened dry food storage items. The DM stated that dry food items do not spoil and did not need an open date. The DM stated for dry storage items they refer to the manufacture's expiration date labeled on the box. A continued interview with the DM regarding the storage bins containing bulk food items revealed that she did not expect staff to date when the food product was opened and placed in bins. The DM stated that staff are to use the expiration date that is on product package. The DM confirmed that none of the bins had any dates. Further interview also revealed when using the sink to thaw food items she expects staff to completely submerge the frozen item(s) in water and have the faucet run water over the top. Observation on 7/29/2023 at 10:05 a.m. of the reach-in freezer near the fryer revealed the open bags of tater tots, french fries, bread patties, and bread fish squares continued to have no open date. During an interview on 7/29/2023 at 10:05 a.m. the DM revealed that open frozen items do not need a label or date. The DM stated that for frozen food items, dietary staff are to use the expiration date that is on the box. The DM confirmed that staff had not placed any date on the opened bags.

Based on observations, staff interviews, record review, and review of the facility's policy titled, CPAP/BIPAP Cleaning/Infection Control, the facility failed to ensure oxygen equipment was properly stored while not in use for two of three Residents (R)#3 and (R#135) receiving Continuous Positive Airway Pressure (CPAP) respiratory treatment and failed to have a current physician order for one of three residents (R#3) with usage of CPAP. The facility also failed to ensure that oxygen equipment was dated and properly stored for one of three residents R#8. The deficient practice had the potential to increase the probability of respiratory complications for the residents receiving respiratory care and treatment. Findings include: Review of policy titled, CPAP/BIPAP Cleaning/Infection Control not dated, CPAP and BIPAPS are to be cleaned on a regular basis, this includes masks, tubing, humidifier chambers, filters, and wiping down the unit itself: 2. Masks should be stored in clear plastic bags when not in use. 4. Humidifiers need to be rinsed, and air dried. 1.Review of the clinical record for R#3 revealed admitting diagnosis included, but not limited to, acute respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. Review of R#3's current care plan initiated 5/17/2023 revealed resident is at risk for acute shortness of breath (SOB)/upper respiratory infection (URI) secondary to sleep apnea. CPAP set-up in room at bedside for use at night during sleeping hours, but resident repeatedly declines to utilize. Interventions: Apply CPAP at night during residents sleeping hours (resident has normal habit of staying up late at night); encourage use and assist needed to apply CPAP at residents' bedtime. Record review of the July 2023 Order Summary Report for R#3 revealed an order dated 7/18/2023 for Oxygen (O2) at four liters per minute (LPM) via nasal cannula every shift and an order dated 7/19/2023 for O2 via nasal cannula to keep saturation 90% or greater every shift. Further review of the physician orders revealed there was not a current physicians order for the CPAP which resident had at bedside. Record review of R#3's Medication Administration Record (MAR) from 5/1/2023 through 5/31/2023 and 6/1/2023 through 6/30/2023 and 7/1/2023 through 7/30/2023 revealed there was not a physician's order for the CPAP. Observation on 7/28/2023 at 10:08 a.m. and at 2:28 p.m. of R#3's room revealed a CPAP on the bedside dresser with the mask lying on the table not properly bagged. The reservoir was closed and filled past the full line with a clear liquid while not in use. During an interview on 7/29/2023 at 1:07 p.m. with Certified Nurse Aide (CNA) GG, revealed that the resident usually wears the nasal cannula to receive her oxygen. CNA GG further stated that he had witnessed the resident wearing the CPAP in the past. During an interview on 7/29/2023 at 2:21 p.m. with Licensed Practical Nurse (LPN) FF revealed the staff attempted to put the CPAP on while in bed. LPN FF further stated that she had been told in shift report that resident refuses to wear the CPAP at night and was not sure if resident had current orders to have it or not. During an interview on 7/29/2023 at 2:46 p.m. with Registered Nurse (RN) AA revealed that she was working the medication cart yesterday (7/28/2023) and noticed the CPAP in resident room. She stated she removed the machine because R#3 did not have a current order for the machine. RN AA further stated that resident once had an order for the CPAP, but when the facility changed to electronic records, the order did not come over. RN AA further stated that she searched the records and could not find an order to discontinue the CPAP. RN AA verified resident did not have orders for the CPAP, the mask unbagged, and the reservoir filled with a clear liquid while not in use. During an interview on 7/29/2023 at 3:03 p.m. with Director of Nursing (DON), she verified R#3 did not have an order for the CPAP. She stated that it is her expectation that the nurses follow through and transcribe the orders in the electronic record correctly. She stated that unless the order was discontinued there should be a current order. DON further stated that CPAP mask should be cleaned and stored in a plastic bag while not in use and the reservoir should be emptied and allowed to air dry. During a follow-up interview on 7/30/2023 at 9:07 a.m. with RN AA revealed that she searched resident record and was not able to locate an order where the CPAP had been discontinued. RN AA stated that she located an order on a paper physician order sheet dated 4/29/2022 for CPAP at night as tolerated. 37739 2. A review of the Electronic Medical Record (EMR) revealed that R#8 was admitted to the facility on [DATE] with diagnosis of altered cardiac status related to Hypertension, Edema Bilateral Lower Extremities, and Pericardial Effusion. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] noted that R#8 had oxygen therapy while she had been a resident at this facility and that she presented with a Brief Interview for Mental Status (BIMS) of 15, indicating that she was cognitively intact. A review of the Baseline Care Plan dated 6/16/2023 noted (oxygen) therapy for R#8. A review of the care plan for R#8 dated June 2023 revealed that R#8 would have no preventable crisis through next review. Medications/labs as ordered. Monitor for (signs and symptoms) of decreased cardiac output, heart rate, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion, and (shortness of breath). Interventions included to notify (physician) (as needed) with any changes; (oxygen) stats (as needed); and (oxygen therapy) (as needed). A review of the nursing progress note dated 6/29/2023 revealed that R#8 was receiving oxygen therapy via nasal canula at 2 litters. On 7/28/2023 at 2:10 p.m. R#8 was observed with an oxygen concentrator and unbagged nasal canula in her room beside the bed. She stated that she had not used it for a while but the staff just left it in the room. She confirmed that the nasal canula had not ever been placed in a bag. On 7/29/2023 at 12:45 p.m. R#8's room was observed with an oxygen concentrator and unbagged nasal canula still in her room beside the bed. During an interview with the Director of Nursing (DON) on 7/29/2023 at 12:55 p.m. she confirmed that the nasal canulas should be bagged and dated when not in use. During an observation on 7/29/2023 at 1:02 p.m. with Register Nurse (RN) CC, also the Unit Manager and Infection Control Preventionist, she confirmed that the nasal canula in R#8's room was not bagged and dated and stated that it should have been. She was observed to remove it from the residents room. 3. A review of the EMR revealed that R#135 was admitted to the facility on [DATE]. A review of the Admission MDS assessment dated [DATE] revealed that R#135 presented with a BIMS score of 13, indicating that the resident is cognitively intact. On 7/28/2023 at 9:53 a.m. R#135 was observed sitting in her room in her wheelchair. She was alert and oriented. On the nightstand, next to the bed, was a CPAP machine. The nasal canula was observed unbagged and resting on the table surface. During an interview with resident, she stated that she brought it from home and the staff does fill it with water for her, so they were aware it was there. On 7/29/2023 at 12:50 p.m. the nasal canula of the CPAP machine was observed still unbagged and resting on the table surface in R#135's room. On 7/29/2023 at 1:08 p.m. RN CC confirmed that the CPAP in R#135's room was sitting on the nightstand and the nasal canula was unbagged with no labeling. She confirmed that it should be in a bag. A review of the Respiratory Therapy note for R#135 dated 7/6/2023 revealed: CPAP at night ordered resident brought home unit in .set up at bedside .nasal mask, hose in place .reservoir filled with distilled water .resident is very familiar with placing mask on .straps adjusted for fit .placed on resident for a few minutes working properly with no complaints .nursing staff instructed on set up and use .will continue to monitor .saturation done on room air with CPAP in use measured 98%.

Based on observations, staff interviews, and a review of the facility policy titled, Infection Control Manual, the facility failed to ensure infection control practices were maintained for one of three Residents (R) (#11) diagnosed with Clostridium Difficile. This failure had the potential of exposing patients to infections due to cross contamination. Findings included: A review of the facility policy titled, Infection Control Manual reviewed 7/21/2023, revealed that it is the policy of the facility to maintain and provide an on-going basis a well-established policy of Infection Prevention and Control Program designed to prevent, identify, and control to the maximum extent possible the on-set and any subsequent spread of infection. VII Transmission Based Precautions: C-2. When a resident is placed on transmission-based precautions, the staff should implement the following: b) Place signage in a conspicuous place outside the resident's room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions, instructions for use of PPE, and/or instructions to see the nurse before entering. Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting (2007). Infection/Condition: Clostridium difficile (C-Diff), Type of Isolation: Contact + Standard, Duration of Precautions: Duration of Illness. A review of the clinical record revealed R#11 was diagnosed on [DATE] with Clostridium difficile. A Lab Results Report with a collection date of 7/12/2023 and a report date of 7/14/2023 revealed a positive result for C-Diff (GDH) AG and C-Diff Toxin A/B. A review of the most recent Quarterly Minimum Data Set MDS for R#11 dated 6/7/2023 revealed resident was always continent of bowel and bladder. A review of the Order Summary Report with active orders as of 7/28/2023 there was not an order for isolation. Review of the Medication Administration Record for July 2023 revealed R#11 received Vancomycin oral capsule 250 Milligrams (mg) 1 capsule by mouth three times a day and Metronidazole 500 mg 1 tablet by mouth three times a day for C-diff for 10 days, start day 7/14/2023. Last date of administration was 7/24/2023 with the 9 a.m. dose. Record review revealed a progress noted dated 7/13/2023 at 9:58 p.m. late entry for 7/12/2023resident had several episodes of diarrhea during the shift. Noted to be foul smelling, grainy and yellow in color. Record review revealed a progress noted dated 7/26/2023 at 12:56 p.m. that reads: Resident continue on contact isolation for C-Diff. She has completed ABT therapy but continues to have yellow mucous loose stools. Record review revealed a progress noted dated 7/28/2023 at 2:20 p.m. that reads: Patient is resting well this morning. Still weak and sleepy continues on loose stools. On IV NS @30cc/hr on gravity flow for 3 days. Tolerating well no distress noted. Started yesterday 7/27/23. Completed her ABT but continues on isolation precautions. Observation on 7/28/2023 at 10:16 a.m. R#11 was lying in bed. There is a red isolation box and barrel located outside of resident's room. No signage for isolation or type of isolation located in or near resident's room. Observation at 12:58 p.m. revealed a staff member donning PPE and entering R#11's room with lunch meal on Styrofoam dinnerware. Still no signage on the room door. Observation on 7/29/2023 at 8:16 a.m. Resident room door is closed, there is no signage on or near resident's room related to Isolation. Staff members enter room with meal tray breakfast on Styrofoam. Observation at 12:38 p.m. revealed residents lunch meal being delivered on regular dinnerware. During an interview on 7/29/2023 at 1:07 p.m. with Certified Nurse Aide (CNA) GG, he stated that he was told today by Registered Nurse (RN) CC that R#11 is not currently on isolation. CNA GG stated R#11 continues to have loose foul-smelling stools. CNA GG further stated that R#11 had had 3 episodes of loose foul-smelling stools today. During an interview on 7/29/2023 at 1:28 p.m. with RN CC, she stated R#11 is not currently on isolation it was discontinued on 7/25/2023 because the antibiotic therapy was completed. RN CC stated that once the medication for C-Diff was complete the isolation was discontinued even though resident continued to have loose foul stools. RN CC further stated the signage on the door was removed at that time as well. RN CC reviewed resident's record and stated that there was never an order for isolation written when resident was diagnosed with C-Diff. RN CC stated she did not ask physician if the isolation needed to be continued due to R#11 continued to be symptomatic. During an interview on 7/29/2023 at 1:41 p.m. with Director of Nursing (DON) verified that there is not an order for isolation and there is no documented evidence in the record that the physician had been notified after treatment was completed that resident continued to be symptomatic. During an interview on 7/29/2023 at 2:21 p.m. with Licensed Practical Nurse (LPN) FF, she stated R#11 continued to have loose foul-smelling stools and it was her understanding that resident is still on isolation/contact precaution. LPN FF further stated that no one had informed her that isolation had been discontinued. During an interview on 7/30/2023 at 8:31 a.m. with Dietary Manager (DM), she stated she was not sure why R#11 was on isolation but probably because she had some type of bacteria. DM further stated that when she returned to work, she did not ask any questions, she followed the process, and sent resident's trays out on Styrofoam. DM informed surveyor she was informed by the DON om 7/29/2023 that resident was not on isolation, so she began sending regular dinnerware. DM stated this morning the CNAs are telling her R#11 is on isolation, so at this point she is confused as to what to do. During an observation and interview on 7/30/2023 at 8:36 a.m. with CNA HH revealed CNA HH was at the kitchenette window informing DM that R#11's food should be on a Styrofoam tray because she is currently on isolation precautions. CNA HH stated that she worked Friday (7/28/2023) and at the time resident was still on isolation and no one had told her anything differently. During a follow-up interview 7/30/2023 at 8:39 a.m. with DON, DON stated we stayed last night and called the physician and updated him on resident's condition. DON further stated the facility did not follow the process with R#11 because there was not an order for isolation when resident was first diagnosed with C-Diff and the staff was not educated on the process. DON further stated that after the antibiotic treatment was completed and resident was still symptomatic, the physician should have been notified at that time and the isolation should not have ended.

Based on observation, interviews and record review, the facility failed to provided treatment and care in accordance with professional standards for two of 22 sampled residents (R) (R#134 and 131) related to (1) failed to assess and monitor a Peripheral Intravenous (PIV) Infiltration that cause a hematoma on the resident left forearm for R#134, and (2) and failed to follow physician orders related to weekly skin assessments to monitor for signs and symptoms of an adverse reaction for a resident receiving anticoagulant therapy. Findings included: A review of the facility policy titled Skin Assessment and Documentation dated October 2020 revealed that it is the facilities policy to provide complete assessment of all resident's skin every seven days (including measurement, color, drainage, and odor) and to document any unusual findings. The procedure for assuring timely review of skin issues or lack of response to treatment is as follows: A Licensed Nurse is responsible for doing a detailed assessment of each resident's skin every seven (7) days and for documenting this on the resident's medical record; it is the responsibility of the Unit Manager to complete weekly wound rounds; it is the responsibility of the Treatment Nurse to complete a weekly Skin Audit Report Form; if the skin issues are identified and have not improved in fourteen (14) days or at any time the condition has worsened, it is the responsibility of the Licensed Nurse to notify the physician for any further intervention and to document the notification any subsequent change in orders; and it is the responsibility of the Licensed Nurse to communicate with the RN Manager or Supervisory on duty or the Assistant Director of Nursing regarding lack of progress of the condition and the need for any further physician notification. 1. A review of the Electronic Medical Record (EMR) revealed that R#134 was admitted to the facility on [DATE] with diagnosis of, but was not limited to, Anemia, Coronary Artery Disease, Deep Venous Thrombosis, Heart Failure, Hypertension, Gastroesophageal Chronic Obstructive Pulmonary Disease, Reflux Disease, COPD, and Respiratory Failure. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#134 presented with a Brief Interview for Mental Status (BIMS) score of 14, indicating that the that the resident was cognitively intact. A review of the Baseline Care Plan and progress notes revealed no notes as to the PIV injury and no documentation that the area had been monitored or reported to the physician or wound care doctor. On 7/28/2023 at 9:58 a.m., R#134 was observed in bed with her left arm resting on a pillow. There was a raised bruised and swollen lump approximately three to four inches on her left forearm. The resident was alert and oriented to time and day. She stated while in hospital, the hospital staff inserted an IV (intervenous) and it blew. She stated, It hurts something awful. She stated that the facility staff gave her some Tylenol and that has taken the edge off. On 7/29/2023 at 9:29 a.m. R#134 was again observed in bed with her left arm resting on a pillow. She stated that her arm feels better than it did yesterday but still hurts. The area was observed to have no visual change. On 7/29/2023 at 3:49 p.m. an interview was conducted with Register Nurse (RN) CC, who was responsible for assisting the Wound Care Physician, over the Infection Control Prevention Program, and the Unit Manger. RN CC stated that R#134 was admitted with the PIV injury to her left forearm. She stated that when R#134 was in the hospital, they infused her arm with iodine, causing the injury. She stated that she was told that the area was assessed while in the hospital by the surgeon and that when the resident was admitted to the facility, they were directed to do nothing for the area and let it go away on its own. When asked if there was any documentation of assessing or monitoring of the area, she stated that they do not monitor the area because they have no orders to do anything for the hematoma. She was asked how would nursing and or the direct care staff know how to handle or care for her if there is no documentation of the area, and she stated that the admission notes were to do nothing, so they were doing nothing. The admission notes and any documentation pertaining to the injured area were requested at that time. On 7/29/2023 at 3:53 p.m. Licensed Practical Nurse (LPN) DD, assigned to care for R#134, was interviewed and stated that she had seen the bruised area on R#134's arm earlier in the day and she checked for orders but there were no orders to monitor or do anything for the area. An observation on 7/29/2023 at 4:20 p.m. revealed R#134 lying in bed with her left arm resting on a pillow. The residents left arm presented with a large, raised, and discolored hematoma. She described the area as tender and painful to touch and appeared to be guarding the left arm. She stated that she can use her fingers on the left hand but sometimes it hurts. On 7/29/2023 at 4:23 p.m. RN CC stated that she had spoken to hospital and R#134's family. She stated that the family told her that the resident was to follow up with family physician. She said that on 7/19/2023, she told the Wound Care Doctor about the injury, and he told her there was nothing for them to do and did not look at the resident because he did not need to see it. She confirmed again that they had not been monitoring or assessments of the PIV injury, the wound care doctor was not seeing the resident for the PIV injury, there were no progress notes related to the PIV injury, and no measuring was ever done of the area since the resident was admitted to the facility. She said, We were told to leave it alone. She further confirmed that she has not mentioned the area to R#134's physician. On 7/29/2023 at 4:43 p.m. observation of R#134's PIV hematoma injury was conducted with the Director of Nursing (DON). When she touched the residents arm, the resident flinched and pulled away with wide eyes. She told the DON that the area was tender multiple times during this observation. As the DON was assessing the area, the resident stated that when the incident first happened, a physician told her that they could lance the area and drain it, but she refused. The DON agreed that the PIV area should be monitored, and the monitoring and assessments should be documented. She further stated that any conversation had with the wound care nurse and the wound care doctor related to the PIV injury should be documented in the residents medical record. On 7/29/2023 at 4:57 p.m. an interview was conducted with RN CC. She stated that she had just spoke to the wound care doctor and he does not remember any conversation with her related to R#134's arm. When asked why she had not documented the initial conversations in R#134's progress notes, she stated, I don't have an answer for this situation. He stated that he doesn't recall the conversation. He told me there was someone on his list that he did not see but he couldn't remember who. She stated that she does rounds with the wound care doctor and she had not documented who the resident was that was not seen by the wound care doctor so she could not verify if it was R#134. 2. On 7/28/2023 at 9:39 a.m. R#131 was observed in bed. A large, dark purple colored bruise the size of a softball was observed on her upper right arm. The resident was alert but confused. A review of the EMR revealed that R#131 was admitted to the facility on [DATE] with diagnoses of, but was not limited to, Sepsis, Chronic Kidney Disease Stage III, Dementia, Hydroureter, Wedge Compression Fracture Of T9-T10 Vertebra, Paroxysmal Atrial Fibrillation, Chronic Systolic (Congestive) Heart Failure, Age-Related Osteoporosis Without Current Pathological Fracture, Cognitive Communication Deficit, Acidosis, Metabolic Encephalopathy, Atelectasis, Acute Kidney Failure, Bacteremia, Hypertension, Elevation Of Levels Of Liver Transaminase Levels, Disorder Of Bilirubin Metabolism, Hypokalemia, Anemia, Malignant Neoplasm, Kyphosis, and Long Term (Current) Use Of Anticoagulants. A review of the Physician Orders dated July 2023 revealed that R#131 was ordered: Eliquis Oral Tablet 2.5 MG (Apixaban) one tablet by mouth two times a day related to Paroxysmal Atrial Fibrillation; long term(current) use of anticoagulants monitor for (signs and symptoms) of bleeding; Weekly Skin Check due every Monday 7 (a.m.) - 7 (p.m.) one time a day every (Monday) for weekly skin assessment. A review of the skin assessments for R#131 revealed that on 7/20/2023 a skin assessment was conducted but no bruising was noted to be identified. There were no other documented skin assessments in the EMR. A review of the Baseline Care Plan dated 7/20/2023 revealed that R#131 was receiving anticoagulant therapy and that there were no skin integrity concerns. A review to the Kardex, with 14-day lookback period, noted no impaired skin for R#131. A review of the progress notes dated 7/27/2023 at 12:22 p.m. revealed R#131 had no changes to skin integrity noted during the shift. An interview on 7/30/2023 at 11:25 a.m. with the DON and RN CC, who was also the Unit Manager, The DON confirmed that there were no skin assessments for R#131 on 7/24/2023. RN CC stated that she does not do the skin assessments for residents who have orders for monitoring, but that the charge nurses are supposed to chart the skin assessments each shift. If there are any bruises, it is expected that the nurse document that in the EMR when they conduct their rounds. She confirmed that the progress note related to R#131's skin on 7/27/2023 noted no skin concerns. She stated that if there was bruising on the skin, it should be documented and that the nurse should monitor for bruising each shift. She confirmed that there was no documentation that R#131 had any bruising on 7/28/2023, 7/29/2023, and/or 7/30/2023 and she had not been informed that R#131 had any bruises. Observation on 7/30/2023 at 11:35 a.m. of R#131 was conducted with RN CC revealed the nurse looked at the residents arms and stated that she did not have any bruising. When asked if she could look further up the residents right arm, under the cotton shirt, the nurse was observed to lift the shirt closer to the residents shoulder and there was a dark, purple bruise the size of a softball. RN CC exclaimed and asked the resident, Oh, how did that happen? The resident stated she did not know. Certified Nursing Assistant (CNA) EE was in the room, making the residents bed at this time. CNA EE stated that she did see the bruise on R#131 earlier but had not reported it to the nurse because it was not new. She stated that she worked last Thursday (7/27/2023) and the bruise was there. She stated that she reported it to the nurse then but could not remember who that nurse was. RN CC stated that she should have been informed of the bruise and confirmed that she had not been made aware that R#131 had the bruise.

Based on observations, interviews, and record review, and reveiw of the facility policy titled, Skin Assessment and Documentation, the facility failed to create a baseline care plan that included the minimum healthcare information necessary to properly care for one of 22 sampled residents (R) (R#134) related to assessing and monitoring for a Peripheral Intravenous (PIV) Infiltration that caused a hematoma on the residents left forearm. Findings included: A review of the facility policy titled Skin Assessment and Documentation dated October 2020 revealed that it is the facilities policy to provide complete assessment of all resident's skin every seven days (including measurement, color, drainage, and odor) and to document any unusual findings. The procedure for assuring timely review of skin issues or lack of response to treatment is as follows: A Licensed Nurse is responsible for doing a detailed assessment of each resident's skin every seven days and for documenting this on the resident's medical record; it is the responsibility of the Unit Manager to complete weekly wound rounds; it is the responsibility of the Treatment Nurse to complete a weekly Skin Audit Report Form; if the skin issues are identified and have not improved in fourteen days or at any time the condition has worsened, it is the responsibility of the Licensed Nurse to notify the physician for any further intervention and to document the notification any subsequent change in orders; and it is the responsibility of the Licensed Nurse to communicate with the RN Manager or Supervisory on duty or the Assistant Director of Nursing regarding lack of progress of the condition and the need for any further physician notification. A review of the Electronic Medical Record (EMR) revealed that R#134 was admitted to the facility on [DATE] with diagnosis of, but was not limited to, anemia, coronary artery disease, deep venous thrombosis, heart failure, hypertension, gastroesophageal reflux disease, chronic obstructive pulmonary disease (COPD), and respiratory failure. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#134 presented with a Brief Interview for Mental Status (BIMS) score of 14, indicating that the that the resident was cognitively intact. A review of the Baseline Care Plan and progress notes revealed no notes as to the PIV injury and no documentation that the area had been monitored or reported to the physician or wound care doctor. On 7/28/2023 at 9:58 a.m., R#134 was observed in bed with her left arm resting on a pillow. There was a raised bruised and swollen lump approximately three to four inches on her left forearm. The resident was alert and oriented to time and day. She stated while in hospital, the hospital staff inserted an IV (intervenous) and it blew. She stated, It hurts something awful. She stated that the facility staff gave her some Tylenol and that has taken the edge off. On 7/29/2023 at 3:49 p.m. an interview was conducted with Register Nurse (RN) CC, who was responsible for assisting the Wound Care Physician, over the Infection Control Prevention Program, and the Unit Manger. RN CC stated that R#134 was admitted with the PIV injury to her left forearm. She stated that when R#134 was in the hospital, they infused her arm with iodine, causing the injury. She stated that she was told that the area was assessed while in the hospital by the surgeon and that when the resident was admitted to the facility, they were directed to do nothing for the area and let it go away on its own. When asked if there was any documentation of assessing or monitoring of the area, she stated that they do not monitor the area because they have no orders to do anything for the hematoma. She was asked how would nursing and or the direct care staff know how to handle or care for her if there is no documentation of the area, and she stated that the admission notes were to do nothing, so they were doing nothing. The admission notes and any documentation pertaining to the injured area were requested at that time. On 7/29/2023 at 3:53 p.m. Licensed Practical Nurse (LPN) DD, assigned to care for R#134, was interviewed and stated that she had seen the bruised area on R#134's arm earlier in the day and she checked for orders but there were no orders to monitor or do anything for the area. Interview on 7/29/2023 at 4:23 p.m. with Registered Nurse (RN) CC revealed that she had spoken to hospital and R#134's family. She stated that the family told her that the resident was to follow up with family physician. She said that on 7/19/2023, she told the Wound Care Doctor about the injury, and he told her there was nothing for them to do and did not look at the resident because he did not need to see it. She confirmed again that they had not been monitoring or assessments of the PIV injury, the wound care doctor was not seeing the resident for the PIV injury, there were no progress notes related to the PIV injury, and no measuring was ever done of the area since the resident was admitted to the facility. She said, We were told to leave it alone. She further confirmed that she has not mentioned the area to R#134's physician. Observationon 7/29/2023 at 4:43 p.m. of R#134's PIV hematoma injury was conducted with the Director of Nursing (DON). When she touched the residents arm, the resident flinched and pulled away with wide eyes. She told the DON that the area was tender multiple times during this observation. As the DON was assessing the area, the resident stated that when the incident first happened, a physician told her that they could lance the area and drain it, but she refused. The DON agreed that the PIV area should be monitored, and the monitoring and assessments should be documented. She further stated that any conversation had with the wound care nurse and the wound care doctor related to the PIV injury should be documented in the residents medical record. Interview on 7/29/2023 at 4:57 p.m. an was conducted with RN CC. She stated that she had just spoke to the wound care doctor and he does not remember any conversation with her related to R#134's arm. When asked why she had not documented the initial conversations in R#134's progress notes, she stated, I don't have an answer for this situation. He stated that he doesn't recall the conversation. He told me there was someone on his list that he did not see but he couldn't remember who. She stated that she does rounds with the wound care doctor and she had not documented who the resident was that was not seen by the wound care doctor so she could not verify if it was R#134.

Based on observations, record review, staff interview, and review of the facility documents titled, Receiving and Storing Perishable, Non-Perishable Foods, Dry storage and Personal Hygiene the facility failed to label dry food items on the date they were received; and the Dietary Manager failed to wear a hair net on three of three survey days. This deficient practice had the potential to affect all 18 residents receiving an oral diet. Findings include: 1. Review of the undated facility document titled, Receiving and Storing Perishable, Non-Perishable Foods, Dry storage revealed products will be labeled the day they are received, and stock will be rotated. Each item will be labeled with the month, day, and year. During the initial walk-through of the kitchen with the cook AA, on 11/16/21 at 8:40 a.m. the following concerns were observed: in the dry storage area on the lower shelf next to the emergency supply, five large bags of opened dry pasta noodles without labels to show date opened and use by date; seven opened spice containers, including lemon pepper, two bottles of ground ginger, poultry seasoning, ground sage, celery salt and jerk seasoning, with no open date or use by date. 2. Review of the undated facility document titled, Personal Hygiene revealed a hair restraint such as hair nets, soft ball caps (with covered top), disposable paper hats will be worn whenever performing task in production areas and throughout the prep and kitchen areas. Observation during the initial walk-through of the kitchen, on 11/16/21 at 8:40 a.m. revealed standing in the kitchen near the doorway of the dry storage pantry the Dietary Manager (DM), was observed without a hairnet covering her shoulder length straight hair. Observation on 11/17/21 at 11:50 a.m. the DM directed surveyor to the ice machine in the kitchen. Dietary Manager was observed not wearing a hair net. Observation on 11/18/21 at 10:00 a.m. with DM was observed not wearing a hairnet with her hair flowing as she directed me through the kitchen area to the dishwashing room. During interview with DM on 11/18/21 at 10:15 a.m., she stated she did not need to wear a hairnet unless she is prepping or handling food. During further interview with the DM, she stated that because seasonings do not expire there is not a need to date them when they are opened, and the delivery date is applied to all seasonings on the date of delivery.

Based on family and staff interviews, clinical record review, and review of the facility policy titled, Cardiopulmonary Resuscitation the facility failed to accurately document the code status (the type of emergency treatment provided in the event of cardiac or respiratory arrest) for one of four sampled residents (R#16). Findings include: Review of the policy titled Cardiopulmonary Resuscitation, initiated [DATE], did not address documentation of a resident's code status. Record review revealed that R#16 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He expired in the facility on [DATE]. Review of the Physician Orders dated [DATE] documented the code status for R#16 as Full Code, calling for cardiopulmonary resuscitation (CPR) if his heart stopped beating or he stopped breathing. Review of the Report Sheet for R#16 which documented communication between the hospital and the facility before transfer, documented the code status as Full Code. Review of the POLST (Physician's Orders for Life-Sustaining Treatment) form, dated [DATE], documented the code status as Allow Natural Death. Review of the Ridgecrest Advanced Directive Checklist dated [DATE], documented R#16 had no advance directive . and was signed by R#16's son. Review of the Ridgecrest Advance Directive and Other ACP Documents Face Sheet, undated/ unsigned, documented the code status as Do Not Resuscitation (DNR). Review of the Nurse's Notes, dated [DATE], revealed CPR was not performed when R#16 was found unresponsive, without pulse or blood pressure (BP), and warm to touch. Review of the Interdisciplinary Discharge Summary, dated [DATE], documented the discharge as Expired. During a telephone interview with R#16's daughter/Responsible Party (RP) on [DATE] at 3:48 p.m., she stated her mother, and the rest of the family were in agreement they did not want R#16 to have CPR in the event of cardiopulmonary arrest. In an interview with the Medical Director (MD) on [DATE] at 4:15 p.m., he stated he recalled R#16 being a resident at the facility for a short time. He stated the resident's family did not want R#16 to receive CPR in the event of cardiopulmonary arrest and asked for his status to indicate DNR. When he reviewed the verbal Physician Order he initialed on admission, dated [DATE], which read, Code Status: Full Code, the MD stated the pre-printed Physician Orders included that order, but he did not intend to make R#16 a full code; he simply did not read the orders thoroughly before he initialed them. He stated the facility practice had been to have the resident or RP complete as much paperwork as possible prior to admission including the POLST. He stated the POLST dated [DATE] which indicated Allow Natural Death, was signed by R#16's son at the hospital prior to transfer but was intended for admission to this facility. He stated he thought the signed POLST followed the resident through transfer to other facilities and did not need to be re-addressed. He stated he understood how the POLST and Physician Orders indicating two (2) different processes could cause confusion during a cardiopulmonary crisis. He stated he would prefer the code status be addressed once the resident was admitted to the facility and the code status be removed from the pre-printed Admission Physician Orders. In an interview with the Social Services Director (SSD)/Admission Coordinator on [DATE]at 4:43 p.m., she stated the Clinical Liaison coordinated the pre-admission evaluation and paperwork with the potential resident/RP and would have addressed the code status prior to admission. She stated she understood how addressing the code status prior to admission with paperwork dated before admission might cause confusion at the receiving facility.

Based on observations, interviews, and record review the facility failed to ensure that one of four [MEDICAL TREATMENT] residents (Resident (R) #4), donned a face mask before leaving his room for transport for [MEDICAL TREATMENT] treatment per COVID-19 facility protocol. The facility failed to ensure proper use of personal protective equipment (PPE) by staff per the facility undated facility checklist for Donning and Doffing PPE, to prevent potential spread of COVID-19 when care was provided for one of four quarantined residents, (R#3), by two different staff. In addition, the facility also failed to establish comprehensive policies and procedures addressing Resident Care for the prevention of potential COVID-19 transmission within the facility. Failure to have written processes in place puts new admission residents, transferred residents and residents leaving the facility for appointments at risk for contracting COVID-19. The sample size was 8 Residents. Findings include: 1. Observation of R#4 leaving the facility for a [MEDICAL TREATMENT] appointment on 7/14/2020 at 9:50 a.m. revealed the Emergency Medical Staff (EMS), both wearing masks, went into R#4's room with a stretcher. The EMS staff were observed pushing R#4 out of her room into the 100 hallway on the stretcher. R#4 said to the EMS staff, I need a mask, and the EMS staff replied, you will get one at [MEDICAL TREATMENT]. During an interview with Certified Nursing Assistant (CNA) BB at the 100-hall nursing station on 7/15/2020 at 9:15 a.m. CNA BB stated, residents going out of their rooms must have on a mask. CNA BB, who was assigned to R#4, said she did not see R#4 leave for [MEDICAL TREATMENT] on 7/14/2020 without a mask. During an interview with R#4 in the doorway of her room on 7/15/2020 at 9 a.m. she stated there was a mask in the room, but she had forgotten to put it on before being placed on the stretcher. R#4 confirmed asking the EMS for a mask and they told her one would be given to her at [MEDICAL TREATMENT]. R#4 stated a mask is required when leaving for [MEDICAL TREATMENT]. Observation of the R#4 leaving the facility without a mask was shared with Administrator during an interview in her office on 7/15/2020 at 9:18 a.m. The Administrator said the staff and EMS know a resident cannot leave the room without a mask. The Administrator said it is the responsibility of the facility staff to make sure a resident does not leave the room without a mask on, but the EMS personnel should also assist. 2. Review of the facility Donning and Doffing PPE Competency Checklist, documented the following: Steps for Donning (putting on) PPE: Wash hands Put on isolation gown, fasten in back of neck and waist Put on Mask or respirator Put on goggles or face shield Place over face and eyes and adjust to fit Don gloves Extend to cover wrist of isolation gown. Steps for Doffing (taking off) PPE: Position self in front of the biohazard bin Grasp the palm area of the other gloved hand and peel off first glove Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove and discard glove in a waist container Remove goggles or face shield from the back by lifting head band or earpieces If the item is reusable, place in designated receptacle for reprocessing Remove gown; unfasten gown ties taking care that sleeves don't contact your body when reaching for ties Pull gown away from neck and shoulders, touching inside of gown only Turn gown inside out; fold or roll into a bundle and discard to a waste container Remove Mask or respirator (grasp elastic ear ties) remove without touching the front. During an interview with the Infection Control Preventionist (ICP) in the facility beauty parlor, on 7/14/2020 at 9 a.m., she stated the facility is running short of gowns. Hooks have been placed on the wall of Isolation rooms for staff to hang the gown assigned to them. The ICP said the CNA assigned to the residents in the quarantined rooms are given one gown per room each shift. The CNA's are to write their name on the gown and after each use place it on the hook with the front side of the gown next to the wall. The ICP said the CNA then disposes of the gown in the biohazard trash box inside of the room at the end of each shift. The face shield is also reused for each of the residents on droplet precautions and it is disinfected before and after each use and kept in the isolation cart outside of the room. Each room has an assigned isolation cart outside the room. The facility currently has four Residents on 14-day quarantine and on droplet precautions. CNA BB was assigned to provide care for the four quarantined Residents on 7/14/2020. Review of the record for R#3 documented the resident was admitted on [DATE] with a negative COVID-19 test but had been placed on droplet precautions with a 14-day quarantine. a. Observation of CNA BB on 7/14/2020 at 12:55 p.m. as she prepared to deliver meal trays to the residents in quarantine on the 100 hallway revealed the following: CNA BB retrieved a face shield from the isolation cart, disinfected it appropriately then placed it on top of isolation cart to dry. CNA BB went into R#3's room, took the extended use gown off the hook in the quarantined room and carried it out of the room a few feet down the hallway to where the isolation cart was parked. CNA BB then placed the dirty gown over the corner of the clean isolation cart. The ICP was nearby and the ICP verified this was not following procedure and immediately began to re-instruct CNA BB on the appropriate process. The ICP instructed CNA BB to throw the gown away with the other PPE before coming out of the room. Review of CNA BB training record revealed CNA BB passed a competency checklist for Donning and Doffing PPE on 4/3/2020 and had attended an in-service on using complete PPE correctly on 6/17/2020. b. Observation of CNA HH on 7/15/2020 6:40 a.m. along with the DON revealed CNA HH was preparing to provide care for R#3 who resided in a quarantined room. CNA HH failed to sanitize the face shield and let dry before donning the face shield per the facility checklist. CNA HH failed to sanitize hands before putting on a clean gown. CNA HH put on double gloves. The CNA donned the face shield upside down, which had not been sanitized prior to use, and entered the R#3's room to provide care. Prior to exiting the room of R#3 CNA HH took off the first layer of gloves and placed them in a biohazard trash container. The CNA doffed the gown inappropriately touching the front side of the contaminated gown to his scrubs as he attempted to hang it on the hook on the wall. CNA HH then came out of the room with the second set of gloves on and removed his face shield. The CNA failed to remove the second pair of gloves and sanitize hands before leaving the room. The DON prompted CNA to remove the second pair of gloves, sanitize hands and sanitize face shield. During an interview with the DON after the observation on 7/15/2020 at 6:35 a.m., in the 100 hallway, she stated CNA HH was nervous but still needed to do it right. Review of the training log for CNA HH revealed he had attended an in-service on using complete PPE correctly on 6/17/2020. 3. Review of the facility COVID-19 Preparedness Plan dated 3/16/2020 failed to include standards, policies, or procedures based on current national standards. The following Resident care areas were not addressed in the plan: a. Admissions or re-admissions from the hospital criteria and procedures to prevent the spread of COVID-19 in the facility. b. Policy and procedures for residents regularly leaving the facility for medically necessary purposes such as [MEDICAL TREATMENT], [MEDICAL CONDITION], and outpatient procedures to identify necessary precautions to prevent the potential spread of COVID-19 within the facility. The facility currently has four [MEDICAL TREATMENT] Residents. During an interview with the ICP on 7/15/2020 at 7:51 a.m. in the beauty shop, said none of the [MEDICAL TREATMENT] Residents have tested positive for COVID-19. The ICP agreed the Preparedness plan did not address residents leaving the facility for [MEDICAL TREATMENT], outpatient procedures or hospital admits and re-admits and stated, the Administrator was working on it. During a phone interview with the Medical Director on 7/15/2020 at 8:31 a.m. he stated [MEDICAL TREATMENT] Residents are together on the first-floor area where other quarantined residents reside. The Medical Director was unaware the COVID-19 Preparedness Plan did not address management of Residents going out of the for treatment. During an interview with the Administrator in her office on 7/15/2020 at 9:18 a.m. she stated the facility placed all [MEDICAL TREATMENT] Residents in private rooms close to the exit so they will not have to be transported throughout the facility when leaving the facility. The Administrator agreed the facility Preparedness Plan, dated 3/16/2020 did not address Residents leaving the facility for [MEDICAL TREATMENT], outpatient procedures or hospital admits and re-admits. Admissions to the facility were ceased in March. The first new admission was accepted on 7/13/2020 from the hospital and is currently on a 14-day quarantine with droplet precautions.

Based on staff interview, record review, review of Administrator and Director of Nursing job descriptions, the facility administration failed to ensure adequate management and monitoring of medications and/or treatment for [REDACTED]. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: Resident (R) #1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings Include: Review of the Administrator job description signed on 8/1/18 revealed: Summary - responsible for the overall management of a facility, plans, develops, directs, monitors and supports all operational, administrative, clinical . programs and services. Functions - directs and coordinates all functions of the facility. Responsibility - is responsible for efficient execution of the programs and services with highest possible standards. Ensures the quality and appropriateness of resident/ patient care meets or exceeds company and regulatory standards. A review of the Director of Nursing job description signed on 10/4/17 revealed that the primary purpose of the job position is to plan, organize, develop and direct the day to day functions of the Nursing Service Department to ensure that the highest degree of quality of care is maintained at all times. However, facility administrative and nursing administrative staff failed to provide effective supervision of licensed nursing staff and failed identify repeated issues concerning the care and management of diabetic residents R#1, R#2, R#3, R#4, R#6, and R#7. 1. Administration failed to ensure that the Physician was notified in a timely manner of a critical change in condition for R#1. Cross Refer to F580. 2. Administration failed to ensure that care plans were being followed related to reporting significant observations of [MEDICAL CONDITION] for R#1 and related to administering medications and/or treatments for the management of diabetes and risk for hyper/[DIAGNOSES REDACTED] for R#1, R#2, R#3 and R#6. Cross Refer to F656. 3. Administration failed to ensure that Physician ordered protocols were being followed for abnormal blood glucose reading interventions for R#1, R#3 and R#7, failed to ensure that correct amounts of insulin were being administered as ordered for R#1, failed to ensure blood glucose readings were being obtained as ordered for R#2, failed to obtain diabetic medication as ordered for R#3, and failed to ensure to ensure nursing staff administered insulin via a sliding scale or routine dose as ordered for R#4 and R#6. Cross refer to F684. 4. Administration failed to ensure appropriate nursing standards were utilized and physician notification, in a timely manner, of signs of [MEDICAL CONDITION] for R#1. Cross Refer to F658. 5. Administration failed to ensure that irregularities were identified regarding: Physician Ordered Protocol for abnormal blood glucose reading interventions for R#1 and R#3, administering the correct amount of insulin as ordered for R#1, obtaining blood glucose readings as ordered for R#2, and administering insulin via a sliding scale dose as ordered for R#4, and failed to act on an irregularity that was identified regarding the unavailability of a diabetic medication for R#3. Cross refer to F756. 6. Administration failed to have an effective Quality Assurance process that identified concerns related to the care and management of diabetic residents. Cross refer to F867. During an interview on 3/2/2020 at 4:45 p.m. with the Administrator and Director of Nursing (DON), and a subsequent interview on 3/3/2020 at 10:00 a.m. with the DON, they both stated that they felt licensed nursing staff had been misinterpreting the Physician's Insulin Protocol regarding continuing to recheck blood glucose readings and administer insulin according to the sliding scale, for initial results greater than 450. They stated that the misinterpretation was that the blood glucose was to continue being rechecked only if it remained above 450 when rechecked. During a post survey interview on 3/24/2020 at 10:00 a.m., the Administrator stated that she was not informed of the incident on 10/31/19 for R#1 and was not made aware until being questioned by the surveyor. The administrator revealed that she was unaware of the real issue related to the management of the diabetic residents. She was delegating review of the consultant reports to the nurse managers and the nurse manager position had some turnover. Documentation issues were identified during those reviews but the fact that nursing staff were not following protocols was not identified. She stated that it is her responsibility to find issues and she was unable to see the errors with the insulin protocol being misinterpreted because it had been going on so long. She confirmed that when they did recently ask the Physician, he clarified the Physician's Insulin Protocol and it was not being followed.

Based on staff interviews, record review, and staff statement review, the facility failed to report significant observations related to [MEDICAL CONDITION], as care planned for one resident (R) (#1), and failed to administer medications and/or treatment related to the management of diabetes and risk for hyper/[DIAGNOSES REDACTED] as care planned for four residents (#1, #2, #3 and #6), from a total sample of nine residents. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: R#1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the policy titled Care Planning initiated 11/15/16 documented the procedure for administering the care plan conference program of the facility includes, but is not limited to the following: 12. DON, Registered Nurse (RN) supervisor, and Licensed Charge Nurses are responsible for assuring provision of care in accordance with the care plan. 1. R#1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A care plan was developed that included that R#1 was at risk for hypo/[MEDICAL CONDITION] and other complications related to the [DIAGNOSES REDACTED]. The care plan also included an intervention for licensed nursing staff to report any significant observations to the Physician. However, licensed nursing staff failed to report significant observations related to [MEDICAL CONDITION] and ketoacidosis to the Physician in a timely manner on 10/31/19, as care planned. Review of the clinical record revealed that on 10/31/19 at 8:00 a.m., R#1 was vomiting and had a finger stick blood sugar (FSBS) reading of HI. LPN CC administered 14 units of [MEDICATION NAME] R. The FSBS was rechecked and remained HI. A review of text messages that occurred between LPN CC and the Physician on 10/31/19 confirmed that the Physician was not notified of the repeated HI glucometer readings and vomiting until 9:44 a.m., with the Physician responding at 10:08 a.m. A review of hospital documentation revealed that the resident was admitted to the hospital with [REDACTED]. During an interview on 3/3/2020 at 12:20 p.m., LPN CC stated that R#1 was in ketoacidosis, that he could smell a fruity smell, and that the resident was vomiting up until the time he was sent to the emergency room . In addition, R#1 also had a care plan intervention for licensed nursing staff to administer diabetic medications as ordered. The Physician's Insulin Protocol revealed an order for [REDACTED]. If greater than 450 on the third recheck, notify the Physician. However, review of the MAR's revealed that licensed nursing staff failed to consistently recheck the FSBS, per the Physician Ordered Protocol for R#1, after an initial reading of greater than 450, for 12 times in October 2019, 12 times in November 2019, 23 times in December 2019, 11 times in January 2020 and nine times in February 2020. Additionally, licensed nursing staff failed to consistently administer the correct amount of insulin, as ordered and as care planned, for FSBS readings greater than 450 for five times in January 2020. Cross refer to F684 2. R#2 had a care plan, developed 7/8/19, for being at risk for hypo/[MEDICAL CONDITION] and other complications related to a [DIAGNOSES REDACTED]. Review of the clinical record revealed an 11/22/19 Physician's Order to obtain FSBS readings before meals and at bedtime (four times daily) and administer insulin ([MEDICATION NAME] R) per a sliding scale. Licensed nursing staff failed to obtain the blood glucose levels as frequently as ordered by the Physician, to determine how much [MEDICATION NAME] R insulin to administer as ordered, as care planned, for the month of December 2019. A review of the clinical record, including the December 2019 MAR's revealed that R#2's blood glucose level was only obtained once daily from 12/1/19 through 12/31/19. Cross refer to F684 3. R#3 had a care plan, dated 9/25/19, for being at risk for hypo/[MEDICAL CONDITION] and other complications related to a [DIAGNOSES REDACTED]. R#3 had Physician's Orders in place that included for licensed nursing staff to complete FSBS checks before meals and at bedtime and administer [MEDICATION NAME] R insulin via a sliding scale with the FSBS checks. For a FSBS reading greater than 450, licensed nursing staff were to recheck every hour for three hours administering insulin as needed. However, licensed nursing staff failed to consistently recheck the FSBS, per the Physician Ordered Protocol, after an initial result of greater than 450 for the following dates, times and FSBS results: A) Once in December 2019: 12/11 at 11:30 a.m. for a FSBS of 492. B) Three times in February 2020: 2/8 at 6:30 a.m. for FSBS of 478, 2/10 at 11:30 a.m. for FSBS of 463 and on 2/19/20 at 9:00 p.m. for a FSBS of 461. Cross refer to F684 4. R#6 had a current care plan for being at risk for hypo/[MEDICAL CONDITION] and other complications related to [DIAGNOSES REDACTED]. Review of the January 2020 Physician's Orders form revealed the resident had a Physician's Order since 6/28/18 for [MEDICATION NAME] 10 units subcutaneous at bedtime every day. Review of the January 2020 MAR indicated [REDACTED]. In addition, there was documentation on the January 2020 MAR indicated [REDACTED]. However, there were no Physician's Orders with parameters to hold the scheduled [MEDICATION NAME]. During a post survey interview on 3/24/2020 at 10:15 a.m., the DON revealed that care plans are located in the resident's charts. She stated nurses should know when a resident is on a diabetic medication, that there is a care plan and it should be reviewed and followed. Care plans are discussed in PAR (patient at risk) meetings and that information is communicated to the nurses. The DON stated that she knows nurses are reviewing the care plan because they have to make nurses notes which have to reflect their diagnosis, and they get that information from the care plan. Cross refer to F684

Based on staff interviews, record review, and review of the facility policy titled Medication Administration General Guidelines, the facility failed to follow the physician ordered protocol for abnormal blood glucose reading interventions for three residents (R) (#1, #3 and #7), failed to administer the correct amount of insulin as ordered for one resident (#1), failed to obtain blood glucose readings as ordered for one resident (#2), failed to obtain diabetic medication as ordered for one resident (#3), and failed to administer insulin via a sliding scale or routine dose as ordered for two residents (#4 and #6) from a total sample of nine residents. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: R#1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: The facility's policy titled Medication Administration General Guidelines updated July 2012 included that the intent of the guideline was that medications were administered as prescribed, in accordance with good nursing principles. However licensed nursing staff failed to consistently implement medication administration general guidelines to administer medications as prescribed for R#1, R#2, R#3, R#4, R#6, and R#7. R#4 was under the care of Physician FF and all other residents were under the care Physician EE. Both Physicians used the same Physician Insulin Protocol. There was a total of 19 residents classified as insulin dependent on 3/2/2020. The facility utilized (name) glucometers for obtaining FSBS results. A review of the (name) Blood Glucose Monitoring System User Instruction Manual revealed that the glucometer displays results between 20-600 mg/dL. A reading of HI appears when the blood glucose level is greater than 600mg/dL and indicates severe [MEDICAL CONDITION]. 1. R#1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#1 had Physician's Orders in place that included for licensed nursing staff to complete finger stick blood sugar (FSBS) checks before meals and at bedtime. Further review of the clinical record, including the Medication Administration Records (MARs), revealed that the FSBS checks were scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. R#1 also had orders for [MEDICATION NAME] R insulin to be administered based on a sliding scale along with the FSBS checks. A review of the Physician's Insulin Protocol, that accompanied the resident's [MEDICATION NAME] R insulin sliding scale order, revealed that licensed nursing staff were to administer a specific dose of insulin based on the FSBS reading obtained. The sliding scale insulin usage started at a FSBS reading of 150. For a FSBS reading greater than 450, licensed nursing staff were to administer 14 units of insulin. Additionally, licensed nursing staff were to repeat the FSBS in one hour and give insulin again according to the result and the sliding scale. Then, two hours after the first reading (of greater than 450), the FSBS was to be checked again and insulin again administered per the sliding scale. Three hours after the first FSBS reading (that was greater than 450), the FSBS was to be checked again and insulin administered per the sliding scale. If the FSBS reading remained above 450 on the third check, the Physician was to be notified. However, licensed nursing staff failed to consistently monitor R#1 and recheck the FSBS three times and administer insulin as needed, per the Physician Ordered Protocol, after an initial FSBS reading of greater than 450 was obtained and an insulin dose administered. During an interview on 3/2/2020 at 4:45 p.m. with the Administrator and Director of Nursing (DON), and a subsequent interview on 3/3/2020 at 10:00 a.m. with the DON, they both stated that they felt licensed nursing staff had been misinterpreting the Physician's Insulin Protocol regarding continuing to recheck blood glucose readings and administer insulin according to the sliding scale, for initial results greater than 450. They stated that the misinterpretation was that the blood glucose was to continue being rechecked only if it remained above 450 when rechecked. However, there was no evidence in the clinical records, that after the initial result of greater than 450 and a dose of insulin was administered, that nursing staff consistently completed a recheck to see if the blood sugar remained above 450. Licensed nursing staff failed to follow the protocol for the following dates, times and FSBS readings for R#1: A) 12 times in October 2019: 10/1 at 6:30 a.m. for a FSBS of 555, 10/5 at 6:30 a.m. for a FSBS of 476, 10/9 at 6:30 a.m. for FSBS of HI, 10/10 at 6:30 a.m. for FSBS of HI, 10/13 at 6:30 a.m. for FSBS of 505, 10/16 at 6:30 a.m. for FSBS of 490 and at 11:30 a.m. for FSBS of 575, 10/22 at 6:30 a.m. for FSBS of 548, 10/24 at 6:30 a.m. for FSBS of HI, 10/26 at 4:30 p.m. for FSBS of 465, 10/27 at 6:30 a.m. for FSBS of 480, and on 10/30/19 at 11:30 a.m. for a FSBS of HI. B) 12 times in November 2019: 11/5 at 11:30 a.m. for FSBS of 525, 11/6 at 9:00 p.m. for FSBS of 511, 11/9 at 6:30 a.m. for FSBS of 473, 11/10 at 6:30 a.m. for FSBS 575, 11/11 at 6:30 a.m. for FSBS of 600, 11/12 at 6:30 a.m. for FSBS of 596, 11/17 at 6:30 a.m. for FSBS of 474, 11/19 at 6:30 a.m. for FSBS of 495, 11/22 at 6:30 a.m. for FSBS of HI, 11/23 at 6:30 a.m. for FSBS of 492, 11/26 at 6:30 a.m. for FSBS of HI, and on 11/27/19 at 6:30 a.m. for FSBS of 493. C) 23 times in December 2019: 12/3 at 6:30 a.m. for FSBS of 578, 12/4 at 4:30 p.m. for FSBS of 502, 12/6 at 6:30 a.m. for FSBS of 519 and at 4:30 p.m. for FSBS of 452, 12/7 at 4:30 p.m. for FSBS of 502, 12/8 at 4:30 p.m. for FSBS of HI, 12/9 at 6:30 a.m. for FSBS of 500, 12/11 at 6:30 a.m. for FSBS of 482 and at 4:30 p.m. for FSBS of 528, 12/12 at 4:30 p.m. for FSBS of 456, 12/13 at 6:30 a.m. for FSBS of 597 and at 4:30 p.m. for FSBS of HI, 12/15 at 6:30 a.m. for FSBS of 567, 12/16 at 4:30 p.m. for FSBS of 528, 12/22 at 6:30 a.m. for FSBS of 509, 12/23 at 11:30 a.m. for FSBS of 590, 12/24 at 6:30 a.m. for FSBS of 529, 12/25 at 6:30 a.m. for FSBS of 560, 12/26 at 4:30 p.m. for FSBS of 483, 12/27 at 6:30 a.m. for FSBS of 495, and on 12/28/19 at 6:30 a.m. for FSBS of 485. D) 11 times in January 2020: 1/10 at 4:30 p.m. for FSBS of 502, 1/11 at 4:30 p.m. for FSBS of 502, 1/14 at 6:30 a.m. for FSBS of 570 and at 9:00 p.m. for FSBS of HI, 1/16 at 6:30 a.m. for FSBS of HI, 1/19 at 6:30 a.m. for FSBS of 486, 1/22 at 6:30 a.m. for FSBS of 500, 1/23 at 6:30 a.m. for FSBS at 508, 1/24 at 6:30 a.m. for FSBS at 519, 1/25 at 6:30 a.m. for FSBS at 462, and on 1/30 at 6:30 a.m. for FSBS of 575. E) nine times in February 2020: 2/6 at 11:30 a.m. for FSBS of 518, 2/13 at 11:30 a.m. for FSBS of 514, 2/14 at 6:30 a.m. for FSBS of 455, 2/15 at 11:30 a.m. for FSBS of 500, 2/17 at 5:30 a.m. for FSBS of 500, 2/23 at 5:30 a.m. for FSBS of 530, 2/25 at 5:30 a.m. for FSBS of 538, and on 2/26 at 9:00 p.m. for FSBS of 553. Additionally, licensed nursing staff failed to consistently administer the correct amount of insulin, as ordered, for FSBS results greater than 450 for five times in January 2020. Twelve units of [MEDICATION NAME] R insulin was administered, instead of the ordered 14 units for a blood glucose results of 570 at 6:30 a.m. on 1/14/2020, a HI result at 6:30 a.m. on 1/16/2020, 486 result at 6:30 a.m. on 1/19/2020, 519 result at 6:30 a.m. on 1/24/2020, and a reading of 462 at 6:30 a.m. on 1/25/2020. R#1 was noncompliant at times with his diabetic management and has had six hospitalization s for diabetic ketoacidosis since 10/31/19. The hospitalization s were as follows: 10/31/19 through 11/4/19, 11/13/19 through 11/15/19, 11/28/19 through 11/29/19, 1/2/2020 through 1/3/2020, 1/5/2020 through 1/8/2020, and 1/26/2020 through 1/29/2020. All of the hospitalization s were reviewed with a concern being identified for 10/31/19 and 1/5/2020. Review of the October 2019 MAR indicated [REDACTED]. A subsequent entry on the MAR indicated [REDACTED]. A 10/31/19 untimed Nurse's Note entry documented that on initial morning rounds, the FSBS was HI and 14 units (of insulin) was given, the FSBS was rechecked and remained HI, the Physician was notified, and new orders were received to send R#1 to the emergency room . A 10/31/19 10:30 a.m. Nurse's Note entry documented that the ambulance service was notified for transportation and a 10:40 a.m. Nurse's Note entry noted that the resident was out of the facility via ambulance service transportation. A review of a written statement provided by LPN CC revealed that on 10/31/19 after the HI FSBS reading at 8:00 a.m. (and [MEDICATION NAME] R insulin coverage) and HI reading again 9:00 a.m., a third check of the blood glucose level was obtained at 9:40 a.m. and continued to read HI on the glucometer. The Physician was notified, and a new order was received to send the resident to the emergency room . A review of text messages that occurred between LPN CC and the Physician on 10/31/19 confirmed that the Physician was not notified of the repeated HI glucometer readings and vomiting until 9:44 a.m., with the Physician responding at 10:08 a.m. A review of hospital documentation revealed that the resident was admitted to the hospital with [REDACTED]. Review of the clinical record revealed on 1/5/2020 R#1 received his regularly schedule Humalog insulin at 6:00 a.m. At 6:30 a.m. the blood sugar was documented, by night shift LPN HH, on the January 2020 MAR indicated [REDACTED]. However, on 1/5/2020 there was no active sliding scale with [MEDICATION NAME] R insulin coverage ordered because the [MEDICATION NAME] R insulin order had been discontinued on 1/3/2020 per review of the Physician's Orders. Therefore, the 14 units of insulin coverage (given in response to the HI reading) was given without a Physician's Order. After the initial reading of HI at 6:30 a.m. and the 14 units of insulin coverage, there is no evidence of further follow-up by licensed nursing staff on the night shift or oncoming day shift. LPN HH (night shift) documented in a written statement that report was always given to the oncoming nurse regarding (insulin) coverage. Day shift LPN GG documented in a written statement that he was not made aware of the HI reading and did not do a recheck of the blood sugar reading. Further review of LPN GG's written statement revealed that R#1 refused the scheduled blood sugar check at 11:30 a.m. At 12:47 p.m. the resident is documented in a 1/5/2020 Nurse's Note entry as being slumped over in bed, nauseated and vomiting coffee ground emesis, and lethargic. The Physician was notified, and the resident was sent to the emergency room . The Nurse's Note entry also includes a blood sugar of 447 just prior to leaving the facility. LPN GG's written statement included that the nursing supervisor had to talk the resident into allowing his blood sugar to be checked at that time. A review of the 1/5/2020 hospital History and Physical revealed that R#1 was admitted with diabetic ketoacidosis associated with type 2 diabetes mellitus. He returned to the facility on [DATE]. During an interview on 3/2/2020 at 1:02 p.m. Physician FF stated he expected the nurses to follow his orders and insulin protocol of rechecking the blood sugar three times following a result of greater than 450. 2. R#2 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of the clinical record revealed an 11/22/19 Physician's Order to obtain FSBS readings before meals and at bedtime (four times daily) and administer insulin ([MEDICATION NAME] R) per a sliding scale. On 12/27/19, the frequency of the FSBS monitoring was decreased from before meals and at bedtime to three times daily. Therefore, for the month of December 2019, R#2's blood glucose levels should have been obtained four times daily, until it was decreased to three times daily on 12/27/19. However, licensed nursing staff failed to obtain the blood glucose levels as frequently as ordered by the Physician, to determine how much [MEDICATION NAME] R insulin to administer as ordered for the month of December 2019. A review of the clinical record, including the December 2019 MAR's revealed that R#2's blood glucose level was only obtained once daily from 12/1/19 through 12/31/19. During an interview on 2/14/2020 at 9:30 a.m., the Administrator stated that they were unable to locate any additional information that the FSBS levels were obtained as ordered for December 2019. 3.R#3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R#3 had Physician's Orders for licensed nursing staff to complete FSBS checks before meals and at bedtime and administer [MEDICATION NAME] R insulin via a sliding scale with the FSBS checks. A review of the Physician's Insulin Protocol, that accompanied the resident's [MEDICATION NAME] R insulin sliding scale order, revealed that licensed nursing staff were to administer a specific dose of [MEDICATION NAME] R insulin based on the FSBS result obtained. The sliding scale insulin usage started at a FSBS reading of 150. For a FSBS reading greater than 450, licensed nursing staff were to administer 14 units of insulin. Additionally, licensed nursing staff were to repeat the FSBS in one hour and give insulin again according to the result and the sliding scale. Then, two hours after the first reading, the FSBS was to be checked again and insulin again administered per the sliding scale. Three hours after the first FSBS reading greater than 450, the FSBS was to be checked again and insulin administered per the sliding scale. If the FSBS reading remained above 450 on the third check, the Physician was to be notified. However, licensed nursing staff failed to consistently recheck the FSBS, per the Physician Ordered Protocol, after an initial result of greater than 450 for the following dates, times and FSBS results: A) Once in December 2019: 12/11 at 11:30 a.m. for a FSBS of 492. B) Three times in February 2020: 2/8 at 6:30 a.m. for FSBS of 478, 2/10 at 11:30 a.m. for FSBS of 463 and on 2/19/20 at 9:00 p.m. for a FSBS of 461. Review of the clinical record and written timeline of communication between the facility and the pharmacy revealed the following information: R#3 had a Physician's Order since 10/18/17 for 2mg of Bydureon to be administered subcutaneously, weekly, for a [DIAGNOSES REDACTED]. However, the medication was changed from a vial to a penlet on 2/13/19 which required a new Prior Authorization. Despite repeated refill requests from the facility to the pharmacy (on 2/13/19, 2/20/19, 5/7/19, 5/10/19, 6/28/19 and 8/14/19) and pharmacy's repeated notification to the facility (on 2/13/19, 2/14/19, 2/16/19, 2/18/19, 2/19/19, 2/20/19, 2/21/19, 5/10/19 and on 10/7/19) that the medication required Prior Authorization before the prescription could be filled, there is no evidence that a Prior Authorization request was submitted by the facility, to the insurance company, for review until 2/26/2020, at which time it was denied. The Physician was notified, and the medication was discontinued. Therefore, R#3 had not received the Bydureon medication as ordered since 2/6/19, prior to the order being discontinued on 2/26/2020. Further review of the timeline of communication between the pharmacy and the facility revealed that prior to 2/26/2020, facility nursing staff notified the Physician of the medication not being available on 5/7/19 and 10/9/19 but there was no evidence of the Physician's response. In addition to the Bydureon medication order, R#3's diabetes was managed with [MEDICATION NAME] R insulin (routine dose and per sliding scale), [MEDICATION NAME], and FSBS before meals and at bedtime. His most recent hemoglobin A1C (average level of blood glucose over the past 2-3 months) was 11.1% (normal 4-5.6%) on 12/9/19. The Physician documented on the lab results noncompliant with Rx. Review of the clinical record revealed that R#3 was noncompliant with multiple aspects of his care including medications, labs, wound treatments, ADL care, etc. On 3/4/2020 at 11:00 a.m., Physician FF was interviewed regarding the Bydureon injection not being received and the Physician stated it had not impacted his health, that he had wanted the Bydureon because it was a weekly injection and he thought it might help with his compliance. He stated that the resident's compliance would make a difference. Physician FF stated he had been told about the resident needing prior authorization for the medication and he told the facility to keep trying for the approval. 4. R#4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Physician's Orders revealed admission orders [REDACTED]. An order was included for FSBS results to be obtained before meals and at bedtime. A review of the Physician's Insulin Protocol, that accompanied the resident's [MEDICATION NAME] R insulin sliding scale order, revealed that licensed nursing staff were to administer a specific dose of insulin based on the FSBS reading obtained. The sliding scale insulin usage started at a FSBS reading of 150. However, a review of the December 2019 MAR's revealed that the sliding scale insulin protocol was not implemented after 12/10/19. Therefore, R#4 was did not receive any [MEDICATION NAME] R insulin coverage for FSBS results greater than 150 between 12/11/19 and 12/31/19. Further review of the documented FSBS results on the December 2019 MAR indicated [REDACTED]. The following is a list of the dates, times, FSBS reading and amount of insulin warranted for R#4 that was not administered: For the 6:30 a.m. FSBS on 12/12/19, 217, 4 units; 12/13/19, 210, 4 units; 12/14/19, 180, 2 units; 12/15/19, 240, 4 units; 12/16/19, 206, 4 units; 12/17/19, 221, 4 units; 12/18/19, 173, 2 units; 12/19/19, 175, 2 units; 12/20/19, 152, 2 units; 12/21/19, 182, 2 units; 12/22/19, 161, 2 units; 12/23/19, 181, 2 units; 12/24/19, 169, 2 units; 12/25/19, 158, 2 units; and 12/29/19, 192, 2 units. For the 11:30 a.m. FSBS on 12/11/19, 350, 8 units; 12/12/19, 313, 8 units; 12/13/19, 193, 2 units; 12/14/19, 324, 8 units; 12/15/19, 245, 4 units; 12/16/19, 324, 8 units; 12/17/19, 285, 6 units; 12/18/19, 243, 4 units; 12/19/19, 179, 2 units; 12/20/19, 241, 4 units; 12/22/19, 151, 2 units; 12/23/19, 180, 2 units; 12/27/19, 167, 2 units; 12/28/19, 158, 2 units; 12/30/19, 162, 2 units; and 12/31/19, 169, 2 units. For the 4:30 p.m. FSBS on 12/11/19, 360, 10 units; 12/12/19, 261, 6 units; 12/13/19, 280, 6 units; 12/14/19, 429, 12 units; 12/15/19, 217, 4 units; 12/16/19, 205, 4 units; 12/17/19, 273, 6 units; 12/18/19, 215, 4 units; 12/19/19, 216, 4 units; 12/20/19, 200, 2 units; 12/21/19, 245, 4 units; 12/22/19, 198, 2 units; 12/25/19, 261, 6 units; 12/26/19, 216, 4 units; 12/27/19, 155, 2 units; 12/28/19, 192, 2 units; 12/30/19, 169, 2 units; and 12/31/19, 222, 4 units. For the 9:00 p.m. FSBS on 12/12/19, 324, 8 units; 12/14/19, 350, 8 units; 12/15/19, 210, 4 units; 12/16/19, 193, 2 units; 12/17/19, 262, 6 units; 12/18/19, 200, 2 units; 12/19/19, 267, 6 units; 12/20/19, 206, 4 units; 12/21/19, 195, 2 units; 12/22/19, 176, 2 units; 12/23/19, 197, 2 units; 12/28/19, 155, 2 units; and 12/31/19, 199, 2 units. During an interview on 3/3/2020 at 10:00 a.m. the DON stated that the insulin sliding scale order was discontinued in error in December (2019), that the nurse misunderstood the orders. During an interview on 3/3/2020 at 10:35 a.m., Unit Manager BB confirmed that it was her error regarding the sliding scale being discontinued for R#4 in December (2019), that she read the order incorrectly. She stated that the resident's Physician was notified of the error that morning (3/3/2020). During an interview on 3/4/2020 at 11:55 a.m. Physician EE confirmed that he was made aware on 3/3/2020 of the medication omission that occurred in December 2019. The Physician stated he did expect nursing staff to follow the Physician's Orders. 5. R#6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the January 2020 Physician's Orders form revealed the resident had a Physician's Order since 6/28/18 for [MEDICATION NAME] 10 units subcutaneous at bedtime every day. Review of the January 2020 MAR indicated [REDACTED]. In addition, there was documentation on the January 2020 MAR indicated [REDACTED]. However, there were no Physician's Orders with parameters to hold the scheduled [MEDICATION NAME]. During an interview with the DON on 3/12/2020 at 9:50 a.m., she confirmed there were no orders to hold the [MEDICATION NAME]. She could not give an explanation why there was no documentation the medication had been administered for the eight of 31 days in January 2020. 6. R#7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the December 2019 Physician's Orders form, and the Insulin Protocol revealed if the finger stick blood sugar is less than 70 mg/dl give glucose (Glucose= glucose gel, fruit juice, fruit juice with added sugar or [MEDICATION NAME] 50% in water intravenous - IV D50W). However, review of the December 2019 MAR indicated [REDACTED]. During an interview with the DON 3/12/2020 at 9:50 a.m., she stated the staff should have documented if the glucose was given.

Based on staff interviews, record review, pharmacy consultant report review, and review of the Pharmacy Services Agreement and Consultant Pharmacist Retainer Agreement, the facility failed to ensure that irregularities were identified regarding the Physician Ordered Protocol for abnormal blood glucose reading interventions for two residents (R) (#1 and #3), administering the correct amount of insulin as ordered for one resident (#1), obtaining blood glucose readings as ordered for one resident (#2), and administering insulin via a sliding scale dose as ordered for one resident (#4); and failed to act on an irregularity that was identified regarding the unavailability of a diabetic medication for one resident (#3), from a total sample of nine residents. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: R#1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had a Pharmacy Services Agreement in place since 1/30/15. The facility also had a Consultant Pharmacist Retainer Agreement in place since 1/30/15. Responsibilities that were included in the consultant responsibilities included review of the drug regimen of each resident as required and report in writing any irregularities to the Administrator and DON, provide consultation on all aspects of the provision of pharmacy services and review and provide a continuing assessment of Nursing Center compliance with laws, rules and regulations as well as the facility's own pharmaceutical related policies and procedures. A review of the consultant pharmacist's medication regimen review reports revealed that residents' medication regimens were reviewed on a monthly basis. However, despite the monthly medication regimen reviews, irregularities concerning licensed nursing staff not following the physician ordered protocol for abnormal blood glucose results for R#1 and #3, administering the incorrect amount of insulin for R#1 , not obtaining blood glucose readings as ordered for R#2, and not administering insulin via a sliding scale dose as ordered for R#4 were not identified. During an interview on 3/10/2020 at 9:30 a.m., the Administrator stated that the facility also had a Registered Nurse (RN) pharmacy consultant come in and review medication regimens on 9/24/19 and 11/1/19. The RN pharmacy consultant identified an irregularity regarding the availability of a medication (Bydureon) for R#3, but the facility did not act on the irregularity. 1. R#1 had physician's orders [REDACTED]. R#1 also had orders for [MEDICATION NAME] R insulin to be administered based on a sliding scale along with the FSBS checks. A review of the Physician's Insulin Protocol, that accompanied the resident's [MEDICATION NAME] R insulin sliding scale order, revealed that licensed nursing staff were to administer a specific dose of insulin based on the FSBS reading obtained. The sliding scale insulin usage started at a FSBS reading of 150. For a FSBS reading greater than 450, licensed nursing staff were to administer 14 units of insulin. Additionally, licensed nursing staff were to repeat the FSBS in one hour and give insulin again according to the result and the sliding scale. Then, two hours after the first reading (of greater than 450), the FSBS was to be checked again and insulin again administered per the sliding scale. Three hours after the first FSBS reading (that was greater than 450), the FSBS was to be checked again and insulin administered per the sliding scale. If the FSBS reading remained above 450 on the third check, the Physician was to be notified. However, licensed nursing staff failed to consistently monitor the resident and recheck the FSBS three times and administer insulin as needed, per the physician ordered protocol, after an initial FSBS reading of greater than 450 was obtained and an insulin dose administered. Licensed nursing staff failed to follow the protocol for FSBS readings greater than 450: A) 12 times in October 2019. B) 12 times in November 2019. C) 23 times in December 2019. D) 11 times in January 2020. E) nine times in February 2020. Additionally, licensed nursing staff failed to consistently administer the correct amount of insulin, as ordered, for FSBS results greater than 450 for five times in January 2020. Twelve units of [MEDICATION NAME] R insulin was administered, instead of the ordered 14 units. A review of the Summary of Consultant Pharmacist's Medication Regimen Review and accompanying reports from November 2019 through February 2020 revealed that the consultant pharmacist had reviewed R#1's medication regimen between 11/1/19-11/27/19, 12/1/19-12/20/19, 1/1/2020-1/31/2020 and 2/1/2020-2/26/2020. However, there was no evidence that irregularities regarding the incorrect amount of insulin administered or the lack of follow up and monitoring of the repeatedly documented blood sugars greater than 450 was identified. 2. Review of the clinical record for R#2 revealed an 11/22/19 physician's orders [REDACTED]. On 12/27/19, the frequency of the FSBS monitoring was decreased from before meals and at bedtime to three times daily. Therefore, for the month of December 2019, R#2's blood glucose levels should have been obtained four times daily, until it was decreased to three times daily on 12/27/19. However, licensed nursing staff failed to obtain the blood glucose levels as frequently as ordered by the Physician, to determine how much [MEDICATION NAME] R insulin to administer as ordered for the month of December 2019. A review of the clinical record, including the December 2019 MAR's revealed that R#2's blood glucose level was only obtained once daily from 12/1/19 through 12/31/19. A review of the Summary of Consultant Pharmacist's Medication Regimen Review and accompanying reports from December 2019 and January 2020 revealed that the consultant pharmacist had reviewed R#2's medication regimen between 12/1/19 -12/20/19 and 1/1/2020-1/31/2020. However, there was no evidence that the irregularity regarding the frequency of FSBS monitoring for December 2019 was identified. 3. R#3 had physician's orders [REDACTED]. Protocol. However, licensed nursing staff failed to consistently recheck the FSBS, per the Physician Ordered Protocol, after an initial result of greater than 450 once in December 2019 and three times in February 2020. A review of the Summary of Consultant Pharmacist's Medication Regimen Review and accompanying reports from December 2019 through February 2020 revealed that the consultant pharmacist had reviewed R#3's medication regimen between 12/1/19-12/20/19, 1/1/2020-1/31/2020 and 2/1/2020-2/26/2020. However, there was no evidence that irregularities regarding the incorrect amount of insulin administered or the lack of follow up and monitoring of the documented blood sugars greater than 450 was identified. R#3 had a physician's orders [REDACTED]. There is no evidence that a Prior Authorization request was submitted by the facility, to the insurance company, for review until 2/26/2020. A review of the Summary of Consultant Pharmacist's Medication Regimen Review and accompanying reports from November 2019 through February 2020 revealed that the consultant pharmacist had reviewed R#3's medication regimen between 11/1/19 -11/27/19, 12/1/19 -12/20/19, 1/1/2020-1/31/2020 and 2/1/2020-2/26/2020. However, there was no evidence that irregularity regarding the unavailability of the Bydureon medication was identified. A review of the Summary of Nurse Consultant's MAR/Med Pass/Med Cart/Med Room Review reports from 9/24/19 and 11/1/19 revealed that irregularities concerning documentation of the administration of the Bydureon medication were identified on 9/24/19. The 11/1/19 report includes that the Bydureon medication required prior authorization. During an interview on 3/4/2020 at 11:00 a.m., Physician FF stated he had been told about the resident needing prior authorization for the medication and he told the facility to keep trying for the approval. During an interview on 3/10/2020 at 9:30 a.m. the Administrator stated that she and the DON get a copy of the consultant report and the DON breaks up the report between her and the Nurse Managers. She stated that she is unsure why they did not catch the breakdown in their system. 4. Review of R#4's physician's orders [REDACTED]. An order was included for FSBS results to be obtained before meals and at bedtime. Review of the December 2019 MAR's revealed that the sliding scale insulin protocol was not implemented after 12/10/19. Therefore, R#4 was did not receive any [MEDICATION NAME] R insulin coverage for FSBS results greater than 150 between 12/11/19 and 12/31/19. Further review of the documented FSBS results on the December 2019 MAR indicated [REDACTED]. The following is a list of the dates, times, FSBS reading and amount of insulin warranted for R#4 that was not administered: For the 6:30 a.m. FSBS on 12/12/19, 217, 4 units; 12/13/19, 210, 4 units; 12/14/19, 180, 2 units; 12/15/19, 240, 4 units; 12/16/19, 206, 4 units; 12/17/19, 221, 4 units; 12/18/19, 173, 2 units; 12/19/19, 175, 2 units; 12/20/19, 152, 2 units; 12/21/19, 182, 2 units; 12/22/19, 161, 2 units; 12/23/19, 181, 2 units; 12/24/19, 169, 2 units; 12/25/19, 158, 2 units; and 12/29/19, 192, 2 units. For the 11:30 a.m. FSBS on 12/11/19, 350, 8 units; 12/12/19, 313, 8 units; 12/13/19, 193, 2 units; 12/14/19, 324, 8 units; 12/15/19, 245, 4 units; 12/16/19, 324, 8 units; 12/17/19, 285, 6 units; 12/18/19, 243, 4 units; 12/19/19, 179, 2 units; 12/20/19, 241, 4 units; 12/22/19, 151, 2 units; 12/23/19, 180, 2 units; 12/27/19, 167, 2 units; 12/28/19, 158, 2 units; 12/30/19, 162, 2 units; and 12/31/19, 169, 2 units. For the 4:30 p.m. FSBS on 12/11/19, 360, 10 units; 12/12/19, 261, 6 units; 12/13/19, 280, 6 units; 12/14/19, 429, 12 units; 12/15/19, 217, 4 units; 12/16/19, 205, 4 units; 12/17/19, 273, 6 units; 12/18/19, 215, 4 units; 12/19/19, 216, 4 units; 12/20/19, 200, 2 units; 12/21/19, 245, 4 units; 12/22/19, 198, 2 units; 12/25/19, 261, 6 units; 12/26/19, 216, 4 units; 12/27/19, 155, 2 units; 12/28/19, 192, 2 units; 12/30/19, 169, 2 units; and 12/31/19, 222, 4 units. For the 9:00 p.m. FSBS on 12/12/19, 324, 8 units; 12/14/19, 350, 8 units; 12/15/19, 210, 4 units; 12/16/19, 193, 2 units; 12/17/19, 262, 6 units; 12/18/19, 200, 2 units; 12/19/19, 267, 6 units; 12/20/19, 206, 4 units; 12/21/19, 195, 2 units; 12/22/19, 176, 2 units; 12/23/19, 197, 2 units; 12/28/19, 155, 2 units; and 12/31/19, 199, 2 units. A review of the Summary of Consultant Pharmacist's Medication Regimen Review and accompanying reports from December 2019 and January 2020 revealed that the consultant pharmacist had reviewed R#4's medication regimen between 12/1/19-12/20/19 and 1/1/2020 -1/31/2020. However, there was no evidence that the irregularity regarding the discontinuation of the [MEDICATION NAME] R sliding scale for the month of December 2019 was identified.

Based on staff interviews, record review, and review of the Facility Assessment and Quality Assurance and Assessment (QAA) policy, the facility failed to have an effective Quality Assurance process that identified concerns related to the care and management of diabetic residents. The facility census was 83. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: Resident (R) #1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: The Facility assessment dated [DATE], documented that the facility's resident population included residents with diabetes. The facility had a Quality Assurance and Assessment (QAA) policy dated 8/13/12. The policy documented that the QAA policy was to identify quality deficiencies and develop and implement plans of action to correct the quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plan. The policy included that the committee would meet at least quarterly to identify issues with respect to which QAA activities were necessary. In the event that a deficiency was discovered, the facility would have a called QAA committee meeting to process a plan of action. A review of the Quality Assurance (QA) committee meeting sign in sheet revealed that the members of the committee included the Administrator, Physician, Director of Nursing, Care Plan Coordinators, Nurse Managers, Business Office Manager, Activities Director, Dietary Director, Environmental Services Director, Maintenance Director, Medical Records, Medical Supply, Social Services staff, Respiratory Care staff person and Restorative Nursing staff person. A review of the 10/23/19 QA meeting information for the 3rd quarter of 2019 revealed that it included information from the Registered Nurse (RN) Pharmacy Consultant. The Activities Monitored section included following insulin sliding scale as ordered by the Physician. The Opportunity for Improvement section included for nurses to identify and use the correct insulin type, for nurses to check insulin sliding scale dosage and draw insulin required coverage and record the injection site. Prior to the 10/23/19 QA meeting, a QA sub-committee meeting was conducted to address the RN pharmacy consultant identified concerns with an inservice initiated on 10/10/19 with licensed nursing staff. A review of the 1/20/2020 QA meeting information revealed that it also included review of the RN Pharmacy Consultant information, as from the 10/23/19 meeting notes. During an interview on 3/10/2020 at 9:30 a.m. the Administrator stated that the RN Pharmacy Consultant visited the facility on 9/24/19 and identified nursing issues for the facility to work on. The consultant returned on 11/1/19 and re-identified that some of the plans in place were not as successful as they wanted them to be and they provided additional inservices. The consultant returned on 2/17/2020, after surveyor entrance on 2/10/2020. Despite the QA meetings, QA sub-committee meetings and nursing concerns identified by the RN consultant, irregularities concerning licensed nursing staff not notifying the Physician timely of a critical change in condition for R#1, not following the physician ordered protocol for abnormal blood glucose results for R#1 and #3, administering the incorrect amount of insulin for R#1 , not obtaining blood glucose readings as ordered for R#2, and not administering insulin via a sliding scale dose as ordered for R#4 were not identified by the facility.

Based on staff interviews, record review, staff statement review, and review of facility policy titled Condition Change Notification, the facility failed to ensure that the physician was notified in a timely manner of a critical change in condition for one resident (R) (#1) from a total sample of nine residents. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: R#1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had a Condition Change Notification policy dated 3/1/12. The policy documented that upon a change in a resident's condition, the facility would immediately inform the physician if there was a significant change in the resident's physical, mental, or psychosocial status such as a deterioration in status in either life-threatening conditions or clinical complications. The policy included that it would be the responsibility of the Licensed Nurse to notify the physician when a condition change warrants notification. R#1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had a plan of care that included to watch for signs of hypo/[MEDICAL CONDITION] and to be alert for signs of ketoacidosis such as [MEDICATION NAME] breath, dehydration, and rapid, weak pulse. Licensed nursing staff were also to report any significant observations to the Physician. R#1 had physician's orders [REDACTED]. Review of the October 2019 MAR indicated [REDACTED]. A subsequent entry on the MAR indicated [REDACTED]. A 10/31/19 untimed Nurse's Note entry documented that on initial morning rounds, the FSBS was HI and 14 units (of insulin) was administered, the FSBS was rechecked and remained HI, the Physician was notified, and new orders were received to send R#1 to the emergency room . The resident left the facility at 10:40 a.m. via ambulance service transportation. Licensed nursing staff failed to report significant observations and/or changes related to [MEDICAL CONDITION] and ketoacidosis to the physician in a timely manner on 10/31/19. A review of a written statement provided by Licensed Practical Nurse (LPN) CC revealed that on 10/31/19 after the HI FSBS reading at 8:00 a.m. (and [MEDICATION NAME] R insulin coverage) and HI reading again 9:00 a.m., a third check of the blood glucose level was obtained at 9:40 a.m. and continued to read HI on the glucometer. The Physician was notified, and a new order was received to send the resident to the emergency room . A review of text messages that occurred between LPN CC and the Physician on 10/31/19 confirmed that the Physician was not notified of the repeated HI glucometer readings and vomiting until 9:44 a.m., with the Physician responding at 10:08 a.m. A review of hospital documentation revealed that the resident was admitted to the hospital with [REDACTED]. During an interview on 3/2/2020 at 1:02 p.m., Physician FF stated that the 40-minute gap in time (from the second reading of HI at 9:00 a.m. and of him being notified at 9:44 a.m.) was a problem and that he should have been notified sooner. The physician stated that with the vomiting (which was occurring at 8:00 a.m.), the resident needed fluids at that point. Cross refer to F684

Based on staff interviews, record review, review of the Charge Nurse job description, and review of the Georgia Board of Nursing Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, licensed nursing staff failed to utilize appropriate nursing standards and notify the physician, in a timely manner, of signs of [MEDICAL CONDITION] for one resident (R) (#1), from a total sample of nine residents. On 3/10/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, Nurse Manager AA and Nurse Manager BB were informed of the Immediate Jeopardy on 3/10/2020 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/31/19. The Immediate Jeopardy is outlined as follows: R#1 had a [DIAGNOSES REDACTED]. A review of the clinical record revealed that on 10/31/19 at 8:00 a.m. the resident was vomiting and had a glucometer reading of HI, which indicated a blood glucose level greater than 600 milligrams (mg) per deciliter (dL), indicating severe [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) CC administered 14 units of [MEDICATION NAME] R insulin at that time. A recheck of the blood glucose level at 9:00 a.m. indicated that it remained at a level of HI. However, LPN CC failed to notify the Physician of the critical situation of the [MEDICAL CONDITION] and vomiting that had been occurring since 8:00 a.m., until 9:44 a.m. After Physician notification, R#1 was sent out to the hospital and admitted with diabetic ketoacidosis. Additional concerns regarding the management of diabetic residents was also identified. Further record review and interviews revealed concerns with following the Physician's protocol for monitoring and interventions for blood glucose readings less than 70 or greater than 450 for R#1, R#7, and R#3, administering the correct amount of insulin for R#1, obtaining finger stick blood sugar checks as frequently as ordered for R#2, obtaining a diabetic medication as ordered for R#3, administering insulin via a sliding scale as ordered by the Physician for R#4, and withholding insulin without an order for [REDACTED].>The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.10(g)(14), Notify of Changes (F580), Scope/Severity: J; 483.21(b)(1), Develop/Implement Comprehensive Care Plan (F656), Scope/Severity: J; 483.21(b)(3), Services Provided Meet Professional Standards (F658), Scope/Severity: J; 483.25, Quality of Care (F684), Scope/Severity: J; 483.45(c)(4), Drug Regimen Review, Report Irregular, Act On (F756), Scope/Severity: J; 483.70, Administration (F835), Scope/Severity: J; 483.75(g), QAPI/QAA Improvement Activities (F867), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at 483.25, Quality of Care (F684), Scope/Severity: J. At the time of the exit on 3/12/2020, the Immediate Jeopardy remained ongoing. Findings include: A review of the Charge Nurse job description for Registered Nurse (RN) and Licensed Practical Nurse (LPN) charge nurses revealed that one of the primary purposes of the position was to provide direct nursing care to the residents. Review of the Georgia Board of Nursing Rule 410-10-.02: Standards of Practice for Licensed Practical Nurses revealed the practice of license practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not limited to the following: A. Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations; B. Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes The facility utilized (name) glucometers for obtaining FSBS results. A review of the (name) Blood Glucose Monitoring System User Instruction Manual revealed that the glucometer displays results between 20-600 mg/dL. A reading of HI appears when the blood glucose level is greater than 600mg/dL and indicates severe [MEDICAL CONDITION]. The manual also included that if HI is displayed again upon retesting, to contact the patient's healthcare provider immediately. However, licensed nursing staff failed to report significant observations and/or changes related to [MEDICAL CONDITION] and ketoacidosis to the physician in a timely manner on 10/31/19 for R#1. R#1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A care plan was developed that included that R#1 was at risk for hypo/[MEDICAL CONDITION] and other complications related to the [DIAGNOSES REDACTED]. The care plan also included an intervention for licensed nursing staff to report any significant observations to the Physician. Review of the October 2019 MAR indicated [REDACTED]. A subsequent entry on the MAR indicated [REDACTED]. A 10/31/19 untimed Nurse's Note entry documented that on initial morning rounds, the FSBS was HI and 14 units (of insulin) was given, the FSBS was rechecked and remained HI, the Physician was notified, and new orders were received to send R#1 to the emergency room . A 10/31/19 10:30 a.m. Nurse's Note entry documented that the ambulance service was notified for transportation and a 10:40 a.m. Nurse's Note entry noted that the resident was out of the facility via ambulance service transportation. A review of a written statement provided by Licensed Practical Nurse (LPN) CC revealed that on 10/31/19 after the HI FSBS reading at 8:00 a.m. (and [MEDICATION NAME] R insulin coverage) and HI reading again 9:00 a.m., a third check of the blood glucose level was obtained at 9:40 a.m. and continued to read HI on the glucometer. The Physician was notified, and a new order was received to send the resident to the emergency room . A review of text messages that occurred between LPN CC and the Physician on 10/31/19 confirmed that the Physician was not notified of the repeated HI glucometer readings and vomiting until 9:44 a.m., with the Physician responding at 10:08 a.m. A review of hospital documentation revealed that the resident was admitted to the hospital with [REDACTED]. During an interview on 3/3/2020 at 12:20 p.m., LPN CC stated that R#1 was in ketoacidosis, that he could smell a fruity smell, and that the resident was vomiting up until the time he was sent to the emergency room . He stated he was concerned about the resident's condition and called the Physician after he sent the text. During an interview on 3/2/2020 at 1:02 p.m., Physician FF stated that the 40-minute gap in time (from the second reading of HI at 9:00 a.m. and of him being notified at 9:44 a.m.) was a problem and that he should have been notified sooner. The Physician stated that with the vomiting, the resident needed fluids at that point, not just insulin coverage, that administering only insulin with DKA can be dangerous.

Based on medical record review, facility investigative summary review, and staff interview, the facility failed to ensure that services were provided during transfer per the care plan for one (1) resident (#1), whose care plan specified the use of a Hoyer lift with two-person assistance during transfers related to the risk for falls, on the survey sample of six (6) residents. This resulted in Resident #1 sustaining a fall during transfer and a left femur shaft fracture. Findings include: Please cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed a 12/21/2012 Minimum Data Set assessment which indicated that the resident was totally dependent for transfer, requiring the assistance of two persons, and that the resident had impaired lower extremity range of motion on both sides. The care plan for Resident #1 identified the resident's decreased mobility and impaired lower extremity range of motion. This care plan identified a 02/03/2012 Problem indicating a fall-risk, with an Intervention being to use a Hoyer lift with two-person assistance during transfer. A Nurses' Notes entry of 01/12/2013 at 3:20 p.m. for Resident #1 documented that certified nursing assistants (CNAs) were attempting to manually place the resident in a wheelchair, but had sat the resident on the floor during the transfer. The facility's investigative summary, completed by the Director of Nursing (DON), regarding Resident #1's fall documented that on 01/12/2013, the resident had been lowered to the ground, landing on her knees, when two CNAs attempted to transfer her from the bed to a shower chair without using the lift as required by the care plan. A Nurse's Notes entry of 01/13/2013 at 9:30 p.m. documented that the resident complained of knee pain, with knee swelling noted. A subsequent Nurse's Notes entry of 01/14/2013 at 9:00 a.m. documented that an order was obtained for an x-ray for both knees, and a Nurse's Notes entry of 01/14/2013 at 9:30 p.m. documented that the x-ray report indicated that the resident had a leg fracture. During interview with the Administrator and the DON conducted on 01/18/2013 at approximately 3:10 p.m., and subsequently on 02/01/2013 at 10:30 a.m., the above findings were acknowledged.

Based on medical record review, hospital Operative Report review, facility investigative summary review, and staff interview, the facility failed to ensure the adequate supervision/assistance to prevent an accident for one (1) resident (#1), who was assessed as being dependent on staff for transfer and mobility, on the survey sample of six (6) residents. This resulted in Resident #1 sustaining a fall during transfer and a left femur shaft fracture, requiring femur closed reduction nail fixation surgical repair. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident required the extensive assistance of two persons for bed mobility, and was totally dependent for transfer, requiring the assistance of two persons. This MDS also indicated that the resident had impairment of lower extremity range of motion on both sides, and had [DIAGNOSES REDACTED]. The care plan for Resident #1 identified, as did the MDS referenced above, that the resident required assistance with activities of daily living related to decreased mobility and impaired range of motion of the lower extremities. This care plan also identified a Problem, initially dated 02/03/2012, indicating the resident was at risk for falls secondary to impaired physical mobility, with one of the Interventions being to use a Hoyer lift with two-person assistance during transfers. The Nurse Aide's Information Sheet for Resident #1 also specified the use of a Hoyer lift with two people during transfer. A Nurses' Notes entry of 01/12/2013 at 3:20 p.m. for Resident #1 documented that certified nursing assistants (CNAs) were attempting to place the resident in a wheelchair, but further documented that the resident was too heavy to manually lift and the CNAs had to sit the resident on the floor to prevent from dropping her. This Notes entry documented that the resident's vital signs were taken and that no injuries were noted at that time. The facility's summary, completed by the Director of Nursing (DON), of the investigation of this fall involving Resident #1 documented that on 01/12/2013 at approximately 10:00 a.m., the resident had been lowered to the ground, landing on her knees, when two CNAs attempted to transfer her from the the bed to a shower chair without using the lift as required by the care plan and as instructed by the Nurse Aide's Information Sheet. This investigation summary also documented that assessment at the time of the incident revealed no complaints of pain or discomfort. However, a Nurse's Notes entry of 01/13/2013 at 9:30 p.m. documented that the resident was complaining of pain in the knees and that the knees were swollen. A Nurse's Notes entry of 01/14/2013 at 9:00 a.m. documented that the physician's office was notified of the resident's fall, and that an order was obtained for an x-ray for both knees related to the fall. In the facility's investigative summary referenced above, the DON documented that upon her arrival at the facility on 01/14/2013, she reviewed the Fall Incident Report for Resident #1's fall, and spoke with the resident, who complained of some pain in the right knee. The DON also noted the resident to have mild edema to both knees, so she therefore notified the physician of the resident's symptoms and received the order for the x-ray of the bilateral knees and upper legs. A Nurse's Notes entry of 01/14/2013 at 9:30 p.m. documented that the x-ray report results for Resident #1 had returned and indicated that the resident had a leg fracture. This Notes entry also documented that the doctor was notified of the results and gave an order to transport the resident to the emergency room for evaluation. This Notes entry also documented that the resident had been transported to the hospital for evaluation. Review of the Medication Administration Record (MAR) for Resident #1 for the period of time from the fall of 01/12/2013 through the hospital transfer of 01/14/2013 revealed that the resident had received the pain medication Vicodin 5/500 milligrams, as routinely ordered for rheumatoid arthritis, three times daily, at 9:00 a.m., 1:00 p.m., and 9:00 p.m., during 01/12/2013, 01/13/2013 and 01/14/2013. This MAR also documented that the resident had received an additional as-needed dose of Vicodin 5/500 milligrams at 3:15 a.m. on 01/14/2013. The hospital Operative Report of 01/16/2013 for Resident #1 documented the resident had a left femur shaft fracture, and documented that the resident had undergone a left femur closed reduction nail fixation. During interview with the Administrator and the DON conducted on 01/18/2013 at approximately 3:10 p.m., and subsequently on 02/01/2013 at 10:30 a.m., the above findings were acknowledged.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to implement care plan interventions to provide activities of daily living (ADL) care for two residents (#13 and #12), to provide passive range of motion exercises for one resident (#13) to assess the intensity of pain and review the pain management plan as needed for one resident ("A"), to provide oxygen as ordered for one resident (#5), to provide nail care for one resident (#13), from a total sample of 21 residents. This failure caused actual harm for resident "A". Findings include: 1. Resident "A" had a care plan since 7/7/10 for nursing staff to assess the location, frequency, duration and intensity of his/her pain, to document the assessment and report an increase in pain trend to the physician, and to review the resident's pain management plan as needed and document the findings. However, despite the resident frequently requesting pain medication, the nursing staff failed to consistently assess the intensity and identify an increase in the intensity of pain for resident "A". See F309 for additional information regarding resident "A". Resident "A" had a care plan since 7/7/10 for staff to assess the resident's need for assistive and/or supportive devices and to provide a shower three times weekly. However, resident and staff interviews revealed that nursing staff had not been assisted the resident to get out of bed to the shower since being readmitted to the facility on [DATE] because of his/her fear of being transferred using the Hoyer lift. See F246 for additional information regarding resident "A". 2. Resident #13 had a care plan since 2/22/10 for requiring total assistance from nursing staff for activities-of-daily living (ADLs). There was an intervention for nursing staff to provide showers three times weekly and bed baths on all other days. There was an intervention to provide nail care with baths. However during an observation of a bed bath on 9/29/10 from 8:45 a.m. to 9:10 a.m., nursing staff failed to bath the resident's entire body and provide nail care. See F312 for addition information regarding resident #13. Resident #13 had a care plan since 2/22/10 for behavioral concerns that included the resident scratched him/herself. There was an intervention for nursing staff to keep the resident's nails trimmed short. However, the resident's nails were observed to have been jagged and uneven on 9/29/10 from 8:45 a.m. to 9:10 a.m. and at 11:30 a.m. See F323 for additional information regarding resident #13. The resident had a care plan intervention since 2/22/10 for staff to provide range of motion exercises to his/her extremities during care. However, range of motion exercises were not provided by nursing staff during an observation of morning care on 9/29/10 from 8:45 a.m. to 9:10 a.m. See F318 for additional information regarding resident #13. 3. Resident #12 had a care plan intervention since 8/17/10 for nursing staff to provide showers three times weekly and bed baths on all other days. However, during an observation of a bed bath on 9/29/10 from 9:45 a.m. to 10:08 a.m., nursing staff failed to bathe the resident's entire body. See F312 for additional information regarding resident #12. 4. Resident #5 had a care plan since 9/23/10 to address his/her potential for shortness of breath because of a recent hospitalization and [DIAGNOSES REDACTED]. There was a 9/23/10 physician's orders [REDACTED]. However, during the initial tour on 9/28/10 between 10 a.m. and 12 p.m., at 12:35 p.m., 2:20 p.m. and 4:25 p.m., on 9/29/10 at 8:10 a.m., 11:00 a.m., 1:40 p.m. and 4:10 p.m., and on 9/30/10 at 7:20 a.m., 10:00 a.m. and 11:05 a.m., nursing staff had incorrectly set the resident's oxygen to infuse at a rate between 2 and 2.5 liters a minute. See F328 for additional information regarding resident #5.

Based on observations, resident and staff interviews, and record reviews, it was determined that the facility failed to thoroughly assess and address one resident's ("A") complaints of pain and failed to administer medication as ordered for one resident (#13) from a total sample of 21 residents. This failure resulted in actual harm for resident "A". Findings include: 1. Resident "A" had [DIAGNOSES REDACTED]. Nursing staff coded the resident on his/her 7/5/10 initial Minimum Data Set (MDS) assessment as having full loss of range of motion of both arms and hands. There was an 8/31/10 Occupational Therapy Daily Note that the resident, the resident's nurse and the charge nurse were educated on the schedule for the resident to be wearing his/her hand and wrist splints and for preventing skin breakdown. There was a care plan intervention since 7/7/10 for nursing staff to assess the location, frequency, duration and intensity of the resident's pain, to document that pain assessment and to report a trend of increased pain to the physician. There was also an intervention nursing staff to review the resident's pain management plan as needed and to document the findings. On 9/28/10 at 1:30 p.m., resident "A" stated that he/she had not been wearing the hand and wrist splints because of having increased pain in his/her fingers. The resident stated that the pain in his/her fingers was "pretty intense" especially in the index fingers. On 9/29/10 at 1:20 p.m., resident "A" stated that the nursing staff had tried to wash his/her hands that morning but, his/her hands were too painful. He/She rated his/her pain at 10 out of 10 on a 0 to 10 pain scale. Resident "A" said that he/she had pain in his/her hands daily but, the pain medication was not effective. Resident "A" said that he/she had reported the increase in pain and ineffectiveness of the pain medication to all of the nurses who provided care for him/her. Resident "A" stated that the nursing staff replied that the nurse practitioner had to be notified but, he/she did not know whether or not the nursing staff had followed up with the nurse practitioner. A review of the September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the August 2010 MAR indicated [REDACTED]. On 9/30/10 at 9:00 a.m., licensed nurse "CC" stated that resident "A" had reported to her on 9/29/10 that his/her pain medication was ineffective. "CC" said that she told the resident that she would follow-up with the nurse practitioner. However, licensed nurse "CC" stated that she had not yet contacted the nurse practitioner. During an interview on 9/30/10 at 2:25 p.m., the nurse practitioner stated that she had not been contacted or made aware of the resident's report that his/her pain medication was not effective. 2. Resident #13 had a physician's orders [REDACTED]. However a review of the Medication Administration Records revealed that nursing staff failed to administer the ordered [MEDICATION NAME] as scheduled 4/2, 4/30, 6/4, 6/11, 6/18, 6/25, 7/2, 7/16, 8/6, 8/13, 8/20, and 8/27/10.