Every finding on record at Solaris Healthcare Parkway

Based on policy review, record review, and interview, the facility failed to ensure a properly executed DNR (Do Not Resuscitate) Order for 3 of 3 sampled residents, as evidenced by incomplete yellow copy DNR Order forms for Residents #134, #116, and #62.The findings included:Review of the policy Advance Directives dated [DATE], documented in part, 5. b. Do Not Resuscitate – Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care DPOA, health care surrogate or health care proxy has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Review of the policy Do Not Resuscitate Order dated [DATE], documented in part, 3. Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT personnel transporting the resident to the hospital. 1. Review of the record revealed Resident #134 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. The record lacked an incapacity form or evidence of a health care surrogate or power of attorney. Review of the record revealed the current code status for Resident #134 was DNR (Do Not Resuscitate). Review of the corresponding yellow copy Do Not Resuscitate Order (DNRO), documenting the resident and or resident representatives' choice for a DNR status, and provided to emergency medical staff upon transfer to the hospital, was incomplete. This form had the printed name of Resident #134 but lacked the resident's signature and the date the resident would have signed the form. 2. Review of the record revealed Resident #116 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the record revealed the current code status for Resident #116 was DNR. Review of the corresponding yellow copy Do Not Resuscitate Order, lacked the resident's date of birth , the date the resident signed the form indicating her wishes, and the resident's printed name. During an interview on [DATE] at 9:48 AM, when asked if she understood her DNR status, Resident #116 stated, Yes, when I stop breathing, I don't want anything done. When asked if she recalled signing the form, the resident stated she did not, and stated she was quite ill upon admission to the facility. 3. Review of the record revealed Resident #62 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. The record also showed evidence of a health care surrogate or power of attorney. Review of the record revealed the current code status for Resident #62 was DNR. Review of the corresponding yellow copy of the Do Not Resuscitate Order, which documents the resident and or the resident's representative's choice for a DNR status, and is provided to emergency medical staff upon transfer to the hospital, revealed it was incomplete. This form had the printed names of Resident #62 and the resident's representative but lacked the resident's date of birth and date the resident's representative would have signed the form. During an interview on [DATE] at approximately 12:30 PM, when asked the process for ensuring a resident's code status, specifically regarding a DNR order, Staff D, Licensed Practical Nurse (LPN), explained the facility's process. The LPN stated the nurse or social worker speaks with the resident and or family to ensure understanding of the DNR and obtains the order. When asked if the DNR Order was valid if incomplete, Staff D replied, No, each section has to be completed, signed, and dated for the form to be valid. During a side-by-side review of the records for Residents #62, #116, and #134, Staff D confirmed that the yellow copies of the DNR Orders were missing the residents' date of birth , date the residents' representative signed the form, and or residents' signature.

Based on observation, record, review and interviews, the facility failed to provide care and services for the treatment and prevention of wounds for 5 of 38 sampled residents as evidenced by failure to follow physician orders for the treatment of a wound for Residents #182 and #36, failure to ensure Resident #184 had treatment for a rash, and failure to complete weekly skin assessments for Residents #182, #27, and #134.The findings included:1. Record review revealed Resident #182 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment. During an observation on 12/01/25 at 11:09 AM, Resident #182 was observed sitting in his wheelchair wearing shorts and a white square dressing that was undated was noted to his right shin. During an interview on 12/01/25 at 11:09 AM, when asked why about the dressing on the right leg, Resident #182 stated, Well that happened in therapy during a fall. When asked when the last time the dressing was changed, he said, yesterday. When asked how often the dressing is changed He stated, every 2-3 days. Review of a physician order dated 11/21/25 instructed staff to cleanse the skin tear to Resident #182 right shin with normal saline (salt water), apply xeroform (Vaseline gauze) and dry dressing daily on day shift (7AM To 3PM). Review of the November and December 2025 Treatment Administration Record (TAR) revealed that the nurses were documenting that the dressing to Resident's right shin wound was being changed daily. During an observation on 12/03/25 at 9:12 8:48 AM, Resident #182 was observed in bed with a white square dressing, not dated, to his right shin. During an interview on 12/03/25 at 9:12 AM, Resident #182 was asked if his dressing was changed yesterday, he stated, No, but I don't think I need the dressing anymore; the last time they changed it was about two days ago; it was almost healed. They should be changing it again today. During an interview on 12/03/25 at 9:12 AM, when asked if the nurse changed the dressing today, he stated it still needed a dressing. 2. Review of the physician orders dated 11/07/25 instructed staff to perform weekly skin checks on Resident #182 every Friday on the 7 AM-3 PM shift. Review of the skin assessments for Resident #182 revealed documentation of a skin check done only on 11/25/25. Review the November and December 2025 TAR revealed documentation of staff signing that skin checks were done on Resident #182 every Friday as ordered. 3. Record review revealed Resident #184 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a BIMS score of 03 on a 0-15 scale, indicating severe cognitive impairment. During an observation on 12/02/25 at 10:18 AM, Staff H was noted in the hallway, As she walked by Resident #184's room, she asked the resident if she was ok and why are you doing this (as she demonstrated the movement of her rubbing the left chest area). The resident said yes, and Staff H continued walking down the hall. During an observation on 12/02/25 at 10:21 AM, Resident #184 was noted sitting on the side her bed scratching the left chest area. During an interview on12/02/25 at 10:22AM when asked if her skin was itching, Resident #184 stated Yes. She was asked if she had a rash, she did not respond but she pulled her shirt down so her left chest could be seen. It revealed a reddened area with small pimples and scratches to her left chest area. During an interview on 12/03/25 T 9:35 AM when asked if she was still having itchiness to your chest area, Resident #184 showed the area on left chest, and she started to scratch. Her left chest area was noted to have increased redness, tiny pimples and scratches that appeared to be a rash. During an interview on 12/03/25 at 9:44 AM, Staff H was asked to go with surveyor to Resident #184's room. At this time, she was made aware that the resident was observed over the past two days scratching her left chest area. She stated, I noticed her doing that yesterday. She was made aware that she was overheard on Monday asking the resident, from the hallway, if she was ok, as she saw the resident rubbing her chest area, but she did not go into her room. Staff H asked the resident if she could look at her chest, as she applied a pair of gloves. The resident pulled down her gown, Staff H assessed her chest area and stated, Oh my, I will take care of it. Review of the physician orders for Resident #184, did not reveal any new orders for a rash. During an interview on 12/04/25 at 8:58 AM, when asked did they obtained medication for the itchy area on your chest, Resident #184 shook her head and said, she began to show the rash by pulling down her gown and it was noted that the redness, pimples and scratches were also now on the right and left side of her chest. During an interview on 12/04/25 at 9:02AM when asked if she received report regarding a skin issue for Resident #184, Staff I, License Practical Nurse, looked at her notes and stated No. During an observation on 12/04/25 at 9:08 AM, Staff I was observed assessing Resident #184's chest area. She stated Yes I see. It looks like a pattern, both areas are circular. She asked the resident if it was itchy and she said a little bit. Staff I stated, I will notify the doctor. During an interview on 12/04/202 at 9:10 AM, Staff I stated, I just wanted to let you know that I notified the doctor and I'm waiting for a response. Review of the physician orders revealed a new order for Resident #184 dated 12/04/25 instructed staff to apply triamcinolone acetonide cream (steroid cream for inflammation, itching) topically to chest daily for 10 days. 4. The facility's policy, 'Dressings, Dry/Clean' with a reference date of 12/10/24 documented: Steps in the procedure: 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing. Record review documented Resident #36 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS with a reference date of 11/03/25, Resident #36 had a BIMS score of 09, indicating the resident had moderate cognitive impairment. Resident #36's diagnoses at the time of the assessment included: Anemia, Hypertension, Hyperlipidemia, Aphasia, Non-Alzheimer's dementia, Seizure disorder, Malnutrition, Anxiety disorder, Depression, Encephalopathy, Hypokalemia, Opioid dependence, and Chronic pain. Resident #36's physician's orders included: Skin prep right elbow intact blood blister with skin prep daily and cover with foam dressing daily – 11/17/25. During an interview, on 12/02/25 at 10:28 AM with Resident #36, it was noted that the resident had a wound dressing on the right arm near the elbow that was not dated. When asked about the wound. Resident #36 stated that the dressing was changed every day and that it was for a blood blister that had opened after a fall. During an interview, on 12/04/25 at 10:16 AM, with the Risk Manager / Wound Care Nurse, when asked about providing dressing changes to the wound, the Wound care Nurse replied, I do rounds with the provider, the nurses on the unit are being done by the nurses on the floor and they report the Unit Manager on the units - care was provided by nurse on shift that day. During an interview, on 12/04/25 at 10:31 AM, with Staff A, Registered Nurse, when asked about Resident #36's wound, Staff A replied, she had knocked her arm on the handle of the closet on 11/13/25 and it became a fluid filled blister. The last time I saw it, it was flat (12/01/25 at about 11:30 AM). The RN was shown the photographic evidence of the dressing that was obtained and acknowledged that she was the one who provided the dressing and acknowledged that the dressing should have been dated and was not. 5. Review of the record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses to include dementia. Review of the MDS assessment dated [DATE] documented the resident had a BIMS score of 3, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS also documented that the resident was at risk for pressure injuries. Review of the current care plan initiated on 02/26/24 and reviewed and or revised on 11/13/25 documented Resident #27 was at risk for skin alterations with an approach for the nursing staff to complete weekly skin checks. Review of current physician orders documented as of 03/29/24 staff were to complete weekly skin checks every Thursday on the 3 PM to 11 PM shift. The orders also instructed as of 08/06/25, staff were to apply a zinc oxide barrier cream to the resident's buttock for preventative measures. Further review of the record revealed the most current weekly skin check was completed on 11/21/25, and lacked a skin check the week of 11/23/25 through 11/29/25. 6. Review of the record revealed Resident #134 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented that the resident had a BIMS score of 10, on a 0 to 15 scale, indicating moderate cognitive impairment. This MDS also documented the resident had a current unhealed pressure injury and was at risk for further pressure injuries. Review of the current care plan initiated on 06/08/25 and reviewed and or revised on 12/01/25 documented Resident #134 was at risk for further skin alteration, and had moisture associated dermatitis as of 10/26/25. One of the approaches was for the nursing staff to complete weekly skin checks. Current physician orders included the weekly skin checks as of 06/16/25 and a protective ointment to the buttock. Further review of the record revealed the most current weekly skin check was completed on 11/21/25, and lacked a skin check the week of 11/23/25 through 11/29/25. During an interview on 12/04/25 at 11:01 AM, when asked how staff knew when a resident's weekly skin check was due to be completed, the Assistant Director of Nursing (ADON) explained that each unit had a schedule, an order was placed in the resident's medical record, and the nurses were expected to sign off the completion of the skin check in the Medication Administration Record (MAR) and complete the documented observation form. The ADON confirmed the weekly skin checks for Residents #27 and #134 were signed off as completed on the respective MARs, but the skin checks were not completed as the observation forms had not been done.

Based on observation, interview, and record review, the facility failed to provide appropriate care and positioning equipment for 2 of 3 sampled residents as evidenced by failure to provide properly fitting wheelchair leg rests for Resident #118 and failure to provide a hand/towel roll for hand contractures to Resident #12. The findings included: 1. Review of clinical record revealed Resident #118 was admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infarction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #118 had a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale, indicating the resident had intact cognition. During an initial interview on 12/01/25 at 11:20 AM, Resident #118 stated that he would like to go to activities but cannot go since his knees do not bend anymore and sitting in the wheelchair causes his legs to hurt. Resident #118 stated that he thinks he is worse now than when he got here. Resident #118 was asked how long it had been since he was in his wheelchair and he replied, at least 2-3 weeks ago. Resident #118 was then asked who he had told about the issue with his legs and the wheelchair to which he replied, 'everyone knows'. Review of the care plan dated 08/25/25 revealed that Resident #118 was interested in participating in his own leisure time activities (watching TV, people watching in the hallway, visiting family, and socializing with staff and resting). He had decreased mobility, secondary to a diagnosis of foot drop, cerebral infarction with bilateral hemiplegia as evidenced by Resident #118 requiring partial/moderate assistance with bed mobility, transfers, dependent with wheelchair, is non-ambulatory. Review of the Physical Therapy Evaluation dated 04/01/25, in part, in the section Musculoskeletal Assessment Contractures revealed Resident #118 did not have any functional limitations present due to contractures and that Lower Extremity Range of Motion was listed as Within Functional Limits (WFL) for both the Right and Left Lower Extremities. Review of the Physical Therapy Discharge summary dated [DATE], in part, revealed Resident #118 required partial / moderate assistance with bed mobility, partial / moderate assistance with transfers, and walked 10 feet with partial / moderate assistance. Review of Occupational Therapy Discharge Summary, in part, revealed Resident #118 required supervision / touch assistance to self-propel a wheelchair and make two turns throughout the nursing facility. Review of the Physical Therapy and Occupational Therapy Evaluations that were completed on 12/03/25, revealed that Resident #118 required substantial / maximal assistance for bed mobility, was dependent on transfers, could not attempt walking, and was able to sit up in wheelchair for 90 minutes. Resident #118's wheelchair was listed as a reclining wheelchair with adaptive equipment / devices of elevating leg rests, head rest, calf pad or other positioning devices to accommodate bilateral lower extremity contractures. In the PT/OT evaluation of 12/03/25, the Musculoskeletal Assessment revealed Resident #118 had impaired Range of Motion (ROM) to both lower extremities (hips, knees and ankles) and had functional limitations present due to contractures to bilateral hips, knees and ankles. An interview was conducted on 12/03/25 at 11:00 AM with Staff E, Licensed Practical Nurse (LPN), who stated he knows Resident #118 well. When Staff E was asked if Resident #118 gets up in his wheelchair, he stated that Resident #118 usually refuses to get up in the wheelchair and that Resident #118 complains of pain in his legs while in bed. Staff E was asked how often Resident #118 gets up in his wheelchair and he stated only for doctors' appointments. Staff E stated that Resident #118 had family visit the day after Thanksgiving and Resident #118's family wanted to bring him outside but Resident #118 refused to get up in the wheelchair but never said why he did not want to get in the wheelchair. An interview was conducted with Staff F, LPN, on 12/03/25 at 11:05 AM who also works on the unit and knows Resident #118. Staff F stated that whenever Resident #118 was in his wheelchair he complained of pain and would request to go back to bed. When Staff F was asked if she knew why he is in pain in the wheelchair she replied, No, he never said why he just asked to go back to bed. Staff F was then asked how often Resident #118 gets up in his wheelchair and she replied, only for doctor's appointments. Staff F was asked when Resident #118 had his last doctor's appointment, she replied he had a cardiologist appointment on 10/06/25. An interview was conducted with Resident #118 on 12/03/25 at 11:17 AM and he was advised that his last doctor's appointment out of the building was on 10/06/25, and he was asked if he remembered how he felt in the wheelchair at that time and Resident #118 replied, it hurt to be in the wheelchair and I was in pain. Resident #118 was asked if he told staff that it was the wheelchair that was causing him to have leg pain and he stated that he had told staff that his legs hurt when sitting in the wheelchair. An interview was conducted on 12/03/25 at 11:28 AM with Staff G, LPN / Unit Manager, who stated that Resident #118 was refusing to get up in the wheelchair, and we think it is because he has a fear of falling. Staff G was asked if Resident #118 had a standard wheelchair or any adaptive wheelchair parts to which she replied, I think he has something to support his legs like a buddy board/calf board. An interview was conducted on 12/03/25 at 11:35 AM with the Rehabilitation Director, who stated that she is an Occupational Therapist (OT) and has worked with Resident #118 in the past. The Rehabilitation Director was asked if Resident #118 had any special adaptations to his wheelchair or if she had been advised that he does not want to get out of bed and she stated that in her knowledge of Resident #118, he does not want to get out of bed and that there were not any orders for adaptive equipment for his wheelchair, but that she would go to his room and check his wheelchair. On 12/03/25 at 12:04 PM the Rehabilitation Director stated that she had just met with Resident #118 and assessed his current wheelchair and he had standard (non-elevating) legs rests on the wheelchair and that Resident #118 advised her that his knees do not bend enough to use that type of leg rest and he agreed to get up in the wheelchair if it had leg rests that would support his legs. The Rehabilitation Director stated that staff would transfer Resident #118 to his wheelchair after lunch and she would work with him on positioning in the wheelchair. On 12/03/25 at 2:01 PM, Staff E stated that they had just tried to transfer Resident #118 from his bed to the wheelchair using a mechanical lift (Hoyer) and Resident #118 was in too much pain to continue the transfer since his knees were bending when he was in the sling. Staff had to lower Resident #118 back to bed. On 12/03/25 at 2:07 PM, the Rehabilitation Director was notified by the surveyor that Resident #118 had to be put back to bed since he was unable to tolerate the Hoyer lift transfer from his bed to the wheelchair. The Rehabilitation Director was asked how she should have found out about Resident #118's decline in his ability to bend his knees and tolerate sitting in the wheelchair. She stated either through a Therapy Quarterly Screening or through a nursing request for a Therapy screening. Observations on 12/03/25 at 2:23 PM revealed Staff E, Certified Nursing Assistant (CNA), and the Rehabilitation Director were able to transfer Resident #118 to the wheelchair. When he passed the surveyor on his way to the therapy gym in his wheelchair, he was in a wheelchair with a reclining back and elevating leg rests (keeping his knees straight out instead of bent) and a pillow under his legs. Observations on 12/03/25 at 3:23 PM revealed Resident #118 was in the therapy gym sitting upright in his wheelchair and stated that he was happy to be out of bed. The Rehabilitation Director stated that Resident #118 was able to self-propel the wheelchair around the gym today and that Physical Therapy had done an Evaluation to initiate Physical Therapy services. The Rehabilitation Director stated that Occupational Therapy had completed Quarterly Screening on Resident #118 on 10/02/25 with documented results that Resident #118 presented with a decline in functional transfers and that Physical Therapy or Occupational Therapy would conduct an evaluation. An interview was conducted on 12/04/25 at 9:54 AM with Resident #118 who was asked if he had expressed fear of falling to staff and he stated that he was nervous about pain having to do with his knees, hips and ankles and not about falling. An interview was conducted on 12/04/25 at 2:55 PM with the Rehabilitation Director who was asked why Resident #118 was not evaluated after the Quarterly Therapy Screening on 10/02/25 and she stated that from what she can recall, therapy staff had asked Resident #118 to transfer to his wheelchair and go to therapy a few times after the screening and Resident #118 refused to get out of bed but that she did not have any documentation of the refusals. An interview was conducted with Resident #118 on 12/04/25 at 3:05 PM to see if he remembered being screened by someone from Occupational Therapy and if he refused to be evaluated by therapy and he replied, 'No. I do not remember that, I may have refused to get up in that wheelchair but I would've gladly started therapy if they could've helped me, I want to get out of here and go home. 2. Record review revealed Resident #12 was readmitted to the facility on [DATE]. Review of the annual assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 on a 0-15 scale, indicating severe cognitive impairment. Review of the medical diagnosis documented a history of CVA (stroke) with Left Hemiparesis (left side paralysis). During an observation on 12/01/2025 at 10:26 AM Resident #12 was in her room sitting in her low chair, and her hands were noted to be contracted. No splints or brace was noted to her hands. Review of the care plan dated 11/02/25 documented Resident #12 had a problem with ADL [Activities of Daily Living] / Mobility, self-care deficit related to Dx [diagnosis] of CVA with (L) [left] Hemiparesis, Aphasia, Seizures, Hypothyroidism, Subdural Hematoma (Hx) [History], Abnormal Gait, Alzheimer's Disease, Muscle Weakness as evidenced by she required total dependence with wheel-chair mobility / non-ambulatory / dependence in bed mobility/transfers x2 / substantial / max with meals dependent /oral hygiene / dressing / bathing / showers / personal grooming, with a goal that Resident #12 will feed herself with substantial / max assist from staff and one of the approaches included to provide a rolled wash cloth in her right hand and to remove it for hygiene and skin observation. Review of a physician order dated 07/09/2024 instructed staff to place a rolled-up wash cloth in Resident #12's right hand once a day at 0900 AM. During an observation on 12/02/25 at 12:42 PM, Resident #12 was observed in her room sitting in her chair, no splint or rolled towel was noted to her right hand. The resident's bilateral hands were contracted. During an observation on 12/03/25 at 9:28 AM, Resident #12 was observed in the hallway sitting in her chair, bilateral hands contracted a hand splint or towel was not noted to her right hand. Review of the December 2025 Medication Administration Record (MAR) revealed documentation that Staff H had signed on 12/01/25 and 12/03/25, indicating that she had applied the rolled towel to Resident #12's right hand. During an interview on 12/03/25 at 9:40 AM, when asked does Resident #12 wear a splint or device to her hands for the contractures. Staff H, Registered Nurse (RN) stated Yes, she has a wrist guard that she is supposed to wear as tolerated but she has behavior issues, so she refuses it. When Staff H was asked if she had tried to put on the wrist guard, she stated, No, we will try. During a follow-up interview on 12/03/25 at 9:45 AM, Staff H stated, I'm sorry, but Resident #12 does not wear a wrist guard, it's a rolled towel, I float so, I didn't know. When she was asked if she had been on this unit for the past few days, Staff H stated, Yes, but I'm everywhere.

Based on observations, interviews and record reviews, the facility failed to assess residents for safe smoking for 2 of 3 sampled residents reviewed for smoking, Residents #38 and #170. The findings included: Review of the facility's policy, titled, 'Smoking Policy' with a reference date of 01/07/22, documented, in part: 'Procedure: 3. A smoking assessment will be completed upon admission, quarterly during care plan review, and upon a change in resident condition 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 09/03/25, Resident #38 had a Brief Interview for Metal Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #38's diagnoses at the time of the assessment included: Heart failure, Hypertension, DM, Hyponatremia, anxiety disorder, Depression, Chronic lung disease, Respiratory failure, Muscle weakness, Chronic pain, and Bronchiectasis.Review of Resident #38's care plan for Nicotine use, with a start date of 12/11/24 documented, 11/12/25 noted coming from smoking patio wearing oxygen. The goal of the care plan was documented as, Patient/resident will demonstrate safe smoking practice thru target date: 12/10/25. Interventions in the care plan included: Complete smoking assessment upon admission and quarterly and as needed - 12/11/24. A Smoking Data Collection and Assessment, with a reference date of 03/05/25, concluded that the resident was able to smoke safely without supervision. Further review of the resident's electronic health records revealed no additional assessments being completed at least quarterly and upon being observed coming from the smoking patio wearing oxygen on 11/12/25. 2. Record review revealed Resident #170 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. According to the resident's most recent complete assessment, an Annual MDS with a reference date of10/03/25, Resident #170 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #170's diagnoses at the time of the assessment included: Anemia, Atrial fibrillation, Gastro-esophageal Reflux disease (GERD), Coronary Artery Disease (CAD), Heart failure, Hypertension, Diabetes Mellitus, Alzheimer' disease, Non-Alzheimer's dementia, Anxiety disorder, Depression, Chronic lung disease, and Respiratory failure.Review of Resident #170's care plan for nicotine use, with a reference date of 10/14/24, documented, 01/20/25 noted smoking in room. Educated on dangers of smoking inside of the building. The goal of the care plan was documented as, Patient/resident will demonstrate safe smoking practice thru target date 01/09/26. An intervention to the care plan included: Complete smoking assessment upon admission and quarterly and as needed - 10/14/24.A Smoking Data Collection and Assessment, with a reference date of 04/01/25, concluded that the resident was able to smoke safely without supervision. Further review of the resident's electronic health records revealed no additional assessments being completed at least quarterly. During an interview on 12/04/25 at 11:38 AM with the Assistant Director of Nursing (ADON) and Staff B, RN/Unit Manager, when asked about completing the smoking assessments for the residents, the RN/UM replied, I am responsible for my units. The Unit Managers are responsible for their units. When asked about assessments being completed for Residents #38 and #170, the RN/UM replied, He moved to me later that year (referring to Resident #38). The ADON replied, they were missed.

Based on policy review, observation, interview, and record review, the facility failed to ensure appropriate care and services for oxygen use for 1 of 3 sampled residents as evidenced by the lack of oxygen order and oxygen saturation assessment for Resident #124.The findings included:Review of the policy Oxygen Administration dated January 2020, documented in part, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Review of the record showed Resident #124 was admitted on [DATE] with a diagnosis including Heart Failure. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating severe cognitive impairment.Review of the progress noted dated 10/18/25, revealed the resident had a productive cough and wheezing for which a chest X-ray was ordered. Based on the results, the resident was diagnosed with Pneumonia.Review of a progress note dated 10/20/25 documented the resident's oxygen saturation was in the 70%s and that the resident was prescribed and administered 2 liters of oxygen (O2) to be delivered by nasal cannula (NC) as well as breathing treatments. Further record review revealed that on 10/22/25, 10/24/25,10/27/25 and 10/31/25, entries were made by the Infectious Disease physician that upon evaluation, Resident #124 was on 2L O2 via NC. There was no corresponding order for oxygen administration with the amount to administer.Top of Form Record review also revealed a lack of oxygen saturation levels for the dates the resident was documented to be on oxygen therapy.On observation on 12/01/25 at 10:02 AM, Resident #124 was resting in bed, pleasantly confused with O2 at 2L via nasal cannula. Review of the current orders also lacked any for the administration of oxygen.During an interview on 12/04/25 at 11:30 AM, the Assistant Director of Nursing (ADON) was asked to locate and provide an order for the use of oxygen currently and in October 2025. The ADON confirmed there was none.

Based on competency review, observation, and interview, the facility failed to ensure infection control practices during the medication pass observation with 1 of 6 licensed nurses (Staff C, Licensed Practical Nurse), as evidenced by the failure to dispose of gloves after use, failure to ensure hand hygiene with glove use, failure to properly disinfect a glucometer (device that measures the resident's blood sugar level), and failure to properly dispose of the used lancet. The medication pass observation was for Resident #38.The findings included:Review of the facility's competency for blood glucose monitoring revealed the following steps: 1. Perform hand hygiene before completing blood glucose testing or disinfecting. 2. Put on single-use gloves prior to blood glucose testing or disinfecting. 12. Dispose of lancet in biohazardous waste sharps container. 14. Clean the glucometer after each use, using the approved bleach disinfectant wipe and ensure all external surfaces of the glucometer remain wet for a period of no less than 3 minute, or contact time designated by manufacturer by wiping both the front and back of the glucometer, wrapping the approved bleach disinfectant wipe around the glucometer and keeping it wrapped for 3 minutes. 17. Remove and dispose of used single-use gloves. 18 Perform hand hygiene after completing blood glucose testing or disinfecting.Review of the manufacturer's instructions for the blood glucose device documented the use of disinfectants to include Medline Micro-Kill Bleach Germicidal Bleach Wipes. The instructions did not include the use of Micro-Kill Two Germicidal Wipes.A medication pass observation was completed on 12/03/25 beginning at 3:48 PM with Staff C, Licensed Practical Nurse (LPN), for Resident #38. The LPN gathered supplies for the blood sugar monitoring on a disposable tray, to include the canister of strips, one lancet, and an alcohol wipe. The glucometer was wrapped in a tissue on top of the medication cart upon arrival by the surveyor. The LPN donned a pair of gloves while standing at the medication cart, locked the cart, and proceeded down the hall, two rooms down, to the room of Resident #38. The LPN obtained the resident's blood sugar level, and walked back to the medication cart, still wearing her used gloves. The LPN entered information into the computer with her gloved hands, threw the lancet into the Sharps container, but did not ensure the lancet fell into the container, then removed her gloves inside-out and placed them on top of the cart. The LPN opened the medication cart and obtained a Micro-Kill Two Germicidal wipe. She then wiped the glucometer, and immediately wrapped it in a dry tissue and stated, Is this OK?.Staff C, LPN proceeded to assist two residents and failed to do any hand hygiene during the blood sugar check or after assisting either resident. The LPN stated she was going to give Resident #38 Tylenol for his headache. The LPN donned a pair of gloves, obtained the Tylenol, locked the medication cart, and gave the Tylenol to Resident #38. The LPN returned to the medication cart wearing the same gloves. The LPN removed her gloves and confirmed she was done, as she placed the canister of strips and glucometer back into the cart. The LPN did not do any type of hand hygiene.During the continued observation and interview, when shown the lancet on top of the sharps' container, the LPN stated, Oh and engaged the top to allow the lancet to fall into the secured section of the container. The LPN was asked to provide the canister of disinfectant wipes which documented a two-minute contact time. When asked what that meant, the LPN stated she needed to wipe the glucometer for two minutes and let it dry for two minutes. When asked if wrapping the glucometer in a dry tissue allowed for a two-minute wet contact time, the LPN stated, No. When asked if applying gloves at the medication cart, walking down the hall, and returning to the medication cart wearing gloves after having cared for a resident was appropriate, the LPN stated, That's the way I always do it.The Director of Nursing (DON) was made aware of the above observation on 12/03/25 at approximately 4:45 PM and agreed with the findings.During an interview on 12/04/25 at 2:46 PM, when asked to confirm which disinfectant wipe was used for the glucometers, the Infection Control Preventionist (ICP) confirmed the use of the Micro-Kill Bleach wipes as per manufacturer's instructions. When asked about taking the canister of glucometer strips into a resident's room, the ICP stated the expectation was that the nurse would take just one strip into the resident's room and the canister would stay in the medication cart.

Based on observation, interview, and record review, the facility failed to ensure accessibility of the call bell for 1 of 1 sampled resident, Resident #99, observed needing assistance and unable to call staff. The findings included: Review of the record revealed Resident #99 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, on a 0 to 15 scale, indicating moderate cognitive impairment. This same MDS documented the resident usually understands and is usually understood and required partial to total assistance from staff for activities of daily living (ADLs). Review of the current resident care plans dated 06/06/24 for Visual impairment, Cognitive Loss/Dementia, ADLs, and Pain, all included the approach: call light within reach. During an observation and interview on 06/03/24 at 12:00 PM, Resident #99 was observed sitting in his wheelchair close to the footboard area of the bed with his meal tray in front of him. When asked why he wasn't eating his food, Resident #99 said he didn't like the entree that was served. When asked if he was aware whether other food options were available, he replied he was not aware that food options were available. When asked if he may want to use the call bell to request another food option, the resident answered, I don't know where it is. At this time, the call bell was clipped to the upper corner of the bed close to the headboard and the red button was dangling down approximately 2-3 inches from the corner of the bed. Photographic Evidence Obtained. When asked if he could move himself in the wheelchair towards that location, the resident said he doesn't really move around the room in his wheelchair. When placed in front of the resident, Resident #99 pressed the call button. A nurse entered the room and Resident #99 requested a grilled cheese sandwich for lunch. An observation on 06/04/24 at 10:17 AM revealed Resident #99 in bed with the call bell cord clipped to the upper corner of the bed. The call bell was located on the bedding next to the right side of the resident's ribcage. An interview with Resident #99 revealed he did not know where the call bell button was. When told the location of the call bell button and prompted to try and reach it, Resident #99 was unable to navigate his hand to touch the call bell. On 06/05/24 at 9:30 AM, Resident #99 was observed in bed. The call bell cord was clipped to the left top corner of bed. When asked if he could reach the call bell, the Resident answered No. Resident #99 was observed trying to drink juice and having difficulty drawing fluid up through the straw. The resident removed the straw from the cup and looked at it. The straw did not have a hole on the bottom where the juice should flow through. The straw appeared squeezed closed on the bottom. The surveyor placed the call bell button within sight of resident. Resident #99 pressed the button, and a nurse entered the room. She saw the problem with the straw and brought the resident a new straw. The resident drank the juice effectively with the new straw. Resident #99 demonstrated understanding of the usefulness of pressing the call button for assistance, and he demonstrated the ability to press the call bell button. On 06/06/24 at 12:17 PM, Staff D, 100-200 Unit Manager, was iinformed of the three observations made of Resident #99's difficulties accessing and using the call bell button. Staff D acknowledged the finding and stated they would need to devise a plan to provide access to the call bell.

Based on observation, record review, interview, and policy review, the facility failed to ensure the anchoring of indwelling urinary catheter tubing for 2 of 3 sampled residents, one of whom had a history of urinary tract infections (UTIs), Residents #34 and #204. The findings included: Review of the policy, titled, Catheter Care, Urinary, revised 01/25/23, documented, in part, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Changing Catheters . 2. Ensure that the catheter remains secured to reduce friction and movement at the insertion site. (Note: Catheter tubing should be secured to the resident's inner thigh.) 1. Review of the record revealed Resident #34 was admitted to the facility on [DATE], with readmission on 05/28/24. Record review revealed a diagnosis of urinary retention with the placement of an indwelling urinary catheter. The physician order dated 05/29/24 documented to secure the indwelling urinary catheter with a leg strap. The current order dated 05/01/24 documented the use of an indwelling catheter for Resident #34. One of the care plan approaches included utilizing a catheter holder to prevent pulling. An observation was made on 06/05/24 at 9:42 AM with Staff A, Certified Nursing Assistant (CNA). Resident #34 was lying in bed, and the indwelling urinary catheter was noted taunt, coming out of the bottom of the adult brief. There was no type of anchoring device for the catheter tubing. Staff A provided personal care, not mentioning the lack of the anchoring device. During an interview on 06/05/24 at 2:58 PM, when asked if she knew about the missing anchor, Staff D, 100-200 Unit Manager, stated she had not been informed. A subsequent observation at this time, with Staff D and the Assistant Director of Nursing (ADON) revealed Resident #34 still did not have any anchoring device for the indwelling urinary catheter tubing. The tubing was again pulled tautly coming from the bottom of the adult brief. 2. Review of the record revealed Resident #204 was admitted to the facility on [DATE]. Admission diagnoses included retention of urine and urinary tract infection (UTI). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #204 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scaled, indicating the resident had minimal cognitive impairment. This MDS also documented the resident had an indwelling urinary catheter with a diagnosis of Obstructive Uropathy (inability to urinate because of an obstruction). Review of a current order, dated 05/21/24, documented the indwelling urinary catheter was to be secured with a leg strap. The current care plan dated 05/21/24 documented the resident had a recent UTI and included utilizing a catheter holder to prevent pulling. An observation on 06/03/24 at 2:39 PM revealed Resident #204 lying in bed. A urinary catheter leg bag was noted with no type of anchoring or securing device. The tube was noted towards the back of his leg. During an observation on 06/05/24 at 8:33 AM, Resident #204 was sitting up in his wheelchair. The urinary catheter leg bag was noted. When asked if he had any type of catheter strap or anchor, the resident pulled up the leg of his pants and there was no anchor. During a subsequent observation with the ADON on 06/05/24 at 3:03 PM, a thigh strap was noted to secure the urinary catheter tubing. Resident #204 stated staff had just put it on.

Based on observation, record review, interview, and policy review, the facility failed to ensure competent nurse staff for 2 of 7 sampled residents observed during the medication administration observation. Staff C, Licensed Practical Nurse (LPN), failed to follow the facility's process related to the administration and documentation of insulin for Resident #49; and Staff B, Licensed Practical Nurse failed to use proper technique during a nasal spray administration for Resident #74. The findings included: 1. A medication administration observation for Resident #49 was made with Staff C, LPN, on 06/04/24 beginning at 4:59 PM. Staff C prepared oral medications that were due at that time, along with an insulin pen stating the resident had 7 units due at that time and headed for the resident's room. At the entrance to the room, the surveyor stopped the LPN from entering the room, and asked the LPN the type of insulin she had for Resident #49. At this time the LPN stated Novolin R (regular insulin), showing the label to the surveyor. The LPN obtained the blood sugar level for Resident #49, then dialed 7 units of insulin on the pen and showed it to the surveyor. The LPN administered the insulin into the resident's left arm. Review of the Medication Administration Record (MAR) for Resident #49 revealed the order dated 12/19/23 for the 7 units of Novolin R insulin, to be administered via the FlexPen. Staff C had signed off the administration of the 7 units of Novolin R, and further documented she had verified the dose before the administration but entering the initials of another person. During an interview on 06/04/24 at 5:51 PM, when asked the process for the administration of insulin to a resident, specifically asking about the insulin dosage, Staff C described the process of checking the resident's blood sugar level and administering the insulin. The LPN did not describe the second nurse verification step. When asked about the 2nd Nurse Verify Before documentation on the MAR, the LPN confirmed their process was to have a second nurse verify the dose, further stating, Because you are a nurse I verified with you. When asked whose initials she documented on the MAR, the LPN stated they were the initials of the other nurse working that shift. When asked why she documented the other nurse's initials, when she did not verify the dose with any other facility nurse, the LPN again stated she verified the dose with the surveyor, but wrote the initials of the other nurse, as they always verify for each other. When asked again if she verified the 7 units with the other nurse whose initials were documented in the MAR, the LPN stated she did not, but again stated she had verified with the surveyor. On 06/05/24 at 2:54 PM, the Director of Nursing (DON) was informed of the insulin administration by Staff C for Resident #49. The DON confirmed they did have a second nurse verify process for insulin administration, and agreed Staff C should not have verified with a non-employee, nor should she have put the initials of the other staff in the MAR when she did not verify with that second staff. The DON was asked to provide their written process for the second nurse verify of insulin. The DON later stated they did not have the second nurse verification as a written process, but again stated it was part of the facility protocols. 2. Review of the policy, titled, Nasal Administration, revised January 2018, documented, in part, Procedure: . H. Use finger of other hand to close the nostril that is not receiving medication by gently pressing the side of the nostril. This policy then described the administration of the nasal spray followed by illustrations of how to occlude the opposite nasal cavity. A medication administration observation was made for Resident #74 on 06/04/24 at 4:38 PM. Staff B, LPN, obtained medications for the resident to include a Deep Sea nasal spray of 0.65% saline solution. The LPN administered two sprays into each nasal cavity but failed to occlude the opposite nasal cavity during the administration. Upon request of the policy on 06/05/24 in the afternoon, the Risk Manager was made aware of the medication administration observation for Resident #74.

Based on record review, interview, and policy review, the facility failed to implement pharmacy recommendations approved by the physician for 1 of 5 sampled residents, Resident #38. The findings included: Review of the policy, titled, Medication Regimen Review, revised January 2018, documented, in part, Procedure: . G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Review of the record revealed Resident #38 was admitted to the facility on [DATE]. Review of the current orders revealed the order initiated on 05/31/23 for the anti-reflux medication, Protonix 40 milligrams (mg), ordered daily for Anemia. Review of the monthly pharmacy reviews revealed on 12/17/23 the pharmacist identified Resident #38 had been on the anti-reflux medication Protonix 40 mg daily for more than 12 weeks, and recommended the medication be discontinued. This recommendation also documented the need for appropriate documentation supporting an underlying chronic disease if continued. On 01/03/24, the physician agreed but documented to decrease the Protonix to 20 mg daily. Review of the subsequent monthly reviews for January 2024 through May 2024 lacked any recommendations related to the Protonix. Review of the current order (05/31/23) and the Medication Administration Record (MAR) documented the resident was still being administered Protonix 40 mg for a diagnosis of Anemia. During a side-by-side record review and interview on 06/06/24 at 11:34 AM, Staff D, the 100-200 Unit Manager, was asked the process for the monthly pharmacy reviews. The Unit Manager explained the pharmacist does the monthly reviews and provided them to the Director of Nursing, who then prints them out and provides them to each Unit Manager. The Unit Managers then speak with the physician either in person or via call, reviews the recommendations, and then the physician will sign them upon his next visit if applicable. The Unit Manager then is responsible for entering the new orders into the electronic medical records. The Unit Manager was shown the recommendation for Resident #38 regarding the Protonix and was unsure as to how or why it was not decreased as per the physician's signature and request.

Based on observation and policy review, the facility failed to prepare pureed food with the correct texture. This had the potential to affect 16 of 165 current residents who had a physician ordered pureed diet. The findings included: Review of the facility's written description of the pureed diet, reprinted from the Manual of Medical Nutrition Therapy 2022, documented, The pureed diet is designed to provide soft, smooth foods that minimize the amount of chewing required and are easy to swallow. Any regular or therapeutic diet may be pureed. The pureed diet is indicated for individuals with chewing or swallowing problems. On 06/05/24 at 11:50 AM, observations in the kitchen revealed the pureed diet Italian Parmesan Breaded Pork and the pureed Parslied Noodles did not look smooth. At this time, a sample of the pureed food prepared for the lunch meal was requested. Upon tasting the food, the pureed pork had chopped up strings in it and the pureed pasta had lumps. At this time, when asked about the process for ensuring the correct texture of the pureed foods, the Director of Food Services (DFS) stated she usually tastes it but did not do so that day. The DFS was asked to taste the pureed foods. The DFS did not collaborate with the findings of stringy pork or lumpy pasta, but stated she would puree those foods again. An observation of the pureed foods served in the main dining room on 06/05/24 at approximately 1:00 PM revealed a smoother texture.

Based on policy review, observation, interview and record review, the facility failed to ensure proper perineal care to residents with a history of and current Urinary Tract Infection (UTI) for 1 of 3 sampled residents observed during perineal care, Resident #3. The finding included: The policy titled perineal care, dated 11/01/2018, documented, in part: the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition .; the following equipment and supplies will be necessary when performing this procedure: wash basin, towels, washcloth, soap (or other authorized cleansing agent) .; and steps in the procedure: #9 for a female resident: a) wet washcloth and apply soap or skin cleansing agent. Review of the in-house UTI [Urinary Tract Infection] list, dated from October 2023 to present (January 29, 2024), evidenced there were 25 cases of facility acquired UTIs during this time. Review of record for education / in-services, dated August 2023, revealed education / in-services was provided regarding pericare / Foley catheter care. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE], with diagnoses that included: Septicemia (blood poisoning by bacteria), and Urinary Tract Infection (UTI) in the last 30 days. The admission Minimum Data Set (MDS) assessment, reference date, 01/04/24, indicated a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #3 was moderately cognitively impaired. This MDS recorded no mood/behavior issue; the functional abilities and goals for toilet hygiene as dependent for admission performance; and shower / bathing was self-substantial assistance for admission performance. Additional record review revealed a urinalysis dated 01/26/24 was positive for UTI. Review of the Physician orders revealed an order dated 01/28/24 for Bactrim DS (Sulfamethoxazole-Trimethoprim) 800-160 mg 1 tablet by mouth twice a day for UTI. Review of care plan, dated 01/29/24, recorded, that Resident #3 had urinary incontinence (loss of bladder control), Cystitis (inflammation of the bladder), and UTI. This care plan recorded Resident #3 had received Macrobid (antibiotic) from 01/16/24 through 01/20/24 and Bactrim DS (antibiotic) was ordered from 01/28/24 through 02/01/24 for a UTI. Review of progress note dated 01/28/24 written at 10:10 PM documented Resident #3 started the antibiotic for UTI. On 01/29/24 at 11:51 AM, an interview was held with the Staff Developer who voiced that the facility conducted a peri care Inservice in August 2023, and they're planning a skills fair for the last week of [DATE]. The skill fair will include providing peri care, and the facility has a male and female mannequin for the skill fair. On 01/29/24 at 12:06 PM, peri care observation was conducted with Staff A and Staff B, Certified Nursing Assistants (CNA). Both CNAs were observed with gloves on in the bathroom. Staff A collected warm water in a basin for the peri care. Subsequently, both CNAs proceeded to go towards Resident #3's bed. Staff A placed the basin on the bedside table. Staff A also placed several small washcloths and a big towel directly on the bedside table without a barrier. Staff A proceeded to draw the curtain and closed it for privacy. Staff A removed the pillow and linens from the bed, obtained a clean sheet to cover Resident #3's upper body, and moved the bedside table closer to the bed. After completing these tasks, and with the same gloves, Staff A obtained a small washcloth from the bedside table, wet it in the water that had no soap, and she proceeded to provide the peri care. On 01/29/24 at 12:14 PM after the peri-care, an interview was held with Resident #3. When asked how she had contracted the UTI (bladder infection), the resident said she didn't know. She then voiced that she gets UTIs all the time and has been getting UTI's once or twice a year. On 01/29/24 at 12:41 PM, another interview was held with the Staff Developer and the Director of Nursing (DON) regarding the peri care observation. The surveyor notified them of the findings, and both acknowledged the findings.

Based on observation, staff interview and clinical record review, the facility staff failed to provide timely care and services for 8 of 11 sampled residents who are dependent upon the staff to provide incontinent care and/or position changes, Residents #2, #3, #4, #6, #7, #8, #9 and #11. The Memory Unit had a census of 25 residents. The facility census was 162. The findings included: Observations on the Locked Memory Care Unit on 05/15/23 beginning at 11:50 AM to 3:00 PM, revealed that multiple dependent residents remained in the dining room and were not provide the necessary services for incontinent care and repositioning. The unit had a census of 25 residents and was staffed with 1 licensed nurse, 2 certified nursing assistants for patient care and 1 activity aide for activities and assistance with dining and snacks. Upon entry onto the unit, there were 12 residents in the dining room along with the activity aide of which 8 residents remained in the dining room the entire time of the surveyor's observations. These residents were later identified as Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #11. Resident #2 came into the dining room at approximately 12:15 PM and remained in the dining room. a. Review of the clinical record for Resident # 7 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart Disease with Heart Failure and Unspecified Dementia, unspecified severity with other behavior disturbances. The resident had a recent hospitalization and additional diagnoses that included Transient Cerebral Ischemic Attack (TIA) and Cognitive Communication Deficit. The 05/09/23 Change in Condition Minimum Data Set Assessment (MDS) noted the resident as extensive assist of two staff for Bed mobility and transfers, uses a wheelchair for mobility; and total assistance of two staff for toilet use and extensive assistance of one staff for personal hygiene. The resident had an indwelling catheter and is always incontinent of bowels. The facility identified a problem on the 01/12/23 for Plan of Care of Activities of Daily Living Functional Status / Rehabilitation Potential related to decreased mobility, secondary to diagnosis of weakness, gait / mobility Abnormality, Osteoporosis, Hypothyroidism, Dementia, history of TIA, history of Cardiac Arrest as evidenced by extensive assist with bed mobility / total / limited with wheelchair / transfers / non-ambulation. Approaches included Hoyer Lift with 2 assist for transfers (added 05/15/23); 1/2 siderails to increase bed mobility, encourage resident to ask for assistance as needed, and observe for signs of overtiring. Another problem was identified on 01/12/23 for Bowel elimination, alteration in secondary to occasional constipation, Gastroesophageal Reflux Disease, history of Pancreatitis, Dementia, Weakness, Gait / Mobility Abnormality as evidence by total incontinent of bowels. Approaches included: Allow time for resident to toilet; cleanse skin well and provide incontinence care after each incontinent episode; observe for verbal / non-verbal signs that resident may need to use the bathroom; and Provide incontinence pads/briefs as needed. Resident #7 was observed to be sitting in a high back wheel chair at a table in the dining room on the locked memory care unit on 05/15/23 at 11:50 AM. The resident was observed to have bluish red bruises under his left eye and bruise, and a small egg size bump on his left forehead above the left eye. The resident ate his lunch and after lunch attempted to move his chair from the table. The Certified Nursing Assistant (CNA), Staff A, convinced the resident to remain in the dining room. The resident informed the aide that he wanted to go to the bathroom. Staff A was the only staff who was left in the dining room with the 13 residents remaining in the dining room. The aide later informed the nurse at 1:05 PM that the resident had to go to the bathroom. At 1:18 PM, the resident again informed Staff A, he needed to go to the bathroom. The staff informed the resident, two of us have to take you to the bathroom and 1 staff has to remain in here. The resident then started expressing his desire to go home and attempting to stand up in his wheelchair multiple times and the aide had to remind him to sit down. At 1:26 PM, Staff A again approached the nurse, I hate to be a pest, again informing the nurse she needed to take the resident to the bathroom. The nurse responded, she had to pass meds. Staff A finally took the resident out of the dining room to take him to his room at 1:40 PM. The other CNA, Staff B, assisted Staff A, with transferring the resident to the bed and put the resident on a bed pan to go to the bathroom. The staff stated they put the resident on the bed pan because they got an order last week. Staff A stated, we weren't trained to use the lift to transfer the resident to the bathroom, so we have to use the Hoyer lift to transfer him to the bed. The resident had to wait over 40 minutes to get assistance to go to the bathroom after expressing his desire to go to the bathroom. Resident #7 also has a history of multiple falls that included: 4 falls so far in May 2023 (05/12/23, 05/09/23, 05/06/23 and 05/04/23); 3 falls in April (04/25/23, 04/20/23 and 04/18/23); and 3 falls in March (03/10/23, 03/08/23 and 03/07/23). b. Review of the clinical record for Resident #6 revealed the resident was admitted to the facility on [DATE] with diagnoses that included convulsions, Cognitive Communication deficit, and Unspecified Dementia. The 02/22/23 MDS Assessment documented the resident required extensive assistance of one staff for bed mobility, transfers, eating, toilet use and personal hygiene. The resident was always incontinent of urine and bowels. The facility identified a problem as Urinary Incontinence, on the care plans that included: Approaches - to Check and change every 2 hours and as needed; Keep perineal and rectal area clean and dry, observe for verbal / non-verbal signs that resident may need to use the bathroom; provide toileting assistance with toileting as needed; and provide incontinence pads / briefs as needed. The Point of Care Summary for Resident #6 documented the resident was incontinent daily. Observation was conducted on 05/15/23 at 11:50 AM in the dining room on the Locked Memory Care Unit that revealed Resident #6 was already sitting in her reclining wheelchair at one of the dining room tables. When her meal came, the resident was fed by the Activity Aide. After lunch, the resident remained at the table and seated in her reclining wheelchair at the table. The resident was not checked and changed every 2 hours or as needed as planned in the plan of care. c. Review of the clinical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Cognitive communication deficit, and Dementia with other behavioral disturbance, restlessness and agitation. The 03/29/23 MDS Assessment documented the resident required limited assistance of one person for bed mobility, dressing, toilet use and personal hygiene. The resident was independent with support of one person for transfers and locomotion off the unit, independent with set-up help only for walk in room and corridor, and eating. The resident was occasionally incontinent of urine and bowels. The facility identified a problem on 01/18/22 care plans that included Urinary Incontinence related to bladder / bowel elimination, alteration secondary to Chronic Pain, Weakness, Gait/Mobility Abnormality, Alzheimer's Disease, Dementia, as evidence by occasional incontinent of bladder/bowels. Approaches included allow time for resident to toilet, observed for decreased in urinary output, maintenance toileting upon rising, after meals, bedtime and as needed; observe for verbal / non-verbal signs that the resident may need to use the bathroom; provide assistance with toileting and locating bathroom as needed; and provide incontinence pads/briefs as needed. A problem identified for ADL Functional Status / Rehabilitation Potential was identified on 02/11/22 with approaches that included assist resident in safe transfer technique as needed for transfer from bed to chair, encourage to ask for assistance a needed, observe for signs of overtiring, observe for unsafe actions and intervene, and provide mobility assistance as needed. The resident was observed to be escorted into the dining room on 05/15/23 by Staff A at 12:15 PM. The resident was seated at one of the dining room tables. The resident got up without assistance at 12:30 PM and was walking toward the door to leave and had approached Resident #11 and said something to him. Staff A then encouraged the resident to sit down. The resident sat in the chair next to Resident #11 and she remained seated in this chair until the surveyor left the unit at 3:00 PM. The resident was not toileted after lunch as her care plan notes. The Point of Care report failed to provide documentation on Resident # 2 continence status on days on 05/10/23, 05/12/23, and on 05/15/23. d. Review of the clinical record for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dysphagia, and Cognitive Communication Deficit. The 02/10/23 MDS Assessment documented the resident was extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene. The resident is always incontinent for urine and frequently incontinent of bowels. The facility identified a problem of Urinary Incontinence related to Bladder / Bowel Incontinence elimination, alteration secondary to Chronic Pain, Hypertension, Dementia, Alzheimer's Disease, and Bipolar Disease, as evidenced by total incontinence of bladder / frequently incontinent of bowels. Approaches included Check and change every 2 hours and as needed; Keep perineal and rectal area clean and dry, observe for verbal / non-verbal signs that resident may need to use the bathroom; provide toileting assistance with toileting as needed; and provide incontinence pads/briefs as needed. The Point of Care Summary for Resident #8 from 05/10/23 to 05/16/23 documented the resident was incontinent of urine and bowels daily. An observation was conducted on 05/15/23 at 11:50 AM in the dining room on the Locked Memory Care Unit revealed Resident #8 was wheeled in by the staff at 12:06 PM and was placed at one of the dining tables. When her meal came, the resident was initially fed by the speech and language therapist. After lunch, the resident remained at the table, and the resident continued to move the table, while another dependent resident, Resident #6 was at the table. The staff moved the resident to another area in the dining room, but the resident continued to grab that table and move it. The resident was brought in a wheelchair to the dining room at 12:06 PM and continued to be in the dining room when the surveyor left the unit at 3:00 PM. The resident was not check and changed every 2 hours as noted on her plan of care. e. Review of the clinical record for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Other Abnormalities of gait and mobility, Cognitive communication deficit, and Unspecified Dementia. The 02/02/23 MDS documented the resident required limited assistance of one staff for bed mobility and transfers, locomotion via wheelchair, extensive assistance of one staff for toilet use and personal hygiene. The resident was occasionally incontinent of urine and bowels. The Point of Care Report for Resident #9 for 05/11/23 through 05/16/23, revealed the Day staff failed to document the resident's continence during their shift, for every day except one, when the staff noted on 05/14/23 the resident was incontinent of urine and bowel. The evening staff noted the resident was incontinent of urine every evening on 05/11/23 through 05/15/23. The resident was also noted as incontinent of urine on night shifts on 05/11/23 through 05/13/23 and 05/15/23. There is no documentation for 05/14/23 regarding the resident's continence on nights and the staff noted the resident was incontinent of bowels on night shifts for 05/11, 05/13/23 and 05/15/23. The facility identified a problem on the care plans on 02/26/23 of Urinary Incontinence related to bladder / bowel elimination, alteration secondary to Parkinson's Disease, Dementia, BPH (Benign Prostatic Hyperplasia), as evidenced by frequently incontinent of bladder / bowels. Approaches included maintenance toileting upon rising, after meals, bedtime and as needed; observe for verbal / non-verbal signs that the resident may need to use the bathroom; provide assistance with toileting as needed; and provide incontinence pads/briefs as needed. Resident #9 was noted to be sitting in his wheelchair at a table in the dining room on 05/15/23 at 11:50 AM. The resident was bent forward in the wheelchair. The resident remained in this spot and remained in the dining room when the surveyor left the unit at 3:00 PM (3 hours and 10 minutes later). The resident was not toileted after lunch or checked for an incontinent episode or provided care. Review of the Point of Care Report failed to provide documentation regarding the resident's continence on 05/15/23 on the day shift. f. Review of the clinical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following nontraumatic intracranial hemorrhage affecting left non-dominant side, Dementia, Alzheimer's Disease, Dysarthria following nontraumatic intracranial hemorrhage, and neuromuscular dysfunction of bladder. A 04/27/23 MDS documented that the resident is extensive assistance of two staff for bed mobility, transfer, toileting and personal hygiene. The resident is occasionally incontinent of urine and bowels. The facility identified a problem on the care plans for Urinary Incontinence on 05/07/21 with approaches that included maintenance toileting upon rising, after meals bedtime and as needed, observe for verbal / nonverbal signs that resident may need to use the bathroom, provide assistance with toileting as needed and provide incontinence pads / briefs as needed. A problem of ADL (Activities of Daily Living) Functional Status/Rehabilitation Status with approaches that included anticipate needs as much as possible, observe for signs of overtiring, predictable routine as much as possible, assist with personal hygiene as needed. The Point of Care Report documented the resident was incontinent of urine daily on each shift except the day shift. Staff failed to document regarding the resident's continence status on 05/10/23, 05/12/23 and 05/15/23. The resident was also documented as incontinent of bowels daily except twice when the staff noted the resident did not have a bowel movement. An observation of the resident was conducted on 05/15/23 beginning at 11:50 AM to 3:00 PM revealed the resident was seated at a table in the dining room and remained in the dining room in the same place. The resident was not provided the necessary care and services for incontinence and positioning. The resident was not toileted after lunch and noted in her plan of care. Resident #3 is one of three residents on the unit who were being transferred via Hoyer Lift. g. Review of the clinical record for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Cognitive Communication Deficit, Dementia, Psychotic Disturbance, mood disturbance and anxiety. The 03/26/23 MDS documented the resident required extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene. The resident was always incontinent of urine and bowels. The facility identified a problem as Urinary Incontinence on 10/07/22. Approaches included Check and change every 2 hours and as needed; Keep perineal and rectal area clean and dry, observe for verbal / non-verbal signs that resident may need to use the bathroom; provide assistance with toileting as needed; and provide incontinence pads/briefs as needed. The Point of Care Summary for Resident #4 documented the resident was incontinent of urine and bowels daily on each shift. An observation was conducted on 05/15/23 at 11:50 AM in the dining room revealed that Resident #4 was wheeled into the dining room at approximately 11:55 AM. The resident fed herself her lunch meal and remained in the dining room in the mid-afternoon. An interview was conducted on 05/15/23 at approximately 2:15 PM with the Certified Nursing Assistant, Staff A. The aide confirmed she brought Resident #4 into the dining room and she had checked and changed the resident after 11:00 AM but is not sure of the time. She further confirmed the resident had to be toileted but she had not toileted the resident since she did it at around 11 AM this morning. h. Review of the clinical record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with diabetic peripheral angiopathy, left Below the Knee Amputation, Cognitive communication deficit and Dementia. The 04/21/23 MDS Assessment documented the resident required extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene, and limited assistance of one staff for locomotion on and off the unit via wheelchair. The resident had an indwelling catheter and is frequently incontinent of bowel. The facility identified a problem on the care plans for bowel incontinence on 01/28/21. Approaches included Maintenance toileting upon rising, after meals and bedtime and as needed, allow time for resident to toilet, observe for verbal / nonverbal signs that resident may need to use the bathroom, and provide assistance with toileting and locating bathroom as needed. An observation of the resident was conducted on 05/15/23 beginning at 11:50 AM to 3:00 PM revealed the resident was seated at a table in the dining room. The resident was served his lunch tray and was eating his lunch when at 12:04 PM, the Registered Nurse entered the dining room and removed the resident from the room to give the resident his medication. The nurse returned the resident to the dining room at 12:05 PM. The resident then finished eating his lunch. After eating his lunch, the resident remained in the dining room, initially wheeling himself around in the dining room, then the nurse placed him against the wall in the dining room. The resident remained there until his family came to visit and took him on the patio at 2:45 PM. The resident was not toileted after lunch as outlined on the plan of care. Review of the Point of Summary Report documentation for Resident #11 from 05/10/23 to 05/16/23 revealed the day shift did not consistently document the continence status of the resident. Staff had documented twice during the 6-day period on 05/11/23 (no bowel movement) and 05/14/23 (incontinent). An interview was conducted with Staff A on 05/15/23 at 2:50 PM. Staff A was assigned 13 of 25 residents on the unit. The surveyor reviewed with her the care and services needed for her residents. She had two of three residents who required a lift for transfers; most of her residents required assistance with toileting and/or to be checked and changed. She stated the care needs of the residents on this unit required 3 to 4 aides because of what they need and the confusion of the residents.

Based on observation, staff interview and review of clinical and administrative records, the facility failed to provide sufficient nursing staff for 1 of 3 nursing units (locked memory care, 100 hall) to ensure that dependent residents on this unit received the necessary care and services in a timely manner that promotes each resident's rights, physical and mental and psychological well-being. The Memory unit had a census of 25 residents at the time of the survey. The facility census was 162. The findings included: Observations on the Locked Memory Care Unit on 05/15/23 beginning at 11:50 AM to 3:00 PM, revealed that multiple dependent residents remained in the dining room and were not provided the necessary services for incontinent care and repositioning. The unit had a census of 25 residents and was staffed with 1 licensed nurse, 2 certified nursing assistants for patient care and 1 activity aide for activities and assistance with dining and snacks. Upon entry onto the unit, there were 12 residents in the dining room along with the activity aide of which 7 of those residents remained in the dining room the entire time (11:50 AM to 3:00 PM). These residents were later identified as Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #11. Resident #2 came into the dining room at approximately 12:15 PM and remained in the dining room as well. a. Resident #7 had an indwelling catheter but is always incontinent for bowels. The resident also required a mechanical lift with two staff for transfers. After lunch, the resident requested to use the bathroom,. There was not sufficient staff on the unit, and the resident had to wait over 40 minutes to receive the needed intervention to provide the resident the opportunity to honor his toileting request. Resident #7 became restless, speaking loudly and continued to attempt to get up in his wheelchair, while the lone staff in the dining room, Staff A, continually attempted to redirect him, while waiting to get another staff to assist her to transfer the resident. It was also noted that Resident #7 also has a history of multiple falls that included: 4 falls so far in May 2023 (05/12/23, 05/09/23, 05/06/23 and 05/04/23); 3 falls in April (04/25/23, 04/20/23 and 04/18/23); and 3 falls in March (03/10/23, 03/08/23 and 03/07/23). The resident was observed to have bluish red bruises under his left eye and bruise, and a small egg size bump on his left forehead above the left eye, from his most recent fall. b. Resident #6 required extensive assistance of one staff for bed mobility, transfers, eating, toilet use and personal hygiene and was always incontinent of urine and bowels. Observation revealed the resident was already sitting in her reclining wheelchair at one of the dining room tables at 11:50 AM on 05/15/23. When the resident's meal came, the resident was fed by the Activity Aide. After lunch, the resident remained at the table and remained seated in her reclining wheelchair at the table and was not checked and changed every 2 hours or as needed or was provided any changes in her positioning. c. Resident #2 required limited assistance of one person for bed mobility, dressing, toilet use and personal hygiene. The resident was independent with support of one person for transfers and locomotion off the unit, independent with set-up help only for walk in room and corridor, and eating. The resident was occasionally incontinent of urine and bowels. The resident's plan of care had the resident on maintenance toileting to toilet after meals. The resident was observed to be escorted into the dining room on 05/15/23 by Staff A at 12:15 PM. The resident was seated at one of the dining room tables. The resident got up without assistance at 12:30 PM and was walking toward the door to leave and approached Resident #11 and said something to him. Staff A then encouraged the resident to sit down. The resident sat in the chair next to Resident #11 and she remained seated in this chair until the surveyor left the unit at 3:00 PM. The resident was not toileted after lunch as her care plan notes. d. Resident #8 required extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene and is always incontinent for urine and frequently incontinent of bowels. The Point of Care Summary for Resident #8 from 05/10/23 to 05/16/23 documented the resident was incontinent of urine and bowels daily. The resident was wheeled into the dining room by staff at 12:06 PM and was placed at one of the dining tables. When her meal came, the resident was initially fed by the speech and language therapist. After lunch, the resident remained at the table, but continued to move the table, while another dependent resident, Resident #6 was at the table. The staff moved the resident to another area in the dining room, but the resident continued to grab the table and move it. The resident remained in the dining room and was not checked and changed every 2 hours for incontince. e. Resident #9 required limited assistance of one staff for bed mobility and transfers, locomotion via wheelchair, extensive assistance of one staff for toilet use and personal hygiene and is noted to be occasionally incontinent of urine and bowels. The Point of Care Report for Resident #9 for 05/11/23 through 05/16/23 revealed the day-shift staff failed to document the resident's continence during their shift, every day except one, when the staff noted on 05/14/23 the resident was incontinent of urine and bowel. The evening staff noted the resident was incontinent of urine every evening on 05/11/23 through 05/15/23 and the resident was noted as incontinent of urine on nights on 05/11/23 through 05/13/23 and 5/15/23 on nights. There is no documentation on 05/14/23 regarding the resident's continence on nights and the staff noted that the resident is incontinent of bowels on nights on 05/11/23, 05/13/23 and 05/15/23. The resident plan of care included maintenance toileting upon rising, after meals, bedtime and as needed; observe for verbalv/ non-verbal signs the resident may need to use the bathroom; provide assistance with toileting as needed; provide incontinence pads/briefs as needed. The resident was observed to be sitting in his wheelchair at a table in the dining room on 05/15/23 at 11:50 AM. The resident was bent forward in the wheelchair. The resident remained in this spot and remained in the dining room when the surveyor left the unit at 3:00 PM (3 hours and 10 minutes later). The resident was not toileted after lunch or checked for an incontinent episode or provided care. Review of the Point of Care Report failed to provide documentation regarding the resident's continence on 05/15/23 on days. f. Resident #3 required extensive assistance of two staff for bed mobility, transfer, toileting and personal hygiene and is occasionally incontinent of urine and bowels. The Point of Care Report documented the resident was incontinent of urine daily on each shift except the day-shift staff which failed to document regarding the resident's continence status on 05/10/23, 05/12/23, and 05/15/23. The resident was also documented as incontinent of bowels daily except twice when the staff noted the resident did not have a bowel movement. The resident was seated at a table in the dining room and the resident remained in the dining room in the same place [NAME] 11:50 AM to 3:00 PM. The resident was not provided the necessary care and services for incontinence and positioning. The resident was not toileted after lunch. Resident #3 was one of three residents on the unit who were to be transferred via Hoyer Lift, requiring two staff for transferring. g. Resident #4 required extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene and was always incontinent of urine and bowels. The Point of Care Summary confirmed the resident was incontinent of urine and bowels daily on each shift. The resident was wheeled into the dining room on 05/15/23 at approximately 11:50 AM and remained in the dining room after lunch and was not checked and changed every 2 hours for incontinence. An interview was conducted on 05/15/23 at approximately 2:15 PM with the Certified Nursing Assistant, Staff A. The aide confirmed she had brought Resident #4 into the dining room, and she had checked and changed the resident after 11:00 AM but is not sure of the time. She further confirmed the resident has to be toileted but she had not toileted the resident since she did at 11:00 AM-ish this morning. h. Resident #11 had an indwelling catheter, is frequently incontinent of bowel and required extensive assistance of one staff for bed mobility, transfer, toilet use and personal hygiene, limited assistance of one staff for locomotion on and off the unit via wheelchair. The resident required maintenance toileting upon rising, after meals and bedtime and as needed. Observation on 05/15/23 revealed the resident was seated at a table in the dining room and was served his lunch tray and was eating his lunch when at 12:04 PM, the Registered Nurse entered the dining room and removed the resident from the room to give the resident medication. The nurse returned the resident at 12:05 PM. The resident then finished eating his lunch. After eating his lunch, the resident remained in the dining room, initially wheeling himself around in the dining room, then the nurse placed him against the wall in the dining room. The resident remained there until his family came to visit and took him to the patio at 2:55 PM. The resident was not toileted after lunch as outlined on the plan of care. Review of the Point of Summary Report documentation for Resident #11 from 05/10/23 to 05/16/23 revealed the day shift did not consistently document the continence status of the resident. Staff had documented twice during the 6-day period on 05/11/23 (no bowel movement) and 05/14/23 (incontinent). Please refer to F677 for additional details regarding the above residents. The surveyor requested the continent status of all the residents on the 100-hall. Further review of the status of the residents on the 100 revealed that 2 of the 25 residents on the unit are continent of bowel and bladder. The remaining 23 residents ranged from 'occasional to always incontinent' of urine and/or bowels, 2 residents had an indwelling Foley catheter but were 'frequently to always' incontinent of bowels. An interview was conducted on 05/16/23 at 9:20 AM with the Scheduler, who reported that on the Day shifts (7AM-3PM) and evening shifts (3PM-11PM), they try to staff (have working) 3 aides; 2 aides on night shifts (11PM-7AM), 1 activity aide who works 9:00 AM to 5:00 PM, and 1 nurse on each shift. The schudler stated that on occasion they have had only 2 staff when one of the staff is out and one of the usual staff is out secondary to injury at this time. Review of the staffing for the Locked Memory Care Unit (100 unit) since May 1- May 15, 2023 revealed on 7AM-3PM shifts, the facility had 2 Certified Nursing Assistant (CNAs) assigned for patient care for 9 of the 14 days (05/01, 05/02, 05/05, 05/06, 05/07, 05/08, 05/10, 05/12, 05/14/23). Review of the facility's incident log for May (05/01-05/14/23) revealed the facility experienced 27 falls throughout the facility with 8 (29.62 %) of those falls occurring on the Memory Care Unit that had occurred on 05/03, 05/04, 05/05, 05/06, 05/08 and 05/09. It was noted that 4 of 8 falls (50%) occurred with Resident #7 and 1 of 8 falls occurred with Resident #6.

Based on observation, interview and record review, the facility failed to ensure a secure environment to prevent an elopement for a resident with dementia and documented wandering and exit-seeking behavior, for 1 of 3 sampled residents reviewed for elopement, Resident #134. The resident eloped from the facility on 03/07/23 between 2:20 PM and 2:30 PM and was returned to the facility by a 'passerby' after being located in the community near the facility at 2:30 PM. It was unknown by facility staff and management precisely where Resident #134 was located. Upon being returned to the facility, Resident #134 was placed in the Memory Care Unit (secured unit). Upon assessment after being returned to the facility, Resident #134 was not harmed and showed no signs of distress. The facility's failure to adequately supervise and provide a secure environment for Resident #134, who was identified as an elopement risk, resulted in the finding of Immediate Jeopardy, past noncompliance on 03/07/23. The Immediate Jeopardy was determined to be corrected on 03/17/23, prior to the survey based on survey verification of compliance with the facility's corrective plan. The findings included: The facility's policy, titled, Missing Resident Code Purple Elopement Policy and Procedure, updated 02/11/19, documented, in part: Policy: All residents will be assessed for elopement risk in order to maintain his/her safety. (To be done upon admission/readmission and as deemed necessary, i.e. behavior changes.) Addendum to Missing Resident Policy and Procedure: The definition of elopement will be defined for the purpose of this Policy and Procedure as follows; Any absence that is not previously authorized by or communicated to the Solaris Healthcare Parkway staff, and results in a resident leaving the premises or a safe area of the center without necessary supervision and puts the resident at risk for harm or injury. Or any absence by a resident living int the center's Memory Care Unit without authorization and/or necessary supervision that puts the resident at risk for harm or injury. The facility's policy for Doors, documented: Ensure that automatic or self-closing devices are properly installed and functioning. Monitor doors with magnetic locks or delayed egress locks to ensure that: Doors release appropriately at preset time delay and upon activation of the fire alarm system. No more than one delayed egress locked door is in the path of travel. Doors with magnetic locking devices unlock upon activation of the fire alarm system. Doors do not reactivate if the fire alarm system is placed in silent mode. The doors should not relock without the system being reset. Systems are returned to working order after performance of maintenance. The department is contacted to obtain any required approval before changes are made to the system. Resident #134 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #134 had a Brief Interview for Mental Status score of 07, indicating severe cognitive impairment. The assessment documented that the resident did not exhibit wandering behaviors during the 7-day look back period and required limited assistance and one person physical assist for Activities of Daily Living, including bed mobility, transfer, walk in room, walk in corridor, locomotion on and off of unit, and toilet use. The assessment documented that the resident was 'occasionally incontinent' of urine and 'frequently incontinent' of bowel. The assessment documented that Resident #134 ambulated via the use of a wheelchair. Resident #134's diagnoses at the time of this assessment included: Hypertension, Neurogenic Bladder, Urinary Tract Infection (UTI) (within the last 30 days), Hyponatremia, Hyperlipidemia, Alzheimer's disease, Malnutrition, Anxiety disorder, Depression, Dementia, Hypo-osmolality, Chronic pain, Nonrheumatic mitral prolapse, Chronic gastric ulcer, disorders of bone density, repeated falls, Retention of urine, restlessness, and agitation. An Elopement Risk Assessment was completed on 10/13/22 for Resident #134. The Assessment documented that Resident #134 was independently ambulatory, verbally expressed 'desire to leave center or go home', cognitively impaired with poor decision-making skills, had indications of dementia or a diagnosis of dementia, and short-term stay changed to long term care. The assessment documented that Resident #134 was not an elopement risk. An Elopement Risk Assessment was completed on 01/04/23 for Resident #134. The Assessment documented that Resident #134 exhibited wandering or exit seeking behavior in the last 90 days, was independently ambulatory, exhibited new behavior that would cause concern related to wandering exit seeking or safety, verbally expressed 'desire to leave center or go home', was cognitively impaired with poor decision making skills, had visual and auditory deficits, had indications of dementia or a diagnosis of dementia. The Assessment documented, the patient is a risk for elopement. Proceed with appropriate safety intervention and Resident had UA C&S [urinalysis / culture and sensitivity] done due to new behaviors and was diagnosed and treated for UTI. Behaviors stopped with treatment. Family in daily to visit and is aware of behaviors and the cessation of behaviors with treatment for UTI. Resident #134 successfully exited the facility, without staff knowledge, on 03/07/23 between approximately 2:20 PM and 2:30 PM. The resident was returned to the facility at 2:30 PM. Prior Elopement Risk Assessments concluded Resident #134 was not at risk for elopement and resided on the 200-hallway, approximately in the middle of the unit between the nurses' station and the emergency exit door at the end of this unit. Prior to the elopement, Resident #134 did not have a care plan for wandering and/or elopement risk and resided on the 200 Unit, which was not a secured unit, and supposedly exited through the emergency exit that was not secured, at the end of the unit. During the survey process of 03/20-24/2023, it was determined that Resident #134 was not interviewable as evidenced by not being able to provide appropriate answers regarding the event/incident. A Nursing Home Adverse Incident Report, submitted to the Agency on 03/21/23, documented the following: Resident is an 83 y/o [year old] long term resident admitted on 12.23.21. On 03.07.23 at approximately 2:05-2:15 pm, resident was observed by [name] Administrator and [name] EVS [Environmental Services Director], sitting across from North Wing 200-Hall nursing station [where she resides] with another female resident - both holding a recent copy of the weekly menu selections. At approximately 2:30 pm, Administrator had returned to front lobby office and was alerted that resident had been observed and redirected back to facility by a passerby familiar with Solaris Campus. Administrator immediately went to front entrance and saw that resident was sitting in the vehicle backseat of the visitor, still holding her weekly menu. Resident was smiling, and appeared to be in no distress, nor discontent. No injuries were noted and no c/o pain. Administrator [NHA] accompanied resident back into the center and DON [Director of Nursing] then escorted her to the MCU [Memory Care Unit] for safety. She joined the activity being conducted. Elopement Assessment was completed and resulted in a score of four (4) at risk for elopement. Decision was made by Nursing leadership in conjunction with Administrator to transfer resident to Secured Memory Care Unit for environmental safety; discussion was had with resident's daughter [name] and informed consent obtained. Attending physician [Name] was notified at approx. [approximately] 3:00pm and new orders for lab testing were received. [The] 200-Hall charge nurse, [Name] LPN [Licensed Practical Nurse], conducted a manual census verification (head count) to confirm all residents were accounted for. A Center-wide audit was conducted to ensure all emergency exit doors remained secured and properly alarmed. QAPI [Quality Assurance and Performance Improvement] AD HOC Meeting was called and attended by NHA, DON, Risk Mngr. [Manager], and Medical Director (by phone). Medical Director review and initiated event investigation. Resident's Hallway Emergency Exit door magnetic locking mechanism was unlocked and dis-alarmed, where resident likely exited independently from the center without notification. Plant Operations Director [Name] had temporarily unlocked the 200-Hall Exit door, (adjacent to HVAC installation project, on 100-Hall/Memory Care Unit) on 03.07.23 in order to increase accessibility of outdoor equipment and supplies for contractor, with minimal disruption to facility residents. Plant Ops. Director had not considered potential of resident exiting the wing through the emergency exit door. Resident ambulates ad lib on the hallway, independently. On the Event Details Note, dated 03/07/23 at 2:30 PM, the DON documented, Resident was observed walking outside the center and was quickly returned and redirected back to the Center's North Wing. Resident has no injury, and no distress noted. Elopement Assessment was conducted by Charge Nurse and resulted in a score of 4 at risk for elopement. Resident was transferred to Memory Care Secured Unit. On 03/22/23 at 8:20 AM, Resident #134 was observed being taken to the shower room by staff, it was noted that Resident #134 was ambulating without the use of assistive devices (e.g. wheelchair, walker). It was noted that resident walked slowly, in small shuffling steps. On 03/22/23 at 8:22 AM, during an interview with the ADON (Assistant Director of Nursing), when asked about Resident #134 ambulation, the ADON stated the resident was ambulatory without the use of assistive devices. During interviews with the nursing staff and the Administrator on 03/23-24/23, they reported that there were no video cameras on the unit that they were aware of. During an interview, on 03/22/23 at 9:16 AM, with Staff B, LPN, when asked about Resident #134's behavior, Staff B replied, She would walk up and down the hall, she would ambulate herself. I am not sure if she was exit seeking. Sometimes she would go to the door to the dining room and sit there. The family comes and takes her out in the mornings. The daughter would come every day about 9:00 or so with the resident's husband and they would be outside for a while and sit for a while and come back. She would spend about 2 hours with her outside on the porch [between the 100-200 Dining room and the lobby / reception area at the main entrance to the facility]. On 03/22/23 at 9:50 AM, the alarm was heard sounding at the Emergency Exit at the end of the 200 unit. When asked about the alarm, Staff C, Plant Operations Assistant, stated, I was making sure the alarm on the door was set and not off. The alarm indicates that the door has been opened. I am going through all of the hallways and checking all of the exit doors. Every day in the morning and before I leave at night, I leave at 5:30 [PM], I usually do it at 5:15-ish [PM]. During an interview, on 03/22/23 at 9:52 AM, with Staff D, LPN (Nurse on day of 03/07/23 and previous day), when asked about Resident #134's behaviors, Staff D replied, she does walk back and forth in the hallways and would walk all the way up to the dining room - it is always closed. She usually does it after lunch and we have her sit with us, and sometimes she would go back to her room. One of her daughters comes almost every day after lunch. She wasn't exit-seeking, just wandering. I have never seen her at the end of the unit and have not seen her touch that door. When asked about the door that Resident #134 exited through, Staff D, stated that the resident exited through the emergency exit at the end of the 200 unit. When asked where Resident #134 was going, Staff D replied, I was helping a nurse on the 100 hallway and by the time that I finished that, somebody was returning [the resident] after she got out the door. They told me that she was found on the street in front of the facility (Central Parkway). Not positive which side of the road. When asked about Resident #134 being ambulatory, Staff D replied, She had a wheelchair for a little bit when she came in. Since then, she has been independently ambulatory without assistive devices. When asked of Resident #134's cognition, Staff D stated, alert (to person and place) with confusion. On 03/22/23 at 10:02 AM, Resident #134 was observed by this surveyor being escorted from the memory care unit by her daughter to the patio with her husband. It was noted that Resident #134 was walking without the use of assistive devices and was taking small shuffling steps. During an interview, on 03/22/23 at 10:10 AM, with Staff E, CNA (Certified Nursing Assistant), who was the CNA on the day of the elopement and previous day, when asked about the incident, Staff E replied, That day she was with the menu and was sitting by the nurse's station. I walked to the TV room to get help with putting a resident in bed, when I came back, I was told that she went out. She walks back and forth on the unit, but never tried to get out or approached the door to my knowledge. During an interview, on 03/22/23 at 10:20 AM, with Resident #134's husband and daughter, when asked about the elopement, Resident #134's daughter replied, They left the door unlocked as they were doing some work and she was found on Central Parkway. Somebody drove by and said that she looked lost and asked if she knew where she was going and brought her back. They called me at home and told me that. They immediately called me and told me about it. I didn't see any construction on the 200 hall. During an interview, on 03/22/23 at 10:38 AM with the Director of Nursing (DON) when asked about the incident and where and when the resident was found, the DON replied, there was a passerby that was a caregiver that brought her back, the Administrator was involved in that part of it. I put her in the Secured Memory Care unit. She scored a 04 on the Elopement risk. Her daughter did not want her to go to the memory care unit. We explained that it was the safest place for her, and she was not happy with that decision. They were doing work on the air conditioning unit on the 100 unit and the door was unlocked for the workers to go in and out, at which time we did not know. She was found on Central Parkway. When Resident #134 first came in, she was wandering and was very confused and on the Memory Care Unit. The daughter was very against it. She wasn't trying to exit seek and didn't go near the door. If they are not exit seeking, we will move them out of the unit. She would never even go out of the double doors without the daughters being here. If we would have known that the door was open, we would have put a fire watch at the door. The Plant Operations Director is new to the position and didn't realize that was not the Memory Care unit. We checked all of the doors and did a head count. One hundred percent (100%) of the facility in-serviced on elopement, door codes, reporting, abuse a focused meeting was scheduled and that was our first one. My ADON and myself went and re-did all of the elopement assessments again to make sure that they were correct - 147 patients were re-evaluated. We QAPI it and we double checked all of the assessments and they were all accurate. We did elopement drills on a Sunday with the Risk Manager and on Friday evening prior to that. The RM (Risk Manager) is checking all of the doors every morning as well as Maintenance doing it and keeping a log. I checked in with the daughter. We did some lab work on her and was found with no infections. During an interview, on 03/22/23 at 10:53 AM, when asked how Resident #134 was found and returned to the facility, the Administrator replied, She was observed by someone driving towards SE Central Parkway, I had just seen her and noticed her, and I had sent a text to [Name] the Plant Operations Director about the shower room and then heard somebody yelling at the receptionist. What happened was a transport company had driven up to pick up a resident for an appointment and said that 'I think I may have seen one of your residents and the transport company yelling to the receptionist. She was right out here (referring to the main entrance of the facility).' When she was first admitted , she was admitted as short term on 12/24/21, was unsafe wandering and they did an elopement assessment and scored high, and we moved her to the memory care unit for about a month until we did another assessment and she did not display the same wandering behaviors. She was doing very well. We did another assessment after the elopement and she scored a 4, which was high, she had a UTI, we will continue to reassess her and if she doesn't show exit seeking, then we will try to transfer her to a less restrictive environment. [Name] (the passerby) asked her where she was going and she said, 'to find her husband' and told her 'I'll take you there and brought her to the facility. During further interview, when asked where the resident was found by the passerby, the Administrator stated that she was unable to confirm where the resident was found, as she did not get details from the passerby, and did not have contact information for that person. During an interview, on 03/22/23 at 1:02 PM with the Plant Operations Director, when asked about the door not being secured, the Plant Operations Director replied, The actual work started about 2 weeks ago. The portable unit was bought for hurricane reasons, we bought 3 or 4 of them about 5 years ago. They were coming in and out for the attic, the insulation, and the tools, this was one of the days where I had one guy. I told the nurse that they were going to be coming in and out and that the door was not armed - (Staff D) She said 'okay', she might have said I'll keep a look out or something, but it wasn't much more than that. When asked about how long the door was unsecured, the Plant Operations Director replied, they got here around 1 PM and started bringing in their stuff. It was open until about 3:00 or so, and I left at 4:30 PM. The facility's actions to remove the Immediate Jeopardy and correction action plan prior to the survey included: 1. Resident #134 was assessed for elopement risk and moved to the secure Memory Care Unit. 2. All emergency exits were checked and found to be secured. 3. Staff D/LPN, Staff E/CNA, the Plant Operations Director and the contractor were in-serviced regarding securing the emergency exits. 4. Elopement risk assessments were completed for all resident not residing on the secured Memory Care Unit on 03/10/23. 5. An Ad Hoc QAPI meetings held on 03/07/23, 03/09/23, and 03/17/23. Interviews during the survey with NHA, DON and President of Solaris revealed management realized the focus of the event as per the RCA should be on environmental and door safety along with education. Initiation of twice daily door checks continued, and education began. They also realized doing daily elopement drills on all shifts was not effective due to disruption to resident care needs and routine, and again as this was not the root cause. This was again discussed and documented at the AD HOC/QAPI meeting of 03/09/23. 6. Emergency exit doors (13) checked daily for function by Plant Operations and Risk Management 7. 100% of staff provided in-service completed as of 03/12/23. 8. Elopement Drills conducted 03/10/23, 03/12/23 and 03/23/23 and are scheduled through August 2023. The survey team verified the corrective actions were implement and completed as evidenced by: 1. AD Hoc QAPI meeting minutes were reviewed for meetings conducted on: a. 03/07/23 b. 03/09/23 c. 03/17/23 d. 03/23/23 2. The facility provided documentation of audits of the emergency doors, twice daily from 03/07/23 and are ongoing. 3. On 03/23/23 at 7:30 AM, this surveyor toured the facility with the Risk Manager and found all 13 doors were secured and functioning properly. 4. Random staff interviews were conducted on 03/22/23 with 4 CNAs and 1 LPN who confirmed in-service training. Surveyors' interviews conducted on 03/22 through 3/24/23 with at least one staff from each department, including nursing, therapy, social services, activities, housekeeping, laundry, maintenance, and dietary; and on each shift were conducted to confirm education. 5. Documented in-services trainings were completed for staff, between 03/08/23 to 03/12/23, included: - 76 of 76 CNAs - 27 of 29 Therapy staff (2 staff were per diem and have not worked since the elopement) - 21 of 21 LPNs - 13 of 13 RNs - 13 of 13 Housekeeping staff - 4 of 4 Laundry staff - 16 of 16 Dietary staff - 3 of 3 Medical Records staff - 10 of 10 Administrative staff - 3 of 3 Activities staff - 6 of 6 Social Services staff - 8 of 8 Nursing Administrative staff - 1 of 1 contracted Beautician - 1 of 1 ARNP (Advanced Registered Nurse Practitioner) 6. Documentation of Elopement Drills was provided for drills conducted on: - 03/10/23 - for the 11:00PM to 7:00 AM staff - 03/12/23 - for the 7:00 AM to 3:00 PM staff and 3:00 PM to 11:00 PM staff - 03/23/23 - for the 3:00 PM to 11:00 pm staff and the 11:00 PM to 7:00 AM staff - Drills are scheduled every 2 weeks through the month of August 2023. No residents were observed wandering or displaying exit-seeking behaviors outside of the secured Memory Care Unit for the duration of the survey - 03/20/23 to 03/24/23. Immediate Jeopardy was determined to be past noncompliance and corrected on 03/17/23, prior to the survey.

Based on interview, record review, and policy review, the facility failed to act on the voiced grievance for 1 of 3 sampled residents who utilize the sit-to-stand transfer device. Resident #49 voiced her concerns to Staff J, Certified Nursing Assistant (CNA), who failed to act upon the voiced grievance. The findings included: Review of the policy, titled, Grievance Policy (undated) documented, in part, All persons are encouraged to make requests, share concerns, and file grievances regarding care and/or services without fear of retribution or negative treatment. Customer Service/Grievance forms are available throughout the facility at the nursing stations and upon request. A concern or grievance may be given orally or in writing. The facility had the capacity to hold 177 residents, located on three different units, North, South, and East. The East unit where Resident #49 resided encompassed the 500, 600, and 700 halls. At the time of the survey there were 57 residents on that unit, and 6 utilized the sit-to-stand transfer device. The East unit's 600 and 700 halls were typically the short-term skilled residents, so the resident turn over and needs varied. Review of the record revealed Resident #49 was admitted to the facility on [DATE] and moved to her current room on 01/01/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident needed the extensive assistance of two persons for transferring and toileting. Review of the current care plan initiated on 02/10/21, and revised on 02/06/23, documented Resident #49 had decreased mobility and needed extensive assistance for transfers. This care plan documented the use of the sit-to-stand as needed to assist with transfers as of 08/31/22. During an interview on 03/20/23 at 11:26 AM, Resident #49 stated for the past year she had been complaining that there were not enough sit-to-stand transfers devices. The resident explained there was only one device per unit. Resident #49 stated that when she needed to go to the bathroom to have a bowel movement, it could take anywhere from 30 to 90 minutes for the staff to get the sit-to-stand, and sometimes it was then too late, and she had an accident. When asked how often it took too long and she had an accident, Resident #49 stated at least half the times. Resident #49 stated, It's one of the things that makes my life miserable. Review of the grievance logs from August 2022 through March 2023 lacked any grievance from Resident #49. During an interview on 03/24/23 at 1:39 PM, Staff J, Certified Nursing Assistant (CNA), explained she had been at the facility for about 10 months, and the 500 hall where Resident #49 resided was her usual assignment. When asked about Resident #49's usual routine for getting out of bed and toileting needs, Staff J explained the resident would get up about 10:30 AM every day and would use the bathroom at that time. The CNA explained she was incontinent of urine, but could tell when she needed to have a bowel movement. When ask how Resident #49 was transferred from the bed to the chair, Staff J stated via the sit-to-stand, with two person assistance. When asked how many sit-to-stands were on the unit, the CNA stated there was just one, and that most of the residents wanted to get up in the morning after breakfast, so the sit-to-stand was in high demand at that time. When asked if Resident #49 had ever voiced a concern with a delay in getting her up related to the lack of sit-to-stands, the CNA stated, Oh yes, because then she gets upset and we get upset because we can't help her timely. When asked if Resident #49 had ever had an accident while awaiting the transfer device, the CNA confirmed she had. When asked how often there was a delay in getting Resident #49 out of bed and into the bathroom, Staff J stated about half the time. When asked if she had told her nurse or management of the issue, the CNA stated she had not and was unsure it would do any good. During an interview on 03/24/23 at 3:23 PM, the Director of Nursing (DON) confirmed she was unaware of the voiced grievance from Resident #49, and confirmed the CNA should have told the nurse or someone of the delay in services related to the lack of transfer devices.

Based on observation, interview and record review, the facility failed to initiate a care plan for newly identified behaviors for 1 of 26 sampled residents, whose care plans were reviewed, Resident #134. The findings included: The facility's policy, titled, Care Plans - Comprehensive, most recently revised on 01/25/23, documented, in part, the following: Policy Statement - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive car plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that included, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified concerns. b. Incorporate risk factors associated with identified problems. e. Reflect treatment goals, timetables and objectives in measurable outcomes. g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The facility's policy, titled, Resident /elopement Risk Management Guidelines - SF, documented, in the section, titled, Resident Guidelines, the following: 2. A care plan will be developed, as appropriate, for all residents identified as at risk for elopement. 5. If wandering behavior is identified for any current resident who previously has not exhibited this behavior, change of condition documentation should be charted in the resident's medical record and a care plan implemented. Resident #134 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #134 had a Brief Interview for Mental Status score of 07, indicating severe cognitive impairment. The assessment documented the resident did not exhibit wandering behaviors during the 7-day look back period and required limited assistance and one-person physical assist for Activities of Daily Living (ADLs). The assessment documented the resident was occasionally incontinent of urine and frequently incontinent of bowel. Resident #134's diagnoses at the time of the assessment included: Neurogenic bladder, Urinary Tract Infection (UTI) within the last 30 days, Alzheimer's disease, Anxiety disorder, Depression, Dementia, Repeated falls, restlessness, and agitation. An Elopement Risk Assessment was completed on 10/13/22 for Resident #134. The Assessment documented that Resident #134 was independent in ambulation, verbally expressed desire to leave enter or go home, cognitively impaired with poor decision-making skills, had indications of dementia or a diagnosis of dementia, and was short-term stay changed to long term care. The assessment documented that Resident #134 was not an elopement risk. An Elopement Risk Assessment was completed on 01/04/23 for Resident #134. The Assessment documented Resident #134 exhibited wandering or exit seeking behavior in the last 90 days, was independently ambulatory, exhibited new behavior that would cause concern related to wandering exit seeking or safety, verbally expressed desire to leave center or go home, was cognitively impaired with poor decision making skills, had visual and auditory deficits, and had indications of dementia or a diagnosis of dementia. The Assessment of 01/04/23 also documented, the patient is a risk for elopement. Proceed with appropriate safety intervention' and 'Resident had U/A C&S [Urinalysis Culture & Sensitivity] done due to new behaviors and was diagnosed and treated for UTI. Behaviors stopped with treatment. Family in daily to visit and is aware of behaviors and the cessation of behaviors with treatment for UTI. Resident #134 successfully exited the facility, without staff knowledge, on 03/07/23, via an unlocked emergency door at the end of the hallway where she resided. A progress note, dated 01/17/23 at 10:19 AM, documented, Resident with UTI symptoms 12/21/22. Culture done and resident was treated for UTI with no further complaints. See progress notes, 12/21/22 - 12/28/22. A Progress Note, dated 01/27/23 at 3:26 PM, documented, Resident alert with confusion. Requires occasional reminders for safety. Walks through the hallway looking for an exit on occasions especially in the afternoons. Redirection at times inefficient. Continues on antibiotic therapy for left lower extremity wound. Medication tolerated well. Afebrile, fluids encouraged. Staff continues to monitor for safety. A progress note, dated 01/20/23 at 10:46 PM, documented, Started ABT [antibiotic] for wound, no adverse reactions noted. Review or Resident #134's Medicine Administration Record (MAR) revealed that Resident #134 was being treated with antibiotics for a wound as of 01/20/23 and was not treated for UTI in the month of January 2023. Record review of the care plans revealed: There was no care plan initiated for the identified wandering behavior on 01/04/23, or prior to the resident exiting the facility on 03/07/23. Review of the care plan for Urinary Incontinence dated 01/18/22 did not list signs or symptoms of UTIs to observe for. The care plan for Cognitive Loss/Dementia, date 01/12/22 and revised 03/20/20, with an intervention Observed for unsafe actions and intervene as needed, had no actions or behaviors listed to observe for. The care plan for Falls, dated 01/12/22, with one intervention being Check Freq, observing for any signs of unsafe behavior - it did not list what unsafe behaviors to observe for. During an interview, on 03/23/23 at 1:48 PM with Staff D, Licensed Practical Nurse (LPN), when asked about the progress note on 01/04/23 regarding UA, Staff D replied, The behavior (referring to Resident #134's wandering behaviors) was not normal. She is compliant and her routine is that the Certified Nursing Assistant (CNA) will come in and the resident will have her clothes picked out for after she is showered. She is pleasant, she does not refuse showers and care. When asked about the progress from on 01/28/23, regarding Resident #134 still exit seeking, Staff D replied, She was on antibiotics for a wound. That (the UTI) was 3 weeks later and should have been resolved. She did not have a UTI on 01/05 and did not have orders for antibiotics. When asked about documentation of behaviors, Staff D replied, I document whatever her behaviors are in my notes. If there are no behaviors, I document no behaviors. During an interview, on 03/24/23 at 1:33 PM with Staff H, MDS (Minimum Data Set) Coordinator, the MDS Coordinator confirmed that she would be responsible for initiating / implementing care plan when new behaviors are identified and upon assessment. When asked why a care plan was not implemented prior to Resident #134 eloping from the facility on 03/07/23, the MDS Coordinator replied, our department was not aware of the behavior and her being at risk. They never notified us. If they did, we would have done the paperwork. When asked how she would be notified of new behaviors, the MDS Coordinator replied, They would have to let us know. We get morning reports from the nurses that write anything pertinent on that sheet, including falls, or changes in condition. The others go and do their assessment, it is up to the staff to let us know.

Based on interview, record review and facility policy, the facility failed to treat 5 of 6 sampled residents, to include a randomly sampled resident who requested to remain anonymous, in a dignified manner, when calling for assistance with personal care (Resident #409, #97, #408, #76 and 1 random). The findings included: Review of the policy Healthcare Abuse, Neglect, Exploitation and Misappropriation of Property, Protection and Response dated 02/12/18 documented, The Health Center Administrator is responsible for assuring that Patients' Rights of personal privacy, confidentiality and dignity will be respected for all aspects of care . 1. During an interview on 12/06/21 at 10:45 AM, a resident who requested to remain anonymous, stated she does not like it here because it takes too long to answer the call light. The resident stated if you need help with the restroom the staff gets annoyed, and you feel like a burden. 2. During an interview on 12/06/21 at 2:18 PM, Resident #409 explained that about one and a half weeks ago she was struggling to put on her nightgown, with her right arm in a cast, and rang for help. Resident #409 further explained she requested help when the Certified Nursing Assistant (CNA) came into the room. The residents stated the CNA responded, You have a left hand and walked out of the room without assisting her. Resident #409 stated she was upset and reported the incident to a nurse. She also stated the staff had been rude to her roommate (Resident #408) about needing to go to the restroom. Review of the record revealed Resident #409 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #409 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented Resident #409 required extensive assistance for dressing. 3a.During an interview on 12/06/21 at 4:12 PM, Resident #97 stated some of the CNA's are very rude and let her roommate (Resident #76) lie in urine for hours. The resident explained that once when she said something about the long wait, the CNA tossed the blanket over her roommate's head after providing care. Resident #97 stated she reported it to administration about a month and a half ago and requested that particular CNA be removed from their care. Resident #97 further explained that last week, when her roommate called for help, a CNA came into the room, shut off the call light and left the room without addressing the resident. After three hours of knowing her roommate (Resident #76) was lying in urine, Resident #97 went down the hall to get help and found the staff in the family room sleeping. Review of the record revealed Resident #97 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE] documented Resident #97 had a BIMS of 15, on a 0 to 15 scale, which indicated she was cognitively intact. 3b. During an interview on 12/09/21 at 8:18 AM, Resident #76 stated that the CNA's have been rude to her several times, and it makes her upset. The resident explained that on one occasion she was wet (with urine) and needed to be changed, when a CNA came in, turned off her call light and left without cleaning her. Resident #76 stated she waited for 3 hours until her roommate got up and went to find help. The resident stated a CNA then came in and cleaned her but was angry. Resident #76 stated when the CNA was finished, she tossed the blanket over her face. The residents reported the incident to administration and requested not to have that CNA care for them anymore. During this interview Resident #76 described a second incident as follows. Resident #76 used the call light as she needed to be cleaned. The CNA told her, If you do it again you will just have to lie in it. The resident said she replied she cannot help not being able to control her urine. Resident #76 stated on another occasion she was in the restroom, used the call bell for help, and after 45 minutes her roommate went to get help. Resident #76 stated her son complained to administration about the incident. Review of the record revealed Resident #76 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] documented Resident #76 had a BIMS score of 12, on a 0 to 15 scale, which indicated mildly impaired cognition. This MDS also documented the resident required extensive to total assistance for care with toileting and bathing. 4. During an interview on 12/09/21 at 7:49 AM, Resident #408 stated sometimes the CNAs on evenings or nights can be short or rude because she has to use the restroom. She went on to say that her daughter had reported it. During an interview on 12/09/21 at 11:00 AM, Resident #408's daughter stated there was an incident a few weeks ago when her mother had to use the restroom and the staff was not nice to her. She stated her mother's roommate told her about it, so she reported it to administration. Review of the record revealed Resident #408 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] documented a BIMS score of 14, on a 0 to 15 scale, which indicated the resident was cognitively intact. This MDS also documented the resident required extensive assistance for toileting.

Based on interview and record review, the facility failed to ensure residents' involvement in the care planning process, document Interdisciplinary Team (IDT) participation in the care planning process, and review and revision by the IDT with each assessment (done via care planning meetings) for 19 of 37 sampled residents, Residents #47, #54, #153, #46, #136, #113, #134, #81, #67, #160, #86, #3, #30, #85, #96, #137, #119, #27, and #127. The findings included: 1. Record review revealed Resident #81 was admitted to the facility on [DATE]. Further review revealed the most current quarterly Minimum Data Set (MDS) assessment was completed on 10/14/21. The record lacked any evidence of any care plan meeting since that assessment. The last documented care plan conference was held on 07/22/21 and lacked any documented participation from the direct care Certified Nursing Assistant. During an interview on 12/08/21 at 2:30 PM, Staff B-MDS Coordinator, confirmed that they have no documented evidence of Certified Nursing Assistant (CNA) participation in the care planning process, and they usually speak to the CNA about each resident, but they don't document the information. She also said that if the resident's electronic record does not have any entry under the care plan tab, they did not have a care plan conference. 2. Record review revealed Resident #137 was admitted to the facility on [DATE]. Further review revealed the most current Quality Minimum Data set (MDS) was completed on 11/10/21. The record lacked any documented participation from a direct care staff, Certified Nursing Assistant. 3. Record review revealed Resident #119 was admitted to the facility on [DATE]. Further review revealed the most current Quality Minimum Data set (MDS) was completed on 11/02/21. The record lacked any documented participation from a direct care staff, Certified Nursing Assistant. 4. Record review revealed Resident #3 was admitted to the facility on [DATE]. Further review revealed the most current Quality Minimum Data set (MDS) was completed on 11/23/21. The record lacked any documented participation from a direct care staff, Certified Nursing Assistant. 5. Record review revealed Resident #160 was admitted to the facility on [DATE]. Further review revealed the most current Quality Minimum Data set (MDS) was completed on 10/24/21. The record lacked any documented participation from a direct care staff, Certified Nursing Assistant. 6. Record review revealed Resident #30 was admitted to the facility on [DATE]. Further review revealed the most current quarterly Minimum Data Set (MDS) assessment was completed on 09/15/21. The record lacked any evidence of any care plan meeting since that assessment. The last documented care plan meeting was on 06/24/21 and lacked any documented participation from the direct care Certified Nursing Assistant (CNA). During an interview on 12/08/21 at 11:38 AM, Staff A and Staff B, MDS coordinators, confirmed they have no documented evidence of CNA participation in the care planning process. The MDS coordinators stated they usually speak with a CNA about each resident but don't document it anywhere. The MDS coordinators also confirmed the way in which they document IDT participation in the care planning process with each assessment is via a Care Conference. The MDS staff identified the Care Conference tab in the electronic medical record under Care Planning, and stated if there was no entry in the record in the Care Conference tab, they did not have a care plan meeting. 7. [NAME] review revealed Resident #54 was admitted to the facility on [DATE]. Further review revealed the most current MDS assessment was completed on 09/26/21. Review of the Care Conference tab in the electronic medical record lacked any care plan meetings. 8. Record review revealed Resident #67 was admitted to the facility on [DATE]. Further review revealed the most current MDS assessment was completed on 10/12/21. The record lacked any evidence of any care plan meeting since that assessment. Review of the record revealed the last care plan meeting was 04/19/21, indicating the lack of a care plan meeting with the 07/13/21 assessment as well. 9. Record review revealed Resident #85's most current MDS assessment was on 10/22/21 for a significant change. The record lacked any care conference/IDT care plan meeting for this significant change. Review of the quarterly care plan meeting, dated 10/13/21, lacked documented CNA participation. 10. Record review revealed Resident #96 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed the Admission MDS was completed on 10/22/21. The record lacked evidence of any care plan meeting. 11. Record review revealed Resident #134's most current quarterly MDS assessment was dated 11/09/21. Further review revealed the last documented care plan meeting was 05/19/21 and lacked any documented CNA participation. The facility failed to have a care plan meeting since that date. 12. Record review revealed the last two quarterly MDS assessments were dated 08/11/21 and 11/10/21. The record revealed the most current IDT care plan meeting was conducted on 05/19/21 and lacked documented CNA participation. The facility failed to have a care plan meeting since that date. 13. Record review revealed Resident #153 was admitted to the facility on [DATE] with a documented care plan meeting on 08/30/21, but no CNA participation. The most current quarterly MDS assessment was dated 11/18/21 and the record lacked any care plan meeting. 14. Record review for Resident #113 revealed the care plan review was completed on 11/15/21. There was no evidence of CNA participation in this review. On 12/09/21 at 10:43 AM, a side by side review of Resident #113's records and interview was held with three RNs/MDS coordinators (Staff A, B and G). When asked who participated in the care planning process and who attended the care conference, the MDS coordinators indicated the personnel who participated in this care plan review included: Activity, Dietary, Social Worker, MDS, and Restorative LPN (licensed practical nurse). 15. Record review for Resident #27 revealed the quarterly comprehensive assessment was completed on 09/08/21, there was no records for evidence of care conference for care plan review in accordance with this quarterly comprehensive assessment. On 12/09/21 at 10:49 AM a side by side review of Resident #27's records and interview was held with three RNs/MDS coordinators (staff A, B, and G) the MDS coordinators have agreed there was no records of care conference for for September 2021 for resident #27. 16. Record review for Resident #127 revealed the care plan review was completed on 11/12/21. There was no evidence of CNA participation in this review. On 12/09/21 at 10:54 AM, a side by side review of Resident #127's records and interview was held with three RNs/MDS coordinators (Staff A, B and G). When asked who participated in the care planning process and who attended the care conference, the MDS coordinators indicated the personnel who participated in this care plan review included: Activity, Social Worker, MDS, Dietary and Restorative LPN. 17. Record review for Resident #47 revealed the care plan review was completed on 10/06/21. There was no evidence of CNA participation in this review. On 12/09/21 at 10:57 AM, a side by side review of Resident #47's records and interview was held with three RNs/MDS coordinators (Staff A, B and G). When asked who participated in the care planning process and who attended the care conference, the MDS coordinators indicated the personnel who participated in this care plan review included: Activity, Social Worker, MDS, Dietary, and Restorative LPN. 18. Record review for Resident #46 revealed the care plan review was completed on 09/28/21. There was no evidence of Dietary personnel participation in this review. On 12/09/21 at 11:00 AM, a side by side review of Resident #46's records and interview was held with three RNs/MDS coordinators (Staff A, B and G). When asked who participated in the care planning process and who attended the care conference, the MDS coordinators indicated the attendees included: activity, CNA, MDS, and the restorative LPN. 19. Record review for Resident #86 revealed the quarterly comprehensive assessment was completed on 10/21/21. There were no records for evidence of a care conference for care plan review in accordance with this quarterly comprehensive assessment. On 12/09/21 at 2:00 PM a side by side review of Resident #86's records and interview was held with two RNs/MDS coordinators (Staff A and G). The MDS coordinators agreed there was no records of care conference for the evidence of care plan review for October 2021 for Resident #86. A care plan review was held on 07/29/21 but there was no evidence of CNA participation in this review. Staff A and G-MDS coordinators revealed personnel who participated in this care plan review included: Activity, Social Worker, MDS, Dietary, and the Restorative LPN.

Based on observation, record review and interview, the facility failed to follow their policy related to smoking materials for 1 of 1 sampled resident, Resident #7, reviewed for smoking. The findings included: During an interview on 12/07/21 at 8:09 AM, with Resident #7, the resident stated she smokes and keeps her own cigarettes and lighter in her purse and locked drawer. Resident #7 then showed the surveyor her cigarettes and her lighter in her purse and gave the key to the surveyor to open drawer to see the cigarettes in her drawer. There were three packs of cigarettes observed in drawer. Review of the electronic medical records revealed Resident #7 included diagnoses to include [CONDITION(S)] and [CONDITION(S)] following other nontraumatic [CONDITION(S)] affecting left non-dominant side (Primary), Heart failure, Hypertensive, Heart Disease with Heart Failure and convulsions. A review of the quarterly Minimum Data Set (MDS) assessment, dated 11/29/21 documented Resident #7 had a Brief Interview Mental Status (BIMS) of 15, indicating intact cognition, and documented she uses tobacco products. A Smoke Risk Assessment completed on 11/29/21 documented she was a safe smoker and to follow the policy. A review of her care plan, dated 12/06/21, revealed the resident was 'at risk for injury secondary to smoking, incident of singeing of her hair with a cigarette. Staff to check resident room or belongings at any time for smoking materials that may indicate unsafe smoking practices and endanger other residents'. Interventions in the care plan included to encourage / offer to keep smoking materials at nursing station for safety, resident re-educated on dangers of smoking indoors will continue to observe for any further behaviors. During an interview on 12/08/21 at 11:53 AM with Staff I-CNA (certified nursing assistant), she stated the resident is alert but some days can be confused; keeps her cigarettes in her purse or in her locked drawer next to her bed; and keeps the lighter in her purse. During an interview on 12/08/21 at 12:00 PM with Staff J-RN (registered nurse), she stated 'Resident #7 was extensive assist for all ADLs (aactivities of daily living. She was assessed for smoking, and we make sure she can light the cigarette appropriately. She likes to hide her cigarettes and we tell her we have to keep them at the nurse's station, but she refuses, if she refuses to give them to us she keeps them. She keeps her cigarettes and lighter in a bag or purse. The policy says to keep the cigarettes and lighter at the nurse's station.' A review of the Smoking policy, dated 09/22/14, under #5, documented cigarettes and lighters will be kept at the nurse's stations and will be given to the resident by the charge nurse when he/she goes out to the designated area. Cigarettes and lighters will be collected by the charge nurse when he/she returns.

Based on record review and staff interview, it was determined that the facility failed to provide the necessary care and services for diabetic management to maintain stable glycemic control of a vulnerable diabetic, Resident # 73. This is evidenced by the consistent elevated blood sugar monitoring levels of 400-600 mg/dl (milligram/deciliter) from July to October 2014; the steadily increasing results of the Hemoglobin A1C (glycated hemoglobin) test that estimates the average blood glucose levels over two to three months. Resident # 73's hemoglobin A1C level in the last 6 months went from 7.9% to 9.0%. The A1C goal for diabetic patients is 7%. High levels of blood glucose can damage the tiny blood vessels in the kidneys, heart, eyes, or nervous system. The facility's failure to provide the necessary services for diabetic management is also evidenced by the staff nurses failing to follow the prescribed physician orders [REDACTED].# 73) reviewed during the stage 2 and expanded samples. It was determined the facility's persistent failure to manage the care and services for Resident # 73 resulted in ongoing Immediate Jeopardy. The facility failed to provide evidence that Resident #73's blood sugar was checked two (2) hrs after a greater than 400 reading, and failed to administer additional insulin coverage as needed and as ordered. This failure posed an immediate threat of a possible hyperglycemic incident up to and including coma and/or systemic complications from prolonged [MEDICAL CONDITION]. In addition, the facility failed to provide the necessary care and services for 2 of 29 sampled patients related to comfort and positioning for Resident #225 as evidenced by the facility failure to turn and reposition a Hospice resident according to the prescribed physician orders [REDACTED].# 363 which he sustained from an incident. The findings include: 1) Review of the clinical record for Resident # 73 discloses that the resident was originally admitted to the facility in 2006 and has a recent readmission with [DIAGNOSES REDACTED]. According to a 2011 physician progress notes [REDACTED]. There is no further evidence of follow-up from this specialist. Further review of the clinical record failed to provide evidence that the resident's treatment plan maintained this goal. The resident's current treatment plan for Diabetic management includes a 02/17/2014 physician order [REDACTED]. The physician further prescribed for the resident to receive [MEDICATION NAME] R (Short acting insulin) 100 units/ml injection solution, inject by subcutaneous route as per insulin sliding scale as follows: if blood sugar is 200-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; if greater than 400 give 10 units, recheck in 2 hours and give sliding scale coverage. Monitoring of the blood glucose level is prescribed before meals and at bedtime (6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM). Further review of the blood glucose monitoring from July to October 2014 failed to provide evidence of the facility maintaining a glucose level of 150-200. The American Diabetes Association suggest the following targets for most adults with Diabetes. Before a meal 70-130 mg/dl; 1-2 hours after the beginning of the meal less than 180 mg/dl. Review of the October 2014 Medication Administration Record (MAR) discloses the resident's blood glucose was routinely monitored 58 times from October 1 to October 15. The current treatment medication plan failed to maintain the resident's blood sugar in the acceptable range 48 times. Eight (8) times the blood glucose level was less than 138 mg/dl. Forty (40) times the blood glucose level was 200-600 mg/dl requiring additional coverage of [MEDICATION NAME] R, fast acting insulin. Thirteen (13) times the resident's blood sugar (BS)/blood glucose level was 400-600 mg/dl. This occurred 13 of the 15 days when the resident's blood sugar was elevated to this range at least once daily. Eight (8) times the elevated BS of 400-600 mg/dl occurred at the 11:30 AM monitoring. Three (3) times the elevated BS of 400-600 mg/dl occurred at the 4:30 PM monitoring. Two (2) times the elevated BS of 400-600 mg/dl occurred at the 9:30 PM monitoring. Twenty-six (26) times the resident's blood sugar was between 200-399 mg/dl. Eight (8) times the residents BS was less than 150 mg/dl (the BS levels were between 87-138 mg/dl). Review of the MAR (Medication Administration Record) for the month of October 2014 documents (13) times the following blood sugar readings greater than 400 mg/dl between the dates of 10/01 and 10/15/2014: 10/02 at 11:30 AM = 406 10/03 at 4:30 PM =413 10/03 at 9:00 PM = 432 10/04 at 11:30 AM = 451 10/05 at 4:30 PM = 488 10/06 at 11:30 AM = 600 10/07 at 11:30 AM = 500 10/08 at 11:30 AM = 500 10/09 at 11:30 AM = 421 10/10 at 11:30 AM = 480 10/13 at 4:30 PM = 500 10/13 at 9:00 PM = 496 10/15 at 11:30 AM = 494 Further review of the MAR and nurse's notes between 10/01 and 10/15/2014 revealed, the record lacked evidence that the blood sugar levels that were over 400 on (8) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Five (5) times, on 10/03, 10/06, 10/07, 10/08 and 10/09/2014, the blood sugar levels were rechecked when the results were greater than 400. Review of the September 2014 MAR discloses that the resident's blood glucose level was routinely monitored 120 times and 92 times the treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar level was elevated between 200-600 mg/dl, 72 times requiring additional insulin coverage per the sliding scale and the blood sugar was below 150 mg/dl 20 times. Review of the MAR for the month of September 2014 documents (26) times the following blood sugar levels greater than 400 mg/dl: 09/01 at 6:30 AM = 409 09/02 at 11:30 AM = 499 09/03 at 11:30 AM = 447 09/04 at 11:30 AM = 500 09/06 at 4:30 PM = 421 09/07 at 4:30 PM = 418 09/08 at 9:00 PM = 416 09/12 at 11:30 AM = 451 09/12 at 4:30 PM = 545 09/12 at 9:00 PM = 500 09/15 at 11:30 AM = 547 09/16 at 11:30 AM = 514 09/17 at 4:30 PM = 414 09/18 at 11:30 AM = 565 09/20 at 11:30 AM = 562 09/21 at 11:30 AM = 505 09/22 at 11:30 AM = 589 09/23 at 11:30 AM = 512 09/24 at 11:30 AM = 599 09/26 at 11:30 AM = 493 09/27 at 6:30 AM = 457 09/28 at 11:30 AM = 576 09/29 at 11:30 AM = 580 09/29 at 4:30 PM = 468 09/30 at 4:30 PM = 457 09/30 at 9:00 PM = 408 Further review of the MAR and nurse's notes for the month of September 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on 20 occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Six (6) times, on 09/15, 09/18, 09/22, 09/23, 09/24 and 09/26/2014, the blood sugar levels were rechecked when greater than 400 mg/dl as required by the physicians order. Review of the August 2014 MAR discloses that the resident's blood glucose level was routinely monitored 124 times and 109 times the current treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar level was elevated between 200-600 mg/dl 95 times requiring additional insulin coverage per the sliding scale and the resident's blood sugar was below 150 mg/dl 14 times. Review of the MAR (Medication Administration Record) for the month of August 2014 documents (35) times the following blood sugar readings greater than 400 mg/dl: 08/01 at 11:30 AM = 468 08/02 at 11:30 AM = 414 08/03 at 11:30 AM = 401 08/04 at 6:30 AM = 404 08/04 at 4:30 PM = 579 08/04 at 9:00 PM = 540 08/05 at 11:30 AM = 500 08/06 at 11:30 AM = 537 08/06 at 9:00 PM = 439 08/09 at 11:30 AM = 542 08/10 at 11:30 AM = 500 08/11 at 11:30 AM = 489 08/12 at 11:30 AM = 486 08/13 at 11:30 AM = 443 08/13 at 4:30 PM = 450 08/13 at 9:00 PM = 515 08/14 at 11:30 AM = 546 08/14 at 4:30 PM = 435 08/15 at 11:30 AM = 510 08/16 at 11:30 AM = 405 08/18 at 9:00 PM = 417 08/20 at 11:30 AM = 543 08/21 at 6:30 AM = was documented on MAR as 10, but in nurses notes as 578 08/21 at 11:30 AM = 500 08/22 at 11:30 AM = 401 08/23 at 11:30 AM = 505 08/24 at 11:30 AM = 500 08/26 at 6:30 AM = 583 08/27 at 11:30 AM = 500 08/28 at 11:30 AM = 464 08/29 at 11:30 AM = 501 08/29 at 4:30 PM = 473 08/29 at 9:00 PM = 500 08/30 at 11:30 AM = 465 08/31 at 6:30 AM = 564 Further review of the MAR and nurse's notes for the month of August 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on (34) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. One (1) time, on 08/13/2014, the blood sugar level was rechecked when greater than 400 mg/dl. Review of the July 2014 MAR discloses that the resident's blood glucose level was routinely monitored 124 times and 110 times the current treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar was elevated between 200-600 mg/dl, (92) times requiring additional insulin coverage per the sliding scale and the resident's blood sugar was below 150 mg/dl (18) times. Review of the MAR (Medication Administration Record) for the month of July 2014 documents (24) times the following blood sugar readings greater than 400 mg/dl: 07/03 at 11:30 AM = 452 07/04 at 11:30 AM = 446 07/06 at 11:30 AM = 427 07/07 at 11:30 AM = 488 07/08 at 11:30 AM = 491 07/09 at 11:30 AM = 431 07/10 at 11:30 AM = 403 07/16 at 11:30 AM = 485 07/17 at 4:30 PM = 505 07/18 at 4:30 PM = 530 07/18 at 9:00 PM = 508 07/19 at 11:30 AM = 401 07/19 at 4:30 PM = 406 07/20 at 6:30 AM = 484 07/21 at 11:30 AM = 464 07/24 at 11:30 AM = 449 07/25 at 9:00 PM =534 07/26 at 4:30 PM = 490 07/27 at 11:30 AM = 427 07/28 at 11:30 AM = 405 07/29 at 11:30 AM = 438 07/30 at 11:30 AM = 599 07/31 at 4:30 PM = 415 07/31 at 9:00 PM = 495 Further review of the MAR and nurse's notes for the month of July 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on (21) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Three (3) times, on 07/21, 07/24 and 07/25/2014, the blood sugar levels were rechecked when greater than 400 mg/dl. Despite the frequent and continued elevation and fluctuation of the resident's blood glucose levels, the facility failed to make adjustments to the resident's treatment plan or seek additional service providers to assist in the management of the resident's diabetes. Review of the physician progress notes [REDACTED]. His assessment included that the resident has Diabetes Mellitus Type 2, brittle. An interview was conducted on 10/17/2014 at 10:30 AM with the Medical Director who is also serving as the resident's primary physician. The physician stated that he did not have certification in endocrinology and his experience with diabetes is from what he sees in his practice. He stated that Resident # 73 is very complicated. The previous physician who cared for the resident told him about the resident. She is very frail and brittle. She is very non-compliant, and she always has food in her room. She has a history when she "bottoms out" very easily. They used to send her out to the hospital often for low blood sugars. He decided to be conservative with her treatment to keep her from bottoming out. He stated, the resident's non-compliance is because she eats everything because her family brings in food. When asked about the resident's hypoglycemic episodes, he stated that he was aware that the resident is no longer having frequent incidents of [DIAGNOSES REDACTED] and agreed that the resident's blood sugars are now running from 400 to 600. The resident also has kidney failure and does not respond to oral medications used to treat diabetes. He further stated, he would rather the resident's blood sugars are on the high side rather than low. He again stated that the resident is very challenging to manage. The physician also gave further clarification regarding the sliding scale order stating that if the blood sugar is greater than 400, then he wants the Blood sugar checked every 2 hours and follow the sliding scale until the blood sugar is within normal range. He doesn't necessarily want to be notified when the blood sugar is greater than 400. He also felt that an endocrinologist will not follow the resident secondary to her non-compliance. The physician was further questioned regarding the resident's frequent elevated blood sugars at 11:30 AM. He stated, she "must be eating the wrong food at breakfast." He further stated, he felt blood sugars of 400 are okay for this resident. A subsequent interview with the physician on 10/17/2014 at 12:20 PM discloses that the resident's full picture of her diabetic management can be seen in her hemoglobin A1C levels and the resident's past three levels were 7.9, 8.3 and most recently on 10/14/2014 is 9.0, and he considers this a "good thing for the resident." The hemoglobin A1C test gives you an average blood glucose for the past 2-3 months and the results provide information about how well the treatment plan is working. According to the Mayo Clinic, for most people who have previously diagnosed diabetes, an A1C level of 7 percent or less is a common treatment target. Per the American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care. 2014;37(Supp 1:S14-S80, table 8, an A1C level of 7% would equal an average blood glucose of 154 mg/dl, and an A1C level of 9% would equal an average blood glucose of 212 mg/dl. The higher the hemoglobin A1C, the higher the risks of developing microvascular complications related to diabetes, such as [MEDICAL CONDITION] (kidney disease or damage), retinopathy (disease of the retina or the light-sensitive tissue at the back of the eye) which can lead to [MEDICAL CONDITION], or [MEDICAL CONDITION] (damage or disease affecting nerves). It should be noted that an interview was conducted on 10/17/2014 at approximately 1:30 PM with a family member of the resident who reports the family is not providing the resident with additional food to facilitate the resident's non-compliance with her food intake. The family member stated they have not brought in food for months and before they would bring in foods previously, they would check with the nurse to verify what the resident's blood sugar has been running. Observation of the resident during the 5 day survey period revealed, the resident remained in bed and unable to reach items in the resident room unless it was brought to her. Furthermore, no extra food was observed in the resident's room. Further review of the resident's hospitalization s and/or emergency room visits discloses a 9/30/2013 transfer to the hospital secondary to the resident having an increase in blood pressure, and questionable [MEDICAL CONDITION] (TIA). The resident was shaking and diaphoretic (perspiring profusely), however the residents blood glucose level at 7:15 PM was 271. There were no further hospital transfers for 2013. There were prior transfers to the hospital in 2011. There is a 04/08/2011 transfer to the hospital for evaluation for the resident having a blood sugar of 32 and a 03/03/2011 transfer for a high blood sugar level; the actual blood glucose level was not provided on the transfer form. Furthermore, the nursing staff failed to provide the necessary care and services to maintain the resident's blood glucose levels, by failing to follow the physician's orders [REDACTED]. The nurses failed to recheck and provide the appropriate sliding scale insulin 8 of 13 times when the resident's blood sugar was greater than 400 in October; 20 of 26 times in September; 34 of 35 times in August, and 21 of 24 times in July. 2) Observations on 10/13/2014 at both 12:00 PM and 3:54 PM revealed Resident #225 lying in bed on her back in a semi-fowlers position, at about a 45 degree angle. The resident had her eyes closed and appeared to be sleeping with both observations. During an interview on 10/13/2014 at 12:00 PM, Licensed Practical Nurse (LPN) K stated that Resident #225 was a "Hospice patient" who was on "Crisis Care" with 24 hour Hospice nurses, but was recently taken off the Crisis Care. LPN K stated the resident receives [MEDICATION NAME] around the clock for comfort. Review of the record reveals Resident #225 was admitted to the facility on [DATE] under Hospice services. The [DIAGNOSES REDACTED]. Resident #225 was observed for over six hours on 10/15/2014 between 9:08 AM and 3:22 PM, during which time the resident was never moved off her back from the semi fowlers position. The following observations were made: On 10/15/2014 at 9:08 AM: Resident #225 was on her back in the bed at about a 45 degree angle, leaning excessively to the left although she had a pillow behind her left shoulder. She was almost leaning against the side rail. On 10/15/2014 at 9:36 AM: Resident #225 remained in a semi-fowlers position at about a 45 degree angle. She was now sitting straight up with the pillow behind her left shoulder and arm, not leaning, but remained on her back. On 10/15/2014 at 10:05 AM: Resident #225 remained in the same semi-fowlers position on her back in bed. During this observation, LPN K was asked to show the surveyor the resident's legs. The resident's feet were lying directly on a pillow and were not offloaded (floating of the resident's heel so that they are off of the mattress and pillow). On 10/15/2014 at 11:12 AM: Resident #225 was in the same position as she was at 9:36 AM and 10:05 AM. On 10/15/2014 at 11:46 AM: Resident #225 was in the same position as noted above, just slid down in the bed slightly. The resident's feet are observable under the foot cradle (a devise to keep the bed linens off the top of the feet) and her feet remain directly on the pillow. On 10/15/2014 at 1:19 PM: Resident #225 is awake, but remains sitting in the same semi-fowlers position on her back, just scooted up in the bed slightly. The resident appears to have finished lunch as a dirty fork is on her stomach. The same pillow remains under her left shoulder; no additional pillows noted to position her to one side or the other. Her feet remain directly on a pillow, and are not offloaded. On 10/15/2014 at 2:19 PM: Resident #225 is awake, sitting in the same semi-fowlers position on her back. The pillows have been turned in another direction under her legs and feet, but her heels remain directly on the pillow. On 10/15/2014 at 3:22 PM: Resident #225 has her eyes closed and appears to be sleeping. Her position has not changed. Additional observations were conducted on 10/16/2014 as follows: On 10/16/2014 at 9:28 AM resident is awake, watching TV(television) sitting in an upright position at approximately 90 degrees in the bed. Her legs are not elevated and her feet/heels are not offloaded. No pillows noted for positioning. The resident answered simple questions when spoken to. When asked, Resident #225 stated that she was in pain. This was reported to LPN J who administered [MEDICATION NAME]. On 10/16/2014 at 9:36 AM: The resident was re-checked to see if the staff re-positioned her for comfort after the administration of the [MEDICATION NAME]. The resident is now leaning to the left, but remains in the same 90 degree sitting position with no offloading. On 10/16/2014 at 10:34 AM: Although the head of the bed has been lowered to about a 45 degree angle, the resident's position remains unchanged. An interview was conducted with certified nursing assistant (CNA) G, who was assigned to Resident #225, on 10/16/2014 at 10:39 AM. CNA G has worked at the facility for over a year and normally works on this unit. CNA G stated that Resident #225 is "total assist and total care." CNA G stated that the resident was on crisis care a week or so ago, but now she does everything for the resident. CNA G confirmed that the resident can answer simple questions, but that she has to anticipate her needs. CNA G stated that the resident does not have any skin issues. When asked what the aide does to prevent skin issues, CNA G stated that she repositions her every two hours and that the resident tends to lean to the left side. CNA G stated that the resident "won't stay on her side. She hurts a lot and we have to be careful. We use pillows to keep her off loaded." CNA G went into the room of Resident #225 on 10/16/2014 at 10:50 AM. With the help of a second CNA, Resident #225 was positioned properly, using a folded pillow (that was on the chair next to the bed) under her left side with the head of the bed slightly elevated. CNA G states that this is how she always positions the resident from side to side. The CNA was informed, this was not observed yesterday and she stated, "I'm sorry, it won't happen again." CNA G agreed that being in the same position for six hours could not be comfortable. During an interview on 10/16/2014 at 11:08:25 AM, LPN J confirmed Resident #225 is a "total assist and cannot help with anything." When asked what the aides are to do related to comfort, LPN J stated, she expects the aides to assess the resident and reposition her at least every two hours. LPN J confirmed that she is responsible to ensure all residents are re-positioned. LPN J was informed that Resident #225 was observed in basically the same position for over six hour on the 10/15/14 and stated, "It won't happen again." LPN J agreed that being in essentially the same position for longer than two hours, let alone for six hours, would not be comfortable. An additional observation on 10/16/2014 at 2:06 PM revealed Resident #225 was positioned slightly to her left side, but again leaning. The resident's feet were still directly on the pillow and not offloaded. This observation of improper positioning was confirmed with the Nurse Consultant at this time. Review of the Admission MDS (Minimum Data Set/Assessment) dated 09/18/2014 documents the resident is an extensive assist of two persons for bed mobility. Review of the physician orders [REDACTED]. The following two care plans were identified in the record: Dated 09/29/2014: Alteration in comfort secondary to cervical [MEDICAL CONDITION] with metastasis with a goal to keep the resident comfortable. The interventions include using pillows, rolled blankets, etc. to aid/maintain proper body alignment as needed/ordered and to turn and position the resident every two hours. Dated 09/29/2014: ADL (Activities of Daily Living)/Mobility self-care deficit with a goal that all ADL/Mobility needs are met and anticipated by the staff. The intervention include to turn and Position every two hours and to use pillows, rolled blankets, etc. to aid/maintain proper body alignment as needed/ordered. Dated 09/29/2014: At risk for pressure ulcers with a goal of no pressure ulcers. One of the interventions includes floating heels per policy. Review of the "Heel Floating Policy" documents, "It is the policy of (name of facility) that all residents will have their heels floated off of the mattress by means of pillows placed beneath their calves. The CNA with monitor the pillow placement on their rounds." During an interview on 10/16/2014 at 1:45 PM, the lack of positioning on 10/13 and 10/15/2014 was discussed with the Nurse Consultant. The Nurse Consultant agreed with the findings. Further review of the record revealed a care plan for Resident #225 that documents the resident has end stage/terminal cervical [MEDICAL CONDITION] with metastasis stage IV. At the bottom of the care plan was hand written the addition, "09/29/14 Crisis Care - Hospice." During an interview on 10/16/2014 at 1:57 PM the MDS Coordinator confirmed the findings on the care plan. The MDS Coordinator started looking through the electronic record to determine the time period that the resident was on crisis care. The MDS Coordinator located a Case Conference Summary (monthly summary from Hospice) that documents the start of crisis care on 09/24/2014 and discontinued the crisis care on 10/02/2014. As per the MDS Coordinator and RN Consultant during this record review and Interview, they agree with the inaccurate review and revision of the care plan and stated that there was a lack of communication between the Hospice nurse and the facility staff as the facility staff should have discontinued the crisis care in the computer, which would have triggered the MDS Coordinator to update the care plan. 3) Resident #363 was newly admitted to the facility for therapy with [DIAGNOSES REDACTED]. On 10/15/2014 at 9:16 AM, Resident #363 was observed sitting in bed. The resident was wearing an arm sleeve to protect the skin. The sleeve was observed pulled down around the wrist and a small skin tear was observed on the left forearm. At 11:35 AM, the skin tear was observed again and looked slightly larger. Certified Nursing Assistant (CNA) B entered the room of Resident #363 on 10/15/2014 at 11:36 AM to assist in the dressing and grooming of the resident. The sleeve was still observed around the resident's left wrist. Resident #363 was observed on 10/15/2014 at 1:54 PM sitting in his wheelchair. The sleeve was pulled up from the wrist over the elbow on the left arm. The resident was able to partially roll down the sleeve and the skin tear was observed uncovered, with the flap of skin sticking to the sleeve. An interview was conducted with CNA B on 10/15/2014 at 2:11 PM which revealed she makes sure Resident #363 is clean and groomed properly. CNA B explained that the nurse had told her to make sure the sleeve was on the resident's arm, but when she went in the room earlier to dress the resident, it had already been in place. An interview was conducted with CNA C on 10/16/2014 at 9:26 AM which revealed she had washed and shaved Resident #363 that morning. An interview was conducted with Registered Nurse (RN) A on 10/16/2014 at 9:27 AM which revealed Resident #363 has fragile skin, but it is intact. An observation was made of Resident #363 on 10/16/2014 at 9:30 AM which revealed the resident sitting in bed with the arm sleeve in place on the left forearm. A review of the most recent Skilled Nurses Assessment does not document any evidence of a skin tear. An interview was conducted with the Unit Manager of the East Wing on 10/16/2014 at 9:41 AM which revealed, Resident #363 receives a skin check every Friday on the 11 - 7 shift. The CNA's are to report to the nurse if they see any new skin conditions during daily care. The Unit Manager observed Resident #363 with the surveyor and acknowledged the skin tear to the left forearm. He verified, there was no assessment or treatment of [REDACTED]. A subsequent interview was conducted with CNA C on 10/16/2014 at 1:50 PM in which she stated, "I saw the skin tear this morning and told the nurse. I didn't have the resident yesterday, but I saw it today and told the nurse." A conflicting interview was conducted with RN A on 10/16/2014 at 2:00 PM which revealed CNA C did not tell her about the skin tear; she was alerted to the skin tear by the Unit Manager.

Based on record review and interview, it was determined the facility failed to ensure adequate monitoring of medications for 2 (Resident #73, and #240) of 6 residents reviewed for unnecessary drugs. This was evidenced by the failure to follow the sliding scale insulin order (a physician order [REDACTED].#73. This was also evidenced by the failure to follow physician set parameters for antihypertensive medications (medications for high blood pressure) for Resident #240. Resident #73, a vulnerable adult with [DIAGNOSES REDACTED]. If uncontrolled, diabetes can result in complications that can affect multiple organs and systems of the body, to include the heart/cardiac, blood vessels, eyes/optical, kidneys/renal, nerves, gums and teeth. Complications from Diabetes can lead to the death of a resident. The failure to follow the physician orders [REDACTED].#73's persistently high blood sugars led to the findings of ongoing immediate jeopardy. The Findings include: 1) Review of the clinical record reveals Resident #73 is a vulnerable adult who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's current treatment plan for Diabetic management includes a 02/17/2014 physician order [REDACTED]. The physician further prescribed for the resident to receive [MEDICATION NAME] R (Short acting insulin) 100 units/ml injection solution, inject by subcutaneous route as per insulin sliding scale as follows: if blood sugar is 200-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; if greater than 400 give 10 units, recheck in 2 hours and give sliding scale coverage. Monitoring of the blood glucose level is prescribed before meals and at bedtime (6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM). Further review of the blood glucose monitoring from July to October 2014 failed to provide evidence of the facility maintaining a glucose level of 150-200. The American Diabetes Association suggest the following targets for most adults with Diabetes. Before a meal 70-130 mg/dl; 1-2 hours after the beginning of the meal less than 180 mg/dl. Review of the October 2014 Medication Administration Record (MAR) discloses the resident's blood glucose was routinely monitored 58 times from October 1 to October 15. The current treatment medication plan failed to maintain the resident's blood sugar in the acceptable range 48 times. Review of the MAR (Medication Administration Record) for the month of October 2014 documents (13) times the following blood sugar readings greater than 400 mg/dl between the dates of 10/01 and 10/15/2014: 10/02 at 11:30 AM = 406 10/03 at 4:30 PM =413 10/03 at 9:00 PM = 432 10/04 at 11:30 AM = 451 10/05 at 4:30 PM = 488 10/06 at 11:30 AM = 600 10/07 at 11:30 AM = 500 10/08 at 11:30 AM = 500 10/09 at 11:30 AM = 421 10/10 at 11:30 AM = 480 10/13 at 4:30 PM = 500 10/13 at 9:00 PM = 496 10/15 at 11:30 AM = 494 Further review of the MAR and nurse's notes between 10/01 and 10/15/2014 revealed, the record lacked evidence that the blood sugar levels that were over 400 on (8) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Five (5) times, on 10/03, 10/06, 10/07, 10/08 and 10/09/2014, the blood sugar levels were rechecked when the results were greater than 400. Review of the September 2014 MAR discloses that the resident's blood glucose level was routinely monitored 120 times and 92 times the treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar level was elevated between 200-600 mg/dl, 72 times requiring additional insulin coverage per the sliding scale and the blood sugar was below 150 mg/dl 20 times. Review of the MAR for the month of September 2014 documents (26) times the following blood sugar levels greater than 400 mg/dl: 09/01 at 6:30 AM = 409 09/02 at 11:30 AM = 499 09/03 at 11:30 AM = 447 09/04 at 11:30 AM = 500 09/06 at 4:30 PM = 421 09/07 at 4:30 PM = 418 09/08 at 9:00 PM = 416 09/12 at 11:30 AM = 451 09/12 at 4:30 PM = 545 09/12 at 9:00 PM = 500 09/15 at 11:30 AM = 547 09/16 at 11:30 AM = 514 09/17 at 4:30 PM = 414 09/18 at 11:30 AM = 565 09/20 at 11:30 AM = 562 09/21 at 11:30 AM = 505 09/22 at 11:30 AM = 589 09/23 at 11:30 AM = 512 09/24 at 11:30 AM = 599 09/26 at 11:30 AM = 493 09/27 at 6:30 AM = 457 09/28 at 11:30 AM = 576 09/29 at 11:30 AM = 580 09/29 at 4:30 PM = 468 09/30 at 4:30 PM = 457 09/30 at 9:00 PM = 408 Further review of the MAR and nurse's notes for the month of September 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on 20 occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Six (6) times, on 09/15, 09/18, 09/22, 09/23, 09/24 and 09/26/2014, the blood sugar levels were rechecked when greater than 400 mg/dl as required by the physicians order. Review of the August 2014 MAR discloses that the resident's blood glucose level was routinely monitored 124 times and 109 times the current treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar level was elevated between 200-600 mg/dl 95 times requiring additional insulin coverage per the sliding scale and the resident's blood sugar was below 150 mg/dl 14 times. Review of the MAR (Medication Administration Record) for the month of August 2014 documents (35) times the following blood sugar readings greater than 400 mg/dl: 08/01 at 11:30 AM = 468 08/02 at 11:30 AM = 414 08/03 at 11:30 AM = 401 08/04 at 6:30 AM = 404 08/04 at 4:30 PM = 579 08/04 at 9:00 PM = 540 08/05 at 11:30 AM = 500 08/06 at 11:30 AM = 537 08/06 at 9:00 PM = 439 08/09 at 11:30 AM = 542 08/10 at 11:30 AM = 500 08/11 at 11:30 AM = 489 08/12 at 11:30 AM = 486 08/13 at 11:30 AM = 443 08/13 at 4:30 PM = 450 08/13 at 9:00 PM = 515 08/14 at 11:30 AM = 546 08/14 at 4:30 PM = 435 08/15 at 11:30 AM = 510 08/16 at 11:30 AM = 405 08/18 at 9:00 PM = 417 08/20 at 11:30 AM = 543 08/21 at 6:30 AM = was documented on MAR as 10, but in nurses notes as 578 08/21 at 11:30 AM = 500 08/22 at 11:30 AM = 401 08/23 at 11:30 AM = 505 08/24 at 11:30 AM = 500 08/26 at 6:30 AM = 583 08/27 at 11:30 AM = 500 08/28 at 11:30 AM = 464 08/29 at 11:30 AM = 501 08/29 at 4:30 PM = 473 08/29 at 9:00 PM = 500 08/30 at 11:30 AM = 465 08/31 at 6:30 AM = 564 Further review of the MAR and nurse's notes for the month of August 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on (34) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. One (1) time, on 08/13/2014, the blood sugar level was rechecked when greater than 400 mg/dl. Review of the July 2014 MAR discloses that the resident's blood glucose level was routinely monitored 124 times and 110 times the current treatment plan failed to maintain the resident's blood sugar level at an acceptable range. The resident's blood sugar was elevated between 200-600 mg/dl, (92) times requiring additional insulin coverage per the sliding scale and the resident's blood sugar was below 150 mg/dl (18) times. Review of the MAR (Medication Administration Record) for the month of July 2014 documents (24) times the following blood sugar readings greater than 400 mg/dl: 07/03 at 11:30 AM = 452 07/04 at 11:30 AM = 446 07/06 at 11:30 AM = 427 07/07 at 11:30 AM = 488 07/08 at 11:30 AM = 491 07/09 at 11:30 AM = 431 07/10 at 11:30 AM = 403 07/16 at 11:30 AM = 485 07/17 at 4:30 PM = 505 07/18 at 4:30 PM = 530 07/18 at 9:00 PM = 508 07/19 at 11:30 AM = 401 07/19 at 4:30 PM = 406 07/20 at 6:30 AM = 484 07/21 at 11:30 AM = 464 07/24 at 11:30 AM = 449 07/25 at 9:00 PM =534 07/26 at 4:30 PM = 490 07/27 at 11:30 AM = 427 07/28 at 11:30 AM = 405 07/29 at 11:30 AM = 438 07/30 at 11:30 AM = 599 07/31 at 4:30 PM = 415 07/31 at 9:00 PM = 495 Further review of the MAR and nurse's notes for the month of July 2014 revealed, the record lacked evidence that the blood sugars that were over 400 mg/dl on (21) occasions were rechecked in two hours as ordered with additional insulin being given as per the sliding scale. Three (3) times, on 07/21, 07/24 and 07/25/2014, the blood sugar levels were rechecked when greater than 400 mg/dl. Despite the frequent and continued elevation and fluctuation of the resident's blood glucose levels, the facility failed to make adjustments to the resident's treatment plan or seek additional service providers to assist in the management of the resident's diabetes. Following the review of the physician's orders [REDACTED]. The corporate nurse reviewed the record, confirmed the physician's orders [REDACTED]. An interview was also conducted with the attending physician, who is also the medical director for the facility, on 10/17/14 at 10:30 AM, who stated that the intent of the order was to keep rechecking the blood sugars every 2 hours and continue to administer the sliding scale insulin coverage until the blood sugar falls into a "normal range." The physician further stated that the order should have been clarified by the nursing staff. During an additional interview via phone on 10/17/2014 at 12:20 PM, the physician further stated that the residents Hb (hemoglobin) A1C (the laboratory value that estimates the average blood glucose level over a three month period) has risen from 7.9 to a current level of 9.0 over the past 6 months. 2) Resident #240 was admitted to the facility in 2012 with a [DIAGNOSES REDACTED].#240 is ordered [MEDICATION NAME] 25 mg tablet, give 0.5 tablet (12.5 mg) by oral route every 12 hours. Protocol: Hold for B/P (blood pressure) less than 110 systolic and hold for pulse less than 60. A review of the October 2014 Medication Administration Record (MAR) revealed, Resident #240 received a dose of [MEDICATION NAME] on October 1st with a pulse rate of 58 beats per minute (bpm), and a dose on October 5th with a pulse rate of 58 bpm. A review of the September 2014 MAR revealed, Resident #240 received a dose of [MEDICATION NAME] on September 4th with a B/P of 90/50, and a dose on September 21st with a pulse of 53 bpm. An interview was conducted with the Director of Nursing (DON) on 10/15/2014 at 3:55 PM in which she acknowledged, the doses were administered outside of the parameters. She stated, the nurses are to follow the physician order [REDACTED]. On 10/16/2014 at 12:42 PM, the DON provided a comment section to show the medication was held by the nurse, but after a review of the notes there was no documentation that the above four doses were held.

Based on clinical and administrative record review and staff interview, it was determined that the Pharmacy Consultant failed to provide evidence that a thorough Medication Regimen Review is performed to identify and report irregularities, medication and monitoring errors and clinically significant risks associated with medications to minimize or prevent adverse or associated consequences and/or medication complications. This is evidenced by the consultant's failure to identify concerns associated with the diabetic management for 1 of 6 residents sampled for unnecessary drugs (Resident # 73). Resident # 73 is a vulnerable, brittle diabetic whose monthly Medication Administration Record (MAR) consistently documented elevated blood glucose monitoring levels of 400-600 mg (milligram)/dl (deciliter) from July to October 2014. These MARs also provide evidence that the staff nurses failed to follow the prescribed physician orders [REDACTED]. Resident # 73's laboratory testing of the Hemoglobin A1C (a blood test to measure the blood sugar level over time) revealed steadily increasing results in the last 6 months ranging from 7.9% to 9.0%. The hemoglobin A1C test gives you an average blood glucose for the past 2 - 3 months and the results provide information about how well the prescribed treatment plan is working. The goal for people with diabetes is a hemoglobin A1C less than 7 %. Out of control diabetes results in complications from the disease. The higher the hemoglobin A1C, the higher the risks of developing complications related to diabetes. High levels of blood glucose can damage the tiny blood vessels in the kidneys, heart, eyes, or nervous system. The facility's failure to identify and manage the care and services for Resident # 73 related to diabetic management resulted in a determination of ongoing Immediate Jeopardy. The findings include: Review of the Monthly Quality Improvement: Consultant Pharmacy Summary discloses that the pharmacist reviews the resident's charts and evaluates the facility's compliance with the Medication Regimen Review (MRR) to include ensuring that new orders are transcribed accurately; previous MRR recommendations are acted upon appropriately or if the physician declined the recommendations include a rationale for the declination; medications have appropriate diagnoses/indication for use, medications are not used in excessive doses or for excessive duration without appropriate documentation; medications are properly monitored; PRN (as needed) medications have specific reason (s) for use in the directions. Medication Record Review includes evaluation of the medication administration record to ensure medications were available for administration; medications to be administered with parameters are given according to the order; documentation is complete (including PRN documentation and sites of administration). Review of the Monthly Quality Improvement: Consultant Pharmacy Summary for the past 6 months failed to identify irregularities associated with Resident #73's diabetic management. Specifically, the review of the MRR for Resident # 73 failed to identify irregularities, medication and monitoring errors or clinically significant risk associated with the diabetic management for the resident. Review of the Medication Administration Record (MAR) for July 2014 discloses that the resident's blood glucose level was greater than 400, 24 times. Twenty-one (21) times the MAR and/or nursing progress notes failed to provide evidence that the resident's blood glucose level was rechecked in 2 hours and the nurse administered the appropriate sliding scale insulin coverage as prescribed by the physician. In August 2014, the resident's blood glucose level was greater than 400, 35 times. Thirty-four (34) times the MAR/nursing progress notes failed to provide evidence that the resident's blood glucose level was rechecked and the sliding scale insulin was administered as prescribed. The September 2014 MAR indicated 26 times the blood glucose level was greater than 400 mg/dl and 20 times the nurses failed to follow the prescribed physician orders [REDACTED]. Review of the consultant MRR for the subsequent months failed to identify irregularities associated with the diabetic management for monitoring and medication administration for Resident # 73. The above practice continues to occur in October 2014 as evidenced by 14 times when the resident's blood sugar (BS) was 400-600 mg/dl occurring on 13 of 15 days at least once daily. The nurses also failed to recheck and provide the appropriate sliding scale insulin 8 of 13 times when the resident's blood sugar was greater than 400 in October 2014. An interview with the physician on 10/17/2014 at 12:20 PM discloses that the resident's full picture of her diabetic management can be seen in her hemoglobin A1C levels and the resident's past three levels were 7.9, 8.3 and most recently on 10/14/2014 is 9.0. An interview was conducted on 10/16/2014 in the afternoon with the Pharmacy Consultant who confirmed that she did not identify any irregularities associated with Resident # 73's diabetic management. She further confirmed that she does not review everyone's MAR when she completes her MRR. Review of the Pharmacy Consultant Agreement signed and dated 10/24/2011 revealed on Schedule 1-A "Required Consultant Services" include: 3. Consultant shall assist Facility in determining that residents' medication therapy is necessary and appropriate. 4. Consultant shall conduct a medication regimen review (MRR) for each Facility resident at least once a month. 5. Consultant shall identify any irregularities as defined in the State Operations Manual. 6. Within three (3) business days of conducting the MRR, Consultant will provide a summary report to the attending physician and the Facility's director of nursing which (a) documents that no irregularity was identified or (b) reports any irregularities.

Based on Administrative record review and interview, it was determined the Administrator failed to oversee the facility and use the facility resources to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Residents #73, #225, #240, #363, and #366) of 29 sampled residents. This was evidenced by the failure to oversee that the appropriate diabetic management was provided for Resident #73 who was an insulin dependent diabetic, appropriate Hospice care for Resident #225 and appropriate treatment for [REDACTED].#363 (please refer to F309). This was evidenced by the failure to oversee that appropriate monitoring of medications was provided for Residents #73, #240 and #366 (please refer to F329). This was evidenced by the failure to ensure complete and accurate monthly pharmacy consultant reviews for Residents #73 and #240 (please refer to F428). This was evidenced by the failure to ensure essential medical equipment, specifically glucometers (machines that measure a resident blood sugar level) were properly maintained on 6 of 10 medications carts (please refer to F456). Failure to ensure these Quality of Care, pharmacy and equipment concerns were identified and appropriate services were provided to the residents led to the findings of ongoing immediate jeopardy. Immediate Jeopardy was identified at: F309, Scope and Severity (J) - Highest Practicable Potential Physical, Mental, Psychosocial Well -Being F329, Scope and Severity (J) - Unnecessary Drugs F428, Scope and Severity (J) - Drug Regimen Review F490, Scope and Severity (J) - Administration Uses Resources Effectively F501, Scope and Severity (J) - Medical Director F520, Scope and Severity (J) - Quality Assessment and Assurance Findings include: Review of the Administrators Job Description dated 6/1/2009 revealed the following duties and responsibilities among others: Provide supervision to department directors, promote growth in staff, make administrative decisions, ability to communicate effectively with medical/healthcare community, ability to interpret and implement regulations, ability to organize and implement systems, coordinate quality assurance program for all departments and assure compliance with State and Federal regulations. A review of the QA&A (Quality Assessment and Assurance) program was completed on 10/17/2014 beginning at 12:00 PM with the Risk Manager and the ADON (Assistant Director of Nursing). The Risk Manager provided evidence of monthly QA&A meetings, all of which were attended by the Administrator. During this interview the Risk Manager and ADON were specifically asked if they were aware of the lack of monitoring for the glucometer controls, and they both stated that they were not. During this continued interview the Risk Manager and ADON were asked if they had identified any facility issues related to care and services related to residents with diabetes, and they both stated that they had not. The Risk Manager and ADON were further asked if they had identified any issues related to the monitoring of resident medications, and they both stated that they had not. During an interview on 10/17/2014 at 4:54 PM, the Administrator was made aware of the findings of Immediate Jeopardy, specifically related to the lack of the provision of diabetic care for Resident #73. The Administrator stated that she was shocked and confirmed she had no knowledge of any facility issues related to the diabetic management of Resident #73.

Based on Administrative record review and interview, it was determined the QA&A (Quality Assessment and Assurance) committee failed to identify quality concerns related to the care of residents who have a [DIAGNOSES REDACTED]. This was evidenced by the failure of the committee to identify issues related to the monitoring of the quality control tests for glucometers (please refer to F456). This was also evidenced by the failure of the committee to identify issues related to following physician orders [REDACTED].#73) sampled for diabetes concerns. These failures led to the findings of ongoing immediate jeopardy. Immediate Jeopardy was identified at: F309, Scope and Severity (J) - Highest Practicable Potential Physical, Mental, Psychosocial Well -Being F329, Scope and Severity (J) - Unnecessary Drugs F428, Scope and Severity (J) - Drug Regimen Review F490, Scope and Severity (J) - Administration Uses Resources Effectively F501, Scope and Severity (J) - Medical Director F520, Scope and Severity (J) - Quality Assessment and Assurance Findings include: A review of the QA&A (Quality Assessment and Assurance) program was completed on 10/17/2014 beginning at 12:00 PM with the Risk Manager and the ADON (Assistant Director of Nursing). The Risk Manager provided evidence of monthly QA&A meetings, that were attended by the Medical Director, Administrator, Director of Nursing, QA Chairperson, ADON (Assistant Director of Nursing), Unit Managers and other department managers. During this interview the Risk Manager and ADON were specifically asked if they were aware of the lack of monitoring the Control Solution Tests of the glucometers, and they both stated that they were not until it was brought to their attention this week by the survey team. During this continued interview the Risk Manager and ADON were asked if they had identified any facility issues related to care and services related to residents with diabetes, and they both stated that they had not. The Risk Manager and ADON were further asked if they had identified any issues related to the monitoring of resident medications, and they both stated that they had not. Review of the facility's policy "Blood Glucose Monitoring" documents, "Control Solution Tests will be done every time the nurse opens a new bottle of test strips and weekly on Sunday on the 11-7 shift. Also, a control test should be done if the nurse suspects problems with the meter, the test strips or if the results appear abnormally high or low. The Control Solution tests will be documented on the Quality Control Record." The survey team identified that Resident #73 had excessively high blood sugar readings for the past three months. Upon further review, it was determined multiple staff did not know how to perform the control test on the glucometers and there was no consistent documentation of these tests being completed (please refer again to F456). The survey team also identified excessively high blood sugar readings (readings of 400 - 600 mg/dl) (milligrams/deciliter) on 98 occasions from 07/01 through 10/15/2014 for Resident #73, and 83 times that the nurses did not follow the sliding scale insulin orders during this time frame (please refer to F329). On 10/17/2014 at 12:37 PM the ADON was specifically asked who was responsible for the Control Solution Tests for the glucometers. The ADON responded that it is the responsibility of the 11pm - 7am nursing staff to do the controls, and that a control log should be completed with each check. When asked who is responsible for ensuring the nursing staff is completing the glucometer Control Solution Tests, the ADON stated that the Unit Managers for each unit would need to ensure the completion of these control checks. When asked who is responsible to ensure the Unit Managers are doing their jobs, the ADON responded, "Obviously no one was checking, but that herself (the ADON) or the Director of Nursing should be overseeing this." The ADON stated that she was aware of the findings by the survey team and that they were now putting together a QA&A plan.