Every finding on record at The Lennwood Nursing and Rehabilitation

Based on interview and record review, the facility failed to complete a discharge summary for 4 of residents (Resident #1, Resident #2, Resident #3, Resident #4) 4 residents reviewed for discharge summaries. 1. The facility failed to ensure 4 of residents (Resident #1, Resident #2, Resident #3, Resident #4) discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included:Record review of Resident #1's Face Sheet, printed 06/30/26, revealed the [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with a primary diagnosis of lack of coordination, and secondary diagnoses of chronic kidney failure and heart failure. Resident #1 was discharged to an acute care hospital from the facility on 05/29/26. Record review of Resident #1's assessments in the electronic health records revealed a discharge summary had not been completed. Record review of Resident #2's Face Sheet, printed 06/30/26, revealed the [AGE] year-old male originally admitted to the facility on [DATE], and readmitted on [DATE] with a primary diagnosis of metabolic encephalopathy (a brain dysfunction caused by chemical, hormonal, or systemic problems in the body), and secondary diagnoses of rhabdomyolysis (a serious medical condition involving the rapid breakdown of damaged skeletal muscle), extrarenal uremia (a functional disease of the kidney which is the result of one or more disorders outside the kidney), acute kidney failure (occurs when the kidneys suddenly stop filtering waste from the blood), and chronic kidney disease (the presence of damaged kidneys that cannot filter blood properly). Resident #2 was discharged to an acute care hospital from the facility on 06/24/26. Record review of Resident #2's assessments in the electronic health records revealed a discharge summary had not been completed. Record review of Resident #3's Face Sheet, printed 06/30/26, revealed the [AGE] year-old male originally admitted to the facility on [DATE], with a primary diagnosis of sepsis (the body's extreme, life-threatening response to an infection), and stage 3 chronic kidney disease (the presence of damaged kidneys that cannot filter blood properly). Resident #3 was discharged to an acute care hospital from the facility on 06/25/26. Record review of Resident #3's assessments in the electronic health records revealed a discharge summary had not been completed. Record review of Resident #4's Face Sheet, printed 06/22/26, revealed the [AGE] year-old male originally admitted to the facility on [DATE], with a primary diagnosis of cerebral atherosclerosis (the narrowing of brain arteries due to the buildup of fatty cholesterol plaques), and secondary diagnoses of heart failure (occurs when the heart muscle weakens or stiffens and cannot pump enough oxygen-rich blood to meet the body's needs), and type 2 diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels). Resident #4 was discharged home from the facility on 06/22/26. Record review of Resident #4's assessments in the electronic health records revealed a discharge summary had not been completed. During an interview with the MDS Coordinator on 06/30/26 at 10:51am, she stated she had been employed at the facility for 11 years. The MDS Coordinator stated the Nursing Staff and Social Worker were responsible for opening and closing the discharge summaries for residents. The MDS Coordinator further stated that if she did not open the discharge summary, the IDT would not get a notification they needed to complete their part of it. The MDS Coordinator was asked to verify in the electronic health records if Resident #2 had a discharge summary, and she confirmed it was not completed. The MDS Coordinator stated LVN A should have completed the Discharge Summary for Resident #2. The MDS Coordinator stated the discharge summary should have been completed by nursing staff after residents discharged from the facility. The MDS Coordinator was asked if there was any risk or harm for the residents if their discharge summaries were not completed, and she stated she did not think so because the discharge summaries for the residents were for the facility, and discharge instructions leave with the resident when they were discharged from the facility. During a telephone interview with LVN A on 06/30/26 at 11:07 am, LVN A stated he was off duty and was unavailable to speak to the Surveyor. LVN A stated he would call Surveyor back in an hour to discuss the facility's discharge planning process. An attempted telephone call to the facility's previous Social Worker on 06/30/26 at 11:22 am was unsuccessful. A voicemail message was left for the previous Social Worker and a telephone call was not returned. An attempted telephone call to LVN A on 06/30/26 at 12:24 pm was unsuccessful. During an interview with the Administrator on 06/30/26 at 1:31 pm, she stated she had been employed at the facility for 2 years. The Administrator stated she was not aware that the Discharge Summary for Resident #1, Resident #2, Resident #3, and Resident #4 had not been completed. The Administrator stated the Nurse on duty during the resident's discharge should complete a Discharge Summary for residents. She stated since the facility had a vacant Social Worker position, the Nurse Staff had been directed to complete the Discharge Summaries for the residents. She stated the facility would do an audit on the recently discharged residents to ensure that they had discharge summaries on their EHR file. The Administrator stated the staff would be re-educated and re-trained via in-Service trainings on the discharge planning process, which included ensuring all discharged residents had completed discharge summaries in their EHR files. The Administrator stated there were not any risks or harm to residents if their Discharge Summaries were not completed after they were discharged from the facility. During a telephone interview with LVN B on 06/30/26 at 2:15 pm, she stated she had been employed at the facility for 1 year. LVN B stated she was unaware that Resident #1, Resident #2, Resident #3, and Resident #4 did not have any discharge summaries in the electronic health records, LVN B stated if a resident discharged from the facility during her shift, the Nurse on duty at the time of the resident's discharge was responsible for completing a Change of Condition for the resident. LVN B stated the Change of Condition documented what the vital signs of the resident, a description of what was going on with the resident, including the reason the resident was discharged from the facility. LVN B stated the nurse was also responsible for notifying the resident's physician or doctor, and their RP or POA (if applicable) of the resident's Change in Condition. LVN B stated that the nurses and SW were responsible for completing the Discharge Summary. LVN B stated the facility no longer had a SW, and therefore the nurses were responsible for completing the Discharge Summaries and recapitulation of medications for each discharged resident. LVN B stated there were no risks or harm to residents if their Discharge Summaries were not completed after they were discharged from the facility. Record review of the HR file for the facility's previous Social Worker revealed she was employed at the facility from 02/05/25 to 02/03/26. Record review of the facility's policy, Discharge Summary and Plan, dated December 2025 reflected: Policy StatementWhen a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.Policy Interpretation and Implementation1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment.13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records:.The discharge summary. Record review of the facility's policy, Transfer and Discharge Including AMA Policy dated 07/10/17, revised on 12/04/25, reflected:Policy:It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.Anticipated Transfers or Discharges - initiated by the resident.Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care.A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following:A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results.A final summary of the resident's status.Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter).A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment.Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. f. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (300 Hall) out of 1 hallways reviewed for accidents and hazards. 1. The facility failed to ensure that 1 of 1 mechanical lift on the 300 Hall was locked, secured and stored in a secure designated area when not in use. 2. CNA B did not remove the unlocked and unsecured mechanical lift parked on the hallway of the 300 Hall in between residents' rooms. This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included: An observation on 06/16/26 at 11:16 AM revealed one unlocked and unsecured mechanical lift parked on the hallway on the 300 Hall in between residents rooms. There were not any residents observed in the hallway during the observation. An observation on 06/16/26 at 11:32 AM revealed one unlocked and unsecured mechanical lift parked on the hallway on the 300 Hall in between resident's rooms. There were not any residents observed in the hallway during the observation. An observation on 06/16/26 at 11:55 AM revealed CNA B entering and exiting residents' rooms on the 300 Hall. An observation on 06/16/26 at 12:03 PM revealed one unlocked and unsecured mechanical lift parked on the hallway on the 300 Hall in between residents rooms. There were not any residents observed in the hallway during the observation. In an interview on 06/16/26 at 12:07 PM with CNA B, she stated that she had been employed at the facility for 7 months. CNA B stated on 06/16/26, she was assigned to the 300 Hall. She stated that she was unaware there was one mechanical lift parked in the hallway of the 300 Hall was unlocked and unsecured. CNA B stated during her employment at the facility she had taken in-service trainings on mechanical lift usage, safety and storage. CNA B stated that she could not recall when she had previously taken in-service trainings on mechanical lift usage, safety, and storage. CNA B stated that her previous in-service trainings stated mechanical lifts were to be always locked when they were not in use and placed in a storage area and not on the hallways. CNA B stated the facility did not have a designated area for mechanical lift storage, but the staff will place the mechanical lifts in unoccupied resident rooms on each hall. CNA B stated she typically did not check the parked mechanical lifts to verify if they were locked and secured. CNA B stated the mechanical lift that was observed on 06/16/26 on the hallway of the 300 Hall was overlooked because she had been assisting a family member with a resident in the resident's room. CNA B stated that harm could be caused to anyone when a parked mechanical lift was on the hallway unlocked, unsecured and not stored. CNA B stated when a parked mechanical lift was on the hallwy unlocked and unsecured it may cause anyone to have accidents and falls. She stated that someone could be harmed by having a serious fall with injuries, such as a head injury when a mechanical lift was unlocked and unsecured. CNA B stated she knew the damage an unlocked mechanical lift could cause because in the past, she bumped against the mechanical lift and hit her foot on the mechanical lift and broke her toe, which caused her some pain and discomfort. An email was sent to ADON A on 06/16/26 at 12:48 PM, requested the facility's policy on accidents and hazards, mechanical lifts, and mechanical lift safety and storage. In an interview on 06/16/26 at 2:06 PM with LVN C, she stated that she had been employed at the facility for 13 years. LVN C stated on 06//16/26 she was assigned to the 300 Hall. She stated that she was unaware on 06/16/26 there was an unlocked and unsecured mechanical lift parked on the 300 Hall in the hallway. LVN C stated that she had taken in-service trainings on mechanical lift safety and storage. LVN C stated that she did not remember when she had previously taken in-service trainings on mechanical lift usage and safety. LVN C stated on 06/16/26 she and other staff completed an in-service training on mechanical lift safety and storage. LVN C stated mechanical lifts should always be locked and secured when they were not in use. LVN C stated mechanical lifts should never be placed on the hallway when not in use. LVN C stated mechanical lifts should be placed in a secure area, such as an unoccupied resident room when not in use. LVN C stated she would now check the mechanical lifts every time she passed them to ensure that they were secure and always locked. LVN C stated that if she observed any staff members store the mechanical lift in the hallway and direct them place the mechanical lift in an unoccupied resident room. LVN C stated she would also direct the staff member to ensure that the parked mechanical lift was locked and secured prior to leaving the area. LVN C stated if a mechanical lift was unlocked, there was a risk of the mechanical lift moving, rolling and someone tripping on the mechanical lift. She stated that another risk of having an unlocked and unsecured mechanical lift on the hall was that someone can grab the mechanical lift and may have a trip and/or a fall. LVN C stated that someone could be harmed by an unlocked mechanical lift in the hallway and may fall and receive injuries such as broken bones, fractures, and skin tears. In an interview on 06/16/26 at 3:11 PM with ADON A, she stated that she had been employed at the facility for 2 days. ADON A stated that she was unaware that the mechanical lift parked on the hallway of the 300 Hall was unlocked and unsecured during three observations on 06/16/26. ADON A stated that her expectation was that all mechanical lifts in the building were to be locked when they were not in use. ADON A stated that all staff have been educated and trained via in-service trainings on the proper usage and safety of mechanical lifts, which included always being locked, secured and stored in a safe place. ADON A stated that she did not know when the staff received their last in-service training on mechanical lift usage, safety and storage. ADON A stated that she will reeducate staff on all shifts with ongoing in-service trainings on mechanical lift safety and storage. ADON A stated she reeducated staff with an in-service training 06/16/26. ADON A stated the in-service training for staff included reeducation on performing routine checks of the mechanical lifts in the building. ADON A stated there were risks to anyone to be injured due to an unlocked and unsecured mechanical lift on the hallways. ADON A stated if anyone touched an unlocked and unsecured mechanical lift, there was a potential for someone to lean against the mechanical lift causing it to roll and also a fall. ADON A stated that there was potential for harm to anyone who attempted to lift themselves with the unlocked and unsecured mechanical lift, which could cause injuries, such as broken bones, fractures, including broken hips, and head injuries. ADON A stated that the facility did not have a policy for mechanical lifts relating to mechanical lift safety and storage. The Administrator was unavailable for an interview on 06/16/26 due to being on Leave. Record Review on 06/16/26 at 12:30 PM revealed ADON A educated staff with an In-Service Training for Mechanical Lifts and Storage. Record Review of facility's policy for Using a Mechanical Lifting Machine, dated December 2025 did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage. Record Review of facility's policy for Accidents and Supervision, dated July 2017 and reviewed and revised December 2025 reflected, Policy:The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes:Identifying hazard(s) and risk(s)Evaluating and analyzing hazard(s) and risk(s)Implementing interventions to reduce hazard(s) and risk(s)Monitoring for effectiveness and modifying interventions when necessaryDefinitions:Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident.Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.Hazards refers to elements of the resident environment that have the potential to cause injury or illness.Risk refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident.Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident.Policy Explanation and Compliance Guidelines:The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident.All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident.The facility should make a reasonable effort to identify the hazards and risk factors for each resident.Various sources provide information about hazards and risks in the resident environment.These sources may include, but are not limited to:quality assessment and assurance (QAA) activities ii. environmental rounds. vii. individual observation.This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. educating staff ii. repairing the device/equipment iii. developing or revising policies and procedures i. Resident-directed approaches may include: i. implementing specific interventions as part of the plan of care ii. supervising staff and residents, etc. iii. facility records document the implementation of these interventions. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on observation, interview, and record review the facility failed to ensure the resident rights to a comfortable, homelike environment, with accommodation of needs for 6 of 12 residents (Resident #43, Resident #60, Resident #39, Resident #62, Resident #63, Resident#56) reviewed for residents' rights.1.The facility failed to ensure the temperature in Resident #60's room was maintained at a safe and comfortable range of 71 to 81 degrees on 9/23/25. The room temperature was 82 degrees Fahrenheit.2.The facility failed on 09/23/2025 to ensure the call light system was accessible to a resident, the call light was lying on the floor in the shared residents' toilets located inside the residents' rooms on 9/23/25 for Resident #43, Resident # 60, Resident #39, and Resident #62.3. The facility failed to ensure Resident #63's and Resident #56's call light was within reach on 09/23/25. This failure could place residents at risk of an uncomfortable environment ,not having a means of directly contacting caregivers in an emergency situation or when they needed support for daily living and diminish their quality of life. 1)Record review of Resident #60's Quarterly MDS, dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #60 had diagnoses of cancer (when abnormal cells grow out of control and spread to other areas of your body), muscle weakness, and lack of coordination. Resident #60 had a BIMS score of 10, which indicated moderate cognition impairment. Record review of Resident #60's care plan dated 09/04/25 reflected, focus: [Resident#60] rights will be respected and maintained through the review date. Goal: Resident rights will be respected and maintained through the review date. Intervention/Tasks: Dignity and respect: I will have the right to: *live in safe, decent, and clean conditions *be free from abuse, neglect, and exploitation *be treated with dignity. An observation on 09/23/25 at 10:51 AM, with Resident #60 revealed he was lying in bed wearing a hospital gown, his face was damp with sweat. Resident #60 stated it was hot in his room, because the air conditioning (AC) unit under the window was not working. When asked how long the AC unit in his room was not working, he replied for the last month. He stated he reported it to the aides taking care of him but was unable to recall a name. Interview and observation on 09/23/25 at 4:00 PM, the Maintenance Director checked the temperature in Resident #60's room with a digital thermometer, the temperature was 82 degrees Fahrenheit. The Maintenance Director stated the room temperatures was supposed to be between 71 to 81 degrees Fahrenheit, or for this building to a comfortable level for the residents. The Maintenance Director attempted to turn the AC unit on and was unable. the Maintenance Director unplugged the AC unit, tested the power outlet, and stated there was no power in it. The Maintenance Director stated he will go and fix it. The Maintenance Director left the room, and came back, he plugged the AC unit and turned it on, and it started working. The Maintenance Director stated he was from another facility and was covering for the main Maintenance Director who was sick. He stated he was not aware of the AC unit not working in Resident #60's room. He stated the direct care staff should report the issue to the Maintenance Department to fix it. He did not answer the question about if there if was risk to the resident. In an interview on 09/25/25 at 12:23 PM, the DON stated he was not aware of the AC unit not functioning in Resident #60's room. He stated normally when they have that situation, they would move the resident to a different room or bring a fan until the AC unit was fixed or move the resident until the AC got fixed and move the resident back to his/her room. The DON stated the risk to residents could be skin breakdown from sweating, uncomfortable environments, and delayed in recovery from illnesses. In an interview on 09/26/25 at 5:56 PM, the Administrator stated her expectations was for all the AC units to be in working conditions in the residents' rooms. She stated the resident should be moved to another room with a working AC unit and get his/her AC unit repaired. She stated the staff was supposed to notify the Maintenance Director and enter the order on the TELS (Electronic maintenance record system) . She stated risk to residents overheating and discomfort. 2)Observation on 09/23/25 at 10:50 AM, revealed resident's shared toilet call light pull string was intertwined on the grab bar for Resident #43. Observation on 09/23/25 at 11:22 AM, revealed resident's shared toilet call light pull string was short and about two feet from the floor for Resident #60. Observation on 09/23/25 at 11:33 AM, revealed resident's shared toilet call light pull string short and about two feet from the floor for Resident #39 and Resident #62. Interview and observation on 09/23/25 at 4:00 PM, the Maintenance Director looked at the call light outlets in the shared residents' toilets located inside the residents' rooms, and stated the call light strings was short, too high and the strings needed to be within the reach of a resident who was on the floor. The Maintenance Director stated he would fix them right away. The Maintenance Director stated the risk to residents was the residents could fall and not get help. 3)Record review of Resident #63's Quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of stroke, partial paralysis of left non dominant side, and severe cognitive impairment (BIMS score of 5). Record review of Resident #63's care plan reflected he was at risk of falls due to increased weakness and interventions included .be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. dated initiated 07/08/24. In an interview and observation on 09/23/25 at 10:07 AM, Resident #63 was lying in bed and his call light was not within reach, he stated he was not sure where his call light was. Observation revealed his call light was on his chair underneath gift bags and birthday decorations. Resident #63 stated he needed his call light to call for assistance. In an observation and interview on 09/23/25 at 10:12 AM, CNA F found Resident #63's call light on his chair underneath personal items and stated that Resident #63's call light should have been within reach on his bed and was not sure why it was not placed next to him. She stated residents not having their call light within reach put them at risk of not being able to call for help. In an interview on 09/23/25 at 2:15 PM, LVN E stated that Resident #63's call light should always be within reach so he could call for assistance. She stated residents without their call light within reach placed them at risk for falls or not getting assistance that they needed. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Sepsis, Hypertension, diabetes and stroke. Resident #56 had a BIMS of 12 indicating she was moderately cognitively impaired. Resident #56 required substantial/maximal assistance with ADLs of transfers and positioning. Review of Resident #56's comprehensive care plan last revised on 05/14/25 reflected Resident #56 was at risk for falls related to [stroke] with left sided weakness. Intervention included Be sure [Resident #56] call light within reach and encourage me to use it for assistance as needed. [Resident #56] need prompt response to all requests for assistance. In an observation and interview on 09/23/2025 at 10:50 AM, revealed Resident #56 sitting in her electric wheelchair. Resident #56's call light device was on the floor next to bed about 3 feet away from electric wheelchair. Resident #56 stated she could not reach the call light and would like it within reach. Observation and interview on 09/23/25 at 10:54 AM, CNA N revealed the call light was not within reach of Resident #56 and moved the call light within reach of Resident #56 by attaching it to her clothing while she was sitting in the electric wheelchair. He stated Resident #56 was dependent on staff for transfers and her call light should be within reach. CNA N stated earlier when he got her up the call light was within reach he thought,. he stated Resident #56 was able to use her call light. In an interview on 09/29/25 at 12:20 PM, the DON revealed his expectation was that call lights was always within reach of a resident. He stated that not having a call light within a resident's reach placed residents at risk of not being able to call for help. In an interview on 09/26/25 at 5:56 PM, the Administrator revealed her expectation was the call light string in the residents' bathrooms to be long enough for the resident in the floor to be able to reach. She further stated it was the responsibility of the Maintenance Director, nurses, and all the staff to make sure residents' call lights was easily accessible to the residents. She stated the risk to residents injury, and delayed response for care and needs. Record review of the facility policy titled Call Lights: Accessibility and Timely Response dated 12/01/2024 reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. The staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director . Record review of the facility policy titled Safe and HomeLike Environment dated 12/2024, reflected Policy: In accordance with residents' rights, the facility will provide a safe, comfortable and home like environment.Definitions. [Comfortable and safe temperature levels] means that the ambient temperature should be in a relatively narrow range that minimizes residents; susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 2 of 2 (Resident #34, and Resident #45) residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #34 and Resident #45's contractures to their left hands on 09/23/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. 1-Record review of Resident #34's Quarterly MDS, dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #34 had diagnoses of hypertension (elevated blood pressure), cerebrovascular accident (It is a serious medical condition that occurs when the brain is damaged due to a lack of blood flow, either from a blocked blood vessel or a ruptured one), and Hemiplegia (paralysis that affects only one side of your body) or Hemiparesis (one-sided muscle weakness) affecting left nondominant side. Resident #34 had a BIMS score of 14, which indicated intact cognition. Further review revealed MDS section GG0115, Functional Limitation in Range of Motion was coded 1 for upper and lower extremities, indicating Impairment on one side. Record review of Resident #34's care plan dated 07/29/25 reflected, focus: [Resident #34] has Hemiplegia/Hemiparesis r/t CVA. Goal: [Resident #34] will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date. Intervention/tasks: PT, OT, ST evaluate and treat as ordered. Record review of Resident #34's CNAs task list dated 09/24/25 did not indicate splint placement or range of motion to be provided to Resident #34's left hand. Record review of Resident #34's order summary, dated 09/23/25, reflected no physician order for left hand splint or range of motion. Record review of Resident #34's OT evaluation and Plan of treatment dated 08/13/24 revealed Range of motion .LUE ROM=impaired. Assessment Summary- Clinical impressions: resident presents with a significant decline in the ability to participate with ADL's secondary to generalized weakness, impaired balance, mobility, decreased activity tolerance, and ADLs. Skilled justification: reason for skilled services: Resident required OT service to. decreased risk for falls and perform UB ADLs with increased (Independence) and safety. Risk factors: due to .physical mobility impairments and associated functional deficits, the resident is at risk for further decline in function and falls. Focus of POT: skilled intervention focus=Restoration, compensation. In an observation and interview on 09/23/25 at 11:10 AM, Resident #34 was observed lying in bed, left hand was contracted, and the resident was not able to open his hand on command, and there was not a contracture management device in place. Resident #34 stated he had a stroke and was not able to use his left hand. He stated he never had a splint or any kind of support for his left hand. In an interview and observation on 09/23/25 at 01:55 p.m., CNA G gently opened Resident #34's left hand revealing his nails to be approximately 0.8 cm in length extending from the tip of his fingers. Inspection of his palm did not reveal any skin breakdown. She stated she had not been instructed on any splint placement or the use of the carrot splint for the resident. She stated she was not sure if the resident was in restorative care or not. She stated it was not on their task list for them to apply any splint or any range of motion exercises. In an interview on 09/25/25 at 09:27 AM, the Physical Therapy Director stated Resident #34 was not using therapy currently. She stated Resident #34 was on OT services from 07/15/24 through 11/07/24 and no splint was ordered for his left hand at that time, because it was not needed for functional ability and skin integrity. When asked if there was any risk to Resident #34, she replied the splint was for the resident's function, and Resident #34 did not have any functional impairment, because the contraction was affecting his non dominant hand, and there was no skin breakdown reported. She further stated until this day, she did not see any need for the splint for Resident #34. 2-Record review of Resident #45's Quarterly MDS, dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses of hypertension (elevated blood pressure), cerebrovascular accident (It is a serious medical condition that occurs when the brain is damaged due to a lack of blood flow, either from a blocked blood vessel or a ruptured one) , weakness, lack of coordination, and Hemiplegia (paralysis that affects only one side of your body) or Hemiparesis (one-sided muscle weakness) affecting left nondominant side. Resident #45 had a BIMS score of 08, which indicated moderate cognition impairment. Further review revealed MDS section GG0115. Functional Limitation in Range of Motion was coded 1 for upper and lower extremities, indicating Impairment on one side. Record review of Resident #45's care plan dated 08/07/25 reflected, focus: [Resident #45] have impaired physical mobility related to contracture(s) to. Goal: [Resident #45] will remain free of complications related to from my contracture(s) through review date. Intervention/Tasks: Refer resident to therapy to be evaluated for therapy intervention. Splints may be applied per physician orders. There was no document in the care plan of Resident#45 refusing the splint for his contracted left hand. Record review of Resident #45's CNAs task list dated 09/24/25 did not indicate splint placement or range of motion to be provided to Resident #45's left hand. Record review of Resident #45's order summary, dated 09/23/25, reflected a physician order dated 04/18/25 and still active Resident to have splint on LUE for 8 hours per day. Monitor for s/s of redness, edema or skin break down one time a day for contracture management and remove per schedule. Record review of Resident #45's OT evaluation and Plan of treatment dated 08/13/24 revealed Range of motion .LUE ROM=impaired. Assessment Summary- Clinical impressions: resident presents with a significant decline in the ability to participate with ADL's secondary to generalized weakness, impaired balance, mobility, decreased activity tolerance, and ADLs. Skilled justification: reason for skilled services: Resident required OT service to increase independence with ADLs, maximize independence with ADLs, increase function activity tolerance, facilitate sitting tolerance and postural control, provision of modalities and strengthening and increase safety awareness . Risk factors: due to .physical mobility impairments and associated functional deficits, the resident is at risk for. further decline in function, increased dependency upon caregivers . Focus of POT: skilled intervention focus=Restoration. In an observation and interview on 09/25/25 at 09:44 AM, Resident #45 was observed up in wheelchair in the hallway. Resident #45's left hand was contracted, and the resident was not able to open his hand on command, and there was not a contracture management device in place. Resident #45 stated he had a stroke and was not able to use his left arm and hand. He stated he never had a splint or any kind of support for his left hand. In an interview and observation on 09/25/25 at 09:57 AM, CNA H gently opened Resident #45's left hand revealing his nails to be approximately 0.6 cm in length extending from the tips of his fingers. Inspection of his palm did not reveal any skin breakdown. She stated she had not been instructed on any splint placement or the use of the carrot splint for the resident. She stated she was not sure if the resident was in restorative care or not. She stated it was not on their task list for them to apply any splint or any range of motion exercises. In an interview on 09/25/25 at 09:59 AM, LVN I stated there was no splint device in Resident #45's room, and she did know if he ever got one from the OT department. She stated the physical therapy department was responsible for putting the order for the splint and supplying one for the resident. She stated the nurses and CNAs was responsible for applying and removed the splints for the residents following the doctor's order. She stated the risk to the resident further decline in mobility and skin breakdown leading to infection development. In an interview on 09/25/2025 10:22 AM, the Physical Therapy Director stated her department put an order for the Resident left hand's splint in the system, and it was the responsibility of the nurses to apply the splint for the Resident. When asked if she gave Resident#45 a splint, she replied she put the order in the system for the splint, and she did not have any document of given the splint to Resident#45. In an interview on 09/25/25 at 12:23 PM, the DON stated they had all residents screened by therapy upon admission and at any time there was a functional decline. He stated they do not have a restorative program, but Range of motion and splinting can be carried out by the nursing staff and the CNAs once therapy determines the need. He stated he had been informed about Resident #45's refusing his splint. He stated therapy sets up the plan for what restorative needs the resident will require and communicate with the MDS nurse. He stated anytime the resident was refusing any service the CNAs had to let the Charge Nurse and himself know. He stated the interventions needed to be care planned. He stated failing to implement interventions for residents with limited Range of motion could lead to worsening of a resident's contractures, decline in function, skin breakdown, and wound by the nails digging in the hand's palm and pain from that pressure. In an interview on 09/26/25 at 5:56 PM, the Administrator stated her expectations were for the Therapy department to assess and to give a splinting device to residents in need to prevent further contraction. She stated the Therapy Department should collaborate with nursing staff, and the nurses to follow up for the management of the device. She stated the risk to residents injury or further damage to muscle, ligament, and pain. Review of the facility's policy titled, Prevention of Decline in Range of Motion, dated July 2017, reflected, The facility in collaboration with the medical director, director of nurses and appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.b. The facility will provide treatment and care .this includes but not limited to .ii. Appropriate equipment (braces or splint) .

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #6, #14, #30) of 7 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #14 had a wanderguard and the placement and functioning of the device was monitored and documented in his medical record. 2. The Administrator and DON failed to implement a system to ensure residents (Resident #6, #14, and #30) at risk for wandering/elopement were monitored and documented in the resident's treatment administration record and that staff were following current physician orders for wanderguard placement. These failures could place the residents at risk for elopement and serious harm. Findings included:1. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Hypothyroidism (condition in which thyroid gland does not make enough thyroid hormones to meet your body's needs), hypertension (high blood pressure) and age-related cognitive decline (the gradual decline in cognitive abilities that occurs as people age).Review of Resident #14's quarterly MDS assessment dated [DATE] reflected Resident #14 had a BIMS of 8 indicating he was moderately cognitively impaired. Resident #14 was partial/moderate to substantial/maximal assistance with ADLs. Review of Resident #14's initial elopement assessment dated [DATE] reflected Resident #14 was at risk for elopement. It was not complete with the following questions blank: 6. Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.) 7. Does the Resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings). The assessment was incomplete including the goals, interventions and clinical suggestions.Review of Resident #14's comprehensive care plan last revised 08/11/25 reflected Resident #14 had impaired cognitive function/dementia or impaired thought processes [related to] Dementia. The care plan did not reflect Resident #14's elopement risk, wandering behavior and did not reflect Resident #14's order for wanderguard placement for resident safety.Review of Resident #14's progress notes for 08/01/25 to 09/22/25 reflected the following:-Dated 07/31/25 nursing skilled evaluation by LVN K reflected Level of cognitive impairment: Moderate impairment (memory loss).Mood and Behavior: Resident wanders at night.-Dated 08/01/25 at 11:00 PM Nurse note by LVN K reflected Patient had to be redirected several times going in and out of room's and rambling in drawer's.-Dated 08/02/25 nursing skilled evaluation completed by RN A reflected Safety Note: Resident is a wanderer and is a high risk for elopement. Wander guard worn.-Dated 08/03/25 nursing skilled evaluation completed by RN A reflected under Safety concerns - note: High risk for elopement; wears a wander guard.-Dated 08/04/25 nursing skilled evaluation completed by RN A reflected Resident #14 had severe impairment and safety note: wanders.-Dated 08/05/25 nursing skilled evaluation completed by RN A reflected Resident #14 had safety concerns: wanders.Dated 08/31/25 at 9:16 PM nursing note by RN A reflected Resident removed wander guard from his leg and placed it on his dinner tray. Resident placed on 24 hour report and oncoming shift notified.Review of Resident #14's elopement assessment dated [DATE] reflected Resident #14 was at risk for elopement due to resident wanders aimlessly or non-goal-directed and Resident #14 was a recent admit not accepting the situation. The assessment was incomplete including the goals, interventions and clinical suggestions.Review of Resident #14's consolidated physician orders dated 09/23/25 reflected Resident #14 had a current order dated 09/04/25 of WANDERGUARDS: CHECK FOR PLACEMENT ANDPROPER WORKING FUNCTION EVERY SHIFT Placement: right ankle Expiration date: 2/15/2026.Review of Resident #14's September 2025 MAR/TAR reflected Resident #14 had no monitoring documentation every shift for wanderguard placement and proper working functioning for wanderguard.Review of Resident #14's Kardex reviewed on 09/23/25 reflected no elopement or wandering risk under safety.Observation on 09/23/25 at 2:28 PM revealed Resident #14 was in the therapy room. Physical Therapist Assistant V checked both legs including ankles and Interview with Physical Therapist Assistant V revealed she could not locate a wanderguard on him.Observation on 09/23/2025 at 2:36 PM revealed Resident #14 was in the therapy room. LVN L checked both of Resident #14's legs including ankles finding no wanderguard placement on Resident #14 and Interview with LVN L revealed there was not a wanderguard on Resident #14. Interview on 09/23/25 at 2:39 PM with LVN L revealed he had completed orientation last week and yesterday was his first day working with residents. He stated to know if the residents were an elopement risk and had a wander guard at the start of the shift the nurses check the elopement risk binder for the list of the current residents with elopement risk, and that they have to check if the residents were wearing the wander guard. LVN L stated he did not know Resident #14 was supposed to wear a wander guard.2. Record review of Resident #6's face sheet dated 09/23/2025 reflected she was a [AGE] year old female with an admission date of 05/16/2025. Diagnoses included Encephalopathy (a state where brain function is disordered, damaged, or malfunctions, leading to an altered mental state), Schizoaffective disorder (a chronic mental health condition, Type 2 diabetes mellitus with diabetic neuropathy, unspecified (elevated blood sugar levels and nerve damage).Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #6 used a wheelchair for ambulation, and she needed supervision with chair/bed to chair transfers and to walk 50 feet with two turns.Record review of Resident #6's care plan with a revision date of 06/03/2025 reflected she needed 24-hour supervision, she used antidepressant medication related to bipolar disorder, review date 07/24/2025 reflected Resident #6 was a risk for elopement. Goal: Resident #6's safety will be maintained through the review date. Interventions: Distract Resident #6 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers.Record review of Resident #6's Kardex dated 09/23/2025 reflected no information Resident #6 was an elopement risk.Record review of Resident #6's physician order summary dated 09/23/2025 reflected Resident #6 had an order for wander guard from 09/04/2025: Check for placement and proper working function every shift. Placement: Right ankle, Expiration date: 02/15/2026, every shift.Record review of Resident #6's TAR dated 09/24/2025 reflected no information regarding the wander guard monitoring for any shift, for the month of September 2025.Observation and interview of Resident #6 on 09/23/2025 at 12:54 PM in her room revealed resident was sitting in her bed. Resident #6 stated she wore a wander guard, she could not remember if the staff were monitoring her wanderguard. Observed a wander guard on her right ankle.3. Record review of Resident #30' s face sheet dated 09/23/2025 reflected she was a [AGE] year-old female with an original admission date of 02/15/2021. Diagnoses included unspecified dementia (memory loss), delusional disorder (false beliefs based on incorrect interpretation of reality), type two diabetes mellitus (elevated blood sugar levels).Record review of Resident #30's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 7 which indicated severe cognitive impairment. Resident #30 used wheelchairs for ambulation, needed moderate assistance with chair/bed to chair transfers and substantial assistance with walking. Record review of Resident #30's care plan with a revision date of 11/29/2021 reflected she was at risk to wander. Goal: Resident #30's safety will be maintained through the review date. Interventions: distract Resident #30 from wandering behaviors by offering pleasant diversions, structured activities, food, conversations, television, book.provide with wander guard. Record review of Resident #30's Kardex dated 09/23/2025 reflected no information that Resident #30 was an elopement risk.Record review of Resident #30's physician order summary dated 09/23/2025 reflected Resident #30 had an order for wander guard from 09/23/2025 with the same start date: Check for placement and proper working function every shift. Placement: Left ankle, Expiration date: 02/15/2026, every shift for safety measures.Record review of Resident #30's TAR dated 09/24/2025 reflected no information regarding the wander guard monitoring for any shift, for the month of September 2025.Observation and interview of Resident #30 on 09/23/2025 at 01:43 PM in the hallway revealed resident was wheeling her wheelchair by herself. Resident #30 stated she was going to the other side of the building. Observed a wander guard on her left ankle, she could not remember if staff were monitoring her wanderguard. In an interview on 09/23/25 at 4:32 PM with CNA M revealed she had worked at the facility for about 6 months and worked all the halls. She stated that the only way she knew a resident was a wander/elopement risk was if staff told her or if she saw a resident wore a wanderguard bracelet. She stated the kardex reflected what a resident needed. She stated Resident #6 did not wander but had a wanderguard. She stated Resident #14 used to have a wanderguard and he mostly stayed in his room. She stated Resident #30 wandered around the facility but did not try to exit. CNA M stated residents who were at risk of elopement would say things like they want to leave or want to go home or actively try to leave the building or was were always going towards the doors saying they want to leave. She stated she received in-services on elopements and responding immediately to alarms and to notify the nurse, DON, and the Administrator if a resident eloped. In an interview on 09/23/25 at 5:37 PM with CNA B she stated She stated she was not sure if a resident's risk of wandering/elopement or wearing of a wanderguard showed up on the kardex. In an observation with CNA B of the Kardex revealed there was no indication of Residents #6, #14, or #30 risk of wandering/elopement or wanderguard status. She stated she thought the kardex reflected the elopement risk of the residents and whether they wore a wanderguard and was not able to find the information. She stated there was also a book at the nurses station that had the picture and information of residents at risk of wandering/elopement. In an interview on 09/25/25 at 10:26 AM with the DON, he stated the current orders for wanderguards are based on residents elopement assessment showing he or she is an elopement risk. He stated Resident #14 was a current wander/elopement risk and should have a wanderguard. He stated if the wanderguard was not on a resident who was at risk for wandering/elopement the resident could go out the door and it would not alarm to inform staff. He reviewed Residents # 6, #14, and #30 physician orders and TAR and stated a check box had not been checked to move the order to the TAR. In an interview on 09/23/25 at 5:55 PM with the Administrator, she stated there were no extra wanderguards at the facility that could be used for testing the wanderguard system. She stated when they discovered Resident #14 was missing his wanderguard the facility acquired a wanderguard from a sister facility. She stated the Interim Maintenance Director was covering from another facility while their Maintenance Director was in the hospital. She stated she did not know if the Maintenance Director had documentation of monitoring and testing of the wanderguard system. In an interview on 09/24/25 at 10:26 AM with the DON he stated He stated all residents' wanderguards were tested and all were working. He stated his expectation was for nurses with residents with wanderguards to stay aware of where those residents are located during their shift. Every nurse's station had a binder with a list and picture of which residents were at risk of wandering/elopement. He stated resident wanderguards were tested frequently with residents being brought up to the door to ensure the alarm sounds and there was an activation device will show if the system was working. He stated he was not sure where the activation device currently was located. He stated it was important to ensure the physician orders to monitor and check placement of wandergaurds were in the TAR because it informed nurses who were was at risk of wandering/elopement and ensured the nurses were checking the wanderguard for working order and placement. He stated the Maintenance Director and a nurse check the wanderguard system at least 3 times a week by taking a resident up to the front door and ensured the alarm activated. In an interview on 09/24/25 at 10:59 AM with the ADON she stated it was her 4th day working at the facility and was trained regarding elopements and wandering residents by the DON and the Human Resources Director and was told the facility did not accept residents who eloped. She was unable to name any residents who were a current elopement/wandering risk. She stated residents were at risk of wandering or elopement when they had diagnoses such as dementia, were confused or not orientated, had UTIs or infections. In an interview on 09/24/25 at 11:09 AM with the [NAME] President of Clinical Operations she stated orders are typically entered into the resident's electronic chart by the floor nurse and then it automatically updates the TAR for nurses and the Point of Care (POC) for CNAs. She stated it was important monitoring of wanderguards were was completed as ordered because it ensured resident safety of those at risk of wandering/elopement. She stated there was a task tab needed to be clicked in the resident record to move the order or area of concern into the resident's care plan and kardex. She stated it was important residents at risk of wandering/elopement and wanderguards were care planned with interventions so nurses and other facility staff were aware of those at high risk or sought exits and kept an closer eye on them. In an interview on 09/24/25 at 1:46 AM with the Administrator she stated She stated the MDS Coordinator reviewed and updated the care plans for all residents. She stated she expected any resident with a wanderguard had it care planned and in the kardex so staff were aware and it was seen and documented across the board for all staff. She stated all door alarms and the wanderguard were checked by a contracted company and were found to be in working order by the company and the Maintenance Director. She stated the Maintenance Director checked the wanderguard system frequently and was currently in the hospital and she was not aware of any documentation of his checking of the wanderguard system and would look for it and the documentation from the contracted company regarding door alarms. She stated the Interim Maintenance Director would be covering the facility while the Maintenance Director was out. She stated the DON was responsible for ensuring nurses monitored and documented the placement, working order, and expiration date of wanderguards. She stated it was important for nurses documented monitoring in the resident electronic record because it ensured staff were checking the device.Record review of the facility's elopement policy, titled Elopement-Overview, dated reviewed December 2024, reflected: The facility elopement definition is as follows: Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.Record review of the facility's accidents and hazard policy titled Safety and Supervision of Residents, dated reviewed December 2024, reflected: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Individualized, Resident-Centered Approach to Safety1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff;b. Assigning responsibility for carrying out interventions;c. Providing training, as necessary;d. Ensuring that interventions are implemented; ande. Documenting interventions.5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; andd. Evaluating the effectiveness of new or revised interventions.Record review of the facility's elopement facility practices, titled Elopement-Facility Practices, dated reviewed December 2024, reflected: The facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement. Guidelinesl. Assess the security of potential internal environmental risk factors including, but not limited to, the following: Elevators Exit Doors Screens Stairwells Windows2. Maintain door alarms and wander control systems in proper working order. (Refer to the Prevention Maintenance Program in the Maintenance Manual.).5. Maintain a current protected list of names and photographs of resident/patients identified at risk for elopement. Assure picture contains the following information:a. Nameb. Descriptionc. Heightd. Weighte. Agef. Pertinent medical informationg. Lot# of Electronic Bracelet if applicableh. Expiration date of Electronic Bracelet' if applicable6. Monitor whereabouts of the at-risk resident/patient during rounds.7. Validate, through observation, the resident/patient is wearing electronic device every shift as indicated & document on the TAR.8. Validate daily that the electronic device is properly functioning & document on the TAR.Record review of the facility's wandering residents policy, titled Wandering, Resident, dated reviewed December 2024, reflected: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.Policy Interpretation and Implementation4. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 5. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering.6. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a monitoring plan will be included.5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:a. Examine the resident for injuries;b. Contact the Attending Physician and report findings and conditions of the resident;c. Notify the resident's legal representative (sponsor);d. Notify search teams that the resident has been located; e. Complete and file an incident report; andf. Document relevant information in the resident's medical record.Record review of the facility's elopement prevention policy, titled Elopement Prevention, dated reviewed December 2024, reflected: The facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired resident/patient and family. The facility will implement individualized interventions & strive to prevent elopement.Guidelines2. Complete admission data collection 3. Review and evaluate risk factor data.4. Determine if the resident/patient is at risk for elopement.5. Include resident/patient and family in development of the Plan of Care.6. Present at the next scheduled Interdisciplinary Plan of Care (IPOC) &/or Standards of Care meeting.7. Develop individualized interventions which may include, but are not limited to, the following: Electronic monitoring/alarm systems Environmental modifications Protected list of names and photographs of those at risk for elopement. Psychosocial interventions Regular rounds Resident/patient and family education Staff interventions Structured group activities8. Communicate risk and interventions with the resident/patient and family and provide education as needed.9. Discuss interdisciplinary interventions with the resident/patient and family and provide education as needed.10. Provide staff training as needed.11. Review and revise Plan of Care as needed.Record review of the facility's elopement management policy, titled Elopement Management, dated reviewed December 2024, reflected: The interdisciplinary team will re-evaluate cognitively &/or psychologically impaired residents/patients who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident/patient and family, individualized interventions will be developed and initiated to manage the elopement behavior. Guidelines.8. Review and revise individualized interventions that may prevent further elopement attempts. 10. Communicate interventions to staff and provide training as needed. 11. Evaluate and document effectiveness of revised interdisciplinary interventions.12. Review and Revise Plan of Care needed.Help shape the future of iQIES. Click Here to participate in iQIES HCD Research or email us at iqies_hcd@cms.hhs.gov.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #53) reviewed for storage of medications.The facility failed to ensure Resident #53's Econazole Nitrate Cream (treatment for skin infection) labeled topical ointment, was secured, and not left at the bedside.This deficient practice could place residents at risk for loss of biologicals, overuse of medication, and not receiving the therapeutic benefit of the medication. Findings included:Record review of Resident #53's admission MDS, dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #53 had diagnoses of hypertension (Elevated blood pressure), and Alzheimer's Disease (a progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Resident #53 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #53's order summary, dated 09/23/25, reflected no physician order for Econazole Nitrate Cream, 1%. Observation of 09/23/25 at 01:53 PM revealed, Resident #53 was not in the room, and there was a box of Econazole Nitrate Cream, 1% with a non-facility's pharmacy label indicating apply topically to the affected area twice daily, and a faded date that read [ ./29/2025] During an interview and observation on 09/23/25 at 2:26 PM, LVN L looked at the medication box and stated, he did not notice the ointment box on the nightstand in Resident #53's room. He stated maybe Resident #53's family member brought it from home. He stated the medication should not be left at the bedside, because it could be used by someone for whom it was not intended. He further stated a confused resident in the facility could eat it, too, and have an adverse reaction to the medication, like an upset stomach. During an interview on 09/25/25 at 12:23 PM, the DON stated he tried to educate residents' family members to let the nurses know if they bring medication from home, so the nurses will get an authorization for use of the medication from the facility primary physician. He stated the nurse for Resident #53 was supposed to take the medication ointment from the resident's room and notify the family, notify the primary physician and see if the primary physician wanted to incorporate the medication ointment in Resident #53's medication regimen, and the facility pharmacy could be able to deliver the medication, because the one found at bedside looked like it was from an outside pharmacy. The DON stated the risk to residents could be taking medication that was contraindicated for them and could react with other medications that they are taking. The DON stated another resident could use ointment medication as a toothpaste or lotion. During an interview on 09/26/25 at 5:56 PM, the Administrator stated there should not be any medications at the bedside, and all the residents' medications should be kept in the medication cart. She stated the risk to residents could be injury, and adverse events if they take too much medication. Review of the facility policy titled Medication Storage dated December/2024 reflected Policy. Medications. are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.14. Outdated., discontinued or deteriorated medications.are immediately removed from stock, disposed.

Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to meet the resident's highest practicable physical, mental, and psychosocial wellbeing for 6 (Residents #14, #8, #6, #29, #30 and #37) of 24 residents reviewed for care plans.1. The facility failed to develop a comprehensive care plan for Residents #8 and #14 who were at risk for elopement/wandering.2. The facility failed to develop a Kardex for Residents #6, #8, #14, #29, #30 and #37 at risk for elopement/wandering.These failures place residents at risk of not having their individualized needs meet, preventative measures and interventions in place to prevent elopements. Findings included:1. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Hypothyroidism (condition in which thyroid gland does not make enough thyroid hormones to meet your body's needs), hypertension (high blood pressure) and age-related cognitive decline (the gradual decline in cognitive abilities that occurs as people age).Review of Resident #14's quarterly MDS assessment dated [DATE] reflected Resident #14 had a BIMS of 8 indicating he was moderately cognitively impaired. Resident #14 was partial/moderate to substantial/maximal assistance with ADLs. Review of Resident #14's initial elopement assessment dated [DATE] reflected Resident #14 was at risk for elopement. It was not complete with the following questions blank: 6. Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.) 7. Does the Resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings). The assessment was incomplete including the goals, interventions and clinical suggestions.Review of Resident #14's comprehensive care plan last revised 08/11/25 reflected Resident #14 had impaired cognitive function/dementia or impaired thought processes [related to] Dementia. The care plan did not reflect Resident #14's elopement risk, wandering behavior and did not reflect Resident #14's order for wanderguard (a wearable, electronic resident bracelet that alerts staff when a resident approaches a protected area, such as a door exit) placement for resident safety.Review of Resident #14's progress notes for 08/01/25 to 09/22/25 reflected the following:-Dated 07/31/25 nursing skilled evaluation by LVN K reflected Level of cognitive impairment: Moderate impairment (memory loss).Mood and Behavior: Resident wanders at night.-Dated 08/01/25 at 11:00 PM Nurse note by LVN K reflected Patient had to be redirected several times going in and out of room's and rambling in drawer's.-Dated 08/02/25 nursing skilled evaluation completed by RN A reflected Safety Note: Resident is a wanderer and is a high risk for elopement. Wander guard worn.-Dated 08/03/25 nursing skilled evaluation completed by RN A reflected under Safety concerns - note: High risk for elopement; wears a wander guard.-Dated 08/04/25 nursing skilled evaluation completed by RN A reflected Resident #14 had severe impairment and safety note: wanders.-Dated 08/05/25 nursing skilled evaluation completed by RN A reflected Resident #14 had safety concerns: wanders.Dated 08/31/25 at 9:16 PM nursing note by RN A reflected Resident removed wander guard from his leg and placed it on his dinner tray. Resident placed on 24 hour report and oncoming shift notified.Review of Resident #14's elopement assessment dated [DATE] reflected Resident #14 was at risk for elopement due to resident wanders aimlessly or non-goal-directed and Resident #14 was a recent admit not accepting the situation. The assessment was incomplete including the goals, interventions and clinical suggestions.Review of Resident #14's consolidated physician orders dated 09/23/25 reflected Resident #14 had a current order dated 09/04/25 of WANDERGUARDS: CHECK FOR PLACEMENT ANDPROPER WORKING FUNCTION EVERY SHIFT Placement: right ankle Expiration date: 2/15/2026.Review of Resident #14's Kardex ( a summary of patient information for daily care) reviewed on 09/23/25 reflected no elopement or wandering risk under safety.2. Record review of Resident #8's Quarterly MDS dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of dementia, had a BIMS score of 14 (intact cognition), and required limited assistance with ADLS. Record review of Resident #8's elopement evaluation, dated 7/24/25, reflected he was not at risk of elopement with and the sections for risk of elopement and clinical suggestions were blank. Review of Resident #8's elopement evaluation dated, 9/4/25, reflected he was at risk of elopement with and the sections for risk of elopement and clinical suggestions were blank. Record review of Resident #8's physician orders reflected an order, start dated 09/04/25: WANDERGUARD: CHECK FOR PLACEMENT ANDPROPER WORKING FUNCTION EVERY SHIFT. Placement: Right Ankle .Record review of Resident #8's psychiatry progress note, date of service 09/17/25, reflected Resident #8 was a poor historian, forgetful with a flat affect and past medical history of dementia, bipolar, psychotic disorder with delusions and had a cognitive communication deficit.Record review of Resident #8's comprehensive care plan last revised 09/08/25 reflected it did not include his wander guard and risk of elopement/wandering.Record review of Resident #8's Kardex did not reflect wander guard elopement/wandering status.3. Record review of Resident #6's face sheet dated 09/23/2025 reflected she was a [AGE] year old female with an admission date of 05/16/2025., Diagnoses included Encephalopathy (a state where brain function is disordered, damaged, or malfunctions, leading to an altered mental state), Schizoaffective disorder (a chronic mental health condition), Type 2 diabetes mellitus with diabetic neuropathy, unspecified (elevated blood sugar levels and nerve damage).Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #6 used a wheelchair for ambulation, and she needed supervision with chair/bed to chair transfers and to walk 50 feet with two turns.Record review of Resident #6's care plan, with a revision date of 06/03/2025, reflected the need for 24-hour supervision and that she used antidepressant medication related to bipolar disorder: a later review on 07/24/2025 reflected Resident #6 was a risk for elopement. Goal: Resident #6's safety will be maintained through the review date. Interventions: Distract Resident #6 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers.Record review of Resident #6's Kardex dated 09/23/2025 reflected no information Resident #6 was an elopement risk.Record review of Resident #6's physician order summary dated 09/23/2025 reflected Resident #6 had an order for wander guard from 09/04/2025: Check for placement and proper working function every shift. Placement: Right ankle, Expiration date: 02/15/2026, every shift.4. Review of Resident #29's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke affecting right side, hypertension (high blood pressure), diabetes (chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood glucose levels), aphasia (language disorder that affects person's ability to communicate effectively). Resident #29 was moderately impaired in daily decision making. Resident #29 had no wandering behavior during the lookback period. Resident #29 required supervision to partial/moderate assistance with ADLs.Record review of Resident #29's physician order dated 09/04/25 reflected an order, start dated 01/21/25: WANDERGUARD: CHECK FOR PLACEMENT AND PROPER WORKING FUNCTION EVERY SHIFT. Placement: Right Ankle .Observation and Interview on 09/23/2025 at 2:50 PM revealed Resident #29 was in his room and had a wanderguard on his left ankle. RN Q stated Resident #29 was confused, and did have wandering and exit seeking behavior at times. She stated she was responsible to check his wanderguard placement and functioning of the wanderguard each shift when she was his charge nurse.5. Record review of Resident #30's face sheet dated 09/23/2025 reflected she was a [AGE] year-old female with an original admission date of 02/15/2021. Diagnoses included unspecified dementia (memory loss), delusional disorder (false beliefs based on incorrect interpretation of reality), type two diabetes mellitus (elevated blood sugar levels).Record review of Resident #30's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 7 which indicated severe cognitive impairment. Resident #30 used wheelchairs for ambulation, and needed moderate assistance with chair/bed to chair transfers and substantial assistance with walking. Record review of Resident #30's care plan with a revision date of 11/29/2021 reflected she was at risk to wander. Goal: Resident #30's safety will be maintained through the review date. Interventions: distract Resident #30 from wandering behaviors by offering pleasant diversions, structured activities, food, conversations, television, book.provide with wander guard. Record review of Resident #30's Kardex dated 09/23/2025 reflected no information that Resident #30 was an elopement risk.Record review of Resident #30's physician order summary dated 09/23/2025 reflected Resident #30 had an order for wander guard from 09/23/2025 with the same start date: Check for placement and proper working function every shift. Placement: Left ankle, Expiration date: 02/15/2026, every shift for safety measures.6. Record review of Resident #37's Quarterly MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of dementia (loss of cognition), major depressive disorder (persistently depressed mood or loss of interest), and severe cognitive impairment (BIMS score of 3). He required moderate assistance with ADLs, ambulated with a wheelchair, and used a wander/elopement alarm daily.Record review of Resident #37's care plan reflected he was an elopement risk/wanderer. Interventions included wanderguard to right ankle, to distract resident with pleasant or structured activities, dated initiated 01/21/25 and revised on 02/11/25. Record review of Resident #37's Kardex did not reflect wander guard elopement/wandering status.Review of Resident #37's elopement evaluation dated, 9/4/25, reflected he was at risk of elopement and the sections for risk of elopement and clinical suggestions were blank. Record review of Resident #37's physician orders reflected an order, start dated 01/21/25: WANDERGUARD: CHECK FOR PLACEMENT AND PROPER WORKING FUNCTION EVERY SHIFT. Placement: Right Ankle .In an interview on 09/23/25 at 4:32 PM with CNA M revealed she had worked at the facility for about 6 months and worked all the halls. She stated the kardex reflected what a resident needed. In an interview and observation on 09/23/25 at 5:37 PM with CNA B of Resident #8 or #37, or Resident #30's Kardex revealed there was no indication of their risk of wandering/elopement or wanderguard status. She stated she thought the kardex reflected the elopement risk of the resident and whether they wore a wanderguard and was not able to find the informationIn an interview on 09/24/25 at 11:09 AM with the [NAME] President of Clinical Operations she stated orders are typically entered into the resident's electronic chart by the floor nurse. She stated there was a task tab that needed to be clicked in the resident record to move the order or area of concern into the resident's care plan and kardex. She stated it was important that residents at risk of wandering/elopement were care planned with interventions so that nurses and other facility staff were aware of those at high risk or sought exits and kept a closer eye on them. In an interview on 09/24/25 at 1:46 PM with the Administrator revealed stated she and the MDS Coordinator reviewed and updated the care plans for all residents who were at risk for elopement/wandering. She stated that she expected any resident with a wanderguard had it care planned and in the kardex so that staff were aware and it was seen and documented across the board for all staff. In an interview on 09/24/25 at 1:50 PM with the MDS Coordinator stated she did not complete the care plans for residents at risk for elopement and did not input the physician orders for wanderguard placement on 09/04/25. She stated she did not update the Kardex but she thought the DON was responsible to update the Kardex for the CNAs to review for residents. She stated care plan/kardex must include at risk for elopement, observation for wandering behaviors wanderguard placement and verification of function, and monitoring for wanderguard function. She stated not having a resident's wanderguard placement, monitoring, or wandering/elopement risk care planned or in the kardex meant staff might not know they were at risk.In an interview on 09/26/25 at 5:44 PM with the Administrator she stated she was not aware that there were residents that did not have their wandering/elopement risk care planned there was also confusion over whose job duty it was to update resident kardex/care plan. She stated residents not having monitoring in place for wanderguards monitoring and placement placed them at risk of eloping and was a failure in their protocol. She stated residents not having a kardex or care plan that reflected their wanderguard placement, wander/elopement risk and interventions placed residents at risk because staff might not know their risk of wandering/elopement and they might elope.Record review of the facility's elopement policy, titled Elopement-Overview, dated reviewed December 2024, reflected: The facility elopement definition is as follows: Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.Record review of the facility's accidents and hazard policy titled Safety and Supervision of Residents, dated reviewed December 2024, reflected: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Individualized, Resident-Centered Approach to Safety1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff;b. Assigning responsibility for carrying out interventions;c. Providing training, as necessary;d. Ensuring that interventions are implemented; ande. Documenting interventions.5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; andd. Evaluating the effectiveness of new or revised interventions.Record review of the facility's wandering residents policy, titled Wandering, Resident, dated reviewed December 2024, reflected: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.Policy Interpretation and Implementation1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering.3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a monitoring plan will be included.5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:a. Examine the resident for injuries;b. Contact the Attending Physician and report findings and conditions of the resident;c. Notify the resident's legal representative (sponsor);d. Notify search teams that the resident has been located; e. Complete and file an incident report; andf. Document relevant information in the resident's medical record.Record review of the facility's elopement prevention policy, titled Elopement Prevention, dated reviewed December 2024, reflected: The facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired resident/patient and family. The facility will implement individualized interventions & strive to prevent elopement.Guidelines1. Complete admission data collection 3. Review and evaluate risk factor data.4. Determine if the resident/patient is at risk for elopement.5. Include resident/patient and family in development of the Plan of Care.6. Present at the next scheduled Interdisciplinary Plan of Care (IPOC) &/or Standards of Care meeting.7. Develop individualized interventions which may include, but are not limited to, the following: Electronic monitoring/alarm systems Environmental modifications Protected list of names and photographs of those at risk for elopement. Psychosocial interventions Regular rounds Resident/patient and family education Staff interventions Structured group activities8. Communicate risk and interventions with the resident/patient and family and provide education as needed.9. Discuss interdisciplinary interventions with the resident/patient and family and provide education as needed.10. Provide staff training as needed.11. Review and revise Plan of Care as needed.Review of facility's policy Care Plans, Comprehensive last revised December 2024 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The care planning process will: b. Include an assessment of the resident's strengths and needs.8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.g. Incorporate problem areas; h. Incorporate risk factors associated with identified problems.m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels.9. Area of concern that are identified through the resident assessment will be evaluated before interventions are added to the care plans.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 (Resident #37, Resident #34, Resident #45, and Resident #60) of 12 residents reviewed for personal care. The facility failed to ensure: 1- Resident #37's nails were trimmed and without jagged edges. 2- Resident #60's nails were trimmed and cleaned. 3- Resident#34's nails were trimmed and cleaned. 4- Resident#45's nails was trimmed and without jagged edges. This failure could place residents who require staff assistance at risk of dermatitis (inflammation of the skin), infections, and low self-esteem.1-Record review of Resident #37's care plan reflected he was at risk of impairment to his skin's integrity due to decreased mobility and incontinence, interventions included to avoid scratching and keep fingernails short, dated initiated 10/04/25. An observation and interview on 09/23/25 at 10:20 AM, Resident #37 was lying in bed with nails that was long and jagged on both hands. Resident #37 stated his nails was too long and raggedy. He stated he was not sure why they was not trimmed and would like them trimmed. In an interview on 09/23/25 at 10:32 AM, LVN E stated she was just about to trim Resident #37's nails. Observation of Resident #37's nails at that time, LVN E stated that his nails was long and jagged in areas. LVN E stated that she usually trimmed Resident #37's nails once a week and she had not been to work in over a week and stated she was going to trim them now . 2-Record review of Resident #60's Quarterly MDS, dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted [DATE]. Resident #60 had diagnoses of cancer (when abnormal cells grow out of control and spread to other areas of your body), muscle weakness, and lack of coordination. Resident #60 had a BIMS score of 10, which indicated moderate cognition impairment. Further review revealed personal hygiene he was coded as supervision or touching assistance. Record review of Resident #60's care plan dated 09/04/25 reflected, focus: [Resident#60] have an ADL Self Care Performance Deficit r/t increased weakness. Goal: [Resident #60] will maintain current level of function in.Personal Hygiene. through the review date. Intervention/Tasks: [Resident #60] require (1) staff participation with personal hygiene and oral care. An observation and interview on 09/23/25 at 10:51 AM, Resident #60 was lying in bed, his fingernails on both hands was long approximately 0.7 cm from the tips of his fingers, and dirty with black matter underneath. Resident #60 stated his nails was too long and he would like them to be cleaned and trimmed. In an interview and observation on 09/23/25 at 12:08 PM, CNA G looked to Resident #60's fingernails and stated they needed to be cleaned and trimmed, because they looked dirty, long, and jagged. CNA G stated CNAs and Nurses was responsible for nail care. She stated that Nurses was responsible for nail care for diabetic residents. She stated nail care for residents was done as needed. She added the risk to residents for not trimming or cleaning nails decreased skin integrity and risk of infections. 3-Record review of Resident #34's Quarterly MDS, dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #34 had diagnoses of hypertension (elevated blood pressure), cerebrovascular accident (It is a serious medical condition that occurs when the brain is damaged due to a lack of blood flow, either from a blocked blood vessel or a ruptured one), and Hemiplegia (paralysis that affects only one side of your body) or Hemiparesis (one-sided muscle weakness) affecting left nondominant side. Resident #34 had a BIMS score of 14, which indicated intact cognition. Further review revealed personal hygiene he was coded as partial/moderate assistance. Record review of Resident #34's care plan dated 07/29/25 reflected, focus: [Resident #34] have an ADL Self Care Performance Deficit. Goal: [Resident #34] will improve current level of function through the review date.Intervention/Tasks: [Resident #34] require (1) staff participation with personal hygiene and oral care. In an observation and interview on 09/23/25 at 11:10 AM, Resident #34 was observed lying in bed, fingernails on both hands was long approximately 0.8 cm in length from the tips of his fingers, jagged and dirty with black substance underneath. Resident #34 stated he would like his fingernails cleaned and trimmed. In an interview and observation on 09/23/25 at 12:11 PM, CNA G looked to Resident #34's fingernails and stated they needed to be cleaned and trimmed, she said they looked dirty, long, and jagged. CNA G stated CNAs and Nurses was responsible for nail care. She stated that Nurses was responsible for nail care for diabetic residents. She stated nail care for residents was as needed. She added the risk to residents for not trimming or cleaning nails decreased skin integrity and risk of infections. 4-Record review of Resident #45's Quarterly MDS, dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses of hypertension (elevated blood pressure), cerebrovascular accident (It is a serious medical condition that occurs when the brain is damaged due to a lack of blood flow, either from a blocked blood vessel or a ruptured one), weakness, lack of coordination, and Hemiplegia (paralysis that affects only one side of your body) or Hemiparesis (one-sided muscle weakness) affecting left nondominant side. Resident #45 had a BIMS score of 08, which indicated moderate cognition impairment. Further review revealed personal hygiene he was coded as supervision or touching assistance. Record review of Resident #45's care plan dated 08/07/25 reflected, focus: [Resident #45] have an ADL Self Care Performance Deficit r/t increased weakness. Goal: [Resident #45] will maintain current level of function in. Personal hygiene through the review date. Intervention/Tasks: [Resident #45] require (1) staff participation with personal hygiene and oral care. In an observation and interview on 09/25/25 at 09:44 AM, Resident #45 was observed up in his wheelchair in the hallway. Resident #45's left hand was contracted with fingernails long approximately 0.6 cm in length from the tips of his fingers. Resident #45 left hand four fingers (4th, 3rd, 2nd and 5th) was drawn up in fist and resting against the hand palm. Resident #45 right hand thumb fingernail was long approximately 0.6 cm in length from the tips of his finger, and jagged. Resident #45's right hand other fingers (4th, 3rd, 2nd and 5th) was trimmed to the tips of his fingers. Resident #45 stated, he was able to trim his hand right four fingernails, but was unable to trim his right-hand thumb, and his left-hand fingernails. Resident #45 was not able to state how he was able to trim some of his fingernails, and he liked his fingernails trimmed. In an interview and observation on 09/25/25 at 09:57 AM, CNA H looked to Resident #45's fingernails and stated they needed to be trimmed, they looked long, and jagged. CNA H stated CNAs and Nurses was responsible for nail care. She stated that Nurses was responsible for nail care for diabetic residents. She stated nail care for residents was done as needed. She added the risk to resident for not trimming or cleaning nails was decreased skin integrity and risk of infections. In an interview on 09/25/25 at 09:59 AM, LVN I revealed, CNAs was responsible for resident nail care, unless the resident had diagnoses of Diabetes, then Nurses was responsible for trimming resident nails. She stated dirty, long fingernails can expose the residents to the risk of developing infections or skin tears. LVN I further stated that although CNAs was responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails was always cleaned and trimmed. In an interview on 09/25/25 at 12:20 PM, the DON revealed there was no expectation on frequency of nail trimming for residents because each person's nails grew at a different rate. He stated that he expected staff to ensure residents nails was kept low and clean. He stated the risk to a resident by not having trimmed, clean, or smooth nails could be skin tears or infections. In an interview on 09/26/25 at 5:56 PM, the Administrator stated residents' fingernails should be cleaned and trimmed to the resident's likening. She stated it was the responsibility of CNAs and nurses to make sure residents' fingernails was kept clean and trimmed. She stated the risk to residents was injuries and development of infection. Record review of facility policy titled Providing Nail Care dated 12/2024 reflected The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 3. Routing cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care to include trimming and filing, will be provided on a regular schedule. nail care will be provided between scheduled occasion as the needs arises. a. Nails should be kept smooth to avoid skin injury .

Based on observations, interviews, 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 2 (300-400-600-Hall cart) medication carts reviewed for pharmacy services. The facility failed to ensure expired medication, was removed from the 300-400-600-Hall medication cart. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from expired supplies.Findings included:Observation on 09/23/25 at 09:21 AM of the 300-400-600-Hall medication cart revealed:-Two boxes of Latanoprost Ophthalmic Solution 0.005 % (Glaucoma ) with open date of 08/09/25-One box of Dorzolamide hcl 2% (Glaucoma ) with open date of 08/09/2025.-One box Timolol maleate 0.5% (glaucoma) with open date of 08/09/2025. -Two boxes of Artificial tears with open date of 08/13/25. During an interview on 09/23/25 at 10:23 AM, LVN I stated all the nurses was responsible for checking for expired medications/supplies in the medication carts at the start of their shift. She stated the expectation was for the solution or liquid medication to be discarded 28 days after opening, unless otherwise specified by the ordering doctor or pharmacy. She stated if a resident was to take expired medication, then the medication strength could be altered, and it could negatively affect the resident. When asked the last time the medications was given to the residents, she replied, she did not administer the eye drops, the eye drops was given by the evening nurses. During an interview on 09/25/25 at 12:23 PM, the DON stated all the nurses was responsible for checking their medication cart at the start of the shift for expired supplies and medications. He stated the solution/liquid medication should be labeled with the date it was opened and discarded no later than 28 days after that date. The DON stated the risk to residents, the medications strength could be ineffective after the expiration date or becomes contaminated, and lead to infection development. During an interview on 09/26/25 at 5:56 PM, the Administrator stated, she expected frequent auditing of the medication carts by the nurses to make sure there was no discharged residents' medication, and no expired medication in the carts. She stated the risk to residents, the medication dose may not be effective and should be used by the manufacturers expiration date. Review of the facility policy titled Medication Storage dated December/2024 reflected Policy. Medications. are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.14. Outdated., discontinued or deteriorated medications.are immediately removed from stock, disposed of accordingly.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #43) observed for infection control. CNA M failed to perform hand hygiene and change gloves while providing incontinence care to Resident # 43. This failure could place residents at risk for infection.Findings included:Record review of Resident #43's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE], and readmitted [DATE] with the diagnoses of hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), and cerebrovascular accident (occurs when blood flow to the brain is interrupted, leading to brain damage). Resident #43 had a BIMS score of 06, which indicated severe cognition impairment. Further review revealed urinary continence/ bowel continence were coded as frequently incontinent. Record review of Resident #43's care plan dated 08/11/25 reflected, focus: [Resident #43] have an ADL Self Care Performance Deficit r/t CVA Goal: [Resident #43] will maintain current level of function in.toilet use.Personal Hygiene. through the review date. Intervention/Tasks: [Resident #43] require extensive assistance of 1 staff participation to use toilet. Observation on 09/25/25 at 1:31 PM, reflected CNA M provided incontinent care to Resident #43. CNA M entered Resident #43's room washed hands, put on clean gloves and explained to the resident that she was to provide incontinent care. CNA M positioned the resident and unfastened her brief, then proceeded to clean the resident. Resident#43's brief was soaked with urine. CNA M cleaned Resident #43 front area, removed gloves, and put on clean gloves without performing any hand hygiene. CNA M helped Resident #43 turned to her left side. When CNA M completed cleaning Resident #43's buttocks area, she pushed the dirty brief under the resident, without any hand hygiene or change of gloves, CNA M proceeded to apply the clean brief. After CNA M applied the clean brief, she removed the dirty brief that was at the left side of the Resident #43 and placed it in the trash can. CNA M removed gloves, covered the resident, positioned the resident, and moved the bedside table closer to the resident. After care, CNA M completed hand hygiene and exited the room. In an interview on 09/25/25 at 1:40 PM, CNA M stated she was to complete hand hygiene before and after care and after taking off Resident #43's dirty brief. CNA M stated she was supposed to change her gloves with hand hygiene after she cleaned the resident before applying the clean brief. CNA M stated she was supposed to sanitize her hands each time she removed the dirty gloves before putting on the clean gloves. CNA M stated she was to complete hand hygiene for infection control[PH1] . In an interview on 09/25/25 at 2:40 PM, the DON stated infection control was important during care. The DON stated during care the staff was to use the hand sanitizer or wash hands if they were physically soiled. The DON stated the staff was expected to complete hand hygiene before care and after care, he also stated during incontinent care the staff was supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean. The DON stated hand hygiene was to be completed for infection control[PH2] . Review of the facility policy dated 12/24 and titled Hand-Washing/Hand Hygiene reflected, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. h. Before moving from a contaminated body site to a clean body site during resident care. This applies to all staff working in all locations within the facility.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review the facility failed to ensure a comfortable, homelike environment, with safe temperature levels within a range of 71 to 81 degrees Fahrenheit for 1 of 6 residents (Resident #60) observed for environmental concerns. The facility failed to ensure the temperature in Resident #60's room was maintained at a safe and comfortable range on 9/23/25. The room temperature was 82 degrees Fahrenheit. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life.Findings included: Record review of Resident #60's Quarterly MDS, dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #60 had diagnoses of cancer (when abnormal cells grow out of control and spread to other areas of your body), muscle weakness, and lack of coordination. Resident #60 had a BIMS score of 10, which indicated moderate cognition impairment. Record review of Resident #60's care plan dated 09/04/25 reflected, focus: [Resident#60] rights will be respected and maintained through the review date. Goal: Resident rights will be respected and maintained through the review date. Intervention/Tasks: Dignity and respect: I will have the right to: *live in safe, decent, and clean conditions *be free from abuse, neglect, and exploitation *be treated with dignity. An observation on 09/23/25 at 10:51 AM, with Resident #60 revealed he was lying in bed wearing a hospital gown, his face was damp with sweat. Resident #60 stated it was hot in his room, because the air conditioning (AC) unit under the window was not working. When asked how long the AC unit in his room was not working, he replied for the last month. He stated he reported it to the aides taking care of him but was unable to recall a name. Interview and observation on 09/23/25 at 4:00 PM, the Maintenance Director checked the temperature in Resident #60's room with a digital thermometer, the temperature was 82 degrees Fahrenheit. The Maintenance Director stated the room temperatures was supposed to be between 71 to 81 degrees Fahrenheit, or for this building to a comfortable level for the residents. The Maintenance Director attempted to turn the AC unit on and was unable. the Maintenance Director unplugged the AC unit, tested the power outlet, and stated there was no power in it. The Maintenance Director stated he will go and fix it. The Maintenance Director left the room, and came back, he plugged the AC unit and turned it on, and it started working. The Maintenance Director stated he was from another facility and was covering for the main Maintenance Director who was sick. He stated he was not aware of the AC unit not working in Resident #60's room. He stated the direct care staff should report the issue to the Maintenance Department to fix it. He did not answer the question about if there if was risk to the resident. In an interview on 09/25/25 at 12:23 PM, the DON stated he was not aware of the AC unit not functioning in Resident #60's room. He stated normally when they have that situation, they would move the resident to a different room or bring a fan until the AC unit was fixed or move the resident until the AC got fixed and move the resident back to his/her room. The DON stated the risk to residents could be skin breakdown from sweating, uncomfortable environments, and delayed in recovery from illnesses. In an interview on 09/26/25 at 5:56 PM, the Administrator stated her expectations was for all the AC units to be in working conditions in the residents' rooms. She stated the resident should be moved to another room with a working AC unit and get his/her AC unit repaired. She stated the staff was supposed to notify the Maintenance Director and enter the order on the TELS (Electronic maintenance record system) . She stated risk to residents overheating and discomfort. Record review of the facility policy titled Safe and HomeLike Environment dated 12/2024, reflected Policy: In accordance with residents' rights, the facility will provide a safe, comfortable and home like environment.Definitions. [Comfortable and safe temperature levels] means that the ambient temperature should be in a relatively narrow range that minimizes residents; susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit.

Based on observations, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history if eloping and wore a wandergaurd, was provided with adequate supervision to prevent him from eloping from the facility on 03/28/25. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. 2. The facility failed to complete an elopement assessment for Resident #1 prior to his elopement on 03/28/25 The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 03/28/25 and ended on 04/01/25. The facility had corrected the non-compliance before the survey began. These failures placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's Face Sheet, dated 05/06/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: dementia, gout (a form of inflammatory arthritis caused by the buildup of uric acid crystals in the body, leading to sudden, severe pain, swelling, and redness in one or more joints), acute kidney failure, Type 2 diabetes, oropharyngeal dysphagia (difficulty swallowing that specifically occurs in the oral cavity and throat), lack of coordination, and major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 03/11/25, revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. In Section P0200. Alarms indicated Resident #1 had a Wander/elopement alarm. Record review of Resident #1' Care Plan, dated 02/21/25, revealed: Focus: [Resident #1] use psychotropic medications r/t Dementia. Date Initiated: 06/20/2024 Revision on: 04/18/2025 Cancelled Date: 04/16/2025 Goal: [Resident #1] will be/remain free of drug related complications. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Discuss with MD, family re ongoing need for use of medication. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Monitor/record occurrence for target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1] is an elopement risk/wanderer. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1's] safety will be maintained through the review date. Date Initiated: 03/28/2025 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Assess for fall risk. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate [sic]. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 WANDER ALERT: Device # Model Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Record review of Resident #1's Social History and Initial Assessment revealed on Page 2, Question 9. Current Behavioral Status was checked as No behavioral Concerns. The document was signed and dated by the previous Social Worker on 06/24/24. Resident #1's family member provided the information to the previous Social Worker for the Social History and Initial Assessment. Record review of the Order Summary for Resident #1 revealed a Physician Telephone Order on 01/21/2025 for WANDERGUARDS: LEFT ANKLE.CHECK FOR PLACEMENT AND PROPER WORKING FUNCTION every shift. Record review of Resident #1's MAR for January 2025 - March 2025 revealed that Resident #1's Wanderguard Checklist was marked with a check markevery day during the Day, Evening and Night Shifts and was in operable condition. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day, Evening, and Night Shifts on 03/27/25. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day and Evening Shifts on 03/28/25. Record review of Resident #1's Elopement Evaluation on 03/28/25 revealed, an Assessment Outcome Score of 9 indicating Resident #1 was at Risk of Elopement. Record review of Resident #1 Assessments revealed that there was not an Elopement Evaluation for him prior to 03/28/25. Record review of an email from the Administration on 05/07/25 revealed that Resident #1 only had 1 Elopement Evaluation on 03/28/25. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:33 AM, revealed: resident was seen sitting in w/c in day area on when coming from helping another resident, he was gone down the hallway walking and pushing his w/c down by the breakroom area. then vanishes when no one seen him or heard any alarms. [Staff] begins to look for him along with nurses notified police, don, and family. resident was located across from facility ground in apartment complex. resident was brought back and evaluated with minor scratch on his chin and his left hand ring finger resident has no complaints. resident is in b/r laying down in bed resting with eyes closed with staff member doing 15 minutes check while asleep WCTM. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:48 PM, revealed: Elopement Evaluation: History of elopement while at home: Yes. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 9.0. Record review of Nurse Progress Notes from the SW's Late Entry on 03/31/25 at 12:30 PM, Effective: 03/28/25 at 12:26 PM revealed, This writer called representative to inform her of resident needing to be placed at another facility due to elopement risk. Resident representative stated she got a call from other facility regarding accepting him and I informed yes referral sent out to see if there would be anyone who would accept him. Record review of Nurse Progress Notes from CNA B's Late Entry on 03/28/25 at 13:42 [1:42 PM], Effective 03/28/25 at 12:44 PM revealed, The resident transferred to [another facility's] Secure Nursing Unit via wheelchair transport with medications and personal belongings at this time. The resident was cooperative prior to exiting the facility. No noted signs and symptoms of respiratory distress and denies discomfort prior to exiting the facility. Report called to [staff] at [another facility's] memory Care Unit. Record review of the facility's Provider Investigation Reports Fax Cover Sheet dated 04/03/25 revealed the following: Intake ID No: NO SR # received - Called in by [DON] on hotline. Record review of the facility's Provider Investigation Report revealed the following: Incident Date: 03/28/25. Time of Incident 3:20 AM. Staff reported [Resident #1], eloped from the facility to the apartment complex across the road. Record review of the facility's Provider Investigation Report's Investigation Summary section of the report reflected: [Resident #1] was brought back to the facility by the DON. Resident received treatment for his scrapes to his chin and finger. Resident placed on Q:15 minute checks. Family notified of need for secure unit and family in agreement. Facility transferred [Resident #1] to [another facility] on 03/28/2025 with resident belongings. The police department were notified about the incident. Record review of the facility's Provider Investigation Report's Facility Investigation Findings section of the report reflected: Confirmed. Record review of the facility's Provider Investigation Report's, Provider Action Taken Post-Investigation section reflected: Elopement In-Service, Wanderguard system checked with no issues identified. Record review of the facility's Provider Investigation Report's view of TULIP on 05/07/25 at 12:00 PM reflected, the wandering of Resident #1 on 03/28/25 from the facility to the apartment complex approximately100 feet across the street from the facility was not uploaded. In a telephone interview on 05/05/25 at 2:25 PM, with Resident #1's family member, she stated that Resident #1 was a resident at the facility for almost 1 year. She stated that prior to Resident #1 being admitted to the facility, he was living with the family member and he had about 2-3 elopement incidents, in which a decision was made to have Resident #1 reside at a Nursing Facility. She stated that initially Resident #1 was admitted to the facility after a hospital stay, which led to him needing physical therapy. She stated that during Resident #1's stay at the facility, she realized that Resident #1 had to be at the facility long term due to his dementia and exit seeking. The family member stated that she did not initially inform the facility that Resident #1 had exit seeking behaviors and had previously eloped from home prior to being admitted to the facility. She stated that no one asked her if Resident #1 was exit seeking or had some elopement incidents while he was staying at her home. She stated that no one asked her about Resident #1's previous elopement history, therefore she did not tell them. The family member stated that Resident #1 had a Wanderguard brace on his ankle due to him exit seeking at the facility. The family member stated that on 03/28/25 at approximately 3 AM, another family member notified her via telephone informing her that their family member had exited the facility although he was wearing a Wanderguard on his ankle and was found at the apartment complex across the street attempting to climb a fence. The family member stated that the neighbor at the apartment complex across observed Resident #1 and asked him, what are you doing? Resident #1 replied, I am trying to go to work, and you can call my [family member], he will come and get me. Resident #1 provided the telephone number for his family member. The neighbor at the apartment complex across the street from the the facility, then called 911 and told them about the incident and then telephoned Resident #1's family member. According to the family member, Resident #1's other family member called the facility and notified the staff at the facility that Resident #1 was not in the facility and the staff were unaware that Resident #1 had eloped from the facility. The family member stated that the police arrived at the apartment complex across the street from the facility and returned the resident to the facility. Resident #1 was then transferred to another facility on 03/28/25, the same day of his elopement. According to the family member, Resident #1 did not receive any serious injuries from eloping from the facility. On 05/06/25 at 12:00 PM an attempt to interview the previous DON via telephone was unsuccessful. On 05/06/25 at 12:15 PM an attempt to interview LVN A via telephone was unsuccessful. On 05/06/25 at 12:17 PM an attempt to interview CNA D via telephone was unsuccessful. In an interview with the SW on 05/06/25 at 4:31, she stated that she was not at work when Resident #1 eloped from the facility on 03/28/25 due to the incident occurring around 3 AM. The SW stated that she received a telephone call during the night by the previous DON stating that during the night shift of 3/27/25 and early morning of 03/28/25. She stated that she was asleep during the original voicemail from staff and in the morning, she woke up and listened to her voicemail message. She stated that she later learned that staff noticed that Resident #1 was missing, and they looked inside the building, and he was not in the building. The SW stated that staff went to look for Resident #1 outside the facility and he was found across the street at an apartment complex. The SW stated that Resident #1 had a Wanderguard on his leg and was exit seeking according to staff but had never exited the facility prior to the incident when he eloped on 03/28/25. The SW stated that according to the staff's records for Resident #1 had a Wanderguard Test on on 03/27/25 and 03/28/25 and it was working properly. She stated that staff sent an alert made for Resident #1 due to his eloping from the facility and then the staff began looking for him She stated that the facility was not aware that the resident had any elopement issues. She stated that if the facility was informed during Pre-Admission that any resident had any previous elopement issues, the facility would have not admitted that person to the facility. She stated that there are not any Power of Attorneys on file for Resident #1 and he was his own RP. The SW stated that she and staff were In-Serviced on Abuse, Neglect and Elopement Procedures and Guidelines after the incident involving Resident #1 eloping from the facility. In an interview with the Administrator on 05/06/25 at 4:53 PM, she stated that she was on vacation when Resident #1 eloped from the facility during the evening shift on 03/28/25. She stated that she is the Abuse Coordinator for the facility and when she returned to work at the facility, the previous DON updated her on the situation involving Resident #1's elopement on 03/28/25. The Administrator stated that the previous DON told her that Resident #1 exited the facility using the front door and was found across the street at an apartment complex. She stated that a man that lived in the apartment complex across the street witnessed him and law enforcement was notified. The previous DON went across the street to get Resident #1 and brought him back to the facility. She stated that Resident #1 did not have any serious injuries according to his head to toe assessment that was given by LVN A. She stated that Resident #1 was placed on 1:1 observation, (a healthcare practice where a staff member provides continuous, one-to-one attention to a patient), after the incident and a staff member was always with him. She stated that the previous DON stayed with Resident #1 until the next shift began at 6 AM. The Administrator stated that Resident #1's Emergency Contacts, Doctor and Behavioral Health were notified of Resident #1's elopement. She reported that Resident #1 had been at the facility for approximately 1 year and there was not any previous history of Resident #1 having any elopement issues or concerns prior to him being admitted to the facility. She stated that if the facility learned that Resident #1 was exit seeking or had any prior elopement concerns, he would not have been admitted to the facility because the facility is not equipped to have a Secured Unit. She stated that the SW then began to find placement for Resident #1 at a facility that had a Secure Unit. She stated that Resident #1 was discharged to another facility with a Secured Unit on 03/28/25. She stated that Resident #1 had a Wanderguard per his doctor's order and his Wanderguard was tested 3 times a day, per his doctor's orders. She stated that no one knows how Resident #1 was able to exit the facility on 03/28/25 due to his Wanderguard and the exterior doors working in proper order. She stated that the staff were In-Serviced on abuse, neglect, and elopement procedures after Resident #1's elopement form the facility. In an interview with the Maintenance Supervisor on 05/06/25 at 5:45 PM, he stated that he had been employed at the facility since 04/12/25. He stated that he was not aware of the elopement incident on 03/28/25 by Resident #1. He stated that there was not any documentation showing that there were any issues with any of the exterior doors at the facility on 03/27/25 and 03/28/25. He stated that he does daily checks on all the doors in the facility. He stated that the exterior doors to the building have a fire alarm and will alert if they are opened. He stated that the front door of the facility will alert and made a ringing sound if a resident with a Wanderguard attempts to exit the front door. He stated that he and other facility staff regularly receive In-Service Trainings on Abuse, Neglect and Elopement Procedures and Protocols. In an interview with CNA C on 05/07/25 at 10:44 AM, she stated that she had been employed at the facility for 1 year. She stated that she was not at the facility on 03/28/25 due to being off duty. She stated that Resident #1 had dementia and during her shifts was observed coming close to the side door on his hallway. She stated that he had not observed Resident #1 exit any doors from the facility. She stated that when she returned to work, she was informed by staff that Resident #1 had exited the building during the night shift on 03/27/25 - 03/28/25. She stated that the night shift duty hours are 10 PM - 6 AM. She stated that Resident #1 did not receive any serious injuries according to his skin assessment on 03/28/25. She stated that all staff receive trainings throughout each week on abuse, neglect, and elopement. She stated that she remembered that she received an In-Service Training on Elopement after the incident on 03/28/25 when Resident #1 eloped from the facility. On 05/07/25 at 11:16 AM an attempt to interview LVN A via telephone was unsuccessful. On 05/07/25 at 11:18 AM an attempt to interview CNA D via telephone was unsuccessful. This was determined to be a Past Non-Compliance Immediate Jeopardy on 05/07/25 at 2:50 PM. The Administrator was notified. The Administrator was provided with the IJ template via email on 05/07/25 at 2:57 PM. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the facility's In-Service Trainings revealed that all staff were in-serviced on the facility's abuse, neglect and elopement policies and procedures, elopement, risk assessments, skin assessments, notification to PCP and RP on 04/01/25. Record review of the facility's In-Service Trainings revealed all staff were in-serviced on the facility's abuse and neglect and policies and procedures on 04/23/25. The In-Service Training paperwork states, All staff if you see or suspect any forms of abuse/neglect towards a resident immediately remove the resident/report to the abuse coordinator [Administrator]. On 05/07/25 at 3:00 PM an observation was made of Resident #2 with a Wanderguard exiting the front door. Resident #2's Wanderguard was operating properly and there was an alarm that sounded. Staff in the Office were able to hear the alarm and staff at the Nurses Station were able to hear the alarm. The Staff in the Administration Offices at the front of the facility were observed walking towards the front door of the facility when the alarm sounded. The Staff on the hallways were observed walking towards each fire door after the fire alarm sounded. In an interview and observation on 05/07/25 at 3:14 PM, the Maintenance Director stated he was not present at the time of Resident #1's elopement and could not state whether or not a door alarm sounded. The Maintenance Director was observed opening the interior fire exit doors on the hallways throughout the facility and the front door. The fire alarms alerted each time the Maintenance Director opened each door. The fire alarms could be heard by staff throughout the building. The Staff at both Nurses Stations and on the hallways stated that there were able to her the fire alarms from their locations. Record review of the facility's Resident Rights policy dated, December 2024 revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; . b. be free from abuse, neglect . Record review of the facility's Elopements policy dated, December 2024 revealed: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: . 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, c. If the resident is not located, notify the Administrator and Director of Nursing Services, the resident's legal representative . 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative; . e. Complete and file an incident report and self-report to your regulatory agency; and f. Document relevant information in the resident's medical record. The facility's Elopements Policy did not include any information regarding Supervision, Accidents and Preventing Elopements.

Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect, in that: The facility did not report an incident of potential neglect for Resident #1 to the State Survey Agency within 24 hours, when Resident #1 eloped from the facility on 03/28/25 through the facility's exit door, that did not alarm when opened. This deficient practice could place residents at-risk of not having incident and accident investigations reported within the timeframe required. reported appropriately. Findings included: Record review of Resident #1's Face Sheet, dated 05/06/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: dementia, gout (a form of inflammatory arthritis caused by the buildup of uric acid crystals in the body, leading to sudden, severe pain, swelling, and redness in one or more joints), acute kidney failure, Type 2 diabetes, oropharyngeal dysphagia (difficulty swallowing that specifically occurs in the oral cavity and throat), lack of coordination, and major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 03/11/25, revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. In Section P0200. Alarms indicated Resident #1 had a Wander/elopement alarm. Record review of Resident #1' Care Plan, dated 02/21/25, revealed: Focus: [Resident #1] use psychotropic medications r/t Dementia. Date Initiated: 06/20/2024 Revision on: 04/18/2025 Cancelled Date: 04/16/2025 Goal: [Resident #1] will be/remain free of drug related complications. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Discuss with MD, family re ongoing need for use of medication. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Monitor/record occurrence for target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1] is an elopement risk/wanderer. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1's] safety will be maintained through the review date. Date Initiated: 03/28/2025 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Assess for fall risk. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate [sic]. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 WANDER ALERT: Device # Model Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Record review of Resident #1's Social History and Initial Assessment revealed on Page 2, Question 9. Current Behavioral Status was checked as No behavioral Concerns. The document was signed and dated by the previous Social Worker on 06/24/24. Resident #1's family member provided the information to the previous Social Worker for the Social History and Initial Assessment. Record review of the Order Summary for Resident #1 revealed a Physician Telephone Order on 01/21/2025 for WANDERGUARDS: LEFT ANKLE.CHECK FOR PLACEMENT AND PROPER WORKING FUNCTION every shift. Record review of Resident #1's MAR for January 2025 - March 2025 revealed that Resident #1's Wanderguard Checklist was marked with a check markevery day during the Day, Evening and Night Shifts and was in operable condition. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day, Evening, and Night Shifts on 03/27/25. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day and Evening Shifts on 03/28/25. Record review of Resident #1's Elopement Evaluation on 03/28/25 revealed, an Assessment Outcome Score of 9 indicating Resident #1 was at Risk of Elopement. Record review of Resident #1 Assessments revealed that there was not an Elopement Evaluation for him prior to 03/28/25. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:33 AM, revealed: resident was seen sitting in w/c in day area on when coming from helping another resident, he was gone down the hallway walking and pushing his w/c down by the breakroom area. then vanishes when no one seen him or heard any alarms. [Staff] begins to look for him along with nurses notified police, don, and family. resident was located across from facility ground in apartment complex. resident was brought back and evaluated with minor scratch on his chin and his left hand ring finger resident has no complaints. resident is in b/r laying down in bed resting with eyes closed with staff member doing 15 minutes check while asleep WCTM. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:48 PM, revealed: Elopement Evaluation: History of elopement while at home: Yes. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 9.0. Record review of Nurse Progress Notes from the SW's Late Entry on 03/31/25 at 12:30 PM, Effective: 03/28/25 at 12:26 PM revealed, This writer called representative to inform her of resident needing to be placed at another facility due to elopement risk. Resident representative stated she got a call from other facility regarding accepting him and I informed yes referral sent out to see if there would be anyone who would accept him. Record review of Nurse Progress Notes from CNA B's Late Entry on 03/28/25 at 13:42 [1:42 PM], Effective 03/28/25 at 12:44 PM revealed, The resident transferred to [another facility's] Secure Nursing Unit via wheelchair transport with medications and personal belongings at this time. The resident was cooperative prior to exiting the facility. No noted signs and symptoms of respiratory distress and denies discomfort prior to exiting the facility. Report called to [staff] at [another facility's] memory Care Unit. Record review of the facility's Provider Investigation Reports Fax Cover Sheet dated 04/03/25 revealed the following: Intake ID No: NO SR # received - Called in by [DON] on hotline. Record review of the facility's Provider Investigation Report revealed the following: Incident Date: 03/28/25. Time of Incident 3:20 AM. Staff reported [Resident #1], eloped from the facility to the apartment complex across the road. Record review of the facility's Provider Investigation Report's Investigation Summary section of the report reflected: [Resident #1] was brought back to the facility by the DON. Resident received treatment for his scrapes to his chin and finger. Resident placed on Q:15 minute checks. Family notified of need for secure unit and family in agreement. Facility transferred [Resident #1] to [another facility] on 03/28/2025 with resident belongings. The police department were notified about the incident. Record review of the facility's Provider Investigation Report's Facility Investigation Findings section of the report reflected: Confirmed. Record review of the facility's Provider Investigation Report's, Provider Action Taken Post-Investigation section reflected: Elopement In-Service, Wanderguard system checked with no issues identified. Record review of the facility's Provider Investigation Report's view of TULIP on 05/07/25 at 12:00 PM reflected, the incident report for elopement of Resident #1 on 03/28/25 was not uploaded. In a telephone interview on 05/05/25 at 2:25 PM, with Resident #1's family member, she stated that Resident #1 was a resident at the facility for almost 1 year. She stated that prior to Resident #1 being admitted to the facility, he was living with the family member and he had about 2-3 elopement incidents, in which a decision was made to have Resident #1 reside at a Nursing Facility. She stated that initially Resident #1 was admitted to the facility after a hospital stay, which led to him needing physical therapy. She stated that during Resident #1's stay at the facility, she realized that Resident #1 had to be at the facility long term due to his dementia and exit seeking. The family member stated that she did not initially inform the facility that Resident #1 had exit seeking behaviors and had previously eloped from home prior to being admitted to the facility. She stated that no one asked her if Resident #1 was exit seeking or had some elopement incidents while he was staying at her home. She stated that no one asked her about Resident #1's previous elopement history, therefore she did not tell them. The family member stated that Resident #1 had a Wanderguard brace on his ankle due to him exit seeking at the facility. The family member stated that on 03/28/25 at approximately 3 AM, another family member notified her via telephone informing her that their family member had exited the facility although he was wearing a Wanderguard on his ankle and was found at the apartment complex across the street attempting to climb a fence. The family member stated that the neighbor at the apartment complex across observed Resident #1 and asked him, what are you doing? Resident #1 replied, I am trying to go to work, and you can call my [family member], he will come and get me. Resident #1 provided the telephone number for his family member. The neighbor at the apartment complex across the street from the the facility, then called 911 and told them about the incident and then telephoned Resident #1's family member. According to the family member, Resident #1's other family member called the facility and notified the staff at the facility that Resident #1 was not in the facility and the staff were unaware that Resident #1 had eloped from the facility. The family member stated that the police arrived at the apartment complex across the street from the facility and returned the resident to the facility. Resident #1 was then transferred to another facility on 03/28/25, the same day of his elopement. According to the family member, Resident #1 did not receive any serious injuries from eloping from the facility. On 05/06/25 at 12:00 PM an attempt to interview the previous DON via telephone was unsuccessful. On 05/06/25 at 12:15 PM an attempt to interview LVN A via telephone was unsuccessful. In an interview with the SW on 05/06/25 at 4:31, she stated that she was not at work when Resident #1 eloped from the facility on 03/28/25 due to the incident occurring around 3 AM. The SW stated that she received a telephone call during the night by the previous DON stating that during the night shift of 3/27/25 and early morning of 03/28/25. She stated that she was asleep during the original voicemail from staff and in the morning, she woke up and listened to her voicemail message. She stated that she later learned that staff noticed that Resident #1 was missing, and they looked inside the building, and he was not in the building. The SW stated that staff went to look for Resident #1 outside the facility and he was found across the street at an apartment complex. The SW stated that Resident #1 had a Wanderguard on his leg and was exit seeking according to staff but had never exited the facility prior to the incident when he eloped on 03/28/25. The SW stated that according to the staff's records for Resident #1 had a Wanderguard Test on on 03/27/25 and 03/28/25 and it was working properly. She stated that staff sent an alert made for Resident #1 due to his eloping from the facility and then the staff began looking for him She stated that the facility was not aware that the resident had any elopement issues. She stated that if the facility was informed during Pre-Admission that any resident had any previous elopement issues, the facility would have not admitted that person to the facility. She stated that there are not any Power of Attorneys on file for Resident #1 and he was his own RP. The SW stated that she and staff were In-Serviced on Abuse, Neglect and Elopement Procedures and Guidelines after the incident involving Resident #1 eloping from the facility. In an interview with the Administrator on 05/06/25 at 4:53 PM, she stated that she was on vacation when Resident #1 eloped from the facility during the evening shift on 03/28/25. She stated that prior to her leaving for vacation, she provided directions to the previous DON on how to report allegations to HHSC via telephone. She stated that she is the Abuse Coordinator for the facility and when she returned to work at the facility, the previous DON updated her on the situation involving Resident #1's elopement on 03/28/25. The Administrator stated that the previous DON told her that Resident #1 exited the facility using the front door and was found across the street at an apartment complex. She stated that a man that lived in the apartment complex across the street witnessed him and law enforcement was notified. The previous DON went across the street to get Resident #1 and brought him back to the facility. She stated that Resident #1 did not have any serious injuries according to his head-to-toe Assessment that was given by LVN A. She stated that Resident #1 was placed on 1:1 observation after the incident and a staff member was always with him. She stated that the previous DON stayed with Resident #1 until the next shift began at 6 AM. The Administrator stated that Resident #1's Emergency Contacts, Doctor and Behavioral Health were notified of Resident #1's elopement. She reported that Resident #1 had been at the facility for approximately 1 year and there was not any previous history of Resident #1 having any elopement issues or concerns prior to him being admitted to the facility. She stated that if the facility learned that Resident #1 was exit seeking or had any prior elopement concerns, he would not have been admitted to the facility because the facility is not equipped to have a Secured Unit. She stated that the SW then began to find placement for Resident #1 at a facility that had a Secure Unit. She stated that Resident #1 was discharged to another facility with a Secured Unit on 03/28/25. She stated that when the previous DON told her that she called in a report to HHSC after Resident #1's elopement, she told her that she did not receive an Intake or Report number. The Administrator stated that she did not confirm or follow-up with HHSC regarding the situation because she thought that the previous DON had already made a Self-Report. She stated that she always uses TULIP to make Self-Reports to HHSC and had never used the telephone number for HHSC to call in a Self-Report, therefore she did not know the procedure of calling in a Self-Report via telephone. She stated that since learning that there was not a Self-Report to HHSC for Resident #1's elopement, she will now review all Self-Reports that are called in to HHSC by the ADON and DON to ensure that a Self-Report was generated for all future incidents. She stated that Resident #1 had a Wanderguard per his doctor's order and his Wanderguard was tested 3 times a day, per his doctor's orders. She stated that no one knows how Resident #1 was able to exit the facility on 03/28/25 due to his Wanderguard and the exterior doors working in proper order. She stated that the staff were In-Serviced on abuse, neglect, and elopement procedures after Resident #1's elopement form the facility. In an interview with the Maintenance Supervisor on 05/06/25 at 5:45 PM, he stated that he had been employed at the facility since 04/12/25. He stated that he was not aware of the elopement incident on 03/28/25 by Resident #1. He stated that there was not any documentation showing that there were any issues with any of the exterior doors at the facility on 03/27/25 and 03/28/25. He stated that he does daily checks on all the doors in the facility. He stated that the exterior doors to the building have a fire alarm and will alert if they are opened. He stated that the front door of the facility will alert and made a ringing sound if a resident with a Wanderguard attempts to exit the front door. He stated that he and other facility staff regularly receive In-Service Trainings on Abuse, Neglect and Elopement Procedures and Protocols. In an interview on 05/07/25 at 1:15 PM ADON stated that prior to 03/28/25, she did not submit the facility's incident and reports, upload the information in TULIP or contact HHSC. She stated that the Administrator was responsible for doing the facility's incident and accident reports in TULIP. She stated that she was on leave when the incident occurred with Resident #1 eloping from the facility on 03/28/25 during the night shift. She stated that the Administrator was on leave also, and the previous DON notified her about the incident when she returned. She stated that the previous DON told her that she contacted HHSC and made report regarding Resident #1's elopement from the facility on 03/28/25. She stated that she was unaware that the previous DON did not report the elopement incident involving Resident #1. She stated that she, took the word of the previous DON and did not have any reason to believe that the previous DON did not call in the incident to HHSC. The ADON stated that the Administrator was on leave recently and gave her instructions on how-to call-in Incident Reports to HHSC via telephone. She stated that she called HHSC several times during the Administrators previous vacation, which included some Self-Reports that were being worked on for the current visit to the facility. The ADON stated that when she called HHSC to report Self-Reports, she received an Intake Number every time. She stated that she did not know how Resident #1 exited the building without his Wanderguard not alarming. She stated that Resident #1's Wanderguard was tested every day, 3 x's per day, per his doctor's orders. She reported that Resident #1's Wanderguard was tested on [DATE] on the Day, Evening and Night Shifts and it was working properly. The ADON stated that there were currently 5 residents at the facility with Wanderguards and each resident that has a Wanderguard has their Wanderguards tested per their doctors' orders and the results of each resident's Wanderguard is recorded on their MAR. She reported that Maintenance also tested the front door and there were not any issues with the front door or the other doors throughout the facility. She stated that no one knew how Resident #1 was able to exit the front door and elope from the facility. The ADON confirmed that all staff were given In-Service Trainings on Abuse, Neglect, Elopement and Supervision after the elopement incident involving Resident #1. On 05/07/25 at 10:33 AM an attempt to interview the previous DON via telephone was unsuccessful. In an interview with CNA C on 05/07/25 at 10:44 AM, she stated that she had been employed at the facility for 1 year. She stated that she was not at the facility on 03/28/25 due to being off duty. She stated that Resident #1 had dementia and during her shifts was observed coming close to the side door on his hallway. She stated that he had not observed Resident #1 exit any doors from the facility. She stated that when she returned to work, she was informed by staff that Resident #1 had exited the building during the night shift on 03/27/25 - 03/28/25. She stated that the night shift duty hours are 10 PM - 6 AM. She stated that Resident #1 did not receive any serious injuries according to his skin assessment on 03/28/25. She stated that all staff receive trainings throughout each week on abuse, neglect, and elopement. She stated that she remembered that she received an In-Service Training on Elopement after the incident on03/28/25 when Resident #1 eloped from the facility. On 05/07/25 at 11:16 AM an attempt to interview LVN A via telephone was unsuccessful. On 05/07/25 at 11:18 AM an attempt to interview CNA D via telephone was unsuccessful. Record review of the facility's In-Service Trainings revealed that all staff were in-serviced on the facility's abuse, neglect and elopement policies and procedures, elopement, risk assessments, skin assessments, notification to PCP and RP on 04/01/25. Record review of the facility's In-Service Trainings revealed all staff were in-serviced on the facility's abuse and neglect and policies and procedures on 04/23/25. The In-Service Training paperwork states, All staff if you see or suspect any forms of abuse/neglect towards a resident immediately remove the resident/report to the abuse coordinator [Administrator]. Record review of the facility's Abuse, Neglect and Exploitation Policy policy dated, 12/2024 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect . c. Include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures, and dementia management and resident abuse prevention . 2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: .VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . B. The Administrator should will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Record review of the facility's Guidelines for Resident Rights Guidelines for All Nursing Procedures dated, December 2024 revealed: Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: a. Preventing, recognizing and reporting resident abuse; b. Resident dignity and respect . Record review of the facility's Resident Rights policy dated, December 2024 revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; . b. be free from abuse, neglect .Record review of the facility's Resident Rights policy dated, December 2024 revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; . b. be free from abuse, neglect . Record review of the facility's Elopements policy dated, December 2024 revealed: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: . 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, c. If the resident is not located, notify the Administrator and Direcgtor of Nursing Services, the resident's legal representative . 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative; . e. Complete and file an incident report and self-report to your regulatory agency; and f. Document relevant information in the resident's medical record.

Based on observation, 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 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure LVN A properly received inventory of Resident #1's Acetaminophen-Codeine #3 (controlled medication) from the pharmacy, resulting in 26 missing tablets. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 10/07/24 and ended on 10/17/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk for unrelieved pain due to their medication not being readily available. Findings included: Review of Resident #1's Face Sheet, dated 03/01/25, reflected she was an [AGE] year-old female, who most recently admitted to the facility on [DATE], with diagnoses including transient cerebral ischemic attack (a temporary disruption of blood flow to the brain, causing stroke-like symptoms that resolve completely within a short period) and peripheral vascular disease (a condition that affects the blood vessels outside of the heart and brain), and rheumatoid arthritis (a long-term autoimmune disease that causes painful inflammation in the joints). Review of Resident #1's Physician's Orders, dated 03/01/25, reflected she was prescribed Acetaminophen-Codeine Oral Tablet 300-30MG (Acetaminophen with Codeine, also referred to as Tylenol #3) orally up to four times per day as needed (for pain). The start date of this medication was 09/12/24. Review of the facility's Provider Investigation Report, dated 10/11/24, reflected during the 10:00PM (10/07/24) to 6:00AM (10/08/24) shift, LVN A signed for a delivery of medications from the pharmacy that contained a blister pack (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) of Resident #1's prescription for Acetaminophen-Codeine #3 (26 tablets). During the following shift (6:00AM to 2:00PM) on 10/08/24, the medication was identified as missing from the medication cart. Although LVN A signed for the medication during the previous shift, she could not recall receiving the medication. LVN A was suspended pending the outcome of the investigation, and she was sent for a drug screen (results indicated she was positive for marijuana). Resident #1's Responsible Party and physician were notified of the incident. The police department and the pharmacy were notified, as well. The facility conducted an audit of all medication carts with no noted discrepancies. The pharmacy performed an audit to determine if there was a discrepancy in delivery with no noted discrepancies. Facility staff were in-serviced on the facility's controlled substance policy which included receiving, storing, and handling narcotic medications. Facility staff were also in-serviced on the facility's drug use policy. Staff were interviewed to ensure competency was achieved from the in-services. LVN A's employment with the facility was terminated. The facility filed a complaint with the Texas Board of Nursing for drug diversion and a positive THC drug screen. Review of a Manifest Form, dated 10/07/24, reflected LVN A signed the form, indicating she had received Resident #1's prescription medication of Acetaminophen-Codeine #3 (26 tablets). Review of the facility's in-service logs, dated from 10/11/24 to 10/17/24, reflected facility staff were in-serviced on procedures for pharmacy services (including receiving medications), controlled substances, and a drug-free workplace. Review of the personnel file for LVN A, completed on 03/01/25, reflected her employment with the facility was terminated effective 10/16/24. Observations of three separate medication carts on 03/01/25 from 10:12AM to 11:30AM, including a review of narcotic logs and count sheets, reflected no evidence of a current drug diversion. It appeared as though facility staff were following the facility's policies and procedures to prevent a drug diversion. These observations were completed with RN B, LVN C, and MA D. During interviews with multiple staff members (RN B, LVN C, MA D, MA E, and RN F) on 03/01/25 from 10:12AM to 11:30AM, they each stated they had been in-serviced on pharmacy services. They were knowledgeable of the facility's policies and procedures related to acquiring, receiving, dispensing, labeling, storing, and administering medications. They were able to verbalize the facility's policies and procedures related to the prevention of drug diversion, including what procedures to take when narcotics were received from the pharmacy as well as the procedure for counting medications. During an interview with the Administrator on 03/01/25 at 12:00PM, she stated Resident #1's prescription medication of Acetaminophen-Codeine #3 (26 tablets) was identified as missing on 10/08/24, during the 6:00AM to 2:00PM shift. The Administrator stated the facility's investigation reflected that LVN A signed for a delivery of the medication during the previous overnight shift (10:00PM to 6:00AM, from 10/07/24 to 10/08/24). LVN A stated although she signed for the medication, she could not recall whether or not she actually saw the medication. LVN A was suspended pending the outcome of the investigation. She was sent for a drug screen, which indicated she was positive for marijuana. The Administrator stated Resident #1's Responsible Party and physician were notified of the incident. The police department and the pharmacy were notified, as well. The facility conducted an audit of all medication carts with no noted discrepancies. The pharmacy performed an audit to determine if there was a discrepancy in delivery with no noted discrepancies. The Administrator reported facility staff were in-serviced on the controlled substance policy which included receiving, storing, and handling narcotic medications. Facility staff were also in-serviced on the facility's drug use policy. Staff were interviewed to ensure competency was achieved from the in-services. LVN A's employment with the facility was terminated, effective 10/16/24. The facility filed a complaint with the Texas Board of Nursing for drug diversion and a positive THC drug screen. The Administrator stated Resident #1 did not miss any of her assigned doses, nor did she sustain any adverse effects due to the incident. The facility ordered and paid for a new prescription of Acetaminophen-Codeine #3. The Administrator stated the risk of a drug diversion included residents not receiving their prescribed medications and potentially experiencing pain as a result, as well as the possibility of an impaired staff member. On 03/01/25 at 3:47PM, the surveyor attempted to contact LVN A via telephone. The surveyor left a voice message requesting a return telephone call. Review of the facility's Controlled Substances Policy, dated 12/2024, reflected, .Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record .

Based on observations, interviews and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Resident #1, Resident #2 and Resident #4) of three residents reviewed for quality of care. 1. On 02/01/25 and 02/02/25, the facility failed to provide wound care to Resident #1's sacral wound. 2. On 02/07/25, the facility failed to follow physician orders to cover Resident #1's and Resident #2's wound(s) with a dry dressing as needed for dislodgment of dressing. 3. On 02/05/25 and 02/07/25, the facility failed to follow physician orders or manufacturer instructions to ensure that Resident #1's, Resident #2's and Resident #4's low air loss mattress pump had the correct settings for appropriate pressure redistribution. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: RESIDENT #1 Record review of Resident #1's Face Sheet dated 02/05/25 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's active diagnoses included hypertensive heart disease (a condition that develops when high blood pressure (hypertension) damages the heart over time), chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), pancytopenia (a condition in which the body has low levels of red blood cells, white blood cells, and platelets), acute kidney failure (a sudden and significant decline in kidney function that occurs over a short period (within days or weeks)), type 2 diabetes (a chronic disease characterized by high blood sugar levels), hyperlipidemia (a condition in which there are abnormally high levels of lipids (fats) in the blood), hypertension (a condition where the blood pressure in the arteries is consistently elevated above normal levels), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly)and vascular dementia (a type of brain damage that occurs when blood flow to the brain is reduced or blocked, leading to damage to brain cells). Resident #1 did not admit with any pressure ulcers. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14 which indicated no cognitive impairment. Resident #1 had range of motion impairment on both sides of her lower extremities and used a wheelchair for mobility. Resident #1 was at risk of developing pressure ulcers and did not have any pressure ulcers or any other skin issues that required treatments at the time of the assessment. Record review of Resident #1's care plan dated 12/13/24 and revised 02/05/25 reflected she had an open area near the coccyx area and an unstageable pressure ulcer to the sacrum. Interventions included, Monitor/document location, size and treatment of skin injury, Treatment to coccyx, administer treatments as ordered and monitor for effectiveness, monitor dressing (FREQ) to ensure it is intact and adhering, Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size, stage. Record review of Resident #1's Order Summary Report dated 02/05/25 reflected: - Order date 01/03/25: Cleanse sacral wound with Dakin solution, apply Santyl ointment, calcium alginate and dry dressing daily and PRN for dislodgment of dressing. - Order date 01/04/25: Cleanse sacral wound with Dakin solution, apply Santyl ointment, calcium alginate and dry dressing daily and PRN. Record review of Resident #1's February 2024 TAR revealed the orders were implemented as written for daily care as evidenced by a checkmark and LVN C's initials on 02/03/25 - 02/07/25. The TAR did not reflect a follow up code or nurse initials to indicate that wound care was provided on 02/01/25 or 02/02/25. The TAR did not reflect a follow up code or nurse initials to indicate that PRN wound care was provided on 02/06/25 (10P - 6A shift) when Resident #1's dressing was removed or became dislodged. Record review of Resident #1's Weight Summary reflected a weight of 103.3 lbs. measured on 01/02/25. Record review of Resident #1's wound care visit dated 01/29/25 reflected it was an evaluation of the wound on her sacrococcyx. The wound progress was noted to have decreased in size. An interview with Resident #1 on 02/07/25 at 11:15 AM revealed she was receiving wound care but she was not sure on her bottom where it was located. Resident #1 said she could not feel her wound and was not in any pain with the wound. She stated the nurses did wound care once a day and the wound nurse was really good. During an observation and interview on 02/07/25 at 11:32 AM, Resident #1 rested quietly in bed on a low air loss (LAL) mattress with a control unit placed at the foot of the bed. The pump's power button was lit up and in the ON position and the weight setting in lbs. pressure adjust knob was pointed between 150 - 180 (lbs.). CNA E assisted LVN C to reposition Resident #1 and prepare for wound care. When LVN C removed Resident #1's brief to provide care, the sacral coccyx wound was exposed without a dressing. CNA E denied she removed the dressing or knew how long the wound was uncovered when LVN C inquired why the wound did not have a dressing. The wound had some light pink, thin, and watery drainage. There was no odor or apparent signs of infection. Resident #1 did not verbalize or demonstrate non-verbal cues suggestive of pain during wound care. RESIDENT #2 Record review of Resident #2's Face Sheet dated 02/05/25 reflected he admitted to the facility on [DATE] and readmitted after a hosptial stay on 01/29/25 with a pressure ulcer to the sacrum stage 4. A record review of Resident #2's Admission MDS Assessment, dated 1/17/25, revealed a [AGE] year-old male who admitted on [DATE]. Resident #2 had a history and diagnoses of Retention of urine, unspecified; Osteomyelitis (infection of the bone); Dependence on renal dialysis; Pressure ulcer of sacral region, Stage 4; and Acquired absence of right leg above the knee. A BIMS score of 12 suggested Resident #2 had a moderate cognitive decline. Resident #2 had a suprapubic urinary catheter and was frequently incontinent of bowel. Resident #2 had a recent discharge on 01/22/25 and readmitted to the facility on [DATE]. A record review of Resident #2's comprehensive care plan, initiated 08/29/24, target date 05/01/25, reflected: [Resident #2] have (1) pressure ulcer r/t immobility. Stage 4 to sacrum (Initiated 09/06/24; Revised 10/07/24). Interventions included Administer medications as ordered; Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing; Monitor dressing daily to ensure it is intact and adhering; and Report loose dressing to Treatment Nurse [LVN C]. A record review of Resident #2's Order Summary Report printed 02/07/25 reflected: - Order date 01/29/25: Low air loss mattress. Adjust ht/wt settings for appropriate pressure redistribution. Apply flat sheet open to length of bed with one disposable pad only. Every shift. - Order date 02/06/25: Cleanse sacral/coccyx wound with Dakin's and pack with Dakin's-soaked gauze and cover with bordered gauze. Cleanse penile shaft and genitals with NS and place thick layer of zinc around genitals. Do not remove previously applied zinc oxide as needed for wound care. - Order date 02/06/25: Cleanse sacral/coccyx wound with Dakin's and pack with Dakin's-soaked gauze and cover with bordered gauze. Cleanse penile shaft and genitals with NS and place thick layer of zinc around genitals. Do not remove previously applied zinc oxide every Monday, Wednesday, and Friday for wound care. If not improvement in 14 days, consider treatment change. - Order date 01/29/25: Weekly weights X 4 weeks every day shift every Friday for 4 weeks. Record review of Resident #2's January 2025 TAR reflected: - 01/31/25 - NA in the box to enter a weight, a checkmark, and LVN B's initials that indicated the order to obtain Resident #2's weight was completed. Record review of Resident #2's February 2025 TAR's reflected: - 02/07/25 - The weight measurement was blank. There was no follow up code or nurse initials that indicated the order was completed. - The orders were implemented as written for Low air loss mattress. Adjust ht/wt settings for appropriate pressure redistribution . as evidenced by a checkmark and a nurse's initials every shift. LVN B initialed the TAR on 02/07/25 Day Shift (6A - 2P) as completed. - The February 2025 TAR did not reflect a follow up code or nurse initials to indicate PRN wound care was provided on 02/06/25 (10P - 6A shift) when Resident #2's dressing was removed or became dislodged. Record review of Resident #2's weight summary reflected a post-dialysis weight of 149.1 on 01/17/25 at 8:49 AM. Record review of Resident #2's wound care visit dated 02/05/25 reflected it was an evaluation his wound and indicated the moisture-associated skin damage to his scrotum (extending to his penile shaft) had decreased in size. The wound to his left medial heel had also decreased in size and the wound to his left lateral foot was unable to be determined since it was the first visit with that injury. The wound for his left lateral foot was noted to have a wound etiology from peripheral artery disease. An interview with Resident #2 on 02/07/25 at 10:45 AM revealed he was receiving wound care and they were being dressed every other day and he was not in any pain. During an observation and interview on 02/07/25 at 12:12 PM, Resident #2 was in a semi-side-lying (left lateral and back) position on a LAL mattress with a control unit placed at the foot of the bed. The pump's power button was lit and in the ON position, the weight setting in lbs knob pointed towards the maximum weight (350 lbs.). The mattress presented a fully inflated firm surface. Resident #2 was pleasant and willingly participated in an interview. Resident #2 was alert and oriented to person, place, time of day, and situation. Resident #2 said that his dressing became soiled overnight but was not replaced by the night nurse or the morning nurse. Resident #2 could not say how the status of the mattress settings interfered with his comfort level. Resident #2 denied current pain related to the firmness of the low air mattress. CNA E assisted LVN C to reposition Resident #2 and prepare for wound care. When LVN C removed Resident #2's brief to provide care, the sacral coccyx wound was exposed without a dressing. The wound was not packed per physician orders. CNA E denied she removed the dressing or knew how long the wound was uncovered when LVN C inquired why the wound did not have a dressing. The wound had a small amount of light pink, thin, and watery drainage. There was no odor or apparent signs of infection. Resident #2 did not verbalize or demonstrate non-verbal cues suggestive of pain during wound care. RESIDENT #4 A record review of Resident #4's Quarterly MDS Assessment, dated 11/29/24, revealed a [AGE] year-old female who admitted on [DATE]. Resident #4 had a history and diagnoses of a Pressure ulcer of sacral region, Stage 4 and Non-Alzheimer's Dementia. Resident #4's cognition was moderately impaired per staff assessment for mental status. Resident #4 had an indwelling catheter and was frequently incontinent of bowel. Resident #4's MDS assessment reflected Resident #4 had a pressure ulcer/injury and at risk of developing pressure ulcers/injuries. The MDS assessment reflected a pressure reducing device for bed, nutrition, or hydration interventions to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications were in place for skin and ulcer/injury treatments. Resident #4 received hospice services. A record review of Resident #4's comprehensive care plan, initiated/revised 04/25/24, reflected: Documented pressure ulcer to Sacrococcyx [Initiated 11/05/24; Revised 04/01/24]. Interventions included require air loss mattress on the bed and make sure it is plugged in at all times and Treatment to sacrococcyx (stage 4). A record review of Resident #4s Order Summary Report reflected: - Order date 07/18/24: Air mattress in use due to impaired skin integrity every shift. - Order date 01/29/25: Weights & Vital signs per facility policy. Record review of Resident #4's weight summary revealed the last weight measured on 01/02/25 at 10:13 AM was 104.2 pounds. An observation on 02/05/25 at 12:34 PM revealed Resident #4 was in bed asleep. She had a low air loss mattress underneath her but it was not turned on. During an observation and interview on 02/07/25 at 12:32 PM, Resident #4 was in a supine (on back) position on a LAL mattress with a control unit placed at the foot of the bed. The pump's power button was lit and in the ON position, the weight setting in lbs knob pointed towards 150 lbs. During an interview on 02/07/25 at 1:45 PM, LVN C said that she was the facility treatment nurse and was responsible for providing wound care as ordered Monday - Friday. LVN C said that the charge nurses were responsible for wound care over the weekends when she [LVN C] was not scheduled. LVN C said that Residents #1, #2, and #4 were last seen by the WMD for wound care on 02/05/25. LVN C said that interventions should reflect on the resident's care plan to turn and reposition every 2 hours, off-load pressure areas, encourage hydration and nutrition to prevent skin breakdown and worsening of wounds. LVN C said that all residents would have either a pressure relieving mattress or a low air loss mattress to prevent and treat pressure ulcers. LVN C said that the low air loss pump settings were based off the resident's current weight to apply the appropriate amount of air to avoid constant pressure under boney surfaces and wounds. LVN C said that she checked that the pumps were on and functioning by feeling the bed to ensure it was inflated but did not check the settings. LVN C said the risk of the bed being too firm or not functioning was development of bed sores or worsened wounds. During an interview on 02/07/25 at 2:00 PM, LVN B said that she checked each resident's low air loss pumps at start of shift and every time she made rounds to make sure the pump was turned on. LVN B said that she felt the mattress to make sure it was inflated. LVN B could not verbalize what the appropriate settings should be for Resident's #1, #2, or #4 low air loss mattresses. During an interview on 02/07/25 at 4:36 PM, RN D said that he was the 2P - 10P nurse assigned to Residents #1, #2, and #4. RN D said that residents had low air loss mattresses to prevent skin breakdown and promote wound healing. RN D said that he did not always check if the settings were correctly set to the residents' weight in pounds. RN D said that he did always check if the bed was on and functioning. Record review of the facility's Wound Care policy, reviewed December 2024, reflected, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Apply treatments as indicated.

Based on observations, interviews, and records review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services for 2 of 3 residents (Resident #2 and Resident #4) reviewed for catheter care. 1. On 02/07/25, LVN B failed to provide ongoing monitoring and report any changes in condition to Resident #2's and Resident #4's urinary catheters (a thin, flexible tube that's inserted into the body to drain urine) and urine output. These failures could place residents at risk of improper catheter care and catheter-associated urinary tract infections. Findings included: RESIDENT #2 A record review of Resident #2's Admission MDS Assessment, dated 1/17/25, revealed a [AGE] year-old male who admitted on [DATE]. Resident #2 had a history and diagnoses of Retention of urine, unspecified; Osteomyelitis (infection of the bone); Dependence on renal dialysis; Pressure ulcer of sacral region, Stage 4; and Acquired absence of right leg above the knee. A BIMS score of 12 suggested Resident #2 had a moderate cognitive decline. Resident #2 had a suprapubic urinary catheter and was frequently incontinent of bowel. Resident #2 had a recent discharge on 01/22/25 and readmitted to the facility on [DATE]. A record review of Resident #2's comprehensive care plan, initiated 08/29/24, target date 05/01/25, did not reflect a focus or interventions for a suprapubic urinary catheter. A record review of Resident #2's Order Summary Report printed 02/07/25 reflected: - Order date 01/29/25: Cleanse Foley Catheter per facility protocol every shift. - Order date 01/29/25: Empty Foley bag every shift and PRN as needed. - Order date 01/29/25: Foley catheter 16 Fr with 10 mL balloon to gravity one time a day. - Order date 01/29/25: Keep urinary drainage bag below the level of the bladder at all times every 8 hours as needed. - Order date 01/29/25: Keep urinary drainage bag below the level of the bladder at all times every shift. - Order date 01/29/25: Monitor Foley Catheter leg strap for proper placement every shift and PRN as needed. - Order date 01/29/25: Monitor Foley Catheter leg strap for proper placement every shift and PRN every shift. - Order date 01/29/25: Monitor Foley Catheter for leakage, blockage, sediment buildup, or low output every shift as needed. - Order date 01/29/25: Monitor Foley output every shift. - Order date 01/29/25: Monitor urine every shift. Notify MD for any abnormal findings. Record review of Resident #2's February 2025 TAR's reflected: - The orders were implemented as written to monitor Foley Catheter leg strap for proper placement every shift and PRN as evidenced by a checkmark and a nurse's initials every shift. LVN B initialed the TAR on 02/07/25 Day Shift (6A - 2P) as completed. - The orders were implemented as written to monitor Foley output every shift as evidenced by a measured urine output amount, a checkmark, and a nurse's initials every shift. LVN B initialed the TAR on 02/07/25 Day Shift (6A - 2P) as completed and entered an x as the urine output amount. - The orders were implemented as written to monitor urine every shift, notify MD for any abnormal findings as evidenced by a checkmark and a nurse's initials every shift. LVN B initialed the TAR on 02/07/25 Day Shift (6A - 2P) as completed. During an observation and interview on 02/07/25 at 12:57 PM, Resident #2 was in a semi-side-lying (left lateral and back) position on a LAL mattress. Resident #2 had a SPC in place at the lower left abdominal area above the pubic bone. The SPC insert site was not covered by a gauze dressing. There was a urinary catheter strap that secured the tubing incorrectly and ineffective to preventing pulling or tugging. The SPC tubing laid across Resident #2's right leg connected to a closed system drainage bag, covered by a privacy bag, that hung on the bed rail. There was no urine drainage in the tubing and the drainage bag was empty. Resident #2 was pleasant and willingly participated in an interview. Resident #2 was alert and oriented to person, place, time of day, and situation. Resident #2 said his catheter leaked at times and he would be wet. RESIDENT #4 A record review of Resident #4's Quarterly MDS Assessment, dated 11/29/24, revealed a [AGE] year-old female who admitted on [DATE]. Resident #4 had a history and diagnoses of a Pressure ulcer of sacral region, Stage 4 and Non-Alzheimer's Dementia. Resident #4's cognition was moderately impaired per staff assessment for mental status. Resident #4 had an indwelling catheter and was frequently incontinent of bowel. Resident #4's MDS assessment reflected Resident #4 had a pressure ulcer/injury and at risk of developing pressure ulcers/injuries. The MDS assessment reflected a pressure reducing device for bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications were in place for skin and ulcer/injury treatments. Resident #4 received hospice services. A record review of Resident #4's comprehensive care plan, initiated/revised 04/25/24, reflected: [Resident #4] have an Indwelling Catheter: Pressure Ulcer of Sacral Region, Stage 4. Interventions included Change catheter and drainage bag based on clinical indications such as infection, obstruction, when the integrity of the closed system is compromised, etc. and Observe/record/report to MD for s/sx UTI. A record review of Resident #4's Order Summary Report reflected: - Order date 01/08/25: Change Foley Catheter 20-22 Fr with 10-30 mL balloon for Sacral Wound one time only for 1 day. [COMPLETED] - Order date 10/22/24: Cleanse Foley Catheter per facility protocol every shift. - Order date 10/22/24: Empty Foley bag every shift and PRN as needed. - Order date 10/22/24: Empty Foley bag every shift and PRN every shift. - Order date 11/25/24: Foley Catheter 20-22 Fr with 10-30 mL balloon for Sacral Wound as needed for Foley Change. - Order date 10/22/24: Keep urinary drainage bag below the level of the bladder at all times every shift. - Order date 10/22/24: Keep urinary drainage bag below the level of the bladder at all times every 8 hours as needed. - Order date 10/22/24: Monitor Foley Catheter leg strap for proper placement every shift and PRN as needed. - Order date 10/22/24: Monitor Foley Catheter leg strap for proper placement every shift and PRN every shift. - Order date 10/22/24: Monitor Foley Catheter for leakage, blockage, sediment buildup, or low output every shift as needed. - Order date 10/22/24: Monitor Foley output every shift. - Order date 10/22/24: Monitor urine every shift. Notify MD for any abnormal findings. An observation of Resident #4 on 02/05/25 at 12:34 PM revealed she was asleep in bed and her indwelling urinary catheter tubing had a cloudy consistency in the urine with a light in color flaky substance floating in it. During an observation and interview on 02/07/25 at 1:21 PM, Resident #4 was in a supine (on back) position on a LAL mattress. Resident #4 had an indwelling urinary catheter in place. There was a urinary catheter strap that secured the tubing to prevent pulling or tugging. The catheter tubing laid across Resident #4's right leg connected to a closed system drainage bag, covered by a privacy bag, that hung on the bed rail. Visible inspection of the indwelling catheter tubing revealed white flakes floating in a small amount of hazy and cloudy urine that drained through the tubing. During an interview on 02/07/25 at 1:45 PM, LVN C said that she was the facility treatment nurse and was responsible for providing wound care as ordered Monday - Friday. LVN C acknowledged that Resident #2's catheter did not have any urine output during rounds with investigator. LVN C said that Resident #2 catheter was leaking earlier in the week (Monday), she notified the nurse, and entered a progress note that there was a urine leak. During an interview on 02/07/25 at 2:00 PM, LVN B said that she changed Resident #2's catheter at the start of shift (02/07/25 7:00 AM) because it needed a drainage bag cover. LVN B said that the drainage bag that was placed by the urologist did not have a drainage bag cover. LVN B said that the drainage bag had a small amount of yellow urine output at the beginning of shift. LVN B said that she did not have a chance to check the urine output since the last time she changed the bag at the start of shift because there was a treatment nurse in the room at the time she was going to do it. LVN B said that Resident #4 catheter was draining clear yellow urine when she checked at the start of shift. LVN B said that the assigned nurses were responsible for performing catheter care to residents with indwelling and suprapubic urinary catheters. LVN B said that catheter care included checking the insert site for trauma, drainage, signs of infection; to check if the tubing dislodged; check for urine color and for any abnormalities that should be reported to the MD. LVN B denied any concerns. During an observation and interview on 02/07/25 at 2:07 PM, LVN B checked the urine output for Resident #4. LVN B said that she did not notice the cloudy urine output or specks in the urine. During an observation of Resident #2's suprapubic catheter, LVN B observed no urine output and an empty drainage bag. LVN B stated that Resident #2 had urine output when she changed the catheter bag in the morning. LVN B said that she would notify the physician about the findings and implement any new orders. Record review of Resident #2's progress notes revealed LVN B sent the NP a message (02/07/25 at 2:27 PM) that Resident #2's catheter was not draining. LVN B entered an Orders Administration Note (at 2:37 PM) that reflected no noted output in the resident's Foley Catheter bag at this time. The resident's NP alerted of the findings. Record review of Resident #4's progress notes revealed LVN B sent the PA a message (02/07/25 at 2:28 PM) regarding the sediment noted in Resident #4's urinary catheter tubing. LVN B entered a progress note at 3:45 PM that indicated new orders were received from the PCP to obtain a UA with C&S for lab pickup. LVN B documented that she notified the hospice RN and the RP. During an interview on 02/07/25 at 4:36 PM, RN D said that he was the 2P - 10P nurse. RN D said that it was the nurse responsibility to provide catheter care and check the urine output of residents with urinary catheters. RN D said a part of catheter care was checking the flow of the urine, check for abdominal distention, odor, and placement of the catheter to avoid trauma and prevent urinary tract infections. RN D said that LVN B notified him of new orders received for Resident #2 that needed to be implemented. RN D said that LVN B reported there was minimal urine output, that Resident #2's brief was wet and there was a new order to flush the catheter with 5 - 10 cc of normal saline. Record review of the facility's Catheter Care, Urinary policy, reviewed December 2024, reflected: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Review the resident's care plan to assess for any special needs of the resident. Input/Output 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Complications 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. b. Check the urine for unusual appearance (i.e., color, blood, etc.). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Managing Obstruction 1. If the catheter material is contributing to obstruction, notify the physician and change the catheter if instructed to do so. 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.

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 one (Resident #2) of five residents reviewed for medications and pharmacy services. The facility failed to administer Resident #2's blood pressure medication Midodrine in accordance with physician orders, by not obtaining his blood pressure prior to administering the medication on seven occasions from 01/12/25 through 01/23/25. The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status, including low blood pressure which could cause fainting or dizziness because the brain was not receiving enough blood. Findings included: Record review of Resident #2's Face Sheet dated 02/05/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted from the hospital on 01/29/25. Resident #2's active diagnoses included encephalopathy (a medical condition that affects the brain's function), type 2 diabetes (a chronic disease that affects how the body uses glucose (sugar) for energy), hyperlipidemia (a condition characterized by abnormally high levels of lipids (fats) in the blood, such as cholesterol and triglycerides), hypertension (a condition characterized by abnormally high levels of lipids (fats) in the blood, such as cholesterol and triglycerides), atrial flutter (a type of heart rhythm disorder where the upper chambers of the heartbeat rapidly and irregularly), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), end-stage renal disease (a condition in which the kidneys have permanently lost their ability to function properly) and a stage 4 pressure ulcer of the sacral region (a localized area of skin damage that develops when pressure on the skin cuts off blood flow to the area). Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident #2 had no behavioral symptoms and no rejection of care. Resident #2 had range of motion impairment on both sides of his lower extremities and use a wheelchair for mobility. Record review of Resident #2's care plan dated 08/29/24 and last updated on 01/23/25 reflected no discussion of his blood pressure medication and related health condition. Record review of Resident #2's January 2025 physician's orders reflected, Midodrine HCl Oral Tablet 5 MG Give 3 tablet by mouth three times a day for low bp- Hold for SBP greater than 110 (start date 01/12/25; dc 'ed 01/23/25). Record review of Resident #2's January 2025 MAR did not reflect all blood pressure recordings three times a day prior to the administration of his Midodrine on 01/12/25 (all three shifts), 01/13/25 (all three shifts), 01/18/25 (AM and HS shift), 01/19/25 (all three shifts), 01/20/25 (PM shift), 01/22/25 (AM and HS shift) and 01/23/25 (AM shift). Record review of Resident #2's nursing progress notes did not reflect all additional blood pressure readings for January 2025 when there was none documented on the MAR. An interview with ADON A on 02/07/25 at 12:30 PM revealed after investigator intervention, the facility was working with their corporate office to see if there was a template available to see if blood pressure readings were being taken, and if their e-charting system could turn red during a medication pass when an ordered blood pressure reading was not documented. The ADON A stated the charge nurses were taking residents' blood pressure readings on their own personal documentation, But that does not suffice .they have their own little system and how they do things. I told them it doesn't help us, it hurts us. Everything needs to be in [e-charting system]. An interview with the DON on 02/07/25 at 12:56 PM revealed after investigator intervention, nursing management in-serviced nursing staff on the blood pressure reading gaps and expectations going forward. She stated the facility was also going to initiate a PIP and ensure that was a focus. The DON stated she knew the nurses were taking the blood pressure of residents because she witnessed it when she rounded the facility. She said she would go around and randomly ask what residents' blood pressure parameters were to the nursing staff to see if they were getting done. The DON stated the medication aides could also take residents' blood pressure and record them in the MARs. The DON said the charge nurses usually wrote their blood pressure readings down on a piece of paper, I have seen them do it, but then they are supposed to transfer them to the computer. The DON stated because she and ADON A were new, they were catching up on a lot of systems and procedures. The potential negative outcome of no recorded blood pressure readings prior to a hypotensive medication being taken was, Negative. hospitalization or worse. Midodrine is a medication used for high blood pressure. Giving a blood pressure medication when a resident has low blood pressure, they can go into cardiac arrest. An interview with LVN B on 02/07/25 at 1:31 PM revealed she was the charge nurse for Resident #2 and the medication aides were the ones who took the residents' blood pressure and administered the medications. LVN B stated it was important to take a hypotensive resident's blood pressure prior to administering their medication because if their blood pressure was too high and the Midodrine was given, then it could cause a stroke. An interview with the ADM on 02/07/25 at 2:29 PM revealed after investigator intervention, the nursing management did an audit on residents' hypotensive and hypertensive medications to make sure the monitoring was in place and would also place the issue on a PIP to be monitored by the ADON and DON. Review of the facility's policy titled, Medication Administration General Guidelines dated December 2024 reflected, .Medication Administration: .2. Obtain and record any vital signs as necessary prior to medication administration.

Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for three (Residents #1, #2 and #3) of five residents reviewed for pressure ulcers and non-pressure wounds. 1. The facility failed to document wound care was provided for Resident #1 in January 2025 on twelve occasions. 2. The facility failed to document wound care was provided for Resident #2 in January and February 2025 on eight occasions. 3. The facility failed to document wound care was provided for Resident #3 in January 2025 and February 2025 on 28 occasions. This failure could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management. Findings included: 1. Record review of Resident #1's Face Sheet dated 02/05/25 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's active diagnoses included hypertensive heart and chronic kidney disease, pancytopenia, acute kidney failure, type 2 diabetes, hyperlipidemia, hypertension, atrial fibrillation and vascular dementia. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14 which indicated no cognitive impairment. Resident #1 had range of motion impairment on both sides of her lower extremities and used a wheelchair for mobility. Resident #1 was at risk of developing pressure ulcers and did not have any pressure ulcers or any other skin issues that required treatments at the time of the assessment. Record review of Resident #1's care plan dated 12/13/24 and revised 02/05/25 reflected she had an open area near the coccyx area and an unstageable pressure ulcer to the sacrum. Interventions included, Monitor/document location, size and treatment of skin injury, Treatment to coccyx, administer treatments as ordered and monitor for effectiveness, monitor dressing (FREQ) to ensure it is intact and adhering, Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size, stage. Record review of Resident #1's January 2025 physician orders reflected the following treatment orders: - Cleanse sacral wound with Darkin solution, apply Santyl ointment, calcium alginate and dry dressing daily and prn. as needed for dislodgment of dressing (start 01/03/25) - Cleanse sacral wound with Darkin solution, apply Santyl ointment, calcium alginate and dry dressing daily and prn. every day shift (start date 01/03/25) Record review of Resident #1's January 2025 TAR reflected no documented treatment to her sacral wound on 01/02/25, 01/09/25, 01/11/25, 01/16/25, 01/17/25, 01/18/25, 01/21/25, 01/24/25, 01/25/25, 01/26/25, 01/29/25 and 01/31/25. Record review of Resident #1's nursing progress notes for January 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no discussion to indicate why the wound care was not performed on the numerous dates. Record review of Resident #1's wound care visit dated 01/29/25 reflected it was an evaluation of the wound on her sacrococcyx. The wound progress was noted to have decreased in size. An interview with Resident #1 on 02/07/25 at 11:15 AM revealed she was receiving wound care but she was not sure on her bottom where it was located. Resident #1 said she could not feel her wound and was not in any pain with the wound. She stated the nurses did wound care once a day and the wound nurse was really good. 2. Record review of Resident #2's Face Sheet dated 02/05/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted from the hospital on 01/29/25. Resident #2's active diagnoses included encephalopathy (a medical condition that affects the brain's function), type 2 diabetes (a chronic disease that affects how the body uses glucose (sugar) for energy), hyperlipidemia (a condition characterized by abnormally high levels of lipids (fats) in the blood, such as cholesterol and triglycerides), hypertension (a condition characterized by abnormally high levels of lipids (fats) in the blood, such as cholesterol and triglycerides), atrial flutter (a type of heart rhythm disorder where the upper chambers of the heartbeat rapidly and irregularly), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), end-stage renal disease (a condition in which the kidneys have permanently lost their ability to function properly) and a stage 4 pressure ulcer of the sacral region (a localized area of skin damage that develops when pressure on the skin cuts off blood flow to the area). Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 12 which indicated no cognitive impairment and no rejection of care issues. Resident #2 was dependent on staff for all areas of mobility and required assistance with ADLs. Resident #2 was frequently incontinent of bowel and had an indwelling catheter (a thin, flexible tube that is inserted into the body to drain or deliver fluids). Resident #2 was at risk of developing pressure ulcers and had one unhealed stage 4 pressure ulcer at the time of the assessment. Resident #2 also had an unstageable deep tissue injury and a diabetic ulcer on his foot, a surgical wound and moisture-associated skin damage. He required a Pressure reducing device for his chair, a pressure reducing device for the bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings and applications of ointments/medications. Record review of Resident #2's care plan dated 08/29/24 and last revised 01/23/25 reflected he had one stage 4 pressure ulcer to his sacrum (initiated 09/06/24) and had a diabetic ulcer. Interventions included 1) Administer treatments as ordered and monitor for effectiveness, 2) Monitor dressing daily to ensure it is intact and adhering. Report lose dressing to treatment nurse, 3) Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage, 4) Treatment to sacrum-Cleanse with NS, pat dry, apply Calcium Alginate with honey, cover with dry dressing daily and prn, 5) Treat wound as per facility protocol, 6) Treatment to left medial heel, 7) Treatment to right lateral foot. Record review of Resident #2's January and February 2025 physician's orders reflected the following treatment orders: - Cleanse LLE wounds with normal saline and dry, dress with xeroform and dry dressing every day shift every Mon, Wed, Fri for Treatment: If no improvement in 14 days consider treatment change. Notify MD if any changes in wound or any s/s of infection (start date 01/31/25 to open ended). -Cleanse wound with Dakin's and pack with Dakin's-soaked gauze and cover with bordered gauze. Cleanse sacrum with NS and place thick layer of zinc around genitals. every day shift every Mon, Wed, Fri for Wound Care If no improvement in 14 days consider treatment change (Start 01/31/25, discontinued 02/03/25). -Cleanse penile shaft and scrotum area with normal saline and dry area. Apply zinc oxide, daily and during incontinence care. one time a day for Incontinence Associated Dermatitis/Weepy Edema/Intertrigo If no improvement in 14 days consider treatment change (start date 01/15/25, discontinued 01/23/25). -Miconazole External Powder 2% apply topically two times a day for candida infection for ten days (start date 01/12/25). Record review of Resident #2's January 2025 TARs reflected no documented treatment to his penile shaft on 01/16/25, 01/18/25, 01/21/25 and 01/23/25 and no documented treatment for his candida infection on 01/13/25 and 01/16/25 through 01/21/25. Record review of Resident #2's February 2025 TARs reflected no documented treatment to his left lower extremity wound on 02/03/25. Record review of Resident #2's nursing progress notes for January and February 2025 reflected no additional wound/skin treatment documented outside of what was already documented on the TAR. There was no discussion to indicate why the wound and skin care was not performed on the numerous dates. Record review of Resident #2's wound care visit dated 02/05/25 reflected it was an evaluation his wound and indicated the moisture-associated skin damage to his scrotum (extending to his penile shaft) had decreased in size. The wound to his left medial heel had also decreased in size and the wound to his left lateral foot was unable to be determined since it was the first visit with that injury. The wound for his left lateral foot was noted to have a wound etiology from peripheral artery disease. An interview with Resident #2 on 02/07/25 at 10:45 AM revealed he was receiving wound care and they were being dressed every other day and he was not in any pain. 3. Record review of Resident #3's Face Sheet dated 02/05/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included chronic peripheral venous insufficiency (a condition where the veins in the legs become damaged, leading to poor blood flow back to the heart), non-pressure chronic ulcer (a persistent open sore or a chronic ulcer that doesn't heal properly) and lower leg amputation (a surgical procedure to remove part or all of the leg below the knee). Record review of Resident #3's admission MDS assessment dated [DATE] reflected a BIMS score of 14 which indicated no cognitive impairment and no rejection of care issues. Resident #3 was dependent on staff for all areas of mobility and required assistance with ADLs. He had range of motion impairment on both sides of his lower extremities and used a wheelchair and walker for mobility. Resident #3 was incontinent of bowel and bladder and was at risk of developing pressure ulcers. Resident #3 did not have any unhealed pressure ulcers at the time of the assessment but did have two venous and arterial ulcers present. Resident #3 had skin treatments which included the application of nonsurgical dressings, applications of ointments/medications and application of dressings to feet. Record review of Resident #3's care plan dated 01/17/25 and last revised 01/20/25 reflected he had a venous stasis ulcer related to peripheral vascular disease. Interventions included 1) Document location of wound, amt of drainage, peri-wound area, pain, edema, circumference measurements, 2) Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, 3) I need skin exposure to moisture minimized due to incontinence, wound drainage or perspiration. Place (specify) to absorb moisture. Record review of Resident #3's January and February 2025 physician's orders reflected the following treatments: -Diphenhydramine Acetate External Cream- Apply to area of rash on bilateral arms, chest and abdomen three times a day (start date 01/18/25 through open ended). -Cleanse LLE with dakins and RLE with NS and dry, apply xeroform, Calcium alginate and cover w/ dry dressing, wrap with kerlix and Co Band. Ammonium lactate to remainder of legs, MWF. as needed for wound care (start date 01/23/25 to open ended). Record review of Resident #3's January and February 2025 TAR reflected no documented skin treatment to his rash every day from 01/21/25 through 02/05/25 on 27 occasions throughout the three nursing shifts. Record review of Resident #3's February 2025 TAR reflected no documented treatment to his left lower extremity wound on 02/03/25. Record review of Resident #3's nursing progress notes for January and February 2025 reflected no additional wound/skin treatment documented outside of what was already documented on the TAR. There was no discussion to indicate why the wound and skin care was not performed on the numerous dates. Record review of Resident #3's wound care visit dated 01/29/25 reflected it was an evaluation of his wounds found on the right leg, left leg, right 3rd toe, and left 3rd medial toe. The wounds were noted to have decreased in size with the exception of the left 3rd medial toe as it was the first visit, so progress was undetermined. 4. An interview with LVN C on 02/05/25 at 4:28 PM revealed she was the facility's wound care nurse and had been in that position for two months. LVN C stated when she worked as a wound care nurse, there were a number of times she was pulled to the floor to work as a charge nurse. She stated when that happened, then each charge nurse on the floor would do their own residents' wound care. If the charge nurse could not do it, then the oncoming nurse on the evening shift would have to complete it. LVN C stated she did not want any of the charge nurses, however, to do the residents' treatments with stage 3 or 4 pressure ulcers. When asked why there was no documented evidence that wound care was completed two days prior on 02/03/25 for Residents #2 and #3, LVN C stated she had to work the floor that day so the treatments would have been delegated to the charge nurses. LVN C stated when wound care was completed, the TAR was supposed to be completed and the charge nurses knew that. LVN C stated she documented wound care every day, I am not sure why there are blanks. She stated Resident #2 had been hospitalized four times in the last few months for the blanks on the TAR were days he was in the hospital or days he was at dialysis. LVN C stated, If he gets wound care done, it is documented .I can only be responsible for myself and do the best I can do. Regarding Resident #2, LVN C stated he had wound care done every single day and his wound was healing. She surmised the reason his TAR had blanks for treatment completed was that it was on days she was off work our out sick, And maybe they [charge nurses] haven't done it. Regarding Resident #3, LVN C stated he had only been at the facility for three weeks, his right leg had completely healed and she did the wound care to his bilateral extremity wounds every time she was at the facility. She said she did not complete Resident #3's wound care on 02/03/25 because the floor nurse was supposed to it, he was responsible for it. LVN C stated when she cannot do wound care, the DON was made aware and would let the charge nurses know they would need to complete it. LVN C stated she had been auditing all resident wounds for the past week that had been healed but had no treatment discontinued orders, But there is not a need usually because I know what to do and what not to do. LVN C stated she would know if wound care was not being done because she would see a discrepancy in the bandage not being dated to the current date. LVN C stated, If it was the same date as I write it then I know it wasn't done. She said the evidence of wound care being provided was not necessarily documentation, but if the wound was healing and anyone could click on the TAR the treatment was provided when it was not. LVN C stated she did not review the TARs to see if resident wound care was being documented as provided. She stated For things like not clicking off on the TARs, sometimes those minor things on the TAR, I don't think to click them off because I know all their [residents] orders. I can take fault for that. LVN C stated that was why she had asked the ADON/DON permission to discontinue the wound orders for residents who were supposed to have them only for a limited amount of time and their wound had healed. An interview with ADON A and the DON on 02/05/25 at 5:06 PM revealed the facility had meetings about residents' skin every Tuesday and Thursday and their focus was on residents with open wounds and major wounds. She stated they also did skin sweeps twice a month and did random checks on residents on the 24-horu report for any skin changes. ADON A and the DON stated they had not run an audit for wounds for the past week, but in an audit, they could see what wound treatment had been missed. ADON A stated she did not remember seeing wound care being missed on the TAR for residents in the facility. She stated how she was alerted of a missed medication was if she went to look at it and it was color coded red in the e-charting system, but she only looked back at the last shift. An interview with ADON A on 02/07/25 at 12:30 PM revealed after investigator intervention, the facility nursing management reviewed wound documentation and saw the gaps in documentation. She said the issue was with the 6AM-6PM nurses, so they were going to make some re-adjustments. She said they did an audit of the wounds but did not know what the outcome was. She said they were going to have LVN C adjust the time of the orders so there were no gaps in documentation. ADON A stated, Hopefully that will eliminate the issue when we modify the times, then nothing will be missed. She said they now had the orders on the TAR on 6a-2p shift and 2p-10p shift and no longer on a 12-hour shift. An interview with LVN B on 02/07/25 at 1:31 PM revealed the charge nurses were responsible for wound care if LVN C was not there and they had to document the treatment was done. An interview with the ADM on 02/07/25 at 2:29 PM revealed she stated, It is a documentation issue. Going forward, we educated [LVN C] and nurses for documenting and checks and balances to make sure it is done. The ADM stated ADON A and the DON would oversee the wound documentation on a daily basis. Review of the facility's policy titled, Medication Administration: General Guidelines dated December 2024 reflected, .Documentation: 1. The individual who administers the medication dose, records the administration on the resident's eMAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications; 2. If a dose regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the eMAR for that dosage administration is notated with the appropriate code and an explanatory note is entered in the resident's Progress Notes. If two consecutive doses of a vital medication are withheld or refused, the physician is notified; 3 .Topical Medications used in treatments are listed on the electric treatment administration record (eTAR); .4. The resident's eMAR/eTAR is initialed by the person administering the medication, in the space provided under the date, and on the lone for that specific medication dose administration and time. Initials on each eMAR/eTAR are verified with a full signature in the space provided at the end of the eMAR/eTAR or on the nursing care center's master employee signature log.

Based on interview and record review, the facility failed to obtain the hospice nursing documentation, most recent hospice plan of care specific to each patient, hospice election form, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, hospice medications information, hospice physician and attending physician orders for one (Resident #5) of three residents reviewed for hospice services and records. The facility failed to obtain the required hospice documentation for Resident #5 when she was admitted to hospice. This failure could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care. Findings included: Record review of Resident #5's Face Sheet dated 02/07/25 reflected she was admitted on [DATE]. Her active diagnoses included malignant neoplasm of the lung, secondary hypertension, chronic obstructive pulmonary disorder and chronic kidney disease. Review of Resident #5's admission MDS assessment dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment. Resident #5 has range of motion impairment on both side of her upper and lower extremities and used a wheelchair for mobility. Resident #5 required substantial/maximum assistance of staff for all ADLs and was always incontinent of bladder and bowel. Resident #5 had a life expectancy of less than six months and received hospice services. Review of Resident #1's care plan dated 01/28/25 reflected she had a terminal illness and received hospice services. Interventions included .The facility/agency will consistent with palliative care, plan and implement to diminish the extent of dehydration experienced; .the facility/agency will plan and implement measures to minimize the development of impactions and discomfort, Gradual or rapid loss of ability to move about independently and/or become bedfast is expected, the facility / agency will plan and implement measures to maintain the activity level as long as possible, Placement of an indwelling catheter may be necessary for comfort and well-being, the facility/ agency will plan and implement measures to ensure the comfort with indwelling catheter and minimize urinary tract infections; Skin breakdown and/or pressure sores are expected with this resident. The facility/agency will, consistent with palliative care, plan and implement measures that will preserve as much skin integrity as possible; Weight loss is expected, The facility/agency will consistent with palliative care, plan and implement measures that diminish this weight loss as much as possible; Will require the frequent use of narcotics/anti-anxiety/hypnotic medications the facility/agency will plan and implement measures to maintain the appropriate levels of medication to ensure comfort. Review of Resident #5's January 2025 Physician Orders reflected she was admitted to hospice on 01/28/25 due to a diagnosis of congestive heart failure. Review of Resident #5's e-chart and hospice binder on 02/05/25 revealed no evidence of the physician's determination of terminal illness, a hospice election form and hospice RN nursing progress notes. An interview with the DON and ADON A on 02/05/25 at 5:06 PM revealed the facility was in the process of updating the residents' hospice binders and there had been a lot of change in facility staff recently. They stated there was no facility staff member designated as the hospice coordinator but they had hired a social worker who had just started employment. The DON stated that it was often difficult to get hospice providers to send the facility the resident's hospice documents. An interview with ADON A on 02/07/25 at 12:30 PM revealed after investigator intervention, the nursing management reached out to the hospice provider of Resident #5 and obtained the missing hospice documentation. An interview with the DON on 02/07/25 at 12:56 PM revealed all resident hospice binder had been updated and the potential harm of incomplete documentation could be, she stated, It can be a very bad outcome, most of our hospice, I have seen here that they are full code, so that is a very important aspect of that binder being correct. The DON stated the new SW would monitor the residents on hospice services going forward. An interview with LVN A on 02/07/25 at 1:31 PM revealed the facility had a new social worker who was going to be responsible for monitoring the hospice binders and documentation. LVN A stated hospice documentation was important, So we know what orders we have and they give us a copy of the DNR. An interview with the ADM on 02/07/25 at 2:29 PM revealed typically hospice documentation for the residents was monitored and tracked by the social worker, but the facility had been without a social worker for the past two months. The ADM stated the newly hired social worker would soon be auditing the residents' hospice binders for compliance. Review of the facility's policy titled, Hospice Program, revised December 2024 reflected, .12. Our facility has designated the Social Services Director and Director of Nursing to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible for the following: b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the terminal illness .; d. Obtaining the following information from hospice: .(2) Hospice election form, (3) Physician certification and recertification of the terminal illness specific to each resident .; e. Ensure that out facility staff provide orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements to hospice staff furnishing care to the residents.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 29% based on 9 errors of 31 opportunities, which involved 2 of 4 residents (Resident #67 and # 56) observed during medication administration. -The facility failed to ensure Resident #67's extended release (ER) medications were not crushed. - LVN A failed to follow physician orders for water flushes after medication administration given via the G-Tube (a tube into the stomach that delivers formula for nutrition and medication) for Resident #56. - LVN A failed to follow facility policy by crushing all medications (tablets) together during observation on medication administration on Resident #56. - LVN A failed to follow physician order for checking Resident #56's residual and placement before medication administration through the G-tube. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications. Findings include: 1.Review of Resident #67's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, major depressive disorder, hypertension, obesity, dysphagia (difficult with swallowing) and asthma. Review of Resident #67's Quarterly MDS assessment, dated 07/12/24, reflected a BIMS score of 12 indicating resident had mild cognitive impairment. Resident #67 required minimal assistance with activities of daily living. Review of Resident #67's physician orders reflected the order for Potassium Chloride ER Tablet Extended Release 20MEQ Give 1 tablet by mouth one time a day for low Potassium, order date 05/13/24, and Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth one time a day for chest pain, order date 09/16/23. Observation on 08/27/24 at 09:37 AM revealed MA B administering to Resident #67; gabapentin 300 mg 1 tablet baclofen 20 mg 1 tablet amlodipine 10 mg 1 tablet potassium cl ER 20 meq 1 tablet (do not crush) losartan potassium 50 mg 2 tablets carvedilol 25 mg 1 tablet baclofen 5 mg 1 tablet isosorbide ER 30 mg (do not crush) tramadol hcl 50 mg, hydralazine 25 mg - half tablet clopidogrel 75 mg 1 tablet fluoxetine hlc 20 mg tylenol 325 mg and aspirin 81 mg low dose. MA B crushed all the medications together and mixed with pudding and administered the medications to the resident. In an interview on 08/27/24 at 09:58 AM with the MA B stated she was not aware but know she realized she was not supposed to crush the medications because they were extended-release medications. MA B stated crushing medications that were not supposed to be crushed might lead to the medication not being effective and resident taking more medication than required that could lead to negative effects. 2.Record review of Resident #56's face sheet dated 08/29/24 reflected a [AGE] year-old female with and admitted [DATE] and a re-admitted [DATE]. The resident had a diagnosis of gastrostomy status. Record review of Resident #56's annual MDS assessment, dated 07/31/24, reflected Resident #56 had BIMS score of 03 which indicated she was severely cognitively impaired. Resident #56 received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Resident was on hospice services. Record review of Resident #56's Physician orders report dated 07/31/24 reflected, .NPO and/or TUBE FEEDING diet NPO texture, ordered 08/07/22. Enteral Feed Order every shift Auscultate for Tube Placement before feeding and medication administration Q Shift and PRN, order date 10/16/23. Enteral Feed Order every shift Check Residual prior to feeding if greater than 150cc return contents and HOLD feeding and notify MD, order date 10/16/23. Enteral Feed Order every shift Flush PEG Tube with 30cc water before and after medication administration, order date 10/16/23. Record review of Resident #56's care plan with a revision date of 03/13/23 reflected, Focus, Tube feeding Jevity 1.2 @70cc/hr X 22 hrs/day, Water flushes q6hr @ 200cc r/t Dysphagia, goal .(Resident #56) will be free of aspiration through the review date. Interventions, .Check for tube placement and gastric contents/residual volume per facility protocol and record. Observation on 08/27/24 at 09:45 AM revealed LVN A administering medication via the G-tube to Resident #56. LVN A prepared the following medications: *Norco 5-325 mg 1 tablet, *Vitamin C 500 mg 1 tablet, *Ferrous sulfate 7.5 cc, *Gabapentin 100 mg 1 tablet, *Multi - vitamin 1 tablet, *Senna 1 tablet, and *Pepcid 40 mg 1 tablet. LVN A crushed all the tablets together and mixed with water in a cup. LVN A then proceed to the resident's room. Resident #56 was in bed and formula was infusing, and LVN A paused the feeding. LVN then tried to flush the G-tube several times because it seemed clogged, after flushing by pushing water with the syringe. LVN A did not check for placement or residual, LVN A then administered the medications that were mixed together and then administered Ferrous sulfate which was in liquid form. LVN A then connected Resident #56 back to the formula without flushing the tubing after medication administration. In an interview on 08/27/24 at 11:06 AM with LVN A she stated, initially she stated she was supposed to crush the medications together cocktail, but when she checked the orders there was no orders to cocktail the medications. LVN A stated she was not supposed to mix the medications together because they could be medication interactions with the medications. LVN A stated she was not aware of the facility policy on G-tube medication administration. Regarding flushing in between medications and after medication administration, LVN A stated she was not aware she was supposed to flush the G-tube because the G-tube was being automatically flushed by the feeding pump when the formula was infusing. LVN A stated she was supposed to flush to prevent the G-tube from clogging or medication interactions during medication administration. LVN A stated she forgot to check for placement and residual during medication administration. LVN A stated she was supposed to check for placement and residual, to make sure the G-tube placement was right and check for residual to make sure the resident did not have too much in her stomach that could lead to vomiting thus aspiration. LVN A stated she had worked in the facility for about one month and she had not completed a check off on G-tube medication administration. In an interview on 08/28/24 at 01:02 PM with the ADON revealed she had been in the facility for about 3 months. The ADON stated MA B was supposed to follow physician orders, and if a medication indicated not to be crushed, she was not supposed to crush the medication. The ADON stated if the resident was taking their medications crushed and they had extended-release medications, the staff was supposed to call the residents primary care provider to get an order for liquid medications. MA B was not supposed to crush the extended-release medications because it defeats the purpose of being extended and the resident could absorb larger dose of medication than intended. ADON stated during G-tube medication administration LVN A was supposed to administer each medication separately and flush after each medication, also flush after medication administration to prevent medication administration. The ADON stated LVN A was supposed to check for placement and residual per physician order and facility policy. The ADON stated, LVN A was supposed to be aware the amount in the stomach to prevent nausea and vomiting which could lead to aspiration. Facility policy, reviewed December 2023 titled Administering Medications Through the Enteral Tubing reflected, The purpose of this procedure is to provide guidelines for the safe administration of medications through and enteral tubing.General Guidelines.3. Do not mix medications together prior to administering through an enteral tubing. Administer each medication separately. 18. Confirm placement of the feeding tube. 20. Check gastric residual volume to assess to tolerance of enteral feeding.26. If administering more than one medication, flush with 15 ml of (or prescribed amount) warm or room temperature water between medications. Review of the facility policy reviewed December 2023, and titled Administering Oral Medications reflected, Purpose. The purpose of this procedure is to provide guidelines for the safe administration of oral medications 6. Check the label of the medication and conform the medication name and the dose with the MAR.

Based on interview and record review, the facility failed to immediately consult with the residents' physicians when there was a significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications; or when there is a need to alter treatment significantly, for two (Residents ##3 and #4) of five residents reviewed for resident rights. 1. The facility failed to consult with the physician when Resident #3 had a change in condition which resulted in a dangerously low blood sugar of 40. Resident #3 died at the facility unexpectedly within 24 hours of his change of condition. 2. The facility failed to notify the physician [MD O] or physician extender [NP M] of Resident #4's x-ray results when he had a change in condition on [DATE]. The x-ray results indicated there were abnormal findings which included widespread bilateral nodular lung opacities and small right pleural effusion opacities which was consistent with severe pulmonary edema or pneumonia. Resident #4 died at the facility unexpectedly within 24 hours of his change of condition. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 PM. The IJ template was provided to the facility's VPCO on [DATE] at 1:30 PM. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: 1) Record review of Resident #3's Face Sheet (not dated) reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnosis of Diabetes Type 2 without complications. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he had no hearing, speech or vision issues and a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 has no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #3 had limited function range of motion in both of his lower extremities, used a wheelchair for mobility and required substantial/maximum assistance from staff for all ADLs. He had an ostomy and indwelling catheter and was always incontinent of bowel and bladder. Resident #3 had identified shortness of breath when laying flat (dyspnea), was five feet two and weight 162 pounds. Resident #3 has one unhealed and unstageable pressure ulcer and one arterial/venous stasis ulcer. He received high-risk drug medication that included an anticoagulant, a diuretic and hypoglycemic medication. Resident #3 did not receive hospice services. Record review of Resident #3's care plan dated [DATE] reflected, Focus Area: Diabetes Mellitus-I will be free from any s/sx of hypoglycemia through the review date; Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #3's [DATE] physician orders reflected he was prescribed Metformin HCI Oral Tablet 500 MG two tablets by mouth two times a day for diabetes (start date [DATE]). Resident #3 also had the following orders, 1. If blood sugar below 70 and resident unable to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as ordered, and re-check BS in 15 minutes and may repeat protocol if indicated remaining with the resident, keep resident comfortable and safe and monitor VS. Hold all diabetic medications and if no improvement notify MD; 2. If blood sugar is less than 70 and patient is ABLE to swallow immediately give 4 oz juice or ,d+[DATE] oz soda recheck BS in 15 minutes and repeat juice if needed. If resident is UNABLE to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as directed and re-check BS in 15 minutes remaining with the resident, keep comfortable and safe, monitor VS, hold all diabetic medications and notify MD as needed; 3. If BS less than 70 and patient is unresponsive immediately administer oral glucose paste, glucagon as directed. Remain with resident, monitor VS, keep safe and hold all diabetic (medication). Further review revealed Resident #3 did not have a physician's order to check his blood sugar routinely or PRN. Record review of Resident #3's clinical chart reflected the following blood sugar readings were documented in his e-chart: [DATE] (40), [DATE] (100), [DATE] (139) (Note: Hypoglycemia occurs when the sugar level in the blood is below 60 mg; extremely low blood sugar can trigger seizures, loss of consciousness, impaired cognitive function and increased risk of falls). Record review of Resident #3's [DATE] MAR reflected he was administered the Metformin as ordered for diabetes. Record review of Resident #3's prealbumin, CMP and CBC dated [DATE] reflected abnormal values: for *pre-albumin of 11 which was considered low (reference range was ,d+[DATE]); *creatinine low at 0.5 (reference range was ,d+[DATE].3); *glucose was high at 144 (reference range was ,d+[DATE]); *white blood cell count was high at 10.6 (reference range was 3XXX,d+[DATE].20, *red blood cell count was low at 2.81 (reference range was 4XXX,d+[DATE].63) and *platelet count was high at 469 (reference range was ,d+[DATE]). Further review revealed PA I was notified by the charge nurse and no new orders were given related to the labs. Record review of Resident #3's nursing progress notes reflected: -[DATE]- Resident was readmitted back into the facility at 7pm from [hospital] on a stretcher with eyes open respiration even heart sound normal- Dx Sepsis, Diabetes , HTN, Asthma ,and decompressive laminectomies. Resident is alert and oriented x 1 able to make needs known wound noted on the coccyx and the left tibia, swollen to both hand and staples to the neck and back was removed, trach was intact, catheter was draining at gravity , resident was resting calmly in his room with no difficulty MD notified and the DON [e-signed by LVN B]. -[DATE]-eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition-At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP ,d+[DATE] Position: Lying r/arm; Pulse: 68, Respirations 18.0, Temp 97.6, Weight 165.1 lb, Pulse Oximetry: O2 96%, Blood Glucose 40.0-[DATE] 08:15; .Resident/Patient had the following medications changes in the past week: no; .Resident/Patient is on: Hypoglycemic medication(s)/Insulin; Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other, Functional Status Evaluation: General Weakness, Behavioral Status Evaluation: [blank] Respiratory Status Evaluation: [blank], Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50, Abdominal/GI Status Evaluation: [blank], GU/Urine Status Evaluation: [blank], Skin Status Evaluation: [blank], Pain Status Evaluation: Does the resident/patient have pain? [blank]; Neurological Status Evaluation: [blank]; Nursing observations, evaluation, and recommendations are: Pt b/s is up to 81; Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: continue to monitor pt.; B. New Testing Orders: Other-- glucagon Injection; C. New Intervention Orders: Other- glucagon injection [e-signed by DON and LVN K]. -[DATE] (2:05 AM): Nurse making round at this time, noticed resident not responsive, assessed by nurse, resident did not respond to touch /verbal command. This nurse call code blue, CPR initiated while other nurse call 911. [e-signed by LVN L]. -[DATE]: 911 crew arrived and took over from nurse [e-signed by LVN L]. -[DATE]: 911 crew left the facility after all efforts made by them to resuscitate resident failed [e-signed by LVN L]. -[DATE]: Upon assessment resident noted without active signs of life. skin cool and dry no respirations no rise and fall of the chest, no carotid or apical pulse no blood pressure pupils non-reactive to light. death pronounced at 4:12 A.M/ [e-signed by the DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a resident's blood sugar was low when checked, the charge nurse was supposed to check the physician's standing orders for blood sugar, if it got to a certain level, then orange juice was given if the resident was able to swallow and there was also glucagon. LVN A stated when the blood sugar was checked and below a certain level, there were protocols to follow and the doctor had to be notified. LVN A stated a dangerously low blood sugar was anything below 70. She stated blood sugar checks were documented on the MAR, as well as in a nursing progress notes if it had to be re-checked. LVN A stated a change of condition was anything that was not ordinary for the resident, such as a change in consciousness, labs, blood pressure and blood sugar changes. When a change of condition occurred, LVN A stated a change of condition form, nursing note and SBAR had to be completed. LVN A stated that she had been the nurse for Resident #3 in the past and thought he had recently come back from a hospital visit and all she remembered was he had a trach and was always pleasant. She stated she was not working with him on the day his blood sugar was 40. An interview with LVN B on [DATE] at 2:49 PM revealed Resident #3 was on her hall and he had a recent surgery on his back the week prior. He had gone to the hospital to for a planned appointment to remove staples from his neck and was there for three to four days when the hospital had originally stated it would only take one day. When he readmitted to the facility, LVN B stated he was not the same as he was prior but did not give specifics. She stated she was working the ,d+[DATE]pm shift the day of his death and he had been in the dining room for dinner eating. She brought him back to his room after dinner and rounded on him again before her shift was over and everything was okay. The next morning, she found out he had died after her shift. LVN B stated, There was nothing acute happening with him on my shift. He did not have a low blood sugar on my shift. If he had a low blood sugar, he was in the dining room, I fed him .even if it went low, he would have been given Glucagon after my shift was over. We checked his blood sugars. He can talk, he can tell us what he wants. There was nothing out of the ordinary for me. He ate, I didn't have any reason to worry. LVN B stated if a resident's blood sugar was 40, she would have called the doctor but already be in the process of sending the resident out to the hospital even before the doctor said so, because 40 is too low on my watch, that is an automatic send out for me unless the doctor says to keep and give medications. But 40 is too low for glucagon to help enough. LVN B stated symptoms of low blood sugar could be nausea and vomiting, aggression, sweating and sleeplessness. LVN B stated the protocol for a low blood sugar reading was for the nurse to initial the MAR to ensure that the blood sugar was checked and was okay. If the blood sugar was not okay and low, then the nurse would administer Glucagon, document in nursing notes and do and E-Interact form. LVN B stated there was not a place on the MAR to indicate emergency glucose was given, only in the nursing notes. If the nurse administered glucagon, the nurse was supposed to re-check it in 15 minutes to see where blood sugar level was and document it in a nursing progress note because it was an issue and also document in the 24 hour report. The doctor would also be contact and if the blood sugar value did not elevate with intervention, notify doctor again to get further orders. LVN B stated she did not remember being told on that date of the low blood sugar of 40 ([DATE]) that there had been a change of condition. She said if an agency nurse was working that morning, she would not have rounded with them because they are always wanting to leave, so I don't remember anything about a low blood sugar. LVN B stated when a resident's blood sugar was low, the charge nurse was supposed to consult with the doctor, then give Glucagon or an orange juice supplement that can push the blood sugars back up, then re-assess the resident. LVN B stated a dangerously low blood sugar was anything below 70. She said blood sugars were documented on the MAR. LVN B stated a change of condition was if a resident's vitals were below their norm or they were restless or in pain. An interview with LVN L on [DATE] at 3:21 PM LVN L stated she was the charge nurse for Resident #3 on the night he died . She had picked up the overnight shift and came in around 11:00 PM on [DATE]. She stated nothing had been reported to her by the afternoon/evening nurse [LVN B]. She said during her first rounds, Resident #3 was asleep in his room but woke up and said hello when LVN L came into the room. Then on her second round about two in the morning, LVN L stated she went into his room and discovered he was not breathing. She said most of the time when she rounded, she went into the residents' rooms and turned the light on and pat them and say hello, just checking. When she did that with Resident #3, she said papacita, when nothing, he did not respond and he had no pulse. LVN L stated they started CPR and someone called 911. EMTs arrived and worked on him for a long time but could not bring him back. LVN L stated there were protocols for hypoglycemia on every resident and if the resident could still talk and was alert, the first protocol was to give oral glucose and if the blood sugar did not come up, Glucagon was available. If the resident was still unresponsive, the nurses could then use glucose gel. She stated it was whatever the facility protocol said on the MAR and it had to be followed step by step. LVN L stated a dangerously low blood sugar was anything less than 70. Once Glucagon was given, LVN L stated the nurse would go back and check the blood sugar in 15 minutes, document the findings in a nursing note all that had been done, call 911 if the blood sugar does not rise and notify the doctor. LVN L stated a change of condition was anything different from the residents' norm. An interview with the DON on [DATE] at 4:40 PM revealed she was working at the facility the morning of [DATE], Resident #3's low blood sugar reading of 40. She stated a CNA came to tell her one of the nurses wanted her help. When the DON got to Resident #3's room, the nurse was at the door and said his blood sugar reading was 40. The DON assessed Resident #3 and his breathing and vitals at that time were normal, But he was doing what they do when their blood sugar is low, like they try to respond but can't, but want to. I told him [Resident #3] he was fine and his blood sugar was low. The DON stated Resident #3 was given Glucagon, and she told the nurse [LVN K] to check it again in ,d+[DATE] minutes. When LVN K checked it again, she gave a glucagon injectable, did not know remember what the blood sugar value was. The DON stated, When someone's blood sugar is in the 40s, they can't swallow so I don't like using the gel. The DON stated, So he came back around and it was a normal day after that. The DON stated she felt Resident #3 died because of his disease process. She stated his health was already poor and he had been getting treatment for multiple venous/stasis ulcers and wound care for pressure ulcers. An interview with CNA D on [DATE] at 12:30 PM revealed she was working the morning on [DATE] when Resident #3's blood sugar was 40. CNA D stated she was passing breakfast trays to the rooms and went into Resident #3's room and he was snoring but would not wake up when she tried to rouse him; she felt something was not right. She knew he was a diabetic so went to tell the nurse who was a PRN nurse (LVN K) who came to his room. LVN K also tried to wake Resident #3 up, but he would not wake up and it was then they knew something was wrong. The charge nurse checked his blood sugar and it was 40. CNA D stated she was present when the reading of 40 was done. She said LVN K did the glucose gun on him twice. After that, he woke up, was thirsty and wanted to get up out of bed. Soon after, a family member was present who sat with him in the dining room while he ate, he was talking and chatting with the family member and staff. CNA D stated Resident #3 told LVN K thank you so much for helping him while he was in the dining room, So he perked back up. CNA D stated LVN K told the family member about the low blood sugar and that he needed to be watched by the following shifts and she would leave a note for the nurses on the shifts. CNA D stated she remembered the morning PRN charge nurse telling the afternoon oncoming charge nurse [LVN B] to check Resident #3's blood sugar because it had been 40. Then the very next day, CNA D stated that Resident #3 was gone and they had already picked up his body by the time she got into work CNA D was worried Resident #3 may have died from a diabetic coma and said, I know from experience you need to monitor at least 48 hours. An attempt to interview MD H on [DATE] at 1:34 was unsuccessful; there was no option to leave a voice mail. An attempt to interview PA I on [DATE] at 1:36 PM was unsuccessful and there was no option to leave a voice mail. An interview with the secondary physician extender listed on Resident #3's Face Sheet [PA J] occurred on [DATE] at 1:43 PM. PA J stated she stopped going to the facility three weeks prior and her role was to work in physiatry and rehab only. However, speaking in general terms, PA J stated from a provider's point of view, the facility should notify the doctor for any low blood sugar, they had standing order to follow which included glucose tablet, then they should re-check the blood sugar and call the doctor back to see what they want to do. An interview with ADON E on [DATE] at 1:53 PM revealed she was week new to the facility so her information was limited. ADON E stated for a low blood sugar of 40, the resident would be at risk of a diabetic coma, so the doctor should be contacted to let them know what the charge nurse's interventions were, the blood sugar reading, the medications administered and then find out what they want the charge nurse to do. ADON E stated that for a blood sugar of 40, her nursing judgement would have sent Resident #3 to the hospital. ADON E stated Resident #3 should have been monitored after his change of condition for three days. She said the charge nurse would monitor and look for confusion, diaphoresis (cold and clammy), paleness of skin, confusion, agitation and anxiety. ADON E stated the nurses did chart by exception, but for an acute condition, they were supposed to chart for three days or as long as the treatment was in place. An interview with CNA F on [DATE] at 2:25 PM revealed he remember Resident #3 and was talking to him around 10:00 PM, a few hours before he died . He said they were talking about sports and two local sports teams and nothing seemed off or out of the ordinary. CNA F stated Resident #3 had been in the hospital recently but he did not know what for, but that night, he was up in his wheelchair and then CNA F laid him down for bed before his shift was over. An interview with the VPCS on [DATE] at 2:47 PM revealed after Resident #3's low blood sugar reading of 40 and subsequent intervention of Glucagon, the nurses on the oncoming shifts that day should have been monitoring the resident for signs and symptoms of hypoglycemia such a confusion and lethargy. She stated the shift to shift report should be given between nurses and they were supposed to print out the 24 hour report and utilize that as well when they did their walking rounds for continuity of care. If there was a change in the resident's condition, such as a fall, a blood sugar that had to be recovered for example and there was any intervention done, it should be reported to the oncoming nurse. VPCS stated, That is what I expect for out of the norm, a prudent nurse to communicate to the oncoming shift so there is continuity of care. 2) Record review of Resident #4's Face Sheet (not dated) reflected he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Hypertension, Major Depressive Disorder, Atherosclerotic Heart Disease, Angina Pectoris, Dementia, Generalized Anxiety Disorder, Diabetes, Hyperlipidemia, Schizophrenia and Parkinson's Disease. Resident #4's attending physician was listed as [MD O] and the nurse practitioner was listed as [NP M]. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed no hearing, speech or vision issues, a BIMS score of 03 which indicated severe cognitive impairment, no signs of delirium, psychosis or rejection of care. Resident #4 had no range of motion limitations but did need help from staff with all ADLs. Resident #4 did not have any assessed health conditions related to shortness of breath, did not use oxygen therapy and was not on hospice services. Resident #4 was prescribed high-risk medication which included an antipsychotic, antidepressant and an anticoagulant. Review of Resident #4's care plan initiated on [DATE] and last revised on [DATE] did not reflect any care areas related to respiratory issues or need for oxygen or related interventions. Record review of NP M's last documented visit on [DATE] with Resident #4 reflected a chief complaint/nature of presenting problem as, Leukocytosis (a condition where your blood has too many white blood cells, which fight infections and diseases), AMS, Abnormal labs, falls x 2. Resident #4 had a non-healing ankle wound that was being treated and a recent white blood cell count of 14 and continued leukocytosis. He was on an antibiotic and seen and examined in his room. He reported malaise and workup so far negative. The Nursing staff report decreased appetite. NP M reviewed Resident #1's recent labs from [DATE] and documented, CBC 16.1, 8.5, 25.5, 561; BMP 131, 4.4, 101, 22, 25, 1.1, 68. NP M documented her plan as, Plan 1. Leukocytosis: Workup so far negative. Currently on cefdinir until [DATE]; 2. Obtain blood cultures x 2 both negative, no growth after 5 days; 3. Obtain echocardiogram; 4. Consult hemo/Onco for further workup: new onset leukocytosis, thrombocytosis, anemia, weakness, negative infection workup; 5. Health shake 3 times daily with each meal; 6. Continue weekly lab work as ordered previously; 7. Continue all medication as ordered in PCC. Record review of Resident #4's physician order [initiated by NP M] dated [DATE] reflected, 2-view Chest X-ray to rule out infiltrates (abnormality in the lung). Record review of Resident #4's x-ray-Chest 1-view dated [DATE] reflected it was reviewed by the radiology clinic at 6:01 PM and reported at 6:01 PM. The chest x-ray was noted on the findings to be compared to his last x-ray a year earlier on [DATE]. The findings indicated Resident #4 had widespread bilateral nodular lung opacities (haziness around the lung with nodule growth) and a small right pleural effusion (fluid around the lungs). The impression reflected, There are widespread bilateral nodular lung opacities. This is consistent with severe pulmonary edema or pneumonia. Consider CT correlation to exclude neoplasm. The findings are worse compared with prior. Record review of nursing progress notes from [DATE] for Resident #4 reflected no indication the physician or physician extender [NP M] and RP was notified of Resident #4's chest x-ray results. Record review of the following pertinent nursing notes for Resident #4 reflected: -[DATE] 12:52 PM- Type: eINTERACT SBAR Summary for Providers-Situation : The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: BP ,d+[DATE], Pulse:70; R 18; Temp: 97.9; Weight: 202.2 lb; O2 96 %; Blood Glucose: 123.0 . Outcome of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other; Functional Status Evaluation: General weakness . Primary Care Provider responded with the following feedback: A. Recommendations: obtain Urine for UA with C&S; New Testing Orders: [blank]; C. New Intervention Orders: [blank] [e-signed by LVN A]. - [DATE]- Nurse's Note- PA in facility to visit with her residents today. Information given to PA regarding noted increased weakness and sleepiness. The resident is afebrile and without noted signs and symptoms of respiratory distress. New orders received to obtain urine for UA with C&S to rule out UTI and a 2-view chest x-ray to rule out infiltrates [e-signed by LVN A]. -[DATE]- Upon shift change at [10:05 PM], CNA called this nurse into resident's room. On getting to room, resident found in his wheelchair unresponsive in the bathroom. Resident assessed, put in bed and CPR initiated immediately while the other nurse, [staff] called 911. 911 crew arrived at [10:25 PM] and took over from the nurses. All efforts made by 911 crew to resuscitate the resident failed. The 911 crew left at [11:00 PM]. DON, resident family and MD notified of the change of condition. At [11:30 PM] Police arrived and took report from the nurses. At [midnight] resident pronounced by DON [e-signed by LVN P]. -[DATE]-Resident laying in bed. intubated with IV to right AC. skin cold and clammy. No signs of life present. No respirations, no rise and fall of chest. no carotid or Apical Pulse. Pupils set non-reactive to light. Death pronounced at 12:00 A.M. [e-signed by DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a charge nurse starts their shift, they should look in the lab book and the radiology book to see who has pending results and then continue to check throughout the shift to see if they have come in. If the charge nurse does not see the results, then they should call and follow up with a phone call. If the findings come back negative, the physician should still be notified to see if there are any new orders. With Resident #4, LVN A could not remember if NP M was notified of his chest x-ray findings. She said the results for Resident #4's x-ray would have come in after her shift was over at 2:00 PM that day. An interview with LVN C on [DATE] at 3:21 PM revealed the results of any x-rays were supposed to be logged under the resident's name in PCC with the results. LVN C stated she was at the facility the night Resident #4 died , but was not assigned to his hall. LVN C stated her shift was over and she heard his nurse calling for help so she went to see what happened and ended up helping the nurse do CPR. LVN C stated when she saw Resident #4, staff had already started CPR and she thought he was already expired by then. An interview with the DON on [DATE] at 4:40 PM revealed she did not remember Resident #4, but if a lab or x-ray came back with abnormal findings or normal findings, the charge nurse should still contact the doctor to let them know the results because the doctor may order antibiotics or prn oxygen. The DON said, But if the resident was already on antibiotics and no respiratory issue, the doctor probably would have just continued with current orders with antibiotics. The DON stated she was not sure what was going on with Resident #4 and she was new to the facility in [DATE]. The DON stated, But if he was already having respiratory issues, the doctor may not have done more intervention, but they should have been notified. An interview with ADON E [DATE] at 1:53 PM revealed she was one week new to the facility so she was not familiar with Resident #4. However, for x-ray results, ADON E stated the doctor should be called with the results regardless if the resident had a pre-existing condition or was already on medications for an infection. She reviewed the x-ray which reflected Resident #4 had lung opacities that were white spots which could mean usually pneumonia. She said it also reflected pulmonary edema which was water in lungs and pleural effusion was water around the lung. ADON E stated, These things are ordered because there was a concern, you would notify them because they doctor might want to change the antibiotic. An interview with the VPCS on [DATE] at 2:47 PM revealed if a resident had known issues to the point where the doctor ordered an x-ray, then the doctor should be contacted with the results of that x-ray. VPCS stated, How do we know there are no new orders because we haven't reached out to the doctor? An interview with NP M on [DATE] at 3:27 PM revealed she recalled that Resident #4 was not critical but she remembered doing a workup on him and was surprised he had passed way. She said he had a slightly elevated white blood cell count on [DATE] prior to his death but he was not on her radar to be declining. NP M stated, As a matter of fact, he walked and went to the dining room every day. NP M remembered ordering a chest x-ray on the day of his death and thought she got the results, but then said she may have been notified after his death. She reviewed her clinical notes and charting system and looked at the x-ray image and findings. NP M then stated she had seen Resident #4 on [DATE] and he died later that night. She said she did not see where his chest x-ray results were told her prior to his death but she was notified when he died . When she had seen Resident #4 that morning on [DATE], she ordered a work up on him. He had an elevated white blood cell count and the nursing staff said he had altered mental status and recent falls. NP M stated Resident #4's labs had been abnormal prior to that visit because he had recently been in the hospital for an ankle wound which caused the elevated white blood cell count. When Resident #4 returned to the facility, his WBC was 15.2 and stayed that way but she did blood cultures and the WBC count started trending down. When NP M saw Resident #4 on [DATE], his WBC was 14 and he had no issues with breathing that she observed. She stated the chest x-ray she ordered was standard procedure to look for something. NP M stated she thought Resident #4 had pneumonia back in February 2024, so if she was looking for something going on, she would typically order a 2-view x-ray, a UA and some lab work. She stated on [DATE], Resident #4 was already on cefdinir, an antibiotic for the ankle wound. When she reviewed the x-ray she ordered during the interview, she stated, I am thinking it came back after he expired. I am reading it now. Looks like he had pulmonary edema. He was not short of breath when I saw him, that would have been a whole different ballgame. That morning he was up, went to dining room, went to breakfast and then he came back to his room and going to the bathroom. NP M continued and stated, You can get flash pulmonary edema and they can literally die right on the floor. It can happen for whatever reason, maybe a little CHF, fine one minute, not the next. NP M said with flash pulmonary edema, usually there would be a report that the resident was foaming at the mouth and that was flash edema. She said there were no reports of that. NP M stated she was working up the change of condition with the two fall and was looking for a possible UTI. She did not feel the WBC was a concern because he admitted with that and his wound, So that in and of it itself is not concerning. NP M stated that had she received the x-ray results prior to his death the night of [DATE], she probably would have sent him out to the hospital but could not say for sure. She said his vitals were stable, he did not appear to have any acute issues and if he was normal, t [TRUNCATED]

Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for two (Residents #3 and #4) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #3 was accurately assessed, monitored, and treated for a change of condition he had with a blood sugar of 40 at 8:15 AM during the morning shift on [DATE]. There was no documented evidence the facility monitored the residents' change of condition after that shift. Resident #3 died later that night on the overnight shift around 2:05 AM with a cause of death as unknown. 2. The facility failed to ensure Resident #4 was accurately assessed, monitored and treated for a change in condition on [DATE]. The facility had no documented evidence they monitored the resident after the initial change was observed. The NP was notified and ordered a chest x-ray. The x-ray results indicated there were abnormal findings which included widespread bilateral nodular lung opacities and small right pleural effusion opacities which was consistent with severe pulmonary edema or pneumonia. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 PM. The IJ template was provided to the facility's VPCO on [DATE] at 1:30 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: 1) Record review of Resident #3's Face Sheet (not dated) reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnosis of Diabetes Type 2 without complications. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he had no hearing, speech or vision issues and a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 has no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #3 had limited function range of motion in both of his lower extremities, used a wheelchair for mobility and required substantial/maximum assistance from staff for all ADLs. He had an ostomy and indwelling catheter and was always incontinent of bowel and bladder. Resident #3 had identified shortness of breath when laying flat (dyspnea), was five feet two and weight 162 pounds. Resident #3 has one unhealed and unstageable pressure ulcer and one arterial/venous stasis ulcer. He received high-risk drug medication that included an anticoagulant, a diuretic and hypoglycemic medication. Further review revealed Resident #3 did not receive hospice services. Record review of Resident #3's care plan dated [DATE] reflected, Focus Area: Diabetes Mellitus-I will be free from any s/sx of hypoglycemia through the review date; Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #3's [DATE] physician orders reflected he was prescribed Metformin HCI Oral Tablet 500 MG two tablets by mouth two times a day for diabetes (start date [DATE]). Resident #3 also had the following orders, 1. If blood sugar below 70 and resident unable to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as ordered, and re-check BS in 15 minutes and may repeat protocol if indicated remaining with the resident, keep resident comfortable and safe and monitor VS. Hold all diabetic medications and if no improvement notify MD; 2. If blood sugar is less than 70 and patient is ABLE to swallow immediately give 4 oz juice or ,d+[DATE] oz soda recheck BS in 15 minutes and repeat juice if needed. If resident is UNABLE to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as directed and re-check BS in 15 minutes remaining with the resident, keep comfortable and safe, monitor VS, hold all diabetic medications and notify MD as needed; 3. If BS less than 70 and patient is unresponsive immediately administer oral glucose paste, glucagon as directed. Remain with resident, monitor VS, keep safe and hold all diabetic (medication). Further review revealed Resident #3 did not have a physician's order to check his blood sugar routinely or PRN. Record review of Resident #3's clinical chart reflected the following blood sugar readings were documented in his e-chart: [DATE] (40), [DATE] (100), [DATE] (139) (Note: Hypoglycemia occurs when the sugar level in the blood is below 60 mg; extremely low blood sugar can trigger seizures, loss of consciousness, impaired cognitive function and increased risk of falls). Record review of Resident #3's [DATE] MAR reflected he was administered the Metformin as ordered for diabetes. Record review of Resident #3's prealbumin, CMP and CBC dated [DATE] reflected abnormal values: for *pre-albumin of 11 which was considered low (reference range was ,d+[DATE]); *creatinine low at 0.5 (reference range was ,d+[DATE].3); *glucose was high at 144 (reference range was ,d+[DATE]); *white blood cell count was high at 10.6 (reference range was 3XXX,d+[DATE].20, *red blood cell count was low at 2.81 (reference range was 4XXX,d+[DATE].63) and *platelet count was high at 469 (reference range was ,d+[DATE]). Further review revealed PA I was notified by the charge nurse and no new orders were given related to the labs. Record review of Resident #3's nursing progress notes reflected: -[DATE]- Resident was readmitted back into the facility at 7pm from [hospital] on a stretcher with eyes open respiration even heart sound normal- Dx Sepsis, Diabetes , HTN, Asthma ,and decompressive laminectomies. Resident is alert and oriented x 1 able to make needs known wound noted on the coccyx and the left tibia, swollen to both hand and staples to the neck and back was removed, trach was intact, catheter was draining at gravity , resident was resting calmly in his room with no difficulty MD notified and the DON [e-signed by LVN B]. -[DATE]-eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition-At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP ,d+[DATE] Position: Lying r/arm; Pulse: 68, Respirations 18.0, Temp 97.6, Weight 165.1 lb, Pulse Oximetry: O2 96%, Blood Glucose 40.0-[DATE] 08:15; .Resident/Patient had the following medications changes in the past week: no; .Resident/Patient is on: Hypoglycemic medication(s)/Insulin; Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other, Functional Status Evaluation: General Weakness, Behavioral Status Evaluation: [blank] Respiratory Status Evaluation: [blank], Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50, Abdominal/GI Status Evaluation: [blank], GU/Urine Status Evaluation: [blank], Skin Status Evaluation: [blank], Pain Status Evaluation: Does the resident/patient have pain? [blank]; Neurological Status Evaluation: [blank]; Nursing observations, evaluation, and recommendations are: Pt b/s is up to 81; Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: continue to monitor pt.; B. New Testing Orders: Other-- glucagon Injection; C. New Intervention Orders: Other- glucagon injection [e-signed by DON and LVN K]. -[DATE] (2:05 AM): Nurse making round at this time, noticed resident not responsive, assessed by nurse, resident did not respond to touch /verbal command. This nurse call code blue, CPR initiated while other nurse call 911. [e-signed by LVN L]. -[DATE]: 911 crew arrived and took over from nurse [e-signed by LVN L]. -[DATE]: 911 crew left the facility after all efforts made by them to resuscitate resident failed [e-signed by LVN L]. -[DATE]: Upon assessment resident noted without active signs of life. skin cool and dry no respirations no rise and fall of the chest, no carotid or apical pulse no blood pressure pupils non-reactive to light. death pronounced at 4:12 A.M/ [e-signed by the DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a resident's blood sugar was low when checked, the charge nurse was supposed to check the physician's standing orders for blood sugar, if it got to a certain level, then orange juice was given if the resident was able to swallow and there was also glucagon. LVN A stated when the blood sugar was checked and below a certain level, there were protocols to follow and the doctor had to be notified. LVN A stated a dangerously low blood sugar was anything below 70. She stated blood sugar checks were documented on the MAR, as well as in a nursing progress notes if it had to be re-checked. LVN A stated a change of condition was anything that was not ordinary for the resident, such as a change in consciousness, labs, blood pressure and blood sugar changes. When a change of condition occurred, LVN A stated a change of condition form, nursing note and SBAR had to be completed. LVN A stated that she had been the nurse for Resident #3 in the past and thought he had recently come back from a hospital visit and all she remembered was he had a trach and was always pleasant. She stated she was not working with him on the day his blood sugar was 40. An interview with LVN B on [DATE] at 2:49 PM revealed Resident #3 was on her hall and he had a recent surgery on his back the week prior. He had gone to the hospital to for a planned appointment to remove staples from his neck and was there for three to four days when the hospital had originally stated it would only take one day. When he readmitted to the facility, LVN B stated he was not the same as he was prior but did not give specifics. She stated she was working the ,d+[DATE]pm shift the day of his death and he had been in the dining room for dinner eating. She brought him back to his room after dinner and rounded on him again before her shift was over and everything was okay. The next morning, she found out he had died after her shift. LVN B stated, There was nothing acute happening with him on my shift. He did not have a low blood sugar on my shift. If he had a low blood sugar, he was in the dining room, I fed him .even if it went low, he would have been given Glucagon after my shift was over. We checked his blood sugars. He can talk, he can tell us what he wants. There was nothing out of the ordinary for me. He ate, I didn't have any reason to worry. LVN B stated if a resident's blood sugar was 40, she would have called the doctor but already be in the process of sending the resident out to the hospital even before the doctor said so, because 40 is too low on my watch, that is an automatic send out for me unless the doctor says to keep and give medications. But 40 is too low for glucagon to help enough. LVN B stated symptoms of low blood sugar could be nausea and vomiting, aggression, sweating and sleeplessness. LVN B stated the protocol for a low blood sugar reading was for the nurse to initial the MAR to ensure that the blood sugar was checked and was okay. If the blood sugar was not okay and low, then the nurse would administer Glucagon, document in nursing notes and do and E-Interact form. LVN B stated there was not a place on the MAR to indicate emergency glucose was given, only in the nursing notes. If the nurse administered glucagon, the nurse was supposed to re-check it in 15 minutes to see where blood sugar level was and document it in a nursing progress note because it was an issue and also document in the 24 hour report. The doctor would also be contact and if the blood sugar value did not elevate with intervention, notify doctor again to get further orders. LVN B stated she did not remember being told on that date of the low blood sugar of 40 ([DATE]) that there had been a change of condition. She said if an agency nurse was working that morning, she would not have rounded with them because they are always wanting to leave, so I don't remember anything about a low blood sugar. LVN B stated when a resident's blood sugar was low, the charge nurse was supposed to consult with the doctor, then give Glucagon or an orange juice supplement that can push the blood sugars back up, then re-assess the resident. LVN B stated a dangerously low blood sugar was anything below 70. She said blood sugars were documented on the MAR. LVN B stated a change of condition was if a resident's vitals were below their norm or they were restless or in pain. An interview with LVN L on [DATE] at 3:21 PM LVN L stated she was the charge nurse for Resident #3 on the night he died . She had picked up the overnight shift and came in around 11:00 PM on [DATE]. She stated nothing had been reported to her by the afternoon/evening nurse [LVN B]. She said during her first rounds, Resident #3 was asleep in his room but woke up and said hello when LVN L came into the room. Then on her second round about two in the morning, LVN L stated she went into his room and discovered he was not breathing. She said most of the time when she rounded, she went into the residents' rooms and turned the light on and pat them and say hello, just checking. When she did that with Resident #3, she said papacita, when nothing, he did not respond and he had no pulse. LVN L stated they started CPR and someone called 911. EMTs arrived and worked on him for a long time but could not bring him back. LVN L stated there were protocols for hypoglycemia on every resident and if the resident could still talk and was alert, the first protocol was to give oral glucose and if the blood sugar did not come up, Glucagon was available. If the resident was still unresponsive, the nurses could then use glucose gel. She stated it was whatever the facility protocol said on the MAR and it had to be followed step by step. LVN L stated a dangerously low blood sugar was anything less than 70. Once Glucagon was given, LVN L stated the nurse would go back and check the blood sugar in 15 minutes, document the findings in a nursing note all that had been done, call 911 if the blood sugar does not rise and notify the doctor. LVN L stated a change of condition was anything different from the residents' norm. An interview with the DON on [DATE] at 4:40 PM revealed she was working at the facility the morning of [DATE], Resident #3's low blood sugar reading of 40. She stated a CNA came to tell her one of the nurses wanted her help. When the DON got to Resident #3's room, the nurse was at the door and said his blood sugar reading was 40. The DON assessed Resident #3 and his breathing and vitals at that time were normal, But he was doing what they do when their blood sugar is low, like they try to respond but can't, but want to. I told him [Resident #3] he was fine and his blood sugar was low. The DON stated Resident #3 was given Glucagon, and she told the nurse [LVN K] to check it again in ,d+[DATE] minutes. When LVN K checked it again, she gave a glucagon injectable, did not know remember what the blood sugar value was. The DON stated, When someone's blood sugar is in the 40s, they can't swallow so I don't like using the gel. The DON stated, So he came back around and it was a normal day after that. The DON stated she felt Resident #3 died because of his disease process. She stated his health was already poor and he had been getting treatment for multiple venous/stasis ulcers and wound care for pressure ulcers. An interview with CNA D on [DATE] at 12:30 PM revealed she was working the morning on [DATE] when Resident #3's blood sugar was 40. CNA D stated she was passing breakfast trays to the rooms and went into Resident #3's room and he was snoring but would not wake up when she tried to rouse him; she felt something was not right. She knew he was a diabetic so went to tell the nurse who was a PRN nurse (LVN K) who came to his room. LVN K also tried to wake Resident #3 up, but he would not wake up and it was then they knew something was wrong. The charge nurse checked his blood sugar and it was 40. CNA D stated she was present when the reading of 40 was done. She said LVN K did the glucose gun on him twice. After that, he woke up, was thirsty and wanted to get up out of bed. Soon after, a family member was present who sat with him in the dining room while he ate, he was talking and chatting with the family member and staff. CNA D stated Resident #3 told LVN K thank you so much for helping him while he was in the dining room, So he perked back up. CNA D stated LVN K told the family member about the low blood sugar and that he needed to be watched by the following shifts and she would leave a note for the nurses on the shifts. CNA D stated she remembered the morning PRN charge nurse telling the afternoon oncoming charge nurse [LVN B] to check Resident #3's blood sugar because it had been 40. Then the very next day, CNA D stated that Resident #3 was gone and they had already picked up his body by the time she got into work CNA D was worried Resident #3 may have died from a diabetic coma and said, I know from experience you need to monitor at least 48 hours. An attempt to interview MD H on [DATE] at 1:34 was unsuccessful; there was no option to leave a voice mail. An attempt to interview PA I on [DATE] at 1:36 PM was unsuccessful and there was no option to leave a voice mail. An interview with the secondary physician extender listed on Resident #3's Face Sheet [PA J] occurred on [DATE] at 1:43 PM. PA J stated she stopped going to the facility three weeks prior and her role was to work in physiatry and rehab only. However, speaking in general terms, PA J stated from a provider's point of view, the facility should notify the doctor for any low blood sugar, they had standing order to follow which included glucose tablet, then they should re-check the blood sugar and call the doctor back to see what they want to do. An interview with ADON E on [DATE] at 1:53 PM revealed she was week new to the facility so her information was limited. ADON E stated for a low blood sugar of 40, the resident would be at risk of a diabetic coma, so the doctor should be contacted to let them know what the charge nurse's interventions were, the blood sugar reading, the medications administered and then find out what they want the charge nurse to do. ADON E stated that for a blood sugar of 40, her nursing judgement would have sent Resident #3 to the hospital. ADON E stated Resident #3 should have been monitored after his change of condition for three days. She said the charge nurse would monitor and look for confusion, diaphoresis (cold and clammy), paleness of skin, confusion, agitation and anxiety. ADON E stated the nurses did chart by exception, but for an acute condition, they were supposed to chart for three days or as long as the treatment was in place. An interview with CNA F on [DATE] at 2:25 PM revealed he remember Resident #3 and was talking to him around 10:00 PM, a few hours before he died . He said they were talking about sports and two local sports teams and nothing seemed off or out of the ordinary. CNA F stated Resident #3 had been in the hospital recently but he did not know what for, but that night, he was up in his wheelchair and then CNA F laid him down for bed before his shift was over. An interview with the VPCS on [DATE] at 2:47 PM revealed after Resident #3's low blood sugar reading of 40 and subsequent intervention of Glucagon, the nurses on the oncoming shifts that day should have been monitoring the resident for signs and symptoms of hypoglycemia such a confusion and lethargy. She stated the shift to shift report should be given between nurses and they were supposed to print out the 24 hour report and utilize that as well when they did their walking rounds for continuity of care. If there was a change in the resident's condition, such as a fall, a blood sugar that had to be recovered for example and there was any intervention done, it should be reported to the oncoming nurse. VPCS stated, That is what I expect for out of the norm, a prudent nurse to communicate to the oncoming shift so there is continuity of care. 2) Record review of Resident #4's Face Sheet (not dated) reflected he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Hypertension, Major Depressive Disorder, Atherosclerotic Heart Disease, Angina Pectoris, Dementia, Generalized Anxiety Disorder, Diabetes, Hyperlipidemia, Schizophrenia and Parkinson's Disease. Resident #4's attending physician was listed as [MD O] and the nurse practitioner was listed as [NP M]. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed no hearing, speech or vision issues, a BIMS score of 03 which indicated severe cognitive impairment, no signs of delirium, psychosis or rejection of care. Resident #4 had no range of motion limitations but did need help from staff with all ADLs. Resident #4 did not have any assessed health conditions related to shortness of breath, did not use oxygen therapy and was not on hospice services. Resident #4 was prescribed high-risk medication which included an antipsychotic, antidepressant and an anticoagulant. Review of Resident #4's care plan initiated on [DATE] and last revised on [DATE] did not reflect any care areas related to respiratory issues or need for oxygen or related interventions. Record review of NP M's last documented visit on [DATE] with Resident #4 reflected a chief complaint/nature of presenting problem as, Leukocytosis (a condition where your blood has too many white blood cells, which fight infections and diseases), AMS, Abnormal labs, falls x 2. Resident #4 had a non-healing ankle wound that was being treated and a recent white blood cell count of 14 and continued leukocytosis. He was on an antibiotic and seen and examined in his room. He reported malaise and workup so far negative. The Nursing staff report decreased appetite. NP M reviewed Resident #1's recent labs from [DATE] and documented, CBC 16.1, 8.5, 25.5, 561; BMP 131, 4.4, 101, 22, 25, 1.1, 68. NP M documented her plan as, Plan 1. Leukocytosis: Workup so far negative. Currently on cefdinir until [DATE]; 2. Obtain blood cultures x 2 both negative, no growth after 5 days; 3. Obtain echocardiogram; 4. Consult hemo/Onco for further workup: new onset leukocytosis, thrombocytosis, anemia, weakness, negative infection workup; 5. Health shake 3 times daily with each meal; 6. Continue weekly lab work as ordered previously; 7. Continue all medication as ordered in PCC. Record review of Resident #4's physician order [initiated by NP M] dated [DATE] reflected, 2-view Chest X-ray to rule out infiltrates (abnormality in the lung). Record review of Resident #4's x-ray-Chest 1-view dated [DATE] reflected it was reviewed by the radiology clinic at 6:01 PM and reported at 6:01 PM. The chest x-ray was noted on the findings to be compared to his last x-ray a year earlier on [DATE]. The findings indicated Resident #4 had widespread bilateral nodular lung opacities (haziness around the lung with nodule growth) and a small right pleural effusion (fluid around the lungs). The impression reflected, There are widespread bilateral nodular lung opacities. This is consistent with severe pulmonary edema or pneumonia. Consider CT correlation to exclude neoplasm. The findings are worse compared with prior. Record review of nursing progress notes from [DATE] for Resident #4 reflected no indication the physician or physician extender [NP M] and RP was notified of Resident #4's chest x-ray results. Record review of the following pertinent nursing notes for Resident #4 reflected: -[DATE] 12:52 PM- Type: eINTERACT SBAR Summary for Providers-Situation : The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: BP ,d+[DATE], Pulse:70; R 18; Temp: 97.9; Weight: 202.2 lb; O2 96 %; Blood Glucose: 123.0 . Outcome of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other; Functional Status Evaluation: General weakness . Primary Care Provider responded with the following feedback: A. Recommendations: obtain Urine for UA with C&S; New Testing Orders: [blank]; C. New Intervention Orders: [blank] [e-signed by LVN A]. - [DATE]- Nurse's Note- PA in facility to visit with her residents today. Information given to PA regarding noted increased weakness and sleepiness. The resident is afebrile and without noted signs and symptoms of respiratory distress. New orders received to obtain urine for UA with C&S to rule out UTI and a 2-view chest x-ray to rule out infiltrates [e-signed by LVN A]. -[DATE]- Upon shift change at [10:05 PM], CNA called this nurse into resident's room. On getting to room, resident found in his wheelchair unresponsive in the bathroom. Resident assessed, put in bed and CPR initiated immediately while the other nurse, [staff] called 911. 911 crew arrived at [10:25 PM] and took over from the nurses. All efforts made by 911 crew to resuscitate the resident failed. The 911 crew left at [11:00 PM]. DON, resident family and MD notified of the change of condition. At [11:30 PM] Police arrived and took report from the nurses. At [midnight] resident pronounced by DON [e-signed by LVN P]. -[DATE]-Resident laying in bed. intubated with IV to right AC. skin cold and clammy. No signs of life present. No respirations, no rise and fall of chest. no carotid or Apical Pulse. Pupils set non-reactive to light. Death pronounced at 12:00 A.M. [e-signed by DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a charge nurse starts their shift, they should look in the lab book and the radiology book to see who has pending results and then continue to check throughout the shift to see if they have come in. If the charge nurse does not see the results, then they should call and follow up with a phone call. If the findings come back negative, the physician should still be notified to see if there are any new orders. With Resident #4, LVN A could not remember if NP M was notified of his chest x-ray findings. She said the results for Resident #4's x-ray would have come in after her shift was over at 2:00 PM that day. An interview with LVN C on [DATE] at 3:21 PM revealed the results of any x-rays were supposed to be logged under the resident's name in PCC with the results. LVN C stated she was at the facility the night Resident #4 died , but was not assigned to his hall. LVN C stated her shift was over and she heard his nurse calling for help so she went to see what happened and ended up helping the nurse do CPR. LVN C stated when she saw Resident #4, staff had already started CPR and she thought he was already expired by then. An interview with the DON on [DATE] at 4:40 PM revealed she did not remember Resident #4, but if a lab or x-ray came back with abnormal findings or normal findings, the charge nurse should still contact the doctor to let them know the results because the doctor may order antibiotics or prn oxygen. The DON said, But if the resident was already on antibiotics and no respiratory issue, the doctor probably would have just continued with current orders with antibiotics. The DON stated she was not sure what was going on with Resident #4 and she was new to the facility in [DATE]. The DON stated, But if he was already having respiratory issues, the doctor may not have done more intervention, but they should have been notified. An interview with ADON E [DATE] at 1:53 PM revealed she was one week new to the facility so she was not familiar with Resident #4. However, for x-ray results, ADON E stated the doctor should be called with the results regardless if the resident had a pre-existing condition or was already on medications for an infection. She reviewed the x-ray which reflected Resident #4 had lung opacities that were white spots which could mean usually pneumonia. She said it also reflected pulmonary edema which was water in lungs and pleural effusion was water around the lung. ADON E stated, These things are ordered because there was a concern, you would notify them because they doctor might want to change the antibiotic. An interview with the VPCS on [DATE] at 2:47 PM revealed if a resident had known issues to the point where the doctor ordered an x-ray, then the doctor should be contacted with the results of that x-ray. VPCS stated, How do we know there are no new orders because we haven't reached out to the doctor? An interview with NP M on [DATE] at 3:27 PM revealed she recalled that Resident #4 was not critical but she remembered doing a workup on him and was surprised he had passed way. She said he had a slightly elevated white blood cell count on [DATE] prior to his death but he was not on her radar to be declining. NP M stated, As a matter of fact, he walked and went to the dining room every day. NP M remembered ordering a chest x-ray on the day of his death and thought she got the results, but then said she may have been notified after his death. She reviewed her clinical notes and charting system and looked at the x-ray image and findings. NP M then stated she had seen Resident #4 on [DATE] and he died later that night. She said she did not see where his chest x-ray results were told her prior to his death but she was notified when he died . When she had seen Resident #4 that morning on [DATE], she ordered a work up on him. He had an elevated white blood cell count and the nursing staff said he had altered mental status and recent falls. NP M stated Resident #4's labs had been abnormal prior to that visit because he had recently been in the hospital for an ankle wound which caused the elevated white blood cell count. When Resident #4 returned to the facility, his WBC was 15.2 and stayed that way but she did blood cultures and the WBC count started trending down. When NP M saw Resident #4 on [DATE], his WBC was 14 and he had no issues with breathing that she observed. She stated the chest x-ray she ordered was standard procedure to look for something. NP M stated she thought Resident #4 had pneumonia back in February 2024, so if she was looking for something going on, she would typically order a 2-view x-ray, a UA and some lab work. She stated on [DATE], Resident #4 was already on cefdinir, an antibiotic for the ankle wound. When she reviewed the x-ray she ordered during the interview, she stated, I am thinking it came back after he expired. I am reading it now. Looks like he had pulmonary edema. He was not short of breath when I saw him, that would have been a whole different ballgame. That morning he was up, went to dining room, went to breakfast and then he came back to his room and going to the bathroom. NP M continued and stated, You can get flash pulmonary edema and they can literally die right on the floor. It can happen for whatever reason, maybe a little CHF, fine one minute, not the next. NP M said with flash pulmonary edema, usually there would be a report that the resident was foaming at the mouth and that was flash edema. She said there were no reports of that. NP M stated she was working up the change of condition with the two fall and was looking for a possible UTI. She did not feel the WBC was a concern because he admitted with that and his wound, So that in and of it itself is not concerning. NP M stated that had she received the x-ray results prior to his death the night of [DATE], she probably would have sent him out to the hospital but could not say for sure. She said his vitals w [TRUNCATED]

Based on interviews, record review, and facility policy review, it was determined the facility failed to care for residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for one (Resident #10) of three residents reviewed for code status. The facility failed to immediately provide potentially life-saving cardiopulmonary resuscitation (CPR) for Resident #10, who was found unresponsive on [DATE] at 3:30 PM and, at the time, was to receive CPR in the absence of a properly executed do-not-resuscitate (DNR) directive. Resident #10 was pronounced dead on [DATE] at 9:56 PM. An Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of the survey team's investigation. This failure placed residents who were to receive full code measures at risk of death. Findings included: A review of the facility policy titled, Exhibit 19, Acknowledgement of Receipt of Advanced Care Planning Materials and Policy, dated ,d+[DATE], revealed, The facility will honor legally executed Advance Directives in accordance with state and federal rules and regulations. It's the resident's responsibility to provide the facility copies of all pertinent documentation which verify the advanced directives and place in resident's medical record and that FULL CODE STATUS will be in effect until documents are complete. Resident #10 was admitted to the facility on [DATE] as a hospice resident. A comprehensive Minimum Data Set assessment was not completed for Resident #10. A baseline care plan was not developed for Resident #10. A review of the physician orders, dated [DATE], revealed there was no current do-not-resuscitate (DNR) order. A review of progress notes, dated [DATE] by Licensed Vocational Nurse (LVN) A, revealed, First hospice nurse came to get nurse; said she believed her patient was gone. Hospice nurse and nurse went to patients' room and both nurses could not get a carotid pulse or any breath sounds. Hospice nurse told nurse the patient's [parent] was just getting ready to sign a DNR, but last nurse could not find the DNR paperwork. Nurse told hospice nurse 'that means [the resident] is a full code.' Hospice nurse said yes but did not want nurse performing CPR because she believed resident had been gone a while. Skin cool to touch. An interview on [DATE] at 2:10 PM with LVN A revealed she started her shift at 6:00 PM on the evening of [DATE] and was assigned to Hall 700. LVN A stated she normally conducted a walk-around with the nurse being relieved to check on all the residents to get a current status on each resident. LVN A stated she could not conduct a walk-around with the nurse being relieved that night due to the departing nurse being too busy. LVN A stated she could not remember the departing nurse's name but had not seen her since that night and did not think she was still a current employee. LVN A stated that, about an hour later, Registered Nurse (RN) B came running to get her, and she followed RN B back to Resident #10's room. LVN A said she entered Resident #10's room and RN B told her, I think [the resident] is gone. LVN A said she checked for a carotid pulse and there was none. LVN A said that RN B told her the family was discussing a DNR directive, but the form had not been signed by the family or physician. LVN A stated she told RN B, Then the resident is a full code, but LVN A said that RN B told her not to call 911 or initiate CPR since she thought Resident #10 was too far gone. LVN A stated she went to the nurses' station and contacted the hospice company and informed them and was told another hospice nurse would be coming to the facility to pronounce the death. LVN A stated that RN B approached her and told her, I was never here, and then left the facility. LVN A stated RN B was not in the facility when the second nurse from the hospice agency arrived and pronounced the time of death. LVN A stated she felt like she had to listen to RN B since she was an RN. An interview on [DATE] at 9:54 AM with RN B revealed she was at the facility on [DATE] admitting Resident #10 into the facility as a new hospice long-term-care resident. RN B stated she was at the nurses' station completing the resident's admission paperwork and went to the resident's room to get a medial arm circumference and she observed Resident #10 lying in the bed and unresponsive. RN B stated she yelled out and got LVN A to come to the room to observe the resident. RN B stated LVN A told her she was unable to find a carotid pulse and that Resident #10 was unresponsive. RN B stated she told LVN A to contact hospice and to follow her facility protocol regarding how to handle the situation. RN B denied telling LVN A not to perform CPR and noted that she told LVN A to follow the facility protocol, whatever the protocol may be. RN B stated she was under the assumption that Resident #10 was a full code, but she was unable to explain how to she came to that determination. RN B also stated she never told LPN A that she had not been at the facility. But RN B stated she did leave before the other hospice nurse arrived without giving any status information and was unable to explain why she didn't remain at the facility until the oncoming hospice nurse arrived. An interview on [DATE] at 9:42 AM with the Director of Nursing (DON) revealed that if there was not a signed DNR in place at the time a resident coded, staff initiated CPR. The DON stated it did not matter who instructed a nurse not to initiate CPR and that it was the nurse's obligation to start CPR. An interview on [DATE] at 11:56 AM with the Administrator revealed it was an absolute must that staff called 911 and initiated CPR when a resident coded and was a full code. The Administrator stated LVN A told him she felt like she had to listen to RN B since RN B was an RN. The Administrator stated they had created an advanced directive binder that was accessible to all staff to quickly check for a resident's code status. The Administrator stated that all the licensed nursing staff had been re-educated about code status . The Administrator and DON were notified of the IJ on [DATE] at 3:38 PM and provided the IJ Template on [DATE] at 3:41 PM . The facility took the following corrective actions prior to entrance on [DATE]: 1. Facility LVN was suspended pending an investigation on [DATE] via phone from ADON [Assistant DON ]. 2. On [DATE], physician and family notified of patient passing. 3. On [DATE], at approximately 11:00 AM, the facility LVN was counseled and provided with education on proper policy involving non-responsive full code patients by the ADON. 4. On [DATE], the DON held house wide education to all staff on proper response to non-responsive patients who are full code, that nurses will initiate CPR on full code patents, non-nurse staff to assist with 911 calls and directing emergency personnel. 5. Facility contacted hospice for response to the incident [DATE]. 6. On [DATE], the hospice DON sent the facility a response regarding a request to discuss the event with the hospice nurse present. The hospice nurse involved will not be allowed in facility in the future. 7. The facility has since established a DNR status binder on each nurses' station for nurses to be able to quickly identify code status of all residents, completed [DATE]. 8. Current DON continues to monitor any code incidents for continued compliance. Monitoring of the facility's response revealed: The hospice nurse (RN B) was not allowed back into the facility. LVN A was counseled and educated about nonresponsive full codes and a facility wide in-service was completed with all staff about DNR and full code status. The facility placed a DNR binder at each nurses' station, which the DON was to check and update daily. An Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of the survey team's investigation .

Based on record review and interviews, it was determined the facility failed to provide pain relief medications as needed for one (Resident #1) of three residents reviewed for pain management. Resident #1 was not able to receive pain medications as prescribed consistently while at the facility, which resulted in Resident #1 being in severe pain and having to go to the emergency room twice during the 12 days while admitted to the facility, in order to receive pain medication. This deficient practice had the potential to affect all residents at the facility should they experience pain and require pain medication. Findings included: A review of the facility admission record revealed the facility admitted Resident #1 on 07/09/2021, and Resident #1 was discharged from the facility on 07/21/2021. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. Per the MDS, the resident received scheduled and as needed pain medications. The resident's pain frequency was almost constant, and the resident rated their pain as a 10 on a numerical scale of 0 to 10. A review of Resident #1's baseline care plan, dated 07/10/2021, revealed a focus for chronic pain related to [CONDITION(S)]. Interventions included to notify the nurse for complaints of pain or discomfort. An interview on 11/26/2021 at 9:58 AM with Resident #1's Family Member (FM) revealed Resident #1 was sent to the facility from the hospital on 07/09/2021 at 6:00 PM. The FM stated that the first night the facility did not have any pain medication that was effective for the resident. Resident #1 called the FM saying the pain was unbearable. The FM went to the facility and had 911 pick Resident #1 up and take the resident to the emergency room (ER) for pain medications. The FM stated they were uncertain but believed they had taken pain medications back to the facility for the facility to use to address Resident #1's pain. On 07/21/2021, the FM was called again by Resident #1, who complained of intense pain, asking to be taken out of the facility because they could not help the resident with their pain. The FM, who explained they were elderly, drove to the facility around 10:00 PM and went with Resident #1 back to the ER for pain medications. The FM said they never returned to the facility. Resident #1 was admitted to a different provider who was able to help with the pain, and the resident passed away there a couple of weeks later. The FM stated they were concerned for other residents at the facility who did not have anyone to advocate for them for pain medications. A review of Resident #1's Hospital Discharge Records, dated 07/09/2021, revealed pain medications Resident #1 received while in the hospital consisted of [MEDICATION(S)] 4 milligrams (mg), given orally every four hours as needed (last given 07/09/2021 at 5:18 AM) and [MEDICATION(S)] 15 mg given orally every 12 hours as needed (last given 07/09/2021 at 9:46 AM). A review of Resident #1's progress notes revealed on that 07/09/2021 at 6:07 PM, Resident #1 arrived at the facility. On 07/09/2021 at 6:45 PM, the nurse documented that the resident was very uncomfortable, reporting a pain level of 10, and was requesting to go back to the hospital. The nurse included that the facility Assistant Director of Nursing (ADON) was notified and was trying to reach the doctor for a pain medication order triplicate (required for controlled substances). Resident #1 was sent to the hospital, and the family was to meet the resident there. On 7/11/2021 at 4:54 PM, the nurse noted Resident #1 returned to the facility. The note indicated that the FM brought in pain medications that they would like returned when the pharmacy delivered the resident's pain medication to the facility. On 07/21/2021 at 9:00 PM, the nurse documented they spoke with the FM, and Was advised to send resident to the nearest hospital to treat pain. A review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's narcotic count sheets provided by the facility revealed [MEDICATION(S)] sulfate 15 mg was first given at 8:25 PM on 07/11/2021. The starting count was 15 tablets. The last [MEDICATION(S)] sulfate was given on 07/18/2021 at 8:00 AM. The first [MEDICATION(S)] 4 mg was given on 07/11/2021 at 8:25 PM. The starting count was 14 tablets. The last [MEDICATION(S)] was given on 07/20/2021 at 5:40 and did not indicate PM or AM. A review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The last dose documented for the [MEDICATION(S)] 4 mg was on 07/19/2021 at 6:02 AM. In an interview on 11/26/2021 at 3:11 PM, Registered Nurse (RN) J revealed RN J had worked a couple of times with Resident #1. RN J could not remember calling the doctor for the refill but was there when the pharmacy called to say the print was too dark on the fax the PA had sent and they could not fill the orders. RN J stated at that time, RN J believed they were already out of the medication, and RN J called the PA to let them know the order did not go through. RN J stated that it was not uncommon at the time for the physician's fax machine to not work well. In an interview on 11/26/2021 at 4:45 PM, the Physician Assistant (PA) revealed the PA was able to find texts showing the triplicates for the narcotics for Resident #1 were sent in by the PA on 07/20/2021. On 07/21/2021, the PA was notified the pharmacy had not filled the order and refaxed the order to the pharmacy. The PA stated there was no reason why a patient should have to go without pain medications. In an interview on 11/27/2021 at 9:42 AM, the Director of Nursing (DON) stated the expectation was that the facility should be able to manage a resident's pain to the best of their ability. The DON stated she had heard some nursing concerns regarding physicians' orders not being accepted by the pharmacy because they were illegible. By the time the pharmacy notified the nurse, it had been several hours, and they must notify the doctor of the order not being filled. The DON stated a new system had been put in place since Resident #1's incident. The DON stated that the PA was available via text. In an interview on 11/27/2021 at 12:04 PM, the Administrator stated it should not happen that a resident in pain could not receive pain medications. The Administrator stated they did not work at the facility at the time Resident #1 could not get pain medications but knew it was the wrong thing to happen at a long-term care facility. In an interview on 11/27/2021 at 3:47 PM, Licensed Vocational Nurse (LVN) I revealed LVN I had worked with Resident #1 a few times. The LVN recalled that the resident was in pain and there was a problem with getting the resident's pain medications filled. LVN I stated what should have happened was the nurse that was giving one of the last doses should have contacted the Doctor or the Physician's Assistant to reorder and send in a triplicate for the narcotic.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Residents #1) of six residents reviewed for change in condition. The facility failed to assess Residents #1 after she received medication for a high grade temperature on [DATE]. The facility failed to complete and document assessment concerning Resident #1 from [DATE] to [DATE]. The facility failed to contact the physician when Resident #1 had a high grade temperature on [DATE]. Resident #1 discharged to the hospital on [DATE], in [MEDICAL CONDITION] and died on [DATE]. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. These failures could affect the 97 residents that reside at the facility placing them at risk for failure/inadequate with follow-up assessment, resulting in delay of care and deterioration in condition. Findings included: Review of the closed record Admission Face Sheet revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated [DATE] with goals and approaches related to Resident #1's needs concerning code status (full code), rights and respect, and nutrition. Review of the MDS assessment dated [DATE] revealed Resident #1 could not communicate, had an abdominal feeding tube, was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. Review of the Physician order [REDACTED].#1 had an order dated [DATE]: [MEDICATION NAME] tablet (generic Tylenol) 650mg 1 tablet via [DEVICE] every four hours for general discomfort/temperature. Review of Resident #1's (MONTH) (YEAR) Medication Administration/treatment Records, revealed no documentation of Tylenol 650mg administered on [DATE], [DATE], or [DATE] for Resident #1, it was blank. Review of Resident #1's clinical nurses' note revealed on [DATE] at 7:00 p.m. at Resident #1 had a change in condition. Resident #1 developed a temperature of 102 degrees Fahrenheit and LVN B administered Tylenol (fever reducing medication) 325mg two tablets per feeding tube at 7:00 p.m. There was no further documentation of an assessment or follow-up of Resident #1's condition in the clinical record. Review of the Resident #1's nurse's note dated [DATE] discharged to the hospital at 1:12 a.m., 911, in [MEDICAL CONDITION] with Cardio [MEDICAL CONDITION] Resuscitator (CPR) performed. Interview on [DATE] at 1:50 p.m. with LVN B revealed Resident #1's family approached her on [DATE] as she was completing her shift. (6:00 a.m.-6:p.m.) LVN B said the family thought Resident #1 was warm to the touch LVN B said she only took Resident #1's temperature and no other vital signs, the temperature read at 102 degrees. LVN B stated she administered Tylenol then reported Resident #1's fever to the nurse in charge, LVN A, and then completed her documentation and left the facility. LVN B said she did not notify the physician about Resident #1's fever because she was not the nurse in charge, she was trying to assist LVN A. LVN B said when she worked the following day [DATE] she did not follow-up on Resident #1's fever. LVN B stated on [DATE] she worked on the other side of the building and was not the nurse in charge of Resident #1. Interview on [DATE] at 2:30 p.m. with LVN A revealed she was aware Resident #1 had a temperature, and had Tylenol administered by the other nurse sometime between 7:00 p.m. and 8:00 p.m. LVN A said, she had worked with the resident from 7:00 p.m. until 10:00 p.m. on [DATE], and only looked in on the resident. When asked for clarification, she said she looked in the door at her. When LVN A was asked if she notified the physician about the fever, she stated no LVN B notified the physician. When LVN A was asked about follow-up documentation concerning her assessment, LVN A said, why would I document anything, I did not do anything for her. When LVN A was asked if she completed a follow-up assessment of Resident #1 the following day ([DATE]), she said she did not because she was not in charge of the resident. LVN A said she worked both sides of the facility. (6:00 a.m.-6:00p.m.) Interview on [DATE] at 4:03 p.m. with ADON D revealed Resident #1 required total care and could not verbally communicate. ADON D said Resident #1 was tube fed and the staff had to anticipate all the resident's needs. ADON D said she was aware Resident #1 had received Tylenol for fever, with no notification to the physician. ADON D said she spoke to the nurse that had administered the Tylenol, the next day [DATE], but did not recall what time of day she had spoken to the nurse. ADON D stated she talked to LVN B before Resident #1 went to the hospital. ADON D stated she had not followed up on Resident #1's fever after she was informed of the fever. When ADON D was asked when she learned of the fever and no notification to the physician, she did not reply. Interview on [DATE] at 3:30 p.m. with LVN C revealed she assessed Resident #1on [DATE], because she had a fever, but had not documented her assessment. When LVN C was asked concerning why she had not documented, she had no answer. LVN C said on [DATE] she worked the other side of the building from 6:00 p.m. until 6:00 a.m., LVN C said the nurses that worked the weekends usually worked on both sides of the building during their 3 days. Interview on [DATE] at 2:00 p.m. with the DON revealed Resident #1 required total care with a feeding tube. The DON said if there was a change in condition with a resident the nursing staff should do a head to toe assessment, call the physician, the family and notify either the ADONs or me. The DON stated no one had called me ([DATE]-[DATE]) to let her know Resident #1 had a fever or discharged from the facility. The DON said when she came to work the following Monday morning, [DATE], she obtained a report of any discharges or changes in the residents over night or over the weekend. The DON said she was aware Resident #1 had been discharged to the hospital, after she reviewed the report, but could not recall who she had spoken to concerning Resident #1's discharge. The DON said she had not reviewed Resident #1's clinical record and was unaware of the missing documentation or a change in condition with the resident, until surveyor intervention. Interview on [DATE] at 4:00 p.m. with DON confirmed she worked 5:00 a.m. until 1:00 p.m. the weekend of [DATE] and [DATE].When asked what she did in the facility when she worked that weekend, the DON said she went to her office and worked on her responsibilities. The DON said she did not check on any discharges or changes in condition, until the following Monday morning ([DATE]). Interview on [DATE] at 10:30 a.m. with the Medical Director revealed he was aware of the situation, he had spoken to the Administrator, the evening of [DATE] around 7:00 p.m. The Medical Director said he had concerns about the nurses because this was basic nursing practices, assessing a resident with follow-up concerning the resident's condition and notifying the physician. Interview on [DATE] at 2:00 p.m. with The Administrator revealed she had spoken with the Medical Director on ([DATE]) and he had shared his concerns about the nurses not assessing and communicating with the physician. The Administrator said she felt the nurses were not communicating changes in condition concerning the residents and documenting their findings, this was the failure. The Administrator said this was why she was now involved in the nursing morning meetings. When asked if she was aware of Resident #1's change in condition and discharge to the hospital, she said, she was aware of Resient#1's discharge to the hospital, but was unaware of any change in condition or the outcome of her discharge. Interview on [DATE] at 1:01 p.m. with Primary Care Physician (PCP) revealed he recalled Resident #1. When asked concerning notification of change of condition concerning a temperature. The PCP said he recalled no phone calls from the facility ([DATE]-[DATE]) and when he visited the facility the following Thursday ([DATE]) he was told the resident had been discharged to the hospital with no explanation from the nurses. The PCP said he contacted the hospital himself to find out what happened to the resident and was told she had died . Review of the ADL sheet for Resident #1, dated [DATE], revealed mouth care and bed bath given. No documentation regarding concerns. Review of the hospital records revealed Resident #1 was pronounced dead eight minutes after arrival to the emergency department. Review of the Change in a Resident's Condition policy and procedure dated (MONTH) (YEAR) provided by the Administrator on [DATE] and identified as current revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative or changes in the resident's medical/mental condition and/or status .the nurse will notify the resident's Attending Physician when there has been a significant change in the resident's physical condition .need to alter the resident's medical treatment, .specific instruction to notify the Physician of changes in the resident's condition .the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status An IJ was identified on [DATE]. On [DATE] at 5:20 p.m., the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] and accepted on [DATE] at 4:59 p.m. revealed all charges nurses were in-serviced on significant change in a resident condition, who to notify and documentation required in the resident's medical record. Plan of Removal received on [DATE] reflected: .1. DON, ADON D, LVN A , LVN B and LVN C were aware of a resident's change in condition and failed to assess the resident post intervention of Tylenol for a fever and notify the Attending Physician of the change. Additionally, DON, & ADON D upon discovery of the incident failed to report to the Administrator and conduct an investigation. The above mentioned employees received ,[DATE] education on [DATE] & [DATE] from the RN/VP of Clinical Services regarding: a. Change in Resident's Condition or Status. A Significant Change of condition is a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgment of the clinical staff. b. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): i. significant change in the resident's physical/emotional/mental condition; ii. need to transfer the resident to the hospital/treatment center; c. If the nurse is unable to notify the resident's attending physician the nurse will notify the Medical Director and if unable to reach him/her the nurse will call the Administrator. d. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. e. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 2. In-Services a. RNs & LVNs will be in-serviced by RN/VP of Clinical Services beginning [DATE] on the following and will continue and be ongoing to be completed by [DATE]. Licensed staff who does not receive training by [DATE] will be unable to work until training is completed. In-service training on the below and comprehension test will be added to licensed staff new hire orientation and will be completed prior to working on the floor to immediately monitor staff comprehension. Administrator will audit new employee files post each Orientation to ensure in-service education is documented and competency test completed for each new employee to immediately monitor comprehension. b. Using the company's policy and procedure on a Change in a Resident's Condition or Status, RN/VP of Clinical Services in-serviced DON, both ADONs, and all RNs & LVNs at facility on [DATE] & [DATE]. c. In-Service will educate on: Change in Resident's Condition or Status. A Significant Change of condition is a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgment of the clinical staff. d. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): i. significant change in the resident's physical/emotional/mental condition; ii. need to transfer the resident to the hospital/treatment center; e. If the nurse is unable to notify the resident's attending physician the nurse will notify the Medical Director and if unable to reach him/her the nurse will call the Administrator. f. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. g. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 3. Quality Assurance a. The facility Medical Director was notified of the above incident on [DATE] at 7:16pm. b. Rounds were made and interviews conducted with nurses by the VP of Clinical Services on [DATE] and [DATE] with no significant changes noted to any residents. During interviews nurses were asked if any resident was experiencing a change of condition. Round and interviews with nurses started [DATE] and will continue thru [DATE]. c. [DATE] VP of Clinical Services conducted review of facility 24-hour Summary/Report with Nurse managers and reviewed the facility policy for change of condition and verified staff comprehension. During review of the 24-hour Summary report no residents flagged for a change in condition. d. [DATE] meeting conducted by VP of Clinical Services with IDT. Review of the new process to monitor significant change in residents with the 24-Hour Summary Report was completed and introduced as a new part of the Clinical Meeting. During review of the 24-hour summary report no residents flagged for a change in condition. e. The facility 24-hour summary/report is a document that identifies residents' change in condition (see sample report) and will be reviewed by the VP of Clinical Services and/or Administrator. i. If a change of condition is identified then the Q[NAME] Additional Resident Review Audit will be completed for that resident by the VP of Clinical Services. f. This process will be completed daily (Monday-Friday) by the VP of Clinical Services and/or Administrator for 30 days, then weekly x 4 weeks, and monthly x 3 months Interview with DON on [DATE] at 6:30 p.m. regarding facility change in condition status revealed no changes in any resident's conditions. Further interview on with DON [DATE] at 9:00 a.m. and 3:15 p.m. revealed no changes in any resident's conditions. Continued interviews with DON on [DATE] at 9:45 a.m. and [DATE] at 9:15 a.m. revealed no changes in resident's condition. Interviews on [DATE], [DATE] and [DATE] with 16 out of the 17 nurses, that the facility employees, revealed they had been in-serviced on change in condition, who to report the change to, and what to document, with a post test and in the past 24 hours concerning the policy and procedure concerning changes in resident's condition or status. The monitoring interviews included nurses from all shifts, 6a.m. - 6 p.m., and 6p.m. to 6a.m. There were no concerns regarding change in condition training and monitoring by the staff. The plan or removal actions appeared to be affective as of [DATE]. Review of the in-services dated [DATE] and [DATE] revealed in-services by the DON and the RN nurse consultant concerning significant change in a resident condition, who to notify and documentation required in the resident's medical record was completed. During an interview with the Administrator on [DATE] at 945 a.m. revealed the facility nurses were all in serviced ([DATE] and [DATE]) with the exception of one PRN nurse that was on leave. The Administrator was notified on [DATE] at 8:30 a.m. the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the Administrator on [DATE] reflected a total census 97 residents.

Based on observations, interviews, and record reviews the facility Director of Nurses (DON) failed to administer in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1of 6 residents (Residents #1) reviewed for changes in condition. The Director of Nurses (DON) failed to implement facility policies and procedures regarding significant change in condition. ADON D failed to follow-up as part of her daily assignment, to assure Resident #1 had assessment and treatment for [REDACTED]. LVN A, LVN B, and LVN C failed to complete an assessment, document an assessment, and notify the physician after Resident #1 developed a high grade temperature on [DATE]. There was no documentation from [DATE] through [DATE]. Resident #1 was discharged to the hospital on [DATE] in [MEDICAL CONDITION] and died at the hospital on [DATE]. These failures could affect the 97 residents that reside at the facility placing them at risk for failure/inadequate assessment with follow-up. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope isolated, because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. Findings included: Review of the Change in a Resident's Condition policy and procedure dated (MONTH) (YEAR) provided by the Administrator on [DATE] and identified as current revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative or changes in the resident's medical/mental condition and/or status .the nurse will notify the resident's Attending Physician when there has been a significant change in the resident's physical condition .need to alter the resident's medical treatment .specific instruction to notify the Physician of changes in the resident's condition .the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status Review of the close record Admission Face Sheet revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated [DATE] with goals and approaches related to Resident #1's needs concerning code status (full code), rights and respect, and nutrition. Review of the MDS assessment dated [DATE] revealed Resident #1 could not communicate, had an abdominal feeding tube, was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. Review of the Physician order [REDACTED].#1 had an order dated [DATE]: [MEDICATION NAME] tablet (generic Tylenol) 650mg 1 tablet via [DEVICE] every four hours for general discomfort/temperature. Review of Resident #1's (MONTH) (YEAR) Medication Administration/treatment Records, revealed no documentation of Tylenol 650mg administered on [DATE], [DATE], or [DATE] for Resident #1, it was blank. Review of Resident #1's clinical nurses' note revealed on [DATE] at 7:00 p.m. at Resident #1 had a change in condition. Resident #1 developed a temperature of 102 degrees Fahrenheit and LVN B administered Tylenol (fever reducing medication) 325mg two tablets per feeding tube at 7:00 p.m. There was no further documentation of an assessment or follow-up of Resident #1's condition in the clinical record. Review of the Resident #1's nurse's note dated [DATE] discharged to the hospital at 1:12 a.m., 911, in [MEDICAL CONDITION] with Cardio [MEDICAL CONDITION] Resuscitator (CPR) performed. Interview on [DATE] at 1:50 p.m. with LVN B revealed Resident #1's family approached her on [DATE] as she was completing her shift. LVN B said the family thought Resident #1 was warm to the touch LVN B said she only took Resident #1's temperature and no other vital signs, the temperature read at 102 degrees. LVN B stated she administered Tylenol then reported Resident #1's fever to the nurse in charge, LVN A, and then completed her documentation and left the facility. LVN B said she did not notify the physician about Resident #1's fever because she was not the nurse in charge, she was trying to assist LVN A. LVN B said when she worked the following day [DATE] she did not follow-up on Resident #1's fever. LVN B stated on [DATE] she worked on the other side of the building and was not the nurse in charge of Resident #1. Interview on [DATE] at 2:30 p.m. with LVN A revealed she was aware Resident #1 had a temperature, and had Tylenol administered by the other nurse sometime between 7:00 p.m. and 8:00 p.m. LVN A said, she had worked with the resident from 7:00 p.m. until 10:00 p.m. on [DATE], and only looked in on the resident. When asked for clarification, she said she looked in the door at her. When LVN A was asked if she notified the physician about the fever, she stated no LVN B notified the physician. When LVN A was asked about follow-up documentation concerning her assessment, LVN A said, why would I document anything, I did not do anything for her. When LVN A was asked if she completed a follow-up assessment of Resident #1 the following day ([DATE]), she said she did not because she was not in charge of the resident. LVN A said she worked both sides of the facility. Interview on [DATE] at 4:03 p.m. with ADON D revealed Resident #1 required total care and could not verbally communicate. ADON D said Resident #1 was tube fed and the staff had to anticipate all the resident's needs. ADON D said she was aware Resident #1 had received Tylenol for fever, with no notification to the physician. ADON D said she spoke to the nurse that had administered the Tylenol, the next day [DATE], but did not recall what time of day she had spoken to the nurse. ADON D stated she talked to LVN B before Resident #1 went to the hospital. ADON D stated she had not followed up on Resident #1's fever after she was informed of the fever. When ADON D was asked when she learned of the fever and no notification to the physician, she did not reply. Interview on [DATE] at 3:30 p.m. with LVN C revealed she assessed Resident #1on [DATE], because she had a fever, but had not documented her assessment. When LVN C was asked concerning why she had not documented, she had no answer. LVN C said on [DATE] she worked the other side of the building from 6:00 p.m. until 6:00 a.m., LVN C said the nurses that worked the weekends usually worked on both sides of the building during their 3 days. Interview on [DATE] at 2:00 p.m. with the DON revealed Resident #1 required total care with a feeding tube. The DON said if there was a change in condition with a resident the nursing staff should do a head to toe assessment, call the physician, the family and notify either the ADONs or her. The DON stated no one had called her ([DATE]-[DATE]) to let her know Resident #1 had a fever or discharged from the facility. The DON said when she came to work the following Monday morning, [DATE], she obtained a report of any discharges or changes in the residents over night or over the weekend. The DON said she was aware Resident #1 had been discharged to the hospital, after she reviewed the report, but could not recall who she had spoken to concerning Resident #1's discharge. The DON said she had not reviewed Resident #1's clinical record and was unaware of the missing documentation or a change in condition with the resident, until surveyor intervention. Interview on [DATE] at 4:00 p.m. with DON confirmed she worked 5:00 a.m. until 1:00 p.m. the weekend of [DATE] and [DATE].When asked what she did in the facility when she worked that weekend, the DON said she went to her office and worked on her responsibilities. The DON said she did not check on any discharges or changes in condition, until the following Monday morning ([DATE]). Interview on [DATE] at 10:30 a.m. with the Medical Director revealed he was aware of the situation, he had spoken to the Administrator, the evening of [DATE] around 7:00 p.m. The Medical Director said he had concerns about the nurses because this was basic nursing practices, assessing a resident with follow-up concerning the resident's condition and notifying the physician. Interview on [DATE] at 2:00 p.m. with The Administrator revealed she had spoken with the Medical Director on ([DATE]) and he had shared his concerns about the nurses not assessing and communicating with the physician. The Administrator said she felt the nurses were not communicating changes in condition concerning the residents and documenting their findings, this was the failure. The Administrator said this was why she was now involved in the nursing morning meetings. When asked if she was aware of Resident #1's change in condition and discharge to the hospital, she said, she was aware of Resient#1's discharge to the hospital, but was unaware of any change in condition or the outcome of her discharge. Interview on [DATE] at 1:01 p.m. with Primary Care Physician (PCP) revealed he recalled Resident #1. When asked concerning notification of change of condition concerning a temperature. The PCP said he recalled no phone calls from the facility ([DATE]-[DATE]) and when he visited the facility the following Thursday ([DATE]) he was told the resident had been discharged to the hospital with no explanation from the nurses. The PCP said he contacted the hospital himself to find out what happened to the resident and was told she had died . Review of the ADL sheet for Resident #1, dated [DATE], revealed mouth care and bed bath given. No documentation regarding concerns. Review of the hospital records revealed Resident #1 was pronounced dead eight minutes after arrival to the emergency department. An IJ was identified on [DATE]. On [DATE] at 5:20 p.m., the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] and accepted on [DATE] at 4:59 p.m. revealed all charges nurses were in-serviced on significant change in a resident condition, who to notify and documentation required in the resident's medical record. Plan of Removal received on [DATE] reflected: .1. DON, ADON D, LVN A, LVN B and LVN C were aware of a resident's change in condition and failed to assess the resident post intervention of Tylenol for a fever and notify the Attending Physician of the change. Additionally, DON, & ADON D upon discovery of the incident failed to report to the Administrator and conduct an investigation. The above mentioned employees received ,[DATE] education on [DATE] & [DATE] from the RN/VP of Clinical Services regarding: a. Change in Resident's Condition or Status. A Significant Change of condition is a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgment of the clinical staff. b. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): i. significant change in the resident's physical/emotional/mental condition; ii. need to transfer the resident to the hospital/treatment center; c. If the nurse is unable to notify the resident's attending physician the nurse will notify the Medical Director and if unable to reach him/her the nurse will call the Administrator. d. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. e. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 2. In-Services a. RNs & LVNs will be in-serviced by RN/VP of Clinical Services beginning [DATE] on the following and will continue and be ongoing to be completed by [DATE]. Licensed staff who does not receive training by [DATE] will be unable to work until training is completed. In-service training on the below and comprehension test will be added to licensed staff new hire orientation and will be completed prior to working on the floor to immediately monitor staff comprehension. Administrator will audit new employee files post each Orientation to ensure in-service education is documented and competency test completed for each new employee to immediately monitor comprehension. b. Using the company's policy and procedure on a Change in a Resident's Condition or Status, RN/VP of Clinical Services in-serviced DON, both ADONs, and all RNs & LVNs at facility on [DATE] & [DATE]. c. In-Service will educate on: Change in Resident's Condition or Status. A Significant Change of condition is a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgment of the clinical staff. d. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): i. significant change in the resident's physical/emotional/mental condition; ii. need to transfer the resident to the hospital/treatment center; e. If the nurse is unable to notify the resident's attending physician the nurse will notify the Medical Director and if unable to reach him/her the nurse will call the Administrator. f. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. g. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 3. Quality Assurance a. The facility Medical Director was notified of the above incident on [DATE] at 7:16pm. b. Rounds were made and interviews conducted with nurses by the VP of Clinical Services on [DATE] and [DATE] with no significant changes noted to any residents. During interviews nurses were asked if any resident was experiencing a change of condition. Round and interviews with nurses started [DATE] and will continue thru [DATE]. c. [DATE] VP of Clinical Services conducted review of facility 24-hour Summary/Report with Nurse managers and reviewed the facility policy for change of condition and verified staff comprehension. During review of the 24-hour Summary report no residents flagged for a change in condition. d. [DATE] meeting conducted by VP of Clinical Services with IDT. Review of the new process to monitor significant change in residents with the 24-Hour Summary Report was completed and introduced as a new part of the Clinical Meeting. During review of the 24-hour summary report no residents flagged for a change in condition. e. The facility 24-hour summary/report is a document that identifies residents' change in condition (see sample report) and will be reviewed by the VP of Clinical Services and/or Administrator. i. If a change of condition is identified then the Q[NAME] Additional Resident Review Audit will be completed for that resident by the VP of Clinical Services. f. This process will be completed daily (Monday-Friday) by the VP of Clinical Services and/or Administrator for 30 days, then weekly x 4 weeks, and monthly x 3 months Interview with DON on [DATE] at 6:30 p.m. regarding facility change in condition status revealed no changes in any resident's conditions. Further interview on with DON [DATE] at 9:00 a.m. and 3:15 p.m. revealed no changes in any resident's conditions. Continued interviews with DON on [DATE] at 9:45 a.m. and [DATE] at 9:15 a.m. revealed no changes in resident's condition. Interviews on [DATE], [DATE] and [DATE] with 16 out of the 17 nurses, that the facility employees, revealed they had been in-serviced on change in condition, who to report the change to, and what to document, with a post test and in the past 24 hours concerning the policy and procedure concerning changes in resident's condition or status. The monitoring interviews included nurses from all shifts, 6a.m. - 6 p.m., and 6p.m. to 6a.m. There were no concerns regarding change in condition training and monitoring by the staff. The plan or removal actions appeared to be affective as of [DATE]. Review of the in-services dated [DATE] and [DATE] revealed in-services by the DON and the RN nurse consultant concerning significant change in a resident condition, who to notify and documentation required in the resident's medical record was completed. During an interview with the Administrator on [DATE] at 945 a.m. revealed the facility nurses were all in serviced ([DATE] and [DATE]) with the exception of one PRN nurse that was on leave The Administrator was notified on [DATE] at 8:30 a.m. the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the Administrator on [DATE] reflected a total census 97 residents.

Based on observation, interview and record review, the facility failed to each resident had the right to be free from neglect for two (Residents #1 and #3) of three residents reviewed for neglect. The facility failed to provide Residents #1 and #3 with a resuscitation device, extra [MEDICAL CONDITION] kit, and a cannula at the bedside. ADON A failed to assure, as part of her daily assignment, Resident #1 had [MEDICAL CONDITION] accessible in the room. RN B had documented the [MEDICAL CONDITION] were available and accessible in Resident # 1's for two shifts, including documenting for one shift prior to the start of the shift. RN B failed to identify where the emergency supplies were located in the resident's' room and/or confirm he had seen the supplies prior to documenting. An Immediate Jeopardy (IJ) identified on 07/19/17. While the IJ was lowered on 07/20/17, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the three residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. Findings included: 1. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. https://medlineplus.gov/ency/article/ 5.htm reflected, A [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [MEDICAL CONDITIONS]. (Retrieved on 07/24/17). Review of the annual MDS assessment dated [DATE] revealed Resident #1 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. An observation on 07/19/17 at approximately 9:00 a.m. revealed Resident #1 lying in bed with a [MEDICAL CONDITION] in place. He was not able to verbally communicate. There was no back-up emergency supplies: Ambu bag (manual resuscitation device), a hand-held device commonly used to provide positive pressure to patients who are not breathing or not breathing adequately. An interview on 07/19/17 at 10:00 a.m. with ADON A revealed Resident #1 was a total care resident and could not verbally communicate. ADON A said Resident #1 was on room air concerning his [MEDICAL CONDITION], the resident required suctioning as needed, [MEDICAL CONDITION] care daily and a change of [MEDICAL CONDITIONS] weekly. When asked concerning the [MEDICAL CONDITION], the ADON A replied the supplies must be in the room. An interview/observation on 07/19/17 at 11:45 a.m. with the DON revealed Resident #1 was total care with a [MEDICAL CONDITION] and a feeding tube. The DON said the [MEDICAL CONDITION] were supposed to be on the wall in bags at the head of the resident's bed and the ADONs were to be checking each morning at the beginning of the shift and on the weekends the charge nurse was supposed to check to make sure the supplies were there. The DON started looking for the [MEDICAL CONDITION] for Resident #1 in his room, after approximately five minutes of searching the DON found the Ambu bag and the additional cannulas in bags, in a box under other bags on the bed side table. ADON A came into the room and the DON said these were supposed to be taped to the wall, ADON A said, Oh I did not know I will go get some tape and put them up there now. An interview on 07/19/17 at 11:56 p.m. with RN B revealed all [MEDICAL CONDITION] were supposed to be in bags at the head of the resident's bed. RN B said he learned in nursing school where the [MEDICAL CONDITION] should be located this made the emergency supplies easily accessible. RN B said he had not had in-service concerning where the supplies should be placed in the resident's room. RN B said he had one resident he was responsible for with trach. Resident #1. An interview on 07/19/17 at 12:00 p.m. with LVN C revealed it was her first week to work at the facility and she had also learned in school that the [MEDICAL CONDITION] were supposed to be at the head of the resident's bed, so in case of an emergency you could find the supplies quickly. LVN C said she had not been told what to do at this facility, so that was good to know. Review of the Medication Administration/treatment Records on 07/19/17, dated 05/17 through 07/17 revealed inconsistent documentation of Ambu bag, extra inner cannula,[MEDICAL CONDITION] set available in room and easily identified. Further review of the documentation revealed [MEDICAL CONDITION] available and easily identified in the room for the day shift (6:00 a.m. - 2:00 p.m.) and the evening shift (2:00 p.m. - 10:00 p.m.) for Resident #1. An interview on 07/19/17 at 2:00 p.m. with RN B revealed no answer as to why he had documented for two shifts at one time, one shift was documented prior to the start of the shift, that the emergency supplies were in Resident #1's room. RN B could not confirm that he had seen the [MEDICAL CONDITION] in Resident #1's room, when he documented the accessibility of the supplies on the Mediaction Addministration Record. An interview on 07/19/17 at 3:00 p.m. with ADON A revealed she knew she was supposed to check the [MEDICAL CONDITION] to make sure they were in the resident's room, but she had not checked today because she had put some in the room this past week, so she knew they were there. Review of the Physician order [REDACTED].#1 had an order dated 07/19/17: Ambu bag, extra inner cannula size 6,[MEDICAL CONDITION] set available in room and easily identified each shift related to [MEDICAL CONDITION] status. 2. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #3 was a [AGE] year-old female who had re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. Review of the Care Plan dated 07/03/17 revealed Resident #3 had impaired breathing mechanics with interventions ensure [MEDICAL CONDITION] are at bedside and visible at all times. Review of the physician orders [REDACTED].#3 had no orders to check for Ambu bag, extra inner cannula, [MEDICAL CONDITION] set available in room and easily identified, monitored for placement each shift related to [MEDICAL CONDITION] until 07/19/17. An observation on 07/19/17 at 12:09 p.m. with the DON revealed Resident #3 had no [MEDICAL CONDITION] in the room. ADON D entered the room and the DON inquired where the supplies were. ADON D said she was not sure. RN E entered the room, and ADON D asked RN E where the [MEDICAL CONDITION] were. RN E said the resident moved sometime yesterday evening and she said she had them on her cart. ADON D left the room returning with the supplies and said RN E had them on her cart and had not had time to get them into Resident #3's room. The DON replied they should have been placed on the wall when she was moved. Review of the nurse's notes dated 07/19/17 revealed Resident #3 was moved at 4:29 a.m. to a different room. Review of the Medication/Treatment Sheets date 05/1/17 through 07/19/17 revealed Resident #3 had no documentation for Ambu bag, extra inner cannula, [MEDICAL CONDITION] kit in room and easily identified. An interview on 07/19/17 at 1:15 p.m. with ADON D revealed she had worked at the facility for four years and no one had every told her she was supposed to check for the [MEDICAL CONDITION] each day and document it was there. An interview on 07/19/17 at 2:30 p.m. with the DON revealed she was aware that there was a resident that had documentation on the supplies being in the room, but she just never got around to checking who that resident was. The DON said she was going to change all [MEDICAL CONDITION] Medication Review Records to require the nurse charge nurses to document the emergency supplies were there, but she had not done that. When asked if she checked for the supplies, the DON said No. 3. An interview on 07/20/17 at 3:00 p.m. with the Medical Director revealed he felt [MEDICAL CONDITION] should be accessible and readily available in the resident's rooms, that is basic nursing practices. 4. Review of the Ventilation policy and procedure dated November 2013 provided by the DON on 07/20/17 and identified as current revealed .the nurse will perform an emergency [MEDICAL CONDITION] change in the event that a [MEDICAL CONDITION] becomes displaced or dislodged .the following supplies are to be kept at the bedside of any resident who has a [MEDICAL CONDITION] .resuscitation bag, [MEDICAL CONDITIONS] kit Review of the Neglect policy and procedure dated December 2016 provided by the ED on 07/20/17 and identified as current revealed, .the facility has designated and implemented processes, which strive to reduce the risk of neglect.definition: Neglect, the failure to provide goods and services necessary to avoid physical harm 5. Taber's Cyclopedic Medical Dictionary21st Edition reflected the following on page 2348, An emergency tracheotomy kit is kept at the bedside at all times Fundamentals of Nursing Seventh Edition by Potter and Perry, reflected the following on page 948, Critical Decision Point: Keep [MEDICAL CONDITION] obturator at bedside with a fresh [MEDICAL CONDITION] to facilitate reinsertion of the outer cannula, if dislodged. Keep an additional [MEDICAL CONDITION] of the same size and shape on hand for emergency replacement 6. An IJ was identified on 07/19/17. On 07/19/17 at 5:10 p.m., the Administrator was notified of the IJ and a plan of removal was requested. 7. Plan of removal dated 07/19/17 and accepted on 07/20/17 at 10:00 a.m. revealed all charge nurses were in-serviced on one Ambu bag and [MEDICAL CONDITION] cannulas (One size smaller than ordered and one size resident has ordered taped to the head of the bed. The charge nurse was to [MEDICAL CONDITION] each shift and document check on the resident's Medication Administration Sheet. If the emergency supplies were not in the resident's room, the charge nurse was to retrieve from the central supply and report to the DON. 8. An observation on 07/19/17 at 5:20 p.m. revealed Resident #1 and Resident #3 had all [MEDICAL CONDITION] in bags on the wall at the head of the bed in the rooms. Further observations on 07/20/17 at 8:00 a.m. revealed Resident #1 and Resident #3 to have [MEDICAL CONDITION] in the room in bags at the head of the bed. Interviews on 07/20/17 with 15 out of the 16 nurses revealed they had been in-serviced and post tested and in the past 24 hours concerning the policy and procedure concerning residents with trachs and the emergency supplies. Review of the in-services dated 07/19/17 and 07/20/17 revealed in-services by the DON and the RN nurse consultant concerning visual checks by the charge nurses and the documentation of the emergency supplies for residents with trachs. Review of the Medication Administration Sheets dated 07/19/17 reveled Resident #1 and Resident #3 had documentation on the Medication Administration [MEDICAL CONDITION] visualized in the room on the wall, documented on the night shift (6:00 p.m. until 6:00 a.m.) The Administrator was notified on 07/20/17 at 10:00 a.m. the IJ was removed. While the IJ removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not IJ at a scope of pattern. 9. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the ED on 07/20/17 reflected three residents with a tracheotomy.

Based on observation, interview and record review, the facility failed to each resident had the right to be free from neglect for two (Residents #1 and #3) of three residents reviewed for neglect. The facility failed to provide Residents #1 and #3 with a resuscitation device, extra [MEDICAL CONDITION] kit, and a cannula at the bedside. ADON A failed to check as part of her daily assignment, to assure Resident #1 had [MEDICAL CONDITION] accessible in the room. RN B had documented the [MEDICAL CONDITION] were available and accessible in Resident # 1's room for two shifts. The RN could not confirm he had seen the emergency supplies in the resident's' room. An Immediate Jeopardy (IJ) identified on 07/19/17. While the IJ was lowered on 07/20/17, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the three residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. Findings included: Review of the Neglect policy and procedure dated December 2016 provided by the ED on 07/20/17 and identified as current revealed, .the facility has designated and implemented processes, which strive to reduce the risk of neglect.definition: Neglect, the failure to provide goods and services necessary to avoid physical harm 1. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. https://medlineplus.gov/ency/article/ 5.htm reflected, A [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [MEDICAL CONDITIONS]. (Retrieved on 07/24/17). Review of the annual MDS assessment dated [DATE] revealed Resident #1 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. An observation on 07/19/17 at approximately 9:00 a.m. revealed Resident #1 lying in bed with a [MEDICAL CONDITION] in place. He was not able to verbally communicate. There was no back-up emergency supplies: Ambu bag (manual resuscitation device), a hand-held device commonly used to provide positive pressure to patients who are not breathing or not breathing adequately. An interview on 07/19/17 at 10:00 a.m. with ADON A revealed Resident #1 was a total care resident and could not verbally communicate. ADON A said Resident #1 was on room air concerning his [MEDICAL CONDITION], the resident required suctioning as needed, [MEDICAL CONDITION] care daily and a change of [MEDICAL CONDITIONS] weekly. When asked concerning the [MEDICAL CONDITION], the ADON A replied the supplies must be in the room. An interview/observation on 07/19/17 at 11:45 a.m. with the DON revealed Resident #1 was total care with a [MEDICAL CONDITION] and a feeding tube. The DON said the [MEDICAL CONDITION] were supposed to be on the wall in bags at the head of the resident's bed and the ADONs were to be checking each morning at the beginning of the shift and on the weekends the charge nurse was supposed to check to make sure the supplies were there. The DON started looking for the [MEDICAL CONDITION] for Resident #1 in his room, after approximately five minutes of searching the DON found the Ambu bag and the additional cannulas in bags, in a box under other bags on the bed side table. ADON A came into the room and the DON said these were supposed to be taped to the wall, ADON A said, Oh I did not know I will go get some tape and put them up there now. An interview on 07/19/17 at 11:56 p.m. with RN B revealed all [MEDICAL CONDITION] were supposed to be in bags at the head of the resident's bed. RN B said he learned in nursing school where the [MEDICAL CONDITION] should be located this made the emergency supplies easily accessible. RN B said he had not had in-service concerning where the supplies should be placed in the resident's room. RN B said he had one resident he was responsible for with trach. Resident #1. An interview on 07/19/17 at 2:00 p.m. with RN B revealed no answer as to why he had documented for two shifts at one time, one shift was documented prior to the start of the next shift that the emergency supplies were in Resident #1's room. RN B could not confirm that he had seen the [MEDICAL CONDITION] in Resident #1's room, when he documented the accessibility of the supplies on the Medication Administration Record. An interview on 07/19/17 at 12:00 p.m. with LVN C revealed it was her first week to work at the facility and she had also learned in school that the [MEDICAL CONDITION] were supposed to be at the head of the resident's bed, so in case of an emergency you could find the supplies quickly. LVN C said she had not been told what to do at this facility, so that was good to know. Review of the Medication Administration/treatment Records on 07/19/17, dated 05/17 through 07/17 revealed inconsistent documentation of Ambu bag, extra inner cannula,[MEDICAL CONDITION] set available in room and easily identified. Further review of the documentation revealed [MEDICAL CONDITION] available and easily identified in the room for the day shift (6:00 a.m. - 2:00 p.m.) and the evening shift (2:00 p.m. - 10:00 p.m.) for Resident #1. An interview on 07/19/17 at 3:00 p.m. with ADON A revealed she knew she was supposed to check the [MEDICAL CONDITION] to make sure they were in the resident's room, but she had not checked today because she had put some in the room this past week, so she knew they were there. Review of the Physician order [REDACTED].#1 had an order dated 07/19/17: Ambu bag, extra inner cannula size 6,[MEDICAL CONDITION] set available in room and easily identified each shift related to [MEDICAL CONDITION] status. 2. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #3 was a [AGE] year-old female who had re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. Review of the Care Plan dated 07/03/17 revealed Resident #3 had impaired breathing mechanics with interventions ensure [MEDICAL CONDITION] are at bedside and visible at all times. Review of the physician orders [REDACTED].#3 had no orders to check for Ambu bag, extra inner cannula, [MEDICAL CONDITION] set available in room and easily identified, monitored for placement each shift related to [MEDICAL CONDITION] until 07/19/17. An observation on 07/19/17 at 12:09 p.m. with the DON revealed Resident #3 had no [MEDICAL CONDITION] in the room. ADON D entered the room and the DON inquired where the supplies were. ADON D said she was not sure. RN E entered the room, and ADON D asked RN E where the [MEDICAL CONDITION] were. RN E said the resident moved sometime yesterday evening and she said she had them on her cart. ADON D left the room returning with the supplies and said RN E had them on her cart and had not had time to get them into Resident #3's room. The DON replied they should have been placed on the wall when she was moved. Review of the nurse's notes dated 07/19/17 revealed Resident #3 was moved at 4:29 a.m. to a different room. Review of the Medication/Treatment Sheets date 05/1/17 through 07/19/17 revealed Resident #3 had no documentation for Ambu bag, extra inner cannula, [MEDICAL CONDITION] kit in room and easily identified. An interview on 07/19/17 at 1:15 p.m. with ADON D revealed she had worked at the facility for four years and no one had every told her she was supposed to check for the [MEDICAL CONDITION] each day and document it was there. An interview on 07/19/17 at 2:30 p.m. with the DON revealed she was aware that there was a resident that had documentation on the supplies being in the room, but she just never got around to checking who that resident was. The DON said she was going to change all [MEDICAL CONDITION] Medication Review Records to require the nurse charge nurses to document the emergency supplies were there, but she had not done that. When asked if she checked for the supplies, the DON said No. 3. An interview on 07/20/17 at 3:00 p.m. with the Medical Director revealed he felt [MEDICAL CONDITION] should be accessible and readily available in the resident's rooms, that is basic nursing practices. 4. Review of the Ventilation policy and procedure dated November 2013 provided by the DON on 07/20/17 and identified as current revealed .the nurse will perform an emergency [MEDICAL CONDITION] change in the event that a [MEDICAL CONDITION] becomes displaced or dislodged .the following supplies are to be kept at the bedside of any resident who has a [MEDICAL CONDITION] .resuscitation bag, [MEDICAL CONDITIONS] kit 5. Taber's Cyclopedic Medical Dictionary21st Edition reflected the following on page 2348, An emergency tracheotomy kit is kept at the bedside at all times Fundamentals of Nursing Seventh Edition by Potter and Perry, reflected the following on page 948, Critical Decision Point: Keep [MEDICAL CONDITION] obturator at bedside with a fresh [MEDICAL CONDITION] to facilitate reinsertion of the outer cannula, if dislodged. Keep an additional [MEDICAL CONDITION] of the same size and shape on hand for emergency replacement 6. An IJ was identified on 07/19/17. On 07/19/17 at 5:10 p.m., the Administrator was notified of the IJ and a plan of removal was requested. 7. Plan of removal dated 07/19/17 and accepted on 07/20/17 at 10:00 a.m. revealed all charge nurses were in-serviced on one Ambu bag and [MEDICAL CONDITION] cannulas (One size smaller than ordered and one size resident has ordered taped to the head of the bed. The charge nurse was to [MEDICAL CONDITION] each shift and document check on the resident's Medication Administration Sheet. If the emergency supplies were not in the resident's room, the charge nurse was to retrieve from the central supply and report to the DON. 8. An observation on 07/19/17 at 5:20 p.m. revealed Resident #1 and Resident #3 had all [MEDICAL CONDITION] in bags on the wall at the head of the bed in the rooms. Further observations on 07/20/17 at 8:00 a.m. revealed Resident #1 and Resident #3 to have [MEDICAL CONDITION] in the room in bags at the head of the bed. Interviews on 07/20/17 with 15 out of the 16 nurses revealed they had been in-serviced and post tested and in the past 24 hours concerning the policy and procedure concerning residents with trachs and the emergency supplies. Review of the in-services dated 07/19/17 and 07/20/17 revealed in-services by the DON and the RN nurse consultant concerning visual checks by the charge nurses and the documentation of the emergency supplies for residents with trachs. Review of the Medication Administration Sheets dated 07/19/17 reveled Resident #1 and Resident #3 had documentation on the Medication Administration [MEDICAL CONDITION] visualized in the room on the wall, documented on the night shift (6:00 p.m. until 6:00 a.m.) The Administrator was notified on 07/20/17 at 10:00 a.m. the IJ was removed. While the IJ removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not IJ at a scope of pattern. 9. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the ED on 07/20/17 reflected three residents with a tracheotomy.

Based on observation, interview, and record review, the facility failed to ensure a resident who needs respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, is provided such care, consistent with professional standards of practice for two (Residents #1 and #3) of three residents reviewed for [MEDICAL CONDITION] services. The facility failed to provide Residents #1 and #3 with a resuscitation device, extra [MEDICAL CONDITION] kit, and a cannula at the bedside. An Immediate Jeopardy (IJ) identified on 07/19/17. While the IJ was lowered on 07/20/17, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the three residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. Findings included: 1. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. https://medlineplus.gov/ency/article/ 5.htm reflected, A [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [MEDICAL CONDITIONS]. (Retrieved on 07/24/17). Review of the annual MDS assessment dated [DATE] revealed Resident #1 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. An observation on 07/19/17 at approximately 9:00 a.m. revealed Resident #1 lying in bed with a [MEDICAL CONDITION] in place. He was not able to verbally communicate. There was no back-up emergency supplies: no Ambu bag (manual resuscitation device), a hand-held device commonly used to provide positive pressure to patients who are not breathing or not breathing adequately. An interview on 07/19/17 at 10:00 a.m. with ADON A revealed Resident #1 was a total care resident and could not verbally communicate. ADON A said Resident #1 was on room air concerning his [MEDICAL CONDITION], the resident required suctioning as needed, [MEDICAL CONDITION] care daily and a change of [MEDICAL CONDITIONS] weekly. When asked concerning the [MEDICAL CONDITION], the ADON A replied the supplies must be in the room. An interview/observation on 07/19/17 at 11:45 a.m. with the DON revealed Resident #1 was total care with a [MEDICAL CONDITION] and a feeding tube. The DON said the [MEDICAL CONDITION] were supposed to be on the wall in bags at the head of the resident's bed and the ADONs were to be checking each morning at the beginning of the shift and on the weekends the charge nurse was supposed to check to make sure the supplies were there. The DON started looking for the [MEDICAL CONDITION] for Resident #1 in his room, after approximately five minutes of searching the DON found the Ambu bag and the additional cannulas in bags, in a box under other bags on the bed side table. ADON A came into the room and the DON said these were supposed to be taped to the wall, ADON A said, Oh I did not know I will go get some tape and put them up there now. An interview on 07/19/17 at 11:56 p.m. with RN B revealed all [MEDICAL CONDITION] were supposed to be in bags at the head of the resident's bed. RN B said he learned in nursing school where the [MEDICAL CONDITION] should be located this made the emergency supplies easily accessible. RN B said he had not had in-service concerning where the supplies should be placed in the resident's room. RN B said he had one resident he was responsible for with trach. Resident #1. An interview on 07/19/17 at 2:00 p.m. with RN B revealed no answer as to why he had documented for two shifts at one time, one shift was documented prior to the start of the next shift that the emergency supplies were in Resident #1's room. RN B could not confirm that he had seen the [MEDICAL CONDITION] in Resident #1's room, when he documented the accessibility of the supplies on the Medication Administration Record. An interview on 07/19/17 at 12:00 p.m. with LVN C revealed it was her first week to work at the facility and she had also learned in school that the [MEDICAL CONDITION] were supposed to be at the head of the resident's bed, so in case of an emergency you could find the supplies quickly. LVN C said she had not been told what to do at this facility, so that was good to know. An interview on 07/19/17 at 3:00 p.m. with ADON A revealed she knew she was supposed to check the [MEDICAL CONDITION] to make sure they were in the resident's room, but she had not checked today because she had put some in the room this past week, so she knew they were there. Review of the Physician order [REDACTED].#1 had an order dated 07/19/17: Ambu bag, extra inner cannula size 6,[MEDICAL CONDITION] set available in room and easily identified each shift related to [MEDICAL CONDITION] status. Review of the Medication Administration/treatment Records on 07/19/17, dated 05/17 through 07/17 revealed inconsistent documentation of Ambu bag, extra inner cannula,[MEDICAL CONDITION] set available in room and easily identified. Further review of the documentation revealed [MEDICAL CONDITION] available and easily identified in the room for the day shift (6:00 a.m. - 2:00 p.m.) and the evening shift (2:00 p.m. - 10:00 p.m.) for Resident #1. 2. Review of the Admission Face Sheet dated 07/19/17 revealed Resident #3 was a [AGE] year-old female who had re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had a [MEDICAL CONDITION], was severely cognitively impaired, and was totally dependent on two staff members for all activities of daily living. Review of the Care Plan dated 07/03/17 revealed Resident #3 had impaired breathing mechanics with interventions ensure [MEDICAL CONDITION] are at bedside and visible at all times. Review of the physician orders [REDACTED].#3 had no orders to check for Ambu bag, extra inner cannula, [MEDICAL CONDITION] set available in room and easily identified, monitored for placement each shift related to [MEDICAL CONDITION] until 07/19/17. An observation on 07/19/17 at 12:09 p.m. with the DON revealed Resident #3 had no [MEDICAL CONDITION] in the room. ADON D entered the room and the DON inquired where the supplies were. ADON D said she was not sure. RN E entered the room, and ADON D asked RN E where the [MEDICAL CONDITION] were. RN E said the resident moved sometime yesterday evening and she said she had them on her cart. ADON D left the room returning with the supplies and said RN E had them on her cart and had not had time to get them into Resident #3's room. The DON replied they should have been placed on the wall when she was moved. Review of the nurse's notes dated 07/19/17 revealed Resident #3 was moved at 4:29 a.m. to a different room. Review of the Medication/Treatment Sheets date 05/1/17 through 07/19/17 revealed Resident #3 had no documentation for Ambu bag, extra inner cannula, [MEDICAL CONDITION] kit in room and easily identified. An interview on 07/19/17 at 1:15 p.m. with ADON D revealed she had worked at the facility for four years and no one had every told her she was supposed to check for the [MEDICAL CONDITION] each day and document it was there. An interview on 07/19/17 at 2:30 p.m. with the DON revealed she was aware that there was a resident that had documentation on the supplies being in the room, but she just never got around to checking who that resident was. The DON said she was going to change all [MEDICAL CONDITION] Medication Review Records to require the nurse charge nurses to document the emergency supplies were there, but she had not done that. When asked if she checked for the supplies, the DON said No. 3. An interview on 07/20/17 at 3:00 p.m. with the Medical Director revealed he felt [MEDICAL CONDITION] should be accessible and readily available in the resident's rooms, that is basic nursing practices. 4. Review of the Ventilation policy and procedure dated November 2013 provided by the DON on 07/20/17 and identified as current revealed .the nurse will perform an emergency [MEDICAL CONDITION] change in the event that a [MEDICAL CONDITION] becomes displaced or dislodged .the following supplies are to be kept at the bedside of any resident who has a [MEDICAL CONDITION] .resuscitation bag, [MEDICAL CONDITIONS] kit 5. Taber's Cyclopedic Medical Dictionary21st Edition reflected the following on page 2348, An emergency tracheotomy kit is kept at the bedside at all times Fundamentals of Nursing Seventh Edition by Potter and Perry, reflected the following on page 948, Critical Decision Point: Keep [MEDICAL CONDITION] obturator at bedside with a fresh [MEDICAL CONDITION] to facilitate reinsertion of the outer cannula, if dislodged. Keep an additional [MEDICAL CONDITION] of the same size and shape on hand for emergency replacement 6. An IJ was identified on 07/19/17. On 07/19/17 at 5:10 p.m., the Administrator was notified of the IJ and a plan of removal was requested. 7. Plan of removal dated 07/19/17 and accepted on 07/20/17 at 10:00 a.m. revealed all charges nurses were in-serviced on one Ambu bag and [MEDICAL CONDITION] cannulas (One size smaller than ordered and one size resident has ordered taped to the head of the bed. The charge nurse was to [MEDICAL CONDITION] each shift and document check on the resident's Medication Administration Sheet. If the emergency supplies was not in the resident's room, the charge nurse was to retrieve from the central supply and report to the DON. 8. An observation on 07/19/17 at 5:20 p.m. revealed Resident #1 and Resident #3 had all [MEDICAL CONDITION] in bags on the wall at the head of the bed in the rooms. Further observations on 07/20/17 at 8:00 a.m. revealed Resident #1 and Resident #3 to have [MEDICAL CONDITION] in the room in bags at the head of the bed. Interviews on 07/20/17 with 15 out of the 16 nurses revealed they had been in-serviced and post tested and in the past 24 hours concerning the policy and procedure [MEDICAL CONDITION] and the emergency supplies. Review of the in-services dated 07/19/17 and 07/20/17 revealed in-services by the DON and the RN nurse consultant concerning visual checks by the charge nurses and the documentation of the emergency supple [MEDICAL CONDITION]. Review of the Medication Administration Sheets dated 07/20/17 revealed Resident #1 and Resident #3 had documentation on the Medication Administration [MEDICAL CONDITION] visualized in the room on the wall, documented on the night shift (6:00 p.m. until 6:00 a.m.) The Administrator was notified on 07/20/17 at 10:00 a.m. the IJ was removed. While the IJ removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not IJ at a scope of pattern. 9. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the ED on 07/20/17 reflected three residents with a tracheotomy.

Based on observations, interviews, and record reviews the facility Administrator and Director of Nurses (DON) failed to administer in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #1 and #3) identified with [MEDICAL CONDITION]. The Director of Nurses (DON) failed to implement facility policies and procedures regarding [MEDICAL CONDITION] when: ADON A failed to check as part of her daily assignment, to assure Resident #1 had [MEDICAL CONDITION] accessible in the room. RN B had documented the [MEDICAL CONDITION] were available and accessible in Resident # 1's for two shifts, including documenting for one shift prior to the start of the next shift The facility failed to provide Residents #1 and #3 with a resuscitation device, extra [MEDICAL CONDITION] kit, and a cannula at the bedside. These failures could affect the three residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. An Immediate Jeopardy (IJ) identified on 07/19/17. While the IJ was lowered on 07/20/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. Findings included: 1. Review of the Ventilation policy and procedure dated November 2013 provided by the DON on 07/20/17 and identified as current revealed .the nurse will perform an emergency [MEDICAL CONDITION] change in the event that a [MEDICAL CONDITION] becomes displaced or dislodged .the following supplies are to be kept at the bedside of any resident who has a [MEDICAL CONDITION] .resuscitation bag, [MEDICAL CONDITIONS] kit 2. An observation on 07/19/17 at approximately 9:00 a.m. revealed Resident #1lying in bed with a [MEDICAL CONDITION] in place. He was not able to verbally communicate. There was no back-up [MEDICAL CONDITION] and there was no Ambu bag (manual resuscitation device), a hand-held device commonly used to provide positive pressure to patients who are not breathing or not breathing adequately. An interview on 07/19/17 at 10:00 a.m. with ADON A revealed Resident #1 was a total care resident and could not verbally communicate. ADON A said Resident #1 was on room air concerning his [MEDICAL CONDITION], the resident required suctioning as needed, [MEDICAL CONDITION] care daily and a change of [MEDICAL CONDITIONS] weekly. When asked concerning the [MEDICAL CONDITION], the ADON A replied the supplies must be in the room. An interview/observation on 07/19/17 at 11:45 a.m. with the DON revealed Resident #1 was total care with a [MEDICAL CONDITION] and a feeding tube. The DON said the [MEDICAL CONDITION] were supposed to be on the wall in bags at the head of the resident's bed and the ADONs are were to be checking each morning at the beginning of the shift and on the weekends the charge nurse was supposed to check to make sure the supplies were there. The DON started looking for the [MEDICAL CONDITION] for Resident #1 in his room, after approximately five minutes of searching the DON found the Ambu bag and the additional cannulas in bags, in a box under other bags on the bed side table. ADON A came into the room and the DON said these were supposed to be taped to the wall, ADON A said, Oh I did not know I will go get some tape and put them up there now. An interview on 07/19/17 at 11:56 p.m. with RN B revealed all [MEDICAL CONDITION] were supposed to be in bags at the head of the resident's bed. RN B said he learned in nursing school where the [MEDICAL CONDITION] should be located this made the emergency supplies easily accessible. RN B said he had not had in-service concerning where the supplies should be placed in the resident's room. RN B said he had one resident he was responsible for with trach. Resident #1. An interview on 07/19/17 at 2:00 p.m. with RN B revealed no answer as to why he had documented for two shifts at one time, one shift was documented prior to the start of the next shift that the emergency supplies were in Resident #1's room. RN B could not confirm that he had seen the [MEDICAL CONDITION] in Resident #1's room, when he documented the accessibility of the supplies on the Medication Administration Record. An interview on 07/19/17 at 12:00 p.m. with LVN C revealed it was her first week to work at the facility and she had also learned in school that the [MEDICAL CONDITION] were supposed to be at the head of the resident's bed, so in case of an emergency you could find the supplies quickly. LVN C said she had not been told what to do at this facility, so that was good to know. An interview on 07/19/17 at 3:00 p.m. with ADON A revealed she knew she was supposed to check the [MEDICAL CONDITION] to make sure they were in the resident's room, but she had not checked today because she had put some in the room this past week, so she knew they were there. Review of the Physician order [REDACTED].#1 had an order dated 07/19/17: Ambu bag, extra inner cannula size 6,[MEDICAL CONDITION] set available in room and easily identified each shift related to [MEDICAL CONDITION] status. Review of the Medication Administration/treatment Records on 07/19/17 dated 05/17 through 07/17 revealed inconsistent documentation of Ambu bag, extra inner cannu8la,[MEDICAL CONDITION] set available in room and easily identified. Further review of the documentation revealed [MEDICAL CONDITION] available and easily identified in the room for the day shift (6:00 a.m. - 2:00 p.m.) and the evening shift (2:00 p.m. - 10:00 p.m.) for Resident #1. An observation on 07/19/17 at 12:09 p.m. with the DON revealed Resident #3 had no [MEDICAL CONDITION] in the room. ADON D entered the room and the DON inquired where the supplies were. ADON D said she was not sure. RN E entered the room, and ADON D asked RN E where the [MEDICAL CONDITION] were. RN E said the resident moved sometime yesterday evening and she said she had them on her cart. ADON D left the room returning with the supplies and said RN E had them on her cart and had not had time to get them into Resident #3's room. The DON replied they should have been placed on the wall when she was moved. Review of the nurse's notes dated 07/19/17 revealed Resident #3 was moved at 4:29 a.m. to a different room. Review of the Medication/Treatment Sheets date 05/1/17 through 07/19/17 revealed Resident #3 had no documentation for Ambu bag, extra inner cannula, [MEDICAL CONDITION] kit in room and easily identified. An interview on 07/19/17 at 1:15 p.m. with ADON D revealed she had worked at the facility for four years and no one had every told her she was supposed to check for the [MEDICAL CONDITION] each day and document it was there. An interview on 07/19/17 at 2:30 p.m. with the DON revealed she was aware that there was a resident that had documentation on the supplies being in the room, but she just never got around to checking who that resident was. The DON said she was going to change all [MEDICAL CONDITION] Medication Review Records to require the nurse charge nurses to document the emergency supplies were there, but she had not done that. When asked if she checked for the supplies, the DON said No. 3. An interview on 07/20/17 at 3:00 p.m. with the Medical Director revealed he felt [MEDICAL CONDITION] should be accessible and readily available in the resident's rooms, that is basic nursing practices. An interview on 07/20/17 at 2:15 p.m. with the ED revealed she felt the failure had occurred due to [MEDICAL CONDITION] not being available in the rooms and the DON had not monitored the staff to ensure the systems were being carried out efficiently. An interview on 07/20/17 at 2:30 p.m. with the DON revealed she felt the failure had occurred due to no follow-up from the management staff and not holding the nursing staff accountable. 4. Taber's Cyclopedic Medical Dictionary21st Edition reflected the following on page 2348, An emergency tracheotomy kit is kept at the bedside at all times Fundamentals of Nursing Seventh Edition by Potter and Perry, reflected the following on page 948, Critical Decision Point: Keep [MEDICAL CONDITION] obturator at bedside with a fresh [MEDICAL CONDITION] to facilitate reinsertion of the outer cannula, if dislodged. Keep an additional [MEDICAL CONDITION] of the same size and shape on hand for emergency replacement 5. An IJ was identified on 07/19/17. On 07/19/17 at 5:10 p.m., the Administrator was notified of the IJ and a plan of removal was requested. 6. Plan of removal dated 07/19/17 and accepted on 07/20/17 at 10:00 a.m. revealed all charges nurses were in-serviced on one Ambu bag and [MEDICAL CONDITION] cannulas (One size smaller than ordered and one size resident has ordered taped to the head of the bed. The charge nurse was to [MEDICAL CONDITION] each shift and document check on the resident's Medication Administration Sheet. If the emergency supplies was not in the resident's room, the charge nurse was to retrieve from the central supply and report to the DON. 7. An observation on 07/19/17 at 5:20 p.m. revealed Resident #1 and Resident #3 had all [MEDICAL CONDITION] in bags on the wall at the head of the bed in the rooms. Further observations on 07/20/17 at 8:00 a.m. revealed Resident #1 and Resident #3 to have [MEDICAL CONDITION] in the room in bags at the head of the bed. Interviews on 07/20/17 with 15 out of the 16 nurses revealed they had been in-serviced and post tested and in the past 24 hours concerning the policy and procedure [MEDICAL CONDITION] and the emergency supplies. Review of the in-services dated 07/19/177 and 07/20/17 revealed in-services by the DON and the RN nurse consultant concerning visual checks by the charge nurses and the documentation of the emergency supple [MEDICAL CONDITION]. Review of the Medication Administration Sheets dated 07/19/17 reveled Resident #1 and Resident #3 had documentation on the Medication Administration [MEDICAL CONDITION] visualized in the room on the wall, documented on the night shift (6:00 p.m. until 6:00 a.m.) 8. The Administrator was notified on 07/20/17 at 10:00 a.m. the IJ was removed. While the IJ removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not IJ at a scope of pattern. 9. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the ED on 07/20/17 reflected three residents with a tracheotomy.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with a comprehensive assessment and plan of care for one (Resident #9) of 13 residents reviewed for pain and one (Resident #3) of seven residents reviewed with catheters. 1. The facility failed to monitor the effectiveness or in-effectiveness of pain medication administration to Resident #9 before and after pain medications had been administered. 2. LVN C failed to assess Resident #9's pain when treatment was being performed. 3. LVN C failed to notify Resident #9's assigned nurse of his moaning and complaint of pain after treatment. The failures could affect the facility 13 residents that were sampled for adequate assessment of pain and could place them at risk for failure inadequate/ unresolved pain. 4. The facility failed to ensure that Resident # 3's supra pubic catheter was anchored or secured to prevent tension and tugging. 5. The facility failed to perform proper assessment of Resident #3's suprapubic catheter site and peg tube site every shift to prevent irritation and infection. This failure placed the facility's fourteen residents that received tube feedings at risk for irritation around site, infection, discomfort and the potential for hospitalization . Findings included: Review of the MDS assessment, dated 8/31/16 for Resident #9 revealed he admitted to the facility on [DATE] and was [AGE] years of age. He had [DIAGNOSES REDACTED]. He had a BIMS score of 12 and was interviewable. He required extensive assistance of one to two staff members for all activities of daily living and was on a scheduled pain regimen. Physician orders [REDACTED].#9 revealed [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth every six hours for pain management. Physician order [REDACTED]. Give two tablets via PE[DEVICE] (Enteral feeding tube) as needed for pain/ fever, not to exceed three Grams of [MEDICATION NAME] in 24 hours. An interview on 10/25/16 at 9:55 AM with Resident #9 reflected he was alert and interviewable. He was pleasant, followed the conversation, and able to respond appropriately. Resident #9 said his pain level was 9 out of 10, with 10 being the highest, and he stayed in pain with limited relief. He said he received pain medication routinely. He stated he had pain all over. He had five invasive tubes in his trunk area. An observation and interview on 10/25/16 at 1:00 PM with CNA H while providing incontinent care to Resident #9 revealed facial frowns, moaning, and groaning during incontinent care. Resident #9 was noted with stiffening and jerking, and guarded body movement during care. CNA H stated Resident #9 always had pain with any care provided to him. She said all you have to do is just touch him, his pain is all the time and he likes to take pain medicine. She inquired if Resident #9 was in pain, and he responded yes. CNA H said she would inform his assigned nurse of his complaint of pain. An interview on 10/25/16 at 1:05 PM with Resident #9 after his incontinent care reflected he had a pain level that was 10 and greater. He said he sometimes asked for pain medication between his scheduled dose, and he occasionally received it. He said the most relief he received from his schedule pain medication was a seven and a half. He said staff rarely asked his pain level, and they did not check afterwards to see if it had helped. An interview on 10/26/16 at 10: 50 AM with Resident #9 reflected he did not receive any PRN medication after incontinent care provided by CNA H on 10/25/16 at 12:45 PM. Resident #9 said he stayed in pain all the time and that he had told the facility staff. He said he had spoken with the physician regarding not obtaining adequate pain relief. He said the physician informed him three different times he would order additional pain medicine. When he asked the staff about additional pain medication, nothing new had been ordered. An interview on 10/26/16 at 11:00 AM with CNA H revealed she had informed Resident #9's assigned nurse of his complaint of pain with incontinent care and he wanted something for pain. CNA H said LVN F informed her Resident #9 received scheduled pain medication and would be given at the scheduled time. CNA H said the nurses always say he has scheduled pain medication when she has informed them of his pain and pain medication request. An observation on 10/26/16 at 12:05 PM of LVN F administering Resident #9's scheduled [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG one tablet per GT ([DEVICE]) reflected his full dose was not given. There was white thick adhered medication noted around the bottom of the medication cup. The medication cup was not rinsed nor any attempt to administer the full dose. The medicine cup was discarded. A review on 10/26/16 at 11:10 AM of clinical records for Resident #9 for 10/25/16 reflected he had not been assessed for his pain after incontinent care, that was observed 10/25/16 at 1:00 PM, the effectiveness of his scheduled every six hours pain medication, and no PRN medication for pain management had been received. Review of the Nurses notes dated 10/23/16 at 10:43 AM to 10/26/16 at 10:04 AM no documentation that any prn pain medication was given or no assessment related to administration of pain medication. Review of Medication Administration Record [REDACTED]. There was no assessment related to administration of pain medications documented on the form. An interview on 10/26/16 at 4:14 PM with LVN G reflected she did not receive any information on 10/25/16 and 10/26/16, during shift report, of Resident #9 ' s complaint or request for pain medication. LVN G said Resident # 9 had scheduled pain medication every six hours and he had [MEDICATION NAME] Tablet 325 MG. Give two tablets (650 MG) via PE[DEVICE] as needed for pain. An observation and interview on 10/27/16 at 10: 25 AM of LVN C assisting the Wound Spec. providing wound care treatment to Resident #9 revealed LVN C did not assess Resident #9's pain level before, during or after treatment. During treatment Resident #9 had facial frowns, moaning, and groaning. He was noted with stiffening, jerking, and guarded body movement during treatment. An interview on 10/ 27/16 at 10:40 AM with LVN C reflected Resident #9 had scheduled pain medication every six hours. LVN C made no response to Resident #9 not being assessed before the procedure, during the procedure, or after the procedure. She made no response to not informing his assigned nurse of his response to treatment. LVN C made no response to Resident #9 having pain medication as needed. An interview on 11/10/16 at 4:00 PM with ADON I revealed residents should be assessed at the beginning of the shift and periodically during the shift for comfort and pain level. She says the residents are assessed verbally, facial expression, and body movements. ADON I said residents are not assessed for scheduled pain medication administration. She said residents are assessed for PRN/ as needed medications effectiveness. She said residents should be asked how they are feeling and if they are having pain. She said the residents should be asked or observed one to two hours after prn pain medication administration if they have any relief, if the pain medication was effective, or monitor their body language. She said pain assessments should be performed at least every shift. (In general) An interview was conducted on 11/10/16 at 4:15 PM via telephone with the DON and revealed all residents have a pain assessment on admission. She said Resident #9 had a pain assessment on admission on 08/23/16. During the residents tenure some residents are assessed more than others according to their condition or needs. The Don agreed to acknowledge and clarify previous information from interview as follows. The Don acknowledged Resident #9 did not have a Care Plan for assessment of pain during his tenure at the facility. The DON acknowledged on review of the Medication Administration Record [REDACTED]. She acknowledged Resident #9 had physician orders [REDACTED]. The DON acknowledged Resident #9 had physician orders [REDACTED]. The Don Acknowledged the facility did not have a policy to assess for scheduled pain medication for residents pain level or assessment of effectiveness or monitoring of pain medication. The DON acknowledged Resident #9 there were daily Medicare Skilled Notes that included a section for pain assessment. This assessment did not assess or monitor the effectiveness of his pain medication administration. Review of the pain assessments, provided by the DON on 11/10/16 revealed the following assessments were not relevant to qualify as pain assessment related to pain medication treatment and/or effectiveness of medication after administration. Pain assessments dated 09/08/16, 09/16/16, and 10/26/16 revealed the assessments were not completed. Section with question #4 when asked does the resident deny pain symptoms? If yes, proceed to question #8 The answer was marked no but the frequency of pain and intensity was left blank/not answered during the assessments. Pain AD assessment dated [DATE], 08/25/16, 09/01/16, 09/07/16, 09/15/16, 9/21/16, 9/28/16,10/05/16 revealed the assessments were not completed to verify effectiveness of pain medication, the forms did not indicate whether pain medication was given at that time. An interview on 11/10/16 at 4:50 PM with ADON I revealed on reviewing the assessment sheets provided by the DON the nursing staff determines the resident is cognitive or the resident is not cognitive, and unable to answer questions. She said if the resident is cognitive, alert, and able to answer questions the Pain Assessment sheet is completed. ADON I said if the resident is not cognitive and not able to answer questions the Pain AD Pain Assessment sheet is completed. An interview on 11/10/16 at 5:00 PM with CNA J reflected the residents sometimes turn on their call lights or while care is being provided they will request pain medication. She stops what she is doing, asks the resident where the pain is, and then goes and informs the nurse of resident's pain. CNA J stated she always reports residents ' pain to the nurse. An interview on 11/10/16 at 5: 05 PM with CNA K reflected he has specific residents that always let him know if they have pain and he lets the nurse know of their complaint. CNA said he could tell if residents, that are not able of verbally let him know, are uncomfortable by their groaning, moaning, or their facial expressions. He stated he always reports these types of things, moaning/groaning, to the nurse. He said he had very good nurses on his shift and they were always attentive to the residents. An interview on 11/10/16 mat 4:45 p.m. with LVN F revealed she was familiar with Resident #9 and the medications he takes. LVN F said that Resident # 9 receives scheduled pain medication. LVN F said when she gives the pain medication, she goes back within 30 minutes to an hour and checks with the resident to make sure he was feeling better and having less pain. The resident usually tells me that his pain is at 8 or a 9 when I give the med and later it is always a 2. LVN F said there was really no place to document the results of giving the pain medication, because there was no pain assessment for resident ion scheduled pain medication. An interview on 11/10/16 at 5:00 p.m. with Nurse Practioner revealed she had just examined Resident #9 the past week and he had reported no pain to her. The nursing staff has reported no pain to me concerning Resident #9; I will certainly see him on this next week and reevaluate his pain level. An observation and interview on 10/27/16 at 11:45 AM with the DON reflected Resident #9 did not have a plan of care for pain management. The facility did not have a system in place for assessment and monitoring Resident #9's pain level before and after each six hour scheduled [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG one tablet nor of his PRN (as needed) ordered medication of one tablet or [MEDICATION NAME] Tablet 325 MG one tablet give two tablets (650 MG) via PE[DEVICE] for pain. The DON acknowledged there was a Medicare Daily Skilled Note of a head-to-toe assessment performed once a day on Resident #9. During that time review of the one assessment dated [DATE] and two assessments dated 10/26/16 reflected Resident's pain assessment was not complete and was regarding generalized pain, not the effectiveness of pain medication administered. The DON acknowledged Resident #9 received his scheduled pain medication every six hours per the Medication Administration Record [REDACTED]. Review of the p/p for Pain Assessment and Management dated March 2015 revealed: Policy Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop, interventions that are consistent with the residents goals and needs and that address the underlying causes of pain. Policy Interpretation and implementation: General Guidelines The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing, Effectively recognizing, Identifying, Addressing causes, Developing and Implementing, Monitoring, and Modifying as necessary. It is important to recognize influences. Conduct a Comprehensive Pain assessment upon admission .i.e Assess the resident's pain and consequences of pain .i.e Documentation .i.e Reporting .i.e to the physician or practitioner: .i.e The facility's CMS 672, Resident Census and Condition of Residents, signed by the MDS Coordinator on 10/25/16 reflected a total census of 102 residents. 2. MDS dated [DATE] of Resident # 3 revealed he admitted on [DATE] and was [AGE] years of age. He had [DIAGNOSES REDACTED]. An observation on 10/26/2016 at 8:53 a.m. of Resident #3 revealed that his suprapubic catheter was not anchored and an off white creamy like drainage was oozing from the catheter-urethral junction. Amber colored urine was noted in the catheter bag. An observation on 10/26/2016 at 2:15 p.m. of Resident # 3 revealed that his suprapubic catheter was again not anchored and at the catheter-urethral junction there was no dressing and an off white, creamy like drainage oozing from the site. An observation on 10/26/2016 at 2:50 p.m. of Resident # 3 revealed that upon returning to the room with LVN B and RNC, the catheter bag and tubing had been changed, the tubing was anchored with a strip of beige tape and there was a dressing around the catheter-urethral junction that was initialed and dated 10/26/16 by the LVN B. An observation of the peg tube site on 10/26/2016 at 3:00 p.m. of Resident # 3 revealed, an off white, creamy like drainage oozing from the site. Interview with the RNC on 10/26/2016 at 3:05 p.m., (upon removal of the dressing around the peg tube site) when asked how the drainage looked to her, she stated, It appears serosanguinous (yellowish with small amounts of blood). The doctor is here today. I will ask him to come down and check out both sites (suprapubic catheter and peg tube) and see about ordering an antibiotic. Interview with the RNC on 10/26/2016 at 3:55 p.m. revealed that Resident # 3's doctor had been notified and telephone orders were entered by the RNC that reflected Enteral feed order every shift cleanse Peg tube site with normal saline, pat dry, apply triple antibiotic ointment and a dry dressing every shift and as needed. Also, Supra Pubic Catheter Site Care - clean with normal saline, pat dry, apply triple antibiotic ointment and a dry dressing every shift and as needed and every shift for catheter care. Review of Resident # 3's physician order [REDACTED].= drainage; R= redness; I= irritation; C= crusting; P= pain; O= no abnormalities. The record had been marked O for o abnormalities for all of October 2016. Review of Resident # 3's physician order [REDACTED]. Review of the facility ' s policy regarding Change in a Resident's Condition or Status dated November 2015, revealed . The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been changes in the resident's condition The facility's CMS 672, Resident Census and Condition of Residents, signed by the MDS on 10/25/16 reflected 14 residents received tube feeding at the facility.

Based on interview and record review the facility failed to not employee an individual who had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. The facility failed to terminate Housekeeper A when her annual employability check reflected her nurse aide certificate had been revoked and she was unemployable in a licensed nursing facility in the state of Texas. An immediate jeopardy was identified on 01/15/16 at 4:15 PM. While the IJ was removed on 01/17/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy and a scope of widespread because the staff were still being trained and the facility was monitoring the effectiveness of the POR. This failure placed all 98 residents at risk for abuse, neglect, mistreatment and/or misappropriation of their property. Findings included: The facility's employee list provided by the DON on 01/15/16 reflected (Hskp) A's date of hire was 08/01/05. Her annual Texas Nurse Aide Registry Verification dated 10/08/15 reflected she had been a nurse aide in the past and her nurse aide certification status was Revoked .Because substantiated findings of abuse, neglect, or misappropriation of resident property has been entered on the Texas Nurse Aide Registry, this individual in (sic) not employable as a nurse aide in a licensed nursing facility in the state of Texas. During an interview with the DON on 01/15/16 at 2:40 PM he stated he did not do the employability checks, they were conducted by MR. During an interview with MR on 01/15/16 at 2:50 PM she stated I saw it was revoked. I guess I saw she works in housekeeping and she's been here for a while and it's been that way and since she is not listed on the EMR . MR stated, the BOM was her supervisor and would spot check behind her or if she (MR) had any questions about a person's employability she would ask the BOM. During an interview with the BOM on 01/15/16 at 3:05 PM she stated, My understanding was since she was not listed on the EMR and it says not employable as a certified nurse aide in a licensed nursing facility it was ok. When queried if Hskp A had access to the residents the BOM stated yes she is a housekeeper. When queried if Hskp A worked on one side or the other the BOM stated she worked on both sides of the facility. The BOM also stated Hskp A was off but she would call her and try to get her to come up to the facility. A copy of Hskp A's time card report was requested at this time to include 10/08/15 through 01/15/16. Hskp A's Time Card Report from 10/08/15 through 01/15/16 reflected she had worked at the facility a total of 70 days after the facility had knowledge of her unemployable status. During an interview with Hskp A on 01/15/16 at 3:15 PM she stated she had not known her nurse aide certification was revoked. She stated she had known it wasn't good but not that it had been revoked. She stated a long time ago she had been working as a CNA at a facility and was assisting another CNA to get a resident back into a chair. Hskp A stated the other CNA had attempted to transfer the resident by herself and dropped her. She stated she did not report the accident as she thought the other CNA would and it turned out the resident's foot had been broken so she and the other CNA had been terminated for failure to report the accident. She also stated she had applied at this facility for a porter position and started as a porter in 2005 before becoming a housekeeper. During an interview with the BOM on 01/15/16 at 4:25 she stated the only staff who have access to the employability checks are herself and MR. She stated the department heads do not typically see the employability checks as they depend on her and the MR to run them and then the BOM would let them know if they are employable or not. When queried about what type of training she and MR had received about employability background checks she stated None and I've been with the company for ten years. During a telephone interview with the Admin on 01/16/16 at 1:47 PM he stated he was the facility's Abuse Co-ordinator. He also stated he had done random checks on employability in all departments but had never checked Hskp A. The facility's policy and procedure, Abuse Prevention Program, dated revised March 2004 reflected the following: 2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. The facility's policy and procedure, Background Screening Investigations dated revised April 2013 reflected the following: 4. Should the background investigation disclose .or information indicating that the individual has been convicted of abuse, neglect, mistreatment of [REDACTED]. The facility's policy and procedure, Abuse Prevention Program, dated revised 10/04/06 reflected the following: Screening of potential employees will include requesting information from previous and/or current employees and verifying information with the appropriate licensing boards and certification registries as well as screening for criminal history per regulatory requirements. Potential employees with negative findings of background checks will not be hired. An immediate jeopardy was identified on 01/15/16 at 4:15 PM. The DON and BOM were notified of the IJ on 01/15/16 at 4:15 PM. A Plan of Removal for the IJ was requested at that time. The facility's POR was accepted on 01/16/16. The plan reflected the following: --The facility terminated the employment of Hskp A on 01/15/16 at 4:25 PM. --The BOM and MR were re-trained on employability status by the DON and both wrote letters of acknowledgement of the current human resources policies regarding NAR and EMR status. --100% of the facility's current employees, including licensed and unlicensed staff, were reviewed by the BOM and MR for NAR and EMR status and all were noted to be eligible for employment at that time of 5:45 PM on 01/15/16. --On 01/16/16 at 11:30 AM the VP of Ops and DON began in-servicing all licensed and line staff on the facility's Abuse & Neglect Policy. A competency exam followed the in-service and an acknowledgement was signed by each employee. This training will continue all day until all staff is trained. If an employee is unable to be trained today they will receive the training prior to returning to duty. --The SW will evaluate and interview a random sample of interviewable residents from each hall to assess for any abuse or neglect issues from this individual or from others. Upon completion of this interview process on 01/16/16, no reports of abuse or neglect were found. --All prospective employees will obtain review of both NAR and EMR for eligibility status to include licensed staff before being hired to work for the facility. --All current employees receiving annual review of NAR and EMR checks will be terminated immediately if noted to have ineligible status on the NAR, revoked certificate on NAR or found to be listed as yes on EMR. --All licensed and line staff are in-serviced and acknowledge the facility's Abuse & Neglect Policy on 01/16/16 or prior to reporting to duty and on an annual basis. --On a weekly basis the Admin will perform weekly and spot checks on prospective new hires and annual reviews of employees that the NAR and EMR checks are occurring by the BOM and MR per the facility's policy. This will ensure no employee is working when identified as ineligible for employment. --All current staff have been in-serviced and acknowledge competency of the facility's Abuse & Neglect Policy. All new hires will be in-serviced during orientation prior tpo working on the floor and beginning employment at the facility. --The Admin is the facility's abuse coordinator and will immediately terminate any employee who shows to be ineligible to work in a nursing facility. --The MD was notified by the VP of Ops of the facility's IJ status on 01/16/16 at 11:20 AM. --The VP of Ops will ensure implementation of this plan by reviewing weekly with the Admin and on a quarterly basis at QA meetings. To verify implementation of the plan the following was conducted: Hskp A's Discipline notice dated 01/15/16 at 4:25 PM reflected she was terminated due to her ineligibility for employment at a nursing facility due to the state employability regulations. The facility's in-service with the topic Employee Eligibility for Employment dated 01/15/16 at 4:30 PM which was conducted by the DON reflected the BOM and MR signatures as having received the in-service. BOM's signed letter dated 01/15/16 reflected she acknowledged that under the Nurse Aide Registry a revoked status deems any perspective and/or current employee ineligible for employment. It also states under the Employee Misconduct Registry a yes status deems any perspective and/or current employee ineligible for employment. It further stated a systemic review of all current employees had been performed as of 5:45 PM on 01/15/16 and no further instances were found. MR's signed letter dated 01/15/16 reflected she acknowledged that under the Nurse Aide Registry a revoked status deems any perspective and/or current employee ineligible for employment. It also states under the Employee Misconduct Registry a yes status deems any perspective and/or current employee ineligible for employment. It further stated a systemic review of all current employees had been performed as of 5:45 PM on 01/15/16 and no further instances were found. On 01/17/16 a second sample of twelve employees to include laundry staff, housekeeping staff, dietary staff, CNAs and nurses were reviewed for employability per the EMR, NAR and license checks through the Texas Board of Nursing and all were found to be employable. On 01/16/16 at 3:00 PM a copy of the facility's in-service was received from the VP of Ops with the understanding the in-service was on-going during that day. This in-service reflected the topics of Abuse and Neglect, Compliance with the Facility Abuse/Neglect policy related to employee verification which was being presented by the VP of Ops on 01/16/16 and was on-going at that time. The evidence revealed 68 employees had signed and dated the Employee Acknowledgement letter. The 68 employees represented staff from all three shifts. During individual interviews with the following nurses they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 3:01 PM, 3:35 PM, 4:00 PM, 4:02 PM with LVN C, LVN D, LVN E, and LVN F. --On 01/17/16 at 11:20 AM with LVN G. During individual interviews with the following CNAs they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 2:50 PM, 3:25 PM, 3:30 PM, 3:47 PM, 3:50 PM, 4:12 PM, 4:30 PM, 4:55 PM and 5:00 PM with CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O and CNA P. During individual interviews with the following Laundry Aides they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 3:14 PM and 3:16 PM with LA S and LA T. --During an individual interview on 01/16/16 at 2:51 PM with Maintenance, he answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition he denied any residents complaining to him about abuse/neglect. --During an individual interview on 01/16/16 at 2:55 PM with Hskp Q, she answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition she denied any residents complaining to her about abuse/neglect. --During an individual interview on 01/16/16 at 2:55 PM with Cook R, she answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition she denied any residents complaining to her about abuse/neglect. The 22 resident interviews conducted by the SW on 01/16/16 reflected no concerns related to abuse/neglect. During individual interviews with the following residents, they denied any staff member being abusive or neglectful and reported they received good care in the facility. The interviews were conducted on the following days: --01/15/16 at 9:25 AM, 9:34 AM, 12:03 PM and 12:36 PM with Resident #1, Resident #2, Resident #3 and Resident #4. --01/17/16 at 11:35 AM, 11:38 AM, 11:45 AM, 11:50 AM, 11:53 AM, 12:00 PM, 12:05 PM and 12:15 PM with Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11 and Resident #12. During individual interviews with the following resident's family members, they denied any staff member being abusive or neglectful and reported they received good care in the facility. The interviews were conducted on the following days: --On 01/15/16 at 12:04 PM with Resident #13's family member. --On 01/16/17 at 11:20 AM with Resident #14's family member. --On 01/17/16 at 12:05 with Resident #11's family member. During an interview with the VP of Ops on 01/17/16 at 2:05 PM when queried about what type of monitoring she was planning on doing going forward she stated she would have the Admin check each person's employability status behind the BOM and MR. The VP of Ops also stated she would be coming to the facility weekly to make sure he is reviewing each employability check as well as quarterly and running spot checks herself. On 01/17/16 at 2:25 PM the VP of Ops and DON were notified the IJ was removed. While the IJ was removed on 01/17/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy and a scope of widespread because the staff were still being trained and the facility was monitoring the effectiveness of the POR. The facility's employee list provided by the DON on 01/15/16 reflected there were 111 employees working for the facility. The facility's census sheet dated 01/15/16 reflected there were 98 residents residing in the facility.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for one (Housekeeper A) of 10 employees reviewed as evidenced by: The facility failed to terminate Housekeeper A when her annual employability check reflected her nurse aide certificate had been revoked and she was unemployable in a licensed nursing facility in the state of Texas. An immediate jeopardy was identified on 01/15/16 at 4:15 PM. While the IJ was removed on 01/17/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy and a scope of widespread because the staff were still being trained and the facility was monitoring the effectiveness of the POR. This failure placed all 98 residents at risk of for abus, neglect, mistreatment and/or misappropriation of their property. Findings included: The facility's policy and procedure, Abuse Prevention Program, dated revised March 2004 reflected the following: 2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. The facility's policy and procedure, Background Screening Investigations dated revised April 2013 reflected the following: 4. Should the background investigation disclose .or information indicating that the individual has been convicted of abuse, neglect, mistreatment of [REDACTED]. The facility's policy and procedure, Abuse Prevention Program, dated revised 10/04/06 reflected the following: Screening of potential employees will include requesting information from previous and/or current employees and verifying information with the appropriate licensing boards and certification registries as well as screening for criminal history per regulatory requirements. Potential employees with negative findings of background checks will not be hired. The facility's employee list provided by the DON on 01/15/16 reflected (Hskp) A's DOH was 08/01/05. Her annual Texas Nurse Aide Registry Verification dated 10/08/15 reflected she had been a nurse aide in the past and her nurse aide certification status was Revoked .Because substantiated findings of abuse, neglect, or misappropriation of resident property has been entered on the Texas Nurse Aide Registry, this individual in (sic) not employable as a nurse aide in a licensed nursing facility in the state of Texas. During an interview with the DON on 01/15/16 at 2:40 PM he stated he did not do the employability checks, they were conducted by MR. During an interview with MR on 01/15/16 at 2:50 PM she stated I saw it was revoked, I guess I saw she works in housekeeping and she's been here for a while and it's been that way and since she is not listed on the EMR . MR also stated, the BOM is her supervisor and would spot check behind her or if she (MR) had any questions about a person's employability she would ask the BOM. During an interview with the BOM on 01/15/16 at 3:05 PM she stated, My understanding was since she was not listed on the EMR and it says not employable as a certified nurse aide in a licensed nursing facility it was ok. When queried if Hskp A had access to the residents the BOM stated yes she is a housekeeper. When queried if Hskp A worked on one side or the other the BOM stated she worked on both sides of the facility. The BOM also stated Hskp A was off but she would call her and try to get her to come up to the facility. A copy of Hskp A's time card report was requested at this time to include 10/08/15 through 01/15/16. Hskp A's Time Card Report from 10/08/15 through 01/15/16 reflected she had worked at the facility a total of 70 days after the facility had knowledge of her unemployable status. During an interview with Hskp A on 01/15/16 at 3:15 PM she stated she had not known her nurse aide certification was revoked. She stated she had known it wasn't good but not that it had been revoked. She stated a long time ago she had been working as a CNA at a facility and was assisting another CNA to get a resident back into a chair. Hskp A stated the other CNA had attempted to transfer the resident by herself and dropped her. She stated she did not report the accident as she thought the other CNA would and it turned out the resident's foot had been broken so she and the other CNA had been terminated for failure to report the accident. She also stated she had applied at this facility for a porter position and started as a porter in 2005 before becoming a housekeeper. During an interview with the BOM on 01/15/16 at 4:25 she stated the only staff who have access to the employability checks are herself and MR. She stated the department heads do not typically see the employability checks as they depend on her and the MR to run them and then the BOM would let them know if they are employable or not. When queried about what type of training she and MR had received about employability background checks she stated None and I've been with the company for ten years. During a telephone interview with the Admin on 01/16/16 at 1:47 PM he stated he was the facility's Abuse Co-ordinator. He also stated he had done random checks on employability in all departments but had never checked Hskp A. An immediate jeopardy was identified on 01/15/16 at 4:15 PM. The DON and BOM were notified of the IJ on 01/15/16 at 4:15 PM. A Plan of Removal for the IJ was requested at that time. The facility's POR was accepted on 01/16/16. The plan reflected the following: --The facility terminated the employment of Hskp A on 01/15/16 at 4:25 PM. --The BOM and MR were re-trained on employability status by the DON and both wrote letters of acknowledgement of the current human resources policies regarding NAR and EMR status. --100% of the facility's current employees, including licensed and unlicensed staff, were reviewed by the BOM and MR for NAR and EMR status and all were noted to be eligible for employment at that time of 5:45 PM on 01/15/16. --On 01/16/16 at 11:30 AM the VP of Ops and DON began in-servicing all licensed and line staff on the facility's Abuse & Neglect Policy. A competency exam followed the in-service and an acknowledgement was signed by each employee. This training will continue all day until all staff is trained. If an employee is unable to be trained today they will receive the training prior to returning to duty. --The SW will evaluate and interview a random sample of interviewable residents from each hall to assess for any abuse or neglect issues from this individual or from others. Upon completion of this interview process on 01/16/16, no reports of abuse or neglect were found. --All prospective employees will obtain review of both NAR and EMR for eligibility status to include licensed staff before being hired to work for the facility. --All current employees receiving annual review of NAR and EMR checks will be terminated immediately if noted to have ineligible status on the NAR, revoked certificate on NAR or found to be listed as yes on EMR. --All licensed and line staff are in-serviced and acknowledge the facility's Abuse & Neglect Policy on 01/16/16 or prior to reporting to duty and on an annual basis. --On a weekly basis the Admin will perform weekly and spot checks on prospective new hires and annual reviews of employees that the NAR and EMR checks are occurring by the BOM and MR per the facility's policy. This will ensure no employee is working when identified as ineligible for employment. --All current staff have been in-serviced and acknowledge competency of the facility's Abuse & Neglect Policy. All new hires will be in-serviced during orientation prior tpo working on the floor and beginning employment at the facility. --The Admin is the facility's abuse coordinator and will immediately terminate any employee who shows to be ineligible to work in a nursing facility. --The MD was notified by the VP of Ops of the facility's IJ status on 01/16/16 at 11:20 AM. --The VP of Ops will ensure implementation of this plan by reviewing weekly with the Admin and on a quarterly basis at QA meetings. To verify implementation of the plan the following was conducted: Hskp A's Discipline notice dated 01/15/16 at 4:25 PM reflected she was terminated due to her ineligibility for employment at a nursing facility due to the state employability regulations. The facility's in-service with the topic Employee Eligibility for Employment dated 01/15/16 at 4:30 PM which was conducted by the DON reflected the BOM and MR signatures as having received the in-service. BOM's signed letter dated 01/15/16 reflected she acknowledged that under the Nurse Aide Registry a revoked status deems any perspective and/or current employee ineligible for employment. It also states under the Employee Misconduct Registry a yes status deems any perspective and/or current employee ineligible for employment. It further stated a systemic review of all current employees had been performed as of 5:45 PM on 01/15/16 and no further instances were found. MR's signed letter dated 01/15/16 reflected she acknowledged that under the Nurse Aide Registry a revoked status deems any perspective and/or current employee ineligible for employment. It also states under the Employee Misconduct Registry a yes status deems any perspective and/or current employee ineligible for employment. It further stated a systemic review of all current employees had been performed as of 5:45 PM on 01/15/16 and no further instances were found. On 01/17/16 a second sample of twelve employees to include laundry staff, housekeeping staff, dietary staff, CNAs and nurses were reviewed for employability per the EMR, NAR and license checks through the Texas Board of Nursing and all were found to be employable. On 01/16/16 at 3:00 PM a copy of the facility's in-service was received from the VP of Ops with the understanding the in-service was on-going during that day. This in-service reflected the topics of Abuse and Neglect, Compliance with the Facility Abuse/Neglect policy related to employee verification which was being presented by the VP of Ops on 01/16/16 and was on-going at that time. The evidence revealed 68 employees had signed and dated the Employee Acknowledgement letter. The 68 employees represented staff from all three shifts. During individual interviews with the following nurses they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 3:01 PM, 3:35 PM, 4:00 PM, 4:02 PM with LVN C, LVN D, LVN E, and LVN F. --On 01/17/16 at 11:20 AM with LVN G. During individual interviews with the following CNAs they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 2:50 PM, 3:25 PM, 3:30 PM, 3:47 PM, 3:50 PM, 4:12 PM, 4:30 PM, 4:55 PM and 5:00 PM with CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O and CNA P. During individual interviews with the following Laundry Aides they each answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition they all denied any residents complaining to them about abuse/neglect. The interviews were conducted on the following days: --On 01/16/16 at 3:14 PM and 3:16 PM with LA S and LA T. --During an individual interview on 01/16/16 at 2:51 PM with Maintenance, he answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition he denied any residents complaining to him about abuse/neglect. --During an individual interview on 01/16/16 at 2:55 PM with Hskp Q, she answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition she denied any residents complaining to her about abuse/neglect. --During an individual interview on 01/16/16 at 2:55 PM with Cook R, she answered all questions on the employability status of employees whether licensed, certified, un-licensed or un-certified correctly. In addition she denied any residents complaining to her about abuse/neglect. The 22 resident interviews conducted by the SW on 01/16/16 reflected no concerns related to abuse/neglect. During individual interviews with the following residents, they denied any staff member being abusive or neglectful and reported they received good care in the facility. The interviews were conducted on the following days: --01/15/16 at 9:25 AM, 9:34 AM, 12:03 PM and 12:36 PM with Resident #1, Resident #2, Resident #3 and Resident #4. --01/17/16 at 11:35 AM, 11:38 AM, 11:45 AM, 11:50 AM, 11:53 AM, 12:00 PM, 12:05 PM and 12:15 PM with Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11 and Resident #12. During individual interviews with the following resident's family members, they denied any staff member being abusive or neglectful and reported they received good care in the facility. The interviews were conducted on the following days: --On 01/15/16 at 12:04 PM with Resident #13's family member. --On 01/16/17 at 11:20 AM with Resident #14's family member. --On 01/17/16 at 12:05 with Resident #11's family member. During an interview with the VP of Ops on 01/17/16 at 2:05 PM when queried about what type of monitoring she was planning on doing going forward she stated she would have the Admin check each person's employability status behind the BOM and MR. The VP of Ops also stated she would be coming to the facility weekly to make sure he is reviewing each employability check as well as quarterly and running spot checks herself. On 01/17/16 at 2:25 PM the VP of Ops and DON were notified the IJ was removed. While the IJ was removed on 01/17/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy and a scope of widespread because the staff were still being trained and the facility was monitoring the effectiveness of the POR. The facility's employee list provided by the DON on 01/15/16 reflected there were 111 employees working for the facility. The facility's census sheet dated 01/15/16 reflected there were 98 residents residing in the facility.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for three (Residents #5, #16 and #22) of 19 residents reviewed. 1. The facility failed to initiate Contact Precautions when Residents #5 and #16 were found to have MDROs (Multi-drug resistant organisms) in their urine on 11/11/15 and 11/13/15, respectively. Nursing staff failed to initiate Contact precautions including posting of signage, to alert any person entering Residents #5 and #16's rooms that pecautions were necessary. This included use of personal protective equipment and the need for specific cleaning procedures. This resulted in the failure of all departments to take precautions, including nursing, therapy, activities, laundry, dietary, and housekeeping. Most antibiotics do not work against MDROs such as [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) and ESBL- (extended-spectrum beta-lactamases) producing Escherichia coli, making treatment options limited to fight the bacteria. Once MDROs are found, the way they spread and how long they exist is determined by how effectively the facility implements and adheres with infection control efforts, such as isolation precautions. Evidence suggest that MDROs are carried from one person to another via the hands of the healthcare provider. Hands are easlily contaminated during the process of care-giving or from contact with environmental surfaces in close proximity to the resident. CDC - MDRO Guideline:Prevention - HICPAC <http://www.cdc.gov/hicpac/mdro/mdro_4.html> Retrieved 11/23/15. 2. The facility failed to update the Infection Control policies to reflect the most recent CDC guidance on Contact Precautions and Isolation Practices. Due to these outdated policies and staff's lack of knowledge of current best practices, Residents #5 and #16 had indwelling urinary catheters placed to contain the infection and no contact precautions were implemented. CDC guidance reflected, for residents with indwelling urinary catheters who have MDROs in their urine, removal of the catheter can help get rid of the infection. CDC- VRE in Healthcare Settings - HAI/organisms/VRE/vre.html, updated 05/10/11 and Retrieved 12/08/15. 3. The facility failed to initiate Contact Precautions when Resident #5 was readmitted to the facility on [DATE] with VRE and physician orders [REDACTED]. 4. The facility failed to collect critical surveillance data to accurately assess the facility's infection rate and for planning infection control efforts, detecting epidemics, directing continuing education, and identifying individual resident problems for intervention. 5. RN B failed to wash her hands before the preparation of Resident #22's medications, during and after the administration of the medications through Resident #22's gastrostomy tube, and prior to instilling eye drop for Resident #22. An Immediate Jeopardy (IJ) was identified on 11/18/15. While the IJ was removed on 11/20/15, the facility remained out of compliance at a scope of, widespread and a severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. Infections with MDROs have been associated with an increased incidence of disease and death, expecially in elderly and disabled residents who are at increased risk for colonization with such organisms. This failure could result in a facility-wide spread of inection and affect all 101 residents. Findings included: 1. A hospital history and physical dated 10/09/15, reflected Resident #5's [DIAGNOSES REDACTED]. This history also reflected Resident #5 was positive for VRE The site of the VRE in this history was illegible. ([MEDICATION NAME]-resistant [MEDICATION NAME]: [MEDICATION NAME] are bacteria that are normally present in the human intestines and cause infections. [MEDICATION NAME] is an antibiotic that is used to treat drug-resistant infections caused by this bacteria. [MEDICATION NAME] that have become resistant to this drug are called [MEDICATION NAME]-resistant [MEDICATION NAME]). Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 </hicpac/mdro/mdro_0.html> Retrieved 11/23/15. Review of the hospital Discharge Continuity of Care paperwork dated 11/05/15, reflected Resident #5 was hospitalized from [DATE] to 11/05/15 for a wound to the left lower leg. The section entitled discharge orders of physician, reflected, Contact Isolation + VRE. 2. According to the MDS dated [DATE], Resident #5 was [AGE] years-old and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment failed to reflect Resident #5 had a MDRO. In addition, the assessment reflected Resident #5 used a wheelchair, had an indwelling urinary catheter; she was always incontinent of bowel; and she did not require isolation or quarantine for active infectious diseases while hospitalized or since she was readmitted . 3. According to the facility's readmission nurse's note by RN B on 11/05/15, Resident #5 was readmitted to the facility on the same date. RN B reviewed the physician orders [REDACTED]. ____ ( name of physician). No documentation in this note reflected the presence of an infection. 4. The interim Plan of Care dated 11/06/15, did not reflect the need for contact isolation. 5. Resident #5 was seen during the initial tour on 11/17/15 at 9:10 AM. ADON A accompanied the surveyor and stated Resident #5 was alert and oriented with some forgetfulness, and had just returned from the hospital for a leg wound. ADON A also stated Resident #5 had an indwelling urinary catheter because she had VRE in her urine which was discovered when her facility admission lab results were received. Resident #5 was in bed, answered questions appropriately and, received oxygen through a nasal cannula. She had a dressing on her lower left leg. During this observation, no signage was posted upon entry to the room to alert any person entering that Resident #5 required contact precautions. There were no biohazardous waste containers set up in the room or bathroom for the linens and trash. There was no personal protective equipment set up outside or in the room; and no dedicated items were observed. 6. During an interview with ADON A on 11/17/15 at 12:41 PM, she stated Resident #5 came back from the hospital with the indwelling urinary catheter but it was discontinued because there was no medical justification. ADON A stated when Resident #5's admission urine culture and sensitivity came back positive for VRE on 11/11/15, an order was obtained to place an indwelling urinary catheter, to contain the urine and infection. When asked why an adult brief was not sufficient, ADON A replied, I guess the doctor thought urine might still leak out. When shown and asked about the hospital discharge paperwork which reflected Resident #5 was to be in contact isolation for VRE since she was readmitted on [DATE], ADON A replied, she had never seen that order and it had never been communicated to her by the admission nurse, RN B. 7. Resident #5's physician orders [REDACTED]. The admission physician orders [REDACTED]. The urine specimen was collected on 11/06/15 according to the laboratory final culture and sensitivity results dated 11/11/15. These results reflected Resident #5 had 10,000 to 50, 000 colony forming units of VRE per milliliter of urine (a colony forming unit is the number of viable bacteria per milliliter of urine). Colony-forming unit - Biology-Online Dictionary <http://www.biology-online.org/dictionary/Colony-forming_unit> Retrieved 11/25/15. The laboratory results also reflected the facility was notified by telephone of these critical results on 11/11/15 at 11:09 AM. Further review of Resident #5's physician orders [REDACTED]. In addition, the physician ordered, Foley Catheter one time only for VRE-urine for 1 week. 8. Review of the nurse's notes dated 11/12/15 revealed an indwelling urinary catheter was, inserted today due to VRE. 9. On 11/17/15 at 3:42 PM, the DON was asked why the indwelling urinary catheter was placed for Resident #5 on 11/12/15. The DON replied it was to contain the VRE in the urine. The DON stated residents could not leave their rooms for activities and meals if they had VRE. The DON stated PA OO was contacted and asked how to allow for Resident #5 to leave the room with VRE. PA OO said to insert the catheter. When asked why not place an adult brief on Resident #5 when she left the room, the DON stated she could touch her brief and contaminate others or the environment. When informed Resident #5 was cognitively intact, the DON replied, Really, she is oriented? At this point the DON was informed to review and provide the Infection control policies regarding selection of appropriate isolation; when secluding a resident was necessary; where infecting organisms originate; and the appropriateness of catheter insertion to contain an infection. The DON was asked why no precautions were initiated when Resident #5 was readmitted on [DATE] with VRE and orders for contact isolation. The DON stated he was not aware of the order. At 4:14 PM on 11/17/15, the DON stated he had reviewed the facility Infection Control policies and procedures and realized they were out of date with current CDC recommendations and that contact isolation did not include keeping a resident in their room. The DON stated he was unable to find a policy regarding appropriate reasons to insert a urinary catheter. 10. On 11/17/15 at 4:41 PM, RN B was observed placing biohazardous waste and linen containers in Resident #5's bathroom. When asked why she was placing the containers, RN B stated contact precautions were not necessary in the past because Resident #5's urinary catheter contained the infection. RN B stated now that Resident #5's catheter was to be discontinued, they had to initiate contact isolation. 11. On 11/17/15 at 5:32 PM, ADON A was interviewed and stated the DON said Resident #5 was oriented enough to train so she would be able to come out of the room without a catheter. ADON A stated when Resident #5 had the catheter, it was not necessary to have those containers set up because the catheter contained everything. 12. Review of Resident #5's physician orders [REDACTED]. 13. Resident #5's nurse's notes dated 11/17/15 reflected at 6:51 PM, her urinary catheter was removed. 14. A review of Resident #5's careplan update on 11/17/15, revealed Resident #5 had a, Knowledge Deficet related to infectious disease process (Contact Isolation) r/t (related to) VRE in urine and urinary incontinence. Risk of harm to others r/t living in a community environment and frequent social contact. The goals related to educating Resident #5 on her infectious process and upon completion and return demonstration, the urinary catheter would be removed. The interventions reflected included education of Resident #5 on knowledge deficits, when to report incontinence, and signs and symptoms of a urinary tract infection. The interventions reflected a brief at all times would be worn by Resident #5 when out of bed. The careplan did not reflect staff interventions for the Contact Isolation such as protective equipment, dedicated items, and collection of biohazardous waste and linens. 15. RN B was interviewed on 11/18/15 at 2:26 PM, and stated she saw Resident #5's order for contact isolation for VRE when she was readmitted to the facility on [DATE]. RN B stated she discussed that order when she spoke with the doctor while reviewing Resident #5's hospital discharge orders. The doctor said to continue the isolation and other orders.She stated she told ADON A and she (ADON A) called the hospital later the same day on 11/05/15. RN B revealed ADON A told her the hospital said the [DIAGNOSES REDACTED]. That was when ADON A stated Resident #5 did not need isolation. RN B stated, Resident #5 was therefore, not placed on contact isolation. RN B added, when Resident #5's urine culture came back with VRE on 11/11/15, We put a catheter in. RN B stated, there was no need for isolation at that time either, due to the catheter. 16. ADON A was interviewed on 11/18/15 at 3:09 PM and stated she had been thinking about the events since Resident #5's readmission to the facility on [DATE]. ADON A stated she thought she now remembered something being mentioned about VRE, and calling the discharging hospital, She stated she spoke with the charge nurse who called in report to the facility on [DATE]. ADON A stated the charge nurse informed her the Resident #5's VRE [DIAGNOSES REDACTED]. ADON A stated she wrote a progress note on the conversation. ADON A was provided Resident #5's progress notes and could not find the note. ADON A then tried to find her note in the computer data base but was unable to find any documentation. ADON A stated she was mixing up information and now recalled calling the hospital because of MRSA, not VRE on Resident #5. ADON A stated she thought it was MRSA of the rectum. ADON A stated she was sure it was MRSA and not VRE. ADON A stated she informed RN B Resident #5 did not need isolation. ADON A stated RN B never told her about the isolation order for VRE. 17. LVN I was interviewed on 11/20/15 at 1:30 PM and stated she was the charge nurse who took the report from the hospital on [DATE]. LVN I stated the hospital nurse stated Resident #5 had VRE of the rectum. When asked if she was sure of the organism, LVN I replied she was certain. LVN I stated Resident #5 used to reside on her unit but was readmitted to the other unit, where ADON A was in charge. ADON A called over to this unit the day Resident #5 was readmitted , and asked for the nurse who took the hospital discharge report. LVN I stated she spoke with ADON A and told her Resident #5 had VRE of the rectum. At that point, LVN I stated ADON A said she was going to call the hospital and get additional information regarding the current status of the infection and how long she would need isolation. LVN I stated she never saw any of Resident #5's paperwork as she was readmitted to the other unit. 18. On 11/18/15 at 7:27 AM, MA G was interviewed and stated she passed medications to all the residents on her unit, to include Residents on the 500, 600 and 700 halls. When asked if any of the residents on her halls were in isolation, MA G said nobody was on isolation precautions. MA G was asked how she knew and replied, I would know because there would be a sign outside their room. Resident #5 resided on the 500 hall. 19. On 11/18/15 at 7:56 AM, LVN D was interviewed and stated she was over the 700 hall and rooms [ROOM NUMBERS]. LVN D stated Resident #5 was on isolation precautions because her indwelling urinary catheter was removed the evening of 11/17/15. LVN D added, when Resident #5 had the catheter, it contained the VRE in the urine so isolation precautions were not necessary. The catheter was put in because she wanted to come out of her room and the catheter made it possible because it held in the urine infection. 20. ADON A was interviewed on 11/18/15 at 8:05 AM and stated she was the one who called and spoke with PA OO about the 11/11/15 lab results which showed VRE in Resident #5's urine. ADON A stated when she asked what isolation precautions were necessary, PA OO stated if a urinary catheter was placed it contained the urine, so you don't have to worry. ADON A stated Resident #5 was not on any isolation precautions prior to the 11/11/15 lab results until the evening of 11/17/15, when the catheter was removed and contact precautions initiated. 21. Housekeeper F was interviewed on 11/18/15 at 8:14 AM and stated she cleaned the 700 and 500 halls. Housekeeper F stated she knew when a resident was on isolation precautions because there would be a sign posted to check with the nurse and boxes for linens and trash in the room. Housekeeper F stated nobody on the 700 hall had any kind of isolation precautions but she thought Resident #5 was because she saw the boxes in the bathroom that day. Housekeeper F stated if a resident was on isolation precautions, she would use a bleach based disinfectant spray and wipes to clean the room. Housekeeper F added she would change out her mop head and water when finished with the room. 22. On 11/18/15 at 9:33 AM, the Housekeeping Supervisor was interviewed and stated he helped oversee the housekeeping staff to insure they had supplies and followed proper cleaning procedures. He added if a resident was on isolation precautions, they would use bleach based disinfectants, and change out any pads or mop heads used for cleaning the room. When asked how he knew who was on isolation precautions, the Housekeeping supervisor stated he attended the morning meetings where such information was shared, or when a nurse asked for isolation supplies. The supervisor added, he was responsible for setting up the supply cabinet outside the room to hold the gowns and gloves. When asked if anyone was on isolation precautions, the supervisor stated Resident #5 was started on precautions the previous evening; and that was the first time since she returned from the hospital that he had been asked to place the supply cabinet outside her room. 23. The Central Supply Supervisor was interviewed on 11/18/15 at 9:46 AM and stated she was in charge of making sure the staff had enough gowns, gloves, masks, washable bags, red bags; and disposable blood pressure cuffs, stethoscopes and thermometers when a resident was on isolation precautions. The supervisor added she was responsible for making sure the cabinets outside the door and the supply closets on the floor were sufficiently stocked. The supervisor stated she became aware during the evening on 11/17/15, that Resident #5 was on isolation precautions and that was the first time since she returned from the hospital she had been asked to stock the cabinet outside her room. 24. According to Resident #16's MDS assessment, dated 08/17/15, she was a [AGE] year-old female admitted to the facility on [DATE]. The assessment reflected Resident #16 had [DIAGNOSES REDACTED]. and Anxiety. Resident #16 required extensive assistance of two persons for transfers and extensive assistance of one staff person for dressing, eating, toileting, personal hygiene and bathing. The assessment also reflected she had both short and long-term memory loss. She had an indwelling catheter and was frequently incontinent of bowel. According to Resident #16's initial MDS assessment dated [DATE], Resident #16 did not present to the facility with an indwelling urinary catheter. 25. Review of Resident #16's physician's orders [REDACTED].#16's increased confusion. The nurse's notes dated 11/10/15 at 02:07 AM, reflected Resident #16 was catheterized solely to collect ordered urine specimen and the catheter was removed once the specimen was obtained. Resident #16's urine culture and sensitivity dated 11/13/15, revealed the urine was positive for bacteria and the organism was Escherichia coli, greater than 100,000 colony forming units per milliliter of urine. Escherichia coli are bacteria that live in human intestines. E.coli (Escherichia coli) | E.coli | CDC <http://www.cdc.gov/ecoli/index.html> Retrieved 11/25/15. The urine culture result also reflected the organism had been confirmed as an Extended-Spectrum Beta Lactamase (ESBL) producer. According to www.medscape.com <http://www.medscape.com> Retrieved 11/24/15: Extended-spectrum beta lactamases (ESBL) are enzymes produced by Gram Negative Bacteria (mainly Escherichia coli and [DIAGNOSES REDACTED] pneumonia), which are responsible for resistance against [MEDICATION NAME], Cephalosporins and Aztreonam antibiotics making them ineffective for treatment. 26. Review of the nurse's notes dated 11/13/15, revealed LVN C contacted Nurse Practitioner PP and informed her of Resident #16's urine and Culture and Sensitivity results. The notes further reflected LVN C told NP PP of the ESBL organism and asked her if an indwelling urinary catheter necessary. NP PP told the nurse there was no need for a catheter and gave the order for Resident #16 to receive one gram of Ertapenam (Antibiotic) intramuscularly once a day for seven days. A physician's orders [REDACTED].#16 was to receive one gram of Ertapenam intramuscularly, once a day for seven days and to be discontinued on 11/20/15. LVN C was interviewed at 3:45 PM on 11/19/15. She stated she found Resident #16 had a urinary tract infection when she reviewed the 24-hour report on 11/13/15. She stated she notified ADON A and NP PP. LVN C stated she told NP PP Resident #16's lab report showed she had E. coli and ESBL in her urine. She stated NP PP ordered an antibiotic. LVN C also stated she asked NP PP if she wanted Resident #16 to have a urinary catheter, and the NP PP said a catheter was not necessary. She stated no orders were given for contact precautions at that time. 27. Resident #16's nurse's notes dated 11/16/15, reflected LVN H received an order from PA OO to insert an indwelling urinary catheter for Resident #16 until the antibiotics were completed due to ESBL in the urine. The notes further reflected the catheter was inserted and that Resident #16 understood the catheter would only be in place until the antibiotics were completed. 28. Physician orders [REDACTED].#16 was to have an indwelling urinary catheter inserted during her antibiotic therapy for ESBL in the urine. 29. Resident #16's care plan initiated on 11/17/15, reflected: I have Indwelling Foley catheter r/t (related to) Multidrug resistant infectious disease process in my urine, urinary incontinence and intermittent confusion; resulting in inability to re-educate and maintain infection control contact precautions in a community. I choose to have a catheter to facilitate and maintain my infectious disease and allow me to have a community living environment . Me and my RP (responsible party) understand without a catheter I am at risk to others in my community. 30. Resident #16 was seen on 11/17/15 at 10:32 AM in her room speaking with a visitor. LVN H stated at that time Resident #16 was alert and oriented to time, person, and place. LVN H added Resident #16 had an indwelling urinary catheter placed during her antibiotic treatment for [REDACTED].#16 had ESBL in her urine and contact isolation was not necessary because she had the catheter placed. During this observation, no signage was posted upon entry to the room to alert any person entering that Resident #16 required contact precautions. Also, there was no personal protective equipment set up outside. 31. On 11/17/15 at 4:51 PM, LVN C was interviewed and stated she was the charge nurse for the 600 hall. When asked why Resident #16 did not have biohazardous waste containers for the linen and trash, LVN C replied it was not necessary. LVN C added because Resident #16 had an indwelling urinary catheter, it contained the infection and no contact precautions were needed. Resident #16's room was observed immediately after this conversation. No biohazardous waste boxes for linens and trash; dedicated items; personal protective equipment or signage alerting any person who entered the room that contact precautions were necessary was observed. 32. On 11/18/15 at 7:27 AM, MA G was interviewed and stated she passed medications to all the residents on her unit, to include Residents on the 500, 600 and 700 halls. When asked if any of the residents on her halls were in isolation, MA G said nobody was on isolation precautions. MA G was asked how she knew and replied, I would know because there would be a sign outside their room. Resident #16 resided on the 600 hall. 33. LVN H was interviewed on 11/18/15 at 7:45 AM, and stated she was the charge nurse for all the residents on the 600 hall, and rooms [ROOM NUMBERS]. LVN H was asked who was on isolation precautions and she replied nobody in her assigned rooms was on any precautions. LVN H stated when Resident #16 got the ESBL in her urine, a catheter was placed so there was no need for isolation. 34. On 11/18/15 at 7:52 AM, Housekeeper E was interviewed and stated today she was assigned to clean the 600 hall and another hall on the other unit. Housekeeper E stated sometimes she is assigned to other hallways. Housekeeper E stated she knew when a resident was on isolation precautions because there would be a sign posted and all of the equipment you need to wear is outside the door. Housekeeper E stated nobody on the 600 hall had any kind of isolation precautions. Housekeeper E stated if a resident was on isolation precautions, she would use a different chemical disinfectant spray and wipes to clean the room. Housekeeper E added she would pay extra attention to the door knobs, window sills, bathroom, and siderails; and she would change out her mop head and water when finished with the room. 35. At 11:15 AM on 11/18/15 an interview was conducted with CNA J. She stated she worked the 600 Hall. When asked if there were any residents on that hall who were on isolation precautions she said she did not know of anyone. She stated if a resident was on isolation precautions she would wear gowns, gloves, and a mask. CNA J added meals would be served on paper plates which remained in the room afterwards and the plastic trays were not to enter the room. She also stated she would dispose of the linens and trash in the special boxes kept in the resident's room. When she was asked how she knew when a resident was on contact isolation precautions, she replied that she knew by the sign that was posted on the wall outside of the room. 36. At 12:00 noon on 11/18/15, Resident #16's room was observed. There was no contact precautions sign on the outside of her room to inform staff and visitors of the precautions and the presence of an infection. There was no container located outside of the room to store the personal protective equipment such as gowns, gloves and masks. There were no isolation boxes in the room for staff to properly dispose of soiled lines and trash properly. 37. The physician orders [REDACTED].#16 and to start contact precautions related to Infection Control for ESBL in the urine. 38. The nurse's notes dated 11/19/15 at 4:31 PM, reflected Resident #16 was on contact isolation for ESBL in the urine. The notes also reflected Resident #16 had voided as soon as the catheter was removed. The nurse's notes dated 11/19/15 at 6:45 PM reflected the staff contacted Resident #16's family member regarding the removal of the catheter and the contact isolation precautions set in place related to the ESBL in the urine. The notes reflected the nurse also explained the facility would not place a urinary catheter any longer for infections and that the contact precautions would remain in place until the infection was resolved. The notes also reflected the catheter had been removed due to inappropriate use of indwelling urinary catheter to contain an infectious disease process and that Resident #16 was on active contact precautions and visitors would need to see the nurse at nurse's station when visiting. 39. At 8:00 AM on 11/19/15, Resident #16's room was observed to have a contact precautions sign posted outside her door. Outside her door was a cabinet of personal protective equipment. The biohazardous containers for Resident #16's trash and linens were in her bathroom. Resident #16's roommate, Resident #7, was also transferred to another room. 40. At 11:05 AM on 11/20/15, Resident #16 was sitting in her wheelchair by the nurse's station. When asked how she felt after the catheter had been removed, she said, It was most definitely better. 41. The Activity Director was interviewed on 11/20/15 at 10:58 AM. He stated he knew when a resident was on isolation precautions because there would be contact precautions sign posted outside of the room and equipment outside of the resident's room. He stated if there was no sign of contact precautions posted outside of the room, he would assume it was safe to enter and there was no need for contact precautions. The Activity Director stated he was unaware Residents #5 and #16 were on contact precautions. He stated he visited with Resident #5 in her room as she was not coping well with her placement and did not usually attend activities. The Activity Director stated Resident #16 would attend activities but would ask to be placed close to the bathroom in case she needed to use it. He added, that was the case even when Resident #16 had her urinary catheter. 42. The Rehabilitation Director was interviewed on 11/20/15 at 12:05 PM. She stated the rehabilitation services were a contracted service however, the rehabilitation staff followed the facility's policies and procedures. When asked how she was informed a resident was on isolation precautions, she replied, she attended the morning staff meetings where care issues were discussed. In addition, she stated prior to seeing a resident, the chart was reviewed and the the nurses were approached for additional information. When asked about Resident #5, the Rehabilitation Director stated she read the notes from the hospital which indicated she was positive for VRE and on contact isolation. She stated she approached ADON A and asked her if Resident #5 was on isolation. ADON told her the [DIAGNOSES REDACTED]. The Rehabilitation Director stated the therapists had not taken any isolation precautions since Resident #5 returned from the hospital on [DATE]. At 12:45 PM on 11/20/15, the Director of Rehabilitation was interviewed again for clarification purposes. She stated when she spoke with ADON A after she reviewed Resident #5's records, she did not take the record with her to show ADON A, she just asked her if Resident #5 was still on isolation precautions. 43. The Medical Director was interviewed on 11/18/15 at 3:20 PM. He stated urinary catheters in the elderly should be avoided if at all possible and placing one for an infection was unnecessary and, just wrong. The Medical Director stated a catheter was not an air-tight system and often leaked. The Medical Dire

Based on observation, interview, and record review, it was determined the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (Residents #5, #16 and #22) of 19 residents reviewed. 1. The DON failed to train staff to initiate Contact Precautions when Residents #5 and #16 were found to have MDROs (Multi-drug resistant organisms) in their urine on 11/11/15 and 11/13/15, respectively. Nursing staff failed to initiate Contact precautions including posting of signage, to alert any person entering Residents #5 and #16's rooms that pecautions were necessary. This included use of personal protective equipment and the need for specific cleaning procedures. This resulted in the failure of all departments to take precautions, including nursing, therapy, activities, laundry, dietary, and housekeeping. Most antibiotics do not work against MDROs such as [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) and ESBL- (extended-spectrum beta-lactamases) producing Escherichia coli, making treatment options limited to fight the bacteria. Once MDROs are found, the way they spread and how long they exist is determined by how effectively the facility implements and adheres with infection control efforts, such as isolation precautions. Evidence suggest that MDROs are carried from one person to another via the hands of the healthcare provider. Hands are easlily contaminated during the process of care-giving or from contact with environmental surfaces in close proximity to the resident. CDC - MDRO Guideline:Prevention - HICPAC <http://www.cdc.gov/hicpac/mdro/mdro_4.html> Retrieved 11/23/15. 2. The DON failed to ensure the Infection Control policies were updated to reflect the most recent CDC guidance on Contact Precautions and Isolation Practices. Due to these outdated policies and staff's lack of knowledge of current best practices, Residents #5 and #16 had indwelling urinary catheters placed to contain the infection and no contact precautions were implemented. CDC guidance reflected, for residents with indwelling urinary catheters who have MDROs in their urine, removal of the catheter can help get rid of the infection. CDC- VRE in Healthcare Settings - HAI/organisms/VRE/vre.html, updated 05/10/11 and Retrieved 12/08/15. 3. The DON failed to ensure staff initiated Contact Precautions when Resident #5 was readmitted to the facility on [DATE] with VRE and physician orders [REDACTED]. 4. The DON failed to ensure critical surveillance data was collected by his ADONs to accurately assess the facility's infection rate and for planning infection control efforts, detecting epidemics, directing continuing education, and identifying individual resident problems for intervention. 5. RN B failed to wash her hands before the preparation of Resident #22's medications, during and after the administration of the medications through Resident #22's gastrostomy tube, and prior to instilling eye drop for Resident #22. An Immediate Jeopardy (IJ) was identified on 11/18/15. While the IJ was removed on 11/20/15, the facility remained out of compliance at a scope of, widespread and a severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. Infections with MDROs have been associated with an increased incidence of disease and death, expecially in elderly and disabled residents who are at increased risk for colonization with such organisms. This failure could result in a facility-wide spread of inection and affect all 101 residents. 1. The DON failed to ensure the Infection Control policies were updated to reflect the most recent CDC guidance on Contact Precautions and Isolation Practices. 2. The DON failed to train staff to initiate Contact Precautions when Residents #5 and #16 were found to have MDROs in their urine. 3. The Administrator and DON failed to ensure the staff were up to date in their knowledge base of current CDC guidance on implentation of Contact precautions to contain a MDRO. Residents #5 and #16 had indwelling urinary catheters placed to contain the infection and no contact precautions were implemented. 4. The DON failed to initiate Contact Precautions when Resident #5 was readmitted to the facility on [DATE] with VRE and physician orders [REDACTED]. 5. The DON failed to ensure critical surveillance data was collected by his ADONs to accurately assess the facility's infection rate and for planning infection control efforts, detecting epidemics, directing continuing education, and identifying individual resident problems for intervention. 6. RN B failed to wash her hands before the preparation of Resident #22's medications, during and after the administration of the medications through Resident #22's gastrostomy tube, and prior to instilling eye drop for Resident #22. The failure by nursing staff to take immediate steps, including the posting of signage to alert any person entering Residents #5 and #16's rooms that contact precautions were necessary, resulted in the failure of all departments to take precautions including nursing, therapy, activities, laundry and housekeeping. Infections with MDROs have been associated with an increased incidence of disease and death, expecially in elderly and disabled residents who are at increased risk for colonization with such organisms. This failure could result in a facility-wide spread of inection and affect all 101 residents. An Immediate Jeopardy (IJ) was identified on 11/18/15. While the IJ was removed on 11/20/15, the facility remained out of compliance at a scope of, widespread and a severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: 1. A hospital history and physical dated 10/09/15, reflected Resident #5's [DIAGNOSES REDACTED]. This history also reflected Resident #5 was positive for VRE The site of the VRE in this history was illegible. ([MEDICATION NAME]-resistant [MEDICATION NAME]: [MEDICATION NAME] are bacteria that are normally present in the human intestines and cause infections. [MEDICATION NAME] is an antibiotic that is used to treat drug-resistant infections caused by this bacteria. [MEDICATION NAME] that have become resistant to this drug are called [MEDICATION NAME]-resistant [MEDICATION NAME]). Management of [MEDICAL CONDITION] In Healthcare Settings, 2006 </hicpac/mdro/mdro_0.html> Retrieved 11/23/15. Review of the hospital Discharge Continuity of Care paperwork dated 11/05/15, reflected Resident #5 was hospitalized from [DATE] to 11/05/15 for a wound to the left lower leg. The section entitled discharge orders of physician, reflected, Contact Isolation + VRE. 2. According to the MDS dated [DATE], Resident #5 was [AGE] years-old and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment failed to reflect Resident #5 had a MDRO. In addition, the assessment reflected Resident #5 used a wheelchair, had an indwelling urinary catheter; she was always incontinent of bowel; and she did not require isolation or quarantine for active infectious diseases while hospitalized or since she was readmitted . 3. According to the facility's readmission nurse's note by RN B on 11/05/15, Resident #5 was readmitted to the facility on the same date. RN B reviewed the physician orders [REDACTED]. ____ ( name of physician). No documentation in this note reflected the presence of an infection. 4. The interim Plan of Care dated 11/06/15, did not reflect the need for contact isolation. 5. Resident #5 was seen during the initial tour on 11/17/15 at 9:10 AM. ADON A accompanied the surveyor and stated Resident #5 was alert and oriented with some forgetfulness, and had just returned from the hospital for a leg wound. ADON A also stated Resident #5 had an indwelling urinary catheter because she had VRE in her urine which was discovered when her facility admission lab results were received. Resident #5 was in bed, answered questions appropriately and, received oxygen through a nasal cannula. She had a dressing on her lower left leg. During this observation, no signage was posted upon entry to the room to alert any person entering that Resident #5 required contact precautions. There were no biohazardous waste containers set up in the room or bathroom for the linens and trash. There was no personal protective equipment set up outside or in the room; and no dedicated items were observed. 6. During an interview with ADON A on 11/17/15 at 12:41 PM, she stated Resident #5 came back from the hospital with the indwelling urinary catheter but it was discontinued because there was no medical justification. ADON A stated when Resident #5's admission urine culture and sensitivity came back positive for VRE on 11/11/15, an order was obtained to place an indwelling urinary catheter, to contain the urine and infection. When asked why an adult brief was not sufficient, ADON A replied, I guess the doctor thought urine might still leak out. When shown and asked about the hospital discharge paperwork which reflected Resident #5 was to be in contact isolation for VRE since she was readmitted on [DATE], ADON A replied, she had never seen that order and it had never been communicated to her by the admission nurse, RN B. 7. Resident #5's physician orders [REDACTED]. The admission physician orders [REDACTED]. The urine specimen was collected on 11/06/15 according to the laboratory final culture and sensitivity results dated 11/11/15. These results reflected Resident #5 had 10,000 to 50, 000 colony forming units of VRE per milliliter of urine (a colony forming unit is the number of viable bacteria per milliliter of urine). Colony-forming unit - Biology-Online Dictionary <http://www.biology-online.org/dictionary/Colony-forming_unit> Retrieved 11/25/15. The laboratory results also reflected the facility was notified by telephone of these critical results on 11/11/15 at 11:09 AM. Further review of Resident #5's physician orders [REDACTED]. In addition, the physician ordered, Foley Catheter one time only for VRE-urine for 1 week. 8. Review of the nurse's notes dated 11/12/15 revealed an indwelling urinary catheter was, inserted today due to VRE. 9. On 11/17/15 at 3:42 PM, the DON was asked why the indwelling urinary catheter was placed for Resident #5 on 11/12/15. The DON replied it was to contain the VRE in the urine. The DON stated residents could not leave their rooms for activities and meals if they had VRE. The DON stated PA OO was contacted and asked how to allow for Resident #5 to leave the room with VRE. PA OO said to insert the catheter. When asked why not place an adult brief on Resident #5 when she left the room, the DON stated she could touch her brief and contaminate others or the environment. When informed Resident #5 was cognitively intact, the DON replied, Really, she is oriented? At this point the DON was informed to review and provide the Infection control policies regarding selection of appropriate isolation; when secluding a resident was necessary; where infecting organisms originate; and the appropriateness of catheter insertion to contain an infection. The DON was asked why no precautions were initiated when Resident #5 was readmitted on [DATE] with VRE and orders for contact isolation. The DON stated he was not aware of the order. At 4:14 PM on 11/17/15, the DON stated he had reviewed the facility Infection Control policies and procedures and realized they were out of date with current CDC recommendations and that contact isolation did not include keeping a resident in their room. The DON stated he was unable to find a policy regarding appropriate reasons to insert a urinary catheter. 10. On 11/17/15 at 4:41 PM, RN B was observed placing biohazardous waste and linen containers in Resident #5's bathroom. When asked why she was placing the containers, RN B stated contact precautions were not necessary in the past because Resident #5's urinary catheter contained the infection. RN B stated now that Resident #5's catheter was to be discontinued, they had to initiate contact isolation. 11. On 11/17/15 at 5:32 PM, ADON A was interviewed and stated the DON said Resident #5 was oriented enough to train so she would be able to come out of the room without a catheter. ADON A stated when Resident #5 had the catheter, it was not necessary to have those containers set up because the catheter contained everything. 12. Review of Resident #5's physician orders [REDACTED]. 13. Resident #5's nurse's notes dated 11/17/15 reflected at 6:51 PM, her urinary catheter was removed. 14. A review of Resident #5's careplan update on 11/17/15, revealed Resident #5 had a, Knowledge Deficet related to infectious disease process (Contact Isolation) r/t (related to) VRE in urine and urinary incontinence. Risk of harm to others r/t living in a community environment and frequent social contact. The goals related to educating Resident #5 on her infectious process and upon completion and return demonstration, the urinary catheter would be removed. The interventions reflected included education of Resident #5 on knowledge deficits, when to report incontinence, and signs and symptoms of a urinary tract infection. The interventions reflected a brief at all times would be worn by Resident #5 when out of bed. The careplan did not reflect staff interventions for the Contact Isolation such as protective equipment, dedicated items, and collection of biohazardous waste and linens. 15. RN B was interviewed on 11/18/15 at 2:26 PM, and stated she saw Resident #5's order for contact isolation for VRE when she was readmitted to the facility on [DATE]. RN B stated she discussed that order when she spoke with the doctor while reviewing Resident #5's hospital discharge orders. The doctor said to continue the isolation and other orders.She stated she told ADON A and she (ADON A) called the hospital later the same day on 11/05/15. RN B revealed ADON A told her the hospital said the [DIAGNOSES REDACTED]. That was when ADON A stated Resident #5 did not need isolation. RN B stated, Resident #5 was therefore, not placed on contact isolation. RN B added, when Resident #5's urine culture came back with VRE on 11/11/15, We put a catheter in. RN B stated, there was no need for isolation at that time either, due to the catheter. 16. ADON A was interviewed on 11/18/15 at 3:09 PM and stated she had been thinking about the events since Resident #5's readmission to the facility on [DATE]. ADON A stated she thought she now remembered something being mentioned about VRE, and calling the discharging hospital, She stated she spoke with the charge nurse who called in report to the facility on [DATE]. ADON A stated the charge nurse informed her the Resident #5's VRE [DIAGNOSES REDACTED]. ADON A stated she wrote a progress note on the conversation. ADON A was provided Resident #5's progress notes and could not find the note. ADON A then tried to find her note in the computer data base but was unable to find any documentation. ADON A stated she was mixing up information and now recalled calling the hospital because [MEDICAL CONDITION], not VRE on Resident #5. ADON A stated she thought it [MEDICAL CONDITION] of the rectum. ADON A stated she was sure it [MEDICAL CONDITION] and not VRE. ADON A stated she informed RN B Resident #5 did not need isolation. ADON A stated RN B never told her about the isolation order for VRE. 17. LVN I was interviewed on 11/20/15 at 1:30 PM and stated she was the charge nurse who took the report from the hospital on [DATE]. LVN I stated the hospital nurse stated Resident #5 had VRE of the rectum. When asked if she was sure of the organism, LVN I replied she was certain. LVN I stated Resident #5 used to reside on her unit but was readmitted to the other unit, where ADON A was in charge. ADON A called over to this unit the day Resident #5 was readmitted , and asked for the nurse who took the hospital discharge report. LVN I stated she spoke with ADON A and told her Resident #5 had VRE of the rectum. At that point, LVN I stated ADON A said she was going to call the hospital and get additional information regarding the current status of the infection and how long she would need isolation. LVN I stated she never saw any of Resident #5's paperwork as she was readmitted to the other unit. 18. On 11/18/15 at 7:27 AM, MA G was interviewed and stated she passed medications to all the residents on her unit, to include Residents on the 500, 600 and 700 halls. When asked if any of the residents on her halls were in isolation, MA G said nobody was on isolation precautions. MA G was asked how she knew and replied, I would know because there would be a sign outside their room. Resident #5 resided on the 500 hall. 19. On 11/18/15 at 7:56 AM, LVN D was interviewed and stated she was over the 700 hall and rooms [ROOM NUMBERS]. LVN D stated Resident #5 was on isolation precautions because her indwelling urinary catheter was removed the evening of 11/17/15. LVN D added, when Resident #5 had the catheter, it contained the VRE in the urine so isolation precautions were not necessary. The catheter was put in because she wanted to come out of her room and the catheter made it possible because it held in the urine infection. 20. ADON A was interviewed on 11/18/15 at 8:05 AM and stated she was the one who called and spoke with PA OO about the 11/11/15 lab results which showed VRE in Resident #5's urine. ADON A stated when she asked what isolation precautions were necessary, PA OO stated if a urinary catheter was placed it contained the urine, so you don't have to worry. ADON A stated Resident #5 was not on any isolation precautions prior to the 11/11/15 lab results until the evening of 11/17/15, when the catheter was removed and contact precautions initiated. 21. Housekeeper F was interviewed on 11/18/15 at 8:14 AM and stated she cleaned the 700 and 500 halls. Housekeeper F stated she knew when a resident was on isolation precautions because there would be a sign posted to check with the nurse and boxes for linens and trash in the room. Housekeeper F stated nobody on the 700 hall had any kind of isolation precautions but she thought Resident #5 was because she saw the boxes in the bathroom that day. Housekeeper F stated if a resident was on isolation precautions, she would use a bleach based disinfectant spray and wipes to clean the room. Housekeeper F added she would change out her mop head and water when finished with the room. 22. On 11/18/15 at 9:33 AM, the Housekeeping Supervisor was interviewed and stated he helped oversee the housekeeping staff to insure they had supplies and followed proper cleaning procedures. He added if a resident was on isolation precautions, they would use bleach based disinfectants, and change out any pads or mop heads used for cleaning the room. When asked how he knew who was on isolation precautions, the Housekeeping supervisor stated he attended the morning meetings where such information was shared, or when a nurse asked for isolation supplies. The supervisor added, he was responsible for setting up the supply cabinet outside the room to hold the gowns and gloves. When asked if anyone was on isolation precautions, the supervisor stated Resident #5 was started on precautions the previous evening; and that was the first time since she returned from the hospital that he had been asked to place the supply cabinet outside her room. 23. The Central Supply Supervisor was interviewed on 11/18/15 at 9:46 AM and stated she was in charge of making sure the staff had enough gowns, gloves, masks, washable bags, red bags; and disposable blood pressure cuffs, stethoscopes and thermometers when a resident was on isolation precautions. The supervisor added she was responsible for making sure the cabinets outside the door and the supply closets on the floor were sufficiently stocked. The supervisor stated she became aware during the evening on 11/17/15, that Resident #5 was on isolation precautions and that was the first time since she returned from the hospital she had been asked to stock the cabinet outside her room. 24. According to Resident #16's MDS assessment, dated 08/17/15, she was a [AGE] year-old female admitted to the facility on [DATE]. The assessment reflected Resident #16 had [DIAGNOSES REDACTED]. and Anxiety. Resident #16 required extensive assistance of two persons for transfers and extensive assistance of one staff person for dressing, eating, toileting, personal hygiene and bathing. The assessment also reflected she had both short and long-term memory loss. She had an indwelling catheter and was frequently incontinent of bowel. According to Resident #16's initial MDS assessment dated [DATE], Resident #16 did not present to the facility with an indwelling urinary catheter. 25. Review of Resident #16's physician's orders [REDACTED]. The nurse's notes dated 11/10/15 at 02:07 AM, reflected Resident #16 was catheterized solely to collect ordered urine specimen and the catheter was removed once the specimen was obtained. Resident #16's urine culture and sensitivity dated 11/13/15, revealed the urine was positive for bacteria and the organism was Escherichia coli, greater than 100,000 colony forming units per milliliter of urine. Escherichia coli are bacteria that live in human intestines. E.coli (Escherichia coli) | E.coli | CDC <http://www.cdc.gov/ecoli/index.html> Retrieved 11/25/15. The urine culture result also reflected the organism had been confirmed as an Extended-Spectrum Beta Lactamase (ESBL) producer. According to www.medscape.com <http://www.medscape.com> Retrieved 11/24/15: Extended-spectrum beta lactamases (ESBL) are enzymes produced by Gram Negative Bacteria (mainly Escherichia coli and [DIAGNOSES REDACTED] pneumonia), which are responsible for resistance against [MEDICATION NAME], Cephalosporins and Aztreonam antibiotics making them ineffective for treatment. 26. Review of the nurse's notes dated 11/13/15, revealed LVN C contacted Nurse Practitioner PP and informed her of Resident #16's urine and Culture and Sensitivity results. The notes further reflected LVN C told NP PP of the ESBL organism and asked her if an indwelling urinary catheter necessary. NP PP told the nurse there was no need for a catheter and gave the order for Resident #16 to receive one gram of Ertapenam (Antibiotic) intramuscularly once a day for seven days. A physician's orders [REDACTED].#16 was to receive one gram of Ertapenam intramuscularly, once a day for seven days and to be discontinued on 11/20/15. LVN C was interviewed at 3:45 PM on 11/19/15. She stated she found Resident #16 had a urinary tract infection when she reviewed the 24-hour report on 11/13/15. She stated she notified ADON A and NP PP. LVN C stated she told NP PP Resident #16's lab report showed she had E. coli and ESBL in her urine. She stated NP PP ordered an antibiotic. LVN C also stated she asked NP PP if she wanted Resident #16 to have a urinary catheter, and the NP PP said a catheter was not necessary. She stated no orders were given for contact precautions at that time. 27. Resident #16's nurse's notes dated 11/16/15, reflected LVN H received an order from PA OO to insert an indwelling urinary catheter for Resident #16 until the antibiotics were completed due to ESBL in the urine. The notes further reflected the catheter was inserted and that Resident #16 understood the catheter would only be in place until the antibiotics were completed. 28. Physician orders [REDACTED].#16 was to have an indwelling urinary catheter inserted during her antibiotic therapy for ESBL in the urine. 29. Resident #16's care plan initiated on 11/17/15, reflected: I have Indwelling Foley catheter r/t (related to) Multidrug resistant infectious disease process in my urine, urinary incontinence and intermittent confusion; resulting in inability to re-educate and maintain infection control contact precautions in a community. I choose to have a catheter to facilitate and maintain my infectious disease and allow me to have a community living environment . Me and my RP (responsible party) understand without a catheter I am at risk to others in my community. 30. Resident #16 was seen on 11/17/15 at 10:32 AM in her room speaking with a visitor. LVN H stated at that time Resident #16 was alert and oriented to time, person, and place. LVN H added Resident #16 had an indwelling urinary catheter placed during her antibiotic treatment for [REDACTED].#16 had ESBL in her urine and contact isolation was not necessary because she had the catheter placed. During this observation, no signage was posted upon entry to the room to alert any person entering that Resident #16 required contact precautions. Also, there was no personal protective equipment set up outside. 31. On 11/17/15 at 4:51 PM, LVN C was interviewed and stated she was the charge nurse for the 600 hall. When asked why Resident #16 did not have biohazardous waste containers for the linen and trash, LVN C replied it was not necessary. LVN C added because Resident #16 had an indwelling urinary catheter, it contained the infection and no contact precautions were needed. Resident #16's room was observed immediately after this conversation. No biohazardous waste boxes for linens and trash; dedicated items; personal protective equipment or signage alerting any person who entered the room that contact precautions were necessary was observed. 32. On 11/18/15 at 7:27 AM, MA G was interviewed and stated she passed medications to all the residents on her unit, to include Residents on the 500, 600 and 700 halls. When asked if any of the residents on her halls were in isolation, MA G said nobody was on isolation precautions. MA G was asked how she knew and replied, I would know because there would be a sign outside their room. Resident #16 resided on the 600 hall. 33. LVN H was interviewed on 11/18/15 at 7:45 AM, and stated she was the charge nurse for all the residents on the 600 hall, and rooms [ROOM NUMBERS]. LVN H was asked who was on isolation precautions and she replied nobody in her assigned rooms was on any precautions. LVN H stated when Resident #16 got the ESBL in her urine, a catheter was placed so there was no need for isolation. 34. On 11/18/15 at 7:52 AM, Housekeeper E was interviewed and stated today she was assigned to clean the 600 hall and another hall on the other unit. Housekeeper E stated sometimes she is assigned to other hallways. Housekeeper E stated she knew when a resident was on isolation precautions because there would be a sign posted and all of the equipment you need to wear is outside the door. Housekeeper E stated nobody on the 600 hall had any kind of isolation precautions. Housekeeper E stated if a resident was on isolation precautions, she would use a different chemical disinfectant spray and wipes to clean the room. Housekeeper E added she would pay extra attention to the door knobs, window sills, bathroom, and siderails; and she would change out her mop head and water when finished with the room. 35. At 11:15 AM on 11/18/15 an interview was conducted with CNA J. She stated she worked the 600 Hall. When asked if there were any residents on that hall who were on isolation precautions she said she did not know of anyone. She stated if a resident was on isolation precautions she would wear gowns, gloves, and a mask. CNA J added meals would be served on paper plates which remained in the room afterwards and the plastic trays were not to enter the room. She also stated she would dispose of the linens and trash in the special boxes kept in the resident's room. When she was asked how she knew when a resident was on contact isolation precautions, she replied that she knew by the sign that was posted on the wall outside of the room. 36. At 12:00 noon on 11/18/15, Resident #16's room was observed. There was no contact precautions sign on the outside of her room to inform staff and visitors of the precautions and the presence of an infection. There was no container located outside of the room to store the personal protective equipment such as gowns, gloves and masks. There were no isolation boxes in the room for staff to properly dispose of soiled lines and trash properly. 37. The physician orders [REDACTED].#16 and to start contact precautions related to Infection Control for ESBL in the urine. 38. The nurse's notes dated 11/19/15 at 4:31 PM, reflected Resident #16 was on contact isolation for ESBL in the urine. The notes also reflected Resident #16 had voided as soon as the catheter was removed. The nurse's notes dated 11/19/15 at 6:45 PM reflected the staff contacted Resident #16's family member regarding the removal of the catheter and the contact isolation precautions set in place related to the ESBL in the urine. The notes reflected the nurse also explained the facility would not place a urinary catheter any longer for infections and that the contact precautions would remain in place until the infection was resolved. The notes also reflected the catheter had been removed due to inappropriate use of indwelling urinary catheter to contain an infectious disease process and that Resident #16 was on active contact precautions and visitors would need to see the nurse at nurse's station when visiting. 39. At 8:00 AM on 11/19/15, Resident #16's room was observed to have a contact precautions sign posted outside her door. Outside her door was a cabinet of personal protective equipment. The biohazardous containers for Resident #16's trash and linens were in her bathroom. Resident #16's roommate, Resident #7, was also transferred to another room. 40. At 11:05 AM on 11/20/15, Resident #16 was sitting in her wheelchair by the nurse's station. When asked how she felt after the catheter had been removed, she said, It was most definitely better. 41. The Activity Director was interviewed on 11/20/15 at 10:58 AM. He stated he

Based on observation, interview and record review the facility failed to implement their policy and procedures to prevent neglect for one (Resident #1) of two residents reviewed for neglect as evidenced by: 1) LVN A, RN E and CNA C failed to perform the [MEDICATION NAME] maneuver correctly when Resident #1 was choking, went unconscious and subsequently expired at the facility. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. This failure placed the 97 residents in the facility who received oral nutrition and medication at risk of choking resulting in harm and possibly death. Findings included: 1) Resident #1 was an [AGE] year-old-male readmitted to the facility on [DATE] per his significant change MDS dated [DATE]. This document further reflected he had [DIAGNOSES REDACTED]. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:20 AM reflected, .this res is noted to be sitting upright in w/ch, in the day area, eyes open, not focusing on anything in particular, face slightly reddened, visibly attempting to catch his breath and choking, MA B stated that she thought that this res might be choking on 'the fish oil pill' this nurse noted MA B and CNA C were calling his name and patting him on the back, this res is not able to respond verbally, ., this res then stood in an upright position, res legs were extended but not bearing weight, .as staff attempting to stand this res upright, . this res began to lose consciousness and was sat down in the w/ch, .RN E who approached the staff surrounding this res and instructed staff to pat this res back, while staff was patting res back, this nurse performed a sternal rub, ., this nurse instructed CNA C to call 911, this res is noted to not be responding, limbs flaccid x 4, skin color changing to a pale yellow, .vitals were taken on this res, no breaths (sic) sounds heard, res not responding to stimuli verbal/touch), eyes closed, limbs remain flaccid x 4. No b/p and pulse noted staff remained with this res awaiting arrival of 911. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:30 AM reflected, 911 and paramedics arrived to this facility, ambulated this res via w/ch to room for privacy, .resident pronounced expired at this time. The facility's Incident Investigation Report dated and signed by the DON on [DATE], reflected on [DATE] at 7:30 AM, reflected Resident aspirated on foreign body .resulting in death (Resident #1) displayed s/s (sic) foreign body occlusion of airway after taking third pill with water . This document further reflected Back thrust (more beneficial in infant and children) do (sic) move air from inside lungs outward and considering the inability of pt to stand on his own .Upon help arriving to scene .Conscious Pt with choking on FBO was stood and positioned by two CNA (sic) and [MEDICATION NAME] (Abdominal thrust) was initiated by a third person .6. Upon pt losing consciousness and arrival of additional staff to scene including a RN. Pt was seated as could no longer be held upright by CNA's, and per instruction of RN: Pt was held in a seated leaning position and back thrusts were again performed by staff . The investigation report also reflected actions taken post-investigation refresher in-service on [MEDICATION NAME] . The American College of Emergency Physician's website, accessed on [DATE], provided the following information related to the [MEDICATION NAME] maneuver: In the event of choking, the American Heart Association and ACEP offer the following guidelines: . Conscious Adult .If the person can speak, cough or breathe, do not interfere. If the person cannot speak, cough or breathe, give abdominal thrusts known as the [MEDICATION NAME] Maneuver Unconscious Adult Position the person on his or her back, arms by side. .If the person is not breathing . give six to 10 abdominal thrusts (the [MEDICATION NAME] Maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts Web Address: <http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Choking-%[MEDICATION NAME]-Maneuver%29/> During an interview with LVN A on [DATE] at 10:50 AM she said she had been on the 300 hall and CNA C was in the day area. LVN A said she was by Resident #1's room when CNA C called for her to come that Resident #1 was choking. LVN A said as she arrived on the scene Resident #1 was in his w/c both MA B and CNA C were rubbing his back while he was choking so she got down in front of him and asked him if he was ok and he could not speak. LVN A stated they stood Resident #1 up and attempted to hold him up while she attempted the [MEDICATION NAME] until he went unconscious. LVN A stated after Resident #1 became unconscious they sat him back into his w/c and she did a sternal rub. LVN A stated RN E came and instructed staff to start hitting him on his back. When asked why they did not lower him to the ground and continue the [MEDICATION NAME] abdominal thrusts LVN A stated she had not thought of that. When asked what she would do differently in the future she stated she would lay him on a hard surface and continue the [MEDICATION NAME] abdominal thrusts. During an interview with CNA F on [DATE] at 12:22 PM she stated she had tried to help hold him up. CNA F also stated she was standing on his left side and they were going back and forth standing him up and sitting him down in his w/c. When CNA F was asked if anyone had instructed them to lay Resident #1 down on the floor on his back to do the [MEDICATION NAME] abdominal thrusts, she stated no. During an interview with MA B on [DATE] at 12:45 PM she stated she had given Resident #1 his third pill followed by a drink of water and he started coughing so she pat him on his back and asked if he was ok. She stated CNA C came around and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his wheel chair. She also stated when LVN A came she instructed them to stand Resident #1 up while she attempted the [MEDICATION NAME]. MA B said they were standing him up and sitting him down and when he went unconscious they sat him down and RN E arrived and instructed them to pat him on the back. When asked if anyone had instructed them to lay him on the ground and continue the [MEDICATION NAME] she stated no one had ever told them to lay him on the ground. During an interview with CNA D on [DATE] at 4:09 PM she stated when she and RN E got to Resident #1 he was unconscious and seated in his wheelchair and RN E went and began pounding him on his back. When asked if they had lay Resident #1 on the floor to do the [MEDICATION NAME] abdominal thrusts CNA D said no they had not placed him on the floor. During an interview with RN E on [DATE] at 4:26 PM she stated when she arrived on the scene Resident #1 was sitting in his w/c and MA B told her he was choking on a pill. RN E stated she told them to do back thrusts. When asked if they had placed Resident #1 on the ground to do the [MEDICATION NAME] abdominal thrusts she said no it had all went so fast. During an interview with the DON on [DATE] at 10:37 AM stated he had initiated an in-service on the [MEDICATION NAME] maneuver but had not in-serviced all direct care staff. He also stated they had no previous in-service on the [MEDICATION NAME] maneuver prior to Resident #1's incident. Review of the staff sign in sheets for the in-service on the [MEDICATION NAME] maneuver dated [DATE] revealed only 41 signatures out of 78 total direct care staff had had the in-service as of [DATE] at 12:00 PM. During an interview with the DON on [DATE] at 12:02 PM when asked why only 41 out of 78 direct care staff had been in-serviced up until this time he stated it was an on-going in-service. He stated we (He and the ADONs) are catching staff as they come in to work and in-servicing them. The DON also stated the day and evening shifts were the focus of the in-service because residents don't eat at night. (Note: Resident #1 choked on medications not food.) During an interview with CNA C on [DATE] at 12:33 PM she stated MA B was giving Resident #1 his morning medications on [DATE]. He was in his w/c by the nurse's station. CNA C stated she (CNA C) looked away for a second and Resident #1 began to make a gurgling noise like he was trying to get something up. CNA C stated she screamed for LVN A and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his w/c. CNA C also stated when LVN A arrived we tried to stand him up and was not able to . When asked, CNA C stated he was able to sit up but not stand. During an interview with ADON H on [DATE] at 1:37 PM she stated Resident #1 was not able to stand at the time of the incident and the staff had commented Resident #1 was dead weight and that it took one person on each side and one behind him to stand him up. ADON H stated if she had been there she would have eased Resident #1 to the floor and proceeded with the [MEDICATION NAME] abdominal thrusts. During an interview with ADON G on [DATE] at 12:52 PM she stated she had been instructed to in-service her direct care staff on the [MEDICATION NAME] maneuver as a result of the incident with Resident #1. When asked what she taught her staff, ADON G stated the facility's policy and procedure on the [MEDICATION NAME] Maneuver was her tool for teaching. When asked what shifts she had in-serviced she stated she felt she had gotten basically all direct care and nursing staff on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift but was still working on the 10:00 PM to 6:00 AM shift as well as PRN staff. ADON G stated she was catching her staff as they came in to work. When asked how she was teaching she stated she first showed them the guidelines from their policy and procedure and then demonstrated on them the [MEDICATION NAME] maneuver and how to ease an unconscious resident to the floor and perform [MEDICATION NAME] abdominal thrusts. The facility's policy and procedure on [MEDICATION NAME] Maneuver revised [DATE] reflected the following: Unconscious Resident . 1. Ease the resident gently to the floor . 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: . The facility's Abuse Prevention Program policy and procedure dated revised [DATE] reflected the following: Our residents have the right to be free from . neglect .Comprehensive policies and procedures have been developed to aid our facility in preventing . neglect . of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .i. The implementation of changes to prevent future occurrences of .Neglect: A failure to provide goods and services necessary to avoid physical harm . An IJ was identified on [DATE] at 3:13 PM. The Administrator and DON were notified at that time of the IJ and a POR was requested. The facility's fifth POR was accepted on [DATE]. The plan reflected the following: -- The facility began in-services of the direct care nursing staff on [MEDICATION NAME] Procedure of unconscious resident on [DATE] by the DON and ADONs to be completed by [DATE]. --On [DATE] one on one corrective action was conducted for RN E by the DON and she was re-trained and showed proficiency on [DATE]. --On [DATE] the DON was re-trained by the MD with return demonstration on the [MEDICATION NAME] maneuver in addition ADONs G, H and N were re-trained with return demonstration. --As of [DATE] direct care nursing staff had been retrained in the [MEDICATION NAME] maneuver with return demonstration by the DON and ADONs G, H and N. In addition direct care nursing staff was taken off the work schedule until successful completion of training and return demonstration. --All new direct care nursing staff will receive training for the [MEDICATION NAME] maneuver upon orientation and this was added to the new hire orientation schedule effective [DATE]. --Choking signage posted in the meal service areas was explained in detail to direct care nursing staff and Facility's policy and procedure for the [MEDICATION NAME] attached next to signage on [DATE]. On [DATE] new choking signage was hung in all meal service areas. --All residents with swallowing difficulties were identified, their care plans reviewed and updated as needed with two residents added on [DATE]. --[DATE] all direct care nursing staff were in-serviced on the locations of lists which identified residents with swallowing problems. A list of these residents was made and staff were in-servised on the multible locations where this list could be found. --As of [DATE] all dietary, environmental and administrative staff will be trained on the [MEDICATION NAME] maneuver which will be completed by [DATE]. In addition staff that do not attend this training or fail to present an understanding of the [MEDICATION NAME] maneuver will be re-moved from the schedule until they attend and demonstrate an understanding. --This process will be monitored by the Admin and BOM. Over the next 60 days the Admin and BOM will monitor weekly the systemic compliance process beginning [DATE] after day 61 the Admin and BOM will conduct random checks. --All CNAs, MAs, RNs and LVNs will have annual skills check offs including return demonstration of the [MEDICATION NAME] maneuver and will be monitored by the Admin and BOM. --All the above noted processes are to be reviewed by the QA committee for recommendations and review. To verify implementation of the plan, the following was conducted: The facility's in-service titled [MEDICATION NAME] Maneuver Refresher Course dated [DATE] which was continued through [DATE] and was conducted by ADONs G and H reflected a total of 68 direct care staff members and nurses attended this in-service which was the majority of staff from all three shifts. The facility's in-service conductd on [DATE] by the DON and ADON H which informed staff where the list of residents with swallowing problems was kept was atteded by 64 direct care staff and nurses which was the majority of staff from all three shifts. During individual interviews with the following nurses they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 2:49 PM, with LVN K. --On [DATE] at 9:59 AM, 10:00 AM, 12:04 PM, 12:11 PM, 1:48 PM and 2:41 PM with RN E, LVN A, LVN O, LVN P, MDS Coordinator and ADON G. --On [DATE] at 9:31 AM, 10:12 AM, 10:33 AM, 11:55 AM, 2:14 PM with LVN R, ADON N, LVN WW, LVN XX . During individual interviews with the following CNAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 12:33 PM, 3:28 PM and 3:35 PM with CNA C, CNA Y and CNA PP. --On [DATE] at 10:26 AM, 11:01 AM, 11:14 AM, 11:20 AM, 11:45 AM, 12:25 PM, 12:32 PM, 3:18 PM, 3:28 PM, 3:41 PM and 3:46 PM with CNA FF, CNA U, CNA F, CNA D, CNA EE, CNA Z, CNA V, CNA Y, CNA X, CNA KK and CNA L. --On [DATE] at 10:00 AM, 10:07 AM, 10:13 AM, 10:20 AM, 10:50 AM, 11:49 AM, 12:18 PM, 12:32 PM, 2:04 PM and 4:04 PM with CNA JJ, CNA DD, CNA II, Staffing Coordinator, CNA AA, CNA CC, CNA T, CNA W, CNA BB and CNA M. --[DATE] at 12:26 PM, 2:39 PM and 3:09 PM with CNA S, CNA HH and CNA GG. During individual interviews with the following MAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 10:35 AM and 12:18 PM with MA B and MA LL. --On [DATE] at 9:46 AM, 10:41 AM and 2:24 PM with MA NN, MA YY and MA MM. On [DATE] at 3:20 PM observations were made of all four meal service areas in the facility and the new [MEDICATION NAME] maneuver poster was observed to be hanging in each meal service room. In addition an observation was made of each area documented in the facility's POR as having the list of residents with swallowing problems which were available for all staff to access. During individual interviews conducted on [DATE] at 3:33 PM, 3:48 PM, 3:55 PM, 4:02 PM, 4:07 PM, 4:40 PM, 4:30 PM and 4:49 PM with RN VV, CNA OO, LVN UU, CNA TT, CNA SS, CNA RR, CNA PP and MA QQ. All these additional staff were interviewed in regards to the [MEDICATION NAME] maneuver with a conscious and unconscious resident and where the list of residents with swallowing problems could be found. They all answered the questions appropriately and knew what to do as well as where to find the lists of residents with swallowing priblems. Additional individual interviews were conducted on [DATE] at 3:10 PM, 3:10 PM, 3:30 PM, 4:19 PM, 4:26 PM and 4:36 PM with CNA BB, CNA S, CNA M, Staffing Coordinator, CNA X and CNA V. All CNAs knew at least two to three or more locations of the list of residents with swallowing problems. Additional individual interviews were conducted on [DATE] at 3:25 PM, 4:15 PM, 4:25 PM and 4:39 PM with LVN O, LVN A, LVN P and LVN Q and they all answered the additional questions about where the location of the list of residents with swallowing problems were kept. On [DATE] at 5:30 PM the Admin and DON were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance as a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. Per the facility's Form CMS-672 Resident Census and Conditions of Residents signed and dated [DATE] by the MDS Coordinator, there were 111 residents residing in the facility and 14 residents had [DEVICE]s.

Based on observation, interview and record review the facility failed to implement their written policy and procedures to prevent neglect for one (Resident #1) of two residents reviewed for neglect as evidenced by: 1) LVN A, RN E and CNA C failed to perform the [MEDICATION NAME] maneuver correctly when Resident #1 was choking, went unconscious and subsequently expired at the facility. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. This failure placed the 97 residents in the facility who received oral nutrition and medication at risk of choking resulting in harm and possibly death. Findings included: The facility's Abuse Prevention Program policy and procedure dated revised [DATE] reflected the following: Our residents have the right to be free from . neglect .Comprehensive policies and procedures have been developed to aid our facility in preventing . neglect . of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .i. The implementation of changes to prevent future occurrences of .Neglect: A failure to provide goods and services necessary to avoid physical harm . The facility's policy and procedure on [MEDICATION NAME] Maneuver dated revised [DATE] reflected the following: Unconscious Resident . 1. Ease the resident gently to the floor . 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: . 1) Resident #1 was an [AGE] year-old-male readmitted to the facility on [DATE] per his significant change MDS dated [DATE]. This document further reflected he had [DIAGNOSES REDACTED]. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:20 AM reflected, .this res is noted to be sitting upright in w/ch, in the day area, eyes open, not focusing on anything in particular, face slightly reddened, visibly attempting to catch his breath and choking, MA B stated that she thought that this res might be choking on 'the fish oil pill' this nurse noted MA B and CNA C were calling his name and patting him on the back, this res is not able to respond verbally, ., this res then stood in an upright position, res legs were extended but not bearing weight, .as staff attempting to stand this res upright, . this res began to lose consciousness and was sat down in the w/ch, .RN E who approached the staff surrounding this res and instructed staff to pat this res back, while staff was patting res back, this nurse performed a sternal rub, ., this nurse instructed CNA C to call 911, this res is noted to not be responding, limbs flaccid x 4, skin color changing to a pale yellow, .vitals were taken on this res, no breaths (sic) sounds heard, res not responding to stimuli verbal/touch), eyes closed, limbs remain flaccid x 4. No b/p and pulse noted staff remained with this res awaiting arrival of 911. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:30 AM reflected, 911 and paramedics arrived to this facility, ambulated this res via w/ch to room for privacy, .resident pronounced expired at this time. The facility's Incident Investigation Report dated and signed by the DON on [DATE], reflected on [DATE] at 7:30 AM, reflected Resident aspirated on foreign body .resulting in death (Resident #1) displayed s/s (sic) foreign body occlusion of airway after taking third pill with water . This document further reflected Back thrust (more beneficial in infant and children) do (sic) move air from inside lungs outward and considering the inability of pt to stand on his own .Upon help arriving to scene .Conscious Pt with choking on FBO was stood and positioned by two CNA (sic) and [MEDICATION NAME] (Abdominal thrust) was initiated by a third person .6. Upon pt losing consciousness and arrival of additional staff to scene including a RN. Pt was seated as could no longer be held upright by CNA's, and per instruction of RN: Pt was held in a seated leaning position and back thrusts were again performed by staff . The investigation report also reflected actions taken post-investigation refresher in-service on [MEDICATION NAME] . The American College of Emergency Physician's website, accessed on [DATE], provided the following information related to the [MEDICATION NAME] maneuver: In the event of choking, the American Heart Association and ACEP offer the following guidelines: . Conscious Adult .If the person can speak, cough or breathe, do not interfere. If the person cannot speak, cough or breathe, give abdominal thrusts known as the [MEDICATION NAME] Maneuver Unconscious Adult Position the person on his or her back, arms by side. .If the person is not breathing . give six to 10 abdominal thrusts (the [MEDICATION NAME] Maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts Web Address: <http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Choking-%[MEDICATION NAME]-Maneuver%29/> During an interview with LVN A on [DATE] at 10:50 AM she said she had been on the 300 hall and CNA C was in the day area. LVN A said she was by Resident #1's room when CNA C called for her to come that Resident #1 was choking. LVN A said as she arrived on the scene Resident #1 was in his w/c both MA B and CNA C were rubbing his back while he was choking so she got down in front of him and asked him if he was ok and he could not speak. LVN A stated they stood Resident #1 up and attempted to hold him up while she attempted the [MEDICATION NAME] until he went unconscious. LVN A stated after Resident #1 became unconscious they sat him back into his w/c and she did a sternal rub. LVN A stated RN E came and instructed staff to start hitting him on his back. When asked why they did not lower him to the ground and continue the [MEDICATION NAME] abdominal thrusts LVN A stated she had not thought of that. When asked what she would do differently in the future she stated she would lay him on a hard surface and continue the [MEDICATION NAME] abdominal thrusts. During an interview with CNA F on [DATE] at 12:22 PM she stated she had tried to help hold him up. CNA F also stated she was standing on his left side and they were going back and forth standing him up and sitting him down in his w/c. When CNA F was asked if anyone had instructed them to lay Resident #1 down on the floor on his back to do the [MEDICATION NAME] abdominal thrusts, she stated no. During an interview with MA B on [DATE] at 12:45 PM she stated she had given Resident #1 his third pill followed by a drink of water and he started coughing so she pat him on his back and asked if he was ok. She stated CNA C came around and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his wheel chair. She also stated when LVN A came she instructed them to stand Resident #1 up while she attempted the [MEDICATION NAME]. MA B said they were standing him up and sitting him down and when he went unconscious they sat him down and RN E arrived and instructed them to pat him on the back. When asked if anyone had instructed them to lay him on the ground and continue the [MEDICATION NAME] she stated no one had ever told them to lay him on the ground. During an interview with CNA D on [DATE] at 4:09 PM she stated when she and RN E got to Resident #1 he was unconscious and seated in his wheelchair and RN E went and began pounding him on his back. When asked if they had lay Resident #1 on the floor to do the [MEDICATION NAME] abdominal thrusts CNA D said no they had not placed him on the floor. During an interview with RN E on [DATE] at 4:26 PM she stated when she arrived on the scene Resident #1 was sitting in his w/c and MA B told her he was choking on a pill. RN E stated she told them to do back thrusts. When asked if they had placed Resident #1 on the ground to do the [MEDICATION NAME] abdominal thrusts she said no it had all went so fast. During an interview with the DON on [DATE] at 10:37 AM stated he had initiated an in-service on the [MEDICATION NAME] maneuver but had not in-serviced all direct care staff. He also stated they had no previous in-service on the [MEDICATION NAME] maneuver prior to Resident #1's incident. Review of the staff sign in sheets for the in-service on the [MEDICATION NAME] maneuver dated [DATE] revealed only 41 signatures out of 78 total direct care staff had had the in-service as of [DATE] at 12:00 PM. During an interview with the DON on [DATE] at 12:02 PM when asked why only 41 out of 78 direct care staff had been in-serviced up until this time he stated it was an on-going in-service. He stated we (He and the ADONs) are catching staff as they come in to work and in-servicing them. The DON also stated the day and evening shifts were the focus of the in-service because residents don't eat at night. (Note: Resident #1 choked on medications not food.) During an interview with CNA C on [DATE] at 12:33 PM she stated MA B was giving Resident #1 his morning medications on [DATE]. He was in his w/c by the nurse's station. CNA C stated she (CNA C) looked away for a second and Resident #1 began to make a gurgling noise like he was trying to get something up. CNA C stated she screamed for LVN A and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his w/c. CNA C also stated when LVN A arrived we tried to stand him up and was not able to . When asked, CNA C stated he was able to sit up but not stand. During an interview with ADON H on [DATE] at 1:37 PM she stated Resident #1 was not able to stand at the time of the incident and the staff had commented Resident #1 was dead weight and that it took one person on each side and one behind him to stand him up. ADON H stated if she had been there she would have eased Resident #1 to the floor and proceeded with the [MEDICATION NAME] abdominal thrusts. During an interview with ADON G on [DATE] at 12:52 PM she stated she had been instructed to in-service her direct care staff on the [MEDICATION NAME] maneuver as a result of the incident with Resident #1. When asked what she taught her staff, ADON G stated the facility's policy and procedure on the [MEDICATION NAME] Maneuver was her tool for teaching. When asked what shifts she had in-serviced she stated she felt she had gotten basically all direct care and nursing staff on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift but was still working on the 10:00 PM to 6:00 AM shift as well as PRN staff. ADON G stated she was catching her staff as they came in to work. When asked how she was teaching she stated she first showed them the guidelines from their policy and procedure and then demonstrated on them the [MEDICATION NAME] maneuver and how to ease an unconscious resident to the floor and perform [MEDICATION NAME] abdominal thrusts. An IJ was identified on [DATE] at 3:13 PM. The Administrator and DON were notified at that time of the IJ and a POR was requested. The facility's fifth POR was accepted on [DATE]. The plan reflected the following: -- The facility began in-services of the direct care nursing staff on [MEDICATION NAME] Procedure of unconscious resident on [DATE] by the DON and ADONs to be completed by [DATE]. --On [DATE] one on one corrective action was conducted for RN E by the DON and she was re-trained and showed proficiency on [DATE]. --On [DATE] the DON was re-trained by the MD with return demonstration on the [MEDICATION NAME] maneuver in addition ADONs G, H and N were re-trained with return demonstration. --As of [DATE] direct care nursing staff had been retrained in the [MEDICATION NAME] maneuver with return demonstration by the DON and ADONs G, H and N. In addition direct care nursing staff was taken off the work schedule until successful completion of training and return demonstration. --All new direct care nursing staff will receive training for the [MEDICATION NAME] maneuver upon orientation and this was added to the new hire orientation schedule effective [DATE]. --Choking signage posted in the meal service areas was explained in detail to direct care nursing staff and Facility's policy and procedure for the [MEDICATION NAME] attached next to signage on [DATE]. On [DATE] new choking signage was hung in all meal service areas. --All residents with swallowing difficulties were identified, their care plans reviewed and updated as needed with two residents added on [DATE]. --[DATE] all direct care nursing staff were in-serviced on the locations of lists which identified residents with swallowing problems. A list of these residents was made and staff were in-servised on the multible locations where this list could be found. --As of [DATE] all dietary, environmental and administrative staff will be trained on the [MEDICATION NAME] maneuver which will be completed by [DATE]. In addition staff that do not attend this training or fail to present an understanding of the [MEDICATION NAME] maneuver will be re-moved from the schedule until they attend and demonstrate an understanding. --This process will be monitored by the Admin and BOM. Over the next 60 days the Admin and BOM will monitor weekly the systemic compliance process beginning [DATE] after day 61 the Admin and BOM will conduct random checks. --All CNAs, MAs, RNs and LVNs will have annual skills check offs including return demonstration of the [MEDICATION NAME] maneuver and will be monitored by the Admin and BOM. --All the above noted processes are to be reviewed by the QA committee for recommendations and review. To verify implementation of the plan, the following was conducted: The facility's in-service titled [MEDICATION NAME] Maneuver Refresher Course dated [DATE] which was continued through [DATE] and was conducted by ADONs G and H reflected a total of 68 direct care staff members and nurses attended this in-service which was the majority of staff from all three shifts. The facility's in-service conductd on [DATE] by the DON and ADON H which informed staff where the list of residents with swallowing problems was kept was atteded by 64 direct care staff and nurses which was the majority of staff from all three shifts. During individual interviews with the following nurses they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 2:49 PM, with LVN K. --On [DATE] at 9:59 AM, 10:00 AM, 12:04 PM, 12:11 PM, 1:48 PM and 2:41 PM with RN E, LVN A, LVN O, LVN P, MDS Coordinator and ADON G. --On [DATE] at 9:31 AM, 10:12 AM, 10:33 AM, 11:55 AM, 2:14 PM with LVN R, ADON N, LVN WW, LVN XX . During individual interviews with the following CNAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 12:33 PM, 3:28 PM and 3:35 PM with CNA C, CNA Y and CNA PP. --On [DATE] at 10:26 AM, 11:01 AM, 11:14 AM, 11:20 AM, 11:45 AM, 12:25 PM, 12:32 PM, 3:18 PM, 3:28 PM, 3:41 PM and 3:46 PM with CNA FF, CNA U, CNA F, CNA D, CNA EE, CNA Z, CNA V, CNA Y, CNA X, CNA KK and CNA L. --On [DATE] at 10:00 AM, 10:07 AM, 10:13 AM, 10:20 AM, 10:50 AM, 11:49 AM, 12:18 PM, 12:32 PM, 2:04 PM and 4:04 PM with CNA JJ, CNA DD, CNA II, Staffing Coordinator, CNA AA, CNA CC, CNA T, CNA W, CNA BB and CNA M. --[DATE] at 12:26 PM, 2:39 PM and 3:09 PM with CNA S, CNA HH and CNA GG. During individual interviews with the following MAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 10:35 AM and 12:18 PM with MA B and MA LL. --On [DATE] at 9:46 AM, 10:41 AM and 2:24 PM with MA NN, MA YY and MA MM. On [DATE] at 3:20 PM observations were made of all four meal service areas in the facility and the new [MEDICATION NAME] maneuver poster was observed to be hanging in each meal service room. In addition an observation was made of each area documented in the facility's POR as having the list of residents with swallowing problems which were available for all staff to access. During individual interviews conducted on [DATE] at 3:33 PM, 3:48 PM, 3:55 PM, 4:02 PM, 4:07 PM, 4:40 PM, 4:30 PM and 4:49 PM with RN VV, CNA OO, LVN UU, CNA TT, CNA SS, CNA RR, CNA PP and MA QQ. All these additional staff were interviewed in regards to the [MEDICATION NAME] maneuver with a conscious and unconscious resident and where the list of residents with swallowing problems could be found. They all answered the questions appropriately and knew what to do as well as where to find the lists of residents with swallowing priblems. Additional individual interviews were conducted on [DATE] at 3:10 PM, 3:10 PM, 3:30 PM, 4:19 PM, 4:26 PM and 4:36 PM with CNA BB, CNA S, CNA M, Staffing Coordinator, CNA X and CNA V. All CNAs knew at least two to three or more locations of the list of residents with swallowing problems. Additional individual interviews were conducted on [DATE] at 3:25 PM, 4:15 PM, 4:25 PM and 4:39 PM with LVN O, LVN A, LVN P and LVN Q and they all answered the additional questions about where the location of the list of residents with swallowing problems were kept. On [DATE] at 5:30 PM the Admin and DON were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance as a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. Per the facility's Form CMS-672 Resident Census and Conditions of Residents signed and dated [DATE] by the MDS Coordinator, there were 111 residents residing in the facility and 14 residents had [DEVICE]s.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care, for one (Resident #1) of one residents reviewed for death as evidenced by: 1) LVN A, RN E and CNA C failed to perform the [MEDICATION NAME] maneuver correctly when Resident #1 was choking, went unconscious and subsequently expired at the facility. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. This failure placed the 97 residents in the facility who received oral nutrition and medication at risk of choking resulting in harm and possibly death. Findings included: 1) Resident #1 was an [AGE] year-old-male readmitted to the facility on [DATE] per his significant change MDS dated [DATE]. This document further reflected he had [DIAGNOSES REDACTED]. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:20 AM reflected, .this res is noted to be sitting upright in w/ch, in the day area, eyes open, not focusing on anything in particular, face slightly reddened, visibly attempting to catch his breath and choking, MA B stated that she thought that this res might be choking on 'the fish oil pill' this nurse noted MA B and CNA C were calling his name and patting him on the back, this res is not able to respond verbally, ., this res then stood in an upright position, res legs were extended but not bearing weight, .as staff attempting to stand this res upright, . this res began to lose consciousness and was sat down in the w/ch, .RN E who approached the staff surrounding this res and instructed staff to pat this res back, while staff was patting res back, this nurse performed a sternal rub, ., this nurse instructed CNA C to call 911, this res is noted to not be responding, limbs flaccid x 4, skin color changing to a pale yellow, .vitals were taken on this res, no breaths (sic) sounds heard, res not responding to stimuli verbal/touch), eyes closed, limbs remain flaccid x 4. No b/p and pulse noted staff remained with this res awaiting arrival of 911. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:30 AM reflected, 911 and paramedics arrived to this facility, ambulated this res via w/ch to room for privacy, .resident pronounced expired at this time. The facility's Incident Investigation Report dated and signed by the DON on [DATE], reflected on [DATE] at 7:30 AM, reflected Resident aspirated on foreign body .resulting in death (Resident #1) displayed s/s (sic) foreign body occlusion of airway after taking third pill with water . This document further reflected Back thrust (more beneficial in infant and children) do (sic) move air from inside lungs outward and considering the inability of pt to stand on his own .Upon help arriving to scene .Conscious Pt with choking on FBO was stood and positioned by two CNA (sic) and [MEDICATION NAME] (Abdominal thrust) was initiated by a third person .6. Upon pt losing consciousness and arrival of additional staff to scene including a RN. Pt was seated as could no longer be held upright by CNA's, and per instruction of RN: Pt was held in a seated leaning position and back thrusts were again performed by staff . The investigation report also reflected actions taken post-investigation refresher in-service on [MEDICATION NAME] . The American College of Emergency Physician's website, accessed on [DATE], provided the following information related to the [MEDICATION NAME] maneuver: In the event of choking, the American Heart Association and ACEP offer the following guidelines: . Conscious Adult .If the person can speak, cough or breathe, do not interfere. If the person cannot speak, cough or breathe, give abdominal thrusts known as the [MEDICATION NAME] Maneuver Unconscious Adult Position the person on his or her back, arms by side. .If the person is not breathing . give six to 10 abdominal thrusts (the [MEDICATION NAME] Maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts Web Address: <http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Choking-%[MEDICATION NAME]-Maneuver%29/> During an interview with LVN A on [DATE] at 10:50 AM she said she had been on the 300 hall and CNA C was in the day area. LVN A said she was by Resident #1's room when CNA C called for her to come that Resident #1 was choking. LVN A said as she arrived on the scene Resident #1 was in his w/c both MA B and CNA C were rubbing his back while he was choking so she got down in front of him and asked him if he was ok and he could not speak. LVN A stated they stood Resident #1 up and attempted to hold him up while she attempted the [MEDICATION NAME] until he went unconscious. LVN A stated after Resident #1 became unconscious they sat him back into his w/c and she did a sternal rub. LVN A stated RN E came and instructed staff to start hitting him on his back. When asked why they did not lower him to the ground and continue the [MEDICATION NAME] abdominal thrusts LVN A stated she had not thought of that. When asked what she would do differently in the future she stated she would lay him on a hard surface and continue the [MEDICATION NAME] abdominal thrusts. During an interview with CNA F on [DATE] at 12:22 PM she stated she had tried to help hold him up. CNA F also stated she was standing on his left side and they were going back and forth standing him up and sitting him down in his w/c. When CNA F was asked if anyone had instructed them to lay Resident #1 down on the floor on his back to do the [MEDICATION NAME] abdominal thrusts, she stated no. During an interview with MA B on [DATE] at 12:45 PM she stated she had given Resident #1 his third pill followed by a drink of water and he started coughing so she pat him on his back and asked if he was ok. She stated CNA C came around and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his wheel chair. She also stated when LVN A came she instructed them to stand Resident #1 up while she attempted the [MEDICATION NAME]. MA B said they were standing him up and sitting him down and when he went unconscious they sat him down and RN E arrived and instructed them to pat him on the back. When asked if anyone had instructed them to lay him on the ground and continue the [MEDICATION NAME] she stated no one had ever told them to lay him on the ground. During an interview with CNA D on [DATE] at 4:09 PM she stated when she and RN E got to Resident #1 he was unconscious and seated in his wheelchair and RN E went and began pounding him on his back. When asked if they had lay Resident #1 on the floor to do the [MEDICATION NAME] abdominal thrusts CNA D said no they had not placed him on the floor. During an interview with RN E on [DATE] at 4:26 PM she stated when she arrived on the scene Resident #1 was sitting in his w/c and MA B told her he was choking on a pill. RN E stated she told them to do back thrusts. When asked if they had placed Resident #1 on the ground to do the [MEDICATION NAME] abdominal thrusts she said no it had all went so fast. During an interview with the DON on [DATE] at 10:37 AM stated he had initiated an in-service on the [MEDICATION NAME] maneuver but had not in-serviced all direct care staff. He also stated they had no previous in-service on the [MEDICATION NAME] maneuver prior to Resident #1's incident. Review of the staff sign in sheets for the in-service on the [MEDICATION NAME] maneuver dated [DATE] revealed only 41 signatures out of 78 total direct care staff had had the in-service as of [DATE] at 12:00 PM. During an interview with the DON on [DATE] at 12:02 PM when asked why only 41 out of 78 direct care staff had been in-serviced up until this time he stated it was an on-going in-service. He stated we (He and the ADONs) are catching staff as they come in to work and in-servicing them. The DON also stated the day and evening shifts were the focus of the in-service because residents don't eat at night. (Note: Resident #1 choked on medications not food.) During an interview with CNA C on [DATE] at 12:33 PM she stated MA B was giving Resident #1 his morning medications on [DATE]. He was in his w/c by the nurse's station. CNA C stated she (CNA C) looked away for a second and Resident #1 began to make a gurgling noise like he was trying to get something up. CNA C stated she screamed for LVN A and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his w/c. CNA C also stated when LVN A arrived we tried to stand him up and was not able to . When asked, CNA C stated he was able to sit up but not stand. During an interview with ADON H on [DATE] at 1:37 PM she stated Resident #1 was not able to stand at the time of the incident and the staff had commented Resident #1 was dead weight and that it took one person on each side and one behind him to stand him up. ADON H stated if she had been there she would have eased Resident #1 to the floor and proceeded with the [MEDICATION NAME] abdominal thrusts. During an interview with ADON G on [DATE] at 12:52 PM she stated she had been instructed to in-service her direct care staff on the [MEDICATION NAME] maneuver as a result of the incident with Resident #1. When asked what she taught her staff, ADON G stated the facility's policy and procedure on the [MEDICATION NAME] Maneuver was her tool for teaching. When asked what shifts she had in-serviced she stated she felt she had gotten basically all direct care and nursing staff on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift but was still working on the 10:00 PM to 6:00 AM shift as well as PRN staff. ADON G stated she was catching her staff as they came in to work. When asked how she was teaching she stated she first showed them the guidelines from their policy and procedure and then demonstrated on them the [MEDICATION NAME] maneuver and how to ease an unconscious resident to the floor and perform [MEDICATION NAME] abdominal thrusts. The facility's policy and procedure on [MEDICATION NAME] Maneuver revised [DATE] reflected the following: Unconscious Resident . 1. Ease the resident gently to the floor . 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: . An IJ was identified on [DATE] at 3:13 PM. The Administrator and DON were notified at that time of the IJ and a POR was requested. The facility's fifth POR was accepted on [DATE]. The plan reflected the following: -- The facility began in-services of the direct care nursing staff on [MEDICATION NAME] Procedure of unconscious resident on [DATE] by the DON and ADONs to be completed by [DATE]. --On [DATE] one on one corrective action was conducted for RN E by the DON and she was re-trained and showed proficiency on [DATE]. --On [DATE] the DON was re-trained by the MD with return demonstration on the [MEDICATION NAME] maneuver in addition ADONs G, H and N were re-trained with return demonstration. --As of [DATE] direct care nursing staff had been retrained in the [MEDICATION NAME] maneuver with return demonstration by the DON and ADONs G, H and N. In addition direct care nursing staff was taken off the work schedule until successful completion of training and return demonstration. --All new direct care nursing staff will receive training for the [MEDICATION NAME] maneuver upon orientation and this was added to the new hire orientation schedule effective [DATE]. --Choking signage posted in the meal service areas was explained in detail to direct care nursing staff and Facility's policy and procedure for the [MEDICATION NAME] attached next to signage on [DATE]. On [DATE] new choking signage was hung in all meal service areas. --All residents with swallowing difficulties were identified, their care plans reviewed and updated as needed with two residents added on [DATE]. --[DATE] all direct care nursing staff were in-serviced on the locations of lists which identified residents with swallowing problems. A list of these residents was made and staff were in-servised on the multible locations where this list could be found. --As of [DATE] all dietary, environmental and administrative staff will be trained on the [MEDICATION NAME] maneuver which will be completed by [DATE]. In addition staff that do not attend this training or fail to present an understanding of the [MEDICATION NAME] maneuver will be re-moved from the schedule until they attend and demonstrate an understanding. --This process will be monitored by the Admin and BOM. Over the next 60 days the Admin and BOM will monitor weekly the systemic compliance process beginning [DATE] after day 61 the Admin and BOM will conduct random checks. --All CNAs, MAs, RNs and LVNs will have annual skills check offs including return demonstration of the [MEDICATION NAME] maneuver and will be monitored by the Admin and BOM. --All the above noted processes are to be reviewed by the QA committee for recommendations and review. To verify implementation of the plan, the following was conducted: The facility's in-service titled [MEDICATION NAME] Maneuver Refresher Course dated [DATE] which was continued through [DATE] and was conducted by ADONs G and H reflected a total of 68 direct care staff members and nurses attended this in-service which was the majority of staff from all three shifts. The facility's in-service conductd on [DATE] by the DON and ADON H which informed staff where the list of residents with swallowing problems was kept was atteded by 64 direct care staff and nurses which was the majority of staff from all three shifts. During individual interviews with the following nurses they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 2:49 PM, with LVN K. --On [DATE] at 9:59 AM, 10:00 AM, 12:04 PM, 12:11 PM, 1:48 PM and 2:41 PM with RN E, LVN A, LVN O, LVN P, MDS Coordinator and ADON G. --On [DATE] at 9:31 AM, 10:12 AM, 10:33 AM, 11:55 AM, 2:14 PM with LVN R, ADON N, LVN WW, LVN XX . During individual interviews with the following CNAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 12:33 PM, 3:28 PM and 3:35 PM with CNA C, CNA Y and CNA PP. --On [DATE] at 10:26 AM, 11:01 AM, 11:14 AM, 11:20 AM, 11:45 AM, 12:25 PM, 12:32 PM, 3:18 PM, 3:28 PM, 3:41 PM and 3:46 PM with CNA FF, CNA U, CNA F, CNA D, CNA EE, CNA Z, CNA V, CNA Y, CNA X, CNA KK and CNA L. --On [DATE] at 10:00 AM, 10:07 AM, 10:13 AM, 10:20 AM, 10:50 AM, 11:49 AM, 12:18 PM, 12:32 PM, 2:04 PM and 4:04 PM with CNA JJ, CNA DD, CNA II, Staffing Coordinator, CNA AA, CNA CC, CNA T, CNA W, CNA BB and CNA M. --[DATE] at 12:26 PM, 2:39 PM and 3:09 PM with CNA S, CNA HH and CNA GG. During individual interviews with the following MAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 10:35 AM and 12:18 PM with MA B and MA LL. --On [DATE] at 9:46 AM, 10:41 AM and 2:24 PM with MA NN, MA YY and MA MM. On [DATE] at 3:20 PM observations were made of all four meal service areas in the facility and the new [MEDICATION NAME] maneuver poster was observed to be hanging in each meal service room. In addition an observation was made of each area documented in the facility's POR as having the list of residents with swallowing problems which were available for all staff to access. During individual interviews conducted on [DATE] at 3:33 PM, 3:48 PM, 3:55 PM, 4:02 PM, 4:07 PM, 4:40 PM, 4:30 PM and 4:49 PM with RN VV, CNA OO, LVN UU, CNA TT, CNA SS, CNA RR, CNA PP and MA QQ. All these additional staff were interviewed in regards to the [MEDICATION NAME] maneuver with a conscious and unconscious resident and where the list of residents with swallowing problems could be found. They all answered the questions appropriately and knew what to do as well as where to find the lists of residents with swallowing priblems. Additional individual interviews were conducted on [DATE] at 3:10 PM, 3:10 PM, 3:30 PM, 4:19 PM, 4:26 PM and 4:36 PM with CNA BB, CNA S, CNA M, Staffing Coordinator, CNA X and CNA V. All CNAs knew at least two to three or more locations of the list of residents with swallowing problems. Additional individual interviews were conducted on [DATE] at 3:25 PM, 4:15 PM, 4:25 PM and 4:39 PM with LVN O, LVN A, LVN P and LVN Q and they all answered the additional questions about where the location of the list of residents with swallowing problems were kept. On [DATE] at 5:30 PM the Admin and DON were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance as a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. Per the facility's Form CMS-672 Resident Census and Conditions of Residents signed and dated [DATE] by the MDS Coordinator, there were 111 residents residing in the facility and 14 residents had [DEVICE]s.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of two residents reviewed for death/general as evidenced by: 1) The DON and Admin failed to implement the [MEDICATION NAME] maneuver correctly when Resident #1 was choking, went unconscious and subsequently expired. 2) The DON failed to re-educate staff upon identifying improper [MEDICATION NAME] Maneuver policy and procedure. 3) The Admin failed to implement the Abuse/Neglect policy and procedure. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. These failures caused continued choking and prolonged airway obstruction for Resident #1, resulting in his death and placed the 97 residents in the facility who received oral nutrition and medication at risk of choking resulting in harm and possibly death. Findings included: 1) Resident #1 was an [AGE] year-old-male readmitted to the facility on [DATE] per his significant change MDS dated [DATE]. This document further reflected he had [DIAGNOSES REDACTED]. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:20 AM reflected, .this res is noted to be sitting upright in w/ch, in the day area, eyes open, not focusing on anything in particular, face slightly reddened, visibly attempting to catch his breath and choking, MA B stated that she thought that this res might be choking on 'the fish oil pill' this nurse noted MA B and CNA C were calling his name and patting him on the back, this res is not able to respond verbally, ., this res then stood in an upright position, res legs were extended but not bearing weight, .as staff attempting to stand this res upright, . this res began to lose consciousness and was sat down in the w/ch, .RN E who approached the staff surrounding this res and instructed staff to pat this res back, while staff was patting res back, this nurse performed a sternal rub, ., this nurse instructed CNA C to call 911, this res is noted to not be responding, limbs flaccid x 4, skin color changing to a pale yellow, .vitals were taken on this res, no breaths (sic) sounds heard, res not responding to stimuli verbal/touch), eyes closed, limbs remain flaccid x 4. No b/p and pulse noted staff remained with this res awaiting arrival of 911. Resident #1's Nurse's Note dated and electronically signed by LVN A on [DATE] at 7:30 AM reflected, 911 and paramedics arrived to this facility, ambulated this res via w/ch to room for privacy, .resident pronounced expired at this time. The facility's Incident Investigation Report dated and signed by the DON on [DATE], reflected on [DATE] at 7:30 AM, reflected Resident aspirated on foreign body .resulting in death (Resident #1) displayed s/s (sic) foreign body occlusion of airway after taking third pill with water . This document further reflected Back thrust (more beneficial in infant and children) do (sic) move air from inside lungs outward and considering the inability of pt to stand on his own .Upon help arriving to scene .Conscious Pt with choking on FBO was stood and positioned by two CNA (sic) and [MEDICATION NAME] (Abdominal thrust) was initiated by a third person .6. Upon pt losing consciousness and arrival of additional staff to scene including a RN. Pt was seated as could no longer be held upright by CNA's, and per instruction of RN: Pt was held in a seated leaning position and back thrusts were again performed by staff . The investigation report also reflected actions taken post-investigation refresher in-service on [MEDICATION NAME] . The American College of Emergency Physician's website, accessed on [DATE], provided the following information related to the [MEDICATION NAME] maneuver: In the event of choking, the American Heart Association and ACEP offer the following guidelines: . Conscious Adult .If the person can speak, cough or breathe, do not interfere. If the person cannot speak, cough or breathe, give abdominal thrusts known as the [MEDICATION NAME] Maneuver Unconscious Adult Position the person on his or her back, arms by side. .If the person is not breathing . give six to 10 abdominal thrusts (the [MEDICATION NAME] Maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts Web Address: <http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Choking-%[MEDICATION NAME]-Maneuver%29/> During an interview with LVN A on [DATE] at 10:50 AM she said she had been on the 300 hall and CNA C was in the day area. LVN A said she was by Resident #1's room when CNA C called for her to come that Resident #1 was choking. LVN A said as she arrived on the scene Resident #1 was in his w/c both MA B and CNA C were rubbing his back while he was choking so she got down in front of him and asked him if he was ok and he could not speak. LVN A stated they stood Resident #1 up and attempted to hold him up while she attempted the [MEDICATION NAME] until he went unconscious. LVN A stated after Resident #1 became unconscious they sat him back into his w/c and she did a sternal rub. LVN A stated RN E came and instructed staff to start hitting him on his back. When asked why they did not lower him to the ground and continue the [MEDICATION NAME] abdominal thrusts LVN A stated she had not thought of that. When asked what she would do differently in the future she stated she would lay him on a hard surface and continue the [MEDICATION NAME] abdominal thrusts. During an interview with CNA F on [DATE] at 12:22 PM she stated she had tried to help hold him up. CNA F also stated she was standing on his left side and they were going back and forth standing him up and sitting him down in his w/c. When CNA F was asked if anyone had instructed them to lay Resident #1 down on the floor on his back to do the [MEDICATION NAME] abdominal thrusts, she stated no. During an interview with MA B on [DATE] at 12:45 PM she stated she had given Resident #1 his third pill followed by a drink of water and he started coughing so she pat him on his back and asked if he was ok. She stated CNA C came around and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his wheel chair. She also stated when LVN A came she instructed them to stand Resident #1 up while she attempted the [MEDICATION NAME]. MA B said they were standing him up and sitting him down and when he went unconscious they sat him down and RN E arrived and instructed them to pat him on the back. When asked if anyone had instructed them to lay him on the ground and continue the [MEDICATION NAME] she stated no one had ever told them to lay him on the ground. During an interview with CNA D on [DATE] at 4:09 PM she stated when she and RN E got to Resident #1 he was unconscious and seated in his wheelchair and RN E went and began pounding him on his back. When asked if they had lay Resident #1 on the floor to do the [MEDICATION NAME] abdominal thrusts CNA D said no they had not placed him on the floor. During an interview with RN E on [DATE] at 4:26 PM she stated when she arrived on the scene Resident #1 was sitting in his w/c and MA B told her he was choking on a pill. RN E stated she told them to do back thrusts. When asked if they had placed Resident #1 on the ground to do the [MEDICATION NAME] abdominal thrusts she said no it had all went so fast. During an interview with CNA C on [DATE] at 12:33 PM she stated MA B was giving Resident #1 his morning medications on [DATE]. He was in his w/c by the nurse's station. CNA C stated she (CNA C) looked away for a second and Resident #1 began to make a gurgling noise like he was trying to get something up. CNA C stated she screamed for LVN A and tried to do the [MEDICATION NAME] abdominal thrusts while Resident #1 was in his w/c. CNA C also stated when LVN A arrived we tried to stand him up and was not able to . When asked, CNA C stated he was able to sit up but not stand. During an interview with the DON on [DATE] at 1:28 PM when asked how the incident with Resident #1 came about he stated when Resident #1 aspirated on the medication they (Staff who responded) deviated from the facility's policy and procedure. When asked about prior in-services regarding the [MEDICATION NAME] Maneuver the DON stated he had relied on the staffs CPR training for the [MEDICATION NAME] Maneuver so there had been no previous [MEDICATION NAME] maneuver in-services. When asked how he ensured his nursing staff were competent in their skills for residents who choke he stated they did annual skills check offs such as IV and [DEVICE]s. The DON also stated he did not know if the [MEDICATION NAME] Maneuver was on the skills check off list but felt if the AHA approved of the every two year renewal of the CPR then his nurses should not have needed the [MEDICATION NAME] Maneuver to be gone over annually. During an interview with the Admin on [DATE] at 9:40 AM he stated he was the Abuse Coordinator for the facility. When asked how he educated his staff about identifying neglect The Admin stated they had new hire orientation (which did not include the [MEDICATION NAME] Maneuver but since the incident with Resident #1 had been revised to include the [MEDICATION NAME] Maneuver), one on one training and situational training as in the in-service for the [MEDICATION NAME] Maneuver. During an interview with the DON on [DATE] at 10:37 AM stated he had initiated an in-service on the [MEDICATION NAME] maneuver but had not in-serviced all direct care staff. He also stated they had no previous in-service on the [MEDICATION NAME] maneuver prior to Resident #1's incident. Review of the staff sign in sheets for the in-service on the [MEDICATION NAME] maneuver dated [DATE] revealed only 41 signatures out of 78 total direct care staff had had the in-service as of [DATE] at 12:00 PM. During an interview with the DON on [DATE] at 12:02 PM when asked why only 41 out of 78 direct care staff had been in-serviced up until this time he stated it was an on-going in-service. He stated we (He and the ADONs) are catching staff as they come in to work and in-servicing them. The DON also stated the day and evening shifts were the focus of the in-service because residents don't eat at night. (Note: Resident #1 choked on medications not food.) During an interview with ADON H on [DATE] at 1:37 PM she stated Resident #1 was not able to stand at the time of the incident and the staff had commented Resident #1 was dead weight and that it took one person on each side and one behind him to stand him up. ADON H stated if she had been there she would have eased Resident #1 to the floor and proceeded with the [MEDICATION NAME] abdominal thrusts. During an interview with ADON G on [DATE] at 12:52 PM she stated she had been instructed to in-service her direct care staff on the [MEDICATION NAME] maneuver as a result of the incident with Resident #1. When asked what she taught her staff, ADON G stated the facility's policy and procedure on the [MEDICATION NAME] Maneuver was her tool for teaching. When asked what shifts she had in-serviced she stated she felt she had gotten basically all direct care and nursing staff on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift but was still working on the 10:00 PM to 6:00 AM shift as well as PRN staff. ADON G stated she was catching her staff as they came in to work. When asked how she was teaching she stated she first showed them the guidelines from their policy and procedure and then demonstrated on them the [MEDICATION NAME] maneuver and how to ease an unconscious resident to the floor and perform [MEDICATION NAME] abdominal thrusts. The facility's policy and procedure on [MEDICATION NAME] Maneuver revised [DATE] reflected the following: Unconscious Resident . 1. Ease the resident gently to the floor . 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: . The facility's Abuse Prevention Program policy and procedure dated revised [DATE] reflected the following: Our residents have the right to be free from . neglect .Comprehensive policies and procedures have been developed to aid our facility in preventing . neglect . of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .i. The implementation of changes to prevent future occurrences of .Neglect: A failure to provide goods and services necessary to avoid physical harm . An IJ was identified on [DATE] at 3:13 PM. The Administrator and DON were notified at that time of the IJ and a POR was requested. The facility's fifth POR was accepted on [DATE]. The plan reflected the following: -- The facility began in-services of the direct care nursing staff on [MEDICATION NAME] Procedure of unconscious resident on [DATE] by the DON and ADONs to be completed by [DATE]. --On [DATE] one on one corrective action was conducted for RN E by the DON and she was re-trained and showed proficiency on [DATE]. --On [DATE] the DON was re-trained by the MD with return demonstration on the [MEDICATION NAME] maneuver in addition ADONs G, H and N were re-trained with return demonstration. --As of [DATE] direct care nursing staff had been retrained in the [MEDICATION NAME] maneuver with return demonstration by the DON and ADONs G, H and N. In addition direct care nursing staff was taken off the work schedule until successful completion of training and return demonstration. --All new direct care nursing staff will receive training for the [MEDICATION NAME] maneuver upon orientation and this was added to the new hire orientation schedule effective [DATE]. --Choking signage posted in the meal service areas was explained in detail to direct care nursing staff and Facility's policy and procedure for the [MEDICATION NAME] attached next to signage on [DATE]. On [DATE] new choking signage was hung in all meal service areas. --All residents with swallowing difficulties were identified, their care plans reviewed and updated as needed with two residents added on [DATE]. --[DATE] all direct care nursing staff were in-serviced on the locations of lists which identified residents with swallowing problems. A list of these residents was made and staff were in-servised on the multible locations where this list could be found. --As of [DATE] all dietary, environmental and administrative staff will be trained on the [MEDICATION NAME] maneuver which will be completed by [DATE]. In addition staff that do not attend this training or fail to present an understanding of the [MEDICATION NAME] maneuver will be re-moved from the schedule until they attend and demonstrate an understanding. --This process will be monitored by the Admin and BOM. Over the next 60 days the Admin and BOM will monitor weekly the systemic compliance process beginning [DATE] after day 61 the Admin and BOM will conduct random checks. --All CNAs, MAs, RNs and LVNs will have annual skills check offs including return demonstration of the [MEDICATION NAME] maneuver and will be monitored by the Admin and BOM. --All the above noted processes are to be reviewed by the QA committee for recommendations and review. To verify implementation of the plan, the following was conducted: The facility's in-service titled [MEDICATION NAME] Maneuver Refresher Course dated [DATE] which was continued through [DATE] and was conducted by ADONs G and H reflected a total of 68 direct care staff members and nurses attended this in-service which was the majority of staff from all three shifts. The facility's in-service conductd on [DATE] by the DON and ADON H which informed staff where the list of residents with swallowing problems was kept was atteded by 64 direct care staff and nurses which was the majority of staff from all three shifts. During individual interviews with the following nurses they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 2:49 PM, with LVN K. --On [DATE] at 9:59 AM, 10:00 AM, 12:04 PM, 12:11 PM, 1:48 PM and 2:41 PM with RN E, LVN A, LVN O, LVN P, MDS Coordinator and ADON G. --On [DATE] at 9:31 AM, 10:12 AM, 10:33 AM, 11:55 AM, 2:14 PM with LVN R, ADON N, LVN WW, LVN XX . During individual interviews with the following CNAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 12:33 PM, 3:28 PM and 3:35 PM with CNA C, CNA Y and CNA PP. --On [DATE] at 10:26 AM, 11:01 AM, 11:14 AM, 11:20 AM, 11:45 AM, 12:25 PM, 12:32 PM, 3:18 PM, 3:28 PM, 3:41 PM and 3:46 PM with CNA FF, CNA U, CNA F, CNA D, CNA EE, CNA Z, CNA V, CNA Y, CNA X, CNA KK and CNA L. --On [DATE] at 10:00 AM, 10:07 AM, 10:13 AM, 10:20 AM, 10:50 AM, 11:49 AM, 12:18 PM, 12:32 PM, 2:04 PM and 4:04 PM with CNA JJ, CNA DD, CNA II, Staffing Coordinator, CNA AA, CNA CC, CNA T, CNA W, CNA BB and CNA M. --[DATE] at 12:26 PM, 2:39 PM and 3:09 PM with CNA S, CNA HH and CNA GG. During individual interviews with the following MAs they each answered all [MEDICATION NAME] maneuver questions appropriately on both conscious and unconscious residents. The interviews were conducted on the folowing days: --On [DATE] at 10:35 AM and 12:18 PM with MA B and MA LL. --On [DATE] at 9:46 AM, 10:41 AM and 2:24 PM with MA NN, MA YY and MA MM. On [DATE] at 3:20 PM observations were made of all four meal service areas in the facility and the new [MEDICATION NAME] maneuver poster was observed to be hanging in each meal service room. In addition an observation was made of each area documented in the facility's POR as having the list of residents with swallowing problems which were available for all staff to access. During individual interviews conducted on [DATE] at 3:33 PM, 3:48 PM, 3:55 PM, 4:02 PM, 4:07 PM, 4:40 PM, 4:30 PM and 4:49 PM with RN VV, CNA OO, LVN UU, CNA TT, CNA SS, CNA RR, CNA PP and MA QQ. All these additional staff were interviewed in regards to the [MEDICATION NAME] maneuver with a conscious and unconscious resident and where the list of residents with swallowing problems could be found. They all answered the questions appropriately and knew what to do as well as where to find the lists of residents with swallowing priblems. Additional individual interviews were conducted on [DATE] at 3:10 PM, 3:10 PM, 3:30 PM, 4:19 PM, 4:26 PM and 4:36 PM with CNA BB, CNA S, CNA M, Staffing Coordinator, CNA X and CNA V. All CNAs knew at least two to three or more locations of the list of residents with swallowing problems. Additional individual interviews were conducted on [DATE] at 3:25 PM, 4:15 PM, 4:25 PM and 4:39 PM with LVN O, LVN A, LVN P and LVN Q and they all answered the additional questions about where the location of the list of residents with swallowing problems were kept. On [DATE] at 5:30 PM the Admin and DON were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance as a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the POR. Per the facility's Form CMS-672 Resident Census and Conditions of Residents signed and dated [DATE] by the MDS Coordinator, there were 111 residents residing in the facility and 14 residents had [DEVICE]s.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for three (Residents #25, #16, and #31) of 12 residents reviewed for assessments related to blood sugar results. Residents #25 and #26 had increased Hemoglobin A1c results identified on 10/16/13 and 10/17/13 without the accuracy of their FSBS results being questioned when the residents were receiving the physician-ordered amounts of sliding scale insulin. Resident #31 had a decreased Hemoglobin A1c result identified on 09/17/13 without staff questioning the accuracy of their FSBS results when the residents were receiving the physician-ordered amounts of sliding scale insulin. LVNs C, D, E and K, who conducted control testing of the facility's four glucometers, did not notify anyone of the abnormal quality check results, which placed the 29 diabetic residents at risk for receiving the wrong dosages of sliding scale insulin during August, Sepetember and October 2013. LVNs C, D, E and K did not take any action for the abnormal readings, and the four glucometers continued to be used. The DON, ADON T and ADON L were unaware the facility's four glucometers had multiple, significant out-of-range quality check results when tested with control solutions. An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. While the IJ was removed on 10/24/13 at 4:35 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure the glucometers were providing the correct results of blood sugar levels and not troubleshooting to determine whether the glucometers were working placed the facility's 29 diabetics at risk for: 1) developing abnormal blood sugar levels without being identified; 2) not receiving the appropriate dosage of insulin as ordered by the physician; and 3) not receiving the therapeutic benefits needed. This could result in a decline in their health and well-being without recognizing hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain damage and death. Findings included: 1) Resident #25's Admission Record with a print date of 10/24/13 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Three of the FSBS were scheduled for 6:30 AM, 11:30 AM and 4:30 PM, and did not have sliding scale insulin ordered according to the results of the FSBS. The three other FSBS were scheduled for 9:00 AM, 1:00 PM and 6:00 PM and had sliding scale [MEDICATION NAME]ordered to be given subcutaneously according to the FSBS result. The following sliding scale was ordered: 0 - 200 mg/dL, no insulin; 201 - 250 mg/dL, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; 401+ mg/dL, give 10 units & notify MD. Resident #25's lab results reflected on 07/19/13, she had a Hemoglobin A1c of 8.5%. The reference range was 4.5 - 5.7%. She had a Glucose level of 168 mg/dL with a reference range of 70 - 110 mg/dL. Resident #25's lab results reflected on 10/16/13, she had a Hemoglobin A1c of 9.2% with a reference range of 4.5 - 5.7%. She had a Glucose level of 208 mg/dL with a reference range of 70 -110 mg/dL. The Hemoglobin A1c results indicated Resident #25's average blood sugar level had increased by 0.7%. The results of her Hemoglobin A1c could have been affected by inaccurate FSBS levels, which were the results from the facility's glucometers The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] date FSBS result insulin given 10/01/13 AM 120 0 units 10/01/13 PM 209 2 units 10/02/13 AM Not done 10/02/13 PM Not done 10/03/13 AM Not done 10/03/13 PM 242 2 units 10/04/13 AM 178 0 units 10/04/13 PM 251 4 units 10/05/13 AM 153 0 units 10/05/13 PM 230 2 units 10/06/13 AM 200 0 units 10/06/13 PM 183 0 units 10/07/13 AM Not done 10/07/13 PM 313 6 units 10/08/13 AM Not done 10/08/13 PM 223 2 units 10/09/13 AM Not done 10/09/13 PM 216 2 units 10/10/13 AM Not done 10/10/13 PM 278 4 units 10/11/13 AM 275 4 units 10/11/13 PM Not done 10/12/13 AM 200 0 units 10/12/13 PM 207 2 units 10/13/13 AM 138 0 units 10/13/13 PM 165 0 units 10/14/13 AM Not done 10/14/13 PM Not done 10/15/13 AM Not done 10/15/13 PM 228 2 units 10/16/13 AM 218 2 units 10/16/13 PM Not done 10/17/13 AM 215 2 units 10/17/13 PM Not done 10/18/13 AM 226 2 units 10/18/13 PM Not done 10/19/13 AM 179 0 units 10/19/13 PM 247 2 units 10/20/13 AM 180 0 units 10/20/13 PM 199 0 units 10/21/13 AM 190 0 units 10/21/13 PM Not done Despite the fluctuations in Resident #27's FSBS results from AM results to PM results, nursing staff continued to use the facility's glucometers without questioning the results received. 2) Retrieved on 11/06/13 from www.medicinenet.com/script/main/art.asp?article key= in regard to the lab test, Hemoglobin A1c: Red blood cells circulate in the body for about three months before they die. Sugar sticks to the red blood cells and gives an idea of how much sugar has been around (in the body) for the preceding six months. The benefit of measuring the Hemoglobin A1c (A1c) is because it gives a more reasonable view of blood sugar levels over the course of time (3 months). The value does not bounce as much as FSBS measurements. "There is a correlation between A1c levels and average blood sugar levels as follows: ...it gives a physician a good idea that someone is diabetic if the value is elevated. ...it is used as a standard tool to determine blood sugar control in patients known to have diabetes." A1c(%) Average blood sugar (mg/dl) 6 135 7 170 8 205 9 240 10 275 11 310 12 345 "The American Diabetes Association currently recommends an A1c goal of less than 7.0%, while other groups... recommend a goal of less than 6.5%." 3) Resident #26's Admission Record with a print date of 10/24/13 reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 10/21/13 at approximately 10:30 AM, during initial tour, LVN CC informed the surveyor Resident #26 used a wheelchair for mobility, was able to feed herself and ate in the main dining room. LVN CC further stated Resident #26 was alert, required the assistance of one person with ADLs and was incontinent of bladder. Resident #26's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Two FSBS were scheduled for 6:30 AM and 4:30 PM with no sliding scale insulin ordered. Resident #26 had FSBS scheduled for 9:00 AM and 6:00 PM with sliding scale [MEDICATION NAME]to be given subcutaneously per the results of the FSBS per the facility's glucometers: 0 - 150 mg/dL, no insulin; 151 - 200 mg/dL, give 2 units; 201 - 250 mg/dL, give 4 units; 251 - 300 mg/dL, give 6 units; 301 - 350 mg/dL, give 8 units; 351- 400 mg/dL, give 10 units; 401+ mg/dL, call the MD. Resident #26's lab results reflected on 07/24/13, she had a Hemoglobin A1c of 9.1%. The reference range was 4.5 - 5.7%. Resident #26's lab results reflected on 10/17/13, she had a Hemoglobin A1c of 9.4% with a reference range of 4.5 - 5.7%. Resident #26's lab work identified an increase in her Hemoglobin A1c of 0.3%, which indicated an increase in her blood glucose levels. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM 295 6 units 10/01/13 PM 338 8 units 10/02/13 AM 331 8 units 10/02/13 PM 389 10 units 10/03/13 AM 362 10 units 10/03/13 PM 400 10 units 10/04/13 AM 153 2 units 10/04/13 PM 273 6 units 10/05/13 AM 293 6 units 10/05/13 PM 258 6 units 10/06/13 AM 257 6 units 10/06/13 PM 360 8 units 10/07/13 AM 361 10 units 10/07/13 PM blank 10/08/13 AM 198 2 units 10/08/13 PM 183 2 units 10/09/13 AM 213 4 units 10/09/13 PM 278 6 units 10/10/13 AM 206 4 units 10/10/13 PM 190 2 units 10/11/13 AM 188 2 units 10/11/13 PM blank 10/12/13 AM 237 4 units 10/12/13 PM 245 4 units 10/13/13 AM 268 6 units 10/13/13 PM 328 8 units 10/14/13 AM 240 4 units 10/14/13 PM 242 4 units 10/15/13 AM 267 6 units 10/15/13 PM 285 6 units 10/16/13 AM 243 4 units 10/16/13 PM 333 8 units 10/17/13 AM 292 6 units 10/17/13 PM 308 8 units 10/18/13 AM 267 6 units 10/18/13 PM 317 8 units 10/19/13 AM 275 6 units 10/19/13 PM 376 10 units 10/20/13 AM 303 8 units 10/20/13 PM 341 8 units 10/21/13 AM 209 4 units 10/21/13 PM 217 4 units Despite the fluctuations in Resident #27's FSBS results and the resident being administered anywhere from 2 units of insulin to 10 units of insulin, nursing staff continued to use the facility's glucometers without questioning the results received. 4) Resident #31's Admission Record dated 03/20/13 reflected the resident, an [AGE] year-old female, was admitted to the facility originally on 12/22/08. [DIAGNOSES REDACTED]. Resident #31's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #31 was ordered to receive sliding scale [MEDICATION NAME]according to the results of the FSBS done at 9:00 AM and 6:00 PM. The following sliding scale was ordered: 0-200 mg/dl, 0 units; 201-250 mg/dl, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; and 401+ mg/dL, give 12 units, notify MD. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM Not done 10/01/13 PM 447 12 units 10/02/13 AM 202 2 units 10/02/13 PM 416 2 units 10/03/13 AM 204 2 units 10/03/13 PM 260 2 units 10/04/13 AM 209 2 units 10/04/13 PM 224 2 units 10/05/13 AM 250 2 units 10/05/13 PM 292 2 units 10/06/13 AM 176 0 units 10/06/13 PM 281 4 units 10/07/13 AM 210 2 units 10/07/13 PM Not done 10/08/13 AM Not done 10/08/13 PM 331 6 units 10/09/13 AM 404 12 units 10/09/13 PM 404 12 units 10/10/13 AM 367 8 units 10/10/13 PM 271 4 units 10/11/13 AM 351 8 units 10/11/13 PM 418 12 units 10/12/13 AM 275 4 units 10/12/13 PM 287 4 units 10/13/13 AM 131 0 units 10/13/13 PM 273 4 units 10/14/13 AM 210 2 units 10/14/13 PM 210 2 units 10/15/13 AM 274 4 units 10/15/13 PM 346 6 units 10/16/13 AM 220 2 units 10/16/13 PM 307 6 units 10/17/13 AM 232 2 units 10/17/13 PM 267 4 units 10/18/13 AM 155 0 units 10/18/13 PM Not done 10/19/13 AM 178 0 units 10/19/13 PM 192 0 units 10/20/13 AM 184 0 units 10/20/13 PM 348 4 units 10/21/13 AM 127 0 units 10/21/13 PM 273 4 units Resident #31's lab report dated 09/17/13 reflected a Hemogolbin A1c of 7.5%. Resident #31's lab report dated 06/18/13 reflected a Hemoglobin A1c of 7.7%. Despite the fluctuations in Resident #31's FSBS results and the resident being administered sliding scale insulin, nursing staff continued to use the facility's glucometers without questioning the results received when Resident #31's Hemogobin A1c had decreased. 5) On 10/23/13 at 1:00 PM, the Versailles Unit (500/600/700 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September, and October 2013. The following are the results for the 700 Hall and half of the 500 Hall which fell out-of-range of the quality check: DATE RESULT RANGE ACTION 08/28/13 88 91-114 09/18/13 68 91-114 09/19/13 74 91-114 09/20/13 376 236-294 09/21/13 65 91-114 09/22/13 63 91-114 09/24/13 63 89-111 09/26/13 60 89-111 09/27/13 66 91-114 09/28/13 63 91-114 09/29/13 66 90-113 09/30/13 67 90-113 10/01/13 68 90-113 10/02/13 75 90-113 10/03/13 65 90-112 10/04/13 66 90-112 10/05/13 68 90-112 10/06/13 72 90-112 10/07/13 64 90-112 10/08/13 72 90-112 10/09/13 66 90-113 10/10/13 66 90-113 10/11/13 65 90-113 10/12/13 65 91-114 10/14/13 70 91-114 10/15/13 63 91-113 10/16/13 62 91-113 385 234-292 10/17/13 67 91-113 10/18/13 63 91-113 10/19/13 76 91-113 10/20/13 86 90-113 10/21/13 63 90-113 10/22/13 65 90-113 The following are the results for the 600 Hall and half of the 500 Hall, which fell out-of-range of the quality check: DATE RESULTS CONTROL ACTION 08/01/13 71 90-112 08/02/13 88 90-112 08/03/13 80 90-112 ? 08/04/13 82 88-110 08/06/13 77 88-110 ? 08/07/13 83 88-110 08/08/13 83 88-110 08/09/13 81 91-113 08/10/13 70 91-113 08/11/13 83 91-113 08/12/13 86 91-113 08/13/13 84 91-110 ? 08/14/13 78 91-114 08/15/13 83 91-114 08/16/13 82 91-114 ? 08/17/13 81 91-114 ? 08/21/13 81 90-112 ? 08/24/13 81 90-112 ? 08/29/13 78 91-114 ? 08/30/13 77 91-114 08/31/13 78 88-110 09/05/13 74 88-110 09/06/13 74 91-114 09/07/13 74 91-114 09/08/13 86 91-114 09/09/13 75 91-114 ? 09/10/13 75 91-114 09/11/13 70 91-114 09/12/13 71 91-114 09/13/13 70 91-114 09/14/13 70 91-114 09/15/13 70 91-114 ? 09/16/13 71 91-114 ? 09/17/13 70 91-114 09/18/13 70 91-114 09/19/13 69 91-114 09/20/13 68 91-114 09/21/13 74 91-114 09/22/13 70 91-114 09/24/13 66 89-111 09/25/13 66 89-111 09/26/13 66 89-111 There was no evidence this unit's staff documented quality checks on the glucometers for 10/14/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. All of the other documented October results were documented to have fallen in range through 10/23/13. On 10/23/13 at 1:15 PM, the Mount Vernon unit (100, 200, 300 and 400 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September and October 2013. The following are the results for the 100 and 200 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/13/13 182 225-280 ? 08/10/13 113 88-109 ? 08/22/13 226 234-292 ? 08/24/13 219 234-292 ? 09/10/13 217 229-286 ? 09/12/13 210 229-294 ? 09/17/13 225 236-294 ? 09/20/13 90 91-110 202 236-294 ? 09/21/13 229 236-294 ? 09/24/13 192 236-294 ? The following are the results for the 300 and 400 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/06/13 85 90-112 - 08/16/13 87 91-114 ? 08/20/13 87 90-112 ? 08/21/13 234 236-294 ? 08/27/13 234 236-294 ? 08/29/13 228 236-294 ? 09/05/13 224 277-283 09/06/13 244 277-283 09/07/13 231 277-283 09/08/13 242 277-283 09/09/13 269 277-283 09/13/13 234 236-294 09/14/13 90 91-114 221 236-294 09/15/13 235 236-294 09/16/13 227 236-294 09/18/13 90 91-114 214 236-294 09/19/13 174 236-294 09/20/13 175 236-294 09/21/13 190 236-291 09/24/13 88 89-111 09/25/13 84 89-111 244 230-286 09/26/13 88 89-111 09/27/13 90 91-114 09/28/13 234 236-286 There was no evidence of quality checks on the glucometer for 09/29/13 and 09/30/13. 10/01/13 79 91-114 10/10/13 123 88-111 ? 10/23/13 88 90-113 There was no evidence quality checks on the glucometer were conducted on 10/04/13, 10/06/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. 6) At 2:35 PM on 10/23/13, an interview was conducted with the Staffing Coordinator, who was also responsible for Central Supply and equipment. She said she was the person responsible for ordering the glucometers. When she checked Central Supply at that time, she could not find any extra glucometers. She stated she had given the last one out a few weeks ago to the Versailles Unit, but she did not have any extra glucometers at that time. 7) On 10/23/13 at 2:00 PM, the 2013 facility in-services and training binder for 2013 was provided to the surveyor by the DON. No evidence was found staff had been trained or in-serviced on the glucometer. 8) At 2:48 PM on 10/23/13, during an interview with the DON, she confirmed the facility was using the Assure Platinum Glucometer. 9) The manufacturer's User Instruction Manual for the Assure Platinum glucometer, the brand of all four facility glucometers, Section B, Step 5 reflected: "Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within this range, the meter and test strip are working correctly. Do not use the system if control solution result is out-of-range. See Troubleshooting on page 12." In the troubleshooting chart on page 12 of the Manual, there were ten actions staff were to take if the result was out-of-range, along with the necessary action to correct the problem. At the very end of the chart is the following information: "Does your Control Solution result still read outside the range printed on the test strip bottle? If yes, the system may not be working correctly. DO NOT USE the system to test your blood glucose until the control solution result is within range. If you need help, please call Customer Service at [PHONE NUMBER] (24 hours a day, 7 days a week, USA and Canada). Contact your diabetes healthcare professional if you cannot reach Customer Service." The manufacturer's instructions included the following: Perform a control solution test: -- Before testing with the glucometer for the first time. -- When you open a new bottle of test strips -- Whenever you suspect the meter or test strips are not functioning properly. -- When test results appear to abnormally high or low or are not consistent with clinical symptoms. --If the test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees Fahrenheit or above 86 degrees Fahrenheit, or humidity levels are above 80%. 10) At 2:00 PM on 10/23/13 an interview was conducted with LVN D. She was asked what she would do if she obtained an out-of-range result when performing the quality check on the glucometer. She stated she would get another nurse to recheck it, and then they would document it on the glucometer log, then on the 24 hour report and pass it on to the nurse on the next shift. LVN D stated she had not had any out-of-range checks on the glucometers when she had to do the glucometer checks. A review of the quality assurance logs for August, September, and October 2013, revealed LVN D had out-of-range results when performing the quality check on the glucometer on 09/26/13, 10/14/13, 10/19/13, and 10/20/13. 11) In an interview on 10/23/13 at 4:00 PM, LVN C stated when he performed glucometer control checks, he would sometimes get out-of-range levels. He stated he would then recheck the glucometer by performing a fingerstick blood sugar on himself. He stated he never informed the ADONs or the DON the glucometer quality control checks were out-of-range. He confirmed he had not received any training on the glucometer. When the surveyor inquired whether a special setting or mode was needed to perform controls on the glucometer, LVN C replied, "Not that I know of." 12) At 10:12 PM on 10/23/13, an interview was conducted with LVN E. He stated he worked both units on the 10:00 PM to 6:00 AM shifts and he was to provide quality checks on the glucometers. He stated he would take a test strip and put it in the glucometer and put the glucometer in the control mode. He stated he would take the low control solution and put a drop on the strip and take the reading. He stated he then documented the range on the log, and then he would do the high control test. LVN E stated he had obtained a few readings, which were out-of-range. He stated he changed the control solutions and rechecked it. He said if the results were still out-of-range, he would put the results in the glucometer log. LVN E stated he did not notify anyone, and he had never been told to notify anyone of an out-of-range reading. He stated he did not see a reason to call up the ADONs for this issue. He said in the morning, the charge nurse or the ADON were supposed to check the ranges, and if there was a problem, they were supposed to address it and write in the log book under the section "Action Taken" what they did to correct the problem. 13) At 11:38 AM on 10/24/13, an interview was conducted with LVN K. She stated a few weeks ago, there was a problem with the glucometer, and it had been written on the 24-hour report. She said, at the change of shift, the night nurse, LVN U, reported to her the problem with the glucometer. LVN K confirmed the date on the 24-hour report was 10/04/13. She stated she went to the Staffing Coordinator (who was in charge of central supply) and got a new glucometer. She stated she left the old glucometer in the cart, but used the new one. She did not label the non-working glucometer as defective or place it out of commission. LVN K stated she did not perform a quality check on the new glucometer before she used it to check the residents' blood sugars. LVN K stated she did not tell anyone about the problems with the glucometer on the 24-hour report, because ADON T made copies of the 24-hour report, and she assumed ADON T would read and see the comment. She also stated she was not aware of what happened to the non-working glucometer. 14) At 1:55 PM on 10/23/13, an interview was conducted with the DON. She stated she was not aware of any problems with the glucometers. At 2:48 PM on 10/23/13, a second interview was conducted with the DON. She stated she was not aware the staff was having any problems with the glucometers or of the out-of-range readings. She stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added the glucometer must be in the control mode in order to perform the quality check, and if it was not in the control mode the readings would be off. She stated the staff should make sure the glucometer was in the control mode to check it. If the staff got a reading outside the normal parameters, they should check it again with a new bottle of control solutions and test strips. If they still got an out-of-range reading then they should notify the ADONs and me (DON). They should also exchange the glucometer for a new one. The DON confirmed again she had not been informed of any issues regarding the glucometers. When asked why she thought the staff did not notify the ADONs or her of any abnormal readings or issues with the glucometers, she stated she could not even begin to determine why they did not notify anyone of the problems. 15) At 2:40 PM on 10/23/13, an interview was conducted with ADON L. She stated she had not been aware of any problems with glucometers or the readings. She stated if the staff had a problem with an out-of-range reading, they should recheck it and use new bottles of control solutions and test strips. If there was still a problem, then the staff should notify her and the DON and get a new glucometer to use. ADON L confirmed she had not been notified by any staff of any problems regarding out-of-range glucometer quality check results. 16) At 2:25 PM on 10/23/13, an interview was conducted with ADON T. She stated she had not been aware of any problems with the glucometers or the readings. She stated staff on the night shift (10:00 PM to 6:00 AM) conducted the checks. When asked what the staff should do if they got an out-of-range reading, she stated they should "alert me." She stated, the staff should "just leave me a note." She said she was not aware of any facility protocol of what to do when a glucometer quality check resulted in out-of-range results, but she would find out. 17) At 10:48 AM on 10/24/13, an interview was conducted with ADON T. She was shown the 24-hour report dated 10/04/13. The report indicated "Glucometer has abnormal low range." She stated she did not see this notation on the 24-hour report, and did not remember any nurse telling her about it. She stated she just could not remember it. 18) At 3:40 PM on 10/23/13, an interview was conducted with the Medical Director. He stated he had just become aware of the issues with the glucometer quality checks being out-of-range and the failure of staff to notify their supervisors. He stated he had not been aware of any problems until today. He stated education was going to be very important to correct this problem. 19) The facility's current Nursing Services Procedure Manual for Diabetic Care, revised April 2001, reflected the following on Obtaining a Fingerstick Glucose Level: Purpose "The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level." "Preparation: ...4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or the facility...." 20) An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. On 10/23/13 at 4:45 PM, the Administrator and DON were informed of the IJ, and a Plan of Removal for the IJ was requested. During this meeting, both the DON and Administrator were asked what they thought caused the failure of staff to take appropriate action when glucometer results fell out-of-range when performing the quality checks. Both were unable to identify the causes of the failures. The DON stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added, the glucometer quality assurance checks were not discussed during the only Quality Assurance and Assessment quarterly meeting she had attended since being hired. 21) The facility's Plan of Removal was accepted on 10/24/13 at 1:15 PM and reflected the following: The following corrective items have been taken for all potentially affected diabetics in the facility. See attached list of resident names. Issue - Failure to Notify Nursing supervisors when glucometer Quality Control Checks are not within control range as indicated and continued use of glucometer. 1. Immediate Action: Checked all Glucometers for control calibration within range and changed all strips and control solutions to new bottles and dated as 10/23/13. All glucometers were within range by 5:30 p.m. ADONs L and T completed this task by 5:30 p.m. Identified all diabetics, refer to attachment identifying residents, and will monitor for signs and symptoms of hypo/[MEDICAL CONDITION] for the next 24 hrs starting at 6:00 p.m. on 10/23/13 and through to 6:00 p.m. on 10/24/13. Outcomes will be documented on a nurse's note for each individual, noting date, time, any signs and symptoms assessed and signature of nurse assessing. This task started at 6:00 p.m. on 10/23/13 and continued until 6:00 p.m. on 10/24/13. This task was to be conducted by charge nurses. All blood sugars were checked and recorded. Insulin was administered as needed per physician order, after the quality controls were checked and verified to be within range. Facility Charge nurses responsible for completion of the 10/23/13, 4:30 p.m. blood sugars, completed them at 5:00 p.m. on 10/23/13. Competency checks with return demonstrations were begun on 10/23/13 at 8:00 p.m. for licensed nursing staff currently on duty and will be completed by 10/24/13 at 4:00 p.m. This task was to be completed by LVN V,

Based on observation, interview and record review, the facility failed to ensure pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals were provided to meet the needs of three (Residents #25, #26 and #31) of 12 diabetic residents reviewed for FSBS results. Residents #25, #26 and #31 had fluctuating FSBS results when the facility's glucometers were being used to check their blood sugar levels without staff questioning the results. Residents #25 and #26 had increased Hemoglobin A1c results identified on 10/16/13 and 10/17/13 without staff questioning the accuracy of their FSBS results when the residents were receiving the physician-ordered amounts of sliding scale insulin. Resident #31 had a decreased Hemoglobin A1c result identified on 09/17/13 without staff questioning the accuracy of their FSBS results when the residents were receiving the physician-ordered amounts of sliding scale insulin. LVNs C, D, E and K, who conducted control testing of the facility's four glucometers, did not notify anyone of the abnormal quality check results, which placed the 29 diabetic residents at risk for receiving the wrong dosages of sliding scale insulin during August, Sepetember and October 2013. LVNs C, D, E and K did not take any action for the abnormal readings, and the four glucometers continued to be used. The DON, ADON T and ADON L were unaware the facility's four glucometers had multiple, significant out-of-range quality check results when tested with control solutions. An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. While the IJ was removed on 10/24/13 at 4:35 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure the glucometers were providing the correct results of blood sugar levels and not troubleshooting to determine whether the glucometers were working placed the facility's 29 diabetics at risk for: 1) developing abnormal blood sugar levels without being identified; 2) not receiving the appropriate dosage of insulin as ordered by the physician; and 3) not receiving the therapeutic benefits needed. This could result in a decline in their health and well-being without recognizing hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain damage and death. Findings included: 1) Resident #25's Admission Record with a print date of 10/24/13 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Three of the FSBS were scheduled for 6:30 AM, 11:30 AM and 4:30 PM, and did not have sliding scale insulin ordered according to the results of the FSBS. The three other FSBS were scheduled for 9:00 AM, 1:00 PM and 6:00 PM and had sliding scale Novolog insulin ordered to be given subcutaneously according to the FSBS result. The following sliding scale was ordered: 0 - 200 mg/dL, no insulin; 201 - 250 mg/dL, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; 401+ mg/dL, give 10 units & notify MD. Resident #25's lab results reflected on 07/19/13, she had a Hemoglobin A1c of 8.5%. The reference range was 4.5 - 5.7%. She had a Glucose level of 168 mg/dL with a reference range of 70 - 110 mg/dL. Resident #25's lab results reflected on 10/16/13, she had a Hemoglobin A1c of 9.2% with a reference range of 4.5 - 5.7%. She had a Glucose level of 208 mg/dL with a reference range of 70 -110 mg/dL. The Hemoglobin A1c results indicated Resident #25's average blood sugar level had increased by 0.7%. The results of her Hemoglobin A1c could have been affected by inaccurate FSBS levels, which were the results from the facility's glucometers The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] date FSBS result insulin given 10/01/13 AM 120 0 units 10/01/13 PM 209 2 units 10/02/13 AM Not done 10/02/13 PM Not done 10/03/13 AM Not done 10/03/13 PM 242 2 units 10/04/13 AM 178 0 units 10/04/13 PM 251 4 units 10/05/13 AM 153 0 units 10/05/13 PM 230 2 units 10/06/13 AM 200 0 units 10/06/13 PM 183 0 units 10/07/13 AM Not done 10/07/13 PM 313 6 units 10/08/13 AM Not done 10/08/13 PM 223 2 units 10/09/13 AM Not done 10/09/13 PM 216 2 units 10/10/13 AM Not done 10/10/13 PM 278 4 units 10/11/13 AM 275 4 units 10/11/13 PM Not done 10/12/13 AM 200 0 units 10/12/13 PM 207 2 units 10/13/13 AM 138 0 units 10/13/13 PM 165 0 units 10/14/13 AM Not done 10/14/13 PM Not done 10/15/13 AM Not done 10/15/13 PM 228 2 units 10/16/13 AM 218 2 units 10/16/13 PM Not done 10/17/13 AM 215 2 units 10/17/13 PM Not done 10/18/13 AM 226 2 units 10/18/13 PM Not done 10/19/13 AM 179 0 units 10/19/13 PM 247 2 units 10/20/13 AM 180 0 units 10/20/13 PM 199 0 units 10/21/13 AM 190 0 units 10/21/13 PM Not done Despite the fluctuations in Resident #27's FSBS results from AM results to PM results, nursing staff continued to use the facility's glucometers without questioning the results received. 2) Retrieved on 11/06/13 from www.medicinenet.com/script/main/art.asp?article key= in regard to the lab test, Hemoglobin A1c: Red blood cells circulate in the body for about three months before they die. Sugar sticks to the red blood cells and gives an idea of how much sugar has been around (in the body) for the preceding six months. The benefit of measuring the Hemoglobin A1c (A1c) is because it gives a more reasonable view of blood sugar levels over the course of time (3 months). The value does not bounce as much as FSBS measurements. "There is a correlation between A1c levels and average blood sugar levels as follows: ...it gives a physician a good idea that someone is diabetic if the value is elevated. ...it is used as a standard tool to determine blood sugar control in patients known to have diabetes." A1c(%) Average blood sugar (mg/dl) 6 135 7 170 8 205 9 240 10 275 11 310 12 345 "The American Diabetes Association currently recommends an A1c goal of less than 7.0%, while other groups... recommend a goal of less than 6.5%." 3) Resident #26's Admission Record with a print date of 10/24/13 reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 10/21/13 at approximately 10:30 AM, during initial tour, LVN CC informed the surveyor Resident #26 used a wheelchair for mobility, was able to feed herself and ate in the main dining room. LVN CC further stated Resident #26 was alert, required the assistance of one person with ADLs and was incontinent of bladder. Resident #26's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Two FSBS were scheduled for 6:30 AM and 4:30 PM with no sliding scale insulin ordered. Resident #26 had FSBS scheduled for 9:00 AM and 6:00 PM with sliding scale Novolog insulin to be given subcutaneously per the results of the FSBS per the facility's glucometers: 0 - 150 mg/dL, no insulin; 151 - 200 mg/dL, give 2 units; 201 - 250 mg/dL, give 4 units; 251 - 300 mg/dL, give 6 units; 301 - 350 mg/dL, give 8 units; 351- 400 mg/dL, give 10 units; 401+ mg/dL, call the MD. Resident #26's lab results reflected on 07/24/13, she had a Hemoglobin A1c of 9.1%. The reference range was 4.5 - 5.7%. Resident #26's lab results reflected on 10/17/13, she had a Hemoglobin A1c of 9.4% with a reference range of 4.5 - 5.7%. Resident #26's lab work identified an increase in her Hemoglobin A1c of 0.3%, which indicated an increase in her blood glucose levels. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM 295 6 units 10/01/13 PM 338 8 units 10/02/13 AM 331 8 units 10/02/13 PM 389 10 units 10/03/13 AM 362 10 units 10/03/13 PM 400 10 units 10/04/13 AM 153 2 units 10/04/13 PM 273 6 units 10/05/13 AM 293 6 units 10/05/13 PM 258 6 units 10/06/13 AM 257 6 units 10/06/13 PM 360 8 units 10/07/13 AM 361 10 units 10/07/13 PM blank 10/08/13 AM 198 2 units 10/08/13 PM 183 2 units 10/09/13 AM 213 4 units 10/09/13 PM 278 6 units 10/10/13 AM 206 4 units 10/10/13 PM 190 2 units 10/11/13 AM 188 2 units 10/11/13 PM blank 10/12/13 AM 237 4 units 10/12/13 PM 245 4 units 10/13/13 AM 268 6 units 10/13/13 PM 328 8 units 10/14/13 AM 240 4 units 10/14/13 PM 242 4 units 10/15/13 AM 267 6 units 10/15/13 PM 285 6 units 10/16/13 AM 243 4 units 10/16/13 PM 333 8 units 10/17/13 AM 292 6 units 10/17/13 PM 308 8 units 10/18/13 AM 267 6 units 10/18/13 PM 317 8 units 10/19/13 AM 275 6 units 10/19/13 PM 376 10 units 10/20/13 AM 303 8 units 10/20/13 PM 341 8 units 10/21/13 AM 209 4 units 10/21/13 PM 217 4 units Despite the fluctuations in Resident #27's FSBS results and the resident being administered anywhere from 2 units of insulin to 10 units of insulin, nursing staff continued to use the facility's glucometers without questioning the results received. 4) Resident #31's Admission Record dated 03/20/13 reflected the resident, an [AGE] year-old female, was admitted to the facility originally on 12/22/08. [DIAGNOSES REDACTED]. Resident #31's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #31 was ordered to receive sliding scale Novolog insulin according to the results of the FSBS done at 9:00 AM and 6:00 PM. The following sliding scale was ordered: 0-200 mg/dl, 0 units; 201-250 mg/dl, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; and 401+ mg/dL, give 12 units, notify MD. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM Not done 10/01/13 PM 447 12 units 10/02/13 AM 202 2 units 10/02/13 PM 416 2 units 10/03/13 AM 204 2 units 10/03/13 PM 260 2 units 10/04/13 AM 209 2 units 10/04/13 PM 224 2 units 10/05/13 AM 250 2 units 10/05/13 PM 292 2 units 10/06/13 AM 176 0 units 10/06/13 PM 281 4 units 10/07/13 AM 210 2 units 10/07/13 PM Not done 10/08/13 AM Not done 10/08/13 PM 331 6 units 10/09/13 AM 404 12 units 10/09/13 PM 404 12 units 10/10/13 AM 367 8 units 10/10/13 PM 271 4 units 10/11/13 AM 351 8 units 10/11/13 PM 418 12 units 10/12/13 AM 275 4 units 10/12/13 PM 287 4 units 10/13/13 AM 131 0 units 10/13/13 PM 273 4 units 10/14/13 AM 210 2 units 10/14/13 PM 210 2 units 10/15/13 AM 274 4 units 10/15/13 PM 346 6 units 10/16/13 AM 220 2 units 10/16/13 PM 307 6 units 10/17/13 AM 232 2 units 10/17/13 PM 267 4 units 10/18/13 AM 155 0 units 10/18/13 PM Not done 10/19/13 AM 178 0 units 10/19/13 PM 192 0 units 10/20/13 AM 184 0 units 10/20/13 PM 348 4 units 10/21/13 AM 127 0 units 10/21/13 PM 273 4 units Resident #31's lab report dated 09/17/13 reflected a Hemogolbin A1c of 7.5%. Resident #31's lab report dated 06/18/13 reflected a Hemoglobin A1c of 7.7%. Despite the fluctuations in Resident #31's FSBS results and the resident being administered sliding scale insulin, nursing staff continued to use the facility's glucometers without questioning the results received when Resident #31's Hemogobin A1c had decreased. 5) On 10/23/13 at 1:00 PM, the Versailles Unit (500/600/700 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September, and October 2013. The following are the results for the 700 Hall and half of the 500 Hall which fell out-of-range of the quality check: DATE RESULT RANGE ACTION 08/28/13 88 91-114 09/18/13 68 91-114 09/19/13 74 91-114 09/20/13 376 236-294 09/21/13 65 91-114 09/22/13 63 91-114 09/24/13 63 89-111 09/26/13 60 89-111 09/27/13 66 91-114 09/28/13 63 91-114 09/29/13 66 90-113 09/30/13 67 90-113 10/01/13 68 90-113 10/02/13 75 90-113 10/03/13 65 90-112 10/04/13 66 90-112 10/05/13 68 90-112 10/06/13 72 90-112 10/07/13 64 90-112 10/08/13 72 90-112 10/09/13 66 90-113 10/10/13 66 90-113 10/11/13 65 90-113 10/12/13 65 91-114 10/14/13 70 91-114 10/15/13 63 91-113 10/16/13 62 91-113 385 234-292 10/17/13 67 91-113 10/18/13 63 91-113 10/19/13 76 91-113 10/20/13 86 90-113 10/21/13 63 90-113 10/22/13 65 90-113 The following are the results for the 600 Hall and half of the 500 Hall, which fell out-of-range of the quality check: DATE RESULTS CONTROL ACTION 08/01/13 71 90-112 08/02/13 88 90-112 08/03/13 80 90-112 ? 08/04/13 82 88-110 08/06/13 77 88-110 ? 08/07/13 83 88-110 08/08/13 83 88-110 08/09/13 81 91-113 08/10/13 70 91-113 08/11/13 83 91-113 08/12/13 86 91-113 08/13/13 84 91-110 ? 08/14/13 78 91-114 08/15/13 83 91-114 08/16/13 82 91-114 ? 08/17/13 81 91-114 ? 08/21/13 81 90-112 ? 08/24/13 81 90-112 ? 08/29/13 78 91-114 ? 08/30/13 77 91-114 08/31/13 78 88-110 09/05/13 74 88-110 09/06/13 74 91-114 09/07/13 74 91-114 09/08/13 86 91-114 09/09/13 75 91-114 ? 09/10/13 75 91-114 09/11/13 70 91-114 09/12/13 71 91-114 09/13/13 70 91-114 09/14/13 70 91-114 09/15/13 70 91-114 ? 09/16/13 71 91-114 ? 09/17/13 70 91-114 09/18/13 70 91-114 09/19/13 69 91-114 09/20/13 68 91-114 09/21/13 74 91-114 09/22/13 70 91-114 09/24/13 66 89-111 09/25/13 66 89-111 09/26/13 66 89-111 There was no evidence this unit's staff documented quality checks on the glucometers for 10/14/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. All of the other documented October results were documented to have fallen in range through 10/23/13. On 10/23/13 at 1:15 PM, the Mount Vernon unit (100, 200, 300 and 400 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September and October 2013. The following are the results for the 100 and 200 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/13/13 182 225-280 ? 08/10/13 113 88-109 ? 08/22/13 226 234-292 ? 08/24/13 219 234-292 ? 09/10/13 217 229-286 ? 09/12/13 210 229-294 ? 09/17/13 225 236-294 ? 09/20/13 90 91-110 202 236-294 ? 09/21/13 229 236-294 ? 09/24/13 192 236-294 ? The following are the results for the 300 and 400 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/06/13 85 90-112 - 08/16/13 87 91-114 ? 08/20/13 87 90-112 ? 08/21/13 234 236-294 ? 08/27/13 234 236-294 ? 08/29/13 228 236-294 ? 09/05/13 224 277-283 09/06/13 244 277-283 09/07/13 231 277-283 09/08/13 242 277-283 09/09/13 269 277-283 09/13/13 234 236-294 09/14/13 90 91-114 221 236-294 09/15/13 235 236-294 09/16/13 227 236-294 09/18/13 90 91-114 214 236-294 09/19/13 174 236-294 09/20/13 175 236-294 09/21/13 190 236-291 09/24/13 88 89-111 09/25/13 84 89-111 244 230-286 09/26/13 88 89-111 09/27/13 90 91-114 09/28/13 234 236-286 There was no evidence of quality checks on the glucometer for 09/29/13 and 09/30/13. 10/01/13 79 91-114 10/10/13 123 88-111 ? 10/23/13 88 90-113 There was no evidence quality checks on the glucometer were conducted on 10/04/13, 10/06/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. 6) At 2:35 PM on 10/23/13, an interview was conducted with the Staffing Coordinator, who was also responsible for Central Supply and equipment. She said she was the person responsible for ordering the glucometers. When she checked Central Supply at that time, she could not find any extra glucometers. She stated she had given the last one out a few weeks ago to the Versailles Unit, but she did not have any extra glucometers at that time. 7) On 10/23/13 at 2:00 PM, the 2013 facility in-services and training binder for 2013 was provided to the surveyor by the DON. No evidence was found staff had been trained or in-serviced on the glucometer. 8) At 2:48 PM on 10/23/13, during an interview with the DON, she confirmed the facility was using the Assure Platinum Glucometer. 9) The manufacturer's User Instruction Manual for the Assure Platinum glucometer, the brand of all four facility glucometers, Section B, Step 5 reflected: "Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within this range, the meter and test strip are working correctly. Do not use the system if control solution result is out-of-range. See Troubleshooting on page 12." In the troubleshooting chart on page 12 of the Manual, there were ten actions staff were to take if the result was out-of-range, along with the necessary action to correct the problem. At the very end of the chart is the following information: "Does your Control Solution result still read outside the range printed on the test strip bottle? If yes, the system may not be working correctly. DO NOT USE the system to test your blood glucose until the control solution result is within range. If you need help, please call Customer Service at [PHONE NUMBER] (24 hours a day, 7 days a week, USA and Canada). Contact your diabetes healthcare professional if you cannot reach Customer Service." The manufacturer's instructions included the following: Perform a control solution test: -- Before testing with the glucometer for the first time. -- When you open a new bottle of test strips -- Whenever you suspect the meter or test strips are not functioning properly. -- When test results appear to abnormally high or low or are not consistent with clinical symptoms. --If the test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees Fahrenheit or above 86 degrees Fahrenheit, or humidity levels are above 80%. 10) At 2:00 PM on 10/23/13 an interview was conducted with LVN D. She was asked what she would do if she obtained an out-of-range result when performing the quality check on the glucometer. She stated she would get another nurse to recheck it, and then they would document it on the glucometer log, then on the 24 hour report and pass it on to the nurse on the next shift. LVN D stated she had not had any out-of-range checks on the glucometers when she had to do the glucometer checks. A review of the quality assurance logs for August, September, and October 2013, revealed LVN D had out-of-range results when performing the quality check on the glucometer on 09/26/13, 10/14/13, 10/19/13, and 10/20/13. 11) In an interview on 10/23/13 at 4:00 PM, LVN C stated when he performed glucometer control checks, he would sometimes get out-of-range levels. He stated he would then recheck the glucometer by performing a fingerstick blood sugar on himself. He stated he never informed the ADONs or the DON the glucometer quality control checks were out-of-range. He confirmed he had not received any training on the glucometer. When the surveyor inquired whether a special setting or mode was needed to perform controls on the glucometer, LVN C replied, "Not that I know of." 12) At 10:12 PM on 10/23/13, an interview was conducted with LVN E. He stated he worked both units on the 10:00 PM to 6:00 AM shifts and he was to provide quality checks on the glucometers. He stated he would take a test strip and put it in the glucometer and put the glucometer in the control mode. He stated he would take the low control solution and put a drop on the strip and take the reading. He stated he then documented the range on the log, and then he would do the high control test. LVN E stated he had obtained a few readings, which were out-of-range. He stated he changed the control solutions and rechecked it. He said if the results were still out-of-range, he would put the results in the glucometer log. LVN E stated he did not notify anyone, and he had never been told to notify anyone of an out-of-range reading. He stated he did not see a reason to call up the ADONs for this issue. He said in the morning, the charge nurse or the ADON were supposed to check the ranges, and if there was a problem, they were supposed to address it and write in the log book under the section "Action Taken" what they did to correct the problem. 13) At 11:38 AM on 10/24/13, an interview was conducted with LVN K. She stated a few weeks ago, there was a problem with the glucometer, and it had been written on the 24-hour report. She said, at the change of shift, the night nurse, LVN U, reported to her the problem with the glucometer. LVN K confirmed the date on the 24-hour report was 10/04/13. She stated she went to the Staffing Coordinator (who was in charge of central supply) and got a new glucometer. She stated she left the old glucometer in the cart, but used the new one. She did not label the non-working glucometer as defective or place it out of commission. LVN K stated she did not perform a quality check on the new glucometer before she used it to check the residents' blood sugars. LVN K stated she did not tell anyone about the problems with the glucometer on the 24-hour report, because ADON T made copies of the 24-hour report, and she assumed ADON T would read and see the comment. She also stated she was not aware of what happened to the non-working glucometer. 14) At 1:55 PM on 10/23/13, an interview was conducted with the DON. She stated she was not aware of any problems with the glucometers. At 2:48 PM on 10/23/13, a second interview was conducted with the DON. She stated she was not aware the staff was having any problems with the glucometers or of the out-of-range readings. She stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added the glucometer must be in the control mode in order to perform the quality check, and if it was not in the control mode the readings would be off. She stated the staff should make sure the glucometer was in the control mode to check it. If the staff got a reading outside the normal parameters, they should check it again with a new bottle of control solutions and test strips. If they still got an out-of-range reading then they should notify the ADONs and me (DON). They should also exchange the glucometer for a new one. The DON confirmed again she had not been informed of any issues regarding the glucometers. When asked why she thought the staff did not notify the ADONs or her of any abnormal readings or issues with the glucometers, she stated she could not even begin to determine why they did not notify anyone of the problems. 15) At 2:40 PM on 10/23/13, an interview was conducted with ADON L. She stated she had not been aware of any problems with glucometers or the readings. She stated if the staff had a problem with an out-of-range reading, they should recheck it and use new bottles of control solutions and test strips. If there was still a problem, then the staff should notify her and the DON and get a new glucometer to use. ADON L confirmed she had not been notified by any staff of any problems regarding out-of-range glucometer quality check results. 16) At 2:25 PM on 10/23/13, an interview was conducted with ADON T. She stated she had not been aware of any problems with the glucometers or the readings. She stated staff on the night shift (10:00 PM to 6:00 AM) conducted the checks. When asked what the staff should do if they got an out-of-range reading, she stated they should "alert me." She stated, the staff should "just leave me a note." She said she was not aware of any facility protocol of what to do when a glucometer quality check resulted in out-of-range results, but she would find out. 17) At 10:48 AM on 10/24/13, an interview was conducted with ADON T. She was shown the 24-hour report dated 10/04/13. The report indicated "Glucometer has abnormal low range." She stated she did not see this notation on the 24-hour report, and did not remember any nurse telling her about it. She stated she just could not remember it. 18) At 3:40 PM on 10/23/13, an interview was conducted with the Medical Director. He stated he had just become aware of the issues with the glucometer quality checks being out-of-range and the failure of staff to notify their supervisors. He stated he had not been aware of any problems until today. He stated education was going to be very important to correct this problem. 19) The facility's current Nursing Services Procedure Manual for Diabetic Care, revised April 2001, reflected the following on Obtaining a Fingerstick Glucose Level: Purpose "The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level." "Preparation: ...4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or the facility...." 20) An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. On 10/23/13 at 4:45 PM, the Administrator and DON were informed of the IJ, and a Plan of Removal for the IJ was requested. During this meeting, both the DON and Administrator were asked what they thought caused the failure of staff to take appropriate action when glucometer results fell out-of-range when performing the quality checks. Both were unable to identify the causes of the failures. The DON stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added, the glucometer quality assurance checks were not discussed during the only Quality Assurance and Assessment quarterly meeting she had attended since being hired. 21) The facility's Plan of Removal was accepted on 10/24/13 at 1:15 PM and reflected the following: The following corrective items have been taken for all potentially affected diabetics in the facility. See attached list of resident names. Issue - Failure to Notify Nursing supervisors when glucometer Quality Control Checks are not within control range as indicated and continued use of glucometer. 1. Immediate Action: Checked all Glucometers for control calibration within range and changed all strips and control solutions to new bottles and dated as 10/23/13. All glucometers were within range by 5:30 p.m. ADONs L and T completed this task by 5:30 p.m. Identified all diabetics, refer to attachment identifying residents, and will monitor for signs and symptoms of hypo/hyperglycemia for the next 24 hrs starting at 6:00 p.m. on 10/23/13 and through to 6:00 p.m. on 10/24/13. Outcomes will be documented on a nurse's note for each individual, noting date, time, any signs and symptoms assessed and signature of nurse assessing. This task started at 6:00 p.m. on 10/23/13 and continued until 6:00 p.m. on 10/24/13. This task was to be conducted by charge nurses. All blood sugars were checked and recorded. Insulin was administered as needed per physician order, after the quality controls were checked and verified to be within range. Facility Charge nurses responsible for completion of the 10/23/13, 4:30 p.m. blood sugars, completed them at 5:00 p.m. on 10/23/13. Competency checks with return demonstrations were begun on

Based on observation, interview and record review it was determined the Administrator and DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for two (Residents #25 and #26) of 12 residents reviewed for glucose monitoring. 1) The Administrator failed to supervise the DON to ensure she was monitoring staff for compliance with assessing diabetic residents regarding accurate quality monitoring checks of their daily blood sugars; and that staff was knowledgeable in what procedures to follow when one of the results was out of range. 2) The Administrator and the DON failed to ensure the facility had a written nursing policy and procedure which addressed how the staff should use the glucometers correctly and one to address what staff were to do in the case of getting an out of range result. 3) The Administrator and DON failed to ensure accountability was assigned for review of the Quality Check on the daily glucometer log. 4) ADON L and ADON T failed to ensure the facility staff was fully trained in the use of the blood sugar glucometers and to provide supervision of staff to ensure the staff was knowledgeable of what procedures to use when they received a result which was out of range. An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. While the IJ was removed on 10/24/13 at 4:35 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure the glucometers were providing the correct results of blood sugar levels and not troubleshooting to determine whether the glucometers were working placed the facility's 29 diabetics at risk for: 1) developing abnormal blood sugar levels without being identified; 2) not receiving the appropriate dosage of insulin as ordered by the physician; and 3) not receiving the therapeutic benefits needed. This could result in a decline in their health and well-being without recognizing hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain damage and death. Findings included: 1) Resident #25's Admission Record with a print date of 10/24/13 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Three of the FSBS were scheduled for 6:30 AM, 11:30 AM and 4:30 PM, and did not have sliding scale insulin ordered according to the results of the FSBS. The three other FSBS were scheduled for 9:00 AM, 1:00 PM and 6:00 PM and had sliding scale [MEDICATION NAME]ordered to be given subcutaneously according to the FSBS result. The following sliding scale was ordered: 0 - 200 mg/dL, no insulin; 201 - 250 mg/dL, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; 401+ mg/dL, give 10 units & notify MD. Resident #25's lab results reflected on 07/19/13, she had a Hemoglobin A1c of 8.5%. The reference range was 4.5 - 5.7%. She had a Glucose level of 168 mg/dL with a reference range of 70 - 110 mg/dL. Resident #25's lab results reflected on 10/16/13, she had a Hemoglobin A1c of 9.2% with a reference range of 4.5 - 5.7%. She had a Glucose level of 208 mg/dL with a reference range of 70 -110 mg/dL. The Hemoglobin A1c results indicated Resident #25's average blood sugar level had increased by 0.7%. The results of her Hemoglobin A1c could have been affected by inaccurate FSBS levels, which were the results from the facility's glucometers The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] date FSBS result insulin given 10/01/13 AM 120 0 units 10/01/13 PM 209 2 units 10/02/13 AM Not done 10/02/13 PM Not done 10/03/13 AM Not done 10/03/13 PM 242 2 units 10/04/13 AM 178 0 units 10/04/13 PM 251 4 units 10/05/13 AM 153 0 units 10/05/13 PM 230 2 units 10/06/13 AM 200 0 units 10/06/13 PM 183 0 units 10/07/13 AM Not done 10/07/13 PM 313 6 units 10/08/13 AM Not done 10/08/13 PM 223 2 units 10/09/13 AM Not done 10/09/13 PM 216 2 units 10/10/13 AM Not done 10/10/13 PM 278 4 units 10/11/13 AM 275 4 units 10/11/13 PM Not done 10/12/13 AM 200 0 units 10/12/13 PM 207 2 units 10/13/13 AM 138 0 units 10/13/13 PM 165 0 units 10/14/13 AM Not done 10/14/13 PM Not done 10/15/13 AM Not done 10/15/13 PM 228 2 units 10/16/13 AM 218 2 units 10/16/13 PM Not done 10/17/13 AM 215 2 units 10/17/13 PM Not done 10/18/13 AM 226 2 units 10/18/13 PM Not done 10/19/13 AM 179 0 units 10/19/13 PM 247 2 units 10/20/13 AM 180 0 units 10/20/13 PM 199 0 units 10/21/13 AM 190 0 units 10/21/13 PM Not done Despite the fluctuations in Resident #27's FSBS results from AM results to PM results, nursing staff continued to use the facility's glucometers without questioning the results received. 2) Retrieved on 11/06/13 from www.medicinenet.com/script/main/art.asp?article key= in regard to the lab test, Hemoglobin A1c: Red blood cells circulate in the body for about three months before they die. Sugar sticks to the red blood cells and gives an idea of how much sugar has been around (in the body) for the preceding six months. The benefit of measuring the Hemoglobin A1c (A1c) is because it gives a more reasonable view of blood sugar levels over the course of time (3 months). The value does not bounce as much as FSBS measurements. "There is a correlation between A1c levels and average blood sugar levels as follows: ...it gives a physician a good idea that someone is diabetic if the value is elevated. ...it is used as a standard tool to determine blood sugar control in patients known to have diabetes." A1c(%) Average blood sugar (mg/dl) 6 135 7 170 8 205 9 240 10 275 11 310 12 345 "The American Diabetes Association currently recommends an A1c goal of less than 7.0%, while other groups... recommend a goal of less than 6.5%." 3) Resident #26's Admission Record with a print date of 10/24/13 reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 10/21/13 at approximately 10:30 AM, during initial tour, LVN CC informed the surveyor Resident #26 used a wheelchair for mobility, was able to feed herself and ate in the main dining room. LVN CC further stated Resident #26 was alert, required the assistance of one person with ADLs and was incontinent of bladder. Resident #26's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Two FSBS were scheduled for 6:30 AM and 4:30 PM with no sliding scale insulin ordered. Resident #26 had FSBS scheduled for 9:00 AM and 6:00 PM with sliding scale [MEDICATION NAME]to be given subcutaneously per the results of the FSBS per the facility's glucometers: 0 - 150 mg/dL, no insulin; 151 - 200 mg/dL, give 2 units; 201 - 250 mg/dL, give 4 units; 251 - 300 mg/dL, give 6 units; 301 - 350 mg/dL, give 8 units; 351- 400 mg/dL, give 10 units; 401+ mg/dL, call the MD. Resident #26's lab results reflected on 07/24/13, she had a Hemoglobin A1c of 9.1%. The reference range was 4.5 - 5.7%. Resident #26's lab results reflected on 10/17/13, she had a Hemoglobin A1c of 9.4% with a reference range of 4.5 - 5.7%. Resident #26's lab work identified an increase in her Hemoglobin A1c of 0.3%, which indicated an increase in her blood glucose levels. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM 295 6 units 10/01/13 PM 338 8 units 10/02/13 AM 331 8 units 10/02/13 PM 389 10 units 10/03/13 AM 362 10 units 10/03/13 PM 400 10 units 10/04/13 AM 153 2 units 10/04/13 PM 273 6 units 10/05/13 AM 293 6 units 10/05/13 PM 258 6 units 10/06/13 AM 257 6 units 10/06/13 PM 360 8 units 10/07/13 AM 361 10 units 10/07/13 PM blank 10/08/13 AM 198 2 units 10/08/13 PM 183 2 units 10/09/13 AM 213 4 units 10/09/13 PM 278 6 units 10/10/13 AM 206 4 units 10/10/13 PM 190 2 units 10/11/13 AM 188 2 units 10/11/13 PM blank 10/12/13 AM 237 4 units 10/12/13 PM 245 4 units 10/13/13 AM 268 6 units 10/13/13 PM 328 8 units 10/14/13 AM 240 4 units 10/14/13 PM 242 4 units 10/15/13 AM 267 6 units 10/15/13 PM 285 6 units 10/16/13 AM 243 4 units 10/16/13 PM 333 8 units 10/17/13 AM 292 6 units 10/17/13 PM 308 8 units 10/18/13 AM 267 6 units 10/18/13 PM 317 8 units 10/19/13 AM 275 6 units 10/19/13 PM 376 10 units 10/20/13 AM 303 8 units 10/20/13 PM 341 8 units 10/21/13 AM 209 4 units 10/21/13 PM 217 4 units Despite the fluctuations in Resident #27's FSBS results and the resident being administered anywhere from 2 units of insulin to 10 units of insulin, nursing staff continued to use the facility's glucometers without questioning the results received. 4) Resident #31's Admission Record dated 03/20/13 reflected the resident, an [AGE] year-old female, was admitted to the facility originally on 12/22/08. [DIAGNOSES REDACTED]. Resident #31's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #31 was ordered to receive sliding scale [MEDICATION NAME]according to the results of the FSBS done at 9:00 AM and 6:00 PM. The following sliding scale was ordered: 0-200 mg/dl, 0 units; 201-250 mg/dl, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; and 401+ mg/dL, give 12 units, notify MD. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM Not done 10/01/13 PM 447 12 units 10/02/13 AM 202 2 units 10/02/13 PM 416 2 units 10/03/13 AM 204 2 units 10/03/13 PM 260 2 units 10/04/13 AM 209 2 units 10/04/13 PM 224 2 units 10/05/13 AM 250 2 units 10/05/13 PM 292 2 units 10/06/13 AM 176 0 units 10/06/13 PM 281 4 units 10/07/13 AM 210 2 units 10/07/13 PM Not done 10/08/13 AM Not done 10/08/13 PM 331 6 units 10/09/13 AM 404 12 units 10/09/13 PM 404 12 units 10/10/13 AM 367 8 units 10/10/13 PM 271 4 units 10/11/13 AM 351 8 units 10/11/13 PM 418 12 units 10/12/13 AM 275 4 units 10/12/13 PM 287 4 units 10/13/13 AM 131 0 units 10/13/13 PM 273 4 units 10/14/13 AM 210 2 units 10/14/13 PM 210 2 units 10/15/13 AM 274 4 units 10/15/13 PM 346 6 units 10/16/13 AM 220 2 units 10/16/13 PM 307 6 units 10/17/13 AM 232 2 units 10/17/13 PM 267 4 units 10/18/13 AM 155 0 units 10/18/13 PM Not done 10/19/13 AM 178 0 units 10/19/13 PM 192 0 units 10/20/13 AM 184 0 units 10/20/13 PM 348 4 units 10/21/13 AM 127 0 units 10/21/13 PM 273 4 units Resident #31's lab report dated 09/17/13 reflected a Hemogolbin A1c of 7.5%. Resident #31's lab report dated 06/18/13 reflected a Hemoglobin A1c of 7.7%. Despite the fluctuations in Resident #31's FSBS results and the resident being administered sliding scale insulin, nursing staff continued to use the facility's glucometers without questioning the results received when Resident #31's Hemogobin A1c had decreased. 5) On 10/23/13 at 1:00 PM, the Versailles Unit (500/600/700 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September, and October 2013. The following are the results for the 700 Hall and half of the 500 Hall which fell out-of-range of the quality check: DATE RESULT RANGE ACTION 08/28/13 88 91-114 09/18/13 68 91-114 09/19/13 74 91-114 09/20/13 376 236-294 09/21/13 65 91-114 09/22/13 63 91-114 09/24/13 63 89-111 09/26/13 60 89-111 09/27/13 66 91-114 09/28/13 63 91-114 09/29/13 66 90-113 09/30/13 67 90-113 10/01/13 68 90-113 10/02/13 75 90-113 10/03/13 65 90-112 10/04/13 66 90-112 10/05/13 68 90-112 10/06/13 72 90-112 10/07/13 64 90-112 10/08/13 72 90-112 10/09/13 66 90-113 10/10/13 66 90-113 10/11/13 65 90-113 10/12/13 65 91-114 10/14/13 70 91-114 10/15/13 63 91-113 10/16/13 62 91-113 385 234-292 10/17/13 67 91-113 10/18/13 63 91-113 10/19/13 76 91-113 10/20/13 86 90-113 10/21/13 63 90-113 10/22/13 65 90-113 The following are the results for the 600 Hall and half of the 500 Hall, which fell out-of-range of the quality check: DATE RESULTS CONTROL ACTION 08/01/13 71 90-112 08/02/13 88 90-112 08/03/13 80 90-112 ? 08/04/13 82 88-110 08/06/13 77 88-110 ? 08/07/13 83 88-110 08/08/13 83 88-110 08/09/13 81 91-113 08/10/13 70 91-113 08/11/13 83 91-113 08/12/13 86 91-113 08/13/13 84 91-110 ? 08/14/13 78 91-114 08/15/13 83 91-114 08/16/13 82 91-114 ? 08/17/13 81 91-114 ? 08/21/13 81 90-112 ? 08/24/13 81 90-112 ? 08/29/13 78 91-114 ? 08/30/13 77 91-114 08/31/13 78 88-110 09/05/13 74 88-110 09/06/13 74 91-114 09/07/13 74 91-114 09/08/13 86 91-114 09/09/13 75 91-114 ? 09/10/13 75 91-114 09/11/13 70 91-114 09/12/13 71 91-114 09/13/13 70 91-114 09/14/13 70 91-114 09/15/13 70 91-114 ? 09/16/13 71 91-114 ? 09/17/13 70 91-114 09/18/13 70 91-114 09/19/13 69 91-114 09/20/13 68 91-114 09/21/13 74 91-114 09/22/13 70 91-114 09/24/13 66 89-111 09/25/13 66 89-111 09/26/13 66 89-111 There was no evidence this unit's staff documented quality checks on the glucometers for 10/14/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. All of the other documented October results were documented to have fallen in range through 10/23/13. On 10/23/13 at 1:15 PM, the Mount Vernon unit (100, 200, 300 and 400 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September and October 2013. The following are the results for the 100 and 200 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/13/13 182 225-280 ? 08/10/13 113 88-109 ? 08/22/13 226 234-292 ? 08/24/13 219 234-292 ? 09/10/13 217 229-286 ? 09/12/13 210 229-294 ? 09/17/13 225 236-294 ? 09/20/13 90 91-110 202 236-294 ? 09/21/13 229 236-294 ? 09/24/13 192 236-294 ? The following are the results for the 300 and 400 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/06/13 85 90-112 - 08/16/13 87 91-114 ? 08/20/13 87 90-112 ? 08/21/13 234 236-294 ? 08/27/13 234 236-294 ? 08/29/13 228 236-294 ? 09/05/13 224 277-283 09/06/13 244 277-283 09/07/13 231 277-283 09/08/13 242 277-283 09/09/13 269 277-283 09/13/13 234 236-294 09/14/13 90 91-114 221 236-294 09/15/13 235 236-294 09/16/13 227 236-294 09/18/13 90 91-114 214 236-294 09/19/13 174 236-294 09/20/13 175 236-294 09/21/13 190 236-291 09/24/13 88 89-111 09/25/13 84 89-111 244 230-286 09/26/13 88 89-111 09/27/13 90 91-114 09/28/13 234 236-286 There was no evidence of quality checks on the glucometer for 09/29/13 and 09/30/13. 10/01/13 79 91-114 10/10/13 123 88-111 ? 10/23/13 88 90-113 There was no evidence quality checks on the glucometer were conducted on 10/04/13, 10/06/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. 6) At 2:35 PM on 10/23/13, an interview was conducted with the Staffing Coordinator, who was also responsible for Central Supply and equipment. She said she was the person responsible for ordering the glucometers. When she checked Central Supply at that time, she could not find any extra glucometers. She stated she had given the last one out a few weeks ago to the Versailles Unit, but she did not have any extra glucometers at that time. 7) On 10/23/13 at 2:00 PM, the 2013 facility in-services and training binder for 2013 was provided to the surveyor by the DON. No evidence was found staff had been trained or in-serviced on the glucometer. 8) At 2:48 PM on 10/23/13, during an interview with the DON, she confirmed the facility was using the Assure Platinum Glucometer. 9) The manufacturer's User Instruction Manual for the Assure Platinum glucometer, the brand of all four facility glucometers, Section B, Step 5 reflected: "Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within this range, the meter and test strip are working correctly. Do not use the system if control solution result is out-of-range. See Troubleshooting on page 12." In the troubleshooting chart on page 12 of the Manual, there were ten actions staff were to take if the result was out-of-range, along with the necessary action to correct the problem. At the very end of the chart is the following information: "Does your Control Solution result still read outside the range printed on the test strip bottle? If yes, the system may not be working correctly. DO NOT USE the system to test your blood glucose until the control solution result is within range. If you need help, please call Customer Service at [PHONE NUMBER] (24 hours a day, 7 days a week, USA and Canada). Contact your diabetes healthcare professional if you cannot reach Customer Service." The manufacturer's instructions included the following: Perform a control solution test: -- Before testing with the glucometer for the first time. -- When you open a new bottle of test strips -- Whenever you suspect the meter or test strips are not functioning properly. -- When test results appear to abnormally high or low or are not consistent with clinical symptoms. --If the test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees Fahrenheit or above 86 degrees Fahrenheit, or humidity levels are above 80%. 10) At 2:00 PM on 10/23/13 an interview was conducted with LVN D. She was asked what she would do if she obtained an out-of-range result when performing the quality check on the glucometer. She stated she would get another nurse to recheck it, and then they would document it on the glucometer log, then on the 24 hour report and pass it on to the nurse on the next shift. LVN D stated she had not had any out-of-range checks on the glucometers when she had to do the glucometer checks. A review of the quality assurance logs for August, September, and October 2013, revealed LVN D had out-of-range results when performing the quality check on the glucometer on 09/26/13, 10/14/13, 10/19/13, and 10/20/13. 11) In an interview on 10/23/13 at 4:00 PM, LVN C stated when he performed glucometer control checks, he would sometimes get out-of-range levels. He stated he would then recheck the glucometer by performing a fingerstick blood sugar on himself. He stated he never informed the ADONs or the DON the glucometer quality control checks were out-of-range. He confirmed he had not received any training on the glucometer. When the surveyor inquired whether a special setting or mode was needed to perform controls on the glucometer, LVN C replied, "Not that I know of." 12) At 10:12 PM on 10/23/13, an interview was conducted with LVN E. He stated he worked both units on the 10:00 PM to 6:00 AM shifts and he was to provide quality checks on the glucometers. He stated he would take a test strip and put it in the glucometer and put the glucometer in the control mode. He stated he would take the low control solution and put a drop on the strip and take the reading. He stated he then documented the range on the log, and then he would do the high control test. LVN E stated he had obtained a few readings, which were out-of-range. He stated he changed the control solutions and rechecked it. He said if the results were still out-of-range, he would put the results in the glucometer log. LVN E stated he did not notify anyone, and he had never been told to notify anyone of an out-of-range reading. He stated he did not see a reason to call up the ADONs for this issue. He said in the morning, the charge nurse or the ADON were supposed to check the ranges, and if there was a problem, they were supposed to address it and write in the log book under the section "Action Taken" what they did to correct the problem. 13) At 11:38 AM on 10/24/13, an interview was conducted with LVN K. She stated a few weeks ago, there was a problem with the glucometer, and it had been written on the 24-hour report. She said, at the change of shift, the night nurse, LVN U, reported to her the problem with the glucometer. LVN K confirmed the date on the 24-hour report was 10/04/13. She stated she went to the Staffing Coordinator (who was in charge of central supply) and got a new glucometer. She stated she left the old glucometer in the cart, but used the new one. She did not label the non-working glucometer as defective or place it out of commission. LVN K stated she did not perform a quality check on the new glucometer before she used it to check the residents' blood sugars. LVN K stated she did not tell anyone about the problems with the glucometer on the 24-hour report, because ADON T made copies of the 24-hour report, and she assumed ADON T would read and see the comment. She also stated she was not aware of what happened to the non-working glucometer. 14) At 1:55 PM on 10/23/13, an interview was conducted with the DON. She stated she was not aware of any problems with the glucometers. At 2:48 PM on 10/23/13, a second interview was conducted with the DON. She stated she was not aware the staff was having any problems with the glucometers or of the out-of-range readings. She stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added the glucometer must be in the control mode in order to perform the quality check, and if it was not in the control mode the readings would be off. She stated the staff should make sure the glucometer was in the control mode to check it. If the staff got a reading outside the normal parameters, they should check it again with a new bottle of control solutions and test strips. If they still got an out-of-range reading then they should notify the ADONs and me (DON). They should also exchange the glucometer for a new one. The DON confirmed again she had not been informed of any issues regarding the glucometers. When asked why she thought the staff did not notify the ADONs or her of any abnormal readings or issues with the glucometers, she stated she could not even begin to determine why they did not notify anyone of the problems. 15) At 2:40 PM on 10/23/13, an interview was conducted with ADON L. She stated she had not been aware of any problems with glucometers or the readings. She stated if the staff had a problem with an out-of-range reading, they should recheck it and use new bottles of control solutions and test strips. If there was still a problem, then the staff should notify her and the DON and get a new glucometer to use. ADON L confirmed she had not been notified by any staff of any problems regarding out-of-range glucometer quality check results. 16) At 2:25 PM on 10/23/13, an interview was conducted with ADON T. She stated she had not been aware of any problems with the glucometers or the readings. She stated staff on the night shift (10:00 PM to 6:00 AM) conducted the checks. When asked what the staff should do if they got an out-of-range reading, she stated they should "alert me." She stated, the staff should "just leave me a note." She said she was not aware of any facility protocol of what to do when a glucometer quality check resulted in out-of-range results, but she would find out. 17) At 10:48 AM on 10/24/13, an interview was conducted with ADON T. She was shown the 24-hour report dated 10/04/13. The report indicated "Glucometer has abnormal low range." She stated she did not see this notation on the 24-hour report, and did not remember any nurse telling her about it. She stated she just could not remember it. 18) At 3:40 PM on 10/23/13, an interview was conducted with the Medical Director. He stated he had just become aware of the issues with the glucometer quality checks being out-of-range and the failure of staff to notify their supervisors. He stated he had not been aware of any problems until today. He stated education was going to be very important to correct this problem. 19) The facility's current Nursing Services Procedure Manual for Diabetic Care, revised April 2001, reflected the following on Obtaining a Fingerstick Glucose Level: Purpose "The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level." "Preparation: ...4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or the facility...." 20) An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. On 10/23/13 at 4:45 PM, the Administrator and DON were informed of the IJ, and a Plan of Removal for the IJ was requested. During this meeting, both the DON and Administrator were asked what they thought caused the failure of staff to take appropriate action when glucometer results fell out-of-range when performing the quality checks. Both were unable to identify the causes of the failures. The DON stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added, the glucometer quality assurance checks were not discussed during the only Quality Assurance and Assessment quarterly meeting she had attended since being hired. 21) The facility's Plan of Removal was accepted on 10/24/13 at 1:15 PM and reflected the following: The following corrective items have been taken for all potentially affected diabetics in the facility. See attached list of resident names. Issue - Failure to Notify Nursing supervisors when glucometer Quality Control Checks are not within control range as indicated and continued use of glucometer. 1. Immediate Action: Checked all Glucometers for control calibration within range and changed all strips and control solutions to new bottles and dated as 10/23/13. All glucometers were within range by 5:30 p.m. ADONs L and T completed this task by 5:30 p.m. Identified all diabetics, refer to attachment identifying residents, and will monitor for signs and symptoms of hypo/[MEDICAL CONDITION] for the next 24 hrs starting at 6:00 p.m. on 10/23/13 and through to 6:00 p.m. on 10/24/13. Outcomes will be documented on a nurse's note for each individual, noting date, time, any signs and symptoms assessed and signature of nurse assessing. This task started at 6:00 p.m. on 10/23/13 and continued until 6:00 p.m. on 10/24/13. This task was to be conducted by charge nurses. All blood sugars were checked and recorded. Insulin was administered as needed per physician order, after the quality controls were checked and verified to be within range. Facility Charge nurses responsible for completion of the 10/23/13, 4:30 p.m. blood sugars, completed them at 5:00 p.m. on 10/23/13. Competency checks with return demonstrations were begun on 10/23/13 at 8:00 p.m. for licensed nursing staff currently on duty and will be completed by 10/24/13 at 4:00 p.m. This task was to be completed by LVN V, ADON T, ADON L, and the DON. Any employees who did not attend scheduled inservic

Based on observation, interview and record review, the facility failed to provide quality laboratory services to meet the needs of three (Residents #25, #26 and #27) of twelve residents reviewed for FSBS results being provided by the facility's four glucometers, Residents #25, #26 and #31 had fluctuating FSBS results when the facility's glucometers were being used to check their blood sugar levels without staff questioning the results. Residents #25 and #26 had increased Hemoglobin A1c results identified on 10/16/13 and 10/17/13 without staff questioning the accuracy of their FSBS results when the residents were receiving the physician-ordered amounts of sliding scale insulin. Resident #31 had a decreased Hemoglobin A1c result identified on 09/17/13 without staff questioning the accuracy of their FSBS results when the residents were receiving the physician-ordered amounts of sliding scale insulin. LVNs C, D, E and K, who conducted control testing of the facility's four glucometers, did not notify anyone of the abnormal quality check results, which placed the 29 diabetic residents at risk for receiving the wrong dosages of sliding scale insulin during August, Sepetember and October 2013. LVNs C, D, E and K did not take any action for the abnormal readings, and the four glucometers continued to be used. The DON, ADON T and ADON L were unaware the facility's four glucometers had multiple, significant out-of-range quality check results when tested with control solutions. An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. While the IJ was removed on 10/24/13 at 4:35 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure the glucometers were providing the correct results of blood sugar levels and not troubleshooting to determine whether the glucometers were working placed the facility's 29 diabetics at risk for: 1) developing abnormal blood sugar levels without being identified; 2) not receiving the appropriate dosage of insulin as ordered by the physician; and 3) not receiving the therapeutic benefits needed. This could result in a decline in their health and well-being without recognizing hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain damage and death. Findings included: 1) Resident #25's Admission Record with a print date of 10/24/13 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Three of the FSBS were scheduled for 6:30 AM, 11:30 AM and 4:30 PM, and did not have sliding scale insulin ordered according to the results of the FSBS. The three other FSBS were scheduled for 9:00 AM, 1:00 PM and 6:00 PM and had sliding scale [MEDICATION NAME]ordered to be given subcutaneously according to the FSBS result. The following sliding scale was ordered: 0 - 200 mg/dL, no insulin; 201 - 250 mg/dL, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; 401+ mg/dL, give 10 units & notify MD. Resident #25's lab results reflected on 07/19/13, she had a Hemoglobin A1c of 8.5%. The reference range was 4.5 - 5.7%. She had a Glucose level of 168 mg/dL with a reference range of 70 - 110 mg/dL. Resident #25's lab results reflected on 10/16/13, she had a Hemoglobin A1c of 9.2% with a reference range of 4.5 - 5.7%. She had a Glucose level of 208 mg/dL with a reference range of 70 -110 mg/dL. The Hemoglobin A1c results indicated Resident #25's average blood sugar level had increased by 0.7%. The results of her Hemoglobin A1c could have been affected by inaccurate FSBS levels, which were the results from the facility's glucometers The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] date FSBS result insulin given 10/01/13 AM 120 0 units 10/01/13 PM 209 2 units 10/02/13 AM Not done 10/02/13 PM Not done 10/03/13 AM Not done 10/03/13 PM 242 2 units 10/04/13 AM 178 0 units 10/04/13 PM 251 4 units 10/05/13 AM 153 0 units 10/05/13 PM 230 2 units 10/06/13 AM 200 0 units 10/06/13 PM 183 0 units 10/07/13 AM Not done 10/07/13 PM 313 6 units 10/08/13 AM Not done 10/08/13 PM 223 2 units 10/09/13 AM Not done 10/09/13 PM 216 2 units 10/10/13 AM Not done 10/10/13 PM 278 4 units 10/11/13 AM 275 4 units 10/11/13 PM Not done 10/12/13 AM 200 0 units 10/12/13 PM 207 2 units 10/13/13 AM 138 0 units 10/13/13 PM 165 0 units 10/14/13 AM Not done 10/14/13 PM Not done 10/15/13 AM Not done 10/15/13 PM 228 2 units 10/16/13 AM 218 2 units 10/16/13 PM Not done 10/17/13 AM 215 2 units 10/17/13 PM Not done 10/18/13 AM 226 2 units 10/18/13 PM Not done 10/19/13 AM 179 0 units 10/19/13 PM 247 2 units 10/20/13 AM 180 0 units 10/20/13 PM 199 0 units 10/21/13 AM 190 0 units 10/21/13 PM Not done Despite the fluctuations in Resident #27's FSBS results from AM results to PM results, nursing staff continued to use the facility's glucometers without questioning the results received. 2) Retrieved on 11/06/13 from www.medicinenet.com/script/main/art.asp?article key= in regard to the lab test, Hemoglobin A1c: Red blood cells circulate in the body for about three months before they die. Sugar sticks to the red blood cells and gives an idea of how much sugar has been around (in the body) for the preceding six months. The benefit of measuring the Hemoglobin A1c (A1c) is because it gives a more reasonable view of blood sugar levels over the course of time (3 months). The value does not bounce as much as FSBS measurements. "There is a correlation between A1c levels and average blood sugar levels as follows: ...it gives a physician a good idea that someone is diabetic if the value is elevated. ...it is used as a standard tool to determine blood sugar control in patients known to have diabetes." A1c(%) Average blood sugar (mg/dl) 6 135 7 170 8 205 9 240 10 275 11 310 12 345 "The American Diabetes Association currently recommends an A1c goal of less than 7.0%, while other groups... recommend a goal of less than 6.5%." 3) Resident #26's Admission Record with a print date of 10/24/13 reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 10/21/13 at approximately 10:30 AM, during initial tour, LVN CC informed the surveyor Resident #26 used a wheelchair for mobility, was able to feed herself and ate in the main dining room. LVN CC further stated Resident #26 was alert, required the assistance of one person with ADLs and was incontinent of bladder. Resident #26's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Two FSBS were scheduled for 6:30 AM and 4:30 PM with no sliding scale insulin ordered. Resident #26 had FSBS scheduled for 9:00 AM and 6:00 PM with sliding scale [MEDICATION NAME]to be given subcutaneously per the results of the FSBS per the facility's glucometers: 0 - 150 mg/dL, no insulin; 151 - 200 mg/dL, give 2 units; 201 - 250 mg/dL, give 4 units; 251 - 300 mg/dL, give 6 units; 301 - 350 mg/dL, give 8 units; 351- 400 mg/dL, give 10 units; 401+ mg/dL, call the MD. Resident #26's lab results reflected on 07/24/13, she had a Hemoglobin A1c of 9.1%. The reference range was 4.5 - 5.7%. Resident #26's lab results reflected on 10/17/13, she had a Hemoglobin A1c of 9.4% with a reference range of 4.5 - 5.7%. Resident #26's lab work identified an increase in her Hemoglobin A1c of 0.3%, which indicated an increase in her blood glucose levels. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM 295 6 units 10/01/13 PM 338 8 units 10/02/13 AM 331 8 units 10/02/13 PM 389 10 units 10/03/13 AM 362 10 units 10/03/13 PM 400 10 units 10/04/13 AM 153 2 units 10/04/13 PM 273 6 units 10/05/13 AM 293 6 units 10/05/13 PM 258 6 units 10/06/13 AM 257 6 units 10/06/13 PM 360 8 units 10/07/13 AM 361 10 units 10/07/13 PM blank 10/08/13 AM 198 2 units 10/08/13 PM 183 2 units 10/09/13 AM 213 4 units 10/09/13 PM 278 6 units 10/10/13 AM 206 4 units 10/10/13 PM 190 2 units 10/11/13 AM 188 2 units 10/11/13 PM blank 10/12/13 AM 237 4 units 10/12/13 PM 245 4 units 10/13/13 AM 268 6 units 10/13/13 PM 328 8 units 10/14/13 AM 240 4 units 10/14/13 PM 242 4 units 10/15/13 AM 267 6 units 10/15/13 PM 285 6 units 10/16/13 AM 243 4 units 10/16/13 PM 333 8 units 10/17/13 AM 292 6 units 10/17/13 PM 308 8 units 10/18/13 AM 267 6 units 10/18/13 PM 317 8 units 10/19/13 AM 275 6 units 10/19/13 PM 376 10 units 10/20/13 AM 303 8 units 10/20/13 PM 341 8 units 10/21/13 AM 209 4 units 10/21/13 PM 217 4 units Despite the fluctuations in Resident #27's FSBS results and the resident being administered anywhere from 2 units of insulin to 10 units of insulin, nursing staff continued to use the facility's glucometers without questioning the results received. 4) Resident #31's Admission Record dated 03/20/13 reflected the resident, an [AGE] year-old female, was admitted to the facility originally on 12/22/08. [DIAGNOSES REDACTED]. Resident #31's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #31 was ordered to receive sliding scale [MEDICATION NAME]according to the results of the FSBS done at 9:00 AM and 6:00 PM. The following sliding scale was ordered: 0-200 mg/dl, 0 units; 201-250 mg/dl, give 2 units; 251 - 300 mg/dL, give 4 units; 301 - 350 mg/dL, give 6 units; 351- 400 mg/dL, give 8 units; and 401+ mg/dL, give 12 units, notify MD. The October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s glucometers at 9:00 AM and 6:00 PM: date FSBS result insulin given 10/01/13 AM Not done 10/01/13 PM 447 12 units 10/02/13 AM 202 2 units 10/02/13 PM 416 2 units 10/03/13 AM 204 2 units 10/03/13 PM 260 2 units 10/04/13 AM 209 2 units 10/04/13 PM 224 2 units 10/05/13 AM 250 2 units 10/05/13 PM 292 2 units 10/06/13 AM 176 0 units 10/06/13 PM 281 4 units 10/07/13 AM 210 2 units 10/07/13 PM Not done 10/08/13 AM Not done 10/08/13 PM 331 6 units 10/09/13 AM 404 12 units 10/09/13 PM 404 12 units 10/10/13 AM 367 8 units 10/10/13 PM 271 4 units 10/11/13 AM 351 8 units 10/11/13 PM 418 12 units 10/12/13 AM 275 4 units 10/12/13 PM 287 4 units 10/13/13 AM 131 0 units 10/13/13 PM 273 4 units 10/14/13 AM 210 2 units 10/14/13 PM 210 2 units 10/15/13 AM 274 4 units 10/15/13 PM 346 6 units 10/16/13 AM 220 2 units 10/16/13 PM 307 6 units 10/17/13 AM 232 2 units 10/17/13 PM 267 4 units 10/18/13 AM 155 0 units 10/18/13 PM Not done 10/19/13 AM 178 0 units 10/19/13 PM 192 0 units 10/20/13 AM 184 0 units 10/20/13 PM 348 4 units 10/21/13 AM 127 0 units 10/21/13 PM 273 4 units Resident #31's lab report dated 09/17/13 reflected a Hemogolbin A1c of 7.5%. Resident #31's lab report dated 06/18/13 reflected a Hemoglobin A1c of 7.7%. Despite the fluctuations in Resident #31's FSBS results and the resident being administered sliding scale insulin, nursing staff continued to use the facility's glucometers without questioning the results received when Resident #31's Hemogobin A1c had decreased. 5) On 10/23/13 at 1:00 PM, the Versailles Unit (500/600/700 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September, and October 2013. The following are the results for the 700 Hall and half of the 500 Hall which fell out-of-range of the quality check: DATE RESULT RANGE ACTION 08/28/13 88 91-114 09/18/13 68 91-114 09/19/13 74 91-114 09/20/13 376 236-294 09/21/13 65 91-114 09/22/13 63 91-114 09/24/13 63 89-111 09/26/13 60 89-111 09/27/13 66 91-114 09/28/13 63 91-114 09/29/13 66 90-113 09/30/13 67 90-113 10/01/13 68 90-113 10/02/13 75 90-113 10/03/13 65 90-112 10/04/13 66 90-112 10/05/13 68 90-112 10/06/13 72 90-112 10/07/13 64 90-112 10/08/13 72 90-112 10/09/13 66 90-113 10/10/13 66 90-113 10/11/13 65 90-113 10/12/13 65 91-114 10/14/13 70 91-114 10/15/13 63 91-113 10/16/13 62 91-113 385 234-292 10/17/13 67 91-113 10/18/13 63 91-113 10/19/13 76 91-113 10/20/13 86 90-113 10/21/13 63 90-113 10/22/13 65 90-113 The following are the results for the 600 Hall and half of the 500 Hall, which fell out-of-range of the quality check: DATE RESULTS CONTROL ACTION 08/01/13 71 90-112 08/02/13 88 90-112 08/03/13 80 90-112 ? 08/04/13 82 88-110 08/06/13 77 88-110 ? 08/07/13 83 88-110 08/08/13 83 88-110 08/09/13 81 91-113 08/10/13 70 91-113 08/11/13 83 91-113 08/12/13 86 91-113 08/13/13 84 91-110 ? 08/14/13 78 91-114 08/15/13 83 91-114 08/16/13 82 91-114 ? 08/17/13 81 91-114 ? 08/21/13 81 90-112 ? 08/24/13 81 90-112 ? 08/29/13 78 91-114 ? 08/30/13 77 91-114 08/31/13 78 88-110 09/05/13 74 88-110 09/06/13 74 91-114 09/07/13 74 91-114 09/08/13 86 91-114 09/09/13 75 91-114 ? 09/10/13 75 91-114 09/11/13 70 91-114 09/12/13 71 91-114 09/13/13 70 91-114 09/14/13 70 91-114 09/15/13 70 91-114 ? 09/16/13 71 91-114 ? 09/17/13 70 91-114 09/18/13 70 91-114 09/19/13 69 91-114 09/20/13 68 91-114 09/21/13 74 91-114 09/22/13 70 91-114 09/24/13 66 89-111 09/25/13 66 89-111 09/26/13 66 89-111 There was no evidence this unit's staff documented quality checks on the glucometers for 10/14/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. All of the other documented October results were documented to have fallen in range through 10/23/13. On 10/23/13 at 1:15 PM, the Mount Vernon unit (100, 200, 300 and 400 Halls) glucometer quality checks documented on the Quality Assurance Logs were reviewed for August, September and October 2013. The following are the results for the 100 and 200 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/13/13 182 225-280 ? 08/10/13 113 88-109 ? 08/22/13 226 234-292 ? 08/24/13 219 234-292 ? 09/10/13 217 229-286 ? 09/12/13 210 229-294 ? 09/17/13 225 236-294 ? 09/20/13 90 91-110 202 236-294 ? 09/21/13 229 236-294 ? 09/24/13 192 236-294 ? The following are the results for the 300 and 400 Halls, which fell out-of-range of the quality check: DATE RESULT CONTROL ACTION 08/06/13 85 90-112 - 08/16/13 87 91-114 ? 08/20/13 87 90-112 ? 08/21/13 234 236-294 ? 08/27/13 234 236-294 ? 08/29/13 228 236-294 ? 09/05/13 224 277-283 09/06/13 244 277-283 09/07/13 231 277-283 09/08/13 242 277-283 09/09/13 269 277-283 09/13/13 234 236-294 09/14/13 90 91-114 221 236-294 09/15/13 235 236-294 09/16/13 227 236-294 09/18/13 90 91-114 214 236-294 09/19/13 174 236-294 09/20/13 175 236-294 09/21/13 190 236-291 09/24/13 88 89-111 09/25/13 84 89-111 244 230-286 09/26/13 88 89-111 09/27/13 90 91-114 09/28/13 234 236-286 There was no evidence of quality checks on the glucometer for 09/29/13 and 09/30/13. 10/01/13 79 91-114 10/10/13 123 88-111 ? 10/23/13 88 90-113 There was no evidence quality checks on the glucometer were conducted on 10/04/13, 10/06/13, 10/15/13, 10/16/13, 10/20/13 and 10/22/13. 6) At 2:35 PM on 10/23/13, an interview was conducted with the Staffing Coordinator, who was also responsible for Central Supply and equipment. She said she was the person responsible for ordering the glucometers. When she checked Central Supply at that time, she could not find any extra glucometers. She stated she had given the last one out a few weeks ago to the Versailles Unit, but she did not have any extra glucometers at that time. 7) On 10/23/13 at 2:00 PM, the 2013 facility in-services and training binder for 2013 was provided to the surveyor by the DON. No evidence was found staff had been trained or in-serviced on the glucometer. 8) At 2:48 PM on 10/23/13, during an interview with the DON, she confirmed the facility was using the Assure Platinum Glucometer. 9) According to the CMS Clincal Laboratory Improvement Amendments (CLIA) Certificate of Waaiver Laboratory Project page dated 12/18/07, the glucose meter test is a waived lab procedure. Title 42, Public Health Chapter IV, CMS, Department of Health and Human Services, Part 493.15 addresses entities performing waived tests. Documented under: Part 493.15(e)(1): laboratories eligible for a certificat of waiver must follow manufacturer's instructions for performing the test. The manufacturer's User Instruction Manual for the Assure Platinum glucometer, the brand of all four facility glucometers, Section B, Step 5 reflected: "Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within this range, the meter and test strip are working correctly. Do not use the system if control solution result is out-of-range. See Troubleshooting on page 12." In the troubleshooting chart on page 12 of the Manual, there were ten actions staff were to take if the result was out-of-range, along with the necessary action to correct the problem. At the very end of the chart is the following information: "Does your Control Solution result still read outside the range printed on the test strip bottle? If yes, the system may not be working correctly. DO NOT USE the system to test your blood glucose until the control solution result is within range. If you need help, please call Customer Service at [PHONE NUMBER] (24 hours a day, 7 days a week, USA and Canada). Contact your diabetes healthcare professional if you cannot reach Customer Service." The manufacturer's instructions included the following: Perform a control solution test: -- Before testing with the glucometer for the first time. -- When you open a new bottle of test strips -- Whenever you suspect the meter or test strips are not functioning properly. -- When test results appear to abnormally high or low or are not consistent with clinical symptoms. --If the test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees Fahrenheit or above 86 degrees Fahrenheit, or humidity levels are above 80%. 10) At 2:00 PM on 10/23/13 an interview was conducted with LVN D. She was asked what she would do if she obtained an out-of-range result when performing the quality check on the glucometer. She stated she would get another nurse to recheck it, and then they would document it on the glucometer log, then on the 24 hour report and pass it on to the nurse on the next shift. LVN D stated she had not had any out-of-range checks on the glucometers when she had to do the glucometer checks. A review of the quality assurance logs for August, September, and October 2013, revealed LVN D had out-of-range results when performing the quality check on the glucometer on 09/26/13, 10/14/13, 10/19/13, and 10/20/13. 11) In an interview on 10/23/13 at 4:00 PM, LVN C stated when he performed glucometer control checks, he would sometimes get out-of-range levels. He stated he would then recheck the glucometer by performing a fingerstick blood sugar on himself. He stated he never informed the ADONs or the DON the glucometer quality control checks were out-of-range. He confirmed he had not received any training on the glucometer. When the surveyor inquired whether a special setting or mode was needed to perform controls on the glucometer, LVN C replied, "Not that I know of." 12) At 10:12 PM on 10/23/13, an interview was conducted with LVN E. He stated he worked both units on the 10:00 PM to 6:00 AM shifts and he was to provide quality checks on the glucometers. He stated he would take a test strip and put it in the glucometer and put the glucometer in the control mode. He stated he would take the low control solution and put a drop on the strip and take the reading. He stated he then documented the range on the log, and then he would do the high control test. LVN E stated he had obtained a few readings, which were out-of-range. He stated he changed the control solutions and rechecked it. He said if the results were still out-of-range, he would put the results in the glucometer log. LVN E stated he did not notify anyone, and he had never been told to notify anyone of an out-of-range reading. He stated he did not see a reason to call up the ADONs for this issue. He said in the morning, the charge nurse or the ADON were supposed to check the ranges, and if there was a problem, they were supposed to address it and write in the log book under the section "Action Taken" what they did to correct the problem. 13) At 11:38 AM on 10/24/13, an interview was conducted with LVN K. She stated a few weeks ago, there was a problem with the glucometer, and it had been written on the 24-hour report. She said, at the change of shift, the night nurse, LVN U, reported to her the problem with the glucometer. LVN K confirmed the date on the 24-hour report was 10/04/13. She stated she went to the Staffing Coordinator (who was in charge of central supply) and got a new glucometer. She stated she left the old glucometer in the cart, but used the new one. She did not label the non-working glucometer as defective or place it out of commission. LVN K stated she did not perform a quality check on the new glucometer before she used it to check the residents' blood sugars. LVN K stated she did not tell anyone about the problems with the glucometer on the 24-hour report, because ADON T made copies of the 24-hour report, and she assumed ADON T would read and see the comment. She also stated she was not aware of what happened to the non-working glucometer. 14) At 1:55 PM on 10/23/13, an interview was conducted with the DON. She stated she was not aware of any problems with the glucometers. At 2:48 PM on 10/23/13, a second interview was conducted with the DON. She stated she was not aware the staff was having any problems with the glucometers or of the out-of-range readings. She stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added the glucometer must be in the control mode in order to perform the quality check, and if it was not in the control mode the readings would be off. She stated the staff should make sure the glucometer was in the control mode to check it. If the staff got a reading outside the normal parameters, they should check it again with a new bottle of control solutions and test strips. If they still got an out-of-range reading then they should notify the ADONs and me (DON). They should also exchange the glucometer for a new one. The DON confirmed again she had not been informed of any issues regarding the glucometers. When asked why she thought the staff did not notify the ADONs or her of any abnormal readings or issues with the glucometers, she stated she could not even begin to determine why they did not notify anyone of the problems. 15) At 2:40 PM on 10/23/13, an interview was conducted with ADON L. She stated she had not been aware of any problems with glucometers or the readings. She stated if the staff had a problem with an out-of-range reading, they should recheck it and use new bottles of control solutions and test strips. If there was still a problem, then the staff should notify her and the DON and get a new glucometer to use. ADON L confirmed she had not been notified by any staff of any problems regarding out-of-range glucometer quality check results. 16) At 2:25 PM on 10/23/13, an interview was conducted with ADON T. She stated she had not been aware of any problems with the glucometers or the readings. She stated staff on the night shift (10:00 PM to 6:00 AM) conducted the checks. When asked what the staff should do if they got an out-of-range reading, she stated they should "alert me." She stated, the staff should "just leave me a note." She said she was not aware of any facility protocol of what to do when a glucometer quality check resulted in out-of-range results, but she would find out. 17) At 10:48 AM on 10/24/13, an interview was conducted with ADON T. She was shown the 24-hour report dated 10/04/13. The report indicated "Glucometer has abnormal low range." She stated she did not see this notation on the 24-hour report, and did not remember any nurse telling her about it. She stated she just could not remember it. 18) At 3:40 PM on 10/23/13, an interview was conducted with the Medical Director. He stated he had just become aware of the issues with the glucometer quality checks being out-of-range and the failure of staff to notify their supervisors. He stated he had not been aware of any problems until today. He stated education was going to be very important to correct this problem. 19) The facility's current Nursing Services Procedure Manual for Diabetic Care, revised April 2001, reflected the following on Obtaining a Fingerstick Glucose Level: Purpose "The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level." "Preparation: ...4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or the facility...." 20) An Immediate Jeopardy (IJ) was identified on 10/23/13 at 4:17 PM. On 10/23/13 at 4:45 PM, the Administrator and DON were informed of the IJ, and a Plan of Removal for the IJ was requested. During this meeting, both the DON and Administrator were asked what they thought caused the failure of staff to take appropriate action when glucometer results fell out-of-range when performing the quality checks. Both were unable to identify the causes of the failures. The DON stated when she first came to the facility about four months ago, she did review the glucometer logs and she did not identify any problems at that time. She stated she had not checked the glucometer logs since then. The DON added, the glucometer quality assurance checks were not discussed during the only Quality Assurance and Assessment quarterly meeting she had attended since being hired. 21) The facility's Plan of Removal was accepted on 10/24/13 at 1:15 PM and reflected the following: The following corrective items have been taken for all potentially affected diabetics in the facility. See attached list of resident names. Issue - Failure to Notify Nursing supervisors when glucometer Quality Control Checks are not within control range as indicated and continued use of glucometer. 1. Immediate Action: Checked all Glucometers for control calibration within range and changed all strips and control solutions to new bottles and dated as 10/23/13. All glucometers were within range by 5:30 p.m. ADONs L and T completed this task by 5:30 p.m. Identified all diabetics, refer to attachment identifying residents, and will monitor for signs and symptoms of hypo/[MEDICAL CONDITION] for the next 24 hrs starting at 6:00 p.m. on 10/23/13 and through to 6:00 p.m. on 10/24/13. Outcomes will be documented on a nurse's note for each individual, noting date, time, any signs and symptoms assessed and signature of nurse assessing. This task started at 6:00 p.m. on 10/23/13 and continued until 6:00 p.m. on 10/24/13. This t