Every finding on record at The Arbors Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 7 residents (Resident #1) reviewed for resident rights in that: Resident #1 was not offered water after he asked repeatedly for water. Resident #1 was left lying on the bed in only a brief with no blanket covering resident. This failure could place all residents at risk for poor hydration and diminished quality of life.Findings included: During a review of an admission record dated 7/1/26 indicated Resident #1 was a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of unspecified dementia (altered cognition), restlessness and agitation, and muscle wasting and atrophy(loss of muscle mass due to disuse). During a review of an admission MDS dated [DATE] for Resident #1 indicated he had severely impaired cognition indicated by a BIMS score of 1. He required supervision or touching assistance with eating; he required substantial to maximum assistance with toileting hygiene; all other ADLs were not attempted and the resident did not perform the activities prior to the current illness, exacerbation, or injury. During a review of the care plan dated 6/3/26 indicated Resident #1 had an ADL self-care performance deficit. Interventions in place included eating required staff assistance. During an interview on 6/29/26 at 11:45 a.m., FM A said on 6/13/26 at approximately 10:28 p.m., a nurse entered Resident #1's room to provide care. Resident #1 said the nurse did not provide Resident #1 with water, even though resident asked repeatedly for water. FM A said the nurse told Resident #1 I just gave you water and the nurse left the room and left the resident in bed, uncovered, wearing only a brief. FM A said Resident #1 continued to yell for water. FM A said Resident #1 had fluids available on his bedside table, but the nurse did not assist the resident to get a drink. FM A said CNA B had to come from another hallway to bring Resident #1 water. During record review of a video on 7/1/26 at 2:14 p.m., Resident #1 was observed lying in his bed in his room, uncovered, and wearing only a brief. Resident #1 had no clothing on. Resident #1 was heard calling out for water multiple times throughout the 1-minute-long video clip. LVN D was observed on video and heard to say what sounded like I already gave you water. LVN D then proceeded to open and re-tape down Resident's brief and exit the room. Resident #1 was left in the room still calling out for water, uncovered by blankets, and wearing no clothing. During an interview on 7/1/26 at approximately 2:30 p.m., the ADM was shown the video and identified the nurse as LVN D. The ADM said she had a problem with the video which included the resident wasn't offered water or covered up by the nurse. The ADM said she planned to move forward with an internal investigation. During an interview on 7/1/26 at 3:00 p.m., LVN D said she frequently took care of Resident #1. LVN D said resident asked for water frequently and she provided water to him anytime he asked. LVN D said there was never an incident where she failed to offer Resident #1 water when he asked for it. LVN D said she had never left the room while resident requested water to delegate that task to any other staff member, she always assisted the resident with water herself. LVN D said Resident #1 had no aversion to being covered by blankets but frequently wriggled out of his blankets. LVN D said she would always cover Resident #1 if he was uncovered before leaving the room. LVN D said if there was a video of her not giving Resident #1 water or not covering him up before leaving the room it's because she must have forgotten to do so. During an interview on 7/1/26 at 3:18 p.m., the DON said she was responsible for supervising all nursing staff in the facility. The DON said she expected rounding to be completed every 2 hours minimum and all resident needs should be addressed. The DON said Resident #1 did ask for water and fluids frequently. The DON said there was no clinical reason not to provide Resident #1 with water when he asked for it. The DON said Resident #1 did not like to wear clothes and should have been covered up with blanket(s) when staff left his room. Review of an undated facility policy titled Resident Rights indicated .The resident has a right to be treated with respect and dignity including.the right to receive the services and/or items included in the plan of care. Review of a Resident Grievance received on 6/7/26 filed by FM A indicated several complaints including resident needed assistance with all meals and fluid intakes. Corrective action that would be taken included staff informed that Resident #1 was an assisted diner for all meals. The grievance was signed on 6/7/26 by the DON.

Based on interview and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 7 residents reviewed for dietary services. Resident #1's dietary card was not brought to the kitchen staff in a timely manner causing Resident #1 to miss meal service. This failure could place all newly admitted residents at risk for poor nutrition/hydration and reduced quality of life.Findings included: During a review of an admission record dated 7/1/26 indicated Resident #1 was a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of unspecified dementia (altered cognition), restlessness and agitation, and muscle wasting and atrophy (loss of muscle mass from disuse). During a review of an admission MDS dated [DATE] for Resident #1 indicated he had severely impaired cognition indicated by a BIMS score of 1. He required supervision or touching assistance with eating; he required substantial to maximum assistance with toileting hygiene; all other ADLs were not attempted and the resident did not perform the activities prior to the current illness, exacerbation, or injury. During a review of the care plan dated 6/3/26 indicated Resident #1 had an ADL self-care performance deficit. Interventions in place included eating required staff assistance. During an interview on 06/29/26 at 12:45 p.m., the DM said there had been issues with getting dietary orders delivered timely to the kitchen staff from nursing. The DM said the kitchen cannot serve a resident if they do not have a dietary card because they would be unaware of any safety restrictions on the diet order. The DM said she was aware of two instances in which a resident's dietary card was not turned in timely, only one resulted in a missed meal. The DM said Resident #1 was admitted at approximately 7:30 p.m. and the dietary order from his admission was not communicated to the kitchen. The DM said the resident did not receive a lunch tray on 6/2/26 due to the dietary card not being turned in, but he did receive a tray later after a family member asked about the missing tray. The DM said she was unsure if Resident #1 had been served breakfast, but without a dietary order, he shouldn't have been served. During an interview on 6/30/26 at 9:15 a.m., [NAME] A said if a resident does not have a dietary card turned into the kitchen they can't be served due to not knowing their dietary restrictions. [NAME] A said the dietary cards are printed by nursing department during admission and are delivered to the kitchen. [NAME] A said if a resident did not have a dietary card the DM could attempt to look in the resident's electronic record for a dietary order, if one was entered. During an interview on 6/30/26 at 9:25 a.m., [NAME] B said she knew Resident #1. [NAME] B said Resident #1 was admitted in the afternoon once the kitchen staff had gone home. [NAME] B said the kitchen did not know Resident #1 was in the facility until a family member voiced concerns during lunch service that the resident had not received a tray. [NAME] B said Resident #1 was served lunch on 6/2/26 after the error was brought to the kitchen's attention. [NAME] B said Resident #1 was not served breakfast on 6/2/26. During an interview on 6/30/26 at 9:35 a.m., LVN C said the charge nurse working the floor when the resident was admitted was responsible for completing the admission. LVN C said part of the admission process is to enter the dietary order and to call the physician if there is no order entered. LVN C said part of the admission process was to then print out and deliver the dietary order to the kitchen. LVN C said the order was to be printed out and hand-delivered to the kitchen. During an interview on 6/23/26 at 10:32 a.m., the ADM said she was responsible for supervision of all staff in the facility and the DM was responsible for supervision of the kitchen staff. The ADM said it was her expectation that dietary cards would be delivered to the kitchen staff promptly to ensure all residents received appropriate meals. The DM said the facility was upgrading their software soon, which would make the process more streamlined, but until then she planned to discuss new admissions in morning meetings with the DM to ensure all new admits had their dietary orders communicated timely to the kitchen. The ADM said risks to residents who did not have their dietary orders turned in timely could lead to dehydration, lack of nutrition, diabetic concerns, and incorrect dietary restrictions. Review of a facility policy titled Diet Orders / Diet Manual indicated .Upon admission, Nursing Service transcribes the diet order as it is written by the physician on the diet transmittal form. Forms are sent to Dietary Service prior to meal service.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) and 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes while performing incontinent care for Resident #6 on 4/6/26. This failure could place residents at risk of exposure to infectious diseases.Findings included: Record review of a facility face sheet dated 4/6/26 for Resident #6 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of a comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 15, which indicated she had intact cognition. She required moderate assistance with toileting hygiene. She was always incontinent with bladder and frequently incontinent with bowels. Record review of a comprehensive care plan dated 3/24/26 for Resident #6 indicated she had an ADL self-care performance deficit and had an intervention required 2 staff members for toilet use. During an observation on 4/6/26 at 2:00 pm, CNA A and CNA B were observed to provide incontinent care on Resident #6. Both CNAs were observed to wash their hands upon entrance to room. CNA A provided care and CNA B helped with resident positioning. During care, CNA A was observed to clean the front perineal area appropriately, and then Resident #6 was rolled over on her left side for CNA A to perform care on her bottom. CNA A was then observed to remove her gloves and put on clean gloves without sanitizing or washing her hands. She was then observed to clean the rectal area, after which she changed gloves again without sanitizing or washing hands. She then applied the clean brief to Resident #6. During an interview on 4/6/26 at 2:30 pm, CNA A said she knew she was supposed to wash or sanitize her hands when changing her gloves, she said she just forgot. She said it was an infection risk to the residents if hand hygiene was not performed appropriately. During an interview on 4/6/26 at 2:35 pm, the Administrator said she expected staff to wash hands or sanitize hands between glove changes. She said it could cause an increase in infection risk for the residents. During an interview on 4/6/26 at 2:45 pm, RN C said she expected CNAs to perform hand hygiene between glove changes. She said residents could be at increased risk of infections if hand hygiene was not performed. The DON was not in facility and was unavailable for interview. Record review of a facility policy titled Fundamentals of Infection Control Precautions, undated, read: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .*after removing gloves or aprons.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards in the facility's only kitchen reviewed for food service safety.The facility did not ensure foods in the freezer were labeled and dated when removed from their original packaging on 1/12/2025.These failures could place residents who received their meals from the kitchen at risk of foodborne illnesses.Findings included:During an observation on 1/12/2026 at 9:17 AM, the DM was present in the kitchen. The walk-in freezer had the following:*an opened box of chicken thighs with two bags of chicken thighs that were not dated or labeled on the box or on the bags of chicken,*two bags of chicken wings sitting on a shelf in the freezer that were not dated or labeled, and*a large roll of ground beef sitting on a shelf in the freezer that were not dated or labeled.During an interview on 1/12/2026 at 9:19 AM, the DM said she was responsible for making sure foods were dated and labeled when removed from their original containers or boxes in the kitchen. She said she removed the chicken and ground beef when she made space for storing bags of ice and forgot to date them. She said if food were not dated or labeled, staff would not know how long they had been in the kitchen or if they were safe to use. During an interview on 1/14/2026 at 10:36 AM, the Administrator said the kitchen staff and DM were responsible for checking food in the kitchen daily to ensure they are dated and labeled. She said if foods were not labeled/dated, then foods could be spoiled or make them sick.Record review of a facility policy titled Food Storage and Supplies undated indicated, .All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated to when opened .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #41) reviewed for infection control. The facility failed to ensure LVN A followed enhanced barrier precautions guidelines when wound care was provided to Resident #41 on 01/13/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: Record review of an admission Record for Resident #41 dated 01/13/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with a diagnosis pressure ulcer (localized injuries to the skin and underlying tissue caused by prolonged pressure) to left hip and left heel. Record review of an admission MDS assessment dated [DATE] for Resident #41 indicated he did not have any impairment in thinking with a BIMS score of 15. He required substantial assistance with activities of daily living. He had one Stage 2 pressure ulcer (a shallow wound with a pink or red base), one stage 3 pressure ulcer (a wound that may go into the skin's fatty layer) and one unstageable pressure ulcer (a wound that penetrates all three layers of skin, exposing muscles, tendons and bones). Record review of a care plan for Resident #41 revised 11/04/2025 indicated he was on enhanced barrier precautions and had pressure ulcer to left heel and left hip. During an observation on 01/13/2025 at 10:10 AM, a sign indicating Resident #41 was on EBP (enhanced barrier precautions) and a container with PPE (personal protective equipment) was located outside of his room. LVN A was organizing supplies at the door of Resident #41's room to perform wound care. LVN A washed her hands in the bathroom. She applied gloves to both hands and cleaned the over bed table of the resident with a sani-cloth bleach wipe and a tray for supplies. She placed a protective barrier on the table and removed her gloves and sanitized her hands. She applied clean gloves and placed the wound care supplies on the barrier that was on the tray. She cleaned a pair of scissors using a sani-cloth bleach wipe and placed it on the tray. She removed her gloves and placed them in the trash and washed her hands in the bathroom. She put on clean gloves, she did not put on a protective gown prior to wound care. A dressing was noted to Resident #41's left heel that was dated 01/12/2026. LVN A removed the dressing and placed it in the trash. LVN A removed her gloves and used hand sanitizer and put on clean gloves. LVN A cleaned Resident #41's left heel with normal saline and gauze and she patted the wound dry with a gauze. She applied Santyl external ointment and calcium alginate topically to the wound bed and covered it with a dressing. She removed her gloves and placed them in the trash. She removed the trash, exited the room, and washed her hands. During an interview on 01/13/2026 at 10:30 AM, LVN A said during the wound care provided to Resident #41 she should have put on a gown prior to providing wound care. She said if a resident was on enhanced barrier precautions then a gown and gloves should be put on when providing wound care. She said the gowns and gloves are to prevent transmission of bacteria from the residents room to other residents. She stated not wearing the proper PPE could increase the chance of spreading infection to other residents. During an interview on 01/14/2026 at 9:30 AM with the ADON, she said she has been working at the facility for 3 weeks. She stated staff caring for residents placed on EBP were to wear the appropriate PPE according to assistance being provided to the resident. She stated staff should utilize gowns and gloves while providing wound care. She said the risk of not utilizing PPE per policy was increased risk of infection to the resident and other residents and staff in the facility. She said she expected the staff to follow the facility policy on infection control protocols and enhanced barrier precautions. During an interview on 01/14/2026 at 9:40 AM with the Regional Compliance Nurse, she said she was filling in as the DON until a full time DON was hired. She stated staff caring for residents on EBP was expected to follow the facilities policies and protocols regarding the use of gowns and gloves when providing care for the residents. She stated staff is educated on infection control policies and EBP upon hire and as needed. She stated the risk of not using proper PPE could be spreading infection to the resident under enhanced barrier precautions and to other residents in the facility. Her expectations are for the staff to follow all infection control and EBP policies and procedures when providing care for the residents. During an interview on 01/14/2026 at 10:00 AM with the administrator, she said staff who provide care to residents that are placed on enhanced barrier precautions are to wear PPE appropriate to the care being provided. She said staff providing wound care should wear gowns and gloves as stated in the facility policy. She stated staff is expected to wear PPE as indicated and that education on infection control policies and EBP policies are provided to all staff upon employment, annually and as needed. She said the risk of staff not following the infection control and EBP policies are increase risk of spreading infections to the residents and staff. Record review of the facility policy titled Enhanced Barrier Precautions dated 4/1/2024. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO's) that employ targeted gown and glove use during high contact resident care activities. It also indicates, EBP are indicated for residents with any of the following . wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO's.

Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, for 1 of 6 (CNA B) reviewed for annual competency evaluations.The facility failed to complete a performance review of CNA B and conducted services based on the results of the review.This deficient practice could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.Findings included:Record review of a personnel file review for CNA B indicated he was hired at the facility on 11/4/2024, with no evidence of a competency evaluation in the past 12 months. His last evaluation was on 11/4/2024.Record review of a CNA proficiency audit dated 11/4/2024 for CNA B indicated he was satisfactory with skills in the facility.During an interview on 1/13/2026 at 3:04 PM, CNA B said he had been employed at the facility for a year. He said he had a competency skills check-off when he was hired at the facility a year ago but could not remember if he had one since then.During an interview on 1/14/2026 at 10:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she would be responsible for ensuring the nurse aides receive their competency evaluations for skills yearly. She said she was not aware that CNA B did not have a yearly evaluation. She said if the evaluations were not done yearly, there was a risk of a lack of patient care.During an interview on 1/14/2026 at 10:23 AM, the Regional Consultant who was acting as the DON in the facility. She said the nurse aide evaluations with skills would be the responsibility between the ADON and DON to ensure they were completed. She said the evaluations should be done on hire and annually thereafter. She said she was not aware that CNA B did not have an annual check-off. She said residents could be at risk for a negative outcome if they were not completed yearly.During an interview on 1/14/2026 at 10:36 AM, the Administrator said the DON was responsible for making sure skill checks offs were done on hire, annually, and prn. She said she was not aware CNA B did not have an annual evaluation. She said residents could be at risk of not getting properly cleaned, infections, and skin issues if staff did not have proper training.Surveyor requested a policy for competency evaluations, and none was provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #62) residents observed for incontinent care.CNA B did not provide proper incontinent care for Resident #62 and wiped from the anal area toward the urethral area (back to front) on 1/13/2026.This failure could place residents at risk for bacterial infections from improper incontinent care. Findings include:Record review of an admission Record for Resident #62 dated 1/13/2026 indicated she was admitted to the facility on [DATE] and readmitted on [DATE] and was [AGE] years old with diagnoses of epilepsy (a chronic brain disorders that causes the wrong signals and seizures), gastrostomy status (an artificial opening in the stomach for feeding), Type 1 diabetes (a disorder where the pancreas produces little to no insulin for the body), and major depression disorder (persistent sadness or loss of interest).Record review of a Significant Change MDS Assessment for Resident #62 dated 12/11/2025 indicated she had moderate impairment in thinking with a BIMS score of 10. She required substantial/maximal assistance with toileting hygiene. She was frequently incontinent with urine/bowel.Record review of a care plan for Resident #62 dated 9/30/2025 indicated she had bowel and bladder incontinence. Interventions included provide pericare after each incontinent episode.During an observation on 1/13/2026 at 2:40 PM, CNA B and CNA C were at the room of Resident #62 to provide incontinent care. Both staff donned (put on) a gown in the hallway and entered the room to provide care and washed their hands in the bathroom and then they donned gloves. CNA B opened the brief of Resident #62 and pulled it down between her thighs and removed a wipe from the bag and wiped across her lower abdomen and placed it in the trash. CNA B removed another wipe and wiped down her right thigh and placed it in the trash. CNA B removed a wipe and wiped down her left thigh and placed it in the trash. CNA B removed a wipe and wiped down middle of her vagina from front to back and placed the wipe in the trash. CNA B removed his gloves and placed them in the trash; CNA B sanitized his hand and donned gloves. Resident #62 was rolled onto her left side and assisted by CNA C. CNA B removed the brief and his gloves and placed them in the trash. CNA B sanitized his hands and donned gloves. CNA B removed wipes and wiped Resident #62's buttocks from her rectum to her urethra (back to front) and removed his gloves and placed them in the trash along with the wipes. CNA B donned gloves and placed a brief underneath her buttocks. The brief was secured, and the resident was positioned on her back. CNA B applied barrier cream to her vaginal area and removed his gloves and placed them in the trash and he sanitized his hands. CNA B donned gloves and the resident was repositioned in bed. Both CNA B and CNA C doffed (took off) their gowns in the bathroom and placed them in the trash. Both sanitized their hands and removed the trash and linens from the room. CNA B lowered the bed and elevated the head of bed. During an interview on 1/13/2026 at 3:04 PM, CNA B said she had been employed at the facility for a year. He said he was always assigned to the same hall and worked on hall 100 with Resident #62. He said he should have wiped from front to back when he provided incontinent care to Resident #62. He said he was taught to wipe from front to back and if he did not it could lead to a UTI.During an interview on 1/13/2026 at 3:14 PM, CNA C said she had been employed at the facility since 9/9/25. She said during the care provided to Resident #62; CNA B should have wiped Resident #62's rectal area from front to back. She said she thought he knew what to do and did not say anything. She said if staff did not wipe the correct way with female residents, then they could be at risk for infection.During an interview on 1/14/2026 at 10:10 AM, the ADON said she has been employed at the facility for 3 weeks. She said if staff provided incontinent care to a female resident, they should wipe from front to back and if they did not there could be a risk for UTI's.During an interview on 1/14/2026 at 10:23 AM, the Regional Consultant who was the acting DON said when incontinent care was provided to a female, she expected the staff to follow policy, and they should clean from front to back. She said if they did not, there could be a risk of introducing bacteria or infections into the urinary tract.During an interview on 1/14/2026 at 10:36 AM, the Administrator said when care was provided to a female resident, staff should clean from front to back and if they did not there was a risk for residents to get UTI's or E. coli (infection caused by fecal material). She said she planned on all nurse aides to receive more training. Record review of a facility policy titled Perineal Care Female (with or without catheter) undated indicated, .Purpose: to clean the female perineum without contaminating the urethral area with germs from the rectal area. J. Cleaning the rectal and buttocks area, b. gently wash the rectal area and buttocks, wiping away from the base of the labia, working from the anus outward .

Based on interview and record review the facility failed to make sure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #5) reviewed for care plans.The facility failed to ensure Resident #5's comprehensive care plan was reviewed and revised when she was admitted to hospice services on 12/18/2025 This failure could place residents at risk of not receiving the care and services to meet their needs.Findings included:Record review of Resident #5's facility face sheet dated 1/14/2026 indicated Resident #5 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis of vascular dementia (problem with blood flow to the brain causing changes in memory, behaviors, and thinking.)Record review of Resident #5's significant change MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 04 indicating severely impaired cognition and was receiving hospice care.Record review of Resident #5's comprehensive care plan indicated it was last reviewed on 11/26/2025 and was not reviewed and revised with her significant change MDS assessment on 12/22/2025 to include her hospice services.Record review of Resident #5's order summary report dated 01/13/2026 revealed Resident #5 had an order on 12/18/2025 to admit to hospice services.During an interview on 1/13/2026 at 2:30 pm the MDS Coordinator said she was responsible for entering the MDS assessments as well as reviewing and revising the care plan with each assessment along with the IDT collaboration. She said that when a resident was on hospice the MDS and care plan should reflect hospice care. She said she was not sure how she missed adding hospice services to Resident #5's comprehensive care plan. She said if a care plan was not reviewed and updated with changes it could affect resident care.During an interview on 1/13/2026 at 3:30 pm the Regional Compliance Nurse said that the MDS Coordinator was responsible for the revision of the resident's care plan at the time of the assessment. She said that inaccurate care plans could result in delays in resident care. She said she expected all resident's care plans to be completed accurately and completely.During an interview on 1/14/2026 at 12:40 pm the Administrator said that comprehensive care plans should be reviewed and revised with significant changes, quarterly, annually and as needed with resident care changes. She said the MDS nurse and IDT should be reviewing the care plan and making sure all the care need areas were addressed. She said not having an accurate care plan could affect resident care needs and expected each resident's comprehensive care to be reviewed, revised and accurate. Record review of undated facility policy titled Comprehensive Care Planning indicated, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions .

Based on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents (Resident #62) reviewed for enteral feeding.The facility failed to ensure Resident #62's head of bed was maintained at 30 degrees elevated while receiving continuous feeding.The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway).Findings included:Record review of an admission Record for Resident #62 dated 1/13/2026 indicated she was admitted to the facility on [DATE] and readmitted on [DATE] and was [AGE] years old with a diagnosis of gastrostomy status (an artificial opening in the stomach for feeding),.Record review of a Significant Change MDS Assessment for Resident #62 dated 12/11/2025 indicated she had moderate impairment in thinking with a BIMS score of 10. She had a feeding tube while a resident.Record review of a care plan for Resident #62 dated 12/8/2025 indicated she required tube feeding. Interventions included to keep the head of bed elevated during and thirty minutes after tube feed.Record review of active physician orders for Resident #62 dated 1/13/2026 indicated she had an order for enteral feed every shift head of bed up at least 30 degrees during administration of enteral formula or water that started on 12/7/2025.During an observation on 1/13/2026 at 2:40 PM, CNA B and CNA C were at the room of Resident #62 to provide incontinent care. Both staff donned (put on) a gown in the hallway and entered the room to provide care and washed their hands in the bathroom and then they donned gloves. Resident #62 had a g-tube that was running and still connected with diabetisource AC at 53 ml/hr. Resident #62's head was lowered. CNA B opened the brief of Resident #62 and pulled it down between her thighs and removed a wipe from the bag and wiped across her lower abdomen and placed it in the trash. CNA B removed another wipe and wiped down her right thigh and placed it in the trash. CNA B removed a wipe and wiped down her left thigh and placed it in the trash. CNA B removed a wipe and wiped down middle of her vagina from front to back and placed the wipe in the trash. CNA B removed his gloves and placed them in the trash; CNA B sanitized his hand and donned gloves. Resident #62 was rolled onto her left side and assisted by CNA C. CNA B removed the brief and his gloves and placed them in the trash. CNA B sanitized his hands and donned gloves. CNA B removed wipes and wiped Resident #62's buttocks from her rectum to her urethra (back to front) and removed his gloves and placed them in the trash along with the wipes. CNA B donned gloves and placed a brief underneath her buttocks. The brief was secured, and the resident was positioned on her back. CNA B applied barrier cream to her vaginal area and removed his gloves and placed them in the trash and he sanitized his hands. CNA B donned gloves and the resident was repositioned in bed. Both CNA B and CNA C doffed (took off) their gowns in the bathroom and placed them in the trash. Both sanitized their hands and removed the trash and linens from the room. CNA B lowered the bed and elevated the head of bed. During an interview on 1/13/2026 at 3:04 PM, CNA B said she had been employed at the facility for a year. He said he was always assigned to the same hall and worked on hall 100 with Resident #62. He said he should have gotten the nurse to disconnect the tubing as it could be pulled while being attached and connected. He said he forgot and was nervous.During an interview on 1/13/2026 at 3:14 PM, CNA C said she had been employed at the facility since 9/9/25. She said during the care provided to Resident #62 they should have asked the nurse to disconnect the feeding because the resident could potentially aspirate.During an interview on 1/14/2026 at 10:10 AM, the ADON said she has been employed at the facility for 3 weeks. She said if staff provided care to a resident with tube feeding before they provided care the staff should inform the nurse to pause the feeding because when the head of bed was lowered there was a risk for aspiration. During an interview on 1/14/2026 at 10:23 AM, the Regional Consultant who was the acting DON said before incontinent care was provided to a resident with a feeding tube, the staff should get the nurse to stop the feeding as there could be a risk for a negative outcome or aspiration when the head of bed was lowered.During an interview on 1/14/2026 at 10:36 AM, the Administrator said before incontinent care was provided to a resident with a feeding tube, the staff should notify the nurse and have them turn the pump off and disconnect to prevent damage or chance of damage to the peg site and risk for aspiration.Record review of a facility policy titled Gastrostomy Tube Care undated indicated, Gastrostomy is a surgically created abdominal opening into the stomach for the purpose of administering feedings. 10. Maintain the resident in a semi to high-Fowler's position following a feeding .

Based on observation, interview, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 6 residents (Resident #5) reviewed for the right to be informed. 1. The facility failed to ensure Resident #5 had a signed medication consent form for Haldol (antipsychotic medication) and lorazepam (antianxiety medication) when ordered on 12/18/2025. 2. The facility did not ensure the need for and benefits of the proposed treatment with antipsychotic or neuroleptic medication was filled out on the HHSC Form 3713 Consent for Antipsychotic or Neuroleptic Medication when ordered on 12/18/2025. These failures could place residents at risk for treatment or services provided without their informed consent.Findings included: Record review of Resident #5's facility face sheet dated 1/14/2026 indicated Resident #5 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis of vascular dementia (problem with blood flow to the brain causing changes in memory, behaviors, and thinking.)Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 05 indicating severely impaired cognition and had received antipsychotic medications.Record review of Resident #5's comprehensive care plan dated 1/12/2026 indicated Resident #5 required anti-psychotic medications related to behavior management and to educate the resident, family, caregivers about risks, benefits and the side effects and the resident used anti-anxiety medications and to educate the resident, family, caregivers about risks, benefits and the side effects and/or toxic symptoms.Record review of Resident #5's order summary report revealed Resident #5 had an order on 12/18/2025 for haloperidol 2mg by mouth daily and lorazepam 0.5mg by mouth every 4 hours as needed for anxiety. Record review of Resident #5's consents for medications revealed no consent and no HHSC form 3713 was obtained prior to administering medications haloperidol or lorazepam to Resident #5. Record review of Resident #5's medication administration record for January 2026 revealed Resident #5 had received haloperidol daily as ordered but had not received lorazepam. During an observation and interview on 1/12/2026 at 9:46 am Resident #5 was sitting on the side of her bed and appeared drowsy . She said she was waking up but might lay back down and sleep a little longer. She was unaware of her medication regimen. During an interview on 1/13/2026 at 3:08 pm LVN A said that when a resident received an order for any medication in the antipsychotic, antidepressant, and antianxiety classification a consent for that medication should be obtained from the resident or their responsible party before administering that medication by the charge nurse. She said form 3713 was completed for the physician to sign as well. She said that residents had the right to know the risk of their medications before taking them. During an interview on 1/13/2026 at 3:30 pm the Regional Compliance Nurse said that the facility was currently without a DON, and she was the acting DON. She said the DON and ADON should be running an order listing report each morning to review each order and ensure consents were obtained for any medications requiring one. She said that system would be readdressed to ensure residents or their responsible person were informed prior to medications being given to protect the residents right to consent.During an interview on 1/14/2026 at 12:40 pm the Administrator said that any medication that required consent, the nurse obtaining the order should be discussing that medication with the resident or responsible person and obtaining that consent prior to administration of the medication. She said by not getting a consent goes against their rights and expected consents be obtained each time. Record review of an undated facility policy titled Resident Rights indicated, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. 5.The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Record review of a facility policy dated 2/12/25 titled Psychotropic Medication revealed, .Resident's Right to be Informed; Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also acceptable .

Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents reviewed for accuracy of assessments. (Resident #5) The facility failed to accurately document Resident #5's hospice services and antiplatelet therapy on her Quarterly MDS assessment on 1/05/2026. Resident #5 had an order on 12/18/2025 to admit to hospice services. This failure could place residents at risk of not receiving needed care and services.Findings included:Record review of Resident #5's facility face sheet dated 1/14/2026 indicated Resident #5 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis of vascular dementia (problem with blood flow to the brain causing changes in memory, behaviors, and thinking.)Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 05 indicated severely impaired cognition. The assessment did not include Resident #5's hospice services and her antiplatelet was miscoded as an anticoagulant.Record review of Resident #5's comprehensive care plan dated 9/23/2025 indicated Resident #5 required antiplatelet medication and did not include her hospice care.Record review of Resident #5's order summary report dated 01/13/2026 revealed Resident #5 had an order on 12/18/2025 to admit to hospice services and for Plavix 75mg po daily (an antiplatelet medication).During an interview on 1/13/2026 at 2:30 pm the MDS Coordinator said she was responsible for entering the MDS assessments as well as reviewing and revising the care plan with each assessment along with the IDT collaboration. She said that when a resident was on hospice the MDS and care plan should reflect hospice care and medications should be properly coded. She said she was sure how she missed adding hospice care and miscoded Resident#5 Plavix on the quarterly MDS assessment. She said inaccurate MDS assessments could result in delays in resident care. During an interview on 1/13/2026 at 3:30 pm the Regional Compliance Nurse said that the MDS Coordinator was responsible for accurately importing MDS assessments and the revision of the resident's care plan at the time of the assessment. She said that inaccurate MDS assessments and care plans could result in delays in resident care. She said she expected all resident's MDS assessments and care plans to be completed accurately and completely. During an interview on 1/14/2026 at 12:40 pm the Administrator said that the MDS nurse was responsible for completing the MDS accurately and then the corporate MDS team reviews them monthly for accuracy. She said that there are times that mistakes just happen and when they are discovered the MDS nurse would submit a revision. She said that incorrect MDS assessments could affect resident care and expected the MDS to be completed accurately each time. She said the facility did not have a policy regarding MDS accuracy and followed the RAI manual.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs received appropriate monitoring for 2 of 6 residents reviewed for unnecessary medications. (Residents #5 and #48)1. The facility did not have appropriate monitoring for psychotropic medications for Resident #5's Haldol (antipsychotic) and lorazepam (antianxiety) from 12/24/2025 to 1/11/2026.2. The facility did not have appropriate monitoring of psychotropic medications for Resident #48's Zoloft and venlafaxine (antidepressants), Quetiapine (antipsychotic), clonazepam (antianxiety) from 12/29/2025 to 1/11/2026. These failures could place residents at risk for unintended, harmful events attributed to the use of medications without the appropriate monitoring or indication for use.Findings included:1. Record review of Resident #5's facility face sheet dated 1/14/2026 indicated Resident #5 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis of vascular dementia (problem with blood flow to the brain causing changes in memory, behaviors, and thinking.)Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 05 indicated severely impaired cognition and had received antipsychotic medications.Record review of Resident #5's comprehensive care plan dated 1/12/2026 indicated Resident #5 required anti-psychotic medications related to behavior management and used anti-anxiety medications and to monitor, record, and report to physician as needed side effects and adverse reactions of psychoactiveMedications.Record review of resident #5's order summary report revealed Resident #5 had an order on 12/18/2025 for haloperidol 2mg by mouth daily and lorazepam 0.5mg by mouth every 4 hours as needed for anxiety. Record review of Resident #5's nurse weekly summary report log revealed Resident #5 had not received a weekly assessment to monitor side effects of psychotropic medications. An assessment was completed on 12/24/205 and not again until 1/11/2026. 2. Record review of Resident #48's facility face sheet dated 1/14/2026 indicated Resident #48 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis Alzheimer's.Record review of Resident #48's quarterly MDS assessment dated [DATE] indicated Resident #48 had a BIMS of 00 indicated severely impaired cognition and had received antipsychotic, antianxiety and antidepressant medications.Record review of Resident #48's comprehensive care plan dated 11/17/2025 indicated Resident #48 required antidepressant, antianxiety and antipsychotic medications and to monitor, record and report side effects to the physician.Record review of Resident #48's order summary report revealed resident #48 had an order for Quetiapine Fumarate 100 milligram tablet by mouth two times a day dated 8/07/2024, Quetiapine Fumarate 50 milligram tablet by mouth one time a day dated 4/29/2025, venlafaxine 100 milligram tablet by mouth one time a day dated 4/26/2025, Zoloft 50 milligram tablet by mouth one time a day every other day dated 712/2025, clonazepam 1 milligram tablet by mouth two times a day dated 8/16/2025. Record review of Resident #48's medication administration record revealed Resident #48 had received quetiapine, venlafaxine, Zoloft, and clonazepam medications and there was no monitoring documented for medication side effects. Record review of Resident #48's nurse weekly summary report log revealed Resident #48 had not received a weekly assessment for monitoring side effects to psychotropic medications. An assessment was completed on 12/29/2025 and not again until 1/11/2026. During an interview on 1/13/2026 at 3:08 pm LVN A said that when a resident received an order for any medication in the antipsychotic, antidepressant, antianxiety classifications the nurse documents on a weekly summary of those medications that they were monitored for any side effects. She said the nurse in charge must initiate the weekly summary assessment and there were times that assessment did not get completed. She said that high risk medications like antipsychotics, antidepressants and antianxiety should be monitored to prevent any adverse effects to those medications. During an interview on 1/13/2026 at 3:30 pm the Regional Compliance Nurse said that once a resident received an order for a high risk medication like an antipsychotic, antianxiety, and antidepressants then the nurse should monitor for any side effects weekly on the weekly nursing summary. She said that the DON and ADON should be monitoring those summaries at least monthly to ensure they were completed. She said medications not being monitored for side effects could result in a negative outcome for the residents.During an interview on 1/14/2026 at 12:40 pm 1he Administrator said that medications that are high risk like antipsychotics, antidepressants, and antianxiety should be monitored to ensure they were not acting as a chemical restraint, or the resident was not having any side effects or adverse reactions. She said the nurse should be monitoring those medications no less than weekly using the nurse weekly summary and expected each resident to be monitored appropriately to prevent any negative outcomes to the resident. Record review of a facility policy dated 2/12/25 titled Psychotropic Medications indicated, .The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Monitoring and Adverse Consequences Medication management is based in the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions as well as documenting medication management steps. Monitoring and accurate documentation of the resident's response to any psychotropic medication treatment (such as, lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regimen review) is essential to evaluate the ongoing effectiveness, benefits as well as risks of non-pharmacological approaches and psychotropic medications. Licensed Nurses- should continually monitor for medication adverse effects and behaviors and report to the physician or their designee as needed. The Weekly Summary in Point Click Care will also cue the nurse to document and report any behaviors or medication adverse effects to the physician or their designee. Any adverse effect or behavior will trigger an alert in PCC for nursing administration review

Based on interviews and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 6 residents (Resident #5) reviewed for baseline care plans. The facility failed to ensure Resident #5's baseline care plan was completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.Findings include:Record review of Resident #5's facility face sheet dated 1/14/2026 indicated Resident #5 was an [AGE] year-old female that was admitted to the facility on [DATE] with the diagnosis of vascular dementia (problem with blood flow to the brain causing changes in memory, behaviors, and thinking.)Record review of Resident #5's admission MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 07 indicating severely impaired cognition, had behaviors, and required assistance with ADL's.Record review of Resident #5's care plan revealed no baseline care plan was completed within 48 hours of admission and a care plan was not initiated until 15 days after admission on [DATE].During an interview on 1/13/2026 at 3:08 pm LVN A said that when a resident was admitted the charge nurse that admitted the resident was responsible for completing the assessments and orders and then activating the initial care plan. She said that care plan should be initiated within 24 hours so nurse aides and nurses would know the care needs of that resident. She said if a resident was to not get a care plan within the first 48 hours at the facility the resident could have a delay in care or injuries. During an interview on 1/13/2026 at 3:30 pm the Regional Compliance Nurse said nursing that admitted the resident should be completing the baseline care plan with 48 hours of admission. She said then the DON or ADON should review admissions in the morning meeting reviewing the baseline care plan for accuracy and completion to ensure each resident received the care they needed. She said she expected the baseline care plan be completed within 48 hours of admission to prevent any care delays or injuries to the residents. During an interview on 1/14/2026 at 12:40 pm the Administrator said the baseline care plan should be started by the admitted nurse and then the IDT should be reviewing and completing them within the 48-hour timeframe. She said if a resident did not receive a baseline care plan on admission it could affect resident care and expected all residents to have a baseline care plan per the guidelines. Record review of an undated facility policy titled Baseline Care Plans indicated, .This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will; be developed within 48 hours of a resident's admission .

Based on observations, interviews, and records review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure Resident #1 was treated with respect and dignity on 9/22/25 from approximately 9:00 a.m. to 1:00 p.m. when there was a brown substance that looked and smelled like feces smeared on the floor in her bathroom.The facility failed to ensure Resident #1 was treated with respect and dignity on 9/21/25 at approximately 6:00 p.m. when staff failed to provide assistance with ADLs.These failures could place residents at risk of psychosocial harm, self-isolation, and diminished quality of life.Findings included: 1.Review of an admission Record for Resident #1 dated 9/22/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of type 2 diabetes, vascular dementia (altered cognition), and muscle wasting and atrophy (muscle weakness). Review of a quarterly admission MDS for Resident #1 dated 8/16/25 indicated she had intact cognition with a BIMS score of 13. She required maximum staff assistance with putting on/taking off footwear, lower body dressing, showers/bathing, and toileting hygiene; she required supervision with personal hygiene; she required cleanup/setup assistance with eating and oral hygiene. She was occasionally incontinent of bladder and frequently incontinent of bowel. Review of the care plan for Resident #1 dated 8/15/24 indicated she had an ADL self-care performance deficit, and appropriate interventions were in place including encouraging resident to use bell to call for assistance. During an interview on 9/22/25 at 10:40 a.m., CNA A said she was working on Resident #1's hall and she rounded on every resident at least once every 2 hours. CNA A said she asked each resident if they needed any assistance and addressed their needs as part of routine rounding. She said she typically rounded at 7:30 a.m. when she came in to work and then she rounded again after breakfast at around 9:00 a.m. During an observation and interview on 9/22/25 at 10:50 a.m., Resident #1 was observed in her room sitting in a wheelchair. She appeared poorly groomed; she had stains on her shirt, a soiled wound-dressing on her right wrist, and a brown smear on her right leg which she identified as feces. Resident #1 said she had IBS and sometimes had episodes of bowel incontinence. Resident #1 said she had an episode of bowel incontinence this morning after breakfast. Resident #1 said she accidentally got feces on the floor and herself and activated her call light for assistance to clean up. Resident #1 said CNA A answered her call light but told her she could clean up the mess herself and did not offer any assistance. Resident #1 said staff did not like to help clean her up when she had bowel incontinence and it made her feel small, like I wanted to hide in my shell, it was humiliating, and it kept her from socializing with other residents because of embarrassment. During an interview on 9/22/25 at 11:00 a.m., a private sitter for Resident #1 said she comes daily to sit with Resident #1 on weekdays. The sitter said there was feces smeared in Resident #1's bathroom, on the floor in front of the toilet. The sitter said CNA A brought a shower chair into the bathroom at approximately 10:30 a.m. for Resident #1's shower and did not offer any assistance with cleaning the bathroom floor. During an interview on 9/22/25 at 3:30 p.m., CNA A said she answered Resident #1's call light after breakfast, at around 9:00 a.m. CNA A said Resident #1 was in the bathroom and had an episode of bowel incontinence. CNA A said she saw feces on the trash can in the bathroom and dirty clothes/towels on the floor. CNA A said Resident #1 told her she did not want any assistance. CNA A said Resident #1 does not usually require assistance for ADLs. During an interview on 9/22/25 at 4:00 p.m., LVN B said CNAs were expected to round on every resident a minimum of once every 2 hours. LVN B said CNAs were expected to ask residents if they had any needs and to address them. LVN B said if the CNA cannot address the need or the resident refused care the CNA was expected to alert the charge nurse. LVN B said she monitored compliance with resident care plans by maintaining good communication with staff and frequent rounding. LVN B said Resident #1 required staff assistance for ADLs. During an interview on 9/22/25 at 5:20 p.m., Resident #1's RP said on 9/21/25 at approximately 6:00 p.m. Resident #1 called him from the facility because she had an episode of bowel incontinence and the CNA staff would not help her clean up. RP said he drove approximately 20 minutes to the facility and Resident #1 was still sitting on the toilet and had not been assisted yet. RP said he asked the charge nurse why no one had assisted Resident #1. RP said he was told Resident #1 was team care (required 2 staff when providing care) and she asked for a different CNA. RP said after approximately 10 minutes the charge nurse and a CNA, whose names he could not recall, went to assist Resident #1. RP said both staff members stood outside the bathroom and handed her towels to clean herself up. During an interview on 9/22/25 at 5:40 p.m., Resident #1 said staff cleaned her bathroom at approximately 12:30 p.m. before her shower. Resident #1 said on 9/21/25 she had an episode of bowel incontinence. Resident #1 said she got feces on herself and activated her call light for assistance. Resident #1 said two CNAs arrived and told her she didn't need help; she could clean up herself. Resident #1 said they left and didn't return so she called her husband's cell phone for help. Resident #1 said it was humiliating. Review of a Nursing Note dated 9/21/25 at 3:14 a.m. by LVN C indicated .CNAs assisted [Resident #1] to restroom after which resident stated she did not want assistance from a CNA present. As resident is a two person assist at all times, CNA informed resident that she would need to find assistance to complete task.Prior to CNA finding assistance residents [RP] arrived to facility. Once met with help he demanded and began to raise his voice and asked why his wife was not assisted. During an interview on 9/22/25 at 11:45 a.m., the ADON said her job duties included supervision of nursing staff. The ADON said CNAs were expected to round a minimum of every 2 hours and were expected to address all needs including cleanliness of room and ADL needs. The ADON said she monitored care delivery at the bedside through good communication and conducting relevant in-services and training. During an interview on 9/22/25 at 12:15 p.m., the ADM said she was ultimately responsible for supervision of nursing staff. The ADM said CNAs were responsible for rounding at a minimum of once every 2 hours and more often for an identified need. The ADM said CNAs were expected to address all residents' needs and alert the charge nurse for any concerns. The ADM said any biological waste (blood, stool, etc .) was the responsibility of the nursing staff to clean it up. The ADM said going forward she planned to address ADL care and cleanliness of rooms during team meetings, in-service education, and rounding. Review of facility policy titled Resident Rooms - Daily dated 2022 indicated .contact Nursing to remove bodily fluids. Review of facility policy titled Resident Rights dated November 2021 indicated You have the right to.Live in safe, decent, and clean conditions.Be treated with dignity, courtesy, consideration, and respect.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility failed to provide a physician ordered medication of Estrace (estradiol), which was ordered to help reduce the thinning of vaginal and pelvic tissues, to Resident #1 for 32 days. This failure could place residents at risk for exacerbation of diagnoses or increased complications. Findings include: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses of chronic atrial fibrillation (irregular heartbeat), dementia (decline in cognitive function), neuromuscular dysfunction of bladder (nerves unable to communicate with muscles in the bladder), and chronic kidney disease. Review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 9 which indicated moderate cognitive impairment, and she required assistance for ADLs. She required maximal assistance for bathing, upper and lower body dressing, and putting on and taking off footwear; she required set-up assistance for oral hygiene, eating, and personal hygiene; she was dependent on staff assistance for toileting hygiene. She was always incontinent of bowel and had an indwelling foley catheter (tube that drains urine from your bladder). Review of a physician order dated 1/17/25 from an Obstetrics/Gynecology office indicated Resident #1 had a vaginal prolapse (weakened pelvic muscles allow pelvic organs to drop from their position) and a new medication order for Estrace (estradiol) Vaginal Cream 3 times a week was sent to the facility. Review of an Order Summary Report of Active Orders as of 2/18/25 indicated there was no pharmacy order for Estradiol. During an interview on 2/18/25 at 9:45 AM, Resident #1 said she had been to her Gynecologist (medical professional who specializes in the healthcare of the female reproductive system) last month and he sent the facility an order for an estrogen cream, but the facility was not administering it to her, and she did not know why. She said she had not discussed the medication with facility staff. During an interview on 2/18/25 at 4:00 PM, LVN D said she was familiar with Resident #1 and cared for her regularly. She said to her knowledge Resident #1 had never been ordered Estradiol and had not received it at the facility. She said orders received by telephone, fax, or electronically are entered into the resident chart by the nurse who received it. During an interview on 2/18/25 at 4:20 PM, LVN E said she knows Resident #1 and does not remember seeing an order for Estradiol in her chart. She said if a resident receives a medication order from an outside provider it should be entered into the resident chart by the nurse who received the order. During an interview on 2/18/25 at 5:00 PM, the DON said she was not aware Resident #1 ever received an order for Estradiol. She said the nurse who received the order should have entered it into the resident chart so the pharmacy could fill the medication order. During a second interview on 2/19/25 at 8:15 AM, the DON said the facility had corrected the deficiency and Resident #1 would begin receiving Estradiol that evening. She said going forward she would personally review all new orders daily and will in-service all nurses on entering physician orders. During an interview on 2/19/25 at 8:30 AM, the ADM said the charge nurse on duty who received the new physician order was expected to enter it into the resident chart. He said nursing managers should have been checking to ensure all new orders are entered correctly. He said the risk to residents not receiving ordered medications could vary from none to severe harm, depending on what the medication was and for what it was prescribed. Review of undated Pharmacy Policy & Procedures Manual 2003 indicated the following: .NEW VERBAL/TELEPHONE The nurse documents an order on the telephone order sheet or enters the order into PCC

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow infection control policies and procedures for 1 of 7 residents reviewed for infection control. (Resident #1) The facility failed to follow infection control guidelines and procedures when CNA B and CNA C performed catheter care for Resident #1 without donning appropriate PPE. The facility failed to follow infection control guidelines and procedures when CNA B and CNA C removed Resident #1's brief and performed catheter care without changing gloves, washing, or sanitizing their hands. This deficient practice could place residents at risk for cross contamination and/or spread of infection. Findings include: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses of chronic atrial fibrillation (irregular heartbeat), dementia (decline in cognitive function), acute cystitis (bladder inflammation), and chronic kidney disease. Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 9 which indicated moderate cognitive impairment, and she required assistance for ADLs. She required maximal assistance for bathing, upper and lower body dressing, and putting on and taking off footwear; she required set-up assistance for oral hygiene, eating, and personal hygiene; she was dependent on staff assistance for toileting hygiene. She was always incontinent of bowel and had an indwelling foley catheter (tube that drains urine from your bladder). Record review of a comprehensive care plan revision on 10/07/2024 indicated Resident #1 had an indwelling foley catheter related to urinary retention and she was on enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of MDROs. There were care interventions in place indicating gloves and gown should be donned if catheter care is to occur. During an observation on 2/18/25 at 10:00 AM, CNA B and CNA C performed catheter care for Resident #1 without donning protective gowns. Prior to performing catheter care CNA B and CNA C removed the briefs Resident #1 was wearing and did not change gloves, wash hands, or sanitize hands before cleaning Resident #1's perineal area and foley catheter tubing. During an interview on 2/18/25 at 11:00 AM, CNA B said she received training in incontinent care and catheter care and had successfully passed yearly skills competency evaluations to be able to work on the floor. She said she should have removed Resident #1's brief prior to washing her hands and starting catheter care. During an interview on 2/18/25 at 11:15 AM, CNA C said she received training in incontinent and catheter care and passed a skills competency check prior to being able to work by herself. She said she should not have moved from a dirty area to a clean area while performing catheter care. During an interview on 2/18/25 at 2:30 PM, Treatment Nurse said all staff receive training in skills competencies and were checked off on each skill prior to being able to work on the halls. She said all residents who are on special precautions have a sign outside of their room, by the door, and staff were trained and expected to wear appropriate PPE when performing care activities for those residents. During an interview on 2/18/25 at 4:20 PM, LVN D said all nursing staff were trained in incontinent care, catheter care, and PPE use. She said staff were educated to identify residents with special precautions by looking for signs outside of their rooms and for bins with PPE supplies by door. She said CNAs were expected to wear the appropriate PPE when caring for residents with special precautions. During an interview on 2/18/25 at 5:00 PM, the DON said every CNA was trained and checked off by a nursing supervisor on all skills before being cleared to work. She said CNAs were trained to identify residents with special precautions by looking for signs and bins of PPE supplies by resident room doors. She said staff were expected to utilize PPE as necessary and to follow infection control guidelines and procedures. She said not wearing PPE and not following infection control guidelines puts residents at risk for infection. She said going forward she intended to in-service all direct care staff concerning cross-contamination and PPE usage. During an interview on 2/19/25 at 8:30 AM, the ADM said all employees received required training including incontinent care, catheter care and PPE use, and were in-serviced regularly. He said as the ADM he was responsible for ensuring all staff have completed required training. He said all direct care staff were educated about residents that require PPE for their care and signs are posted outside of resident's room to identify that need. Review of a CNA Proficiency Audit dated 10/29/24 indicated CNA B had successfully demonstrated all required skills and proficiencies. The audit was signed by ADON. Review of an undated CNA Proficiency Audit indicated CNA C had successfully demonstrated all required skills and proficiencies. The audit was signed by DON. Review of a facility policy titled Infection Control Plan: Overview last revised on 03/2024 indicated .The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . Review of a facility policy titled Enhanced Barrier Precautions last revised on 4/1/24 indicated .EPB are used in conjunction with standard precautions and expand the use of PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

Based on interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and for 1 of 7 residents reviewed for physical environment. (Resident #3) The facility failed to ensure access to warm water for showering for Resident #3. This failure placed all residents in the facility at risk for discomfort, potential skin irritation, and a decline in the resident's quality of life. Findings: Record review of Resident #3's undated face sheet indicated he was an [AGE] year-old male admitted on [DATE] with diagnoses of left femur fracture, prostate cancer, and generalized muscle weakness. Review of an MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment, and he required assistance for ADLs. He required maximal assistance with toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear; he required moderate assistance with upper body dressing and personal hygiene; he required supervision for oral hygiene; he required setup assistance with eating. He was always incontinent of both bowel and bladder. Review of the comprehensive care plan revised on 10/21/24 indicated Resident #3 had impaired cognitive function and had an ADL self-care performance deficit. Care interventions in place included provide the resident with a homelike environment the resident prefers, and bathing assistance of 1-2 staff as needed. During an interview on 2/18/25 at 3:30 PM, CNA F said on 10/24/24 she and CNA G did assist Resident #3 with a shower. She said prior to starting Resident #3's shower she felt the water temperature with her hand, and it was warm. She said that CNA G and LVN D also verified the water was warm. She said LVN D asked Resident #3 to feel the shower water temperature and he said it was okay. She said there was no indication from Resident #3 that he was uncomfortable at any time. During an interview on 2/18/25 at 4:00 PM, LVN D said on 10/24/24 CNA F and CNA G took Resident #3 into the shower, and she went with them to cover a wound dressing on his leg so it would not get wet. She said Resident #3 appeared to be in good spirits when she left. She said Resident #3's sitter called her back to his room because he seemed uncomfortable. She said she asked Resident #3 what was wrong, and he said the water was too cold. She said she felt the water temperature with her hand, and it was cool, but not cold. She said she instructed CNA F and CNA G that if the water did not warm up, they would have to take Resident #3 to another room to shower. During an interview on 2/19/25 at 8:30 AM, the Maintenance Supervisor said the facility began having problems with the hot water on hall 400 toward the end of 2023, and he had a plumbing service company replace a mixing valve. He said he first became aware of new issues with water temperature after the incident on 10/24/24 and he assessed and adjusted the mixing valve himself. He said he checked a sample of rooms on each hallway every week and had not identified any new problems with the hot water supply. During an interview on 2/19/25 at 9:00 AM, the ADM said he was not aware of any problems with the water temperatures in resident rooms because he had only been working at the facility for 4 months. He said the Maintenance Supervisor kept a recorded log of water temperatures in resident rooms and should be checking every week to assure appropriate water temperatures. He said the facility suspended CNA F and CNA G from working at the facility until they completed individual counseling and 1-on-1 in-services related to ensuring that water temperatures are at a comfortable level for residents before beginning a bath or shower. Review of Water Temperature Logbook from 10/22/24 to 2/04/25 indicated all sampled resident rooms had warm water of appropriate temperature. Review of policy titled Resident Rights revised 11/2021 indicated residents .have the right to live in safe, decent, and clean conditions . and .have the right to make your own choices regarding personal affairs, care, benefits, and services .

Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident # 9 and Resident # 25) reviewed for quality of care. The facility failed to ensure Residents # 9 and Resident # 25's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: 1.Record review of a facility face sheet dated 10/7/24 for Resident # 9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), and chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure). Record review of a Quarterly MDS assessment dated [DATE] for Resident # 9 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Section H (Bladder and Bowel) indicated that she had an indwelling catheter. Record review of a comprehensive care plan dated 9/17/24 for Resident # 9 indicated that she had an indwelling catheter and had an intervention that read: .ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra . Record review of a physician's order summary report dated 10/7/24 for Resident # 9 indicated that she had the following order dated 3/15/24: .Ensure catheter strap in place and holding every shift . During an observation and interview on 10/7/24 at 3:46 pm Resident # 9 was observed lying in bed. She had no strap or anchor on the catheter tubing. She said she could not remember the last time she had one on it. She said it felt a little uncomfortable when moving because it felt like it was pulling on her bladder. 2. Record review of facility face sheet dated 10/07/2024 revealed Resident # 25 was an [AGE] year-old male that admitted on [DATE] with diagnoses of encephalopathy (a brain disease that alters brain function or structure), diabetes (high blood glucose), and urinary retention (difficulty emptying bladder). Record review of admission MDS assessment dated [DATE] revealed Resident # 25 had a BIMS score of 04, indicating severe impairment in thinking. Section H (bladder and bowel) indicated indwelling catheter was present at the time of MDS. Record review of comprehensive care plan initiated on 09/26/2024 and revised 10/01/24 revealed Resident # 25 had an indwelling catheter at the time the care plan was initiated with intervention to ensure tubing was anchored to the resident's leg or linens so that the tubing was not pulling on the urethra. Record review of the physician order summary, indicated an order dated 09/26/24 that read: Resident # 25 may have an indwelling catheter and had an order to . Ensure catheter strap in place and holding, every shift change as needed . Resident #25 had an order with a revision date of 10/07/2024 to . ensure catheter strap in place and holding every shift until 10/11/24. Record review of nurses note dated 09/27/24 revealed Resident # 25 admitted from the hospital on 09/26/24 with an indwelling catheter due to urinary retention. Record review of a Treatment Administration Record (TAR ) for Resident #25 for 10/01/24 to 10/07/24 had no indication for monitoring placement of a catheter strap. Record review of nurses note dated 10/08/224 read: Urology faxed orders for foley catheter to be discontinued 10/11/24 @0800. Resident has appointment with urology that same day AT 1515. NP notified; family aware . During an observation and interview on 10/07/24 at 10:15 am, Resident # 25 had an indwelling catheter present in a privacy bag and the tubing was not secured with a securement device. Resident # 25's family representative stated he was at the hospital a few weeks ago and they put the catheter in due to retention caused by an enlarged prostate. During on observation on 10/07/2024 at 10:30 am, Resident # 25 received catheter care by CNA B. Resident # 25 did not have a catheter tubing securement device in place. During an observation on 10/07/24 at 3:35 pm, Resident # 25 had his arm looped around the foley catheter drain line and draped across his shoulder, the catheter was not secured with a securement strap as ordered. During an observation and interview on 10/08/24 at 8:00 am, CNA A said that Resident #25 had a strap applied to secure his foley catheter earlier this morning by the nurse. CNA A said that not having a securement strap could cause harm or pain to the resident from the pulling or weight of the drainage bag pulling on the urethra. During an interview on 10/09/24 at 09:05 am, the DON said the nurses were responsible for assessing residents with indwelling catheters to ensure there was a securement device in place. She stated the charge nurse should also assess the securement device on each shift to ensure the resident was not having any discomfort from tension or pulling of the tubing. The DON stated she expected every resident with an indwelling catheter to have a securement device. The DON said she would be in servicing the staff. During an interview on 10/09/2024 at 11:35 am, the Administrator stated the nursing staff were responsible for ensuring catheters were secured and in place. He stated by not having a device it could cause discomfort, infections, and dislodgement. He stated he expected each resident with a catheter to have a securement device. He stated all physician orders should be followed. Record review of Nursing Policy and Procedure Manual for Catheter Care General Guidelines revised 2/13/2007 had no indication for application of a urinary securement strap. 46273

Based on observations, interviews, and record review the facility failed to ensure the right to resident and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 10 residents (Resident #3 and Resident #18) reviewed for call lights. The facility failed to ensure the emergency call light in Resident #3's and #18's shared bathroom was accessible from the floor on 10/7/24. These failures could affect residents who used their call lights or desire to use the call lights and place them at risk of not being able to notify staff of their needs. Findings include: Record review of a facility face sheet dated 10/7/24 for Resident #3 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar) and muscle wasting and atrophy (the loss of muscle mass and shortening of muscle fibers). Record review of a comprehensive MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. She required moderate to maximal assistance with toileting hygiene and personal hygiene. She required partial/moderate assistance with toileting transfers. She was frequently incontinent of bladder and bowel. Record review of a comprehensive care plan dated 7/30/24 for Resident #3 indicated that she was at risk for falls and had an intervention that read: .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Record review of a facility face sheet dated 10/7/24 for Resident #18 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: anemia (a condition where your blood produces a lower-than-normal amount of healthy red blood cells, leading to a lack of oxygen in the body), hypertension (high blood pressure), and myocardial infarction (heart attack). Record review of a comprehensive MDS assessment dated [DATE] for Resident #18 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. She required moderate to partial assistance with toileting and supervision/touching assistance with personal hygiene. She required partial/moderate assist with toilet transfers. She was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of a comprehensive care plan dated 8/13/24 for Resident #18 indicated that she was at risk for falls and had an intervention that read .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . During an observation and interview on 10/7/24 at 11:01 am the emergency call light in Resident #3's and #18's shared bathroom was observed with no string on the emergency call light. Resident #18 said that she did use the restroom independently and had not had any falls in the restroom. When exiting room, Resident #18 was observed ambulating into the restroom independently. CNA C was observed entering the room to assist the resident. During an observation on 10/7/24 at 11:28 am Resident #3 was observed ambulating independently into the restroom. During an interview on 10/7/24 at 10:38 am CNA C said that she had been employed here about a month. She said she would have maintenance fix the call light string. She said if a resident were to fall in the restroom, they would need to be able to reach the light to call for help. If they could not reach the light, they would be unable to call for help. During an interview on 10/9/24 at 11:28 am the Administrator said all staff were responsible for checking for bathroom call lights during their rounds. He said maintenance was responsible for installing the call light strings. He said residents could be at risk of a number of things and if they were in distress, the distress could escalate if they were not able to call for help. He said going forward they would be in-servicing the staff and making sure that administrative staff checked the call lights during their Champion Rounds and discuss the findings in the daily morning meetings. During an interview on 10/9/24 at 11:39 am the DON said all staff would be responsible to check the call lights during their Champion Rounds. She said a resident could potentially fall and not be able to call for help. She said they could possibly lay there for a long time. She said going forward they would be holding in-services and checking during their rounds. During an interview on 10/9/24 at 11:45 am the Maintenance Man said that he was responsible for ensuring the call lights were installed and functional. He said a resident could lay there a while without being able to call for help if they fell . He said he would be in-servicing staff and checking lights to ensure strings were there. Record review of a facility policy titled Resident Rights undated, read .the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #15) reviewed for infection control. CNA D did not wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #15. CNA D wiped down the catheter tubing and without changing the washcloth picked up the washcloth and started at the top of the catheter and wiped down again while performing catheter care for Resident #15. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a Face Sheet dated 10/08/2024 for Resident # 15 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included dementia (a decline in cognitive abilities), acute cystitis with hematuria (irritation of the bladder with blood in the urine), and encephalopathy (brain dysfunction). Record review of a Care Plan dated 2/20/2022 for Resident # 15 indicated he had an indwelling suprapubic urinary cathete r with interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag. Record review of a Quarterly MDS dated [DATE] for Resident # 15 indicated a BIMS score of 12 which indicated moderate cognitive impairment. He required substantial to maximal assistance with dressing, toileting hygiene, and showering. He was always incontinent of bowel and bladder. During an observation on 10/8/2024 at 2:02 pm in Resident # 15's room revealed, CNA D and LVN E were present to provide foley catheter care. Both staff washed their hands in the bathroom of Resident # 15's room and donned gloves. CNA D and LVN E positioned Resident # 15 in supine position to perform his foley catheter care. CNA D removed the blanket from Resident # 15. CNA D removed a washcloth from a basin on the over the bed table and began cleaning around the foley catheter insertion site working in a downward motion. CNA D after wiping downward on the catheter tubing picked up the washcloth and without turning the washcloth started back at the top of the catheter tubing wiping in a downward motion again. CNA D doffed gloves and without washing hands or sanitizing donned new gloves. CNA D then began drying the catheter tubing wiping in a downward motion and without turning the towel started back at the top of the catheter again wiped in a downward motion. CNA D then applied barrier cream around the catheter insertion site and on the catheter tubing. CNA D then retrieved trash bag with dirty linens and removed them from Resident #15's room. Both CNA D and LVN E went to the hall shower room across from Resident # 15's room and washed hands. During an interview on 10/08/2024 at 2:31 PM, LVN E said when asked if CNA D should have done anything differently with the foley catheter care provided to Resident #15, she said she should not have put barrier cream around the foley catheter insertion site and catheter tubing. She said CNA D had wiped down the catheter tubing without changing to a clean portion of the washcloth. She said while drying the catheter she wiped in a downward motion and without changing to a clean portion of the towel and started back at the top of the catheter tubing and wiped down again. She said she did notice that CNA D did not wash or sanitize her hands between glove changes . LVN E said CNA D's failures could cause the resident to get an infection. During an interview on 10/08/2024 at 2:37 PM, CNA D said after the catheter care while her and LVN E were washing their hands in the shower room, LVN E told her she should not have put barrier cream around the foley catheter insertion site and catheter tubing. She said she was nervous and had hand sanitizer in her pocket but had forgotten to use it in between glove changes. She said she always got confused when she tried to fold the washcloth to use it multiple times and must have forgotten to fold the washcloth to a clean area when she was wiping the catheter tubing . CNA D said by not using the correct procedure could cause the resident to get an infection. Record review of C.N.A Proficiency Audit dated 9/16/2024 for CNA D indicated she had been trained and had demonstrated handwashing and male foley catheter care procedure in accordance with the facility's standard of practice. During an interview on 10/09/2024 at 11:32 AM, the Administrator said the nurse managers were responsible for training CNA's in performing catheter care. He said going forward there would be a plan in place for training CNA's to properly perform catheter care. He said the potential risk if catheter care was not performed correctly was a possible infection for the resident. During an interview on 10/09/2024 at 11:35 AM, the DON said the nurse managers were responsible for making sure CNAs are trained properly to perform catheter care. She said if catheter care was not done properly the resident would be put at risk for infection at the catheter insertion site and internally. She said all nursing staff would be educated on infection control and catheter care with check offs. Record review of a facility policy titled Catheter Care with a revised date of February 13, 2007, indicated, .16. Gently wash, rinse and dry around the juncture of the catheter and meatus . 17. Then wash the catheter from the meatus down the tube about 3 inches. 18. Dispose of wash cloths. 19. Remove gloves. 20. Straiten clothing and bedding. 21. Wash Hands .

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for 3 of 3 Residents reviewed for accidents. (Residents #1, #2 and #3) The facility did not provide adequate training to van drivers to prevent accidents. Resident #1 slipped out of her wheelchair during transport and complained of back pain. She was taken to the emergency room and assessed for injury. A CT scan was performed and results showed [CONDITION(S)] (swelling) in the posterior low back. Resident complained of pain to her back. The facility transported 2 other wheelchair dependent residents (Resident #2 and Resident #3), after the incident without adequately training staff on securing residents in the van with safety devices. On 06/13/2022 at 5:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/14/2022, the facility remained out of compliance at a scope of a pattern and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of their plan of removal. These failures could place residents at risk for injury during transport in the facility van and place them at risk for serious harm, hospitalization , or death. Findings included: Record review of a fire department incident report dated 05/13/22 at 7:41 a.m. showed FD was dispatched for a medical assist for Resident #1 at 7:41 AM a location at Hwy 69 and local church. FD arrived at the scene at 7:45 AM. Departed the scene at 8:11 AM. Report Showed: Report from the facility that there was a patient in the floor of a van and needed assistance. We helped the patient up and return to the station. During an interview on 06/13/22 at 2:17 p.m. fireman for the local fire department said he responded with 3 other firemen on 05/13/22 at about 7:30 a.m. He said when he arrived, he saw a woman (Resident #1) lying in the floorboard of a van with the facility logo on the side. He said the woman's right foot was wedged underneath the front seat on the passenger side. He said before the woman could be moved, he had to rearrange her foot to avoid injury. He said he and two other firemen were able to get the woman back into her wheelchair. He said the woman complained of pain to her back. Resident #1 Record review of consolidated physician orders dated 06/01/2022 indicated Resident #1 was a [AGE] year-old female, admitted [DATE] with diagnoses of dependence on [CONDITION(S)], end stage renal disease, Diabetes, heart failure, muscle wasting and atrophy, chronic pain, pain in left shoulder and muscle weakness. She was to receive [CONDITION(S)] 3 times weekly on Monday, Wednesday, and Friday. Record review of a MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated she had moderately Impaired cognition and was alert to person, place, and time. Resident #1 required a wheelchair to ambulate and required assistance of two staff to transfer. Record review of a comprehensive care plan for Resident #1, dated 04/23/2022 indicated she used a wheelchair for locomotion and required 1 to 2 staff participation for mobility. She was a fall risk due to muscle weakness and staff will provide care to meet resident's needs to prevent injury. Record review of a nurse's note dated 05/13/22 at 8:11 a.m., indicated Resident #1 was being transported to the emergency room due to a fall on the facility van. Review of an emergency room report dated 05/13/22 revealed Resident #1 arrived at the emergency room at 8:20 a.m. Resident #1 was in her wheelchair traveling in a van to [CONDITION(S)]. The van slowed down to avoid a wreck, resident slid out of her wheelchair into the floor of the van. Resident complained of mild dull achy bilateral hip and low back pain. Resident #1 was given [MEDICATION(S)] ([MEDICATION(S)]) 5/325 MG tablet for pain. A CT scan was performed. The results showed [CONDITION(S)] (swelling) in the posterior low back. There were no fractures. Record review of facility transportation calendar dated from 05/13/22 to 06/13/22 revealed Resident #1 was transported in the facility van 9 times. (05/23/22, 05/25/22, 05/27/22, 06/01/22, 06/03/22, 06/06/22, 06/08/22, 06/10/22 and 06/13/22) Resident #2 was transported in the facility van 1 time (05/18/22) and Resident #3 was transported in the facility van 1 time (06/07/22). All three residents required being secured in their wheelchairs. Resident #2 Record review of consolidated physician orders dated 06/01/2022 indicated Resident #2 was an [AGE] year-old female, admitted [DATE] with diagnoses of abnormalities of gait and mobility, muscle wasting and atrophy, dementia, and fracture to left pelvis . Record review of a comprehensive care plan for Resident #2, dated 02/22/2022 indicated she was a fall risk and used a wheelchair for locomotion and required 1 to 2 staff participation for mobility. Staff will provide care to meet resident's needs to prevent injury. Resident #3 Record review of consolidated physician orders dated 06/01/2022 indicated Resident #3 was an [AGE] year-old male, admitted [DATE] with diagnoses of [CONDITION(S)], presence of artificial hip joint, abnormalities of gait and mobility, and muscle wasting and atrophy. Record review of a comprehensive care plan for Resident #3, dated 01/24/2022 indicated he was a fall risk and used a wheelchair for locomotion and required 1 to 2 staff participation for mobility. Staff will provide care to meet resident's needs to prevent injury. During an interview on 06/13/22 at 8:15 a.m. CNA A said she was driving the facility van on 05/13/22 transporting Resident #1 to [CONDITION(S)] around 7:30 a.m. CNA A said she had strapped Resident #1 to take her to her appointment. CNA A said she applied the brakes to avoid stalled traffic and Resident #1 slid under her safety belt on to the floor of the van. CNA said she called the DON to report the incident. CNA said the local fire department came and helped Resident #1 back into her wheelchair. CNA A said she took Resident #1 to the emergency room for evaluation and treatment. CNA A said Resident #1 complained of pain to her back and there was a red area on Resident #1 left clavicle bone where the shoulder strap rubbed when she slid out of the wheelchair. CNA A said she had received training on the van safety equipment but did not know there was a lap belt that needed to be used. During an interview on 06/13/22 during entrance conference at 8:00 a.m., the DON said on 05/13/22 in the early morning hours, she received a phone call from CNA A telling her Resident #1 had slid out of her wheelchair while being transported to [CONDITION(S)]. The DON said she told the administrator who called the local fire department for assistance. The DON said she instructed CNA A to take Resident #1 to the emergency room for evaluation and treatment because Resident #1 was complaining of pain to her back. During an interview on 06/13/22 during entrance conference at 8:00 a.m., the Administrator said on 05/13/22 around 7:30 a.m., she called the local fire department and asked for assistance to get Resident #1 back into her wheelchair because she slid out when the CNA A had to stop to avoid an accident. During an interview on 06/13/2022 at 1:05 p.m. Resident #1 said she remembered the incident on 05/13/22 when being driven to [CONDITION(S)]. She said CNA A was driving her to her appointment. She said CNA A strapped her and her wheelchair before leaving the facility. She said there was a big truck on the road and CNA A had to stop. She said when CNA A applied the brakes, she slid under the strap and out of her wheelchair on to the floor. She said the firemen came and put her back in her chair. She said she hit the back of her head and her tail bone. She said the back of her head and tail bone were hurting at the time of the incident, but no longer hurt. She said she had a bruise on her left shoulder, but it had healed. She said she felt safe riding in the van. During an interview on 06/13/22 at 1:15 p.m. CNA A said Resident #1 had bruising on the left side of her collar bone and chest after the incident, but it had fully healed. Observation on 06/13/22 at 1:05 p.m. revealed Resident #1 was returning from [CONDITION(S)] and sitting in her wheelchair in the facility van. The van was being driven by CNA C. There was a shoulder strap extending under the left-side arm rest, across her mid torso and under the right-side arm rest and locked into a buckle on the floor. There was no lap belt. During an interview on 06/13/22 at 1:15 p.m. CNA B said she had been trained by the maintenance director to use the safety harnesses designed to secure residents in wheelchairs during transport. CNA B said the last time she received training was 05/13/22 after the incident with Resident #1. CNA B said she did not know there was a lap belt which needed to be used to secure a resident in their wheelchair that prevented them from sliding out of the chair during a sudden stop. During an interview on 06/13/22 at 1:15 p.m. CNA A said she had been trained by the maintenance director to use the safety harnesses designed to secure residents in wheelchairs during transport. CNA A said the last time she received training was 05/13/22 after the incident with Resident #1. CNA A said she did not know there was a lap belt which needed to be used to secure a resident in their wheelchair that prevented them from sliding out of the chair during a sudden stop. Record review of installation instruction for seat beats in the facility van showed Pelvic belt restraints should make snug contact across the front of the body and the junction of the thigh and pelvis. Also: Restraints should not be held away from body by wheelchair components as arm rest or wheels. During an interview on 06/13/22 at 3:25 p.m. Maintenance Director said he had provided training to all staff who drive the facility van on 05/13/22 after the incident with Resident #1. He said he did not know there was a lap belt which needed to be used to secure a resident in their wheelchair that prevented them from sliding out of the chair during a sudden stop. Review of in-service training dated 05/13/22 at 10:00 a.m. revealed Maintenance Director conducted in-service training for CNA A and CNA B on Van proper seatbelt restrains-loading and unloading. The Administrator was notified on 6/13/2022 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 6/13/2022 at 5:10 p.m. The facility's Plan of Removal was accepted on 6/13/2022 at 9:25 p.m. and included: Plan of Removal: Problem: Accidents/Hazards/Supervision Interventions: * The facility van will not be used for transports until transport staff are trained on how to properly secure wheelchair residents according to the installation manual. * The Regional Compliance nurse in-serviced the DON and Administrator on 6/13/22 regarding: * Following the installation manual on securing wheelchairs in the van and ensuring that transport staff are trained according to the manual. * All staff who complete transports in the facility van will be trained on how to properly secure wheelchair residents before transports are completed. * On 6/14/22 a maintenance supervisor from a sister facility will begin in-servicing all staff who complete transports on how to properly secure wheelchair residents in the facility van according to the installation manual and provide return demonstration from the staff. In-servicing will be completed by 8:30 a.m. If staff are not in-serviced, they will be in-serviced prior to assuming their duties on their next scheduled shift. * On 6/14/22 a maintenance supervisor from sister facility will check installation of the lap belt and shoulder belt to ensure proper installation according to the manual. * On 6/14/22 the Administrator will be present during van training. * The medical director was notified regarding this plan on 6/13/22 at 5:48pm. * Resident's that require facility assisted transport have the potential of being affected. On 06/14/22 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview on 06/14/22 at 9:37 a.m. the Administrator said a QAPI meeting was held which included the Medical Director, facility administrator, director of nursing, and maintenance director to review plan of removal on 04/13/2022. She said training was provided to all staff who transport residents in the van on use of safety equipment. She said training was provided by a qualified maintenance director at a sister facility on 06/14/22 at 8:15 AM. Review of an In-service Training Attendance Roster dated 06/14/22 at 8:15 a.m., revealed the maintenance director, CNA A, CNA B, CNA C and Receptionist had attended training on Van Policy Regarding Securing Residents. During observations and interviews on 06/14/22 from 12:39 p.m. until 1:15 p.m. the maintenance director, CNA A, CNA B, and CNA C were observed securing a wheelchair in the facility van. All observations showed staff were able to demonstrate their ability to follow the safety instructions on securing residents on the van for safe transport. All observation included securing a shoulder strap and a lap belt. All staff said they had received training on the proper technique of securing residents for transport. On 6/14/2022 at 1:20 p.m., the Administrator was informed the IJ was removed, while the IJ was removed on 6/14/2022, the facility remained out of compliance at a scope of a pattern and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective system that were put into place.

Based on interview and record review, the facility failed to develop and implement their written policies and procedures to prohibit neglect for 5 of 15 residents reviewed for neglect. (Resident #s 14, 2, 21, 24, and 18) The facility did not clarify physician orders, notify the physician of continued Hi finger stick blood sugar (FSBS), and obtain orders for sliding scale insulin to correspond to elevated FSBS for Resident #14 when she had FSBS results greater than 450 for 22 days during the month of [DATE]. On [DATE] Resident #14 had a FSBS result over 600 at midnight and became pale and lethargic. The resident died an hour later. Resident #s 2, 21, 24, and 18 did not have parameters for physician notification, insulin administration, or emergency interventions for finger stick blood sugar results. An Immediate Jeopardy situation was identified [DATE] at 11:57 a.m. While the Immediate Jeopardy was removed on [DATE] at 4:45 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The failure could place 15 residents who were diabetics at risk for not receiving treatment to meet their needs and at risk for prevention of serious illness or death. Findings included: The abuse and neglect policy revised [DATE] indicated The resident has the right to be free from abuse, neglect, .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 1. In a closed record, an undated face sheet indicated Resident #14 was originally admitted [DATE]. The sheet indicated the resident died on [DATE]. A care plan initiated on [DATE] indicated Resident # 14 had a goal of would not have complications related to diabetes. Interventions included diabetes medications as ordered, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by the physician, and monitor/document/report to physician as needed for signs and symptoms of [MEDICAL CONDITION]. Readmission orders [REDACTED]. An Order Summary Report dated [DATE] indicated Resident #14 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #14 had the following orders: *accuchecks (FSBS) as needed for [DIAGNOSES REDACTED]/[MEDICAL CONDITION], start date [DATE], *FSBS one time a day start date [DATE], (sic) *FSBS on time a day start date [DATE], (sic) *FSBS before meals and at bedtime *if BS less than 70 or greater than 400 notify the physician start date [DATE], *[MEDICATION NAME] (long acting insulin) 20 units subcutaneously one time a day with a start date of [DATE], *[MEDICATION NAME] solution (fast acting insulin) inject as per sliding scale: if FSBS was ,[DATE] give 2 units; ,[DATE]= 4 units; ,[DATE] =6 units; ,[DATE]= 8 units; ,[DATE]=10 units and notify physician, An MDS dated [DATE] indicated Resident #14 was cognitively intact and required supervision and set up help with transfers, walking in room, dressing, eating, and toilet use. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for [DATE] at 12:00 a.m., 1:30 a.m., 4:00 a.m., 7:00 a.m., and 11:00 a.m. The undated Assure Platinum blood glucose monitoring system (the type used for Resident #14) User instruction manual indicated High blood sugar readings if your blood glucose is above 600mg/dl, you will receive a Hi. Repeat the test with a new strip. If this message shows again, contact your healthcare professional immediately! Contact your physician for advice if test result are very high (above 240mg/dl) and/or you have symptoms of high blood glucose. A nursing noted dated [DATE] at 1:30 a.m. indicated Resident #14 requested her blood sugar level be checked. Her blood sugar was high and resident said she felt like it was dropping. The note indicated the oncoming shift would be informed to report to provider. A nursing noted dated [DATE] at 12:19 a.m. indicated Resident #14 was resting in bed and her blood sugar reading was high. The notes indicated the resident had no signs of distress noted and they would continue to monitor. The nurse practitioner was paged. A nursing noted dated [DATE] at 1:01 a.m. indicated the nurse heard from the NP who said to continue to monitor blood sugar results for Resident #14. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for the following days and times: *[DATE] - 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. A nursing noted dated [DATE] indicated after the administration of the [MEDICATION NAME] insulin, Resident #14's blood sugar glucose reading continued to be elevated. The NP was paged at 12:51 a.m. and 1:50 a.m. At 4 a.m., the resident's blood sugar result was 459. The note indicated the nurse would report to oncoming shift. The [DATE] MAR contained 4 pages with FSBS times due. According to the MAR, the staff were to inform FSBSs on Resident #14 a total of 7 times a day. There were only insulin orders to correspond to 3 of those times. The times indicated on the MAR for FSBS were 0000, 0400, 1100, 1130, 1700, and 2000. Sliding scale insulin was scheduled for 0700 and 1100 and routine insulin was scheduled for 2200. The [DATE] MAR and [DATE] nursing notes for Resident #14 indicated the physician was not notified of FSBS results greater than 450 on the following days and times: *[DATE] - 8:00 p.m. *[DATE] - 12:00 a.m., *[DATE] - 12:00 a.m., 10:00 p.m. 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m., 4:00 a.m. *[DATE] - 4:00 a.m. *[DATE] - 12:00 a.m., 11:00 a.m. 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 10:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 7:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 4:00 a.m., 10:00 p.m., 7:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 7:00 a.m., 11:00 a.m., 8:00 p.m., 10:00 p.m. The [DATE] MAR showed that no FSBS checks were done for Resident #14 at 12 a.m. on ,[DATE] and ,[DATE]. A nursing note dated [DATE] indicated an order was received for [MEDICATION NAME] AD 2 after Resident #14's first loose bowel movement and then 1 capsule as needed after subsequent loose bowel movement and laboratory services for a stool culture and a sample to check for ova and parasites test (checks for parasites in stool) and [MEDICAL CONDITION] (bacterial infection in digestive tract). During an interview on [DATE] at 3:45 p.m., LVN L said [DATE] was her first night to work at the facility since she was rehired. LVN L said she did not administer insulin or notify the physician on [DATE], [DATE], [DATE], [DATE], and [DATE] when she checked Resident #14's blood sugar level at 12:00 a.m. and it was Hi (greater than 600mg/dl) because there was not an order to do so. She said even thoush the protocol was to notify the physician if a FSBS result was high or if the parameters provided by the physician required it, she was not concerned about Resident #14's high blood sugar results because Resident #14 normally had high results and would bottom out quickly and the family was okay with it being high. LVN L said the night before Resident #14 died ([DATE]), the resident had 11 episodes of diarrhea. She said on [DATE] she notified the NP because Resident #14 was pale, lethargic, had a Hi blood sugar result, and a low blood pressure. LVN L said residents receiving FSBS should have parameters for when to notify the physician. A nursing note dated [DATE] at 12:10 a.m. completed by LVN L indicated Resident #14's scheduled midnight finger stick result registered Hi on the glucometer. The note indicated the resident continued with complaints of feeling weak and listless. The note indicated the resident had a pale skin color and the NP was notified of the resident's status and vital signs. New orders were received to start an IV with normal saline to infuse, and immediately obtain a CBC and CMP laboratory panels. A nursing note dated [DATE] at 12:30 a.m. indicated upon securing the IV, Resident #14 stated I feel hot. Noted resident's body then stiffen like tonic [MEDICAL CONDITION] activity as her eyes rolled back in her head and the resident took one gasping breath. CPR (cardio-pulmonary resuscitation) was initiated. A nursing note dated [DATE] at 1:01 a.m. documented Resident #14 was pronounced dead remotely by a physician. During an interview on [DATE] at 9:50 a.m., LVN K said she was working on [DATE] and [DATE] at midnight and checked blood sugar levels for Resident #14. LVN K said when the glucometer read Hi they just kept monitoring to make sure Resident #14 was not bottoming out. LVN K said a Hi reading on the glucometer may indicate a blood sugar of 500 or greater and the physician should be notified. LVN K said she could not recall if she notified the physician of the Hi result and she did not document that she notified the physician or NP. LVN K said residents receiving FSBS should have parameters for when to notify the physician. During an interview on [DATE] at 10:35 a.m., LVN A said a Hi result on the glucometer would mean the blood sugar was greater than 500 to 600. LVN A said the physician should be notified of Hi results and results outside the given parameters. LVN A said residents receiving FSBS should have parameters for when to notify the physician. During a telephone interview on [DATE] at 3:26 p.m., the NP said the facility had protocols for when blood sugars readings were high. The NP said she could not recall being notified that Resident #14 had high blood sugars readings the six days prior to her death. She said if she was aware of the continuous Hi results, she would had given orders for the resident to have sliding scale insulin. 2. Consolidated physician orders [REDACTED].#2 was a [AGE] year old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included finger stick blood sugar two times a day in the morning and at bedtime. There were no parameters given for the blood sugars. A care plan with an initiation date [DATE] indicated Resident #2 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. 3. A face sheet dated [DATE] indicated Resident #18 was 89, admitted [DATE] with [DIAGNOSES REDACTED]. Most recent MDS dated [DATE] indicated Resident #18 was severely impaired cognitively, required extensive assistance of 2 staff for ADLs, and was a diabetic. A care plan last updated [DATE] indicated Resident #18 had diabetes. Interventions included administer diabetes medication as ordered, monitor/document side effects and effectiveness, FSBS as ordered, monitor/document/report signs and symptoms of hypo/[MEDICAL CONDITION] and infection. A MAR dated [DATE] to [DATE] indicated Resident #18 FSBS were checked four times a day, there were no parameters for MD notification. 4. Consolidated physician orders [REDACTED].#21 was [AGE] years old with [DIAGNOSES REDACTED]. The orders included finger stick blood sugar two times a day in the morning and at bedtime. There were no parameters given for the blood sugars. A care plan with an initiation date [DATE] indicated Resident #21 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. After surveyor intervention a clarification order dated [DATE] at 6:00 p.m. indicated parameters were given to notify physician or nurse practitioner for blood sugars less than 60 or greater than 450. 5. Consolidated physician orders [REDACTED].#24 was [AGE] years old with [DIAGNOSES REDACTED]. The orders included Accucheck (finger stick blood sugar) one time a day every Monday, Wednesday, and Friday for diabetes. The orders did not include blood sugar parameters. A care plan with an initiation date of [DATE] indicated Resident #24 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. After surveyor intervention a clarification order dated [DATE] at 6:00 p.m. indicated parameters were given to notify physician or nurse practitioner for blood sugars less than 60 or greater than 450. The administrator was notified on [DATE] at 11:57 a.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:44 p.m. and included: .Blood Glucose Parameters, Notification and Documentation Interventions: On [DATE] (NP) was asked to visit the facility and review the blood glucose readings from [DATE] to [DATE] for all residents that received Accuchecks. She reviewed these findings and the following orders were made and initiated: PARAMETERS <60 or >450 o (Resident ) - changed NPH from 18 units to 22 units 2 times per day o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday and prn. o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday. All residents who receive blood glucose had their treatment record reviewed for notification parameters on [DATE]. The following were clarified to reflect(NP) notification parameters that if the blood glucose is less than 60 or greater than 450 to notify the physician/ medical director. o (list of 12 residents) A notice was placed on the communication board in Point Click Care on [DATE] in Point Click Care regarding the blood glucose parameters of less than 60 or greater than 450 requires immediate verbal physician notification. The licensed nurses were inserviced regarding the following beginning [DATE]. All nurses not inserviced [DATE] will be inserviced on their first shift when they return to work. The nurses will be provided a print out of this inservice to keep for their review o Ensure that you are following the physician's orders [REDACTED]. o Ensure that you are documenting the results of a resident's blood glucose on the TAR each time you obtain a blood glucose and initial. o Ensure that you are notifying the physician or nurse practitioner if the resident's blood glucose is out of the parameters as listed on the TAR. Unless otherwise stated the parameters to notify are if the blood glucose is <60 or > 450. Notification should occur immediately and should be documented on the TAR. Any new orders received from the MD or NP should be initiated by the nurse. o Signs of [DIAGNOSES REDACTED] . o Signs of [MEDICAL CONDITION] . Monitoring The DON and or ADON at least 5 times per week for 4 weeks, will review the treatment records to ensure the following for all residents that receive accuchecks: o That accuchecks were performed as ordered and initialed as complete o If required, the correct dose of insulin was administered according to the accucheck o If the blood sugar was outside the parameters that physician or NP notification occurred and was documented. o Any new orders were initiated and transcribed. o Any new orders for accuchecks have parameters, if not contact the physician/ medical director for clarification orders . The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *During an interview on [DATE] at 1:00 p.m., LVN K, the charge nurse for Halls 200 and 300, said she was in-serviced that morning ([DATE]) on blood glucose, when to notify the physician, and abuse/neglect. She said for resident's with high or low FSBS results, she would document who she notified and the response on the back of the resident's MAR/TAR. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] 1:15 p.m., the ADON said she was in-serviced yesterday ([DATE]). She said she was in-serviced on blood glucose, when to notify the physician, and abuse/neglect. She said she was told to make sure blood glucose readings were documented on the TAR and if the FSBS results were >60 or <450, she would notify the physician. The ADON said they should document in the progress notes after notifying the physician. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] at 1:30 p.m., the DON said she started the in-service on [DATE] at night. She said she in-serviced 2 night nurses and 2 morning nurses. The DON provided a copy of the in-serviced material. She said a copy of the in-service would be hanging on the desk at the nursing station. *During an interview on [DATE] at 3:33 p.m., the MDS coordinator said she was in-serviced regarding residents with FSBS checks. She said she would notify the physician or NP for a resident with a FSBS greater than 450 or less than 60. She said she would document the results on the resident's TAR. *During an interview on [DATE] at 3:38 p.m., the treatment nurse said she was in-serviced and she would notify the physician or NP of a resident with a FSBS greater than 450 or less than 60. *The new telephone orders were reviewed and all diabetic residents in the facility had parameters. On [DATE] at 4:45 p.m., the corporate nurse and regional of operations were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. An order listing report dated [DATE] indicated 15 residents were diabetics.

Based on interview and record review, the facility failed to consult with the physician to alter treatment significantly or to commence a new form of treatment for 1 of 15 residents reviewed for physician notification. (Resident #14) The facility did not clarify physician orders, notify the physician of continued Hi finger stick blood sugar (FSBS), and obtain orders for sliding scale insulin to correspond to elevated FSBS for Resident #14 when she had FSBS results greater than 450 for 22 days during the month of [DATE]. On [DATE] Resident #14 had a FSBS result over 600 at midnight and became pale and lethargic. The resident died an hour later. An Immediate Jeopardy situation was identified [DATE] at 11:57 a.m. While the Immediate Jeopardy was removed on [DATE] at 4:45 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The failure could place 15 residents who were diabetics at risk for not receiving treatment to meet their needs and at risk for prevention of serious illness or death. Findings included: In a closed record, an undated face sheet indicated Resident #14 was originally admitted [DATE]. The sheet indicated the resident died on [DATE]. A care plan initiated on [DATE] indicated Resident # 14 had a goal of would not have complications related to diabetes. Interventions included diabetes medications as ordered, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by the physician, and monitor/document/report to physician as needed for signs and symptoms of [MEDICAL CONDITION]. Readmission orders [REDACTED]. An Order Summary Report dated [DATE] indicated Resident #14 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #14 had the following orders: *accuchecks (FSBS) as needed for [DIAGNOSES REDACTED]/[MEDICAL CONDITION], start date [DATE], *FSBS one time a day start date [DATE], (sic) *FSBS on time a day start date [DATE], (sic) *FSBS before meals and at bedtime *if BS less than 70 or greater than 400 notify the physician start date [DATE], *[MEDICATION NAME] (long acting insulin) 20 units subcutaneously one time a day with a start date of [DATE], *[MEDICATION NAME] solution (fast acting insulin) inject as per sliding scale: if FSBS was ,[DATE] give 2 units; ,[DATE]= 4 units; ,[DATE] =6 units; ,[DATE]= 8 units; ,[DATE]=10 units and notify physician, An MDS dated [DATE] indicated Resident #14 was cognitively intact and required supervision and set up help with transfers, walking in room, dressing, eating, and toilet use. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for [DATE] at 12:00 a.m., 1:30 a.m., 4:00 a.m., 7:00 a.m., and 11:00 a.m. The undated Assure Platinum blood glucose monitoring system (the type used for Resident #14) User instruction manual indicated High blood sugar readings if your blood glucose is above 600mg/dl, you will receive a Hi. Repeat the test with a new strip. If this message shows again, contact your healthcare professional immediately! Contact your physician for advice if test result are very high (above 240mg/dl) and/or you have symptoms of high blood glucose. A nursing noted dated [DATE] at 1:30 a.m. indicated Resident #14 requested her blood sugar level be checked. Her blood sugar was high and resident said she felt like it was dropping. The note indicated the oncoming shift would be informed to report to provider. A nursing noted dated [DATE] at 12:19 a.m. indicated Resident #14 was resting in bed and her blood sugar reading was high. The notes indicated the resident had no signs of distress noted and they would continue to monitor. The nurse practitioner was paged. A nursing noted dated [DATE] at 1:01 a.m. indicated the nurse heard from the NP who said to continue to monitor blood sugar results for Resident #14. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for the following days and times: *[DATE] - 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. A nursing noted dated [DATE] indicated after the administration of the [MEDICATION NAME] insulin, Resident #14's blood sugar glucose reading continued to be elevated. The NP was paged at 12:51 a.m. and 1:50 a.m. At 4 a.m., the resident's blood sugar result was 459. The note indicated the nurse would report to oncoming shift. The [DATE] MAR contained 4 pages with FSBS times due. According to the MAR, the staff were to inform FSBSs on Resident #14 a total of 7 times a day. There were only insulin orders to correspond to 3 of those times. The times indicated on the MAR for FSBS were 0000, 0400, 1100, 1130, 1700, and 2000. Sliding scale insulin was scheduled for 0700 and 1100 and routine insulin was scheduled for 2200. The [DATE] MAR and [DATE] nursing notes for Resident #14 indicated the physician was not notified of FSBS results greater than 450 on the following days and times: *[DATE] - 8:00 p.m. *[DATE] - 12:00 a.m., *[DATE] - 12:00 a.m., 10:00 p.m. 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m., 4:00 a.m. *[DATE] - 4:00 a.m. *[DATE] - 12:00 a.m., 11:00 a.m. 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 10:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 7:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 4:00 a.m., 10:00 p.m., 7:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 7:00 a.m., 11:00 a.m., 8:00 p.m., 10:00 p.m. The [DATE] MAR showed that no FSBS checks were done for Resident #14 at 12 a.m. on ,[DATE] and ,[DATE]. During an interview on [DATE] at 3:45 p.m., LVN L said [DATE] was her first night to work at the facility since she was rehired. LVN L said she did not administer insulin or notify the physician on [DATE], [DATE], [DATE], [DATE], and [DATE] when she checked Resident #14's blood sugar level at 12:00 a.m. and it was Hi (greater than 600mg/dl) because there was not an order to do so. She said even thoush the protocol was to notify the physician if a FSBS result was high or if the parameters provided by the physician required it, she was not concerned about Resident #14's high blood sugar results because Resident #14 normally had high results and would bottom out quickly and the family was okay with it. She said on [DATE] she notified the NP because Resident #14 was pale, lethargic, had a Hi blood sugar result, and a low blood pressure. A nursing note dated [DATE] at 12:10 a.m. completed by LVN L indicated Resident #14's scheduled midnight finger stick result registered Hi on the glucometer. The note indicated the resident continued with complaints of feeling weak and listless. The note indicated the resident had a pale skin color and the NP was notified of the resident's status and vital signs. New orders were received to start an IV with normal saline to infuse, and immediately obtain a CBC and CMP laboratory panels. A nursing note dated [DATE] at 12:30 a.m. indicated upon securing the IV, Resident #14 stated I feel hot. Noted resident's body then stiffen like tonic [MEDICAL CONDITION] activity as her eyes rolled back in her head and the resident took one gasping breath. CPR (cardio-pulmonary resuscitation) was initiated. A nursing note dated [DATE] at 1:01 a.m. documented Resident #14 was pronounced dead remotely by a physician. During an interview on [DATE] at 9:50 a.m., LVN K said she was working on [DATE] and [DATE] at midnight and checked blood sugar levels for Resident #14. LVN K said when the glucometer read Hi they just kept monitoring to make sure Resident #14 was not bottoming out. LVN K said a Hi reading on the glucometer may indicate a blood sugar of 500 or greater and the physician should be notified. LVN K said she could not recall if she notified the physician of the Hi result and she did not document that she notified the physician or NP. During an interview on [DATE] at 10:35 a.m., LVN A said a Hi result on the glucometer would mean the blood sugar was greater than 500 to 600. LVN A said the physician should be notified of Hi results and results outside the given parameters. During a telephone interview on [DATE] at 3:26 p.m., the NP said the facility had protocols for when blood sugars readings were high. The NP said she could not recall being notified that Resident #14 had high blood sugars readings the six days prior to her death. She said if she was aware of the continuous Hi results, she would had given orders for the resident to have sliding scale insulin. The administrator was notified on [DATE] at 11:57 a.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:44 p.m. and included: .Blood Glucose Parameters, Notification and Documentation Interventions: On [DATE] (NP) was asked to visit the facility and review the blood glucose readings from [DATE] to [DATE] for all residents that received Accuchecks. She reviewed these findings and the following orders were made and initiated: PARAMETERS <60 or >450 o (Resident ) - changed NPH from 18 units to 22 units 2 times per day o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday and prn. o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday. All residents who receive blood glucose had their treatment record reviewed for notification parameters on [DATE]. The following were clarified to reflect(NP) notification parameters that if the blood glucose is less than 60 or greater than 450 to notify the physician/ medical director. o (list of 12 residents) A notice was placed on the communication board in Point Click Care on [DATE] in Point Click Care regarding the blood glucose parameters of less than 60 or greater than 450 requires immediate verbal physician notification. The licensed nurses were inserviced regarding the following beginning [DATE]. All nurses not inserviced [DATE] will be inserviced on their first shift when they return to work. The nurses will be provided a print out of this inservice to keep for their review o Ensure that you are following the physician's orders [REDACTED]. o Ensure that you are documenting the results of a resident's blood glucose on the TAR each time you obtain a blood glucose and initial. o Ensure that you are notifying the physician or nurse practitioner if the resident's blood glucose is out of the parameters as listed on the TAR. Unless otherwise stated the parameters to notify are if the blood glucose is <60 or > 450. Notification should occur immediately and should be documented on the TAR. Any new orders received from the MD or NP should be initiated by the nurse. o Signs of [DIAGNOSES REDACTED] . o Signs of [MEDICAL CONDITION] . Monitoring The DON and or ADON at least 5 times per week for 4 weeks, will review the treatment records to ensure the following for all residents that receive accuchecks: o That accuchecks were performed as ordered and initialed as complete o If required, the correct dose of insulin was administered according to the accucheck o If the blood sugar was outside the parameters that physician or NP notification occurred and was documented. o Any new orders were initiated and transcribed. o Any new orders for accuchecks have parameters, if not contact the physician/ medical director for clarification orders . The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *During an interview on [DATE] at 1:00 p.m., LVN K, the charge nurse for Halls 200 and 300, said she was in-serviced that morning ([DATE]) on blood glucose, when to notify the physician, and abuse/neglect. She said for resident's with high or low FSBS results, she would document who she notified and the response on the back of the resident's MAR/TAR. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] 1:15 p.m., the ADON said she was in-serviced yesterday ([DATE]). She said she was in-serviced on blood glucose, when to notify the physician, and abuse/neglect. She said she was told to make sure blood glucose readings were documented on the TAR and if the FSBS results were >60 or <450, she would notify the physician. The ADON said they should document in the progress notes after notifying the physician. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] at 1:30 p.m., the DON said she started the in-service on [DATE] at night. She said she in-serviced 2 night nurses and 2 morning nurses. The DON provided a copy of the in-serviced material. She said a copy of the in-service would be hanging on the desk at the nursing station. *During an interview on [DATE] at 3:33 p.m., the MDS coordinator said she was in-serviced regarding residents with FSBS checks. She said she would notify the physician or NP for a resident with a FSBS greater than 450 or less than 60. She said she would document the results on the resident's TAR. *During an interview on [DATE] at 3:38 p.m., the treatment nurse said she was in-serviced and she would notify the physician or NP of a resident with a FSBS greater than 450 or less than 60. *The new telephone orders were reviewed and all 15 diabetic residents in the facility had parameters. On [DATE] at 4:45 p.m., the corporate nurse and regional of operations were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. An order listing report dated [DATE] indicated 15 residents were diabetics.

Based on interview and record review, the facility failed to ensure treatment and care based on the comprehensive assessment and in accordance with the professional standards of practice were provided for 5 of 16 residents reviewed for quality of care. (Resident #14, 2, 18, 21, & 24) The facility did not clarify physician orders, notify the physician of continued Hi finger stick blood sugar (FSBS), and obtain orders for sliding scale insulin to correspond to elevated FSBS for Resident #14 when she had FSBS results greater than 450 for 22 days during the month of [DATE]. On [DATE] Resident #14 had a FSBS result over 600 at midnight and became pale and lethargic. The resident died an hour later. Resident #s 2, 21, 24, and 18 did not have parameters for physician notification, insulin administration, or emergency interventions for finger stick blood sugar results. An Immediate Jeopardy situation was identified [DATE] at 11:57 a.m. While the Immediate Jeopardy was removed on [DATE] at 4:45 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The failure could place 15 residents who were diabetics at risk for not receiving treatment to meet their needs and at risk for prevention of serious illness or death. Findings included: 1. In a closed record, an undated face sheet indicated Resident #14 was originally admitted [DATE]. The sheet indicated the resident died on [DATE]. A care plan initiated on [DATE] indicated Resident # 14 had a goal of would not have complications related to diabetes. Interventions included diabetes medications as ordered, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by the physician, and monitor/document/report to physician as needed for signs and symptoms of [MEDICAL CONDITION]. Readmission orders [REDACTED]. An Order Summary Report dated [DATE] indicated Resident #14 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #14 had the following orders: *accuchecks (FSBS) as needed for [DIAGNOSES REDACTED]/[MEDICAL CONDITION], start date [DATE], *FSBS one time a day start date [DATE], (sic) *FSBS on time a day start date [DATE], (sic) *FSBS before meals and at bedtime *if BS less than 70 or greater than 400 notify the physician start date [DATE], *[MEDICATION NAME] (long acting insulin) 20 units subcutaneously one time a day with a start date of [DATE], *[MEDICATION NAME] solution (fast acting insulin) inject as per sliding scale: if FSBS was ,[DATE] give 2 units; ,[DATE]= 4 units; ,[DATE] =6 units; ,[DATE]= 8 units; ,[DATE]=10 units and notify physician, An MDS dated [DATE] indicated Resident #14 was cognitively intact and required supervision and set up help with transfers, walking in room, dressing, eating, and toilet use. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for [DATE] at 12:00 a.m., 1:30 a.m., 4:00 a.m., 7:00 a.m., and 11:00 a.m. The undated Assure Platinum blood glucose monitoring system (the type used for Resident #14) User instruction manual indicated High blood sugar readings if your blood glucose is above 600mg/dl, you will receive a Hi. Repeat the test with a new strip. If this message shows again, contact your healthcare professional immediately! Contact your physician for advice if test result are very high (above 240mg/dl) and/or you have symptoms of high blood glucose. A nursing noted dated [DATE] at 1:30 a.m. indicated Resident #14 requested her blood sugar level be checked. Her blood sugar was high and resident said she felt like it was dropping. The note indicated the oncoming shift would be informed to report to provider. A nursing noted dated [DATE] at 12:19 a.m. indicated Resident #14 was resting in bed and her blood sugar reading was high. The notes indicated the resident had no signs of distress noted and they would continue to monitor. The nurse practitioner was paged. A nursing noted dated [DATE] at 1:01 a.m. indicated the nurse heard from the NP who said to continue to monitor blood sugar results for Resident #14. The [DATE] MAR for Resident #14 indicated a Hi FSBS result for the following days and times: *[DATE] - 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. A nursing noted dated [DATE] indicated after the administration of the [MEDICATION NAME] insulin, Resident #14's blood sugar glucose reading continued to be elevated. The NP was paged at 12:51 a.m. and 1:50 a.m. At 4 a.m., the resident's blood sugar result was 459. The note indicated the nurse would report to oncoming shift. The [DATE] MAR contained 4 pages with FSBS times due. According to the MAR, the staff were to inform FSBSs on Resident #14 a total of 7 times a day. There were only insulin orders to correspond to 3 of those times. The times indicated on the MAR for FSBS were 0000, 0400, 1100, 1130, 1700, and 2000. Sliding scale insulin was scheduled for 0700 and 1100 and routine insulin was scheduled for 2200. The [DATE] MAR and [DATE] nursing notes for Resident #14 indicated the physician was not notified of FSBS results greater than 450 on the following days and times: *[DATE] - 8:00 p.m. *[DATE] - 12:00 a.m., *[DATE] - 12:00 a.m., 10:00 p.m. 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m. *[DATE] - 12:00 a.m., 4:00 a.m. *[DATE] - 4:00 a.m. *[DATE] - 12:00 a.m., 11:00 a.m. 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 10:00 p.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 7:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m. *[DATE] - 4:00 a.m., 10:00 p.m., 7:00 a.m., 11:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 5:00 p.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 4:00 a.m., 8:00 p.m., 10:00 p.m. *[DATE] - 12:00 a.m., 8:00 p.m. *[DATE] - 12:00 a.m., 7:00 a.m., 11:00 a.m., 8:00 p.m., 10:00 p.m. The [DATE] MAR showed that no FSBS checks were done for Resident #14 at 12 a.m. on ,[DATE] and ,[DATE]. A nursing note dated [DATE] indicated an order was received for [MEDICATION NAME] AD 2 after Resident #14's first loose bowel movement and then 1 capsule as needed after subsequent loose bowel movement and laboratory services for a stool culture and a sample to check for ova and parasites test (checks for parasites in stool) and [MEDICAL CONDITION] (bacterial infection in digestive tract). During an interview on [DATE] at 3:45 p.m., LVN L said [DATE] was her first night to work at the facility since she was rehired. LVN L said she did not administer insulin or notify the physician on [DATE], [DATE], [DATE], [DATE], and [DATE] when she checked Resident #14's blood sugar level at 12:00 a.m. and it was Hi (greater than 600mg/dl) because there was not an order to do so. She said even thoush the protocol was to notify the physician if a FSBS result was high or if the parameters provided by the physician required it, she was not concerned about Resident #14's high blood sugar results because Resident #14 normally had high results and would bottom out quickly and the family was okay with it being high. LVN L said the night before Resident #14 died ([DATE]), the resident had 11 episodes of diarrhea. She said on [DATE] she notified the NP because Resident #14 was pale, lethargic, had a Hi blood sugar result, and a low blood pressure. LVN L said residents receiving FSBS should have parameters for when to notify the physician. A nursing note dated [DATE] at 12:10 a.m. completed by LVN L indicated Resident #14's scheduled midnight finger stick result registered Hi on the glucometer. The note indicated the resident continued with complaints of feeling weak and listless. The note indicated the resident had a pale skin color and the NP was notified of the resident's status and vital signs. New orders were received to start an IV with normal saline to infuse, and immediately obtain a CBC and CMP laboratory panels. A nursing note dated [DATE] at 12:30 a.m. indicated upon securing the IV, Resident #14 stated I feel hot. Noted resident's body then stiffen like tonic [MEDICAL CONDITION] activity as her eyes rolled back in her head and the resident took one gasping breath. CPR (cardio-pulmonary resuscitation) was initiated. A nursing note dated [DATE] at 1:01 a.m. documented Resident #14 was pronounced dead remotely by a physician. During an interview on [DATE] at 9:50 a.m., LVN K said she was working on [DATE] and [DATE] at midnight and checked blood sugar levels for Resident #14. LVN K said when the glucometer read Hi they just kept monitoring to make sure Resident #14 was not bottoming out. LVN K said a Hi reading on the glucometer may indicate a blood sugar of 500 or greater and the physician should be notified. LVN K said she could not recall if she notified the physician of the Hi result and she did not document that she notified the physician or NP. LVN K said residents receiving FSBS should have parameters for when to notify the physician. During an interview on [DATE] at 10:35 a.m., LVN A said a Hi result on the glucometer would mean the blood sugar was greater than 500 to 600. LVN A said the physician should be notified of Hi results and results outside the given parameters. LVN A said residents receiving FSBS should have parameters for when to notify the physician. During a telephone interview on [DATE] at 3:26 p.m., the NP said the facility had protocols for when blood sugars readings were high. The NP said she could not recall being notified that Resident #14 had high blood sugars readings the six days prior to her death. She said if she was aware of the continuous Hi results, she would had given orders for the resident to have sliding scale insulin. 2. Consolidated physician orders [REDACTED].#2 was a [AGE] year old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included finger stick blood sugar two times a day in the morning and at bedtime. There were no parameters given for the blood sugars. A care plan with an initiation date [DATE] indicated Resident #2 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. 3. A face sheet dated [DATE] indicated Resident #18 was 89, admitted [DATE] with [DIAGNOSES REDACTED]. Most recent MDS dated [DATE] indicated Resident #18 was severely impaired cognitively, required extensive assistance of 2 staff for ADLs, and was a diabetic. A care plan last updated [DATE] indicated Resident #18 had diabetes. Interventions included administer diabetes medication as ordered, monitor/document side effects and effectiveness, FSBS as ordered, monitor/document/report signs and symptoms of hypo/[MEDICAL CONDITION] and infection. A MAR dated [DATE] to [DATE] indicated Resident #18 FSBS were checked four times a day, there were no parameters for MD notification. 4. Consolidated physician orders [REDACTED].#21 was [AGE] years old with [DIAGNOSES REDACTED]. The orders included finger stick blood sugar two times a day in the morning and at bedtime. There were no parameters given for the blood sugars. A care plan with an initiation date [DATE] indicated Resident #21 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. After surveyor intervention a clarification order dated [DATE] at 6:00 p.m. indicated parameters were given to notify physician or nurse practitioner for blood sugars less than 60 or greater than 450. 5. Consolidated physician orders [REDACTED].#24 was [AGE] years old with [DIAGNOSES REDACTED]. The orders included Accucheck (finger stick blood sugar) one time a day every Monday, Wednesday, and Friday for diabetes. The orders did not include blood sugar parameters. A care plan with an initiation date of [DATE] indicated Resident #24 had diabetes mellitus with a goal of no complications related to diabetes mellitus. The interventions included monitoring for signs and symptoms of low and high blood sugar, but did not provide blood sugar parameters. After surveyor intervention a clarification order dated [DATE] at 6:00 p.m. indicated parameters were given to notify physician or nurse practitioner for blood sugars less than 60 or greater than 450. The administrator was notified on [DATE] at 11:57 a.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:44 p.m. and included: .Blood Glucose Parameters, Notification and Documentation Interventions: On [DATE] (NP) was asked to visit the facility and review the blood glucose readings from [DATE] to [DATE] for all residents that received Accuchecks. She reviewed these findings and the following orders were made and initiated: PARAMETERS <60 or >450 o (Resident ) - changed NPH from 18 units to 22 units 2 times per day o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday and prn. o (Resident) - changed the Accuchecks from Monday, Wednesday and Friday to once per week on Monday. All residents who receive blood glucose had their treatment record reviewed for notification parameters on [DATE]. The following were clarified to reflect(NP) notification parameters that if the blood glucose is less than 60 or greater than 450 to notify the physician/ medical director. o (list of 12 residents) A notice was placed on the communication board in Point Click Care on [DATE] in Point Click Care regarding the blood glucose parameters of less than 60 or greater than 450 requires immediate verbal physician notification. The licensed nurses were inserviced regarding the following beginning [DATE]. All nurses not inserviced [DATE] will be inserviced on their first shift when they return to work. The nurses will be provided a print out of this inservice to keep for their review o Ensure that you are following the physician's orders [REDACTED]. o Ensure that you are documenting the results of a resident's blood glucose on the TAR each time you obtain a blood glucose and initial. o Ensure that you are notifying the physician or nurse practitioner if the resident's blood glucose is out of the parameters as listed on the TAR. Unless otherwise stated the parameters to notify are if the blood glucose is <60 or > 450. Notification should occur immediately and should be documented on the TAR. Any new orders received from the MD or NP should be initiated by the nurse. o Signs of [DIAGNOSES REDACTED] . o Signs of [MEDICAL CONDITION] . Monitoring The DON and or ADON at least 5 times per week for 4 weeks, will review the treatment records to ensure the following for all residents that receive accuchecks: o That accuchecks were performed as ordered and initialed as complete o If required, the correct dose of insulin was administered according to the accucheck o If the blood sugar was outside the parameters that physician or NP notification occurred and was documented. o Any new orders were initiated and transcribed. o Any new orders for accuchecks have parameters, if not contact the physician/ medical director for clarification orders . The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *During an interview on [DATE] at 1:00 p.m., LVN K, the charge nurse for Halls 200 and 300, said she was in-serviced that morning ([DATE]) on blood glucose, when to notify the physician, and abuse/neglect. She said for resident's with high or low FSBS results, she would document who she notified and the response on the back of the resident's MAR/TAR. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] 1:15 p.m., the ADON said she was in-serviced yesterday ([DATE]). She said she was in-serviced on blood glucose, when to notify the physician, and abuse/neglect. She said she was told to make sure blood glucose readings were documented on the TAR and if the FSBS results were >60 or <450, she would notify the physician. The ADON said they should document in the progress notes after notifying the physician. She verbally listed the signs and symptoms of hyper/[DIAGNOSES REDACTED]. *During an interview on [DATE] at 1:30 p.m., the DON said she started the in-service on [DATE] at night. She said she in-serviced 2 night nurses and 2 morning nurses. The DON provided a copy of the in-serviced material. She said a copy of the in-service would be hanging on the desk at the nursing station. *During an interview on [DATE] at 3:33 p.m., the MDS coordinator said she was in-serviced regarding residents with FSBS checks. She said she would notify the physician or NP for a resident with a FSBS greater than 450 or less than 60. She said she would document the results on the resident's TAR. *During an interview on [DATE] at 3:38 p.m., the treatment nurse said she was in-serviced and she would notify the physician or NP of a resident with a FSBS greater than 450 or less than 60. *The new telephone orders were reviewed and all diabetic residents in the facility had parameters. On [DATE] at 4:45 p.m., the corporate nurse and regional of operations were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. An order listing report dated [DATE] indicated 15 residents were diabetics.

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure ulcers from developing and worsening for 2 of 2 residents reviewed for pressure ulcers. (Residents #s 4 and 8) The facility did not provide pressure relieving interventions for Resident #4's feet to prevent the resident from developing a pressure ulcer. The resident was admitted without pressure ulcers and was identified to be at risk for developing wounds. He developed a facility-acquired DTI on his left heel within 14 days of admission. The facility did not implement interventions to consistently provide pressure relief after the resident was noted to be non-compliant with the use of pillows. The pressure ulcer worsened to an unstageable and required debridement and an antibiotic. The facility did not cover the resident's wound for approximately 3 hours while the resident was up in his wheelchair. It was left exposed until surveyor intervention. The facility did not provide interventions for Resident #8's feet to prevent the resident from developing a pressure ulcer. The resident was admitted without pressure ulcers and was identified to be at high risk for developing wounds. She developed a facility acquired unstageable pressure ulcer on the outer side of her right foot. The resident's left heel was soft and spongy to touch. This failure could place 2 residents with pressure ulcers at risk for the development of new pressure ulcers and the worsening of existing pressure ulcers. Findings included: 1. Physician orders [REDACTED].#4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included the following: *pressure relieving mattress (initial date 4/17/17), *offload heels while in bed for wound prevention (initial date 4/25/17), *cleanse wound to left heel with wound cleanser, pat dry, apply nickel thick size amount of Santyl (topical debridement) and cover with alginate and then apply a foam dressing every day and as needed for loose or soiled dressing (initial date 6/25/17). An admission MDS dated [DATE] indicated Resident #4 had severe cognitive impairment, required extensive assistance of 2 for transfers, and had impairment of range of motion in both upper and lower extremities. He was at risk for the development of pressure ulcers and not have pressure ulcers upon admission. A care plan initiated 4/28/17 indicated Resident #4 developed a stage 3 pressure ulcer on his left heel on 4/25/17 with an intervention to ensure heels are floated with the use of pillows. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *4/25/17 - DTI measuring 1.5 cm x 1.9 cm x unable to determine. The heel was red and blue with no blister or open area. Pillows were used to float the resident's heels. *5/2/17 - DTI measuring 1.2 cm x 2.1 cm. The low air loss mattress was checked and indicated pillows were used to float the resident's heels. A Wound Care Specialist Evaluation dated 5/8/17 indicated Resident #4's left heel pressure ulcer had deteriorated and was now unstageable (due to necrosis). The recommendations included to off-load the wound, float the resident's heels in bed, and apply Prevalon boots (minimizes pressure, friction and shear on feet, heels and ankles of non-ambulatory residents) while in bed. The evaluation indicated pillows were being used to offload the resident's heels. A nursing progress note dated 5/8/17 indicated the wound care physician indicated Resident #4's left heel pressure ulcer was an unstageable. The note indicated Resident #4's heels were floated on a pillow while he was in bed. The note did not address the use of heel lifts or Prevalon boots. A nursing progress note dated 5/13/17 indicated Resident #4 continuously kicked the pillows used to off-load his heels off the bed or to the side. The nurse indicated she explained the importance of keeping his heels floated to the resident, but Resident #4 was non-compliant. The notes did not address any other interventions attempted to provide pressure relief for his heels. A nursing progress note dated 5/14/17 indicated Resident #4's heels were not floated and the pillow was on the floor. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *5/15/17 - Unstageable measuring 3 cm x 2.3 cm. The assessment indicated pillows were used to float the resident's heels. No other pressure relieving interventions were listed. A nursing progress note dated 5/15/17 indicated Resident #4 continued to forget to keep his heels floated on a pillow. The note indicated when the nurse reeducated the resident on the importance of pressure relief, he said he tried to. A nursing progress note dated 5/17/17 indicated Resident #4 remained non-compliant with keeping his heels floated on a pillow. A Wound Care Specialist Evaluation dated 5/22/17 indicated Resident #4's unstageable left heel pressure ulcer further deteriorated and a recommendation for heel wedge to float heels in bed was made. The evaluation indicated pillows were in use to offload the resident's heels. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *5/23/17 - DTI measuring 3.3 cm x 2.7 cm. The assessment indicated the resident was non-compliant with keeping his heels floated on pillows. A care plan initiated 5/29/17 indicated Resident #4 developed an unstageable pressure ulcer on his left heel. Interventions included to ensure his heels were floated with the use of pillows, administer treatments as ordered, monitor interventions for effectiveness, and replace loose or missing dressing as needed. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *6/6/17 - DTI measuring 2.3 cm x 2.9 cm with eschar (dead tissue) present. Pillows were in use to offload the resident's heels. A nursing progress note dated 6/9/17 indicated new orders to cleanse Resident #4's left heel with wound cleanser, apply skin prep, and cover with foam pad every day with extra foam pad to be added for extra comfort. Patient teaching provided on the importance of floating his heels and the resident acknowledged understanding. A nursing progress note dated 6/16/17 indicated Resident #4 was placed on Bactrim DS (antibiotic) two times a day for 10 days for wound healing for his left heel pressure ulcer. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *6/19/17 - Unstageable measuring 3.0 cm x 3.0 cm with eschar present. The assessment indicated the resident was more compliant with floating heels. Pillows were in use to offload the resident's heels. A nursing progress note dated 6/19/17 indicated Resident #4's left heel pressure ulcer was debrided by the wound care physician. The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *6/26/17 - DTI measuring 2.2 cm x 2.5 cm x 0.2 cm with 25% eschar present in the wound bed and yellow drainage. No odor was noted. *7/3/17 - Stage 3 measuring 2.5 cm x 1.8 cm x 0.2 cm. A Wound Care Specialist Evaluation dated 7/3/17 indicated Resident #4's left heel pressure ulcer was a stage 3. The wound bed was described to have 90% granulation tissue (healing tissue) and 10% necrotic tissue. The most recent MDS dated [DATE] indicated Resident #4 had severe cognitive impairment with inattention and disorganized thinking that changed in severity. He required extensive assistance of 2 for bed mobility, limited assist of one for transfers, and limited assist of one for toileting. He was frequently incontinent of bowel and bladder. He had 2 stage 3 pressure ulcers with the largest measuring 2.0 cm x 2.0 cm x 0.2 cm and the most severe tissue type indicated the presence of eschar (dead tissue). The Weekly-Ulcer Assessments for Resident #4's left heel pressure ulcer (performed by the treatment nurse) indicated: *8/7/17 - Stage 3 measuring 2.4 cm x 2.7 cm x 0.2 cm. Pillows were in use to offload the resident's heels and a low air mattress was in place. A Wound Care Specialist Evaluation dated 8/14/17 indicated Resident #4's left heel pressure ulcer was a stage 3 measuring 2.0 cm x 2.5 cm x 0.2 cm with 95% granulation tissue and 5% necrotic tissue. Recommendations included debridement, continue wound care with Santyl and calcium alginate, off-load the wound, and float the resident's heels while in bed. During an interview on 8/15/17 at 9:25 a.m., LVN B said they were unsuccessful in keeping Resident #4's heels floated on a pillow. She said the resident was confused upon admission and could not remember or did not understand the need of floating his heel. LVN B said she did not consult the physician of his non-compliance and the facility did not attempt to identify other interventions to offload Resident #4's heels. During an observation and interview on 8/14/17 at 10:15 a.m., CNA D said Resident #4 was in the shower and he had a pressure ulcer on his heel. A low air loss mattress was on his bed and a pressure relieving pad was in his wheelchair. The CNA said the resident did not have a dressing on the pressure ulcer. During an observation on 8/14/17 at 12:15 p.m. Resident #4 was assisted to the toilet by staff. The resident's left heel pressure ulcer left heel was exposed and not covered with a dressing. During an observation and interview on 8/14/17 at 12:42 p.m., Resident #4 was in his room in his wheelchair with his feet on the ground. The resident had on house slippers and his left heel pressure ulcer was exposed without a dressing covering the wound. He said the nurse took the dressing off that morning before he took a shower. The left heel pressure ulcer had pale wound edges, granulation tissue covered the wound base and yellow/grey slough was visible on the wound margins. During an observation and interview on 8/14/17 at 1:00 p.m., the physical therapist aide asked Resident #4 if he was ready to go to therapy. Resident #4's left heel pressure ulcer was not covered with a dressing, exposing the wound. The surveyor intervened and informed the physical therapy aide there was no dressing to cover the resident's left heel pressure ulcer. The physical therapist aide said he would notify the nurse. During an interview on 8/15/17 at 8:55 a.m., LVN A said she did not replace Resident #4's dressing on his left heel pressure ulcer after his shower on 8/14/17 (at 10:15 a.m.). She said she waited until after the noon meal was served because she could not provide wound care during meals service. LVN A said it was against company policy to use pressure relieving devices such as heel lifts or boots. She said they could only use pillows to provide pressure relief. She said she did not consult with the physician or other staff for alternatives for pressure relief for Resident #4's left heel pressure ulcer after the resident was non-compliant with offloading his heels on the pillows. During an interview on 8/15/17 at 8:55 a.m., RN C said it was not acceptable practice to leave Resident #4's left heel pressure ulcer exposed without a dressing for a period of 3 hours because of meal service. RN C said the treatment nurse should have covered the resident's wound with a dressing soon after the resident's shower. He said using devices such as heel lifts and boots to offload pressure was not against company policy. RN C said he would not expect a confused resident to keep their foot on a pillow. He said other pressure relieving devices could be attempted according to nursing judgement. During an observation and interview on 8/14/17 at 3:55 p.m., Resident #4 was in his wheelchair and his heels were not offloaded. The wound care physician evaluated Resident #4's left heel pressure ulcer and debrided necrotic tissue from the wound bed. She said there was about 5% necrotic tissue at the edges and provided the following measurements: 2.0 cm x 2.5 cm x 0.2 cm. During an interview on 8/16/17 at 8:10 a.m., the DON said she would expect wound care dressings to be applied as ordered to protect stage 3 pressure ulcer from becoming contaminated. 2. Physician orders [REDACTED].#8 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders included: apply skin prep to right outer foot two times a day and as needed for wound healing. An Initial Skin assessment dated [DATE] indicated Resident #8 admitted to the facility without pressure ulcers. A Braden Scale dated 6/6/17 indicated Resident #8 was high risk for developing pressure ulcers. An MDS dated [DATE] indicated Resident #8 had severe cognitive impairment, unclear speech, and was usually understood and usually understood others. Resident #8 had inattention, disorganized thinking, and altered levels of consciousness that was present daily. She required extensive assistance of 2 for bed mobility, transfers, and toileting. She had impaired range of motion of the upper and lower extremities on one side and an indwelling urinary catheter. The resident did not have any pressure ulcers upon admission and was at risk for the development of pressure ulcers. A Care Plan dated 7/27/17 indicated Resident #8 developed a DTI on her right outer foot on 7/27/17 and was at risk for the development of more pressure ulcers. Interventions included: Ensure heels are floated with use of pillows. A Wound Care Specialist Evaluation dated 7/31/17 indicated Resident #8 had an unstageable DTI on her right lateral foot measuring 0.7 cm x 0.8 cm. The evaluation listed recommendations to continue skin prep once daily, to off-load the wound, and to position per facility policy. A Wound Care Specialist Evaluation dated 8/7/17 indicated Resident #8's unstageable DTI on her right lateral foot deteriorated. The measurements were 1.5 cm x 0.8 cm. The evaluation listed recommendations to continue skin prep daily, offload wound, and position per facility policy. A Wound Care Specialist Evaluation dated 8/14/17 indicated Resident #8's unstageable DTI on her right lateral foot measured 0.8 cm x 0.7 cm. The evaluation indicated to continue to offload the wound and position per facility policy. During an observation and interview on 8/14/17 at 10:19 a.m., Resident #8 was lying on her back in bed with her right hip and knee flexed. Her right leg was externally rotated with the outer side of the right foot lying on the bed. She was calling out help, help me please while flexing and extending her left leg rubbing her left heel back and forth over the foam mattress. The resident's feet were not offloaded from the mattress to provide pressure relief. LVN B said Resident #8 had a DTI on her outer right foot and the treatment was skin prep two times a day. During an interview on 8/14/17 at 3:35 p.m., LVN A said she had not attempted other pressure relieving interventions for Resident #8's feet. During an observation and interview on 8/14/17 at 4:05 p.m., Resident #8 was lying in bed on her back with her right hip and knee flexed. The unstageable DTI on the right side of her foot was lying directly on a pillow without pressure relief. The peri-wound was a deep purple/maroon color with a raised scab in the center. The wound care physician assessed the wound and said it was an unstageable DTI caused by pressure and measured 0.8 cm x 0.7 cm with an immeasurable depth. During an observation on 8/15/17 at 8:39 a.m., Resident #8 was positioned on her back with her right hip and knee drawn toward her chest and externally rotated. The resident's right outer foot was resting against the mattress without pressure relief to the unstageable pressure ulcer. CNA D placed a small red sofa pillow under Resident #8's right knee. Resident #8 was repeatedly extending and pushing against the mattress with her left heel. There was no pressure relieving device to prevent sheering and pressure to the left heel. During an observation and interview on 8/15/17 at 9:30 a.m., Resident #8's right foot was not offloaded. LVN B said it was difficult to keep the resident's right foot positioned on the pillow to provide pressure relief. LVN B said she did not consult with the physician or other disciplines about alternative pressure relieving interventions for Resident #8's feet. She said she did not expect Resident #8 to follow directions due to her mental status. LVN B said Resident #8 did not have measures in place to prevent break down to her left heel. She assessed the resident's left heel and indicated it was soft and boggy (spongy) to touch. During an interview on 8/15/17 at 8:55 a.m., RN C said Resident #8 should have had interventions in place to provide pressure relief for her right outer foot as ordered. During an interview on 8/16/17 at 8:10 a.m., the DON said orders to offload a pressure ulcer should be followed and if unable to maintain offloading of a current pressure ulcer, staff should consult the physician and attempt other methods. The DON said she would not expect a confused resident to follow directions to keep their foot offloaded and should have other nursing interventions to address methods to offload other than pillows. The DON said there was not a facility policy indicating not to use heel lifts or other specialized pressure reducing devices such as boots. The website, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages, accessed 8/23/17 indicated Pressure Injury: .A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) . A Wound Care Policy and Procedure with a revision date of March 7, 2007 indicated the ideal characteristic of wound dressings would protect the area against microbial contamination and provide moisture to the wound unless contraindicated by excessive exudate (drainage) from the wound. A Pressure Injury: Prevention, Assessment, and Treatment policy and procedure with a revision date of 8/12/16 indicated the cause of pressure ulcers as .unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure shearing of tissue against bone causing tissue and vessel destruction. The CMS 672 dated 8/14/17 indicated 2 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 4 residents reviewed for medications. (Resident #9) Resident #9 admitted without a [DIAGNOSES REDACTED]. The facility did not plan or implement behavior interventions for wandering or agitation prior to administration of [MEDICATION NAME](medication used for mania, an abnormally elevated energy level) and [MEDICATION NAME] (antipsychotic medications). The facility did not monitor for adverse reaction of the antipsychotic medication. This failure could place the 32 residents receiving [MEDICAL CONDITION] medications at risk for over sedation, at risk for falls, weight loss, and decreased quality of life. Findings included: Electronic physician orders for 7/19-8/19/14 indicated Resident #9 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders included the following medications: [REDACTED]. Resident #9 also received [MEDICATION NAME] 0.5 mg- give 1/2 tab 0.25 mg as needed (PRN) every 2 hours. An MDS dated [DATE] indicated Resident #9 made himself understood and usually understood others. No [MEDICAL CONDITION], no behaviors but did wander. He required extensive assistance with his ADLs, he required supervision with eating. He was occasionally incontinent of urine, but continent of bowel. A nursing care plan dated 7/22/14 indicated Resident #9 was at risk for adverse consequences related to antipsychotic medications for treatment of [REDACTED]. An admission care plan dated 7/10/14 indicated Resident #9 was at risk for falls and had a personal alarm. The care plan indicated Resident #9 should be assessed for possible contributors. An admission assessment tool dated 7/10/14 indicated Resident #9 was independent with eating, and toileting. He required supervision with transfers, but did not use a mobility device. During an observation 8/18/14 at 12:37 p.m., Resident #9 was in the dining room. He was very thin in appearance, did not eat or drink any fluids. CNAs asked Resident #9 to take a bite of food, and he would answer " ok. " Resident #9 attempted to put food on his plate, but cognitively could not get the food to his mouth. During an observation on 8/19/14 at 8:55 a.m., MA attempted to help Resident #9 to eat, but he would not eat anything. During an observation and interview on 8/19/14 at 9:40 a.m., LVN A attempted to feed Resident #9. He would take a bite then spit it out. LVN A said they had put his [MEDICAL CONDITION] medications on hold for a few days. She said Resident #9 had done better since his [MEDICAL CONDITION] medication was held. Nursing notes for Resident #9 indicated the following: 7/10/14 *4:00 p.m., Resident upset when family left the facility, demanded to go home. *5:37 p.m. - upset yelling, given [MEDICATION NAME]. Resident #9 became calm, ate 100% of dinner, no other behaviors. *7:47 p.m., attempted to leave the facility. 7/11/14 *2:21 a.m. - personal alarm ringing sitting beside bed, blood on scalp. *8:54 a.m. - lying on face on floor, next to bed. *7/15/14 4:09 p.m. - attempting to exit the building, non-compliant using the wheelchair, slight agitation with staff when redirected, non-threatening manner. A physician order dated 7/16/14 indicated Resident #9 was to receive [MEDICATION NAME] 125 mg at noon and [MEDICATION NAME] 250 mg at bedtime for dementia without behavior disturbance. A nursing note dated 7/16/14 at 11:22 a.m., indicated a new order for Resident #9 to be administered [MEDICATION NAME] 125 mg at noon and 250 mg at bedtime. There were no documented indications for the increased medication. A nursing note dated 7/17/14 at 4:43 p.m., indicated Resident #9 had increased confusion and was asking to go home. No maladaptive behaviors were documented. A new order was recieved for [MEDICATION NAME] 25 mg at 2:00 p.m., daily. There was no physician order for [REDACTED]. A physician order dated 7/26/14 indicated Resident #9 was to receive [MEDICATION NAME] 200 mg once daily at bedtime. There was no documented indication for the increased medication. At www.fda.gov/downloads/drugs/drugsafety/ucm 6.pdf accessed on 8/21/14 " ... Medication Guide [MEDICATION NAME] (SER-oh-[MEDICATION NAME]) (quetiapine [MEDICATION NAME]) Tablets ... " " [MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. 2. risk of suicidal thoughts or actions (antidepressant medicines, depression and other serious mental illnesses, and suicidal thoughts or actions) ... " An undated pharmacy consultant note to Resident #9's physician signed by the NP on 8/14/14 indicated there was not an appropriate [DIAGNOSES REDACTED]. The NP documented mood disorder with psychiatric features. Nursing notes for Resident #9 indicated the following: *7/17/14 6:04 p.m. - attempting to leave, asking staff to take him home, got upset grabbed CNAs arms and squeezed her arm, ate 25 % of his meal, before he became agitated. *7/20/14 11:53 p.m. - stated, "I've got to go home, I got to feed my donkeys..." at times gets aggressive, swinging at staff, calm and cooperative at this time. *7/21/14 9:58 a.m. -Attempted to go out the doors. Nursing notes from 7/21/14-7/23/14 had no behaviors documented, except wandering and wanting to go home. A physician's order dated 7/23/14 increased [MEDICATION NAME] 100 mg one at bedtime, for dementia without behaviors. No psychiatric indication for its use was documented. Nursing notes for Resident #9 indicated the following: *7/24/14 1:27p.m., -Resident lethargic, no attempts to leave facility. *7/25/14 3:37 p.m., -Requesting to go home, agitation at times. PRN [MEDICATION NAME] given. A nursing note dated 7/29/14 at 9:56 a.m., indicated Resident became agitated, looking for wife. PRN [MEDICATION NAME] given. A physician order dated 7/29/14 indicated Resident #9 was to receive an increase to [MEDICATION NAME] 300 mg once daily at bedtime. There was no documented indication for the increased medication. A nursing note dated 7/30/14 at 9:54 a.m., indicated Resident #9 was constantly asking to go home, forgetful. A nursing note on 8/1/14 at 6:54 p.m., indicated the NP was notified regarding Resident #9's increased agitation. There was no agitation documented in the nursing notes. A physician order was received to increase Resident #9's [MEDICATION NAME] dosage. A physician order dated 8/1/14 indicated Resident #9 was to receive [MEDICATION NAME] 250 mg once a day at 12:00 noon, and [MEDICATION NAME] 500 mg once a day at 6:30 p.m. for dementia without behavior disturbance. There was no documented indication for the increased medication. Nursing notes for Resident #9 indicated the following: *8/6/14 5:31 a.m., Found lying on floor 4 centimeter (cm) abrasion to his lower back. *8/8/14 9:05 a.m.-Sitting on floor on bottom, resident assisted with toileting, getting dressed, weak, unable to stand, " ...does not know where he is and can't get across what he is trying to say ... " Discontinued [MEDICATION NAME] 25 mg at 8 a.m.- 2 p.m. *8/11/14 10:30 p.m., Resident found lying in doorway on right side, small laceration above right eye, and abrasion to shoulder. *8/12/14 10:05 a.m., Resident aroused but went back to sleep, unable to understand resident, unsteady, only ate a few bites then pushed food away. *8/13/14 12:58 p.m., New order to hold [MEDICATION NAME] for 3 days and hold [MEDICATION NAME] for 7 days, due to extreme sedation, noted to call NP on 8/15/14 for an update. *8/15/14 12:03 p.m., less lethargic today, and more alert but not as alert as before. *8/17/14 1:07 a.m., - no behavior issues. *8/18/14 1:06 a.m., no adverse reaction, resuming [MEDICATION NAME] and 1 time dose of [MEDICATION NAME]. *8/19/14 12:29 a.m. - no behaviors. A PRN MAR indicated [REDACTED]. Resident #9's agitation was listed as follows: getting upset over dentures, getting up repeatedly, getting up and trying to leave, agitation and restlessness. Weight records for Resident #9 from 7/23/14-8/19/14 indicated he had lost 12.8 pounds (lbs) (7/23/14-119.2 lbs and 8/19/14 -104.6 lbs.) A meal intake log indicated Resident #9's meal consumption was the following: *7/10/14 (admission)-7/16/14 he was eating 76-100% of his meals, *7/22-7/27/14- 1 meal less than 25%; 2 meals 25-50% and 4 meals 50-75%, the rest of his meals above 75%, and *8/3-8/18- 16 meals of less than 25%-50% and 3 meals he ate nothing. During an interview on 8/18/14 at 9:00 a.m., LVN A said Resident #9 received hospice services. She said he had dementia, wandered and was on 15 minute checks. LVN A said Resident #9 ambulated, but was unsteady, incontinent at times, a fall risk and had fallen. She was unsure of any weight loss. LVN A said they had been adjusting his medications. A physician's order dated 8/16/14 indicated Resident #9's [MEDICATION NAME] 250 mg once daily at noon and [MEDICATION NAME] 500 mg once daily at 6:30 p.m. was restarted. No documentation in nursing notes or physician progress notes [REDACTED]. During an interview on 8/19/14 at 3:30 p.m., the NP said when Resident #9 was admitted they offered behavior management, but family refused. She said she started him on low dose of [MEDICATION NAME]. The NP said Resident #9 continued to wander and she added [MEDICATION NAME]. She said when Resident #9 became lethargic; she put his medication on hold. The NP said when she checked Resident #9's MAR, she noticed staff had been giving him PRN [MEDICATION NAME] in addition to his [MEDICATION NAME] and [MEDICATION NAME]. The NP said she discontinued his [MEDICATION NAME]. The NP said she was unaware Resident #9 not eating meals and weight loss. She said she was unaware his [MEDICATION NAME] and [MEDICATION NAME] was restarted. She said intentions were for staff to notify her prior to restarting his medication, but did not remember being notified. During an interview on 8/19/14 at 5:20 p.m., the NP said she was not going to decrease Resident #9's [MEDICAL CONDITION] medications, because he was not currently lethargic. She said she did not think his weight loss was related to his medications. She said she would recommend adding finger foods. The NP said Resident #9 had not been seen by a psychiatrist or psychologist because he was on hospice. During an interview on 8/19/14 at 4:00 p.m., the SW said Resident #9 had not been seen by psychological services, due to they were more of a counseling service, and they did not have a psychiatrist that came to the facility. She said the psychological services that came to the facility on ly made recommendations on medications. During an interview on 8/19/14 at 5:00 p.m., Resident #9's family said they admitted him when he began wandering, and had increased confusion. Resident #9's wife said he had eaten 100% of his meals when he was at home, and denied falling. Resident #9's daughter-in-law said she thought he had fallen some. The CMS 672 dated 8/18/14 indicated 32 residents received antipsychotic medications.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief intervention to ensure adequate pain relief for 1 of 10 residents reviewed for pain (Resident #12), and failed to provide care and services to maintain highest practicable, mental, and psychosocial well-being in accordance with the comprehensive assessment for 2 of 2 residents reviewed for indwelling urinary catheters. (Resident #s 5 and 34). Resident #12 exhibited severe pain and grabbed her leg during wound care. She was not offered as needed pain medication prior to wound care. Resident #12 was assessed with [REDACTED]. Resident #s 5 and 34 indwelling catheter bags and tubing were not secured. This failure could place 49 residents who received pain management, at risk for lack of pain assessment, discomfort and decreased quality of care and 2 residents with indwelling catheters at risk for discomfort, urethral trauma and urinary tract infections (UTIs). Findings included: 1. Electronic physician orders [REDACTED].#12 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12 received Tylenol extra strength tablets (2) as needed every 6 hours, and [MEDICATION NAME]-[MEDICATION NAME] 5-325 milligram (mg) one by mouth as needed every 6 hours. Resident #12's nursing admission assessment indicated she had clear comprehension, and made herself understood. Her assessment indicated she received as needed pain medication in the last 5 days, her worst pain in the last 5 days on a scale of 1-10 (with 10 being the worst pain she had ever felt) was "7" and her pain was frequent. A pain assessment dated [DATE] indicated Resident #12's [MEDICAL CONDITION] blisters to both lower extremities. Her pain was described as aching, daily, constant/persistent and weight bearing or movement caused pain to worsen. A pain assessment for Resident #12 dated 8/16/14 noted staff initials indicated the resident had pain. However, there was no documentation the level of pain was rated according to the pain scale (1-10) and there was not description of her pain. During an interview on 8/20/14 at 10:50 a.m., the DON said Resident #12's pain assessment only indicated the pain assessment was done. She said it did not document the resident's pain. She said Resident #12's pain should be documented in the nursing notes. Nursing progress notes for Resident #12 dated 8/16- 20/14 did not mention pain, lack of pain, pain scale or when pain medication was provided. During an observation and interview with Resident #12's daughter on 8/18/14 at 9:30 a.m., Resident #12 was lying in her bed. Both legs were wrapped in Kerlix gauze. Resident #12's daughter said prior to admission her mother received 3rd [MEDICAL CONDITION] her right lower leg from sugar water she was heating for a hummingbird feeder. She said Resident #12 had a blood clot in her left leg. Resident #12's daughter said the resident's wounds had become infected and she spent a long time in the hospital recovering from her wounds. Her daughter said Resident #12 did not like to ask for pain medication, and would try to go without it. During an observation and interview on 8/19/14 at 4:05 p.m., LVN M and the wound care physician provided wound care to both Resident #12's legs. When the dressing was removed and [MEDICAL CONDITION] cleaned, Resident #12 sat up suddenly in bed and grabbed her left leg and grimaced in pain. No medication for pain was offered. Resident #12's daughter was present and following the wound care Resident #12 told her she needed something for pain and the nurse was notified. During an interview on 8/20/14 at 11:10 a.m., Resident #12's daughter said Resident #12 did not receive the requested medication for pain until 40 minutes after notifying the nurse on 8/19/14. The pain management policy updated 9/2011 indicated " ... if pain is triggered initiate pain management care plan which includes non- pharmacological and pharmacological interventions for the resident's pain relief. Interventions should be specific for the resident based on information collected during the evaluation and interview process... " " ...Document pain as the fifth vital sign, evaluating or checking with the resident for the presence of pain during the morning, afternoon and evening medication pass and PRN... " 2. Physician orders [REDACTED].# 5 was a [AGE] year old male admitted [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#5 received an antibiotic for to treat an UTI. An annual MDS dated [DATE] indicated Resident # 5 was able to understand and be understood by others, had poor memory recall, had verbal and physical behaviors of yelling, hitting, pushing others that put the resident and others at risk for injuries, and needed extensive assistance of two people for transfers and ADLs. A Care Plan dated 6/4/14 indicated Resident # 5 required an indwelling urinary catheter related to possible urinary obstruction and the resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. During an observation an interview on 8/18/14 at 3:08 p.m., CNA E provided incontinent care for Resident #5. His indwelling catheter bag and tubing were not secured to the resident's leg. CNA E said he had never seen Resident # 5's indwelling catheter secured to the resident with anything in the past. 3. Physician orders [REDACTED].#34 was [AGE] years old, readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. An annual MDS dated [DATE] indicated Resident #34 was able to understand and be understood by others; his recall had to be triggered with cueing, and he required aindwelling catheter for bladder management. A Care Plan dated 8/6/14 indicated Resident #34 required an indwelling urinary catheter and was at risk for UTI's. During an interview on 8/18/14 at 3:35 p.m., Resident #34 said he had never had his indwelling catheter tubing secured when up in his wheelchair. During an interview on 8/20/14 at 3L30 p.m., the DON said the men's Foley catheter tubing was to be secured on top of the thigh with an adhesive circle that had a holder on it. A Staff Education/Orientation Policies and Procedures dated 7/1/2013 under # 28. Secures catheter: B. Males: 1) indicated the F/C was to be "secured on the top of thigh or lower abdomen allowing for slack." <http://www.nursingtimes.net/why-more-attention-must-be-given-to-catheter-fixation/ 63.article accessed on 8/27/14> titled " ...Why more attention must be given to catheter fixation ... " indicated " ...Failing to secure urinary catheters can result in complications, including infection and discomfort for patients ... " The CMS 672 dated 8/18/14 indicated 49 residents were on pain management and 2 had indwelling Foley catheters.