Every finding on record at Space Coast Healthcare and Rehabilitation Center

Based on interview, and record review, licensed nurses failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident with a Full Code status found unresponsive for 1 of 9 residents reviewed for advance directives, (#1).On [DATE] at approximately 11:20 PM, resident #1 was observed unresponsive in his bed. Registered Nurse (RN) B checked his vitals and notified Licensed Practical Nurse (LPN) C to call 911, Emergency Medical Services (EMS). RN B again checked resident's vitals and found resident #1 to have no pulse and no respirations but did not initiate CPR. When EMS arrived, they assessed the resident to have no pulse but warm to the touch and started CPR with use of a machine that supplied continuous chest compressions then transported resident #1 to the hospital where he was later pronounced deceased . The facility's failure to honor resident #1's expressed wishes to be resuscitated and the physician's order for Full Code status resulted in Immediate Jeopardy starting on [DATE]. This failure placed all residents with Full Code status at risk of not having their wishes for resuscitation honored. The Immediate Jeopardy was determined to be removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross reference F609. Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, type 2 diabetes, hypertension, depression, other seizures, obesity and bipolar disorder. Review of the Minimum Data Set Medicare 5-Day assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 10/15 which indicated he had moderate cognitive impairment. Review of the electronic medical record (EMR) revealed an Interdisciplinary Plan of Care Meeting form dated [DATE] signed by resident #1 which indicated his code status was verified as Full Code. A care plan initiated on [DATE] and revised [DATE] indicated resident #1 had elected Advance Directives for Full Code/Provide CPR. The goal was the resident's wishes would be honored through the next review date. Interventions included, Code Status: Full Code/Provide CPR. In a telephone interview on [DATE] at 1:31 PM, resident #1's brother stated his brother made his own decisions and wanted to be a Full Code. He recalled resident #1 was improving cognitively and physically at the facility and was on the verge of being able to go to an Assisted Living Facility. Review of the facility's Policy and Procedure for CPR, effective [DATE] and revised on [DATE], revealed for procedure, step #1. If a resident was found unresponsive, staff should begin evaluation to determine presence or absence of pulse, and/or respirations. Points under #1 included, remain with the resident, call out for help, a licensed nurse will assume command of the scene and will direct other personnel in the effort, direct a staff member to announce the emergency per facility protocol, code blue and room number, and direct staff to bring emergency equipment including crash cart to the scene. #2 of the procedure included a staff member other than the nurse evaluating the resident should check the code status of the electronic health record, electronic medication administration record or point of care kiosk to determine if provision or withholding of resuscitative efforts may begin. #4 indicated if resident was a full code and pulse was absent begin chest compressions and monitor respirations. The procedure described if additional CPR certified personnel were present, they may assist with CPR as directed by the licensed nurse in command. A Nursing Progress Note dated [DATE] at 1:37 AM, by RN B noted Certified Nursing Assistant (CNA) A called her to resident #1's room. Upon her first observation, she noted the resident to be unresponsive, and a call was placed to EMS at 11:21 PM. The note read, Staff attempted to initiate CPR, but resident was cold, stiff. pupils dilated, without vital signs and no signs of life. The note documented that EMS arrived at 11:23 PM, placed a chest compression device on the resident and transported him to the hospital. Review of the medical record revealed no documentation of vital signs, or lack of vital signs after 8:32 PM on [DATE]. Review of the EMS Run Report dated [DATE] showed EMS received the emergency 911 call at 11:22 PM and were immediately dispatched to the facility. Per the report, EMS arrived on scene at 11:24 PM and reached the resident at 11:26 PM, where the resident was observed alone in the room with no facility staff at the bedside performing CPR. EMS documentation showed that upon arrival, resident #1 was unresponsive and warm, with a body temperature of 97 degrees Fahrenheit (F). EMS indicated they initiated resuscitative efforts. Vital signs obtained by EMS at 11:31 PM, revealed five minutes after reaching the resident his temperature was 97 degrees Fahrenheit, as documented in the report. Under the assessment section with assessment time of 11:27 PM, the mental status was unresponsive, the skin warm. The narrative section of the report documented the resident was found in cardiac arrest at the facility with a reported duration of cardiac arrest approximately 10 minutes prior to EMS arrival. The EMS personnel noted however that nursing staff were unsure of the downtime, and when they arrived the patient was found to be alone in the room with no medical professionals at his bedside performing CPR, no nursing staff met the EMS crew for a handover report on the incident, medical history of the individual (resident #1) or a medication list. The narrative read, prior to arrival computer aided dispatch (911 dispatch) notes indicated the facility staff were performing CPR and had an automated external defibrillator or AED on the scene, but EMS noted that upon arrival they found none of this to be true and no skills were being performed by the facility. The report indicated EMS personnel departed the facility with the resident at 11:35 PM, arrived at the hospital at 11:45 PM and transferred the resident to hospital care at 11:47 PM. The report showed that resuscitative efforts performed by EMS included CPR, intubation with placement of an endotracheal tube (breathing tube), placement of an intraosseous access to his left lower extremity with administration of the medication Epinephrine and manual defibrillation (electrical shock). An Intraosseous (IO) access is a rapid, lifesaving medical procedure that involves drilling a specialized needle into the bone marrow to deliver fluids and medication (retrieved on [DATE] from www.scienceinsights.org). The normal range of body temperature for adults is 97 degrees F to 99 degrees F, and can depend on activity level, time of day, weather, and age. Adults over the age of 65 tend to have a lower body temperature with a typical range of 96.4 degrees F to 98.5 degrees F, (retrieved on [DATE] from www.clevelandclinic.org). CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple the chance of survival after cardiac arrest. If a person is found unresponsive, the sooner you start CPR and/or use the defibrillator/AED, the better. Cardiac arrest is time sensitive so there is no amount of time where waiting is good. You should never just wait for help to arrive, it is so important that people act right away, it makes all of the difference between life and death, (retrieved on [DATE] from www.heart.org). On [DATE] at 7:00 AM, RN B confirmed she worked the 11:00 PM - 7:00 AM shift beginning on [DATE]. She explained she started her shift at about 10:30 PM and waited for the 3:00 PM - 11:00 PM shift to finish. RN B stated CNA A approached the nurse's station and asked her to come check on resident #1. She recalled she went to the room and observed the resident was unresponsive with no pulse and no respirations. RN B stated she instructed LPN C to call EMS and returned to the room to re-assess resident #1. She explained she made sure there was no pulse/heart rate or respirations. She recalled resident #1's skin was cold to the touch. RN B conveyed she did not start CPR, and instead she phoned the Director of Nursing (DON) because she felt there was no reviving him. RN B confirmed she did not initiate CPR. She reported EMS arrived within 3 minutes of being called, put a machine on him for chest compressions and took him to the hospital. In a telephone interview on [DATE] at 10:36 AM, LPN C verified she worked the 3:00 PM - 11:00 PM shift on the date of the event. She recalled she last saw resident #1 at approximately 8:30 PM when she gave him his night medications. She stated she closed the door and said good night to him and returned to her rounds. LPN C reported that later a CNA came to the nurse's station while she was giving report to RN B and asked them to come and check on resident #1. LPN C stated she went to the room with RN B, then went to call EMS. She explained EMS arrived within 5 minutes. LPN C recalled RN B remained in the room but said she was not aware if CPR was initiated by facility staff. She confirmed she did not perform CPR on resident #1. In a telephone interview on [DATE] at 10:25 AM, CNA A stated she worked the 11:00 PM - 7:00 AM on [DATE] and confirmed resident #1 was on her assignment. She explained she started her shift around 10:45 PM. She recalled after she spoke with the previous CNA (CNA D), she started to do her rounds checking residents' vital signs and passing ice water. CNA A stated she got to resident #1's room around 11:20 PM. She recalled she knocked on the door and went in quietly as he did not respond but did not turn on the room light. She reported that as she proceeded to put the cup on the table, she noticed his hands were hanging over the side of the bed and he was unresponsive. She stated she immediately went to the nurse station and asked RN B and LPN C to come to the room to check on him. She recalled RN B went into the room and took over while she remained in the hallway. CNA A was unsure which nurse called EMS. In a telephone interview on [DATE] at 9:25 AM, CNA D confirmed she was resident #1's assigned CNA from 3:00 PM - 11:00 PM on [DATE]. She recalled she last saw resident #1 around 7:00 PM when she put some more ice water in his room. She explained he was in bed watching television. She reported that at the end of her shift, she overheard CNA A speaking with the nurses and heard later that resident #1 had expired. CNA D recalled one of the nurses was on the phone and told the other nurse to do CPR. She said they did not call a Code Blue overhead which was the process when there was a code and there was no CPR. Review of hospital records dated [DATE] revealed under the History and Physical section the emergency physician documented EMS had reported they were told by facility nursing staff the resident was found unresponsive, but EMS told them that upon arrival to the facility CPR was not in progress. The physician's note continued that EMS reported they evaluated the resident who was found to not have a pulse but was still warm so CPR was initiated. The emergency physician noted the resident was initially asystole (no heartbeat), but after initiating CPR the resident was found to have irregular heart rhythm activity (ventricular fibrillation) and was defibrillated (shocked). In the medical decision-making section, the physician noted the patient (resident #1) presented with cardiopulmonary arrest, with an unknown downtime and CPR was not initially initiated by the facility staff until EMS arrived; prognosis grim; and he was deceased . In a joint interview on [DATE] at 10:54 AM, with the Administrator, DON and Regional Nurse Consultant (RNC), the DON stated she received a call from RN B at approximately 11:22 PM and was informed the nurse had discovered resident #1 deceased in his room. The DON recalled RN B reported to her the resident had no pulse, no respirations and his arms were blue. RN B told her LPN C was calling 911(EMS). The DON stated she immediately called the Administrator and informed her of resident #1's death then headed to the facility. The Administrator and DON stated they both came to the facility and began an investigation. The RNC stated the facility did not file any reports as they had not identified anything within the facility's control that had not been done. She explained the nurses and CNAs had reported resident #1 was cold to the touch, gray and blue with signs of lividity. The RNC said those were signs of irreversible death. The National Library of Medicine lists the overt clinical signs of irreversible death as rigor mortis, dependent lividity, decapitation, transection and decomposition. The organization defined rigor mortis as the post-mortem stiffening of muscles which started immediately after death. The site clarified that rigor mortis appeared approximately two hours after death in the muscles of the face and progressed to the limbs over the next few hours completing the process between six to eight hours after death, (retrieved on [DATE] from www.ncbi.nlm.nih.gov). Dependent Lividity also known as livor mortis is the discoloration of the skin appearing on the lowest, or dependent, parts of the body. It is caused entirely by the force of gravity acting on the blood components inside the vessels. This pooling of the blood results in the characteristic reddish-purple discoloration visible on the skins surface of the body parts closest to the ground. During the first three hours after death the discoloration will disappear or blanch if pressure is applied to the skin. As time passes, the blood components begin to coagulate and break down within the vessels leading to what is called fixed lividity, where the discoloration of the skin on the dependent parts of the body is fixed or permanent. This begins around six to eight hours after death, (retrieved on [DATE] from www.biologyinsights.com). The Facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) revised [DATE] indicated that in the event a resident experienced cardiac arrest or respiratory arrest, CPR would be provided in the absence of a valid State of Florida DNR (Do Not Resuscitate) Order Form or documented verbal wishes which indicated otherwise. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] the Director of Nursing/Designee completed an audit of current residents' code status and advance directives. There were no current residents identified as having been affected by the alleged deficient practice. *On [DATE] the facility created a Quality Assurance and Performance Improvement (QAPI) plan which included honoring advance directives and recognizing when to initiate or withhold CPR. *On [DATE], the facility Administrator and the Director of Nursing were reeducated by the Regional Nursing Consultant/Designee on the components F678 with an emphasis on honoring advance directives and following the facility CPR policy and procedure. *On [DATE] the new hire orientation for licensed nurses was updated to include a review of federal regulation F678. *The facility provided education to licensed nurses regarding; Honoring Advance Directives, Facility policy and procedure for CPR, Components of federal regulation F678, recognizing when to initiate or withhold CPR (Do Not Resuscitate/Full Code) and Code Blue on the following dates totaling 37/37 licensed nurses:[DATE]-(15 licensed nurses in-person)[DATE]-(7 licensed nurses in-person)[DATE]-(2 licensed nurses in-person)[DATE]-(4 licensed nurses in-person)[DATE]-(2 licensed nurses in-person)[DATE]-(5 licensed nurses (2) via phone and (3) in-person)[DATE]-(2 licensed nurses via phone) *The Director of Nursing/Designee conducted Code Blue Drills every day on each shift, starting on [DATE] (41 in total). *An AD HOC Quality Assurance (QA) meeting was held with the facility's Medical Director in attendance via phone on [DATE] and [DATE]. The Interdisciplinary Team (IDT) reviewed and met to analyze data; implement interventions/systematic changes to ensure residents' Advanced Directives were honored. The AD HOC QA Committee approved the QAPI initiatives for implementation. Interviews conducted on [DATE] with nine licensed nurses indicated they were knowledgeable of advanced directives and facility procedures when to provide or withhold CPR. All licensed nurses interviewed verified they had participated in several Code Blue drills. The surveyor validated the education with attendance sheets for code blue drills and in-services. Review of QAPI audits revealed daily code blue drills were conducted per removal plan. The resident sample was expanded to include five additional residents who had expired in the facility in the last 90 days. Interviews and record reviews revealed no concerns for residents #5 through #9 related to provision or withholding of CPR related to wishes expressed through advanced directives. Based on the facility's corrective actions, the Immediate Jeopardy was removed on [DATE].

Based on interview, and record review, the facility failed to report an alleged violation of neglect for 1 of 6 residents reviewed for code status, of a total sample of 9 residents, (#1). Findings: Cross reference F678. Resident #1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (impaired brain function), type 2 diabetes, essential hypertension, depression, other seizures, and bipolar disorder. Review of the Minimum Data Set Medicare 5-Day assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 10/15 which indicated he had moderate cognitive impairment. The medical record contained a care plan initiated [DATE] and revised on [DATE] which indicated resident #1 had elected to be a Full Code, noting he wished to receive cardiopulmonary resuscitation (CPR). Review of resident #1's medical record revealed a progress note written by Registered Nurse (RN) B dated [DATE]. The note indicated that Certified Nursing Assistant (CNA) A called RN B to resident #1's room. RN B documented she observed resident #1 was unresponsive and described him as cold, stiff, pupils dilated, without vital signs and no signs of life. The note indicated 911/ Emergency Medical Services (EMS) was called at 11:21 PM and they arrived at 11:23 PM to the facility. The nurse's note detailed that EMS personnel placed a chest compression device on the resident and transported him to the hospital. In a phone interview on [DATE] at 9:25 AM, CNA D confirmed resident #1 was on her assignment during the 3:00 PM - 11:00 PM shift on [DATE]. She recalled the last time she saw resident #1 was around 7:00 PM when she put some more ice water in his room. She stated he was watching television at that time. In a phone interview on [DATE] at 10:36 AM, Licensed Practical Nurse (LPN) C stated she worked on A-Wing the evening of [DATE]. She recalled she last saw resident #1 at about 8:30 PM when she gave him his night medications. She explained after she gave the resident his medications, she closed the door and said good night. LPN C stated she was giving report to the oncoming nurse when CNA A asked RN B to come to the room. LPN C said she went to the room with RN B, and they found the resident unresponsive, and RN B instructed her to call 911/EMS. LPN C said she went to call 911 and RN B stayed in the room with the resident. She clarified she never returned to the room, did not perform CPR and was not aware if RN B started CPR or not. In a phone interview on [DATE] at 10:25 AM, CNA A stated she worked on the 11:00 PM - 7:00 AM shift which started on [DATE]. She recalled she spoke with the off-going CNA D and then began rounds. She explained she tried to do vital signs and pass water and ice at the beginning of the shift. CNA A reported resident #1's room was the second room she attended to at the beginning of her shift. She stated she knocked on the door and went in quietly when he did not answer. The CNA explained she went to place the water on the overbed table and noticed something was wrong with resident #1. CNA A stated she quickly exited the room and headed to the nurse's station to alert RN B and LPN C to come to the room. She stated one of the nurses called 911 but she did not re-enter the room. On [DATE] at 7:00 AM, RN B confirmed she worked the 11:00 PM - 7:00 AM shift the night of [DATE]. She stated she was waiting for the previous shift to get done when CNA A asked her to check on resident #1. RN B recalled she observed him unresponsive and found he had no pulse and no respirations. She stated she stuck her head out of the room and told LPN C to call EMS. She stated she went back in the room and found resident #1 was cold to the touch, hands were blue, arms were stiff, face pale, eyes fixed and dilated. RN B stated she left the room to call the Director of Nursing (DON) because she knew there was no reviving him. RN B confirmed she did not initiate CPR. She stated EMS arrived within minutes of being called and put a machine on resident #1 to do chest compressions and took him to the hospital. RN B acknowledged she was aware resident #1 was a Full Code status. In a joint interview with the Administrator, DON and Regional Nurse Consultant (RNC) on [DATE] starting at 10:54 AM, the DON recounted she learned of the incident from a phone call from RN B a little before 11:30 PM, on the night of [DATE]. The DON stated when she arrived at the facility a short time later law enforcement were present to investigate the death as a possible homicide. The DON recalled the detectives interviewed staff about the event and left. She confirmed the facility began their own investigation at that time but did not file any reports to the state for possible abuse or neglect. The Administrator stated the facility held two ad hoc quality meetings to discuss resident #1's death, the investigation, including a chart review, history, and formalized timeline. He said the facility began education with staff including to identify resident behaviors and appropriate staff response to behaviors. The Administrator said he felt they had conducted a thorough review of the incident. The RNC stated the facility completed audits of all residents in the building. She confirmed a report had not been filed with the state agency regarding the death as they felt there was nothing the facility could have intervened with or prevented. She said the facility had not identified any instance of potential abuse or neglect. On [DATE], the Administrator in a letter to the state agency area office indicated the facility, self-identified the event as possibly reaching the level of an Immediate Jeopardy citation and immediately began the investigation. The Administrator's letter recounted actions taken by the facility to remove any immediate threats to residents in the facility as well as continued corrective actions. The letter did not include the facility having filed the required reports for an alleged violation of abuse or neglect with the agency nor give an explanation as to why the required reports were not filed.

Based on interview, and record review, the facility neglected to ensure necessary care and services were provided by ensuring nurses coordinated with physicians to provide proper provision of care for 1 of 1 resident reviewed for insulin-dependent Diabetes Mellitus with an insulin pump, of a total sample of 5 residents, (#1). The facility failed to recognize the critical need for insulin orders and blood glucose finger sticks upon admission and failed to implement physician ordered finger stick blood glucose monitoring after it was prescribed. These combined failures in care coordination resulted in a lack of proper blood glucose monitoring and treatment for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. The resident required emergency 911 transfer to the hospital and re-hospitalization with Intensive Care Unit (ICU) level care, for 5 days. DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. DKA is diagnosed if your blood glucose level is above 250 milligrams/deciliter (mg/dL), your blood is acidic, you have ketone (acid molecules) in your urine or blood, and your blood bicarbonate level is lower than 18 milliequivalents/ liter. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25). Resident #1 was hospitalized for five days requiring critical care in the ICU, and an intravenous (IV) insulin drip. She returned to the facility on 5/23/25 for continued recovery and therapy until 6/18/25, when the resident had a planned discharged to an inpatient rehabilitation hospital. From admission on [DATE], the facility's nurses did not coordinate vital care needs with the on-call provider to ensure finger stick blood glucose monitoring and insulin orders were implemented on admission. On 5/13/25, the Interdisciplinary Team (IDT) reviewed resident #1's hospital records and admission orders. The IDT failed to recognize finger stick and insulin orders were missing for a high-risk resident with an insulin pump. On 5/14/25, the attending physician and Advanced Practice Nurse Practitioner (APRN) jointly assessed resident #1. On 5/15/25, the attending physician entered an order for finger stick blood glucose testing in the Electronic Medical Record (EMR). Nurses failed to properly finalize the order to link to the Medication Administration Record (MAR) in which prompts notified nurses to perform the tests. The resident's primary care providers did not recognize test results were missing that if implemented, would have detected resident #1's unstable blood glucose levels and prevented complications, worsening of condition, and mitigated the risk of serious injury/impairment/death with the implementation of appropriate interventions. Eight days after resident #1 arrived at the facility, on Monday, 5/19/25, a nurse observed the resident sitting on the floor in her room. After performing two finger stick blood glucose tests with readings of high (exceeded device measurement parameters), physician's orders were obtained to transport the resident to the hospital via 911 Emergency Medical Services (EMS) for dangerously high blood sugar. The facility's neglect to recognize and implement proper provision of care and services for a high-risk resident with type I Diabetes Mellitus and an insulin pump contributed to the destabilization of resident #1's medical conditions and placed all residents at risk for neglect and serious injury/impairment/death. For eight days, the facility was unaware resident #1 was missing critical clinical monitoring and insulin until the resident's condition worsened with weakness and altered mental status and she fell. This failure resulted in Immediate Jeopardy which began on 5/12/25.Findings: Cross reference F635 and F726 Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included: acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, and history of venous thrombosis/embolism (blood clot). The Minimum Data Set (MDS) 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. The assessment noted resident #1 had an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered during the lookback period but did receive high-risk opioid and anticonvulsant medications. The resident received hemodialysis before admission and during the stay. Resident #1's pre-admission clinical documents faxed from the hospital Case Manager on 5/08/25 for the facility's pre-admission review and acceptance noted the resident was admitted to the hospital on [DATE] for multiple episodes of loss of consciousness, and possible seizure. The History of Present Illness (HPI) section of the physician's notes indicated the resident's family reported that no recent doses of medications were missed. The documents detailed that hyperglycemia was treated with sliding scale insulin and finger stick blood glucose monitoring. The notes showed her home medications included Omnipod 5 Dexg7g6 Pods (Gen5) 1 dose daily via insulin pump, Lantus Insulin 4 Units (IU) subcutaneous (SQ) daily, and Lispro Insulin 2 IU SQ three times daily before meals. The Agency for Healthcare Administration (AHCA) Form 5000-3008 signed by the hospital provider dated 5/12/25 documented resident #1's Discharge Summary and Discharge Medication List reports were attached. The hospital discharge physician's ordered medication list dated 5/12/25, documented orders to continue home medications which included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily; Insulin Glargine (Lantus), 4 IU SQ daily; and Insulin Lispro, 2 IU SQ three times daily before meals. Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed physician's ordered discharge medications included, New: Oxycodone immediate release 10 Milligrams (MG) every 4 hours as needed for 3 days, Tylenol 650 MG every 6 hours as needed, Minoxidil 60 Gram Foam, topical (on skin) daily. The medication list directed the resident continue taking the following medications: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ daily, Lantus Insulin 4 IU SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals, Creon 36,000 IU three times daily, Divalproex Sodium 500 MG twice daily, Lacosamide 100 MG twice daily, Levothyroxine 50 Micrograms (MCG) once daily, Midodrine 10 MG three times daily, Gabapentin 300 MG at bedtime, In a telephone interview on 7/29/25 at 10:06 AM, the Director of Admissions explained she received hospital referrals and was responsible for screening/accepting potential admissions to the facility. She said she did not have any clinical or medical professional credentials and sent off any potentially complicated or special clinical needs referrals to the facility Director of Nursing (DON) or designee and the Corporate Office for further review and approvals. She recalled she received resident #1's first referral via facsimile and didn't see anything that required further approval, so she independently accepted the resident for admission. She said she had worked at the facility for approximately a year and a half and didn't recall any previously admitted residents with an insulin pump and stated, I don't necessarily consider that something we can't handle. On 7/29/25 at 10:40 AM, the DON recalled there was not a pre-admission clinical review completed for resident #1's 1st admission, and the facility had not previously accepted any residents with an insulin pump in the last few years since she worked at the facility. The DON said she didn't think the Director of Admissions was aware the resident had an insulin pump and if she had known, additional clinical review was required. In a telephone interview with APRN D, the DON, and the Assistant Director of Nursing (ADON) on 7/28/25 at 12:24 PM, APRN D said insulin pumps could not be administered by nurses at the facility, and they required special monitoring with an outpatient specialist. The APRN could not recall any other residents with an insulin pump at the facility prior to resident #1. On 7/31/25 at 9:24 AM, the Director of Operations explained the facility did not have a written policy for what conditions, devices, etc. the facility did or did not accept. She said there were practices the facility followed that dictated when additional clinical review was required. Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to diabetes mellitus type I, history of recent DKA, encephalopathy, history of acute kidney injury, dependence on dialysis, chronic hypotension, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included on 5/13/25 diabetes mellitus with a goal for no complications, and interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms. On 5/13/25 a care plan for risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history was implemented. On 5/13/25 a care plan for pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status was begun and on 5/16/25 a care plan related to adverse effects of high-risk medication monitoring, risk for pressure injuries. The discharge care plan initiated on 5/13/25 noted the resident wished to be discharged from the facility to community/prior living arrangements (home). There were no care plans addressing resident #1's insulin pump from 5/12/25 to 5/19/25. The May 2025 Medication Administration Report (MAR) showed resident #1's 5/12/25 admission physician's ordered medications included: Bumetanide (diuretic) 2 MG once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 Units (IU) three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, and Oxycodone 10 MG every 6 hours as needed for pain. After the resident returned from the hospital on 5/23/25, orders were added that included: Lantus Insulin 4 (IU) once daily for diabetes mellitus increased to 6 IU on 5/31/25, Lispro Insulin 2 IU before meals and changed on 5/24/25 to Novolog Aspart Insulin 2 IU before meals with finger sticks and parameters to notify the APRN for readings of less than 60 mg/dL, or more than 250 mg/dL for diabetes mellitus, and blood glucose finger sticks twice daily with parameters to notify the MD (Medical Doctor) when less than 60 mg/dL, or more than 400 mg/dL. Review of the physician's orders placed on admission to the facility admission on [DATE] included all of medications listed on the hospital physician's discharge medication orders, except for the insulin orders, Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily; Insulin Glargine (Lantus), 4 IU SQ daily; and Insulin Lispro, 2 IU SQ three times daily before meals. No finger sticks were ordered. The Nursing admission Evaluation Comprehensive Nursing Assessment completed by Registered Nurse (RN) F on 5/13/25 included a skin assessment with a body map. The image and description did not document areas on resident #1's body with the dialysis catheter or insulin pump. The Special Needs section indicated no catheters or devices were present. The Drug Regimen Review section of the Comprehensive Assessment documented that a review of all medications was performed, no significant medication issues were found, and that the physician was notified on 5/12/25 with no response from the provider noted. The list of medication classes (categories) was marked positive for diabetic medication. A Diabetic Medication Care Plan was checked and initiated with an intervention for diabetic medication as ordered by the physician and to monitor/document for side effects and effectiveness. In a telephone interview with RN F on 7/30/25 at 1:20 PM, the nurse explained the facility practice for new admissions included nurse's review of the hospital's history and physical and discharge medications. She said the documents were sometimes already scanned to the Electronic Medical Record (EMR), and an envelope with photocopies came with the resident from the hospital. She said the normal practice was to notify the on-call provider, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and said that finger sticks should have been entered by either herself or the on-coming nurse, as she was a diabetic. She recalled admission orders were obtained from APRN E who wanted the resident's long-acting insulin further evaluated for appropriate orders with the pump. The RN stated, they need finger stick blood sugar orders; I'm not sure if it was an oversight on my part or my co-worker. On 7/29/25 at 10:46 AM, APRN D recalled she participated in the IDT meeting on 5/13/25, the morning after resident #1 was admitted . She explained that APRN E gave admission orders to hold the insulin. She said the resident's hospital records were reviewed which noted the resident had type 1 Diabetes, and it was common knowledge to do finger stick checks for all diabetics with insulin, especially those who were very brittle with an insulin pump. She said pumps could not be managed in a Skilled Nursing Facility (SNF). The APRN said she had assumed there were already orders in place for finger sticks twice a day and she did not recall if the records were checked during the meeting for confirmation. Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org). In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and said she never gave orders to hold newly admitted resident's routine insulin. She did not recall resident #1 specifically, but stated, I would still give orders for blood glucose finger sticks, especially if they had an insulin pump. APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's hospital discharge medications but did not include any insulin. The hospital records with laboratory results were noted as reviewed with a blood sugar result of 240 mg/dL. The Diabetes Mellitus diagnosis had comments noted as, blood glucose trends were stable and within normal limits and no medications were taken, but review of finger stick blood glucose monitoring was not mentioned in the report. Nowhere in the note including the Physical Exam section mentioned the insulin pump on resident #1's body although there was at least 60 minutes documented as time spent assessing the resident. The MD (Medical Doctor) History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration documented resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244 mg/dL. The Diabetes Mellitus with hyperglycemia diagnosis had comments that noted that no blood glucose finger sticks were available for review and physician's orders were placed for daily blood glucose finger sticks to evaluate insulin. There was no other mention of insulin in the note. In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, she explained she expected hospital physician's discharge orders to be followed for medications and said blood glucose finger stick orders were standard protocol for all diabetics with insulin. She explained when she saw resident #1 on 5/14/25 she did not recall there were any insulin orders. The physician recalled the resident's blood glucose was over 200 mg/dL with a diagnosis of diabetes mellitus which needed to be evaluated for insulin coverage. She stated she sent a text message the same day to APRN D with directives to follow up. She said she was unaware up until this interview that the resident used an insulin pump. In an interview on 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, she jointly assessed resident #1 with the primary care physician. She said on 5/13/25, she ordered labs to check a longer blood glucose history which showed the resident's blood glucose had previously been stable with insulin/insulin pump coverage. The APRN said the physician gave orders to check finger sticks twice daily and they both expected nurses had performed the tests. On 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, two days after resident #1 was admitted to the facility, she let the physician know more medical records were needed. She said a blood test indicated the resident had stable blood sugars with the previous insulin regimen. The APRN explained the same day during a joint assessment of the resident with the physician, it was determined finger sticks were needed twice daily to see how often she would need insulin coverage. APRN D did not say why she never followed up on the blood glucose finger stick monitoring results or need for insulin. The APRN said the facility never had a resident with an insulin pump before and stated, she's on dialysis and that further complicates her condition. Review of resident #1's Order Audit Report showed the primary care physician entered orders on 5/15/25 at 2:47 PM for blood glucose finger stick monitoring every morning for five days for diabetes. The report noted Licensed Practical Nurse (LPN) C confirmed the order on 5/15/25 at 3:23 PM, three days after resident #1's admission to the facility. On 7/29/25 at 2:48 PM, LPN C explained it was the facility's practice to implement finger sticks for newly admitted residents who had been on insulin. The nurse explained when physicians entered their own orders into the computer, nurses verified the entry and confirmed it. The LPN recalled after the physician entered resident #1's Accu-Chek orders on 5/15/25, she confirmed it however, she later learned from the DON that it wasn't categorized properly. The nurse explained the order didn't go into the MAR to alert nurses to perform the test, and therefore the order was never implemented. APRN D's Follow Up Progress Note dated 5/15/25 documented time spent on resident #1's assessment took at least 55 minutes. No new glucose laboratory results were mentioned, and the section for Diabetes Mellitus diagnosis noted, no medications, and blood glucose trends revealed levels were stable and within normal limits, which was in conflict with the only result for blood glucose testing performed on 5/13/25 and resulted on 5/14/25 was 244 mg/dL. The note read, Hospital and facility records including but not limited to laboratory findings, radiology, clinical record, medication review, medication administration record reviewed in detail. Normal or target blood sugar levels for diabetes are less than 100 mg/dL for fasting blood sugar, 70-130 mg/dL before a meal, and less than 180 mg/dL after a meal. If you have unstable diabetes you may need to check your blood sugar multiple times a day, (retrieved on 8/14/25 from www.medicinenet.com). APRN D's Follow Up Progress Note dated 5/19/25 and signed at 11:43 AM, noted resident #1's assessment took at least 55 minutes. No new laboratory results were mentioned and there was no diagnosis of Diabetes Mellitus included under the Assessment/Plan. The note mentioned the hospital and facility records were reviewed in detail. The note contained an addendum dated 5/20/25 that documented staff had called to report resident #1 was found to be unresponsive and non-verbal with her right hand shaking or seizing; blood glucose level was obtained and read high. It was noted the resident was sent out to the emergency room (ER) for evaluation due to altered mental state and elevated blood glucose. The note indicated at 5:00 PM the resident was re-admitted to the hospital ICU with DKA (undated). In an interview on 7/31/25 at 2:48 PM, LPN B recalled on 5/19/25, resident #1 was part of her assignment. The nurse explained she observed the resident on the floor in her room beside the bed in an altered mental state with weakness, drowsiness, but no apparent injuries. The LPN said she notified APRN F who directed her to check the resident's blood sugar. She immediately attempted two finger sticks that both read, high, which was reported to APRN F who gave orders to send the resident out via 911 to the hospital. The nurse said she was unaware the resident was diabetic with an insulin pump until she called resident #1's mother about the change in condition. She said the resident's mother asked about finger stick results and was concerned about possible DKA. The Change In Condition (SBAR) [Situation Background Assessment Recommendation] notes completed by LPN B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high. The SBAR noted at 12:30 PM, the physician was notified and gave orders to send the resident to the ER via 911 Emergency Medical Services. In a joint interview with the DON and ADON on 8/01/25 at 10:40 AM, the DON reviewed resident #1's 5/19/25 fall incident record. The DON explained that LPN B entered the resident's room at 12:20 PM and observed her sitting on the floor to the side of the bed. They said LPN B assessed the resident with no injuries and found a high blood glucose reading. They explained APRN D had seen the resident earlier that morning and was contacted by phone of the event. The DON stated, they got an order to send her out because of the high reading. The EMS Patient Care Record dated 5/19/25 noted an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia for resident #1. The ED triage note dated 5/19/25 at 2:01 PM, indicated resident #1 arrived from the facility with a chief complaint of hyperglycemia (high blood glucose). The treatment initiated prior to arrival was a blood glucose check with a result of 582 mg/dL. The Primary Assessment section of the triage indicated resident #1 was awake, alert, and oriented to person, place and time. The ED RN documented, arrived via EMS for hyperglycemia. She wrote that EMS reported resident #1's blood glucose was 582 mg/dL, and upon arrival to ED fingerstick blood glucose was 560 mg/dL. The ED nurse documented resident #1 denied pain and was alert and oriented to person, place, time and situation, but said she felt weak. The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and ICU care, resident #1's blood glucose levels were, in the 600's. The Order Reconciliation Home Medications on hospital records dated 5/19/25 and the hospital Discharge Progress Notes Medication Update dated 5/23/25 for facility re-admission included Lispro Insulin 2 IU three times a day before meals, and Lantus Insulin 4 IU once a day. The Weights and Vitals Summary report showed resident #1 didn't receive any finger stick glucose checks from 5/12/25 to 5/19/25, for eight days. Over eight days from 5/12/25 until 5/19/25, while resident #1 did not receive the needed care and services for her type 1 diabetes, there were nine licensed nurses over three shifts, two APRNs, and one physician who evaluated, assessed, and made critical clinical decisions about resident #1's plan of care. In a telephone interview on 7/17/25 at 4:39 PM, resident #1's stepmother explained the facility had not properly monitored resident #1's diabetes which caused her to be re-hospitalized . She said since the incident, the resident's condition had declined, she required further therapy at an inpatient rehabilitation facility and stated, she's not doing very well. In a telephone interview from the inpatient rehabilitation facility on 8/02/25 at 10:08 AM, resident #1 explained she used the insulin pump at home before she was hospitalized in early May 2025. She said before her hospitalization, her mother assisted her with managing the insulin pump and to obtain prescriptions. Resident #1 had a broken speech pattern with delayed thought processing which caused frequent pauses. The resident said she never told any of the nurses or providers that she didn't use insulin. She relayed she had hoped to return home from the nursing home with her mother but needed additional therapy at an inpatient rehabilitation hospital to get better. She said she was weaker after her re-hospitalization on 5/19/25 and believed her condition had worsened since then. Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present at the meeting and expressed concerns to the facility regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25. On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother. On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The doctor explained in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all the hospital information when she assessed the resident and had she known about the insulin orders/pump, the plan of care would have been much different and included closer monitoring and more testing. The doctor said insulin pumps were dangerous, especially for someone on dialysis and could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week [without insulin], and it could have been prevented; definitely she could have died. On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role since mid-July 2025. He explained it was critical for nurses to inform doctors of an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she returned from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the seven days prior to the event, so that irregular or concerning highs and lows in blood glucose would have been caught. Review of resident #1's hospital admission records dated 5/19/25 confirmed the resident's admitting diagnosis was for Diabetes Mellitus with Ketoacidosis with blood glucose readings of greater than 600 ml/dL that required IV insulin, and ICU admission. Review of the ED treatments flowsheet dated 5/19/25 at 3:40 PM, revealed a foley urinary catheter was ordered and inserted by the nurse for urine output monitoring in the critically ill patient and to manage acute urinary retention. Review of her hospital Discharge Summary for her admission from 5/19/25 to 5/23/25 revealed the reason for hospitalization was DKA and the principal discharge diagnosis was DKA, resolved. The secondary diagnosis on discharge was candiduria, urinary tract infection. The HPI section documented by the hospital physician on 5/24/25 included this was a [AGE] year old female who presented to the emergency department from the [name of the SNF] with reported hyperglycemia. Past medical history included type 1 diabetes mellitus and end stage renal disease with dialysis. In the Discharge Summary the physician documented resident #1's blood sugar was in the 600's mg/dL, and her CO2 (Carbon Dioxide) was 16. The Hospital Course section detailed resident #1 was admitted to the hospital ICU due to DKA, given intravenous fluids and intravenous insulin drip. The physician described a urinalysis which was concerning for a UTI, so she was initially placed on an antibiotic, but after urine culture showed the infection was actually Candida she was switched to an antifungal medication. Normal carbon dioxide levels in the blood range from 20 to 29 millimoles/liter. Low CO2 levels can be a signal of health problems such as too much acid in the blood or ketoacidosis (DKA), (retrieved on 8/14/25 from myclevelandclinic.org). Candida fungal species are considered important parts of microbial normal flora in the mouth, ear and vagina in healthy people, and candida is normally colonized on the external side of the urethral opening in healthy females. This normally occurring yeast may turn opportunistic causing UTI due to predisposing factors in some people such as women, diabetics, having indwelling catheters, and malnutrition, (retrieved on 8/14/25 from nlm.nih.gov). Review of an undated statement completed by the facility's MD Consultant and presented during the survey by the facility, revealed in the MD statement, [resident #1's name] is a [AGE] year-old female with a complex medical history, including type 1 diabetes complicated by diabetic ketoacidosis. In conflict with the hospital physician's discharge summary, the consultant physician wrote that resident #1's primary reason for her admission was a Urinary Tract Infection (UTI), which is a well-documented cause of acute mental status changes. The consulting physician felt this was also the case with resident #1. The statement indicated the absence of any abnormal blood glucose levels during her hospitalization, made it .clear that there were no indications of acut

Based on interview, and record review, the facility failed to implement and review physician's admission orders for 1 of 3 residents reviewed for admission orders, of a total sample of 5 residents, (#1). The facility did not verify, implement, or initiate expected treatments and prescribed medications consistent with the resident's medical status and as listed in the hospital discharge summary. The Interdisciplinary Team (IDT) failed to recognize that essential components of the admission orders to maintain a chronic condition, including critical medications were missing or not transcribed into the Electronic Medical Record (EMR). This failure resulted in a lack of proper blood glucose monitoring and insulin medication for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. The resident required emergency 911 transfer to the hospital and re-hospitalization with Intensive Care Unit (ICU) level care, for five days. DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25). While hospitalized for five days, resident #1 required emergency Intravenous (IV) insulin and re-hospitalization with ICU care. She returned to the facility on 5/23/25 for continued recovery and therapy until 6/18/25, when the resident had a planned discharged to an inpatient rehabilitation hospital. On 5/12/25, the facility's nurses did not coordinate vital care needs with the on-call provider to ensure finger stick blood glucose monitoring and insulin orders were implemented on admission. On 5/13/25, the IDT reviewed resident #1's hospital records and admission orders but failed to recognize finger sticks and insulin orders were missing for a high-risk resident with an insulin pump. The resident's primary care providers did not recognize test results were missing that if implemented, would have detected resident #1's unstable blood glucose levels and prevented complications, worsening of condition, and mitigated the risk of serious injury/impairment/death. Eight days after resident #1 arrived at the facility, Monday, 5/19/25, a nurse observed her sitting on the floor in her room. After performing two finger stick blood glucose tests with readings of high (exceeded device measurement parameters), physician's orders were obtained to transport the resident to the hospital via 911 Emergency Medical Services (EMS) for dangerously high blood sugar. The facility's failure to recognize and implement proper provision of care and services with admission physician's orders for immediate care for a high-risk resident with type I Diabetes Mellitus and an insulin pump contributed to the destabilization of resident #1's medical conditions and placed newly admitted diabetic residents at risk for serious injury/impairment/death. For eight days, the facility was unaware resident #1 was missing critical medications and clinical monitoring until the resident's condition worsened with weakness, altered mental status and a subsequent fall. This failure resulted in Immediate Jeopardy which began on 5/12/25.Findings:Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included: acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, and history of blood clot. The Minimum Data Set 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The assessment indicated the resident received hemodialysis before admission and during the stay. Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org). Resident #1's pre-admission clinical documents faxed from the hospital Case Manager on 5/08/25 for the facility's pre-admission review and acceptance noted the resident was admitted to the hospital on [DATE] for multiple episodes of loss of consciousness, and possible seizure. The History of Present Illness section of the physician's notes indicated the resident's family reported that no recent doses of medications were missed. The physician notes detailed that hyperglycemia (high blood sugar) was treated with sliding scale Insulin and Accu-Cheks (finger sticks). Resident #1's home medications were listed as Omnipod 5 Dexg7g6 Pods (Gen5) 1 dose daily via insulin pump, Lantus Insulin 4 Units (IU) subcutaneous (SQ) daily, and Lispro Insulin 2 IU SQ three times daily before meals. Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed hospital physicians ordered discharge medications that included new medications and to continue taking other medications that were previously ordered including Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ daily, Lantus Insulin 4 IU SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals. Lantus is a prescription drug used to help manage blood sugar levels in adults with type 1 and type 2 diabetes. It is a long acting insulin that is injected under your skin to add to or replace your body's natural insulin. Insulin Lispro is a prescription drug for managing blood sugar that is taken as an injection under your skin, intravenously or by insulin pump. This medicine acts quickly to lower your blood sugar, (retrieved on 8/14/25 from www.healthline.com). The Agency for Healthcare Administration (AHCA) Hospital Transfer Form 5000-3008 signed by the hospital provider dated 5/12/25, documented resident #1's Discharge Summary and Discharge Medication List reports were attached. The hospital discharge physician's ordered medication list dated 5/12/25 documented continued home medications included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose subcutaneous (SQ) daily, Insulin Glargine (Lantus), 4 units SQ daily, and Insulin Lispro, 2 units SQ three times daily before meals. Review of the May 2025 Medication Administration Report (MAR) showed physician's ordered admission medications on 5/12/25 included: Bumetanide (diuretic) 2 Milligrams (MG) once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 IU three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, Oxycodone 10 MG every 6 hours as needed for pain. There were no orders for insulin or blood glucose monitoring noted on the MAR for May 2025. Review of resident #1's admission physician's orders dated 5/12/25 revealed the orders included all of the medications listed on the hospital physician's discharge medication orders, except for the insulin orders. No point of care blood glucose testing (finger sticks) was ordered. On 5/13/25 a care plan was initiated for Diabetes Mellitus with a goal for no complications, included interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms. Additional care plans dated 5/13/25 for risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history; and for pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status. On 5/16/25 a care plan was initiated for adverse effects of high-risk medication monitoring, and risk for pressure injuries. In a telephone interview with Registered Nurse (RN) F on 7/30/25 at 1:20 PM, the nurse explained the facility's practice for new admissions included a review of the hospital's history and physical and discharge medications. She said the documents were sometimes scanned ahead of time to the EMR and an envelope with copies came with the resident from the hospital. The nurse explained normal practice was to notify the on-call provider, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and said finger sticks should have been ordered by either herself or the on-coming nurse. She explained admission orders were obtained from Advanced Practice Registered Nurse (APRN) E who wanted the resident's long-acting insulin to be further evaluated for appropriate orders with the pump. The RN stated, they [diabetic residents] need finger stick blood sugar orders; I'm not sure if it was an oversight on my part or my co-worker. In a joint interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), on 7/28/25 at 12:18 PM, the DON explained in addition to the admitting nurse's review, all new admissions were also reviewed every morning by the IDT to ensure accuracy and make any needed revisions. They confirmed APRN D was present for this meeting. The DON recalled there was a discussion about resident #1's insulin pump and it was unclear if it was used. The DON stated, she (APRN) reviews the discharge orders and if there are any discrepancies she covers that. At 12:24 PM, APRN D joined the interview by telephone. APRN D recalled resident #1's admission on [DATE] and said she was at the IDT meeting on 5/13/25. She said she presumed twice daily finger stick orders were already in place, but she didn't confirm it in the EMR, nor did she recall if anyone else checked. A review of APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's medications but did not include any insulin. The APRN documented that the hospital records with laboratory results were reviewed with a blood sugar result of 240. The Diabetes Mellitus diagnosis had comments including, blood glucose trends were stable and within normal limits and no medications were taken. Finger stick monitoring was not mentioned in the report. The Physical Exam did not note an insulin pump on her body but mentioned at least 60 minutes was spent assessing the resident. The Nursing admission Evaluation Comprehensive Nursing Assessment completed by RN F on 5/13/25 included a Drug Regimen Review section with documentation that a review of all medications was performed, no significant medication issues were found, and the MD was notified on 5/12/25. No response from the provider was noted. The list of medication classes was marked positive for diabetic medication. A Diabetic Medication Care Plan was checked as positive with an intervention for diabetic medication as ordered by the doctor and to monitor/document for side effects and effectiveness. In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and she did not ever give orders to hold routine insulin. She did not recall resident #1 specifically but stated, I would still give orders for [blood glucose finger sticks], especially if they had an insulin pump. The MD History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration, contained documentation that resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244. The Diabetes Mellitus with hyperglycemia diagnosis had comments written that no blood glucose finger sticks were available for review and physician's orders were placed for daily blood glucose finger sticks to evaluate insulin. The EMR showed RN F admitted resident #1 on 5/12/25 at 10:00 PM during the 3:00 PM to 11:00 PM shift and handed off care to RN A on 5/12/25 for the 11:00 PM to 7:00 AM shift, on 5/13/25. In a telephone interview on 7/30/25 at 11:31 AM, RN A explained nurses relied on the hospital discharge medication orders and normally continued whatever insulin regimen was listed and always included finger sticks. The nurse said the medication list was scanned ahead of time into the EMR and/or copies were in an envelope (admission Packet) that came from the hospital with the resident. She explained the admitting provider was informed when residents had been on insulin. The RN said she worked during the 11:00 PM to 7:00 AM shift but could not recall if she specifically had resident #1 on her assignment for the 5/12/25 to 5/13/25 shift. On 7/29/25 at 2:48 PM, Licensed Practical Nurse (LPN) C explained it was the facility's practice to implement finger sticks for newly admitted residents who had been on insulin. The nurse recalled she usually worked the 7:00 AM to 3:00 PM shift and resident #1 had previously been part of her assignment. She said she was unaware the resident was diabetic and confirmed she should have at least received finger sticks with admission orders if the hospital records showed she was on insulin. The nurse said all new admission paperwork included an Admissions Checklist form. In a telephone interview on 8/01/25 at 11:55 AM, LPN J said she usually worked the 3:00 PM to 11:00 PM shift and recalled resident #1 was assigned to her a few times during her admission to the facility. The nurse said the evening shift received most of the new admissions from the hospital. She explained nurses used the hospital discharge summary and medications list, contacted the on-call provider, and obtained admission orders. The nurse said it was common and accepted practice for physicians to approve whatever medications were listed in the discharge orders. The nurse explained it was expected practice to initiate blood glucose finger stick orders for all diabetics who had insulin orders. In an interview with LPN B on 7/28/25 at 2:41 PM, the nurse recalled that approximately mid-morning on 5/19/25, she contacted resident #1's mother because she had a change in condition. She said the resident's mother told her she was supposed to be receiving insulin with finger sticks to check her blood sugar. The nurse said she explained that nurses got orders from the physician for whatever medications were listed on the hospital discharge medication list. The LPN stated, I'm not sure why insulin wasn't put on the admission orders, the family said she was supposed to be on insulin. The Change in Condition (SBAR) [Situation Background Assessment Recommendation] notes completed by LPN B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high (unreadable over the machine's range). At 12:30 PM, the physician was notified and gave orders to send the resident to the emergency room (ER) via 911 EMS. Tight control of sugar in the blood with intensive insulin therapy reduces the risk of diabetic complications. Typical range for a point of care blood glucose machine is from 20 mg/dL to a high of 600 mg/dL, (retrieved on 8/15/25 from www.nlm.nih.gov). Review of the Weights and Vitals Summary report revealed no finger stick blood glucose checks were completed for resident #1 from 5/12/25 to 5/19/25, a total of eight days. In a joint interview with the DON and ADON on 7/28/25 at 12:18 PM, the DON explained hospital records were received both prior to admission and photocopies that contained the history and physical and physician's ordered discharge medications/treatments came later with the resident. She said it was the facility's practice, and her expectation that nurses reviewed the hospital medical history summaries and discharge medication list, contact the physician regarding the findings of the review, obtain admission orders, and enter/process them into the EMR. She recalled when resident #1 was admitted , the discharge medication list had handwritten marks by the insulin orders indicating for the APRN to review. A photocopy of the hospital's Follow-up and Plan - Discharge Orders Medications: Continue dated 5/12/25 that was scanned into resident #1's EMR showed handwritten stars marked beside the four insulin orders, as mentioned by the DON and ADON. The Emergency Medical Services Patient Care Record dated 5/19/25 indicated an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression documented by the medics of Diabetic Hyperglycemia. The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and ICU care, resident #1's blood glucose levels were, in the 600's. In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, the doctor explained she expected hospital physician's discharge medication orders to be followed for new admissions and said blood glucose finger sticks were standard orders for all diabetics with insulin. She recalled when she saw resident #1 on 5/14/25 she did not know of any insulin orders and the EMR didn't have all the hospital records for her to review. She recalled the resident's blood glucose lab result was over 200 with a diagnosis of Diabetes Mellitus which needed to be evaluated for insulin. She said she was unaware until informed during the interview that the resident had an insulin pump and recalled resident #1's hospital records were later found after she assessed her on 5/14/25. In a telephone interview on 7/17/25 at 4:39 PM, and a written statement from 7/22/25 resident #1's stepmother explained the resident was an insulin dependent, brittle diabetic that had medication orders from the discharge hospital for insulin but did not receive them during her stay at the facility. Resident #1's stepmother indicated her daughter was unable to administer or ask for her medications herself due to her medical condition. She said while her daughter was at the facility they did not properly monitor her diabetes which caused her to be re-hospitalized . Resident #1's stepmother said she was found unresponsive by a nurse and sent to the hospital with DKA where she could have died. She said since the incident, the resident had declined and required further therapy at an inpatient rehabilitation facility and stated, she's not doing very well. On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother. Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present for a care plan meeting and expressed concerns to the facility at that time regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25. In an interview with the DON and NHA on 8/02/25 at 9:25 AM, the DON recalled on 6/13/25 during a care review meeting, it was identified that resident #1's finger stick orders entered on 5/15/25 were never implemented but she failed to explain why the admission insulin orders were missed. She explained an Ad Hoc meeting was held on 6/17/25 where a performance improvement plan (PIP) was developed for correction and monitoring to ensure accuracy of the EMR processing steps linked nurse prompts to the MAR, so tests would not be missed but they again failed to address why a newly admitted type 1 diabetic resident did not receive the hospital ordered insulin or why staff did not identify the resident's insulin pump and take action. The DON acknowledged resident #1's high blood sugar readings that were too high to register on the glucose monitor, but said they believed resident #1 was transferred to the ED because of the fall. The facility did not recognize the fall may have been an effect of the acutely high blood sugar readings. In a telephone interview from the inpatient rehabilitation facility on 8/02/25 at 10:08 AM, resident #1 explained she used the insulin pump at home before she was hospitalized in early May 2025. Resident #1 had a broken speech pattern and said she had delayed thought processing. This caused her to respond slowly to questions. Resident #1 stated she never told the facility about her insulin pump during the week before she was re-hospitalized , nor did she tell them she had not used her insulin pump recently. She could not recall if she or the facility staff ever spoke about finger stick blood glucose monitoring but explained before her initial hospitalization her mother assisted her to manage the device and obtain prescriptions. She relayed she had hoped to return home from the nursing home with her mother but now needed additional therapy at an inpatient rehabilitation hospital to get better. She said she felt weaker after her re-hospitalization on 5/19/25 and believed her conditions had worsened since then. On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The physician said that in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all of the hospital information when she assessed the resident and had she known about the insulin orders and pump, the plan of care would have been much different. She said the care would include closer monitoring of someone on dialysis and that an insulin pump could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week, and it could have been prevented; definitely she could have died. On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role mid-July 2025. He explained it was critical for nurses to inform physicians of a resident with an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she was re-admitted from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the prior seven days because irregular or concerning highs and lows would have been caught. Resident #1's unsigned Admissions Checklist form dated 5/12/25 noted 19 steps for nurses to follow that included: Verify medications with MD/NP (Medical Doctor/Nurse Practitioner), Complete the medication reconciliation, and put in medication orders. Review of the facility's standards and guidelines titled Nursing - Physician's Orders dated 3/10/23 noted nurses were responsible for monitoring orders including blood sugar. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following:*On 5/19/25, resident #1's physician was notified of a fall and change in condition with a blood sugar reading of high. The physician provided orders to send the resident to the hospital via 911 emergency for further evaluation. On 5/23/25, resident #1 returned to the facility from the hospital. Physician's admission Orders were implemented for Insulin and finger stick blood sugar monitoring.*From 6/13/25 to 6/17/25, nurse re-education was provided on the order entry EMR process, with specific focus on physician clarification, transcription and implementation of physician's orders. On 7/31/25, education was added for attention to orders related to the treatment of diabetes according to accepted standards of practice and facility standard practices. On 8/01/25, 82% of licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, an audit was completed for 100% of current residents. Orders were verified as transcribed to reflect accurate eMAR (electronic medication administration record) and eTAR (electronic treatment administration record) documentation Identified concerns/discrepancies were corrected.*On 7/31/25, an audit was completed of all admitted /re-admitted residents in the previous 30 days. Physician's orders were verified to ensure appropriate orders consistent with accepted standards of practice and facility standard practices for the treatment of diabetes. No concerns were identified.*On 7/31/25, education for all licensed nurses was initiated for the following: 1. Hospital record review to include medication reconciliation, treatments, and order verification with the attending physician to ensure appropriate orders for the treatment of diabetes in accordance with accepted standards of practice and facility standard practices. 2. admission chart reviews during clinical meeting with two nurses to review all ordered medications and treatments. 3. Order Listing review for accuracy of all medications and treatments and their transcription to the eMAR. On 8/01/25, 82% of all licensed nurses had completed with posttests for retention validation. Remaining licensed staff were required to receive the education prior to working their next scheduled shift. Any newly hired staff will receive the education on day 1 orientation.*On 7/31/25, an Ad hoc (for this purpose) Quality Assurance Performance Improvement (QAPI) meeting was conducted that included Medical Director review of the F635 Immediate Jeopardy (IJ) template and the facility's immediacy removal plan of action. Upon review, the Medical Director approved the facility's proposed plan. Review of the in-service attendance sheets noted staff participated in education on the topics listed above.From 8/01/24 to 8/02/24, interviews were conducted with 11 licensed nurses who represented all shifts. 5 RNs and 6 LPNs verbalized their understanding of the education provided.The resident sample was expanded to include 4 additional residents identified with Diabetes Mellitus. Observations, interviews, and record reviews revealed no concerns related to admission orders or Diabetes for residents #2, #3, #4, and #5.Effective 8/01/25, the scope and severity were reduced to a level D.

Based on interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to obtain and implement critical physician medication admission orders for the care of a resident admitted from the hospital with a diagnosis of Type 1 Diabetes Mellitus for 1 of 3 residents, reviewed for admission orders, of a total sample of 5 residents, (#1).For eight consecutive days following admission, for all three nursing shifts and involving nine different licensed nurses, the facility did not obtain or implement physician orders for routine blood glucose monitoring (finger sticks) or insulin administration. This failure resulted in resident #1 developing severe hyperglycemia (high blood sugar) and Diabetic Ketoacidosis (DKA) requiring emergency transfer to the hospital, admission to the Intensive Care Unit (ICU), and emergency intravenous insulin therapy.DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. DKA is diagnosed if your blood glucose level is above 250 milligrams/deciliter (mg/dL), your blood is acidic, you have ketone (acid molecules) in your urine or blood, and your blood bicarbonate level is lower than 18 milliequivalents/ liter. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25).This failure placed the resident in a situation in which serious injury/harm/impairment/death was likely to occur and resulted in the resident's hospitalization with life-threatening DKA requiring ICU-level care.Findings:Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, history of blood clot, and hypothyroidism (low thyroid function).The Minimum Data Set 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The resident received high-risk opioid and anticonvulsant medications. The assessment indicated the resident received hemodialysis before admission and during her stay.Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed physician ordered discharge medications included, New: Oxycodone IR 10 Milligrams (MG) every 4 hours as needed for 3 days, Tylenol 650 MG every 6 hours as needed, Minoxidil 60 Gram Foam, topical (on skin) daily. Medications to continue included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ (subcutaneous) daily, Lantus Insulin 4 IU (International Units) SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals, Creon 36,000 IU three times daily, Divalproex Sodium 500 MG twice daily, Lacosamide 100 MG twice daily, Levothyroxine 50 Micrograms (MCG) once daily, Midodrine 10 MG three times daily, Gabapentin 300 MG at bedtime.Review of the May 2025 Medication Administration Report (MAR) showed resident #1's 5/12/25 admission physician orders included, Bumetanide (diuretic) 2 MG once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 international units (IU) three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, Oxycodone 10 MG every 6 hours as needed for pain. There were no orders for insulin or blood glucose monitoring noted on the MAR for May 2025.After the resident returned from the hospital on 5/23/25, orders were added that included Lantus Insulin 4 IU once daily for diabetes mellitus increased to 6 IU on 5/31/25, Lispro Insulin 2 IU before meals and changed on 5/24/25 to Novolog Aspart Insulin 2 IU before meals with finger sticks and parameters to notify the APRN (Advance Practice Registered Nurse) for readings of less than 60, or more than 250 for diabetes mellitus, and Accu-Chek (blood glucose monitoring finger sticks) twice daily with parameters to notify the MD (Medical Doctor) when less than 60, or more than 400.The Agency for Healthcare Administration (AHCA) Form 5000-3008 signed by the hospital provider dated 5/12/25 documented resident #1's Discharge Summary and Discharge Medication List reports were attached.The hospital discharge physician ordered medication list dated 5/12/25 documented continued home medications included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily, Insulin Glargine (Lantus), 4 IU SQ daily, and Insulin Lispro, 2 IU SQ three times daily before meals.Resident #1's physician's facility admission orders for 5/12/25 included all medications listed on the hospital physician's discharge medication orders, except for insulin. No finger sticks were ordered.Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to Diabetes type I, history of recent DKA, encephalopathy, history of acute kidney injury, dependence on dialysis, chronic hypotension, neuropathy, hypothyroidism, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included: (5/13/25) Diabetes Mellitus with a goal for no complications and interventions for Diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms, (5/13/25) risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history, (5/13/25), pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status, (5/16/25) adverse effects of high-risk medication monitoring, risk for pressure injuries, (5/27/25) seizure history, and indwelling urinary catheter with failed voiding trial, dehydration or potential fluid deficit related to diuretic medication, hemodialysis, type I diabetes with recent DKA, and (6/02/25) hypoglycemia. The discharge care plan initiated on 5/13/25 noted the resident wished to be discharged from the facility to community/prior living arrangements (home).In a telephone interview on 7/30/25 at 1:20 PM, Registered Nurse (RN) F explained the process for new admission included a review of the hospital's history and physical and discharge medications. She stated the normal practice was to notify the on-call physician, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and relayed that finger sticks should have been entered by either herself or the on-coming nurse. She explained admission orders were obtained from APRN E who wanted the resident's long-acting insulin further evaluated for appropriate orders with the pump. The RN stated, they need finger stick blood sugar orders, I'm not sure if it was an oversight on my part or my co-worker.On 7/29/25 at 10:46 AM, APRN D recalled she participated in the Interdisciplinary team (IDT) meeting on 5/13/25, the morning after resident #1 was admitted . She explained APRN E gave admission orders to hold the insulin. She said the resident's hospital records were reviewed which noted the resident had type 1 Diabetes, and it was common knowledge to do finger stick checks for all diabetics with insulin, especially those who were very brittle with an insulin pump. She said pumps could not be managed in a Skilled Nursing Facility (SNF). The APRN said she assumed there were already orders in place for finger sticks twice a day and she did not recall if the records were checked during the meeting for confirmation.Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org).In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and she never gave orders to hold new admission routine insulin. She did not recall resident #1 specifically and stated, I would still give orders for finger stick blood glucose monitoring, especially if they had an insulin pump.Review of APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's hospital discharge medications but did not include any insulin. The hospital records with laboratory results were noted as reviewed with a blood sugar result of 240. The Diabetes Mellitus diagnosis had comments noted as, blood glucose trends were stable and within normal limits and no medications were taken. Blood glucose finger stick monitoring or review was not mentioned in the report. The Physical Exam did not note an insulin pump on resident #1's body but the note mentioned at least 60 minutes was spent assessing the resident.The physician's History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration documented resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244. The Diabetes Mellitus with hyperglycemia diagnosis had comments that noted no blood glucose finger stick results were available for review, so physician orders were placed for daily blood glucose finger sticks to evaluate the need for insulin.In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, the doctor explained she expected hospital physician discharge orders to be followed for medications, and blood glucose finger sticks were standard orders expected for all diabetic residents with insulin. She explained when she saw resident #1 on 5/14/25 she did not recall any insulin orders. She did recall the resident's blood glucose was over 200 with a diagnosis of Diabetes Mellitus which needed to be evaluated for insulin coverage. The doctor stated she sent a text message the same day to APRN D with directives to follow up. She said she was unaware until the surveyor's telephone interview that the resident had an insulin pump.In interviews on 7/29/25 at 10:46 AM, and 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, she jointly assessed resident #1 with the MD. She said on 5/13/25, she ordered labs to check a longer blood glucose history that showed the resident's blood glucose was stable with insulin/insulin pump coverage. The APRN said the MD gave orders to check finger sticks twice daily and they both expected nurses had done them. APRN D recalled on 5/14/25, two days after resident #1 was admitted to the facility, she let the MD know more medical records were needed. She said a blood test showed the resident had stable blood sugars with the previous insulin regimen. The APRN explained the same day during a joint assessment of the resident with the physician, it was determined finger sticks were needed twice daily to see how often she would need insulin coverage and recalled the pump was on her torso, but she didn't see it or remember how it was hooked up. The APRN said the facility never had a resident with an insulin pump before and stated, she's on dialysis and that further complicates her condition. APRN D referred to resident #1 and stated, When her records were reviewed in the morning, we saw she was a type 1 (diabetic); usually there are standing orders; all diabetics should have finger sticks; it's common knowledge to do finger sticks for all diabetics; when she came back from the hospital (5/23/25), it was apparent she was unpredictable.Review of resident #1's Order Audit Report showed the primary care physician entered orders on 5/15/25 at 2:47 PM, for blood glucose finger stick monitoring daily for 5 days in the morning for diabetes. The report noted Licensed Practical Nurse (LPN) C confirmed the order on 5/15/25 at 3:23 PM.On 7/29/25 at 2:48 PM, LPN C explained that it was the facility's practice to place newly admitted residents who had been on insulin with finger stick blood glucose monitoring orders. The nurse explained when doctors entered their own orders into the computer, nurses verified the entry and confirmed it. The LPN recalled after the physician entered resident #1's finger stick blood glucose monitoring orders on 5/15/25, she confirmed it however, she later learned from the Director of Nursing (DON) that it wasn't categorized properly, so it didn't get entered into the MAR to alert nurses to perform the test. The nurse said she was not aware resident #1 had an insulin pump and stated, we don't do insulin pumps.In a telephone interview on 7/30/25 at 11:31 AM, RN A said she worked the 11:00 PM to 7:00 AM shift. She said hospital admissions usually arrived during the 3:00 PM to 11:00 PM shift and most of the time, physician admission orders were already entered and processed during that shift before she came in. The nurse explained she did not recall if on 5/13/25 the previous shift's nurse informed her that resident #1 needed insulin or finger stick orders clarified. The nurse said she had never received report from other nurses of any resident at the facility with an insulin pump.In a telephone interview on 8/01/25 at 10:53 AM, RN I explained medication orders for residents admitted from the hospital were transcribed from the physician's discharge orders list. The nurse recalled resident #1 was included in her assignments when she worked all shifts. She said she never received information in nurse-nurse reports that the resident had an insulin pump. The RN explained licensed nurses were expected to use proper nursing judgement when they cared for insulin-dependent diabetic residents. She added, nurses were trained to contact the provider when they noticed finger stick or insulin orders were missing and stated, it's basic nursing.On 8/01/25 at 1:14 PM, in a telephone interview, RN H recalled resident #1 and was unsure if the resident had an insulin pump. The RN explained all nurses were expected to know residents who had been on insulin, especially with a pump, were likely unstable and required close blood glucose monitoring. The nurse said when skin assessments were done, any device on the resident's body was supposed to be noted on the assessment. She said it was important for nurses to pay attention to diabetics for insulin and finger stick orders and the physician needed to be informed to obtain orders if they were missing.In a telephone interview on 8/01/25 at 11:19 AM, LPN J recalled resident #1 was included in her assignments throughout her stay. She said nurses were expected to note any devices or ports with their locations on the skin assessments, and she didn't remember the resident having an insulin pump. The LPN explained nurses were expected to ensure finger stick orders were in place for any resident with insulin. The nurse stated, I would need to contact the provider for finger sticks.On 8/01/25 at 10:51 AM, LPN G recalled when resident #1 came to the facility the first time, she was on orientation and there was nothing significant about her condition. The nurse said she didn't remember seeing an insulin pump or any discussions/reports from other nurses and stated, I'm surprised nobody captured that; she was undressed many times.On 8/01/25 at 3:38 PM, LPN K said she worked the 3:00 PM to 11:00 PM shift. The nurse said she did not recall anything about an insulin pump for resident #1. She explained that anyone with an insulin pump should have finger sticks and stated it was concerning if she didn't see those orders. The LPN stated, I would question why there aren't finger sticks; it's nursing 101.On 7/28/25 at 2:41 PM, LPN B said she worked the 7:00 AM to 3:00 PM, shift and resident #1 was included in her assignments. The nurse recalled around mid-morning on 5/19/25, she was alerted by a Certified Nursing Assistant (CNA) that something was wrong with the resident. The LPN said she called the resident's mother about a change in condition and was informed the resident was insulin-dependent and at risk for DKA. The nurse explained she had not received that information in nurse-nurse report from the out-going shift and wasn't sure why the resident wasn't on insulin. She performed two finger sticks that both read high which meant it was too high for the glucometer to read. After the LPN contacted APRN D to inform her of the readings, the APRN gave orders to send the resident via 911 emergency transportation to the hospital.Review of resident #1's admission and weekly skin assessments throughout her stay from 5/12/25 to 5/19/25, revealed no documentation of insulin pump device present.The EMS (Emergency Medical Services) Patient Care Record dated 5/19/25 noted an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia.Review of resident #1's hospital admission records dated 5/19/25 confirmed the resident's admitting diagnosis was for Diabetes Mellitus with Ketoacidosis (DKA) with blood glucose readings of greater than 600 milligrams per deciliter that required IV insulin, and ICU admission.The hospital physician admission note dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated.Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present and expressed concerns regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25.On 7/28/25 at 12:40 PM, the DON said she became aware of resident #1's missing finger sticks on 6/13/25 after a routine chart review. She explained the nurse had not properly confirmed the order in the EMR after it was entered by the MD on 5/15/25. The DON said the error prevented prompts from appearing on the nurse's MAR which directed the nurses to perform the tests, so they were not done. On 7/30/25 at 11:01 AM, in a joint interview with the DON and Assistant DON (ADON), the DON said the clinical team reviewed all hospital re-admissions including resident #1's on 5/19/25. The DON stated, we didn't connect the missed orders.Nursing progress notes from 5/12/25 to 5/18/25 contained no documentation history of blood glucose checks nor notations that resident #1 indicated to anyone she had not recently used her insulin pump at home.The admission Nursing assessment dated [DATE] identified diabetes as an active diagnosis but did not include physician orders for blood glucose monitoring or insulin administration.Interviews with eight licensed nurses confirmed awareness of the resident's diabetic status but no action to clarify or obtain orders for glucose monitoring or insulin administration.On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The doctor said in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all the hospital information when she assessed the resident and had she known about the insulin orders/pump, the plan of care would have been much different and included closer monitoring and more testing. The doctor said insulin pumps were dangerous, especially for someone on dialysis and could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week, and it could have been prevented; definitely she could have died.On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role since mid-July 2025. He explained it was critical for nurses to inform doctors of an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she returned from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the seven days prior to the event, and that irregular or concerning highs and lows would have been caught.Review of the EMR revealed after resident #1 returned to the facility from the hospital, from 5/23/25 through 6/18/25, she required routine and sliding scale insulin coverage with finger stick checks twice daily, and before meals. Prescribed insulin doses were revised three times when her blood sugar levels were unstable until she was discharged on 6/18/25.In a joint interview with the DON and ADON on 8/01/25 at 10:40 AM, the ADON explained she was the facility's clinical educator and conducted nurse training for new hire orientation and re-education. The ADON said education was provided for nurses that covered the facility's policies and procedures and a competency checklist. She said competency was validated using observation, demonstration, and the checklist. The DON explained re-hospitalizations were reviewed during the IDT clinical meetings every weekday morning. The DON stated when the IDT reviewed resident #1's 5/19/25 re-hospitalization, they found the resident had high blood sugar.Review of the facility's nurse's orientation program on 8/02/25, included education for physician's order processing and accuracy review. Blood glucose monitoring via finger stick education noted that nurses were expected to contact the physician for needed follow-up/clarifications.The LPN job description dated May 2022 listed Duties and Responsibilities that included consultation and coordination with the IDT and health care professionals to assess, plan, implement, and evaluate individual resident care plans. Specific Requirements included the ability to plan and provide procedures necessary to provide quality care, the ability to communicate information concerning a resident's condition, and knowledge of nursing and practices and procedures.The RN Job Description dated May 2022 listed Duties and Responsibilities that included consultation and coordination with the IDT and health care professionals to assess, plan, implement, and evaluate individual resident care plans. Essential functions included monitoring the chronic health conditions of residents; being familiar with reportable changes and potential causes for concern. Specific Requirements included the ability to plan and provide procedures necessary to provide quality care, the ability to communicate information concerning a resident's condition, and knowledge of nursing and medical practices and procedures.The DON's Job Description dated October 2020 noted the primary purpose included to ensure that the highest degree of quality care was maintained at all times. Duties and Responsibilities included to ensure that competent and qualified individuals provided nursing care. Nursing care functions included monitoring of residents for preventable decline, and monitoring medication passes and treatment schedules to ensure medications and treatments were provided as scheduled.The undated Nurse Practitioner Job Description noted the APRN was the go-to person for ensuring the best patient care and medical guidance was achieved. Responsibilities included examining patients and their medical records, ordering and studying diagnostic tests, prescribing medications, maintaining accurate schedules and records, and proposing treatments for chronic conditions and illnesses.The Facility Assessment Tool dated 2/01/25 noted the facility provided services for medication administration/assessment/management, management/early identification of problems/deterioration of medical conditions including diabetes. Staff training/education and competencies were noted as verified upon orientation, at least annually, and as needed designed to ensure competency for all staff. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following:*On 5/19/25, resident #1's physician was notified of a fall and change in condition with a blood sugar reading of high. The physician provided orders to send the resident to the hospital via 911 emergency for further evaluation. On 5/23/25, resident #1 returned to the facility from the hospital. Physician's admission Orders were implemented for Insulin and finger stick blood sugar monitoring.*On 7/31/25, licensed nurse education on Diabetes Management was initiated that included recognition of residents with high-risk type 1 Diabetes Mellitus and blood sugar treatment and monitoring requirements to prevent severe complications. On 8/01/25, 71% of all licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, 100% of current residents with diagnosis of diabetes were audited to ensure blood sugar monitoring was performed and documented per physician's orders.*On 7/31/25, licensed nurse education was initiated that included: 1. Diabetic management on type 1 diabetes and signs and symptoms of hypoglycemia and hyperglycemia and when to notify the physician. On 8/01/25, 71% of all licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, an Ad hoc (for this purpose) Quality Assurance Performance Improvement (QAPI) meeting was conducted that included Medical Director review of the F726 Immediate Jeopardy (IJ) template and the facility's immediate removal plan of action. Upon review, the Medical Director approved the facility's proposed plan. Review of the in-service attendance sheets noted staff participated in education on the topics listed above.From 8/01/24 to 8/02/24, interviews were conducted with 11 licensed nurses who represented all shifts. 5 RNs and 6 LPNs verbalized their understanding of the education provided.The resident sample was expanded to include 4 additional residents identified with Diabetes Mellitus. Observations, interviews, and record reviews revealed no concerns related to admission orders or Diabetes for residents #2, #3, #4, and #5.

Based on interview, and record review, the facility failed to report an incident involving possible neglect to the State Agency (SA) within the required timeframes for 1 of 3 residents reviewed for neglect, of a total sample of 5 residents, (#1). The facility did not report possible neglect regarding a rehospitalization involving a resident with type 1 diabetes and an insulin pump who had not received physician's ordered finger stick blood glucose monitoring or insulin and was subsequently re-hospitalized for Diabetic Ketoacidosis (DKA). The deficient practice had the potential to place residents at risk for unreported neglect and delayed investigation. DKA is a life-threatening complication that affects people with diabetes which requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates a medical emergency. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin, and without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25).Findings:Review of resident #1's Minimum Data Set (MDS) Discharge Return Anticipated Assessment with an Assessment Reference Date (ARD) of 5/19/25 showed the resident was discharged from the facility to an acute care hospital. The MDS 5-day Assessment with an ARD of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The resident received hemodialysis before admission and during the stay.Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to Diabetes type I, history of recent DKA, encephalopathy, history of acute kidney injury, dependence on dialysis, chronic hypotension, neuropathy, hypothyroidism, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included: (5/13/25) Diabetes Mellitus with a goal for no complications and interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms; (5/13/25) risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, fall risk score, and fall history; (5/13/25), pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis; (5/16/25) adverse effects of high-risk medication monitoring, risk for pressure injuries, (5/27/25) seizure history, and indwelling urinary catheter with failed voiding trial, dehydration or potential fluid deficit related to diuretic medication, hemodialysis, type I diabetes with recent DKA, and (6/02/25) hypoglycemia. A Change in Condition (SBAR) [Situation Background Assessment Recommendation] note completed by Licensed Practical Nurse (LPN) B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high. At 12:30 PM, the physician was notified and gave orders to send the resident to the emergency room (ER) via 911 emergency medical services (EMS).In an interview on 7/31/25 at 2:48 PM, LPN B recalled that on 5/19/25, resident #1 was part of her assignment. The nurse explained she observed the resident on the floor in her room beside her bed in an altered mental state with weakness, drowsiness, and no apparent injuries. The LPN said she notified Advance Practice Registered Nurse (APRN) F who directed her to check the resident's blood sugar. She immediately attempted two finger sticks that both read, high, which was reported to APRN F who gave orders to send the resident out via 911 to the hospital. The nurse said she had been unaware the resident was diabetic with an insulin pump until she called the resident's mother about the change in condition. She said the resident's mother inquired what her daughter's finger stick results and was concerned about possible DKA. The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and Intensive Care Unit (ICU) care, resident #1's blood glucose levels were, in the 600's.Review of the medical records revealed both the Order Reconciliation Home Medications on hospital records dated 5/19/25 for the resident's initial admission to the facility and the hospital Discharge Progress Notes Medication Update dated 5/23/25 for re-admission to the facility included Lispro Insulin 2 international units (IU) three times a day before meals, and Lantus Insulin 4 IU once a day.Lantus is a prescription drug used to help manage blood sugar levels in adults with type 1 and type 2 diabetes. It is a long acting insulin that is injected under your skin to add to or replace your body's natural insulin. Insulin Lispro is a prescription drug for managing blood sugar that is taken as an injection under your skin, intravenously or by insulin pump. This medicine acts quickly to lower your blood sugar, (retrieved on 8/14/25 from www.healthline.com).The Weights and Vitals Summary report showed resident #1 didn't receive any finger stick blood glucose checks from 5/12/25 to 5/19/25, for eight days. Over eight days from 5/12/25 until 5/19/25, 9 licensed nurses over 3 shifts, 2 APRNs, and 1 Medical Doctor (MD) evaluated, assessed, and made critical clinical decisions about resident #1's plan of care, yet she did not receive regular blood glucose monitoring or insulin medication.On 7/28/25 at 12:40 PM, the DON said she became aware of resident #1's missing finger sticks on 6/13/25 after a routine chart review. She explained the nurse had not properly confirmed the order in the electronic medical record (EMR) after it was entered by the physician on 5/15/25. The DON said the error caused the nurses' medication administration record (MAR) to not prompt the nurse to perform the tests, so they were not done. On 7/30/25 at 11:01 AM, in a joint interview with the DON and Assistant Director of Nursing (ADON), the DON said the clinical team reviewed all hospital re-admissions including resident #1's on 5/19/25. The DON stated, we didn't connect the missed orders.On 8/02/25 at 9:25 AM, in a joint interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON explained that clinical staff reviewed all SBARs and hospital transfers. She said their investigation found that resident #1 had a fall with high blood glucose readings so the provider wanted the resident to go to the ER and stated, we contributed the elevated blood sugar to a Urinary Tract Infection (UTI). The DON recalled during a routine meeting on 6/13/25, the clinical team identified resident #1's physician's orders entered by the physician on 5/15/25 and confirmed by a nurse were not properly linked to the MAR for nurses to perform finger sticks. The NHA explained adverse incidents and possible neglect were discussed monthly as well as regulatory compliance, facility investigations and risk management issues. The NHA recalled the facility determined resident #1's hospital transfer on 5/19/25 was because of a fall so they did not feel there was possible neglect or a requirement to report to the SA. The NHA described neglect as, neglect is intentionally or unintentionally withholding services to a resident.Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present for care plan meeting and expressed concerns at that time regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25. On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother.The EMS (Emergency Medical Services) Patient Care Record dated 5/19/25 noted an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia.On 7/31/25, after the facility was made aware of surveyor's concerns related to resident #1 not receiving insulin or regular blood glucose monitoring during her first admission to the facility, the facility completed an Immediate Facility Reported Incident (FRI) report for possible neglect of resident #1 to the State Agency.Review of the Risk Manager Job Description dated October 2020 detailed Duties and Responsibilities that included incident investigations and ensuring neglect allegations were thoroughly investigated with appropriate corrective actions. The facility's standards and guidelines titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of Unknown Source and Investigation dated 4/01/22 showed the facility reported suspected neglect to the SA using Immediate and 5-day Federal reports no later than 24 hours the facility conducted their own internal investigations, analyzed occurrences to identify adverse events, and utilized committees for review of regulatory compliance.

Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted for a rehospitalization involving possible neglect when a resident with type 1 diabetes did not receive physician's ordered blood glucose monitoring or insulin resulting in rehospitalization for Diabetic Ketoacidosis (DKA) for 1 of 5 residents reviewed for neglect, of a total sample of 5 residents, (#1). DKA is a life-threatening complication which requires immediate medical attention which can affect people with diabetes. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates a medical emergency. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin, and without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25).Findings:Review of resident #1's Minimum Data Set (MDS) Discharge Return Anticipated Assessment with an Assessment Reference Date (ARD) of 5/19/25 showed the resident was discharged from the facility to an acute care hospital. The MDS 5-day Assessment with an ARD of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The resident received hemodialysis before admission and during the stay.Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to diabetes type I, history of recent DKA, encephalopathy (brain dysfunction), history of acute kidney injury, dependence on dialysis, chronic hypotension, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included: (5/13/25) Diabetes Mellitus with a goal for no complications and interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms; (5/13/25) risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history; (5/13/25), pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis; (5/16/25) adverse effects of high-risk medication monitoring, risk for pressure injuries. The Change in Condition (SBAR) [Situation Background Assessment Recommendation] notes completed by Licensed Practical Nurse (LPN) B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high. At 12:30 PM, the physician was notified and gave orders to send the resident to the emergency room (ER) via 911 emergency medical services (EMS).In interviews on 7/28/25 at 2:41PM, and 7/31/25 at 2:48 PM, LPN B recalled on 5/19/25, resident #1 was part of her assignment, and she was new to her at that time. The nurse explained she observed the resident on the floor in her room beside her bed in an altered mental state with weakness, drowsiness, and no apparent injuries. The LPN said she notified Advanced Practice Registered Nurse (APRN) F who directed her to check the resident's blood sugar. She immediately attempted two finger sticks for blood glucose that both read, high, which was reported to APRN F. The APRN gave orders to send the resident out via 911 to the hospital. The nurse said she was unaware at that time the resident was a diabetic with an insulin pump until she called resident #1's mother about the change in condition. She said the resident's mother inquired about the results of blood glucose finger sticks and was concerned about possible DKA. LPN B stated she was not sure why insulin was not put on the admission orders as the family said resident #1 was supposed to be on insulin.The EMS Patient Care Record dated 5/19/25 noted an Emergency Dispatch Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia.The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and ICU care, resident #1's blood glucose levels were, in the 600's.The Order Reconciliation Home Medications on hospital records dated 5/19/25 and the hospital Discharge Progress Notes Medication Update dated 5/23/25 for re-admission to the facility included Lispro Insulin 2 IU three times a day before meals, and Lantus Insulin 4 IU once a day.Lantus is a prescription drug used to help manage blood sugar levels in adults with type 1 and type 2 diabetes. It is a long-acting insulin that is injected under your skin to add to or replace your body's natural insulin. Insulin Lispro is a prescription drug for managing blood sugar that is taken as an injection under your skin, intravenously or by insulin pump. This medicine acts quickly to lower your blood sugar, (retrieved on 8/14/25 from www.healthline.com).The Weights and Vitals Summary report showed resident #1 didn't receive any finger stick blood glucose checks from 5/12/25 to 5/19/25, for eight days. Review of the Medication Administration Report (MAR) for the time period of 5/12/25 to 5/19/25 revealed no insulin or other medications to treat her blood glucose were administered to resident #1 during for that time frame. Over eight days from 5/12/25 until 5/19/25, 9 licensed nurses over 3 shifts, 2 APRNs, and 1 Medical Doctor (MD) evaluated, assessed, and made critical clinical decisions about resident #1's plan of care.On 8/02/25 at 9:25 AM, in a joint interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON explained that clinical staff reviewed all SBARs and hospital transfers. She said their investigation found that resident #1 had a fall with high blood glucose readings and the provider wanted the resident to go to the emergency room and stated, we contributed the elevated blood sugar to a Urinary Tract Infection (UTI).On 7/28/25 at 12:40 PM, the DON said she became aware of resident #1's missing finger sticks on 6/13/25 after a routine chart review. She explained that the nurse had not properly confirmed the order in the electronic medical record (EMR) after it was entered by the MD on 5/15/25. The DON said the error prevented the nurses MAR prompts to perform the tests and they were not done. On 7/30/25 at 11:01 AM in a joint interview with the DON and ADON, the DON said the clinical team reviewed all hospital re-admissions including resident #1's on 5/19/25. The DON stated, we didn't connect the missed orders. Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present and expressed concerns regarding medication administration that occurred during her daughter's first admission to the facility from the hospital on 5/12/25.On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother.On 8/02/25 at 9:25 AM, in a joint interview with the DON and NHA, the DON recalled during a routine meeting on 6/13/25, the clinical team identified resident #1's physician's orders entered by the physician on 5/15/25 and confirmed by a nurse were not properly linked to the MAR for nurses to perform finger sticks. She explained that on 6/17/25 an Ad Hoc meeting was held when a Performance Improvement Plan (PIP) was developed for the EMR processing error. The NHA explained the team discussed regulatory compliance, possible neglect, facility investigations and risk management issues and stated, neglect is intentionally or unintentionally withholding services to a resident.Review of the Risk Manager Job Description dated October 2020 detailed Duties and Responsibilities that included incident investigations and ensuring neglect allegations were thoroughly investigated with appropriate corrective actions. The DON Job Description dated October 2020 detailed Duties and Responsibilities that included rehospitalization reviews and participation in risk management and safety to mitigate risk factors.The facility's standards and guidelines titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of Unknown Source and Investigation dated 4/01/22 showed the facility conducted their own internal investigations, analyzed occurrences to identify adverse events, and utilized committees for review of regulatory compliance.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified and addressed a systemic process failure related to physician's admission orders for immediate care. Following a resident's rehospitalization for Diabetic Ketoacidosis (DKA) due to not receiving physician's ordered blood glucose monitoring or insulin, the facility did not identify an underlying electronic order error until approximately three weeks later. Approximately one month later, the QAPI committee initiated only an Ad hoc review, and a limited Performance Improvement Plan (PIP) focused solely on the electronic order error, without evaluating broader systemic factors. This narrow scope delayed the implementation of broader corrective actions and placed residents at risk of harm due to unaddressed deficiencies. Findings: Review of the facility's standards and guidelines titled Quality Assurance and Performance Improvement dated 3/10/23 defined an adverse event as, an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof. The policy detailed Performance Improvement (PI) identified areas of opportunity and underlying causes and provided approaches to correct systemic problems or barriers to improvement. QAPI was defined as taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality. The program's intent noted plans were focused on safety, health, and outcomes that ensured accepted standards of quality care and services.In a joint interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 8/02/25 at 9:25 AM, the DON recalled on approximately 5/13/25, an Interdisciplinary Team (IDT) that included nurse managers and Advanced Practice Registered Nurse (APRN) D reviewed resident #1's rehospitalization. The DON explained the resident fell on 5/12/25 and had a blood glucose reading of high (exceeded glucometer parameters) and the provider wanted the resident to go to the Emergency Room. She relayed a Urinary Tract Infection (UTI) was attributed to resident #1's severely high blood glucose reading. The DON said on 6/13/25 during a routine care review meeting, it was identified that resident #1's finger stick orders entered on 5/15/25 were never implemented. The DON explained a week later on 6/17/25, an Ad Hoc meeting was conducted where a PIP was developed for correction and monitoring to ensure accuracy of the Electronic Medical Record (EMR) processing steps to link nurse prompts to the electronic Medication Administration Record (eMAR) and ensure tests/treatments were not missed. The DON recalled that all committee members were present and included the former Medical Director who was also resident #1's primary care physician. The NHA explained regular QAPI meetings were held monthly and on 6/18/25, the next day, the sole new PIP developed on 6/17/25 was discussed during the June meeting along with regular items that included departmental reports, concerns for possible additional PIPs, pattern tracking, risk management, falls, customer service, grievances, adverse event reporting, regulatory compliance, rehospitalizations, and any outside agency visits or past and outstanding non-compliance. The NHA explained the IDT discussed all events where it was determined if SA reporting was necessary. Review of resident #1's hospital admission records dated 5/19/25 confirmed the resident's admitting diagnosis was for Diabetes Mellitus with Ketoacidosis (DKA) with blood glucose readings of greater than 600 milligrams per deciliter that required Intravenous (IV) insulin, and Intensive Care Unit (ICU) admission.In a telephone interview on 7/28/25 at 12:24 PM, APRN D recalled after resident #1 returned from the hospital, her blood sugars were very unstable. The APRN stated, she was very brittle; after she got back, we realized how brittle she really was.Review of the EMR revealed after resident #1 returned to the facility from the hospital, from 5/23/25 through 6/18/25, she required routine and sliding scale insulin coverage every day with finger stick checks twice daily, and before meals. Prescribed insulin doses were revised three times when her blood sugar levels were unstable until she was voluntarily discharged from the facility to an inpatient rehabilitation hospital on 6/18/25.On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The doctor said in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all of the hospital information when she assessed the resident and had she known about the insulin orders/pump, the plan of care would have been much different. She explained the care should have included closer monitoring and more testing. The doctor said insulin pumps were dangerous, especially for someone on dialysis and she felt they could not be used in a Skilled Nursing Facility (SNF). The physician recalled later the facility reviewed resident #1's order error and she suggested finger sticks for all newly admitted residents with diabetes for five days however, she was no longer the Medical Director. On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role since mid-July 2025. He said he assessed resident #1 after she was re-admitted from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the 7 days prior to the event, and that irregular or concerning highs and lows would have been caught. The physician relayed he was only recently involved in the facility's QAPI meetings and was aware of surveyor's concerns that were identified during the survey.

Based on interview, and record review, the facility failed to follow generally accepted accounting principles to handle residents' funds for 2 of 2 residents reviewed for personal funds, of a total sample of 59 residents, (#32, and #47). Findings: 1. Review of resident #32's medical record revealed he was readmitted to the facility on [DATE]. His diagnoses included type 2 diabetes, absence of right and left leg above the knee, and glaucoma. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 10/19/24 revealed resident #32 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact. On 1/13/25 at 11:31 AM, resident #32 said, They hardly have money in here. He explained last week he attempted to access his money three or four times and every time he was told they did not have any money available. He spoke with Receptionist K, who handed out the money. He indicated he needed to buy phone cards which the Activities Director purchased for him. Resident #32 stated he placed the request approximately 2 weeks ago and he still did not receive them. He mentioned the Administrator was aware and has done nothing to fix it. Resident #32 shared he had not received his quarterly statements in at least six months. He said he was, tired of not having money. The next day, 1/14/25 at 12:37 PM, resident #32 stated the Activities Director told him he may not have access to the money, until God knows when. He mentioned it was not right for him not to have access to the money in his account to recharge his calling cards. Review of a Grievance Report dated 5/13/24 filed by resident #32 read, not being able to get our money for a while and we are suppose [sic] to be able to get money daily. The follow-up comment added by the Business Office Manager (BOM) on 5/17/24 read, New company that issues checks for us to deposit in our accounts. Once check clears we withdraw the funds and place them in the petty cash box. The form did not show resident #32 was notified of the resolution. Review of resident #32's Resident Trust statement from 3/01/24 thru 1/17/25 revealed a balance of $6,901.43. The statement showed 2 transactions posted on 12/10/24 for cash withdrawals dated from August to September 2024 as follows: 8/15/24 cash withdrawal $112.94 9/12/24 cash withdrawal $92.28 2. Review of resident #47's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, type 2 diabetes, and polyarthritis. Review of the MDS quarterly assessment with ARD of 9/28/24 revealed resident #47 had a BIMS score of 13 out of 15 which indicated she was cognitively intact. On 1/13/25 at 10:46 AM, resident #47 stated she used to get $50.00 approximately three times a month but was recently told she did not have any money in her account. She indicated she was getting money and now she owed them about $400.00, so the facility would keep the new deposits until her negative balance was paid off. She indicated she did not sign anything and was just told she had to pay for it. Review of resident #47's Resident Trust statement from 3/01/24 thru 1/17/25 revealed a balance of negative $370.33. The statement showed 8 transactions posted on 12/10/24 for cash withdrawals dated from April to September 2024 as follows: 8/15/24 cash withdrawal $18.45 4/05/24 cash withdrawal $50.00 5/16/24 cash withdrawal $50.00 5/16/24 cash withdrawal $20.12 9/03/24 cash withdrawal $50.00 6/11/24 cash withdrawal $50.00 6/13/24 cash withdrawal $16.88 6/06/24 cash withdrawal $50.00 On 1/16/25 at 8:58 AM, the BOM explained her responsibilities included handling the resident trust accounts. She stated residents' quarterly statements were mailed out by a third-party company since April 2024. She indicated prior to April 2024 they hand delivered the statements to the residents and obtained their signature on a copy as proof of delivery. She mentioned now she had no way to confirm if residents received their quarterly statements. The BOM explained residents could get up to $50.00 daily from their petty cash. She added if more than $50.00 was needed, they could cut a check to the resident, responsible party or a vendor. She repeated if cash was needed, residents could get $50.00 every day from 9 AM to 4 PM. She shared when the box ran low of cash, she requested a replenishment check, so there could be a day or so when the box was empty. She indicated they had experienced this in the last couple of months since the transition to the new company. She explained when they had about 60 of them trying to all get money at the same time they could run out of money, and this was mostly an issue during the holidays. She stated residents shared their concerns about access to their funds with her, and once she explained the process they were okay. She mentioned she had never written any grievances if they left upset about it although she was aware of the grievance process. She indicated there were concerns with Activities purchasing debit cards with resident trust account for resident #32. The BOM stated the last purchase of items for resident #32 was in November 2024 and did not include calling cards. She mentioned they were now waiting for the check to clear, which usually took two days, but the money would be available to residents today. She indicated resident #32's calling cards would be purchased through the resident shopping done by Activities. She explained last November, she requested three months of statements from their third-party company and performed a house audit and noticed there were transactions not posted into several resident accounts. She stated she identified four residents whose accounts were negative. She shared resident #47's account was negative $370.00. She stated she questioned how this was possible because she emailed the third-party billing company daily all transactions to be posted into the resident trust accounts. She indicated resident #47 did not come to get money very often. She explained they noticed account balances were not what she anticipated them to be, account balances were off, and she explained to the residents they were completing an audit. She stated when they confirmed account discrepancies, she informed the four residents affected by a negative balance and they were understanding of it but it still does not make it right though. She mentioned they received their monthly $160.00 allowance into their account but since they overdrew the account, they kept the money to cover the negative balance. She stated she did not have them sign anything because they understood why their accounts were overdrawn. She validated this was their billing error, and not the residents fault. She indicated the Administrator was aware of the issue. Later at 1:20 PM, the BOM explained the decision was made in December to post back transactions and deduct the money from the residents' accounts. On 1/16/25 at 9:45 AM, the Activities Director confirmed he purchased the minutes cards for resident #32 when he ordered them. He explained each card cost approximately $30.00 to $35.00. He indicated resident #32 may have called Receptionist K and added his name to the shopping list. He explained he went every two weeks but, It has not been obviously done because of the transfer [from current facility name to the new one]. He indicated it had been a while since he last purchased the cards for resident #32 and he handed the receipts to the business office. On 1/16/25 at 9:47 AM, Receptionist K confirmed resident #32 called to request money a couple of days ago and was told they did not have it. She explained to him the money was not available but should be soon. She indicated there were a lot of times the box was empty because they could not get a new check to replenish it until the box was low. Review of the facility's Resident Trust Fund (RTF) Policy - Florida dated 4/24/24 revealed the purpose was, To ensure that the facility residents have access to, and are able to manage, their personal funds. The document included, . the facility must provide cash within one day of request or a check within 3 days. The policy read, The facility acts as a fiduciary of its resident's funds and has established and maintains a system that assures fill sand [sic] complete and separate accounting, according to generally accepted accounting principles, of each residents' personal funds entrusted to the facility on the resident's behalf in a clear and understandable manner. The document revealed proper bookkeeping techniques were to be employed, by which staff could determine, upon request, the amount of individual resident funds.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for residents who ate their meals in the B Wing dining room to ensure resident dining did not resemble an instutional experience. Findings: On 1/13/25 at 12:50 PM, during meal observation in the B wing day/dining room, seven residents were observed seated at three tables that had been prepared for lunch. There were no tablecloths or centerpieces on any of the tables, the walls of the room were bare, with no pictures, or posters. There was no music, leaving the room very quiet. Each resident had a serving tray on the table in front of them which contained their lunch. The plates, cups, bowls and eating utensils were not removed from the trays and placed on the table. When the trays were served, the staff left the room. On 1/14/25 at 12:45 PM, the lunch meal observation revealed the same observations. The dining area was lacking decorations, tablecloths, centerpieces, and/or music. The residents had their serving tray in front of them with the utensils and dishware on top. Once the trays were served the staff left the room. On 1/14/25 at 1:30 PM, Certified Nursing Assistant (CNA) J was in the dining room collecting trays. She acknowledged the residents' meals arrived on the floor in a cart full of trays, and each resident was served their meal on a tray in the dining room. She acknowledged there were no tablecloths on the table and the room was usually silent. On 1/16/25 at 8:56 AM, the Administrator observed the B wing dining room and acknowledged it was not home-like and needed some work. The Policy and Procedure, Guideline: Resident Rights-Safe/Clean/Comfortable Homelike Environment with effective date 4/02/22, read, It is the policy of this facility to provide the residents with a safe, clean, comfortable home-like environment in such a way that it acknowledges and respects the residents' rights.

Based on observation, interview, and record review, the facility failed to ensure waste was disposed of in a sanitary manner. Findings: During Kitchen observation on Monday 1/13/25 at 9:45 AM, an uncovered dumpster was observed located at the back of the facility. The dumpster was designed to have two parallel lids to cover the container. One lid was noted to be missing, and the other lid was warped and half torn from the hinge preventing it from sealing the dumpster. Two adult briefs were observed on the ground in front of the dumpster. The Certified Dietary Manager (CDM) acknowledged the container should have lids that closed to prevent pests and rodents from getting inside the container. She stated the maintenance department was responsible for maintaining the dumpsters. On 1/13/25 at 9:48 AM, the Maintenance Director acknowledged the dumpster did not have lids that closed and fit securely which could attract rodents and insects. He stated the dumpster had been in this condition for about 2 months. He explained the regional maintenance consultant was aware the dumpster needed to be replaced. On 1/13/25 at 09:54 AM, the Administrator stated he had not been informed the dumpster was in disrepair and needed to be replaced. He stated he would call the garbage collection company to have it replaced. On 1/14/25 at 10:20 AM, the broken dumpster was observed with garbage bags and boxes inside. The garbage bags contained food items, drink cans, plastic utensils, paper products and adult briefs. One bag was noted to be torn open. On 1/16/25 at 11:22 AM, the Administrator verified the facility continued to use the dumpster despite the missing and warped lids as they did not have anywhere else to dispose of the refuse. He stated a new dumpster was scheduled for delivered next week but the facility would have to use the dumpster until then. The Food and Drug Administration's 2017 Food Code referred to the use of outside receptacles for waste in chapter 5-501.15(A). Receptacles and waste handling units for refuse, recyclables and returnables used with materials containing food residue and use outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's policy and procedure for Quality Assurance and Performance Improvement revised 3/10/23 revealed the QAPI program included comprehensive data-driven activities that focused on indicators of the outcomes of care and quality of life. The policy indicated the QAPI program took a systematic, interdisciplinary, comprehensive and data-driven approach to maintain and improve safety and quality. The facility had deficiency cited at F584, F585, F694 and F814 during the previous recertification survey conducted 5/15/23 through 5/19/23. During the current survey, the facility was found to be in noncompliance with F584, F585, F694 and F814. As a result of the repeat deficiencies, it was identified there was insufficient auditing and oversight to correct the deficiencies. On 1/17/25 at 3:54 PM, the Administrator stated the QAPI committee met monthly and included staff from various departments. He explained the committee reviewed and discussed the previous month's data gathered by departments. The committee determined what Performance Improvement Plans (PIPs) to put in place to address the identified areas. The Administrator clarified audits were a part of PIP monitoring and were brought to QAPI to evaluate the effectives of the plan. He explained PIPs continued to be addressed until the committee determined the facility had reached a level of substantial compliance. The Administrator verified PIPs were developed and implemented based on survey outcomes. He explained the goal of QAPI activities was to make and sustain improvements in identified areas. The Administrator acknowledged repeat citations were identified during the current survey. He stated there was no excuse and acknowledged there was obvious system breakdown which needed to be addressed.

Based on observation, interview, and record review, the facility failed to ensure correct signage was posted for Enhance Barrier Precaution (EBP), failed to ensure Personal Protective equipment (PPE) was readily available for residents on EBP, and failed to ensure proper infection control measures were practiced, by failing to store residents' equipment in a sanitary manner on 1 of 2 Wings, (A wing). Findings: On 1/14/25 at 9:23 AM, observation showed signage on resident #5's room door for contact Isolation, a container with the appropriate PPE was not noted. Certified Nursing Assistant (CNA) D was sitting in the resident's room, and stated the contact isolation was for resident #5 due to wounds and explained she was providing one-on-one observation to the resident for safety. The CNA stated that gloves were in the room, but no other PPE was in place. On 1/14/25 at 9:27 AM, Licensed Practical Nurse (LPN) A stated resident #5 was on contact isolation due to a wound. On 1/14/25 at 9:30 AM, the Infection Preventionist (IP) who explained she was also the Assistant Director of Nursing. She stated resident #5 was on EBP due to a wound. The signage posted on the resident's door was observed with the IP. She acknowledged the signage was incorrect, and should have been for EBP, not contact isolation, and acknowledged that the appropriate PPE was not in place. The IP stated EBP was initiated for residents with wounds, gastrostomy tubes (GT), and indwelling catheters. However, resident #31 was currently receiving GT feed, and had no signage in place regarding EBP, and PPE was not readily available. This was acknowledged by the IP. She verbalized that a total of thirty (30) residents were currently on EBP but was unable to say if signage was posted for them. She shared that prior to 1/01/25 signage was posted, and caddies with PPE were outside of the resident doors in the hallways, but the caddies were removed from the hallways due to pillage'. The IP stated PPE were available in the CNA's supply room at the nurses' station. On 1/16/25 at 8:52 AM, CNA B stated that when providing care for residents on EBP, she had to retrieve PPE from the CNA supply room by the nurses' station, prior to going into the resident's room. She said it was a lengthy process. On 1/16/25 at 9:00 AM, Licensed Practical Nurse (LPN) E stated signage for EBP was posted on the walls in the resident's room, and PPE would be in a container at the resident's door. LPN E stated she had some residents on EBP, and signage was posted on the wall in the resident's room, but PPE was not available at the doors, or in the residents' rooms. The LPN stated if she had to do catheter care she would need PPE and would have to go to the CNAs supply room at the nurses' station instead of having it readily available at the resident's room. On 1/16/25 at 9:29 AM, the IP stated that a Quality Assurance and Performance Improvement (QAPI) meeting was held on 1/15/25 for implementing that EBP signs would be placed above the residents' bed in a sleeve. PPE would be made available in the supply room at the nurses' station, and she considered that as being readily available. She shared that prior to the QAPI, Transmission Based Precaution signage was posted on the residents' doors, and caddies with the appropriate PPE were outside the rooms. However, since 1/01/25, the caddies were removed from the hallways, gloves were available in each room, and gowns and other PPE had to be retrieved from the supply closet at the nurses' station. The policy Enhanced Barrier Precautions with effective date of 4/01/24, and revision date of 4/03/24 read, Make gown and gloves available inside of the resident's room .Signage indicating enhanced barrier precautions to be placed inside of resident room. PPE to be kept inside resident room and easily accessible for use. 2. On 1/13/25 at 10:48 AM, and on 1/16/25 at 1:20 PM, observations showed two basins on the floor in the bathroom of room #A-17. The basins were not labeled with the individual resident's name and were not stored in a plastic bag. On 1/16/25 at 1:23 PM, Registered Nurse (RN) F stated that in a perfect world resident's equipment/ basin should be labeled, placed in a plastic bag, and stored in the resident's closet, not stored on the floor. On 1/16/25 at 1:25 PM, an observation of the basins on the bathroom floor was conducted with the IP. She acknowledged the findings, and stated for proper infection control practices, the basins should not be stored on the floor, they should be labeled and placed in the individual residents' closet/drawer to prevent cross contamination. On 1/16/25 at 1:38 PM, CNA M stated bed pans, and basins for residents should be placed in a plastic bag, labeled, and stored in the resident's closet or empty drawer. The facility's policy Nursing-Infection Control Prevention and Control Program with effective date 2/21/23 did not address storage of resident equipment.

Based on observation, interview, and record review, the facility failed to ensure that dignity was maintained for 2 of 2 residents reviewed for dining, of a total sample of 59 residents, (#13, and #88). Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, stroke, history of traumatic brain injury, and history of falls. The resident's Significant Change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/23/24 revealed the resident's cognition was severely impaired. The assessment noted she was dependent for all Activities of Daily Living (ADLs). The assessment noted the resident did not have any documented behaviors during the lookback period. On 1/13/25 at approximately 12:45 PM, the resident was observed eating lunch in the B wing dining room. She used a built-up spoon to assist with her meal. When she began to eat her dessert, instead of using the spoon she picked up the bowl of pudding and held it in both hands and licked the pudding out of the bowl. She also had a frozen treat cup and held it in both hands and licked the ice cream until it was gone. On 1/16/25 at 1:50 PM, the resident was observed eating her frozen treat cup and then pudding by holding the container and licking the food out of it. Further observation revealed the built-up spoon was too big to fit in the dessert cups she was given. No staff were present in the dining room at that time to observe resident #13 licking the food out of the container. 2. Resident #88 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture, dementia, and need for assistance with personal care. The resident's Quarterly MDS assessment with ARD of 12/18/24 revealed the resident's cognition was severely impaired. On 1/13/25 at approximately 12:45 PM, the resident was sitting at a table in the B wing dining room with another resident who was eating her lunch. Resident #88 sat at the table watching resident #13 eat her lunch for 45 minutes before staff served her lunch. On 1/13/25 at 1:05 PM, Certified Nursing Assistant (CNA) G took a box of wipes to resident #88 and told her to wipe her mouth and hands. She was informed that resident #88 had not received her lunch yet. She stated she thought the resident had finished eating and said she would go to the kitchen and get her a tray. There were no staff in the dining area while the residents were eating. On 1/13/25 at 1:15 PM, CNA J served resident #88's lunch tray she stated the kitchen had run out of food. On 1/15/25 at 1:40 PM, the Certified Dietary Manager stated on Monday they had to cook a 2nd portion of meals and were having trouble with the oven. She said she was not sure if the intern expressed to the staff that the trays would be late. On 1/16/24 at 3:30 PM, the Director Of Nursing (DON) stated her expectation was for staff to observe residents in the B Wing dining area while they were dining. She acknowledged resident #13 should not have to lick her food from the bowl and should have utensils to accommodate the food being eaten. The DON also acknowledged that residents seated at a table should receive their meals at approximately the same time.

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 residents were evaluated for safe self-administration of medications and failed to obtain a physician order for self-administration of medication for 2 of 9 residents reviewed for choices, of a total sample of 59 residents, (#37, #95). Findings: 1. Resident # 37, a [AGE] year-old female was admitted to the facility initially on 11/18/19, with her most recent readmission on 4/24/23. Her diagnoses included diabetes type II, generalized muscle weakness, hypertension, chronic obstructive pulmonary disease, and age-related osteoporosis. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview For Mental Status (BIMS) score was 15/15 indicating the resident's cognition was intact. On 1/13/25 at 11:44 AM, resident #37 was lying in bed in the supine position. A bottle of nasal spray was noted on the resident's tray table. On 1/15/25 at 9:57 AM, the resident was sitting up in bed, and a bottle of nasal spray was on her tray table. Resident #37 stated the nurses were aware she had the nasal spray, and she self-administered the nasal spray. She said she was tested and passed the test to be able to self-administer the nasal spray. Clinical record review revealed no assessment for self-administration of medications, and a physician's order for the nasal spray, or for self-administration of the spray could not be identified. On 1/15/25 at 10:41 AM, Licensed Practical Nurse (LPN) A explained that if a resident would like to self-administer medication, the resident had to be assessed, and a physician's order for self-administration of the medication would be obtained. On 1/15/25 at 11:06 AM, observation of the nasal spray was conducted with LPN A. She acknowledged that a bottle of nasal spray was observed on the resident's tray table. The resident reiterated that nurses knew she had the nasal spray, and she was tested to be competent. Resident #37 said sometimes her nostrils got clogged up, and she had to use the nasal spray, otherwise she got very anxious. LPN A said the nasal spray should be kept on the medication cart. Review of the physician's orders conducted with LPN A revealed no orders for the nasal spray, or for self-administration of the medication. The findings were acknowledged by the LPN. 2. Resident #95, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included fracture of the right femur, dementia, and essential hypertension. Review of the resident's Medicare-5-day MDS dated [DATE], revealed the resident's cognition was intact, with a BIMS score of 13 of 15. On 1/13/25 at 10:57 AM, resident # 95 was observed sitting on the side of her bed, with the top drawer of her bedside table open. In the drawer a bottle of Vitamin B-12, and a pharmacy container labeled Rosuvastatin was noted. The resident said she gave herself the Vitamin B-12, and did not consider it a medication. She said she was not sure if the nurses documented or knew about the Vitamin B-12. Vitamin B-12 (cobalamin) plays an essential role in red blood cell formation, cell metabolism, nerve function and the production of DNA, (retrieved on 2/03/2025 from mayoclinic.org). Rosuvastatin (Crestor) is commonly used to lower bad cholesterol levels . and fats (triglycerides) in the blood. It also increases good cholesterol levels (HDL), (retrieved on 2/03/2025 from webmd.com). In a review of the resident's clinical records, an order for self-administration of Vitamin B-12, and an assessment for self-administration of medication could not be identified. On 1/15/25 at 10:41 AM, LPN A stated Vitamin B-12 was an over-the-counter medication that was provided on the medication cart, and any medications taken by the resident should have a physician's order to prevent drug interaction with other medications. The LPN said nurses needed to know what medications a resident took, and the medications should be documented. On 1/15/25 at 11:17 AM, LPN A reviewed the resident's clinical records, and shared that a physician's order for vitamin B-12, nor an order for the resident to self-administer the medication could not be found. On 1/15/25 at 11:23 AM, an observation conducted in the resident's room with LPN A revealed two bottles of vitamin B-12, 1000 microgram (mcg), and an empty pharmacy container labeled for Rosuvastatin in the top drawer of the resident's bedside table. Resident #95 stated she took the Vitamin B-12 every day. On 1/15/25 at 11:24 AM, LPN A notified the Director of Nursing (DON) of the nasal spray retrieved from resident #37's room, the two bottles of Vitamin B-12, and the empty pharmacy container labeled for Rosuvastatin retrieved from resident #95's room. The DON stated that for residents to self-administer medications, the resident(s) had to have an assessment for self-administration of medications, and a physician's order had to be obtained. She stated if the medications were to be stored at bedside, a lock box should be in place to secure the medications. The DON acknowledged that resident #37 and resident #95 did not have a physician's order for self-administration of the nasal spray, or Vitamin B- 12, and an assessment for self-administration was not conducted for the residents as required. The facility's policy Nursing-Self Administration Medication Program with an effective date of 4/01/22 read, If a resident requests to self -administer drugs, it is the responsibility of the IDT (Interdisciplinary Team) to determine that it is safe for the resident to self-administer drugs, before the resident may exercise that right .The nurse or designee should complete a Self-Administration of Medication Evaluation and report the findings to the Unit Manager or designee .Once the resident has been deemed safe by the IDT an order should be obtained from the resident's physician . listing the medication(s) that may be self-administered.

Based on observation, interview, and record review the facility failed to ensure the privacy, and confidentiality of resident records was maintained for 1 resident, of a total sample of 59 residents, (#519). Findings: On 1/16/25 at 10:20 AM, the computer on medication cart #1 located to the left of the nurses' station on the A Wing was noted with the screen open, facing the hallway. Pertinent information regarding resident #519 was visible to other staff, residents, and any visitors walking by the medication cart. On 1/16/25 at 10:24 AM, Registered Nurse (RN) F was standing at medication cart #1. She verbalized that she had previously locked her computer screen when she walked away from the medication cart. On 1/16/25 at 10:29 AM, the Assistant Director of Nursing (ADON) confirmed the computer screen on medication cart #1 was locked by RN F. The ADON stated she logged on to the computer at medication cart #1 to ascertain the correct spelling of resident #519's name and forgot to lock the screen when she walked away. She acknowledged that leaving the computer screen open was a Health Insurance Portability and Accountability Act (HIPAA) violation. The policy Health Information Privacy And Accountability Act with effective date of 4/01/22, and revision date of 2/21/23 read, The Center shall protect the privacy of our residents .as related to their personal health information and maintain compliance with HIPAA laws in order to protect the privacy of health care information and privacy of the resident . Staff should lock/log off computers or tablets when not in use.

Based on interview, and record review, the facility failed to follow the grievance process to make a prompt effort to resolve the grievance and keep the resident apprised of the progress toward resolution for 1 of 5 residents reviewed for personal property, of a total sample of 59 residents, (#56). Findings: Review of resident #56's medical record revealed she was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, type 2 diabetes, and osteoarthritis. Review of the Minimum Data Set significant change in status assessment with Assessment Reference Date of 11/12/24 revealed resident #56 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. On 1/13/25 at 1:42 PM, resident #56 shared she lost her cell phone in her previous room, a few weeks ago. She explained she reported it to staff, they searched for it, but it was not found, and the facility did not replace it. She indicated she had to buy a new phone. She recalled she had to borrow her roommate's cell phone to contact her cell phone company to report it lost. She mentioned her daughter lived in England and she had not spoken to her in a month because of her missing phone. She recounted she could not speak with her daughter on Christmas or on her daughter's birthday at the beginning of January. She stated she reported the phone lost but it was hard to get someone from the facility for a follow-up discussion. Later, on 1/15/25 at 10:19 AM, resident #56 stated she should not have to pay the almost $80.00 she spent on the new phone for which she indicated she could hardly afford. She mentioned she had been without a phone for almost a month and both the charger and phone disappeared. She could not recall the staff she informed about her missing phone but recalled her assigned Certified Nursing Assistant (CNA) along with several CNAs and her assigned nurse at the time searched her room for the phone but did not locate it. She said, All they said was they could not find it. She stated when she spoke with the Social Services Director requesting a room change, she told the Social Services Director about her missing phone and she made sure everyone knew about the missing phone. Review of the medical record census revealed resident #56 was moved to her current room on 1/01/25. Review of the Grievance Log from December 2023 to January 13th, 2025 did not reveal any grievances for resident #56. Review of resident #56's Inventory of Personal Effects dated 10/17/24 included 1 cell phone, and 1 charger. On 1/16/25 at 2:05 PM, the Social Services Director confirmed she was the Grievance Officer. She explained Grievance forms were located on both nursing units, and anyone could complete the form, including residents, families, or any staff. She indicated grievances were discussed during management morning meetings and given to the appropriate department for investigation and resolution. Later at 3:13 PM, the Social Services Director indicated resident #56 had come to her office today about her missing phone. The Social Services Director stated she would write up a grievance form tomorrow when resident #56 provided the copy of the receipt showing purchase of her new phone. She indicated the resident had to return to her room so she could not complete it at that time. The Social Services Director explained resident #56 told her she had informed the CNAs about the missing phone, and she responded that the CNAs sometimes forgot to tell her because they got busy. She indicated she would request a refund because she looked on the inventory sheet and confirmed resident #56 had a cell phone and the charging cable. She explained the expectation was for staff to write up a grievance form or personally let her know when residents reported missing items or shared any concerns. She indicated she or her assistant attended the care plan meetings. The Social Services Assistant, who was present, showed a notebook where she had taken notes during care plan meetings. The Assistant mentioned she had an entry in her notebook during the last care plan meeting on 12/03/24 that resident #56 requested bed rails and shared a concern about call light response on the 3:00 PM to 11:00 PM shift. She indicated resident #56 did not mention the missing phone at that time. When asked why a grievance form was not completed for those concerns shared on 12/03/24 during the care plan meeting, she answered she was hoping nursing would document it. She looked in resident #56's progress notes and confirmed she did not see any notes from nursing addressing the bed rails request. On 1/17/25 at 10:50 AM, CNA L recalled resident #56's assigned CNA informed the B-Wing Unit Manager (UM) the resident had lost her cell phone. She explained she was not her assigned CNA, but was sitting by the nurses' station and overheard the conversation. She stated this incident happened before resident #56 was transferred to her new room. CNA L stated the UM instructed that CNA to fill out a witness statement, to cover everyone. She confirmed she had assisted on the search for the phone but it was not found. She recalled when resident #56 moved rooms, the CNA who moved her room emptied all of her things and her cell phone was not there. CNA L mentioned resident #56 told her since losing her cell phone, she could not communicate with her daughter, and she was ordering a new one. On 1/17/25 at 11:03 AM, the B-Wing UM stated she learned resident #56 lost her phone sometime in December when a CNA brought it to her attention at the nurses' station. She mentioned that it occurred over a weekend and the CNA had searched her room trying to find it. The B-Wing UM indicated she also tried looking for the cell phone herself. She confirmed she asked the CNA to write a statement and brought it to the Social Services Director, then it was discussed during the morning meeting. She stated she did not keep a copy of the statement she gave to the SSD and confirmed she collected a witness statement from the CNA who informed her and searched for the phone. The UM said, Apparently I should have gotten a different form, it should had been a grievance form, but the Social Services Director received the witness statement. On 1/17/25 at 11:13 AM, the Social Services Director stated the UM told her she had a witness statement, and she instructed the UM to complete a grievance form. She remembered during the morning meeting the UM said something about the phone, and she told her to write it up on a grievance form. The Social Services Director stated since she did not receive the grievance form, she figured they had found the phone. Review of the facility's policy, Social Services - Grievance Process revised on 2/21/23 revealed the Grievance Coordinator was responsible for overseeing and implementing the grievance procedure; receiving and tracking grievances through to their conclusion; and leading any necessary investigations by the facility. The document included grievances could be voiced as verbal or written complaints to a staff member or the Grievance Coordinator. The procedure listed grievances would be documented on the facility Grievance Report, listed on the facility's Grievance Tracking Log, investigated accordingly, and the facility should make prompt efforts to resolve the grievances.

Based on observation, interview, and record review, the facility failed to provide nail care and removal of chin hair for 3 of 3 residents observed for Activities of Daily Living (ADL) care of a total sample of 59 residents, (#13, #87, and #88). Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses to include dementia, stroke, history of traumatic brain injury, history of falls. The resident's Significant Change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/23/24 revealed the resident's cognition was severely impaired. The assessment noted she was dependent on staff for all ADLs. The assessment noted the resident did not have any behaviors toward herself or others. On 1/13/25 at approximately 12:45 PM, the resident was eating lunch in the B wing dining room, and was seen picking up food with her hands. Her nails were long and had a dark substance under each nail. Resident #13 had an ADL care plan dated 10/03/24, which directed staff to, Check nail length and trim and clean on bath day and as necessary. On 1/15/25 at 11:12 AM, Registered Nurse (RN) I acknowledged resident #13 had long, dirty nails on both hands and stated the Certified Nursing Assistants (CNAs) knew they were supposed to clean and trim the resident's nails on shower days and as needed. She stated they should have been looking at the resident's nails every day. 2. Resident #88 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture, dementia, and need for assistance with personal care. The resident's Quarterly MDS assessment with ARD of 12/18/24 revealed the resident's cognition was severely impaired. The assessment noted she required substantial maximum assistance for personal hygiene (which included shaving). The assessment noted the resident did not have any behaviors toward herself or others. On 1/13/25 at approximately 12:45 PM, the resident was sitting at a table in the B wing dining room for lunch. She had long facial hair on her chin. The resident was observed several times over the next two days with the facial hair present on her chin. On 1/15/25 at 11:09 AM, RN I acknowledged the hair on the resident's chin and stated the CNAs know they were supposed to remove facial hair from the female residents' faces unless told not to do so. She stated the hair should have been removed on the resident's shower day or anytime it was noticed. She also stated the resident did not refuse care. On 1/16/25 the Director of Nursing (DON) stated her expectation was for the CNA to ensure the residents' nails were kept clean and trimmed. She also stated the female residents should not have facial hair and it should be removed on shower days and when seen. She said the CNAs had all received education regarding ADL care for residents. The Activities of Daily Living policy implemented on 4/01/22, revealed, The facility shall provide care and services for the following activities of daily living as needed based on the individual care plan of each resident. Hygiene- bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 32131 3. Resident # 87, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included heart failure, need for assistance with personal care, atrial fibrillation, cardiac pacemaker, anxiety disorder, and psychotic disorder. Review of the resident's significant change MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 11 of 15. The assessment revealed the resident had functional limitation in range of motion on both sides of his lower extremities and was dependent on the assistance of one staff for toileting hygiene, and personal hygiene. A care plan for ADL self-care performance deficit related to activity intolerance was initiated on 6/14/24, with revision on 7/02/24. An intervention initiated on 6/17/24 was to, check nail length and trim and clean on bath days and as necessary. Observations on 1/13/25 at 10:30 AM, 1/14/25 at 10:33 AM, and on 1/15/25 at 9:05 AM, showed resident #87's fingernails on his bilateral hands were untrimmed, with a dark substance underneath the fingernails of the resident's left hand. Resident #87 stated his fingernails were trimmed approximately one month ago. On 1/15/25 at 9:17 AM, CNA C stated nail care was provided for residents on shower days, and during ADL care. The CNA acknowledged that resident #87 was included in her assignment, and verbalized he was assigned to her also on 1/13/25, but she did not provide nail care. The resident's fingernails were observed with the CNA. She acknowledged that the resident's fingernails on bilateral hands were untrimmed, with a dark substance underneath the nails. The CNA stated nail care should have been provided for the resident. On 1/15/25 at 9:57 AM, the A Wing Unit Manager (UM) stated nail care was provided by the CNAs, who should clean and file the residents' nails on shower days and as needed. The observations of the resident's fingernails on 1/13/25, 1/14/25, and 1/15/25 were discussed with the UM, who stated she would address the resident's nail care. The facility's policy Nursing-Activities of Daily Living with effective date of 04/01/22 read, A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to provide an on-going program of activities to meet the needs and preferences for 3 of 4 residents reviewed for activities, of a total sample of 59 residents, (#13, #40, and #88). Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses to include dementia, stroke, history of traumatic brain injury, history of falls. The resident's Significant Change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/23/24 revealed the resident's cognition was severely impaired. The assessment noted she was dependent on staff for all Activities of Daily Living (ADLs). The assessment noted the resident did not have any behaviors toward themselves or others. Section F (Activities) indicated the following to be very important to the resident: music that she liked, going outside when the weather is good, activities that she enjoys with a group, reading magazines, newspapers and hearing the news. The resident's care plan dated 11/07/18 and revised on 8/24/21 indicated the resident was dependent on staff for social needs. On 1/13/24 at 10:50 AM, resident #13 was observed in the day room sitting in her wheelchair looking out the window. On 1/14/25 at 12:55 PM, the resident was observed sitting in the day room at a table, with no activities. On 1/15/25 at 12:45 PM, the resident was observed in the day room sitting at a table with the TV on, but the resident was not watching television. On 1/15/25 at 4:15 PM, observed the resident in the day room sitting at a table with no activities available. On 1/16/25 at 8:30 AM, the resident was observed lying in bed with her eyes open. She stated she ate her breakfast. There was no television on in her room. On 1/16/25 at 11:00 AM, the resident was observed lying in bed with no television on and no radio seen or heard in the room. On 1/16/25 at 3:00 PM, the resident was observed lying in bed, staring at the wall. Review of the resident's record revealed no notes from Activity staff that indicated resident #13 was offered activities and declined. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses including adjustment disorder, respiratory failure, contractures, and abnormal posture. The resident's Quarterly MDS assessment with ARD of 11/19/24 revealed the resident's cognition was moderately impaired. The assessment noted the resident was dependent on staff for all ADL activities. Section F (Activities) indicated reading books, magazines, newspapers; listening to music he liked; keeping up with the news; doing things with a group, and participating in his favorite activities to be somewhat important to the resident. Review of the resident's care plan dated 10/26/23, indicated when the resident chose not to participate in organized activities, the resident preferred to watch television or go outside for social and sensory stimulation. On 1/13/25 at 10:30 AM, and 2:00 PM, the resident was lying in bed with his eyes closed and the television was off. On 1/14/25 at 8:35 AM, and 1:39 PM, the resident was lying in bed with his eyes closed and the television was off. On 1/15/25 at 8:43 AM, and 11:40 AM, the resident was lying in bed with his eyes closed and the television was off. On 1/16/25 at 8:32 AM, the resident was lying in bed with his eyes open and the television was off. The resident asked staff for his breakfast. Review of the resident's medical record revealed no notes from Activity Staff which indicated the resident was offered activities and declined. 3. Resident #88 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture, dementia, and need for assistance with personal care. The resident's Quarterly MDS assessment with ARD of 12/18/24 revealed the resident's cognition was severely impaired. The assessment noted the resident did not have any behaviors toward themselves or others. Section F (Activities) indicated doing favorite activities, going outside, doing things with groups of people, being around pets, and listening to music was important to her. The residents' Activity Care Plan dated 10/01/24, indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. On 1/13/25 at 10:50 AM, resident #88 was observed in the day room sitting at a table with her hands folded, with no activities observed, On 1/14/25 at 8:40 AM, observed the resident in the day room sitting at a table, with no activities noted. On 1/14/25 at 11:15 AM, observed the resident was sitting in the day room with her head on the table. No activity was seen. On 1/14/25 at 1:49 PM, the resident was observed sitting in the day room rocking back and forth in her wheelchair, no activities were observed. On 1/15/25 at 11:30 AM, observed the resident sitting in the day room in her wheel chair at a table. No activity. On 1/15/25 at 2:10 PM, the resident was observed in the day room looking around the room with no activity. On 1/16/25 at 8:30 AM, the resident was observed lying in bed in her room. She was staring at the curtains, with no television or radio playing. On 1/16/25 at 11:30 AM, the resident was observed lying in bed with her eyes closed. On 1/16/25 at 2:10 PM, the resident was observed lying in bed with her eyes open. There was no activity occurring in the room, including the television or radio. Review of the resident's record revealed no notes from Activity Staff that indicated the resident was offered activities and declined. On 1/17/25 at 2:26 PM, the Activity Director stated all the activities were done in the main dining room. He stated if the residents self-isolated they usually did not come to activities. When asked about the residents who were cognitively impaired, he said, the families will do things with them, or they don't want to do anything. He said his department did room rounds for the residents who did not get out of bed. He said he had three assistants, and they did 1:1 activities for about 30 residents a month. He stated they usually did their documentation at the end of month. The Activity Director was asked for written documentation of the 1:1 interactions with those residents and he provided a handwritten paper he said was completed during a 1:1 activity. The paper read: Bedrock Activities One-On-One. The paper was a questionnaire with a series of questions including: resident name, room number, how did the resident feel about the care they received, how was the meals/food, was there anything they would like to report/ any issues, brief summary of the conversation during the one-on-one. The paper did not indicate any actual activity being provided to the residents. Review of the records did not provide any documentation of activities provided to the residents. The Community Life Program Policy, dated 4/01/22 read: The Community Life Department as part of the Multidisciplinary care team, provides comprehensive leisure programming geared to the enhancement of the social, emotional, intellectual, physical, creative and spiritual well-being of our resident population. The Community Life Program should be made available to all members of the resident population through service delivery in different areas: large group programs, small groups, special interest groups, special events, outside community trips, and individual intervention.

Based on interview, and record review, the facility failed to ensure a resident received proper and timely treatment to maintain his vision for 1 of 3 residents reviewed for vision and hearing, of a total sample of 59 residents, (#32). Findings: Review of resident #32's medical record revealed he was readmitted to the facility on [DATE]. His diagnoses included type 2 diabetes, absence of right and left leg above the knee, and glaucoma. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of [DATE] revealed resident #32 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. On [DATE] at 11:45 AM, resident #32 stated he was told by his optometrist he had bleeding behind his left eye and needed to see a specialist. He explained she wrote it on her visit note last year but the facility did not follow up timely. He indicated when he finally saw the specialist, a treatment of injections was started but he was told the bleeding might not stop because he should have been seen sooner. Review of resident #32's optometrist Eye Exam Report dated [DATE] read, Set up external retinal consult in ,d+[DATE] weeks. Review of resident #32's optometrist Eye Exam Report dated [DATE] read, Still haven't had OMD (Ophthalmologist) consult yet. Rewrite TO (telephone order) to set up external retinal consult ,d+[DATE] weeks . Will discuss with Social Service. Review of resident #32's optometrist Eye Exam Report dated [DATE] read, Still haven't had OMD consult yet. Rewrite TO for the 3rd time to set up external retinal consult in ,d+[DATE] weeks . Will email and discuss with social service and DON (Director of Nursing). Review of resident #32's physician orders revealed the following orders: Set up appointment with retina specialist for diabetic retinopathy was entered on [DATE]. The order was discontinued on [DATE] and entered as prescriber written. Set up appointment with retina specialist for diabetic retinopathy was entered on [DATE]. The order was entered as verbal order. Consult external Ophthalmology for diabetic retinopathy and glaucoma eval (evaluation). Please schedule appointment and arrange transportation. The order was entered on [DATE]. Review of resident #32's care plan revised on [DATE] revealed a focus for impaired visual function related to risks for diabetic retinopathy, retinal hemorrhage, severe diabetic retinopathy with macular edema, and glaucoma. The interventions included, Appointment for eye exam as ordered initiated on [DATE], Arrange consultation with eye care practitioner as required and Consult Retina specialist as ordered initiated on [DATE]. Another intervention initiated on [DATE] read, Ophthalmologist/retinal consult ASAP (as soon as possible) as ordered. On [DATE] at 7:46 AM, the Social Services Director stated she did not find any email messages from the Ophthalmologist except for the notes already uploaded into his medical record. On [DATE] at 9:12 AM, the DON stated she did not recall any details of resident #32's eye consultation. On [DATE] at 9:46 AM, the transportation and scheduler for residents' appointments explained she was responsible for setting up outside specialty physician's appointments. She explained the process included the clinical team entered the order and she pulled a daily report to identify and schedule the appointment. She indicated after the appointment was set up, she entered the information on a calendar she placed in a scheduling binder located on each nursing unit and shared a digital calendar among the clinical team so they could see residents' upcoming appointments. She explained for the order to show up in her report it must be entered as a verbal or telephone order. She indicated any order entered as prescriber written did not come across on her consults report. She stated she had communicated this to the clinical team more than once. She verified her report dated [DATE] and stated resident #32's order for the retina specialist was not included. She indicated that order was entered on [DATE] as prescriber written so it did not show in the report. She explained the second order entered on [DATE] was entered as verbal with an expiration of 3 days and the order expired on [DATE] at 8:59 AM. She stated she pulled the report on [DATE] at 3:25 PM, and the order was not there, even though she used a range of dates from [DATE] to [DATE]. She indicated the third order was entered by the primary physician and confirmed by a nurse on [DATE] as prescriber entered so it did not show on her report. She stated when she ran her report on [DATE], she saw the consult order, and she worked on it. She indicated she made the specialist appointment and set up transportation for [DATE] and resident #32 went by himself. She explained she communicated to the clinical team to let all the providers who entered orders know that a telephone or verbal order was needed or the clinical team needed to ensure it was entered correctly so she did not miss setting those appointments as ordered. Review of the Progress Notes from the Ophthalmologist consult on [DATE] revealed, significant evidence of advanced diabetic retinopathy on today's exam. The patient was explained that diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness around the world. Frequent examinations are important . Review of the Facility Assessment updated on [DATE] revealed they work with the current clinical professionals to ensure they retained medical practitioners who were adequately trained and knowledgeable in the care of residents. The document read, The Medical Director and Director of Nurses works closely to ensure that care and services rendered legally and appropriately.

Based on interview and record review, the facility's nursing staff neglected to provide post-fall care and services including comprehensive physical and neurological assessments, physician notification and frequent monitoring according to accepted standards of practice, for 1 of 2 residents reviewed for falls with major injury, out of a total sample of 9 residents, (#22). The failure to address resident #22's change in condition delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was likelihood resident #22 could have fallen again or suffered brain injury, coma, or death from an unidentified head injury. On 3/02/22 at 5:00 PM, resident #22 had an unwitnessed fall. He sustained skin tears and abrasions, and complained of left hip pain. The Licensed Practical Nurse (LPN) Unit Manager (UM) assisted the resident back to bed with help from other staff, but neither the assigned nurse nor the UM notified the physician or initiated post-fall protocols to monitor the resident for adverse outcomes. During the overnight shift, the assigned nurse noted resident #22 was lethargic and continued bleeding from a wound on his left arm. The resident had dried blood on his forehead and still reported left hip pain. Resident #22 informed the nurse he fell on the previous shift, but she failed to notify the physician, nursing administration and his family of the incident and her findings. The physician was notified the following day at 7:35 AM, and resident #22 waited approximately four hours for non-emergency transport to the hospital where he was diagnosed with a left hip fracture. Resident #22 required surgical repair of the hip. The facility's failure to provide adequate post fall nursing assessment and ongoing monitoring and care placed all residents who fell at risk for neglect. This failure resulted in Immediate Jeopardy starting on 3/02/22. The Immediate Jeopardy was removed on 4/28/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F580, F607, F684 and F835. Resident #22, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was transferred to the hospital on 3/03/22 and readmitted to the facility on [DATE] with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Discharge - Return Anticipated assessment with assessment reference date of 3/03/22 revealed resident #22 had an unplanned discharge to the hospital. He required supervision for bed mobility, dressing, and toilet use, and was independent with transfers, locomotion, and personal hygiene. The MDS assessment revealed resident #1 had one fall with a major injury, defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. A subdural hematoma most often results from a head injury and occurs when bleeding fills the area around the brain causing compression of brain tissue. This type of injury can lead to death, (retrieved on 5/11/22 from www.medlineplus.gov). Review of resident #22's hospital record revealed a History and Physical Observation dated 3/03/22 at 6:00 PM regarding his chief complaint of a fall. The document read, States he fell immediate pain in his left side and was unable to ambulate. The result of a Computed Tomography (CT) scan of the left hip showed resident #22 had an acute fracture of the left hip with associated soft tissue swelling. In addition, the radiology report described multiple compression fractures of indeterminate age spanning his mid to lower spine and read, Cannot exclude acute fractures. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 3/08/22 revealed resident #22 was hospitalized for a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document listed the resident's skin issues as a left hip surgical incision, right arm abrasion, left shoulder skin tear, and left elbow abrasion. Review of the medical record revealed resident #22 had physician orders for Aspirin 81 milligrams (mg) once daily and [MEDICATION(S)] 75 mg once daily. [MEDICATION(S)] and Aspirin are classified as platelet aggregation inhibitors as they prevent platelets in the blood from adhering to each other to form clots. One of the most commonly reported adverse effects of these drugs is bleeding, including life threatening and fatal bleeding (retrieved on 5/04/22 at www.drugs.com). Resident #22 had a care plan for anti-platelet therapy, initiated on 11/14/21, that directed nursing staff to monitor for, document, and report adverse reactions and signs and symptoms of bleeding including sudden, severe headaches, muscle or joint pain, lethargy, bruising, and sudden changes in mental status or vital signs. A Nursing Progress Note dated 3/03/22 at 5:12 AM read, Upon rounds patient notified me that a fall had occurred yesterday during 2nd shift. The assigned nightshift nurse, Licensed Practical Nurse (LPN) H, noted resident #22 had wounds and abrasions on his upper body and complained of pain in both shoulders and his left hip. LPN H's note indicated she cleansed the resident's abrasions and wounds with normal saline, applied triple antibiotic ointment and covered them with dressings, then notified a Unit Manager (UM). Review of the medical record revealed no nursing documentation on 3/02/22 regarding resident #22's fall during the evening shift. There was no evidence that any nurse notified the physician of the incident and the resident's injuries at the time it occurred. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record did not show neurological checks were initiated to monitor resident #22 for possible bleeding as a result of a head injury sustained in the unwitnessed fall. The medical record did not reflect any additional actions taken by LPN H to ensure resident #22 was thoroughly assessed and that his post-fall care needs were addressed after she observed his injuries and was made aware of the fall. The facility's Incident Completion Checklist: Falls (undated) included detailed directions for nurses of required post-fall protocols. Nurses were expected to obtain the resident's vital signs and document a progress note regarding his/her condition including range of motion and pain. In addition, a Change in Condition form, pain evaluation, skin assessment was to be completed. The document indicated nurses were expected to initiate orders in the electronic medical record for neurological checks for 24 hours after a fall and post-fall documentation every 8-hour shift for three days. The policy and procedure for Abuse, Neglect, Exploitation & Misappropriation revised on 11/28/17 revealed staff were . charged with a continuing obligation to treat residents so they are free from abuse, neglect . The document defined neglect as . the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. The document included examples of neglect such as failure to take precautionary measures to protect the health and safety of a resident, failure to notify the resident's representative of an incident or fall, and failure to report suspected neglect. On 4/26/22 at 1:26 PM, and on 4/27/22 at 9:51 AM, the B Wing UM stated on 3/02/22 she heard a loud noise as she walked in the hallway near resident #22's room. She recalled when she arrived in the room, he was on the floor bleeding and complained of back and hip pain. The B Wing UM stated she and other staff assisted the resident from the floor to his wheelchair and she provided first aid for his left arm skin tear. When asked if she initiated the fall protocols for assessment of neurological status, skin condition and pain level, she said, I don't remember what we did. She validated it was important to monitor the resident closely after unwitnessed falls, especially since he took blood thinner medications. She explained. We worry about them hitting their head because it could cause bleeding in the brain. The B Wing UM stated she was knowledgeable of the post-fall protocols but did not initiate any of the required interventions. She explained resident #22's assigned nurse, LPN L, was on break at the time of the incident, but was expected to initiate the fall protocol and call the physician when she returned to the floor. When asked if LPN L was aware resident #22 fell , the B Wing UM said, I don't recall if I told her the resident fell . I left that evening and did not follow up after that. The B Wing UM stated when she arrived at work the following morning, she discovered LPN L had refused to follow the fall protocols and none of the required assessments, notifications and documentation were done. On 4/26/22 at 1:48 PM, and on 4/27/22 at 2:48 PM, in telephone interviews with LPN H, she stated she received change of shift report from LPN L on 3/02/22 at the start of the 11:00 PM to 7:00 AM shift but was not informed of resident #22's fall. LPN H explained during medication pass rounds she was at the resident's bedside and noted he was lethargic, had blood oozing from underneath a dressing on his left arm and there was dried blood on his forehead, just below hairline, above his left eye. She stated the resident explained he fell the previous evening. LPN H stated she made one attempt to call the attending physician, but he did not answer his phone. When asked what nursing interventions she implemented during her shift, LPN H recalled she either reinforced or replaced the dressing on the area of the resident's arm that was bleeding although she did not have a physician's order for the treatment. She explained she did not initiate neurological checks or conduct a thorough skin evaluation as she was not the nurse involved in the fall and it did not occur on her shift. LPN H stated she handed over resident #22's care to the B Wing UM when she arrived at work the following morning. LPN H stated she was not aware resident #22 hit his head until the B Wing UM shared the information with her that morning. On 4/26/22 at 3:20 PM, the Assistant Director of Clinical Services (ADCS) acknowledged post-fall protocols did not only involve completing paperwork. She stated all nursing staff involved should have addressed the resident's actual and potential injuries. She confirmed nurses should have informed the physician of the unwitnessed fall immediately, and obtained appropriate orders. The ADCS stated her expectation was nurses would conduct neurological evaluations after any unwitnessed fall as a head injury could cause an intracranial bleed. She validated there was no documentation in the resident's medical record to indicate nurses provided the required post-fall care. On 4/27/22 at 12:43 PM, resident #22's fall incident and post-fall care were discussed with the DCS and ADCS. The DCS stated her expectation was the B Wing UM should have assessed resident #22 thoroughly before lifting him from the floor, and then followed the facility's fall protocols to notify the physician and initiate assessments. The ADCS stated all nurses who interacted with resident #22, including the B Wing UM and LPNs H and L, were responsible for ensuring he got the appropriate care. The ADCS stated when she was notified of the resident's fall the following morning, she went to his room. She acknowledged she was the first Registered Nurse, (RN) and member of nursing administration to interact with the resident after his fall. However, when asked if she assessed the resident at that time, the ADCS said, I was in there getting him ready to go out, but I did not do an assessment. Review of the job description for Assistant Director of Clinical Services (ADON) (undated) revealed duties and responsibilities included assist with implementation of policies and procedures and compliance with standards of practice. On 4/28/22 at 11:11 AM, in a telephone interview, LPN J stated she was one of the nurses who worked on the B Wing on 3/02/22 on the night shift. She recalled at some point early in the shift, a Certified Nursing Assistant exited resident #22's room and informed his assigned nurse, LPN H, the resident was in pain. LPN J stated LPN H went to the resident's room and was informed he fell . LPN J confirmed it was accepted nursing practice and facility policy to conduct thorough evaluations, then notify the physician, family member and the DCS if a resident fell . LPN J stated resident #22 did not leave the facility that night. She said, He was not sent out. On 4/28/22 at 11:45 AM, the facility's Medical Director stated he was also resident #22's attending physician. He confirmed his expectation was one of the nurses would have notified him of the resident's fall and injuries. The Medical Director was informed the nightshift nurse, LPN H observed one of resident #22's wounds still bleeding approximately eight hours after he fell . He acknowledged resident #22 experienced a delay in assessment and explained the outcome could have been worse if the resident had suffered adverse effects from bleeding out into his hip or brain. The Medical Director acknowledged resident #22 did not receive necessary post-fall care and services. The Facility assessment dated [DATE] indicated the facility was able to provide services to include general care related to mobility and fall or fall with injury prevention, and person-centered care. The document indicated the facility would prevent neglect. The document listed resources needed to provide competent support and care for residents such as staff who were knowledgeable of identification of change in condition and neglect. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 4/25/22, the facility entered a complaint investigation related to a report regarding a resident who sustained a fall involving injury and pain. The facility failed to provide quality care and services post fall, did not address the resident's change in condition, did not initiate neurological checks, and did not notify the physician/responsible party at the time of the fall. The fall was not communicated during nurse-to-nurse change of shift report between 3-11 and 11-7 nurses nor documented for follow up, which contributed to a delay in treatment putting the resident at risk for further harm. *On 4/27/22, a quality review of residents who sustained a fall with or without injury and/or pain over the last 30 days was completed by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers to ensure post fall care was provided at the time of the fall, the physician/responsible party was notified of the fall, falls were communicated between licensed nurses during shift to shift report, fall protocol was initiated, and fall documentation was completed per policy to ensure quality care was provided and there was not a delay in treatment which would put the resident at further risk for harm or neglect. *As of 4/27/2022 education was provided to current licensed nurses by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers related to the below: Licensed Nurses must follow post fall protocol to ensure quality of care is provided, resident needs are met and to avoid delay in care and possible further harm or neglect: 1. Resident will be evaluated and post-fall care provided 2. Initiate neurological checks as per policy or directed by physician 3. Notify physician and resident representative 4. Re-evaluate fall risk utilizing the post fall evaluation 5. Update care plan and nurse aide Kardex with interventions 6. Initiate post fall documentation every shift for 72 hours 7. Interdisciplinary team to review fall documentation and complete root cause analysis 8. Update plan of care with new interventions as appropriate 9. Review resident weekly Licensed nurses must complete nurse to nurse report each shift to ensure proper follow up of clinical processes to include post-fall protocol and change in condition. Administrative staff to include the Executive Director, Director of Clinical Services, Assistant Director of Nursing, Unit Manager(s) must provide oversight; including after hours to the nursing department to ensure post fall protocol is followed per policy and shift to shift report is given. Nurse Manager, on call must be notified of all falls with or without injury/pain at the time of the fall. On call nurse manger monthly schedule is posted on both nursing units, conference room, break room and at the time clock. Nursing Management on call schedule changes will be indicated on the monthly schedule. If you are unable to reach the on-call nurse manager, call the Administrator immediately. Additional education included the following policies: N-1259 Fall Management and N-1265 Abuse / Neglect / Misappropriation / Exploitation. *On 4/27/22, the Executive Director and the Director of Clinical Services received education from the Regional Director of Clinical Services regarding the above listed elements of F600 are followed including policy and procedures related to Fall Management, falls and failure to provide education for Licensed Nurses related to falls when deficient practice is identified so that residents do not experience a delay in care which could potentially results in further harm or neglect. *On 4/27/22, the B Wing Unit Manager and Director of Clinical Services were suspended by the Executive Director regarding failure to ensure the above listed elements of F600 are followed including policy and procedures related to Fall Management, falls and failure to provide education for Licensed Nurses related to falls when a deficient practice is identified so that residents do not experience a delay in care which could potentially results in further harm or neglect. *On 4/27/22, a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis. * On 4/27/22, an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed. The following team members were in attendance: Executive Director, Regional Director of Clinical Services. The Medical Director agreed and approved the committee recommendations. *The facility currently has a total of 34 Licensed Nurses. 8 Licensed Nurses received education regarding the above-mentioned beginning on 4/27/22. 21 Licensed nurses received education regarding the above mentioned on 4/28/22. The rate of education compliance for current Licensed Nurse staff as of 4/27/22 is: 23.5%. The rate of education compliance for current Licensed Nurse staff as of 4/28/22 is: 85.2%. Education to be completed at 100% by 4/28/2022. As of 4/28/22, any Licensed Nurse who did not receive education related to the above mentioned was notified by ADCS and UM indicating they may not return to work until the education is received. *On 4/27/22, Certified Nursing Assistant education was initiated by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers regarding do not move a resident after a fall and call for a nurse. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 4/28/22, interviews conducted with 19 facility staff representing all shifts including 1 Registered Nurse, 6 LPNs, 10 CNAs and 2 Personal Care Attendants revealed staff received in-services on the above-mentioned topics and were knowledgeable of the facility's policies and procedures regarding falls, changes in condition and communication at change of shift. The sample was expanded to include 2 additional residents who sustained fractures. Observation, interview and/or record reviews revealed no concerns related to assessments, interventions, and notifications for residents #4 and #21.

Based on interview and record review the facility failed to ensure an appropriate discharge process was followed for a facility-initiated discharge, failed to document the discharge location in the resident's medical record, and failed to ensure the required information regarding the discharge was communicated to the receiving health care institution for 1 of 3 residents reviewed for discharge rights, of a total sample of 9 residents, (#1). On 3/02/22 at 5:43 PM, resident #1 was discharged from the facility to the Emergency Department of a hospital over 50 miles away via ridesharing service. There was no communication between the two facilities regarding the reason for the transfer, and resident #1 arrived at the hospital without a medication list or wound care orders for his multiple, complex pressure ulcers. The hospital contacted the facility regarding the discharge being unsafe and inappropriate for hospital admission. Instead of readmitting resident #1, the facility arranged for another ridesharing service to transport him to a homeless shelter that could not accommodate wheelchair-bound persons or meet his care needs. The facility initiated the resident's discharge without timely notification and failed to adequately prepare the resident for discharge or document discussion related to the discharge in the medical record. This failure resulted in Immediate Jeopardy starting on 3/02/22. The Immediate Jeopardy was removed on 4/28/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F623, F624, F745, F835. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note documented by the Advanced Practice Registered Nurse dated 3/01/22 revealed the resident's history included admission to an acute care hospital for infected chronic decubitus (pressure) ulcers to sacral area, he was stabilized, and transferred to the facility for medical management and rehabilitation. Documentation read, multiple chronic decubitus ulcer to sacral area .unstageable with bone present. The resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to his scheduled pain medications, resident #1 requested and received as needed [MEDICATION(S)] 30 mg every four hours regularly for pain levels of 3 to 9. Review of the resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 1/20/22 revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15/15. The assessment indicated the resident required supervision with assist of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. His balance during transitions and walking, moving on/off toilet, surface to surface transfer was not steady, and the resident was only able to stabilize with staff assistance. He had functional limitation in range of motion of his bilateral lower extremities, and had one stage III and two stage IV pressure ulcers, which were present on admission. Wound care notes on 3/02/22 revealed the following pressure ulcers: Stage IV right posterior thigh measuring 5.4 x 5.2 x 1.5 centimeters (cm), Stage 4 left posterior thigh measuring 6.5 x 3.9 x 2.5 cm, and Stage 3 sacrum measuring 4.5 x 3.4 x 0.2 cm. Documentation read, Wounds can be managed at home if daily dressing changes are prescribed by a Home Health Nurse. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was updated on 3/02/22 at 7:50 PM, after the resident was discharged from the facility and read Patient discharging home on 03/02/2022 with all belongings, and no medications. Home Health needed for care. Patient to follow up with primary care provider in 3-5 days. The resident's discharge MDS assessment with ARD of 3/02/22 revealed the resident's discharged status was other, his cognition was intact with a BIMS score of 15/15. The resident was assessed as being independent with his Activities of Daily Living, and had one stage III and two stage IV pressure ulcers that were present on admission. Progress note dated 3/02/22 read, Resident discharged from facility, resident belongings packed and provided with self during transfer Resident transferred into vehicle by staff w/o [without] any incident. Review of the resident's Discharge Plan and Instructions with effective date 1/17/22 indicated the resident was discharged to the hospital on 3/02/22 at 5:43 PM, accompanied by his mother. The document indicated the resident was receiving Home Care Services and receiving wound care services through (name of Home Health Agency). Review of the clinical record indicated the resident's mother lived out of State, and he left the facility unaccompanied. The Discharge Plan and Instructions form conflicted with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Admission/Discharge To/From Report for the period 1/01/22 to 4/06/22 erroneously indicated the resident was discharged to a nursing home. A Nursing Progress note documented by Licensed Practical Nurse (LPN) B dated 3/02/22 at 11:45 PM, indicated nurse management from the hospital in [NAME] contacted the facility regarding resident #1's unexpected arrival at the hospital. Documentation read, .no one was aware of resident being admitted . (name of hospital staff) asked if there was anyone else she could speak with from the facility regarding the matter. I informed her that I would either have the A-wing Unit Manager or the facility Administrator [name] reach back out to her. (Name of hospital staff) stated this needed to happen immediately. I called (Administrator) regarding the issue and provided her with the information provided to me. (Administrator) stated that the resident was discharged home and that he decided to self-check himself into a facility she would handle the situation tomorrow. A Social Services progress note dated 3/04/22 revealed the facility received a call from the hospital Case Manager (CM) and Psychiatric Nurse and informed the resident was not a fit for their care and he would be discharged back to the facility. Transportation was set up for him after verifying that home health services can be provided to him at a homeless shelter upon arrival to the shelter, the [patient] refused to get out and went back to the hospital. (Name of hospital) admitted him to the hospital and set him to fly out on 3/4/2022 back home with his mother On 4/06/22 at 2:33 PM, in a telephone interview with the hospital's Social Worker (SW), she verbalized the facility sent the resident to the hospital with paperwork, that said discharge to hospital, and paid $225.00 for transportation via a ridesharing service. The SW reported she called the facility, spoke to the Administrator, and told her it was not a safe discharge, and the facility should take the resident back. She said the resident had gaping wounds to his buttocks and was in a wheelchair. She stated the facility agreed to take the resident back and arranged for another ride sharing service to retrieve the resident from the hospital. She explained instead of readmitting the resident, the facility took him to a homeless shelter in [NAME]. The homeless shelter sent the resident back to the hospital because he was not an appropriate candidate for the shelter. The SW said everyone at the hospital was dumbfounded at the facility's action, and she had never been more upset with a Nursing Home. On 4/06/22 at 4:11 PM, on 4/07/22 at 10:53 AM, and on 4/26/22 at 11:23 AM, the facility CM explained the process for a resident to be transferred/discharged to another facility included obtaining a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The CM verbalized those procedures were not completed as required for resident #1. She stated the facility was aware the resident was not going to his home when he left the facility. She reported the resident was transported to the hospital via ridesharing service that was arranged by the Administrator. The CM stated she could not say if the drug rehab facility was contacted prior to the resident's discharge, and verbalized she was not involved in the case after the resident left the facility. Review of the resident's clinical record revealed a discharge order for home with HHA services dated 3/02/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The CM acknowledged there was inadequate documentation and noted the facility did not follow protocols and guidelines for the resident's discharge. On 4/07/22 at 10:55 AM, the A Wing LPN Unit Manager (UM) stated at first, the resident wanted to go home and Home Health Agency (HHA) referral was made. She said when the HHA personnel visited the resident at the facility to assess the services he required, the resident decided he wanted to go to a drug rehab facility. The UM recalled the HHA personnel started calling, and looking for different facilities, and found a medical substance abuse facility in [NAME]. The UM reported the facility had no communication with the substance abuse facility but when the HHA personnel spoke to them, they informed they did not take patients as direct admissions, and patients would have to go through the emergency room . The UM said when transferring /discharging a resident to another facility, communication should be done with the receiving facility. She stated she assisted in completing the resident's discharge paperwork and conveyed a nurse-to-nurse report between facilities was not done. On 4/07/22 at 11:59 AM, and on 4/26/22 at 12:39 PM, the Social Services Director (SSD) stated the facility paid for transportation to take resident #1 to the hospital in [NAME], and HHA services would start upon his discharge from the hospital/drug rehab facility. He said the resident was transported from the facility by a ridesharing service to the hospital in [NAME] per the resident's request, and it was not necessary to communicate with the receiving facility if the discharge was done upon the resident's request. He stated he did not communicate with the drug rehab personally, and verbalized the HHA personnel navigated the discussion, and to my knowledge the Medical Director (MD) was not notified. The SSD explained on 3/04/22 a nurse from the hospital called and stated the hospital would discharge the resident and the facility needed to figure out where to put him. He said the resident knew he could not go back home, and the resident has a right to be homeless. The SSD said he contacted the HHA and was informed they provided services at homeless shelters. He reported the facility's Corporate office arranged for the resident to be transported from the hospital to a homeless shelter in [NAME]. On 4/25/22 at 12:49 PM, in a telephone interview, resident #1 stated when he started to complain that his dressings were not being changed, the facility informed him they found a bed at a hospital that would care for his wounds. He said they placed him in an Uber and sent him off to [NAME] with no medications. Resident #1 explained when he arrived at the hospital, he checked in and explained he was discharged from the facility without medications. He verbalized the hospital staff got upset, and asked why the facility sent him as he was supposed to get wound care and physical therapy at the facility. He noted the hospital told him admission was unnecessary, and all they would do was send him to another Skilled Nursing Facility. The resident was unable to reliably recall the details of his discharge, and said he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/26/22 at 1:20 PM, in a telephone interview the HHA's Account Executive verbalized the facility's Administrator called regarding a referral for HHA for resident #1. She recalled she visited the resident to assess if the HHA could meet his needs, reviewed his care needs, and spoke with the resident about the services they provided. She said the resident was very aware, and when she asked for the address of where he was going, he could not provide an address. The HHA Account Executive remembered she told the resident about the homeless shelter, but he did not want to do that. She said she called a hospital that provided drug rehab, but could not recall who she spoke with. She said she was told the resident could not be a direct admission, but could self-admit to the hospital. The HHA Account Executive said the facility's SSD and CM were with her during her conversation with the resident. She could not recall if the facility staff contacted any other facility and noted, they relied on me. On 4/26/22 at 2:45 PM, in a telephone interview, LPN B recalled that on 3/02/22 during the 3 PM to 11 PM shift, the SSD and CM came to the unit and directed her to pack resident #1's belongings and medications. They told her resident #1 was to be discharged . She said she asked about the discharge location and was told it would be a facility in [NAME]. LPN B stated she asked about the method of transportation, and was told via ridesharing service. She recalled she told the SSD and CM that she did not feel comfortable giving the resident and/or the driver narcotics and verbalized she would only do so with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She remembered she received a call from the hospital in [NAME] at approximately 11:45 PM and was informed the resident was dropped off at the hospital. LPN B noted she told the hospital staff she understood the resident was going to a rehab facility. She said she searched the internet of the address listed on the Discharge Plan and Instructions and noted it was an inpatient psychiatric hospital. She explained the hospital staff told her they knew the staff at the inpatient psychiatric hospital personally and would reach out to them. LPN B said the hospital staff called back, and reported she spoke to both UM at the inpatient psychiatric hospital, and they were not aware of any plans for the resident's admission. On 4/28/22 at 11:52 AM, the Medical Director recalled the facility notified him that resident #1 did not want to be discharged home, instead he wanted to go to a drug rehab facility. The Medical Director indicated he told the facility to get the information regarding the drug rehab, and he would give the appropriate orders. He said he was later told the resident was transferred to a homeless shelter. He stated the initial order was for discharge home, and the facility should have delayed the discharge process, until all aspects of the discharge were sorted out. He recalled that from what he was told, he assumed the background work was done by the facility, including communication with the drug rehab facility. The facility's policy, Transfer/Discharge Notification & Rights to Appeal with effective date 9/23/2017, and revised 3/26/2018 read, Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements .When the center transfers or discharges a resident .the facility will ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The policy Discharge of Resident to Home or Other Center with effective date 11/30/14 and revised 8/03/18 read, Upon determination by the Interdisciplinary team that resident is appropriate for discharge, the nurse will obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .e. May discharge home with med) .Provide resident a copy of the Discharge Plan, and the pharmacy Medication list. Document final disposition in the resident's clinical record. Review of the immediate measures implemented by the facility revealed the following, which were verified by the survey team. *On 4/26/22 a quality review of residents who discharged over the last 30 days was completed by the Director of Clinical Services, (DCS), Executive Director, SSD and the Regional DCS to ensure communication between both institutions regarding reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record. *On 4/26/22 an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed. The Medical Director agreed and approved the committee recommendations. *On 4/26/22 the DCS, Executive Director, SSD and CM were educated by the Regional DCS regarding ensuring communication between both institutions to include reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record with emphasis on ensuring type of transport: non-emergent with medical personnel or pre-arranged private transportation with family, responsible party, or other persons designated by the resident or resident representative to the agreed upon destination, with the appropriate paperwork to include medication list, treatment orders and /or any home health needs to ensure a safe discharge that meets the physical and psychosocial needs of the resident with documentation in the medical record. *On 4/28/22 SSD and CM were educated by the Regional DCS regarding their role as resident advocates to ensure safe discharges. *On 4/28/22 SSD was educated by the Executive Director regarding Nursing Home transfer form must be sent with residents that are sent to the hospital. *Additional education included the following policies: *SS-197 Interdisciplinary discharge planning, CM-110 Care management discharge summary, CM-125 Interdisciplinary discharge planning, N-750 Discharge of resident to home or other center. *The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of the quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Interviews conducted with staff (including 1 Registered Nurses, 7 LPNs) on 4/28/22 between 2:00 PM to 3:46 PM, revealed the facility had provided education on the discharge process and requirements to ensure a safe and orderly discharge for residents.

Based on interview and record review, the facility failed to arrange safe and orderly discharge to meet health and safety needs, and failed to offer adequate orientation and preparation for discharge for 1 of 3 residents reviewed for discharge of a total sample of 9 residents, (#1). On 3/02/22 at 5:43 PM, resident #1 was discharged from the facility to the Emergency Department of a hospital over 50 miles away via ridesharing service. There was no communication between both facilities regarding the reason for the transfer, and resident #1 arrived at the hospital without a medication list or wound care orders for his multiple, complex pressure ulcers. The hospital contacted the facility regarding the discharge being unsafe and inappropriate for hospital admission. Instead of readmitting resident #1, the facility arranged for another ridesharing service to transport him to a homeless shelter that could not accommodate wheelchair-bound persons or meet his care needs. The facility initiated the resident's discharge without timely notification and failed to adequately prepare the resident for discharge or document discussion related to the discharge in the medical record There was the likelihood resident #1 experienced excruciating pain from the lack of routine pain medications needed for severe pain. He was at risk for worsening of his stage III and IV pressure ulcers while he was seated in cars and in the emergency room for over four hours due to the lack of a plan to provide wound care as well as other interventions to treat his advanced stage pressure ulcers. The resident was transported by non-medical transport to two separate locations by drivers who were neither aware of nor qualified to address the resident's needs. This failure resulted in Immediate Jeopardy starting on 3/02/22. The Immediate Jeopardy was removed on 4/28/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F622, F623, F745, F835. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 1/20/22 revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15/15. The assessment indicated the resident required supervision with assist of one staff person for bed mobility, transfers, dressing, toilet use and personal hygiene. His balance during transitions and walking, moving on/off toilet, surface to surface transfers was not steady, and the resident was only able to stabilize with staff assistance. He had functional limitation in range of motion of his bilateral lower extremities, and had one stage III and two stage IV pressure ulcers, which were present on admission. The resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to his scheduled pain medications, resident #1 requested and received as needed [MEDICATION(S)] 30 mg every four hours regularly for pain levels of 3 to 9. Wound care notes on 3/02/22 revealed the following pressure ulcers: Stage IV to right posterior thigh measuring 5.4 x 5.2 x 1.5 centimeters (cm), Stage 4 to left posterior thigh measuring 6.5 x 3.9 x 2.5 cm, and Stage 3 to Sacrum measuring 4.5 x 3.4 x 0.2 cm. Documentation read, Wounds can be managed at home if daily dressing changes are prescribed by a Home Health Nurse. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was updated on 3/02/22 at 7:50 PM after the resident was discharged from the facility and read Patient discharging home on 03/02/2022 with all belongings, and no medications. Home Health needed for care. Patient to follow up with primary care provider in 3-5 days. Progress note dated 3/02/22 read, Resident discharged from facility, resident belongings packed and provided with self during transfer Resident transferred into vehicle by staff w/o (without) any incident. Review of the resident's Discharge Plan and Instructions with effective date 1/17/22 incorrectly indicated the resident was discharged to the hospital on 3/02/22 at 5:43 PM, accompanied by his mother with Home Health Services. The clinical record indicated the resident's mother lived out of State, and he left the facility unaccompanied. The Discharge Plan and Instructions form conflicted with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to indicate the discharge process was explained to the resident, or that the resident understood the reason for discharge. Review of the facility's Admission/Discharge To/From Report for the period 1/01/22 to 4/06/22 conflicted with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress note documented by Licensed Practical nurse (LPN) B dated 3/02/22 at 11:45 PM, indicated nurse management from the hospital in [NAME] contacted the facility regarding resident #1's unexpected arrival at the hospital. Documentation read that hospital staff stated they needed to speak to someone in administration immediately. LPN B's note indicated she called the Administrator and informed her of the telephone call from the hospital. The Administrator informed the resident was discharged home and that he decided to self-check himself into a facility and she would handle the situation tomorrow. The hospital's History and Physical dated 3/03/22 revealed the resident's chief complaint was buttock wounds. Documentation revealed the resident verbalized he received wound care at the facility, was seen by the wound care doctor on 3/02/22 who said he did not need daily wound care, and the facility decided to discharge him. The document read, Today facility called medical ride and paid them to bring patient to ED [Emergency Department]. Currently patient is complaining of back pressure ulcer pain Patient was discharged few hours back but was readmitted due to placement issue. A Social Service progress note dated 3/04/22 revealed the facility received a call from the hospital Case Manager (CM) and Psychiatric nurse and was informed the resident was not a fit for their care and he would be discharged back to the facility. Documentation read, Transportation was set up for him after verifying that home health services can be provided to him at a homeless shelter upon arrival to the shelter, the [patient] refused to get out and went back to the hospital. On 4/06/22 at 2:16 PM, the Social Service Director (SSD) and the facility's CM explained the discharge process began on admission, and a Journey home meeting was held with the resident/responsible party within one to two days after admission to identify the resident's plans for discharge, and assess any need for skilled services, Home Health Services (HHS), Durable Medical Equipment (DME) and any potential barriers to discharge. The SSD stated resident #1 was to be discharged home, then he requested to go to a substance abuse treatment facility. He said at the resident's request, the facility provided transportation via ridesharing service to a hospital in [NAME]. Review of the local map of the area, revealed the resident was transported to the Emergency Department of a hospital over 50 miles away from the facility. (Retrieved from Google maps 4/18/22) On 4/06/22 at 2:33 PM, in a telephone interview, the hospital's Social Worker (SW) verbalized the facility sent the resident to the hospital with paperwork, that read, discharge to hospital, and paid $225.00 for transportation via a ridesharing service. The SW reported she called the facility, spoke to the Administrator, and told her it was not a safe discharge, and the facility should take the resident back. She said the resident had gaping wounds to his buttocks and was in a wheelchair. She stated the facility agreed to take the resident back, and the facility arranged for another ridesharing service to retrieve the resident from the hospital. She explained instead of readmitting the resident, the facility transported him to a homeless shelter in [NAME]. The homeless shelter sent the resident back to the hospital because he was not an appropriate candidate for the shelter. The SW said everyone at the hospital was dumbfounded at the facility's actions, and she had never been more upset with a Nursing Home. On 4/06/22 at 3:12 PM, the Administrator stated resident #1's admission meeting with the Interdisciplinary Team (IDT) revealed the resident had plans to return to the community. She recalled the resident was alert and oriented, was wheelchair bound, independent with activities of daily living, and needed support with wound care. The Administrator stated when the resident was referred to the Home Health Agency (HHA), the representative reported the resident changed his mind, and decided he wanted to go his mother who lived out of State. The resident requested to check into a drug rehab, and the HHA would provide service after drug rehab. She explained the facility paid for transportation via ridesharing service to a hospital in [NAME] but then the hospital called and said the resident did not go to the drug rehab facility, and he did not qualify to be admitted to the hospital. She said she directed the SSD to seek appropriate community resources for the resident, and the facility paid to transport the resident from the hospital to a homeless shelter in [NAME], via ridesharing service. The Administrator reported that when the resident arrived at the homeless shelter, he refused to get out of the vehicle and wanted to be transported back to the hospital. When asked if the facility believed this was a safe discharge, the Administrator stated, We had a solid discharge plan in place that was safe, but the patient was manipulative and changed his mind at the last minute. The Administrator did not explain how the resident's discharge from the facility was safe when the physician was not involved and thought the resident was being discharged home. On 4/06/22 at 3:44 PM, the Director of Clinical Services (DCS) stated resident #1 was a handful, and had major wounds to the bone, that were a long way off from closing when he was discharged . She said his discharge planning was on and off, and reported when the resident first came to the facility, his plan was to go home with his mother who lived out of State. The DCS stated she considered the drug rehab was a safe discharge for the resident, but she did not know the resident was not admitted to the hospital, and went from the hospital to a homeless shelter. She stated I do not think a homeless shelter would have been a safe discharge. On 4/06/22 at 4:11 PM, on 4/07/22 at 10:53 AM, and on 4/26/22 at 11:23 AM the CM verbalized the facility was aware the resident was not going home when he left the facility, and transportation to the hospital via ridesharing service was arranged by the Administrator. She explained the process for a resident to be transferred/discharged to another facility required a physician order, a referral to the receiving facility, and communication with the admission personnel of the receiving facility. The CM verbalized those procedures were not done for resident #1. She stated she could not say if the drug rehab facility was contacted prior to the resident's discharge, and verbalized she was not involved in the discharge process after the resident left the facility and was not aware the resident was sent to a homeless shelter. The CM stated she would not consider it a safe discharge to the homeless shelter for the resident, as she did not think he could get the care he required. The CM reviewed the resident's clinical record and confirmed a discharge order to home with HHA services dated 3/02/22. She validated there was no order for discharge to the hospital, or drug rehab facility. She acknowledged there was inadequate documentation and verbalized the facility did not follow protocols and guidelines for the resident's discharge. On 4/07/22 at 10:55 AM, the A Wing Unit Manager LPN (UM) stated that at first the resident wanted to go home and HHA referral was made. She said when HHA personnel visited the resident to assess the services he required, the resident decided he wanted to transfer to a drug rehab facility. The UM recalled the HHA personnel called and found a medical substance abuse facility in [NAME] but the facility had no communication with them. She recalled the HHA personnel spoke to the substance abuse facility, and was informed they did not take patients as direct admission. The UM explained when transferring /discharging a resident to another facility, communication should be done with the receiving facility. She stated she assisted in completing the resident's Discharge Plan and Instructions form and verbalized a nurse-to-nurse report between facilities was not done. She said she was not aware the resident was sent to a homeless shelter. On 4/07/22 at 11:59 AM, the SSD stated the facility paid for transportation to take resident #1 to the hospital in [NAME] by a ridesharing service per the resident's request. He said it was not necessary to communicate with the receiving facility if the discharge was done upon the resident's request. The SSD verbalized that on 3/04/22 a nurse from the hospital called and stated the hospital would discharge the resident and the facility needed to figure out where to put him. He said the resident knew he could not go back home, and stated the resident has a right to be homeless. The SSD reported the facility's Corporate office arranged for the resident to be transported from the hospital to a homeless shelter in [NAME]. Additional information provided by the facility via email from the HHA representative on 4/14/22 revealed the HHA representative met with resident #1 in his room on 3/02/22 at approximately 3:50 PM, accompanied by the facility's SSD and CM. The HHA representative statement read, When I asked him to confirm his address to where we would be taking care of him he gave me several options When I asked him for any addresses or phone numbers for any of those contacts he could not On 4/25/22 at 12:49 PM, in a telephone interview, resident #1 stated when he complained his dressings were not being changed as ordered, the facility informed him they found a bed at a hospital that would care for his wounds. He said they placed him in an Uber [ridesharing service] and sent him off to [NAME] with no medications. He explained the facility did not discuss transfer to another facility, and he did not have any discussion regarding going to a drug rehab facility. He stated, no way he would go to a drug rehab since he would not be weaned off prescription medications that he had been taking for a long while. Resident #1 said when he arrived at the hospital, he checked in and explained he was discharged from the facility without medications. He verbalized the hospital staff got upset, and asked why the facility sent him since he was supposed to get wound care and physical therapy at the facility. Resident #1 confirmed he could not do his own wound care and would not have selected to go to a homeless shelter. He was unable to reliably recall the details of his discharge, and said he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/25/22 at 1:04 PM, in a telephone interview, the Manager at the homeless shelter in [NAME] verbalized that for admission, clients must be able to care for themselves without assistance. He explained the men were housed in an open pavilion with cots, had to go up and down stairs, and get in and out of a portable toilet. He stated the shelter did not allow outside services such as Home Health to come in to provide care. The Manager reported the shelter was not an appropriate location for someone with resident #1's care needs. On 4/26/22 at 12:39 PM, the SSD acknowledged his responsibilities included re-evaluation of a discharge, and finding alternative resources if necessary. He confirmed the Medical Director was not notified of the change in discharge location for resident #1, and acknowledge the Home Health nurse navigated the discussion regarding drug rehab facility rather than the facility. The SSD acknowledged although the facility was responsible for the resident, the HHA staff took over the discharge arrangements from that point. He recalled he and the Administrator discussed the homeless shelter option after the hospital staff contacted the facility. He explained he contacted the homeless shelter on the morning of 3/03/22 and they agreed to accept the resident. He could not recall the name of the person he spoke with, and noted it was someone who answered the phone. When asked if he inquired whether the shelter could accommodate the resident's complex wound care needs, he said I just asked if they had beds. On 4/26/22 at 1:20 PM, in a telephone interview, the HHA's Account Executive recalled she visited the resident to assess if the HHA could meet his needs, reviewed his care needs, and spoke with the resident about the Home Health Services (HHS). She said the resident was asked for the address of where he was going but he could not provide an address. She said the facility's SSD and CM were with her during her conversation with the resident. She could not recall if the facility staff called or research any other facility to address the resident's needs, and added, they relied on me. On 4/26/22 at 2:45 PM, in a telephone interview, LPN B recalled on 3/02/22 during the 3 PM to 11 PM shift, the SSD and CM came to the unit. She said they directed her to pack resident #1's belongings and medications as he was being discharged to a facility in [NAME]. She recalled she told the SSD and CM that she did not feel comfortable giving the resident and/or the driver narcotics and verbalized she would only do so with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She recalled she told the A Wing UM she felt it was an unsafe discharge. The LPN said the UM said she agreed, but the Administrator was in charge. LPN B stated she told the UM, I'm making you all know it's not right. LPN B recalled she received a call from the hospital in [NAME] at approximately 11:45 PM and they reported the resident was dropped off at the hospital. LPN B told them she understood the resident was to be discharged to the inpatient psychiatric hospital for rehab. The hospital staff verbalized she knew the staff at the inpatient psychiatric hospital personally and would reach out to them. LPN B said the hospital staff called back, and reported she spoke to both UM at the inpatient psychiatric hospital, and they were not aware of any plans for the resident's admission. The LPN stated she provided the hospital staff with the Administrator's name and contact information, and she called the Administrator and informed her of the communication with the hospital. On 4/28/22 at 10:59 AM the A Wing Unit Manager (UM) stated LPN B verbalized to her that she felt the resident's discharge was unsafe. The UM said she told LPN B that she was not happy about it. The UM said she did not notify the Medical Director of changes to the resident discharge plans and did not obtain an updated discharge order to reflect the resident's discharge location. On 4/28/22 at 11:52 AM, the Medical Director recalled the facility notified him that resident #1 did not want to be discharged home, instead he wanted to go to a drug rehab facility. The Medical Director verbalized he told the facility to get the information regarding the drug rehab facility, and he would give the appropriate orders. He said he was later told the resident would be transferred to a homeless shelter. He verbalized the initial order was for discharge home and could not say why the SSD/CM could not have made arrangement for the resident to go to his mother out of State as the hospital did. The Medical Director stated the facility should have delayed the discharge process, until all aspects of the discharge were sorted out. He recalled from what he was told he assumed the background work was done by the facility, including communication with the drug rehab facility. He acknowledged it was not a safe and orderly discharge and stated the facility needed to put better processes in place. Job description for the Manager of Social Services indicated the Primary purpose was to plan, organize, the operation of the Social Services department in accordance with current federal, state, and local standards, guidelines, and regulations . to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The Case Manager Job functions indicated the CM facilitates and coordinates the admission and discharge process Duties and Responsibilities included, Work with team members to ensure discharge-planning goals and objectives are developed and discussed .Assist in planning the services required in the resident's discharge plan as necessary. The facility's policy Transfer/Discharge Notification & Rights to Appeal with effective date 9/23/2017, and revised 3/26/2018 read, Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements.The Center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. Review of the immediate measures implemented by the facility revealed the following, which were verified by the survey team. *On 4/26/22 a quality review of residents who discharged over the last 30 days was completed by the Director of Clinical Services, (DCS), Executive Director, SSD and the Regional DCS to ensure communication between both institutions regarding reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record. *On 4/26/22 an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed. The Medical Director agreed and approved the committee recommendations. *On 4/26/22 the DCS, Executive Director, SSD and CM were educated by the Regional DCS regarding ensuring communication between both institutions to include reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record with emphasis on ensuring type of transport: non-emergent with medical personnel or pre-arranged private transportation with family, responsible party, or other persons designated by the resident or resident representative to the agreed upon destination, with the appropriate paperwork to include medication list, treatment orders and /or any home health needs to ensure a safe discharge that meets the physical and psychosocial needs of the resident with documentation in the medical record. *On 4/28/22 SSD and CM were educated by the Regional DCS regarding their role as resident advocates to ensure safe discharges. *On 4/28/22 SSD was educated by the Executive Director regarding Nursing Home transfer form must be sent with residents that are sent to the hospital. *Additional education included the following policies: *SS-197 Interdisciplinary discharge planning, CM-110 Care management discharge summary, CM-125 Interdisciplinary discharge planning, N-750 Discharge of resident to home or other center. *The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of the quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Interviews conducted with staff (including 1 Registered Nurse, 7 LPNs) on 4/28/22 between 2:00 PM to 3:46 PM, revealed the facility had provided education on the discharge process and requirements to ensure a safe and orderly discharge for residents.

Based on interview and record review, the facility failed to provide necessary post-fall care and services to assess and treat injuries; and failed to monitor for signs and symptoms of worsening condition for 1 of 2 residents reviewed for falls with major injury, out of a total sample of 9 residents, (#22). The failure of nurses to address resident #22's change in condition delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a likelihood resident #22 could have fallen again or suffered brain injury, coma, or death from an unidentified head injury. On 3/02/22 at 5:00 PM, resident #22 had an unwitnessed fall. He sustained skin tears and abrasions, and complained of left hip pain. The Unit Manager (UM) assisted the resident back to bed with help from other staff, but neither the assigned nurse nor the UM notified the physician or initiated post-fall protocols to monitor the resident for adverse outcomes. During the overnight shift, the assigned nurse noted resident #22 was lethargic and continued bleeding from a wound on his left arm. The resident had dried blood on his forehead and still reported left hip pain. Resident #22 informed the nurse he fell on the previous shift, but she failed to notify the physician, nursing administration and his family of the incident and her findings. The physician was notified the following day at 7:35 AM, and resident #22 waited approximately four hours for non-emergency transport to the hospital where he was diagnosed with a left hip fracture. Resident #22 required surgical repair of the hip. The facility's failure to provide adequate post fall assessment and care placed all residents who fell at risk. This failure resulted in Immediate Jeopardy starting on 3/02/22. The Immediate Jeopardy was removed on 4/28/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F580, F600, F607 and F835. Resident #22, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was transferred to the hospital on 3/03/22 and readmitted to the facility on [DATE] with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Discharge - Return Anticipated assessment with assessment reference date of 3/03/22 revealed resident #22 had an unplanned discharge to the hospital. He required supervision for bed mobility, dressing, and toilet use, and was independent with transfers, locomotion, and personal hygiene. The MDS assessment revealed resident #1 had one fall with a major injury, defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. A subdural hematoma most often results from a head injury and occurs when bleeding fills the area around the brain causing compression of brain tissue. This type of injury can lead to death, (retrieved on 5/11/22 from www.medlineplus.gov). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 3/08/22 revealed resident #22 was hospitalized for a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document listed the resident's skin issues as a left hip surgical incision, right arm abrasion, left shoulder skin tear, and left elbow abrasion. Review of the medical record revealed resident #22 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] and Aspirin are classified as platelet aggregation inhibitors as they prevent platelets in the blood from adhering to each other to form clots. One of the most commonly reported adverse effects of these drugs is bleeding, including life threatening and fatal bleeding (retrieved on 5/04/22 at www.drugs.com). Resident #22 had a care plan for anti-platelet therapy, initiated on 11/14/21, that directed nursing staff to monitor for, document, and report adverse reactions including sudden, severe headaches, muscle/joint pain, lethargy, bruising, and sudden changes in mental status or vital signs. Review of a Nursing Progress Note dated 3/03/22 at 5:12 AM read, Upon rounds patient notified me that a fall had occurred yesterday during 2nd shift. The assigned nightshift nurse, Licensed Practical Nurse (LPN) H, noted resident #22 had wounds and abrasions on his upper body and complained of pain in both shoulders and his left hip. LPN H's note indicated she cleansed the resident's abrasions and wounds with normal saline, applied triple antibiotic ointment and covered them with dressings, then notified a Unit Manager (UM). Review of the medical record revealed no documentation of resident #22's fall during the evening shift on 3/02/22, nor any additional actions taken by LPN H to ensure resident #22's post-fall care needs were thoroughly evaluated and addressed after she was made aware of the fall. A Change in Condition form dated 3/03/22 at 1:15 PM, was completed by the B Wing UM. The form indicated on 3/02/22 at 5:00 PM, resident #22 reported pain left side and Left hip that was worse with movement. The document revealed the resident had sharp, new onset pain of intensity level 9 on a 0 to 10 scale. The B Wing UM noted he had skin tears to his left elbow, left forearm and left hip, and was on blood thinner medication. The attending physician was notified of the incident on 3/03/22 at 7:35 AM, and he gave an order to send resident #22 to the hospital emergency room for evaluation and treatment. Review of resident #22's hospital record revealed a History and Physical Observation dated 3/03/22 at 6:00 PM regarding his chief complaint of a fall. The document read, States he fell immediate pain in his left side and was unable to ambulate. The result of a Computed Tomography (CT) scan of the left hip showed resident #22 had an acute left hip fracture with associated soft tissue swelling. In addition, the radiology report described multiple compression fractures of indeterminate age spanning his mid to lower spine and read, Cannot exclude acute fractures. On 4/25/22 at 3:19 PM, the Director of Clinical Services (DCS) confirmed resident #22 fell on [DATE] at about 5:00 PM. She stated staff checked his vital signs and noted a skin tear on his left forearm. She explained the resident had full range of motion to his arms, complained of left hip pain, and staff assisted him back into his wheelchair then called the physician. The DCS was informed the resident's medical record did not indicate physician notification was made at the time of the fall, nor include documentation of assessments and interventions to ensure his well-being. She reviewed the medical record and said, At this point I don't see that anything was done at the time he fell . According to the Centers for Disease Control and Prevention (CDC), falls can cause broken bones and serious head injuries . especially if the person is taking certain medicines (like blood thinners). In fact, falls are the most common cause of traumatic brain injury. The CDC recommends that anyone who falls and hits their head should see a physician immediately (retrieved on 5/05/22 from www.cdc.gov/falls/facts.html). On 4/25/22 at 3:42 PM, Certified Nursing Assistant (CNA) G recalled she was seated at the B Wing nurses' station on 3/02/22 when the B Wing UM called out for staff to come to resident #22's room. CNA G stated when she got to the room, the resident was on the floor and was bleeding from his arm. She stated the resident complained of pain, and she assisted the UM to place him in his wheelchair, then back into bed. On 4/26/22 at 1:26 PM and on 4/27/22 at 9:51 AM, the B Wing UM stated on 3/02/22 she heard a loud noise as she walked in the hallway near resident #22's room. She recalled when she arrived in the room, he was on the floor bleeding and complained of back and hip pain. The B Wing UM stated she and other staff assisted the resident from the floor to his wheelchair and she provided first aid for his left arm skin tear. When asked if she initiated the fall protocols for assessment of neurological status, skin condition and pain level, she said, I don't remember what we did. She validated it was important to monitor the resident closely after the unwitnessed falls, especially since he took blood thinner medications. She explained. We worry about them hitting their head because it could cause bleeding in the brain. The B Wing UM stated resident #22's assigned nurse, LPN L, was on break at the time of the incident, but was expected to initiate the fall protocol and call the physician when she returned to the floor. When asked if LPN L was aware resident #22 fell , the B Wing UM said, I don't recall if I told her the resident fell . I left that evening and did not follow up after that. Review of the job description for LPN - Unit Manager dated 3/08/22 revealed duties and responsibilities included provide regular resident status updates to appropriate personnel, complete required documentation in an accurate and timely manner, and adhere to facility policies and procedures. Review of the facility's policy and procedure Fall Management revised on 7/29/19 revealed post-fall strategies which included evaluation, provision of post-fall care, neurological checks according to policy or as directed by the physician and notification of the physician and resident's representative. Additional strategies were updating the care plan, initiating post-fall documentation every shift for 72 hours and interdisciplinary team review with completion of a root cause analysis. The facility's Neurological Evaluation policy revised on 9/14/21 directed nurses to perform neurological checks every 15 minutes eight times, every 30 minutes four times, every 60 minutes four times, and every eight hours eight times until 72 hours is completed, unless otherwise ordered by the physician. The policy directed nurses to document neurological checks, vital signs and observations in the medical record. On 4/26/22 at 1:48 PM and on 4/27/22 at 2:48 PM, in telephone interviews with LPN H, she stated she received change of shift report from LPN L on 3/02/22 at the start of the 11:00 PM to 7:00 AM shift but was not informed of resident #22's fall. LPN H explained during medication pass rounds she was at the resident's bedside and noted he was lethargic, had blood oozing from underneath a dressing on his left arm and there was dried blood on his forehead, just below hairline, above his left eye. LPN H stated the resident explained he fell the previous evening and a few CNAs who had worked on the previous shift confirmed the incident occurred. LPN H stated the CNAs told her the B Wing UM and other nursing staff picked the resident up off the floor. LPN H stated she called the B Wing UM's phone, but she did not answer. Next, she called the A Wing UM to tell her the resident was still in the facility, and she responded, He's still in the building? He was supposed to get sent out! LPN H stated she made one attempt to call the attending physician, but he did not answer his phone. She confirmed she did not initiate neurological checks or conduct a thorough skin evaluation as she was not the nurse involved in the fall and it did not occur on her shift. LPN H stated she handed over the issues regarding resident #22 to the B Wing UM when she arrived at work the following morning. LPN H stated she was not aware resident #22 hit his head until the B Wing UM arrived the next morning and shared that information with her. On 4/26/22 at 2:35 PM, the A Wing UM stated she never received a phone call from LPN H during the night shift on 3/02/22 regarding resident #22. She said, No nurse called me. On 4/26/22 at 3:20 PM, the Assistant Director of Clinical Services (ADCS) recalled the B Wing UM informed her about resident #22's fall on the morning of 3/03/22, the day after the incident. The ADCS stated she instructed the B Wing UM to initiate the required post-fall assessments since they had not been done by LPN L the previous evening. The ADCS acknowledged the primary concern was not completion of paperwork, instead all nursing staff involved should have focused on the resident's actual and potential injuries. She explained nurses should have informed the physician of the unwitnessed fall and obtained appropriate orders. The ADCS stated her expectation was nurses would conduct neurological evaluations after any unwitnessed fall as a head injury could cause intracranial bleed. She validated there was no documentation in the resident's medical record to indicate required post-fall care was provided. On 4/27/22 at 12:43 PM, resident #22's fall incident and post-fall care were discussed with the DCS and ADCS. The DCS stated her expectation was the B Wing UM should have assessed resident #22 thoroughly before lifting him from the floor and then followed the facility's fall protocols. The ADCS stated all patients were the responsibility of all nurses, and each nurse should have ensured the resident got the appropriate care. She stated she was in the room with resident #22 as staff prepared to send him to the hospital. She recalled he complained of pain and required premedication for the ambulance transport. The facility's Incident Completion Checklist: Falls (undated) included directions for nurses to obtain vital signs, a change in condition form, pain evaluation, skin assessment and neurological checks for all unwitnessed falls. Nurses were expected to initiate orders in the electronic medical record for neurological checks for 24 hours after a fall and post-fall documentation every shift for three days. On 4/28/22 at 10:30 AM, the Administrator stated she spoke to resident #22 yesterday, 4/27/22, and he confirmed he hit his head on the wall when he fell . She stated the resident told her he was able to transfer himself from his bed to the wheelchair after the fall and even attended two smoke breaks. The Administrator stated the resident informed her he had no pain until the following morning. The Regional DCS was asked if the resident who hit his head during a fall and suffered a fracture was safe to transfer himself from his bed to a wheelchair without supervision. She acknowledged resident #22's leg fracture would make him unstable and more likely to fall again. Review of the resident's medical record including the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 5:00 PM on 3/02/22 until he was discharged to the hospital on 3/03/22, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the MAR by LPN H indicated resident #22 exhibited symptoms of pain, sedation and drowsiness during the overnight shift on 3/02/22 to 3/03/22. On 4/28/22 at 11:45 AM, the facility's Medical Director stated he was also resident #22's attending physician. He confirmed his expectation was one of the nurses would have notified him of the resident's fall and injuries. The Medical Director stated he did not have an answering service and responded to all his calls. He explained if he did not answer the phone immediately, he would respond to voicemails. The Medical Director was informed the nightshift nurse, LPN H observed one of resident #22's wounds still bleeding approximately eight hours after he fell . He acknowledged resident #22 experienced a delay in assessment and explained the outcome could have been worse if the resident had suffered adverse effects from bleeding out into his hip or brain. The Medical Director acknowledged resident #22 did not receive necessary post-fall care and services. The Notification of Change in Condition policy revised on 12/16/20 revealed the facility would . promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in status or condition. Examples included notification of accident and the need to implement new treatment. The document indicated the nurse would conduct an evaluation of the resident and document findings on the 24-hour report and in the medical record including completion of a Change in Condition/SBAR form. The policy directed nurses to call emergency medical services if no response is received from the attending physician and Medical Director. The Facility assessment dated [DATE] indicated the facility's services included general care for mobility and fall or fall with injury prevention. The facility's resources needed to provide competent support and care for residents every day included staff who were knowledgeable of identification of change in condition. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 4/25/22, the facility entered a complaint investigation related to a report regarding a resident who sustained a fall involving injury and pain. The facility failed to provide quality care and services post fall, did not address the resident's change in condition, did not initiate neurological checks, and did not notify the physician/responsible party at the time of the fall. The fall was not communicated during nurse-to-nurse change of shift report between 3-11 and 11-7 nurses nor documented for follow up, which contributed to a delay in treatment putting the resident at risk for further harm. *On 4/27/22, a quality review of residents who sustained a fall with or without injury and/or pain over the last 30 days was completed by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Mangers to ensure post fall care was provided at the time of the fall, the physician/responsible party was notified of the fall, falls were communicated between licensed nurses during shift to shift report, fall protocol was initiated, and fall documentation was completed per policy to ensure quality care was provided and there was not a delay in treatment which would put the resident at further risk for harm. *As of 4/27/2022 education was provided to current licensed nurses by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers related to: Licensed Nurses must follow post fall protocol to ensure quality of care is provided, resident needs are met and to avoid delay in care and possible further harm: 1. Resident will be evaluated and post fall care provided 2. Initiate neuro checks as per policy or directed by physician 3. Notify physician and resident representative 4. Re-evaluate fall risk utilizing the post fall evaluation 5. Update care plan and nurse aid Kardex with interventions 6. Initiate post fall documentation every shift for 72 hours 7. Interdisciplinary team to review fall documentation and complete root cause analysis 8. Update plan of care with new interventions as appropriate 9. Review resident weekly Licensed nurses must complete nurse to nurse report each shift to ensure proper follow up of clinical processes to include post fall protocol and change in condition. Nurse Manager, on call must be notified of all falls with or without injury/pain at the time of the fall. On call nurse manger monthly schedule is posted on both nursing units, conference room, break room and at the time clock. Nursing Management on call schedule changes will be indicated on the monthly schedule. If you are unable to reach the on call nurse manager call the Administrator immediately. Additional education included the following policies: N-1259 Fall Management *On 4/27/22, the B Wing Unit Manager and Director of Clinical Services were suspended by the Executive Director pending investigation regarding failure to ensure the above listed elements of F684 are followed including policy and procedures related to Fall Management, falls and failure to provide education for Licensed Nurses related to falls when a deficient practice is identified so that residents do not experience a delay in care which could potentially results in further harm. *On 4/27/22, a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis. * On 4/27/22, an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed. The following team members were in attendance: Executive Director, Regional Director of Clinical Services. The Medical Director agreed and approved the committee recommendations. *The facility currently has a total of 34 Licensed Nurses. 8 Licensed Nurses received education regarding the above-mentioned beginning on 4/27/22. 21 Licensed nurses received education regarding the above mentioned on 4/28/22. The rate of education compliance for current Licensed Nurse staff as of 4/27/22 is: 23.5%. The rate of education compliance for current Licensed Nurse staff as of 4/28/22 is: 85.2%. Education to be completed at 100% by 4/28/2022. As of 4/28/22, any Licensed Nurse who did not receive education related to the above mentioned was notified by ADCS and UM indicating they may not return to work until the education is received. *On 4/27/22, CNA education was initiated by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers regarding do not move a resident after a fall and call for a nurse. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed according to the facility's plan. On 4/28/22, interviews conducted with 19 facility staff representing all shifts including 1 Registered Nurse, 6 LPNs, 10 CNAs and 2 Personal Care Attendants revealed staff received in-services on the above-mentioned topics and were knowledgeable of the facility's policies and procedures regarding falls, changes in condition and communication at change of shift. The sample was expanded to include 2 additional residents who sustained fractures. Observation, interview and/or record revealed no concerns related to assessments, interventions, and notifications for residents #4 and #21.

Based on interview and record review, the facility failed to effectively utilize its resources to oversee and support frontline, management and administrative staff to ensure post-fall protocols were implemented (#22) and arrange for safe and orderly discharge (#1), for 2 of 9 sampled residents; and failed to ensure policies and procedures were executed to promote the highest practicable physical, mental, and psychosocial well-being for all residents who had falls or were discharged from the facility. On 3/02/22 at 5:00 PM, resident #22 had an unwitnessed fall. He sustained skin tears and abrasions and complained of left hip pain. Neither the Unit Manager (UM) nor the assigned nurses notified the physician and initiated post-fall protocols, and resident #22's left hip fracture was not discovered until he was transferred to the hospital approximately 18 hours later. The resident required surgical repair of the hip. The facility's administration was not aware of the delay in assessment and treatment nor the contributing factors. On 3/02/22 at 5:43 PM, resident #1 was discharged from the facility to the Emergency Department of a hospital over fifty miles away via a ridesharing service. There was no communication between both institutions regarding the reason for the transfer, and resident #1 arrived at the hospital without a medication list or wound care orders for his multiple, complex pressure ulcers. The hospital contacted the facility regarding the discharge being unsafe and inappropriate for hospital admission. Instead of readmitting resident #1, the facility arranged for another ridesharing service to transport him to a homeless shelter that could not accommodate wheelchair-bound persons or meet his care needs. The facility's failure to ensure administration developed and implemented systems and processes that provided adequate support and oversight for staff placed all residents who fell and/or were discharged from the facility at risk for serious harm, injury or death. These failures resulted in Immediate Jeopardy starting on 3/02/22. The Immediate Jeopardy was removed on 4/28/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600, F622, F624, and F684. 1. Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was transferred to the hospital on 3/03/22 and readmitted to the facility on [DATE] with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nursing Progress Note dated 3/03/22 at 5:12 AM revealed resident #22 informed Licensed Practical Nurse (LPN) H he fell on the previous evening shift. LPN H noted the resident had wounds and abrasions on his upper body and complained of pain in both shoulders and his left hip. Review of the medical record revealed no nursing documentation related to resident #22's fall on 3/02/22, nor any actions taken by LPN H to ensure his post-fall care needs were thoroughly evaluated and addressed after she was made aware of the fall and observed his injuries. On 4/27/22 at 9:51 AM, the B Wing LPN UM stated as the first person to respond to resident #22's room when he fell , she picked him up off the floor with assistance from other staff, then provided first aid for his wounds. She explained the resident's assigned nurse, LPN L, was expected to initiate all post-fall interventions and documentation when she returned from her lunch break. The B Wing LPN UM could not recall if she told LPN L that resident #22 fell and acknowledged she did not follow up to ensure the required notifications and assessments were done. She stated when she returned to work the following morning, she discovered LPN L had not initiated any of the required post-fall protocols. The B Wing LPN UM stated about a week prior to resident #22's fall, LPN L refused to complete required documentation when another resident fell . The B Wing LPN UM recalled she reported LPN L's noncompliance to the Director of Clinical Services (DCS) and said, I am not sure why she was allowed to come back. The B Wing LPN UM explained she was hired approximately four weeks prior to the fall incident and felt she did not have adequate orientation and training to ensure her success in the position. She explained there was no UM on the B Wing to facilitate a smooth transition, so she learned on-the-job with assistance from the A Wing UM and the DCS who were busy performing their duties. The B Wing LPN UM stated she asked for additional support many times and said, I felt like I was kind of floating out there. I told them I felt like I didn't have the proper tools to do my job. There is lack of communication and training for managers. Things start to break down as problems at the top trickle down. If we as managers can't do our job the way it should be done, nurses have no direction and don't have someone they can go to who knows answer. The B Wing LPN UM explained the facility did not have a dedicated or scheduled on-call nursing supervisor to deal with after-hours nursing issues and crises. On 4/26/22 at 3:20 PM, the Assistant Director of Clinical Service (ADCS) explained on the day resident #22 fell , she had been on staff for only two weeks. The ADCS stated the DCS and the A Wing UM were both out of town and she was not informed of the incident until the following morning. She stated her inquiries showed the B Wing UM did not understand the importance of completing documentation prior to leaving the building. She said, The agency nurse (LPN L) was known noncompliant with policies and had to be constantly re-educated. The ADCS could not explain why the facility continued to utilize the services of agency nurse LPN L, or how she was monitored based on her known noncompliance with facility policies and procedures. On 4/27/22 at 12:43 PM, during an interview with the facility's DCS and ADCS, the DCS stated the B Wing LPN UM should have directed LPN L to follow the facility's fall protocols. She stated if LPN L refused, it would be insubordination and the B Wing UM should have dealt with that or implemented the fall protocol interventions herself. When asked whether the assigned nurse or the nurse who first responded to the fall was responsible for documentation, the ADCS said, It is not defined. The DCS confirmed the facility did not have a designated evening or night shift supervisor, and she could not clarify how agency nurses would know who to call and their contact numbers in the event of an emergency. The DCS acknowledged she did not follow up on resident #22's fall with fracture incident investigation when she returned to work as she was told the Regional DCS reviewed it and had no concerns. The administrative team was informed the B Wing LPN UM reported she lacked leadership and management experience prior to hire and expressed concerns about inadequate support from administration while she learned her role. The DCS and ADCS confirmed they were aware the B Wing UM was not able to manage her duties independently. The ADCS said, She never really got out of training. She was never able to fully manage the unit without assistance. On 4/27/22 at approximately 12:52 PM, the Administrator explained she was also not at work for two days around the time of the resident's fall. She stated when she returned to work, no one informed her there was a delay in care for resident #22, and as Risk Manager she would have investigated further to rule out neglect if she had known. She said, This is the first time I am hearing these details. She acknowledged the DCS and ADCS had mentioned concerns regarding the B Wing UM's job performance, and she directed the DCS to address the issues. The Administrator could not recall what measures were implemented to closely oversee and support the B Wing UM to mitigate negative outcomes of her identified inadequate performance. On 4/27/22 at 2:48 PM, in a telephone interview, LPN H stated after she observed resident #22's injuries and learned he fell on the previous shift, she called the B Wing LPN UM, but she did not answer. LPN H recalled she then called the A Wing LPN UM who answered but did not provide any specific directions. LPN H was informed that on 4/26/22 at 2:35 PM, the A Wing LPN UM stated she never received any phone calls regarding resident #22. LPN H explained she also tried to contact the attending physician, but he did not respond. She explained she was contracted to work in the facility through a staffing agency and other facilities usually provided agency nurses with packets that contained essential information such as contact numbers. LPN H said, It is very disorganized at that facility. When I started here I had to go looking, and another nurse gave me the numbers for the Unit Managers. On 4/28/22 at 10:54 AM, LPN I stated she worked at the facility for the past three months through a staffing agency. She said, With that facility you have to be very careful because you need to follow up on everything. If you don't ask, you won't know anything. She was not aware if there was a nursing supervisor on call after 6:00 PM and recalled frequent instances when she was not able to contact a physician. LPN I stated when she needed advice or support she usually asked another nurse. On 4/28/22 at 11:45 AM, the Medical Director stated if nurses did not get a timely response from an attending physician, the expectation was they would reach out to the Medical Director. He explained in resident #22's situation, he was also the attending physician. The Medical Director acknowledged it would be beneficial if the facility had an assigned on-call nurse and a backup physician in the event the Medical Director was not immediately available. 2. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Home health needed for care. Patient to follow up with primary care provider in 3-5 days. However, the resident's Discharge Plan and Instructions indicated the resident was discharged to the hospital on 3/02/22 at 5:43 PM. A Nursing Progress note documented by LPN B on 3/02/22 at 11:45 PM, indicated nurse management from the hospital contacted the facility regarding resident #1's unexpected arrival. The note revealed LPN B notified the Administrator regarding the issue. LPN B wrote, . [name of Administrator] stated that the resident was discharged home and that he decided to self-check himself into a facility . she would handle the situation tomorrow. A hospital CM [Case Management] Narrative Note dated 3/03/22 revealed the facility arranged transportation for resident #1 to return to the facility but then redirected transportation to a homeless shelter. The note indicated resident #1 was returned to the hospital after the shelter deemed him inappropriate for the type of services available there, and declined to accept him. On 4/06/22 at 3:12 PM and 4/26/22 at 12:03 PM, the Administrator stated resident #1 changed his mind at the last minute and decided not to be discharged to his previous home. She acknowledged staff should have notified the physician of the change in discharge plans and obtained a new order as this was a deviation from the plan of care. The Administrator stated the facility paid for the resident's transportation to the hospital based on discharge plans made by the Home Health Agency (HHA) representative, and then to a homeless shelter as arranged by the facility's Social Services Director (SSD). She acknowledged the facility, not the HHA, was responsible for its residents and must ensure discharge requests were appropriate. The Administrator stated she was not aware resident #1 was being discharged to the hospital, did not know if he was offered the option of placement in another nursing facility, and she was under the impression the SSD had verified the homeless shelter could meet the resident's needs. On 4/26/22 at 12:39 PM, the SSD explained in his role as a resident advocate, he would re-evaluate any unsafe discharge and utilize other resources. The SSD acknowledged although the HHA nurse navigated the discussion related to discharge, the facility was responsible for the resident. He stated the resident's transportation was arranged jointly by the Administrator and the corporate office. He confirmed resident #1's physician was not informed of the change in discharge plans. The SSD acknowledged he did not verify the drug rehabilitation center admission process and requirements prior to resident #1's discharge. He stated he determined, in conjunction with the Administrator and the HHA, that a homeless shelter would be an appropriate discharge location for resident #1. However, the SSD validated when he contacted the homeless shelter he only asked if there were available beds, but did not inquire about its appropriateness for a paraplegic, wheelchair-bound resident who had complex wounds and chronic medical conditions. On 4/28/22 at 11:52 AM, the Medical Director stated when he was made aware of a potential change in discharge location for resident #1, he told staff to confirm the arrangements and then he would give a new order. The Medical Director acknowledged the facility's failure to delay the discharge, communicate with the drug rehabilitation center and complete background work on the homeless shelter culminated in a discharge that was not safe and orderly. He stated improved processes were necessary. The job description for the Executive Director (Administrator) revealed she was Responsible for day-to-day clinical and administrative activities of the facility . with a purpose of ensuring residents received the highest degree of quality care. The Administrator's duties included hire, orient, and train qualified staff; guide the implementation of policies and procedures; monitor incident reports; and schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations. The Facility assessment dated [DATE] read, The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. The document provided an organizational chart to display the facility's reporting hierarchy and indicated it would ensure a sufficient number of qualified clinical and non-clinical staff were available to meet residents' needs. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 4/25/2022, the facility entered a complaint investigation related to a report regarding a resident who was inappropriately discharged to a higher level of care without providing the resident a notice of discharge and without communication between both institutions; the reason for the transfer, and without a medication list or treatment orders for wound care. * On 4/25/2022, the facility entered a complaint investigation related to a report regarding a resident who sustained a fall involving injury and pain. The facility failed to provide administrative oversight by ensuring nurses followed post fall protocol to include: not addressing the residents change in condition, did not notify the physician/responsible party at the time of the fall, did not initiate neurological checks, the administrator was not notified of the fall, the fall was not communicated during nurse to nurse shift report for 3-11/11-7 shifts or document follow up which contributed to delay in treatment putting the resident at risk for further harm. * On 4/26/22, a quality review of residents who discharged over the last 30 days was completed by the Director of Clinical Services, Executive Director, Social Services Director and the Regional Director of Clinical Services to ensure communication between both institutions regarding reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record. * On 4/26/22, the Director of Clinical Services, the Executive Director, the Social Services Director, and the Case Manager were educated by the Regional Director of Clinical Services regarding ensuring communication between both institutions to include reason for transfer and medication and treatment lists are provided as applicable to adequately prepare the resident for a safe discharge and the discussion is documented in the medical record. The Social Services Director and Case Manager were educated regarding their roles as resident advocates to ensure safe discharges. * On 4/26/22, an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed on discharge process. The following team members were in attendance: Executive Director, Director of Clinical Services, Regional Director of Clinical Services, Social Services Director and Case Manager. The Medical Director agreed and approved the committee recommendations. * On 4/27/22, a quality review of residents who sustained a fall with or without injury and/or pain over the last 30 days was completed by the Director of Clinical Services, Assistant Director of Clinical Services and Unit Managers to ensure administration is reviewing that post fall care is provided at the time of a fall, the physician/responsible party is notified of the fall, falls are communicated between licensed nurses during shift to shift report and fall documentation is completed per policy to ensure post fall care is provided and there is not a delay in treatment which would put the resident at further risk for harm. * As of 4/27/22, the Nurse Manager on call must be notified of all falls with or without injury/pain at the time of the fall. On call nurse manger monthly schedule is posted on both nursing units, conference room, break room and at the time clock. Nursing Management on call schedule changes will be indicated on the monthly schedule. If you are unable to reach the on call nurse manager call the Administrator immediately. Additional education included the following policies: N-1259 Fall Management. * On 4/27/22, the Executive Director, Director of Clinical Services, and Assistant Director of Clinical Services received education from the Regional Director of Clinical Services regarding the components of F835. *On 4/27/22, Director of Clinical Services and B Wing Unit Manager were suspended pending investigation by the Executive Director regarding failure to ensure the elements of F835 are followed. * On 4/27/22, an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed on fall incidents. The following team members were in attendance: Executive Director, Regional Director of Clinical Services. The Medical Director agreed and approved the committee recommendations. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed with administrative and frontline staff according to the facility's plan. On 4/28/22, interviews conducted with 19 facility staff representing all shifts including 1 Registered Nurse, 6 LPNs, 10 CNAs and 2 Personal Care Attendants revealed staff received in-services on the above-mentioned topics and were knowledgeable of the facility's policies and procedures regarding falls, changes in condition and communication at change of shift. On 4/28/22, interviews conducted with 8 nurses (1 Registered Nurse and 7 LPNs) revealed the facility had provided education on the discharge process and requirements to ensure a safe and orderly discharge for residents.

Based on observation, interview and record review, the facility failed to follow a physician's order for a dental consultation, and failed to arrange emergency dental services for tooth pain in a timely manner, for 1 of 10 sampled residents (#7). Findings: Resident #7 was admitted to the facility on [DATE]. The Admission/Readmission Data Collection form dated 2/20/20 revealed resident #7 had broken, chipped natural teeth and red, inflamed oral mucous membranes. The document indicated she also had a lesion or ulcer in her mouth. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 8/25/20 revealed resident #7 had clear speech, was able to express her ideas and wants, and had clear comprehension. The MDS assessment indicated resident #7 did not reject evaluation or care that is necessary to achieve the resident's goals for health and well-being. Review of the medical record revealed resident #7 had a care plan for oral and dental health problems related to poor oral hygiene and tooth pain, initiated on 5/06/20. The goal was resident #7 would be free of mouth infection or pain. The interventions directed staff to Coordinate arrangements for dental care, transportation as needed and monitor, document, report any oral and dental problems that need attention. Review of nurses' progress notes, medication administration records (MARs) and treatment administration records (TARs) for September and October 2020 revealed resident #7 received Tylenol for a headache on 9/05/20 at 9:39 PM. The medication was ineffective with a follow-up pain level of 5 on a 0 to 10 scale. On 9/06/20 at 11:07 AM, resident #7 again complained of a headache and received Tylenol. Later that evening at 6:26 PM, a nurse's note read, Tylenol given for toothache with some relief. The medication was deemed ineffective as her pain level was 5 after receiving the medication. The note indicated resident #7 complained of pain in a tooth that is noticeably loose on her left lower mouth. The documentation revealed the attending physician was notified, but there were no new orders or interventions noted in the medical record. A nurse's progress note dated 9/07/20 at 3:31 AM revealed resident #7 was extremely agitated, yelled at staff, refused her medication and was noncompliant with care. Resident #7 demanded to be let out of the facility as she was being held against her will. The physician was contacted again and gave an order for [REDACTED]. On 9/11/20 at 7:49 PM, the MAR indicated [REDACTED]. A nurse's note dated 9/12/20 at 2:47 PM read, dental consult obtained for resident loose tooth on left lower jaw and increased pain. Placed in tar and weekend sup (supervisor)aware; stated she would let B wing (nurse manager) know of above. The MAR indicated [REDACTED]. The following day, on 9/15/20 at 1:25 PM, resident #7 requested and received Tylenol again for tooth pain. Nurses continued to administer Tylenol for pain on 9/23/20 at 10:22 AM and 9/29/20 at 10:59 AM. On 10/13/20 at 1:43 AM, resident #7 received Tylenol for a tooth ache, which on re-assessment at 2:22 AM was reported to be ineffective. The note revealed resident #7 had a pain level of 5 and tooth still hurts. A Behavior Note written a few hours later, on 10/13/20 at 5:15 AM read, Resident was awake all night. She continuously asked for Aspirin for her tooth ache. Resident educated on that she has no order for Aspirin and was given Tylenol at 1:43am . resident kept asking for Aspirin every 5-10 mins (minutes) throughout the course of the night. Resident redirected several times. (Social Worker) aware of resident needing dental, awaiting dental appointment. A nurse's progress note dated 10/14/20 at 2:13 AM read, Resident still (complains of) tooth pain, becoming worse. Has not been given a dental appt yet. Needs dental consult asap (as soon as possible). Will notify day shift nurse to follow up with the nurse manager. The Order Summary Report retrieved on 10/16/20 revealed a physician's order dated 7/27/20 for [MEDICATION NAME] (Tylenol) 325 milligrams, 2 tablets every 4 hours as needed for pain, and an order dated 9/06/20 for pain assessment every shift. An order dated 7/27/20 read, Dental as needed and an order dated 9/12/20 read, Dental consult for loose tooth on left lower jaw. On 10/16/20 at 9:59 AM, the Social Services Director (SSD) confirmed she was responsible for arranging dental consultations. She stated there was an opportunity at least every 3 months to identify dental issues during scheduled nutrition, social services and nursing assessments. The SSD explained between these assessments, staff or residents could inform her of acute issues. The SSD stated after the nurse obtained a physician's order, she would get a consent form signed by the resident or their representative and fax all paperwork to the dental provider. The SSD recalled she was informed resident #7 had a loose tooth last week, obtained consent from resident #7's representative on 10/09/20, then contacted the dentist. She explained she was waiting for the dentist to visit the facility but did not have a scheduled date yet. The SSD was informed a dental consult was ordered over a month ago, on 9/12/20 and resident #7 had been experiencing worsening tooth aches since then. The SSD stated she was not aware of the consultation ordered in September and said, I was not told about pain. That is not good. I will call right now to see if we can get (the dentist) in ASAP. They have done that for me before. The SSD acknowledged 4 weeks was an unreasonable amount of time for resident #7 to have to wait for treatment for [REDACTED]. On 10/16/20 at 10:18 AM, Licensed Practical Nurse (LPN) C recalled resident #7 had tooth pain within the past few weeks and received pain medication. LPN C stated she reported the tooth pain to either the B Wing Unit Manager (UM), SSD or another nurse. She said, They shouldn't have to wait to see the dentist. On 10/16/20 at 10:24 AM, the B Wing UM stated she was made aware of resident #7's dental concerns on 10/14/20 when she read the nurse's note on the 24-hour report reviewed in a clinical morning meeting. She stated she informed the SSD that resident #7 required a dental appointment. The physician's orders for resident #7 were reviewed with the B Wing UM. She discovered the dental consultation order dated 9/12/20, and stated she did not recall seeing any documentation regarding tooth pain or discussion related to the order for a dental consultation. The B Wing UM could not explain how the nurses' notes and consultation about resident #7's dental issues were missed during the process of reviewing orders and the 24-hour report in daily clinical meetings. On 10/16/20 at 10:37 AM, the SSD stated the dentist was in the process of calling in a prescription for an appropriate pain medication for resident #7, and would be able to see and treat her in 4 days. On 10/16/20 at 3:11 PM, the Director of Nursing (DON) stated her expectation was nurses would obtain a dental consultation order, and the management team would review it along with all new orders in the daily clinical meeting. The DON stated nurse managers should communicate this information to the SSD either verbally or in writing. The DON stated she was told the B Wing UM informed the SSD of the consultation verbally, but the SSD had no recollection of the dental consultation for resident #7. The DON stated the SSD did not attend daily clinical meetings and did not participate in the order review process as was typical in other facilities. The DON acknowledged it was not acceptable for resident #7 to experience tooth pain without receiving effective pain management or dental services in a timely manner. On 10/16/20 at 3:24 PM, resident #7 was noted to have very poor dentition, with missing and a black, decayed tooth visible in the front of her mouth. She pointed to her left lower jaw and stated she had a tooth that was painful sometimes. She said, Not now, most in the nights. Review of the facility's policy and procedure for Dentist Services revised on 11/27/17, revealed the facility would contract with a licensed dentist to provide routine and 24-hour emergency dental services. The procedure directed staff to obtain an order for [REDACTED].

Based on observation, interview and record review, the facility failed to follow a physician's order for a dental consultation, and failed to arrange emergency dental services for tooth pain in a timely manner, for 1 of 10 sampled residents (#7). Findings: Resident #7 was admitted to the facility on [DATE]. The Admission/Readmission Data Collection form dated 2/20/20 revealed resident #7 had broken, chipped natural teeth and red, inflamed oral mucous membranes. The document indicated she also had a lesion or ulcer in her mouth. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 8/25/20 revealed resident #7 had clear speech, was able to express her ideas and wants, and had clear comprehension. The MDS assessment indicated resident #7 did not reject evaluation or care that is necessary to achieve the resident's goals for health and well-being. Review of the medical record revealed resident #7 had a care plan for oral and dental health problems related to poor oral hygiene and tooth pain, initiated on 5/06/20. The goal was resident #7 would be free of mouth infection or pain. The interventions directed staff to Coordinate arrangements for dental care, transportation as needed and monitor, document, report any oral and dental problems that need attention. Review of nurses' progress notes, medication administration records (MARs) and treatment administration records (TARs) for September and October 2020 revealed resident #7 received Tylenol for a headache on 9/05/20 at 9:39 PM. The medication was ineffective with a follow-up pain level of 5 on a 0 to 10 scale. On 9/06/20 at 11:07 AM, resident #7 again complained of a headache and received Tylenol. Later that evening at 6:26 PM, a nurse's note read, Tylenol given for toothache with some relief. The medication was deemed ineffective as her pain level was 5 after receiving the medication. The note indicated resident #7 complained of pain in a tooth that is noticeably loose on her left lower mouth. The documentation revealed the attending physician was notified, but there were no new orders or interventions noted in the medical record. A nurse's progress note dated 9/07/20 at 3:31 AM revealed resident #7 was extremely agitated, yelled at staff, refused her medication and was noncompliant with care. Resident #7 demanded to be let out of the facility as she was being held against her will. The physician was contacted again and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note read, Resident also has chief complaint of tooth ache, assess the mouth and the tooth is very loose. On 9/11/20 at 7:49 PM, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 9/12/20 at 2:47 PM read, dental consult obtained for resident loose tooth on left lower jaw and increased pain. Placed in tar and weekend sup (supervisor)aware; stated she would let B wing [nurse manager] know of above. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The following day, on 9/15/20 at 1:25 PM, resident #7 requested and received Tylenol again for tooth pain. Nurses continued to administer Tylenol for pain on 9/23/20 at 10:22 AM and 9/29/20 at 10:59 AM. On 10/13/20 at 1:43 AM, resident #7 received Tylenol for a tooth ache, which on re-assessment at 2:22 AM was reported to be ineffective. The note revealed resident #7 had a pain level of 5 and tooth still hurts. A Behavior Note written a few hours later, on 10/13/20 at 5:15 AM read, Resident was awake all night. She continuously asked for Aspirin for her tooth ache. Resident educated on that she has no order for Aspirin and was given Tylenol at 1:43am . resident kept asking for Aspirin every 5-10 mins (minutes) throughout the course of the night. Resident redirected several times. [Social Worker] aware of resident needing dental, awaiting dental appointment. A nurse's progress note dated 10/14/20 at 2:13 AM read, Resident still [complains of] tooth pain, becoming worse. Has not been given a dental appt yet. Needs dental consult asap (as soon as possible). Will notify day shift nurse to follow up with the nurse manager. The Order Summary Report retrieved on 10/16/20 revealed a physician's order dated 7/27/20 for Acetaminophen (Tylenol) 325 milligrams, 2 tablets every 4 hours as needed for pain, and an order dated 9/06/20 for pain assessment every shift. An order dated 7/27/20 read, Dental as needed and an order dated 9/12/20 read, Dental consult for loose tooth on left lower jaw. On 10/16/20 at 9:59 AM, the Social Services Director (SSD) confirmed she was responsible for arranging dental consultations. She stated there was an opportunity at least every 3 months to identify dental issues during scheduled nutrition, social services and nursing assessments. The SSD explained between these assessments, staff or residents could inform her of acute issues. The SSD stated after the nurse obtained a physician's order, she would get a consent form signed by the resident or their representative and fax all paperwork to the dental provider. The SSD recalled she was informed resident #7 had a loose tooth last week, obtained consent from resident #7's representative on 10/09/20, then contacted the dentist. She explained she was waiting for the dentist to visit the facility but did not have a scheduled date yet. The SSD was informed a dental consult was ordered over a month ago, on 9/12/20 and resident #7 had been experiencing worsening tooth aches since then. The SSD stated she was not aware of the consultation ordered in September and said, I was not told about pain. That is not good. I will call right now to see if we can get [the dentist] in ASAP. They have done that for me before. The SSD acknowledged 4 weeks was an unreasonable amount of time for resident #7 to have to wait for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/16/20 at 10:18 AM, Licensed Practical Nurse (LPN) C recalled resident #7 had tooth pain within the past few weeks and received pain medication. LPN C stated she reported the tooth pain to either the B Wing Unit Manager (UM), SSD or another nurse. She said, They shouldn't have to wait to see the dentist. On 10/16/20 at 10:24 AM, the B Wing UM stated she was made aware of resident #7's dental concerns on 10/14/20 when she read the nurse's note on the 24-hour report reviewed in a clinical morning meeting. She stated she informed the SSD that resident #7 required a dental appointment. The physician's orders for resident #7 were reviewed with the B Wing UM. She discovered the dental consultation order dated 9/12/20, and stated she did not recall seeing any documentation regarding tooth pain or discussion related to the order for a dental consultation. The B Wing UM could not explain how the nurses' notes and consultation about resident #7's dental issues were missed during the process of reviewing orders and the 24-hour report in daily clinical meetings. On 10/16/20 at 10:37 AM, the SSD stated the dentist was in the process of calling in a prescription for an appropriate pain medication for resident #7, and would be able to see and treat her in 4 days. On 10/16/20 at 3:11 PM, the Director of Nursing (DON) stated her expectation was nurses would obtain a dental consultation order, and the management team would review it along with all new orders in the daily clinical meeting. The DON stated nurse managers should communicate this information to the SSD either verbally or in writing. The DON stated she was told the B Wing UM informed the SSD of the consultation verbally, but the SSD had no recollection of the dental consultation for resident #7. The DON stated the SSD did not attend daily clinical meetings and did not participate in the order review process as was typical in other facilities. The DON acknowledged it was not acceptable for resident #7 to experience tooth pain without receiving effective pain management or dental services in a timely manner. On 10/16/20 at 3:24 PM, resident #7 was noted to have very poor dentition, with missing and a black, decayed tooth visible in the front of her mouth. She pointed to her left lower jaw and stated she had a tooth that was painful sometimes. She said, Not now, most in the nights. Review of the facility's policy and procedure for Dentist Services revised on 11/27/17, revealed the facility would contract with a licensed dentist to provide routine and 24-hour emergency dental services. The procedure directed staff to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the facility would provide dental services to ensure the resident maintains his/her highest practicable level of well-being.