Every finding on record at The Mission at Blue Skies of Texas East

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Residents #5) reviewed for incontinent care and catheter care The facility failed to ensure while providing incontinent care for Resident #5, CNA B cleaned Resident #5's rectal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #5's face sheet, dated 08/06/2026, revealed an admission date of 03/23/2009 and, a readmission date of 04/11/2021. Resident #5 had diagnoses which included: Asthma (long-term inflammatory disease of the airways. It is characterized by variable and recurring symptoms and reduced lung function), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Type 2 diabetes mellitus (high level of sugar in the blood), Irritable bowel syndrome (common condition that affects the stomach and intestines, also called the gastrointestinal tract), Anxiety (A group of mental illnesses that cause constant fear and worry), Dementia (decline in cognitive abilities)and, Hypertension (High blood pressure). Record review of Resident #5's quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated the resident was moderately impaired cognitively. Resident #5 was indicated to always be incontinent of bowel and bladder. Record review of Resident #5's care plan, dated 02/16/2024, revealed a problem of has urgency of bladder incontinence with incontinent episodes of bowel due to irritable bowel syndrome with diarrhea r/t Confusion, Dementia, ImpairedMobility. With urgency of urination. Frequent UTI. and, an intervention of INCONTINENT: Check me as needed and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Observation on 08/06/2026 at 8:34 a.m. revealed while providing incontinent care for Resident #5, CNA B did not clean the resident's rectal area and Resident #5 had a bowel movement. During an interview on 08/06/2026 at 9:10 a.m. with CNA B, she stated she should have wiped the resident's skin completely clean and she did not see there was feces left around the rectal area and between the buttocks. During an interview with the ADON and Administrator on 08/06/2026 at 12:09 p.m., they stated staff should wipe residents skin and rectal areas completely clean during incontinent care. It was important prevent fecal matter from causing skin breakdown and infection. They stated infection control training and incontinent care training were provided at least once a year, and staff's skills were checked once a year by the DON and ADON. Record review of the facility's policy titled Perineal care, dated February 2018, revealed, Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #5) reviewed for infection control.The facility failed to ensure CNA A sanitized between her fingers while providing incontinent care for Resident #5 on 08/06/2026, This deficient practice could place residents at-risk for infection due to improper care practices.The findings were: Record review of Resident #5's face sheet, dated 08/06/2026, revealed an admission date of 03/23/2009 and, a readmission date of 04/11/2021. Resident #5 had diagnoses which included: Asthma (long-term inflammatory disease of the airways. It is characterized by variable and recurring symptoms and reduced lung function), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Type 2 diabetes mellitus (high level of sugar in the blood), Irritable bowel syndrome (common condition that affects the stomach and intestines, also called the gastrointestinal tract), Anxiety (A group of mental illnesses that cause constant fear and worry), Dementia (decline in cognitive abilities)and, Hypertension (High blood pressure). Record review of Resident #5's quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated the resident was moderately impaired cognitively. Resident #5 was indicated to always be incontinent of bowel and bladder. Record review of Resident #5's care plan, dated 02/16/2024, revealed a problem of has urgency of bladder incontinence with incontinent episodes of bowel due to irritable bowel syndrome with diarrhea r/t Confusion, Dementia, ImpairedMobility. With urgency of urination. Frequent UTI. and, an intervention of INCONTINENT: Check me as needed and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. An observation on 08/06/2026 at 08:34 a.m., revealed while providing incontinent care for Resident #5, CNA A, while sanitizing her hands with ABHR gel during care, did not sanitize between her fingers. During an interview on 08/06/2026 at 9:01 a.m. CNA A stated she should sanitize between her fingers when she used sanitizer just like she did when she used soap and water. She did not realize she did not sanitize between her fingers. She stated she received infection control within the year. During an interview with the ADON and Administrator on 08/06/2026 at 12:09 p.m., they stated staff should sanitize all surfaces of their hands to ensure appropriate hand hygiene and prevention infection to the resident. they stated infection control training was provided, and staff's skills were checked annually. Record review of the facility's policy titled Hand Hygiene , dated February 2025, revealed, Apply ABHR (Alcohol based hand rub) to palm of hand, rub hand together, cover all surfaces, focus on thumbs, fingertips, between fingers and fingernails.

Based on interview, and record review, the facility failed to develop and implement a care plan to meet the resident's needs for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan accurately documented the resident's need for supervision when actively eating/drinking. These failures could place residents at risk of their needs not being met. The findings include: Record review of Resident #1 's face sheet, dated 8/6/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and discharged to hospital on 7/12/25. Resident #1 had diagnoses which included: heart failure, acute respiratory failure, prostate cancer, pacemaker, Bell's Palsy (dripping of the face), dementia (decline in mental ability), anxiety (a feeling of unease), lack of coordination, and dysphasia (difficulties swallowing). The RP was listed as: family member. Record review of Resident#1's quarterly MDS, dated [DATE], reflected a BIMS score of 03, indicative of severe impairment in cognition. The ADLs for eating was documented as independent and support was set-up. Record review of Resident# 1's Care Plan, dated 2/17/25, reflected the goals and interventions included: Eating as Set up assistance. Record review of Resident#1's Physician' Orders, dated July 2025 reflected: Diet was listed as controlled carb diet; soft and bite texture, Nectar/Mildly Tick consistency. The physician order, revised 11/12/24, reflected the resident required standard swallowing precautions: and Supervision and assistance with positioning and set up of meal tray every shift. Record review of Resident #1's SP evaluation, dated 1/16/24, authored by the SP, read: .Oral Phase=Mild. [mildly impaired to chew and managing food in month]. Record review of Resident #1's SP evaluation, dated 2/19/25, authored by the SP, read: .Supervision for Oral Intake=Distant Supervision. During an interview on 8/6/25 at 10:11 AM, the SP stated: she saw the resident several times and the resident had difficulties with swallowing. The SP evaluation on 01/16/24 reflected a mild oral dysphasia to effectively manage food in his mouth. The SP stated the last evaluation on swallowing was done on 2/19/25 and the findings demonstrated the resident [#1] had mild oral and pharyngeal (second stage of swallowing) and no overt signs of aspiration. The SP stated the resident required close supervision in feeding; distant supervision. The SP defined distant supervision as a staff member being present or within eyesight when feeding or drinking occurred by the resident. The SP stated based on the SP findings after 2/19/25, a staff should not lose eyesight of the resident when the activity of eating or drinking occurred. During an interview on 8/6/25 at 3:44 PM, the Dietician stated: the resident was on a diabetic diet (controlled carbs), soft bite texture, and nectar mildly thicken. The Dietician stated the resident required supervision for eating. The Dietician stated supervision meant the staff had to be in proximity when Resident #1 ate for safety reasons. During an interview on 8/6/25 at 5:10 PM, the DON stated: the process of accurate clinical documentation started with assessments and then completion of the care plan. The DON stated the SP assessment, dated 2/19/25, that Resident#1 required distant supervision and the physician order stated the resident required supervision when eating and drinking. The DON stated she could not give an explanation why the care plan did not mention anything about supervision when the resident was actively eating of drinking liquids.During an interview on 8/7/25 at 11:44 AM, the DON stated she was aware of the SP assessment done on 2/19/25 and the recommendation for supervision of Resident #1 when he actively ate or drank liquid. The DON stated the care plan for Resident #1 did not list any instructions on supervision when the resident actively ate or drank liquids. The DON stated the information was necessary to convey to nursing staff special instructions which involved Resident #1. During a telephone interview on 8/7/25 at 11:48 AM, the MD stated she was aware of the SP recommendation for Resident #1 to be supervised when actively eating and consuming liquids. The MD stated she agreed with the recommendation and when her company took over the medical management of residents, Resident #1's order reflected the resident be supervised when actively eating or drinking. During an interview on 8/7/25 at 4:38 PM, the MDS Nurse stated: the process of documentation was for the facility to conduct assessments, the assessment information was captured in the MDS and then reflected in the care plan. The MDS Nurse stated the clinical record task did not properly capture the SP recommendation on 2/19/25 and the MD order on 11/12/2024; and she had no further explanation. The MDS Nurse stated the data had to be accurate for continuity of care and to avoid any clinical errors. Record review of the facility's Documentation Policy dated January 2025, read: .General Principles.All entries must be factual, accurate, complete, current, and legible. Record review of the facility's, undated, Feeding the Resident procedure read: Resident Care Plan.List the type of diet as part of appropriate plan of care.If resident is unable to feed himself/herself, list the amount of assistance, adaptive equipment, frequency of weight monitoring, feeding program or occupational therapy for functional training.

Based on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that were complete; and accurately documented for 1 of 3 residents (Resident #1) reviewed for documentation. The facility failed to ensure Resident #1's nurse progress notes accurately documented when the resident's vitals were taken. These failures could place residents at risk of their records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team. The findings include: Record review of Resident #1 's face sheet, dated 8/6/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and discharged to hospital on 7/12/25. Resident #1 had diagnoses which included: heart failure, acute respiratory failure, prostate cancer, pacemaker, Bell's Palsy (dripping of the face), dementia (decline in mental ability), anxiety (a feeling of unease), lack of coordination, and dysphasia (difficulties swallowing). The RP was listed as: family member. Record review of Resident #1's Nurse Note, dated 7/12/25 at 9:50 AM, authored by LVN A, reflected the resident went out on pass with family. Record review of Resident #1's Nurse Note, dated 7/12/25 at 12:17 PM, authored by LVN A, reflected the resident returned to the facility at 12:15 PM. Record review of Resident #1's Nurse Note, dated 7/12/25 at 10:31 AM, authored by LVN A, reflected vitals were taken at 10:31 AM and some vital readings listed were: temperature 97.7 Fahrenheit and blood pressure 99/62. Record review of Resident #1's Nurse Note, dated 7/12/25 at 10:36 AM, by LVN A reflected she did a skin check of the resident. The resident's skin was described as Warm & dry.During a telephone interview on 8/7/25 at 3:41 PM, LVN A stated she assessed the resident on 7/12/25 in the morning around 8:00 AM. LVN A stated I made a mistake by entering the notes when the resident was not in the facility. LVN A stated she should have entered the notes at time of occurrence or made a comment of a late entry note. LVN A stated she was in a hurry in writing her nurse notes, on 7/12/25, and made a mistake in listing the resident as continent when the resident had always been incontinent. LVN A stated she was in a hurry and listed the wrong time for the vitals on the 7/12/25 nurse note. LVN A stated the vitals were taken before the resident went out on a family visit on 7/12/25 at 10:00 AM. The LVN A stated accurate documentation informed the interdisciplinary team of services and care given to a resident. During an interview on 8/7/25 at 3:47 PM, the DON stated her expectation was nursing documentation occurred at the time of occurrence or sometime shortly after. The DON stated the nurse [LVN A] could have made a late entry or in the nurse note stated the information written referred to a different time and date. The DON stated she could not explain the inaccurate medical record which involved LVN A and the nurse documentation on 7/12/25 in reference to Resident #1. During an interview on 8/8/25 at 10:08 AM, the Administrator stated: the LVN [A] should have entered her notes as a late entry on 7/12/25. The Administrator stated not labeling the nurse notes as late entry might have caused a confusion to the reader as to when the assessment was done. The Administrator stated the clinical record for any resident had to reflect the current condition of the resident. The Administrator stated, the clinical had to capture the right information. The Administrator stated the information may have been inaccurately documented in the clinical record which involved Resident#1. Regarding the documentation vitals were documented at 10:32 AM for Resident #1 on 7/12/25 when the resident was not in the facility, the Administrator offered the following explanation: not usual for vitals to be done at an earlier time and placed in the formal record at a different time. Record review of the facility's Documentation Policy dated January 2025, read: .General Principles.All entries must be factual, accurate, complete, current, and legible.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 5 (memory unit) satellite kitchens. The facility failed to ensure dietary staff used facial hair restraints properly during plate preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 6/24/25 at 12:35 p.m. revealed CNA F was plating meals for the lunch service for residents in the memory unit. CNA F was observed wearing a facial hair restraint over his chin, but not over his moustache. CNA F continued to plate the lunch meal for residents in the memory unit while not wearing the facial hair restraint properly. Observation on 6/25/25 at 8:13 a.m. revealed CNA F plating a breakfast plate for residents in the memory unit and was observed wearing a facial hair restraint over his chin, but not over his moustache. CNA F, after observing the State Surveyor walk into the unit, pulled up the facial hair restraint over his moustache. During an interview on 6/25/25 at 8:41 CNA F stated he had the required food handler's certification for handling food. CNA F stated part of his duties required he plate meals for the residents. CNA F stated anytime there was food in the satellite kitchen he was supposed to be wearing the hair restraint. CNA F stated he was wearing the facial hair restraint improperly and it was not covering his moustache because it kept falling off and kept getting caught on his name tag. CNA F stated his hair, including hair on his face had to be covered because you did not want any hair falling on the resident's food causing a contamination. During an interview on 6/25/25 at 9:04 a.m., the Dietary Manager stated every unit in the facility had a satellite kitchen and the floor staff, including the CNA staff had training and required a food handler's certificate. The DM stated hair restraints were supposed to be worn while food is being served. The DM stated, proper use of the facial hair restraint included covering the moustache. The DM stated, if the hair restraint was not worn correctly, hair could fall into the food and contaminate it which could result in the resident choking or getting sick. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on the interview and record review, the facility failed to ensure that 1 of 2 residents (Resident #17) reviewed for medication errors was free of any significant medication errors. The facility failed to administer Resident #17's insulin Lispro medication (a quick acting medication used to lower blood sugar) as prescribed. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health. The findings included:Record review of Resident #17's face sheet dated 6/27/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, type 2 diabetes (chronic medical condition in which the body does not produce enough insulin or does not use insulin effectively), and chronic kidney disease stage 3 (moderate decrease in kidney function due to damaged kidneys not filtering blood as well as they should, often caused by diabetes). Record review of Resident #17's most recent quarterly MDS assessment, dated 4/9/25 revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections.Record review of Resident #17's Order Summary Report dated 6/25/25 revealed the following:- Blood glucose monitoring for signs and symptoms of hyper/hypoglycemia as needed for monitoring. May perform fingerstick for accu checks (blood glucose monitoring) if Dexacom (medical device used to monitor glucose continuously) not available, with order date 1/21/25 and no end date.- Insulin Lispro 100 unit/mL Solution pen injector, inject 11 units subcutaneously at bedtime related to type 2 diabetes, with order date 5/25/25 and no end date.- Insulin Lispro 100 unit/mL Solution pen injector, inject 20 units subcutaneously before meals for type 2 diabetes. Notify provider if BS less than 75 ml/dl and/or greater than 350ml/dl with order date 5/25/25 and no end date.- Lantus insulin 100 unit/mL Solution pen-injector, inject 65 unit subcutaneously two times a day. Hold for BS more than 350. Notify MD/NP for BG less than 75 or Greater than 350, with order date 5/1/25 and no end date.Record review of Resident #17's Medication Administration Record for June 2025 revealed the scheduled bedtime dose of Lispro insulin was not administered on 6/24/25 and the scheduled 7:30 a.m. dose was not administered on 6/25/25. Record review of the MAR revealed LVN E documented an X in the section meant for the blood sugar reading and documented 9 with her initials. The MAR indicated the code 9 meant Other/See Progress Notes. Record review of Resident #17's MAR revealed LVN A documented an X in the section meant for the blood sugar reading and documented 15 with her initials. The MAR indicated the code 15 meant Awaiting Pharmacy fill. Record review of Resident #17's clinical record progress note authored by LVN E dated 6/24/25 and time stamped 4:04 p.m., revealed, called pharmacy to ask why Lispro insulin in not here as it was ordered through (computer) on 06/20/25. Pharmacy states they have no record of it being ordered. They will send tonight. Reported to ADON.Record review of Resident #17's clinical record progress note authored by LVN E dated 6/24/25 and time stamped 10:56 p.m., revealed the insulin Lispro was awaiting delivery from the pharmacy.Record review of Resident #17's clinical record progress note authored by LVN E dated 6/24/25 and time stamped 11:59 p.m., revealed the insulin Lispro was awaiting delivery from the pharmacy and was reported to the ADON.Record review of Resident #17's clinical record progress note authored by LVN A dated 6/25/25 and time stamped 9:49 a.m. revealed a request for a STAT delivery of the insulin Lispro and pharmacy stated it would be in the facility in a couple of hours.Record review of Resident #17's clinical record progress note authored by LVN A dated 6/25/25 and time stamped 10:00 a.m. revealed, insulin Lispro is in facility now.During a telephone interview on 6/25/25 at 12:02 p.m., LVN E stated she recalled ordering insulin Lispro for Resident #17 a few days ago. LVN E stated on 6/24/25 the insulin Lispro was not available in the medication cart, so LVN E placed a phone call to LVN B and asked if the insulin Lispro was in their emergency medication stock. LVN E stated LVN B told her it was not available in their emergency medication stock. LVN E stated she placed a call to the ADON and was instructed to document the insulin Lispro not being available in the resident's clinical record. LVN E stated she notified the NP twice but never got a call back. LVN E stated if Resident #17 did not receive his insulin it could result in the blood sugar spiking and might result in hospitalization. During an interview on 6/25/25 at 1:34 p.m., LVN A stated when she clocked in at 6:50 a.m. on 6/25/25, Resident #17's insulin Lispro was not available. LVN A stated the insulin Lispro was delivered at approximately 10:00 a.m. on 6/25/25, and when it (insulin Lispro) was delivered, it was late, but he got it, his sugar was high. His blood sugar was 400. LVN A stated Resident #17 did not receive the scheduled morning dose, that was supposed to be administered before breakfast, and the blood sugar obtained at that time was 386. LVN A stated she had not made contact with the physician regarding Resident #17's elevated blood sugar reading and stated, I have to call the doctor about other things, it's on my list to tell him (the physician), but I have not called him about it yet. During an interview on 6/25/25 at 1:58 p.m., LVN B, who identified herself as the Staff Development Coordinator and Staff Educator, stated LVN E called her on the evening of 6/24/25 and asked her if there was insulin Lispro in the emergency medication stock and LVN E told LVN B it was not. LVN B stated LVN E asked her if she could order the insulin Lispro from the pharmacy STAT and LVN B told her to do that because Resident #17 needed his insulin. LVN B stated she was asked by LVN A in the morning on 6/25/25 about Resident #17's insulin Lispro not being available and LVN B told LVN A the insulin Lispro for Resident #17 had already been ordered and instructed LVN A to call the pharmacy to verify and follow up. LVN B stated she was on the unit when Resident #17's insulin Lispro was delivered and signed for it at approximately 10:00 a.m. or 10:30 a.m. LVN B stated she assumed LVN A had given Resident #17 his morning dose of insulin Lispro. LVN B stated she was not aware Resident #17 did not receive his bedtime dose of insulin Lispro. LVN B stated the nurses should have made it a priority to provide Resident #17 with his insulin Lispro and if it was not available, they should have notified the physician and obtain further instruction on what to do or give an alternative. LVN B stated she had not reported the incident to the DON. During an interview on 6/25/25 at 2:20 p.m., the ADON stated she was notified by telephone on 6/24/25 at 8:03 p.m. by LVN E to inform her Resident #17's insulin Lispro was not available. The ADON stated LVN E asked her if the insulin Lispro was in the emergency medication stock and told her it was not. The ADON stated LVN E asked her how to get the insulin Lispro and told LVN E to reach out to the pharmacy, and I walked her through if it had already been ordered and to call pharmacy to see the status. The ADON stated she told LVN E to reach out to the on-call NP to notify them to get some kind of treatment order, or an alternative treatment in the meantime until the insulin Lispro could be made available. The ADON stated LVN E confirmed she understood and that was the last time the ADON had heard from her about Resident #17. During an interview on 6/25/25 at 2:42 p.m., the DON stated she had not been notified regarding Resident #17 not having his insulin Lispro available. The DON stated medications were ordered at least 7 days in advance per the facility protocol to avoid running out. The DON stated if the insulin Lispro was not available in the emergency medication stock then the nurses should have notified her, and it would need to be delivered STAT. The DON stated, she would have been calling the doctor to give an alternate order for caring for the resident such as monitoring blood sugar levels more frequently, monitor for symptoms or given an alternate insulin. The DON stated, we need to know what to do as soon as possible. The night nurse should have notified the doctor.In an interview with the medical director on 7/11/25 at 11:15 AM, he stated by Resident #17 missing dose of insulin with meals the resident was not negatively impacted, because Resident #17 is non-compliant with his diet. Additionally, he is on oral hypoglycemic medication, along with long-acting insulin which in theory provided necessary coverage.Record review of the facility document titled Administering Medications dated December 2024 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of .medications .Medication Administration Record (MAR): Also referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional .The Director of Nursing (DON) will supervise and direct all nursing personnel who administer medications and/or have related functions .Medications must be administered in accordance with the orders, including any required time frame .Record review of the facility document titled Diabetes Mellitus-Hypoglycemia and Hyperglycemia Best Practices dated March 2025 revealed in part, .Residents with a diagnosis of Diabetes Mellitus will be monitored for signs and symptoms of Hypo and Hyperglycemia, with immediate interventions per doctor's orders and Diabetic Protocol .Specific Resident needs .Notify the resident's physician regarding any insulin that may need to be held .

Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representatives when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident #17) reviewed for physician notification of changes in condition. The facility failed to notify Resident #17's physician when his blood sugar levels were out of physician ordered parameters on 6/25/2025. This deficient practice could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included: Record review of Resident #17's face sheet dated 6/27/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, type 2 diabetes (chronic medical condition in which the body does not produce enough insulin or does not use insulin effectively), and chronic kidney disease stage 3 (moderate decrease in kidney function due to damaged kidneys not filtering blood as well as they should, often caused by diabetes). Record review of Resident #17's most recent quarterly MDS assessment, dated 4/9/25 revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections. Record review of Resident #17's Order Summary Report dated 6/25/25 revealed the following: - Blood glucose monitoring for signs and symptoms of hyper/hypoglycemia as needed for monitoring. May perform fingerstick for accu checks (blood glucose monitoring) if Dexacom (medical device used to monitor glucose continuously) not available, with order date 1/21/25 and no end date. - Insulin Lispro 100 unit/mL Solution pen injector, inject 11 units subcutaneously at bedtime related to type 2 diabetes, with order date 5/25/25 and no end date. - Insulin Lispro 100 unit/mL Solution pen injector, inject 20 unit subcutaneously before meals for type 2 diabetes. Notify provider if BS less than 75 ml/dl and/or greater than 350ml/dl with order date 5/25/25 and no end date. - Lantus insulin 100 unit/mL Solution pen-injector, inject 65 unit subcutaneously two times a day. Hold for BS more than 350. Notify MD/NP for BG less than 75 or Greater than 350, with order date 5/1/25 and no end date. Record review of Resident #17's Medication Administration Record for June 2025 revealed: - 6/25/25 morning blood sugar reading was 386 ml/dl documented by LVN A - 6/25/25 at 11:00 a.m. blood sugar reading was 400 ml/dl documented by LVN A Record review of Resident #17's medical record revealed no documentation of notification to the physician on 6/25/25 for blood glucose readings more than physician ordered parameters of 350 ml/dl or more. During an interview on 6/25/25 at 1:34 p.m., LVN A stated when she clocked in at 6:50 a.m. on 6/25/25, Resident #17's insulin Lispro was not available. LVN A stated the insulin Lispro was delivered at approximately 10:00 a.m. on 6/25/25, and when it (insulin Lispro) was delivered, it was late, but he got it, his sugar was high. His blood sugar was 400. LVN A stated Resident #17 did not receive the scheduled morning dose, that was supposed to be administered before breakfast, and the blood sugar obtained at that time was 386. LVN A stated she had not made contact with the physician regarding Resident #17's elevated blood sugar reading and stated, I have to call the doctor about other things, it's on my list to tell him (the physician), but I have not called him about it yet. During an interview on 6/25/25 at 1:58 p.m., LVN B, who identified herself as the Staff Development Coordinator and Staff Educator, stated LVN A should have notified the physician regarding Resident #17's blood sugar level reading past the physician ordered parameters as soon as possible because a spike in blood sugar levels essentially meant the resident was hyperglycemic and measures should be taken to bring the sugar levels down or refer him to the hospital for further evaluation and treatment. During an interview on 6/25/25 at 2:20 p.m., the ADON stated, Resident #17's physician should have been notified when the resident's blood sugar level reading was past the physician ordered parameters as soon as the results were obtained. The ADON stated, a blood sugar reading over the physician ordered parameters could result in the resident's kidneys being affected. During an interview on 6/25/25 at 2:42 p.m., the DON stated Resident #17's physician should have been notified when the resident's blood sugar level reading was past the physician orders parameters as soon as possible, you don't wait to call (the physician), you call right then. The DON stated notification to the physician was crucial because the resident could go into a diabetic coma and the physician would be able to instruct what to do, such as monitoring blood sugar levels more frequently, monitor for symptoms, or give an alternate insulin. Record review of the facility document titled, Diabetes Mellitus-Hypoglycemia and Hyperglycemia Best Practices, dated March 2025 revealed in part, ,,,Residents with a diagnosis of Diabetes Mellitus will be monitored for signs and symptoms of Hypo and Hyperglycemia, with immediate intervention per doctor's orders and Diabetic Protocol .Unless otherwise ordered by the physician, report blood glucose levels greater than 350 or less than 60 .

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 #17) of 3 residents reviewed for medications. The facility failed to stock an emergency supply of Lispro (fast-acting insulin) to maintain Resident #17's medical condition during a medication absence resulting in a blood sugar level of 386. This failure could place the residents at risk of not receiving therapeutic doses of their medication. Findings included: Record review of Resident #17's face sheet dated 6/27/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, type 2 diabetes (chronic medical condition in which the body does not produce enough insulin or does not use insulin effectively), and chronic kidney disease stage 3 (moderate decrease in kidney function due to damaged kidneys not filtering blood as well as they should, often caused by diabetes). Record review of Resident #17's most recent quarterly MDS assessment, dated 4/9/25 revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections.Record review of Resident #17's Order Summary Report dated 6/25/25 revealed the following:- Insulin Lispro 100 unit/mL Solution pen injector, inject 20 units subcutaneously before meals for type 2 diabetes. Notify provider if BS less than 75 ml/dl and/or greater than 350ml/dl with order date 5/25/25 and no end date.Record review of Resident #17's Medication Administration Record for June 2025 revealed the scheduled bedtime dose of Lispro insulin was not administered on 6/24/25 and the scheduled 7:30 a.m. dose was not administered on 6/25/25. Record review of the MAR revealed LVN E documented an X in the section meant for the blood sugar reading and documented 9 with her initials. The MAR indicated the code 9 meant Other/See Progress Notes. Record review of Resident #17's MAR revealed LVN A documented an X in the section meant for the blood sugar reading and documented 15 with her initials. The MAR indicated the code 15 meant Awaiting Pharmacy fill. During an interview on 7/11/25 at 9:30 a.m., LVN A stated when she clocked in at 6:50 a.m. on 6/25/25, Resident #17's insulin Lispro was not available. LVN A stated the insulin Lispro was delivered at approximately 10:00 a.m. Resident #17 did not receive the scheduled morning dose, which was supposed to be administered before breakfast, and the blood sugar obtained at that time was 386. LVN A stated she did not administer the scheduled insulin as it was unavailable in the stat safe, and the pharmacy had not delivered it. In an interview with the medical director on 7/11/25 at 11:15 AM, he stated by Resident #17 missing dose of insulin with meals the resident was not negatively impacted, because Resident #17 is non-compliant with his diet. Additionally, he is on oral hypoglycemic medication, along with long-acting insulin which in theory provided necessary coverage. Interview with LVN D on 7/11/25 at 11:30 a.m., confirmed insulin is available in the stat safe. Additionally, the pharmacy sends out a one-month supply of insulin for all diabetic residents In an interview with the DON on 7/11/25 at 10:55 AM, the DON stated that the pharmacy now automatically delivers Insulin for all residents, and insulin is now available in the stat safe in case any resident needs it and runs out of insulin. Interview with the Administrator on 7/11/25 at 11:15 AM, the administrator said currently the facility maintains a one-month stock of insulin for all diabetic residents, and insulin is available in the stat safe. Observation on 7/11/25 at 11:20 AM noted insulin in the stat safe. Record review of the facility document titled Administering Medications dated December 2024 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of.medications.Medication Administration Record (MAR): Also referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional.The Director of Nursing (DON) will supervise and direct all nursing personnel who administer medications and/or have related functions.Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #151) reviewed for enteral feeding: The facility failed to ensure Resident #151's medications were diluted before administering the medications into the resident's feeding tube, did not label the resident's feeding formula and water containers with the appropriate identifiers and did not discard the feeding containers after the feeding was completed. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #151's face sheet dated 6/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the air sacs in one or both lungs), gastro-esophageal reflux (condition in which stomach contents flow backward into the esophagus, the tube that connects the mouth to the stomach), heart failure and gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach) status. Record review of Resident #151's baseline care plan dated 6/18/25 revealed the resident utilized a feeding tube and would be evaluated by Occupational Therapy, Physical Therapy, and Speech Therapy to improve overall functional mobility, ADLs and to improve oral intake. Record review of Resident #151's Order Summary Report dated 6/26/25 revealed the following: - Flush (feeding) tube with 20-30 ml (cc) of water before and after administration of medication pass every shift related to gastrostomy with order date 6/18/25 and no end date. - Docusate 100mg, give 1 tablet via g-tube (feeding tube) one time a day for constipation, with order date 6/24/25 and no end date. - guaifenesin oral liquid 200mg/10ml, give 20ml via g-tube three times daily for cough related to pneumonia, with order date 6/18/24 and no end date. - Pregabalin 200mg capsule, give 1 capsule via g-tube three times a day for pain with order date 6/18/25 and no end date - Enteral Feed Order every shift via feeding tube, Glucerna 1.2 at 65 mL/hour from 10:00 p.m. to 4:00 a.m. Free water flush 200 mL TID. Discard excess Glucerna after completed, with order date 6/26/25 and no end date. - Gravity feeding - Change feeding administration set daily; label the formula container, syringe, and administration set with the resident's name, date, time, and nurse's initials, every night shift, related to gastrostomy, with order date 6/18/25 and no end date. During an observation and interview on 6/25/25 at 9:11 a.m. revealed LVN C prepared to administer Resident #151's medications. LVN C dispensed 10 mL of Resident #151's liquid guaifenesin into a medication cup, placed the resident's Docusate tablet into a small plastic pouch and crushed it, and then obtained Resident #151's Pregabalin capsule and emptied the contents into a small plastic pouch. LVN C then returned to Resident #151's bedside and flushed the feeding tube with 30 mL of water. LVN C then poured the undiluted guaifenesin liquid into the feeding tube and flushed with 10 mL of water. LVN C then poured the undiluted Docusate powder into the feeding tube and flushed with 10 mL of water. LVN C then poured the undiluted contents of the Pregabalin into the feeding tube and flushed with 10 mL of water. LVN C then administered 30 mL of water after the medication pass. During an observation and interview on 6/25/25 at 9:24 a.m., Resident #151 stated he was provided formula and water from a feeding pump during the overnight hours from 10:00 p.m. to 4:00 a.m. Resident #151 pointed to the formula and water containers hanging from a feeding pole with formula and water in the containers and stated those were used for his feedings. Observation of the formula and water containers revealed they were not labeled. During an observation and interview on 6/25/25 at 9:25 a.m., LVN C stated she should have diluted Resident #151's medications in water before administering them into the feeding tube because not doing so would result in the feeding tube clogging and having to be replaced and could result in discomfort or the feeding tube would need to be replaced which would interrupt giving the resident his medications and feedings. LVN C observed the feeding formula and water containers hanging from the feeding pole and stated the containers should have been labeled because it would indicate how long the containers had been there, and who the containers belonged to. LVN C stated, that information was important because what if the bag (containers) were hanging for too long and it was old and should not be given to the resident. LVN C stated she began her shift on 6/25/25 at 7:00 a.m. and the feeding formula and water containers were administered during the overnight shift. During a telephone interview on 6/25/25 at 2:42 p.m., LVN D stated she had set up the feeding kit for Resident #151 during the overnight shift on 6/24/25. LVN D stated Resident #151 received nocturnal feedings from 10:00 p.m. to 4:00 a.m. LVN D stated she could not remember if she had labeled Resident #151's formula and water containers, but stated it was important because labeling the containers would indicate the date and time they were administered because the feeding formula was only good for 24 hours. LVN D stated, I should have thrown it (the formula and water containers) away after using it because he (Resident #151) won't get it again until 10:00 p.m. and that would be more than 24 hours and whoever came in after that would have to spike a new bag (container). LVN D stated it was a possibility another nurse could use the same set up. LVN D stated when she started the 10:00 p.m. feeding for Resident #151 at 10:00 p.m. on 6/24/25, there was one (feeding and water container) already and I remember having to throw away the old set because it was still hanging there. During an interview on 6/26/25 at 5:14 p.m., the DON stated, medications should be crushed individually and diluted with room temperature water before administering medications through a feeding tube because particles could get stuck in the feeding tube causing it to clog. The DON stated, if particles of medication get stuck in the feeding tube it could prevent the resident from getting the full benefits of the medication. The DON stated, feeding formula containers were supposed to be discarded after use because she believed the formula was only good for 24 hours. The DON stated she expected the formula and water containers to be labeled with the resident's name, the time it was opened, the expiration date, the nurse's initials, the time of the feeding and when the feeding was completed the formula was supposed to be thrown away. The DON stated, you can't use the same feeding more than once because it could introduce contaminants and make the resident sick. Record review of the facility document titled Enteral Tube Medication Administration, dated January 2025 revealed in part, .Purpose .To ensure the safe, accurate and appropriate administration of medications via enteral feeding tubes, minimizing the risk of aspiration, tube blockage, and drug-nutrient interactions in residents unable to take mediations orally .Review flushing instructions and fluid restrictions .Prepare Medications One at a Time .Crush each immediate-release tablet into a fine powder and dissolve in 15-30 mL of room temperature water .Viscous Liquids .Dilute thick or hyperosmolar liquids in 15-30 mL of water (or approved fluid) .Flush the tube with 15 mL (or prescribed amount) of water between each medication .

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in resident condition for 1 of 3 residents (Resident #1) reviewed for physician notification of changes in condition. The facility failed to notify Resident #1's physician when his blood sugar levels were out of physician ordered parameters on 3/07/2025, 3/10/2025, 3/13/2025 and 3/14/2025. This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely intervention and a decline in condition. The findings included: Record review of Resident #1 face sheet dated 3/14/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, nontraumatic subarachnoid hemorrhage ( bleeding in the space between the brain and the membrane that covers it) [NAME] acute on chronic diastolic congestive heart failure (the heart's main pumping chamber becomes stiff and unable to fill properly). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment and required substantial and/or total dependence for ADL care. The assessment indicated the resident used insulin injections daily. Record review of Resident #1's Care Plan for diabetes mellitus initiated on 3/13/2025 revealed the resident had diabetes with hypoglycemic episodes (incidents of low blood glucose) with interventions which included fasting serum blood sugar as ordered by a physician. Record review of Resident #1's Order Summary Report for March 2025 revealed an order with a start date of 3/07/2025 for accuchecks before meals and at bedtime related to diabetes mellitus .notify MD/NP for blood glucose less than 100 or greater than 350. Record review of Resident #1's blood glucose readings for March 2025 revealed: -3/07/2025 at 8:15 p.m. - 96 mg/dl documented by LVN C -3/10/2025 at 4:38 p.m. - 87 mg/dl documented by LVN B -3/13/2025 at 10:35 a.m. - 93 mg/dl documented by LVN A -3/14/2025 at 11:51 a.m. - 75 mg/dl documented by LVN A Record review of Resident #1's medical record revealed no documentation of notification of physician on 3/07/2025, 3/10/2025, 3/13/2025 or 3/14/2025 for blood glucose readings less than physician ordered parameters of 100 or below. During an observation of two binders at the nurses' station on 3/14/2025 at 11:12 a.m. revealed a collection of laminated facility information on a single ring hanging on a hook. A review of the information contained revealed no guidelines, policies or protocols were included for blood glucose monitoring. A review of a three-ring binder located in a cabinet below the desk labeled agency revealed no information regarding blood glucose monitoring. During an observation and interview on 3/14/2025 at 11:43 p.m., LVN A completed a finger stick blood glucose reading of Resident #1, which resulted in a result of 75 mg/dl. LVN A spoke to Resident #1 and asked how he was feeling. Resident #1 stated he felt fine (limited interview due to baseline cognitive status). During the observation Resident #1 was awake and alert. He was able to interact appropriately with LVN A and he did not have any signs or symptoms of hypoglycemia that were noticeable. His hands were steady, and he was not shaking or jittery and there were no indications of sweating. LVN A told Resident #1 that he needed to eat and that she was going to take him to lunch. LVN A wheeled Resident #1 in his wheelchair to the dining room where he was served a glass of juice while waiting on his meal. Following the interaction LVN A continued on with other tasks unrelated to Resident #1. During an interview on 3/14/2025 at 3:02 p.m., LVN A stated she did not notify Resident #1's physician today (3/14/2025) or on 3/13/2025 following blood sugar readings less than 100. She stated she did not completely read the parameters on the order for notification. She stated she only saw the upper level of 350 for notification. She stated she was trained to immediately act on a blood sugar of less than 60. She stated for low blood glucose she would provide some juice or other form of sugar. She stated although Resident #1's blood sugar was 75 it was not critical low, and lunch was about to be served which would elevate his blood sugar. LVN A stated she assessed the resident to determine if he was symptomatic . She stated she looks for clammy skin, lethargy, sweating and kind of being out of it. She stated Resident #1 had none of those symptoms. She stated she was an agency nurse and had not received any in-service training on low blood sugars or change of condition from the facility. During an interview on 3/14/2025 at 3:25 p.m., LVN B stated she did not notify Resident #1's physician when his blood sugar was less than 100 on 3/10/2025. She stated a normal range for blood glucose levels was 70-110. She stated she did not notify the physician because the resident was getting ready to eat and his blood sugar was in the normal range. She stated she was an agency nurse and the other staff had told her the facility policy was to notify for under 60. She said, it was not really a policy, it was just what they did. She stated she did not see the addition to the blood glucose monitoring order that would have indicated a notification of the physician for a blood glucose less than 100. She stated she was trained to open the orders fully in PCC . She stated in order to view the parameters she would have to click on it to see the full order. She stated that was difficult to do with every patient. She stated she relied on the nurse's report to notify her if there were any changes to an order. She stated she had not received specific training from the facility but there was a binder called Agency cheat sheets with instructions. She stated she had not read the entire binder and it was meant as more of a guideline. During an interview on 3/14/2025 at 4:07 p.m., LVN C stated she did not notify Resident #1's physician when his blood glucose ready was less than 100 on 3/07/2025. She stated she did not see a note to notify the physician. She stated a normal blood glucose was 70-100. She stated they do not typically notify the physician until they drop below 70. She stated she could not recall where or not the order had brackets that indicated parameters to notify the doctor at the time. LVN C stated to her knowledge Resident #1 tended to drop his blood sugars rapidly, but his reading was nothing that alarmed her. She stated he did not have any symptoms of low blood sugar and was alert and oriented at baseline. She stated he was completely asymptomatic. During an interview on 3/14/2025 at 4:53 p.m., the ADON stated previous to 3/07/2025 they did not have parameters for notification of the physician on Resident #1's blood glucose monitoring because the nurses would notify the NP or MD based on nursing judgement. She stated they changed that because they noticed a trend of elevated blood glucose for Resident #1 who had a history of hypoglycemia (low blood glucose). The ADON stated in February 2025 Resident #1 had an infection and had been to the hospital quite a bit and had developed liable blood sugars since his return from the hospital. She stated the parameters were a way to ensure Resident #1 was not overlooked so they added parameters for physician notification. The ADON stated for a diabetic, blood sugars should be between 90-100. If they are a frail diabetic, they like to see them over 100. She stated for someone who is not diabetic a normal reading would be 70-90's. The ADON stated the nurses should follow the physician order and notify the physician for blood glucose levels outside of parameters. She stated the nurses should then follow up with the physician recommendations and carry out any recommended treatment. During an interview on 3/17/2025 at 9:23 a.m., the DON and Administrator stated the did not have a protocol or policy in place for diabetics or blood glucose monitoring. She stated on 3/12/2025 they started working on a protocol, but it was not completed and not all staff had been trained. She stated they treat agency staff as regular staff for training to ensure all are included. During an interview on 3/17/2025 at 12: 55 p.m., the Staffing Educator stated agency staff are held to the same standards as agency staff. She stated if they have an in-service training, agency staff were included. She stated she did not have any in-service training for blood glucose monitoring or change of condition that she was able to locate within the last year. She stated she was new to the facility as of December 2024 and there might have been something before, she came but was not certain. She stated she provided training on diabetic protocol to all staff but had not discussed training agency staff with her supervisor, the DON. She stated she would have to look for a copy of the diabetic protocol to see if she could find it. Nothing was provided to surveyor before exit. During an interview on 3/17/2025 at 2:18 p.m., the DON stated staff should normally notify the physician for a blood glucose less than 60 or 70. She stated Resident #1's provider wanted the notification higher because of his underlying morbidity (sickness or unhealthy state, disease process). The DON stated her expectations was for the staff to follow physician orders for notification because not every resident had the same parameters. She stated it was important so the resident could be treated with he right interventions. Record review of a facility policy, titled Change in Resident's Condition Policy dated May 2024 revealed: I. Purpose: Frontline caregivers play a crucial role in supporting best care practices for their residents, and when a change of condition is notified or communicated early, there is a heightened risk for decline. If a change of condition is detected, staff will notify the attending physician .5. The nurse supervisor/charge nurse will notify the resident's attending physician . when there has been c. there is a significant change in the resident's physical, mental, or psychosocial status.

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records, in that: 1. The facility failed to ensure Resident #1's 2:00 a.m. blood glucose readings were documented in his medical record on 2/24/2025, 2/27/2025, 3/02/2025, 3/03/2025, 3/04/2025 and 3/07/2025. 2. The facility failed to ensure Resident #1's hospital stay from 2/11/2025-2/17/2025 were uploaded into his medical record. These failures could put residents at risk of resident medical records containing incomplete and/orinaccurate information affecting care. The findings included: 1. Record review of Resident #1 face sheet dated 3/14/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, nontraumatic subarachnoid hemorrhage and acute on chronic diastolic congestive heart failure. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment and required substantial and/or total dependence for ADL care. The assessment indicated the resident used insulin injections daily. Record review of Resident #1's Order Summary Report for March 2025 revealed: -03/07/2025 accuchecks (blood glucose) at 2:00 am to monitor for low blood sugar levels, one time a day, notify MD/NP for blood glucose less than 100 or greater than 350. Record review of Resident #1's medical record including progress notes, MARs and vital signs documentation revealed blood glucose readings were documented in the MAR as completed, however the actual blood glucose levels were not recorded in the medical record as follows: -2/24/2025 missing documentation by LVN D -2/27/2025 missing documentation by LVN F -3/02/2025 missing documentation by LVN H -3/03/2025 missing documentation by LVN D -3/04/2025 missing documentation by LVN J -3/07/2025 missing documentation by LVN J During an interview on 3/14/2025 at 4:18 p.m., LVN F stated she did obtain a 2:00 a.m. blood glucose for Resident #1 on 2/27/2025. She stated normally there was a place to document in PCC, but she could not locate a place to document. She stated she wrote in pink pen on the 24-hour nurses notes the result instead of documenting in the medical record. She stated Resident #1's blood glucose reading was in the 100's overnight and he had no symptoms of low blood sugar. LVN F stated she was an agency nurse. Attempted interview on 3/14/2025 at 4:30 p.m. with agency LVN H. Left a voicemail and sent a text message which read delivered. During an interview on 3/14/2025 at 4:42 p.m. RN J stated he was regular staff at the facility and had started approximately 10 days ago. He stated he did obtain a blood glucose reading during the night on Resident #1 on 3/04/2025 and 3/07/2025. He stated there was no place to add a value of the reading so he did not document the results in the chart. He stated the blood sugar was normal. He stated if it had been out of the ordinary, he would have followed the parameters, notified the physician and documented in Resident #1's progress notes. During an interview on 3/14/2025 at 4:53 p.m., the ADON stated an insurance auditor brought to her attention on 3/07/2025 that Resident #1's 2:00 a.m. blood glucose monitoring was not accurately documented in his medical record on 3/07/2025. She stated the blood glucoses were monitored as indicated by the nurses' initials in the electronic medical record. She stated there just was no place to record the results in the MAR. She stated, at that time she added supplemental documentation to the original order so there was a space for blood sugars input on the MARs. The ADON stated the facility had a triple check system for all new orders. She stated the nurse puts in the order and she (ADON) checks for accuracy. She stated the third check was performed by either the MDS Coordinator or DON. She stated it was a team effort with the IDT team. The ADON stated she (ADON) actively reviews MARS/TARS to ensure staff were documenting monitoring and reviews 24-hour notes. The ADON stated the documentation was overlooked during the checks. During an interview on 3/17/2025 at 10:44 a.m., LVN D stated she was an agency nurse. She stated Resident #1 had orders to check his blood sugar at 2:00 a.m. She stated every time she had checked his blood sugar had been within normal limits. She stated he never had any symptoms of either hyper or hypoglycemia (high or low blood glucose levels). She stated if she documented the reading it would have been in the 24-hour nurses notes, or a progress notes. She stated her answer was not specific because she was not looking at her computer during the interview. She stated she did take the blood sugar; she just was not sure if or where it was recorded. She stated she had worked as agency off and on for 4 years with the facility. She stated she could not remember if she had any training on blood glucose monitoring or documentation. She stated as a nurse, it would be typical for her to record the blood glucose number. She stated it would be important to document in order to see trends. Second attempted interview with agency LVN H on 3/17/2025 at 10:35 a.m. A voicemail was left, and a text was sent requesting a return call. The text message read delivered. No return call was received. During an interview on 3/17/2025 at 2:18 p.m., the DON stated her expectation was for staff entering blood glucose orders to click on the supplemental order when the order was originally entered. She stated if that supplemental order was missing, alternatively the nurses should still record the blood glucose results somewhere in the medical record such as progress notes. She stated it was important to document the results for accuracy. The DON stated the facility did not have a policy for diabetes, diabetic monitoring, or blood glucose monitoring. 2. Record review of Resident #1's February 2025 MAR revealed staff had documented the resident was hospitalized between 2/11/2025-2/17/2025. Record review of Resident #1's medical record on reviewed on 3/14/2025 revealed the resident's hospital records upon re-admission were not uploaded into the electronic medical record for review. During an interview on 3/14/2025 at 2:25 p.m., the Administrative Services Manager stated she oversees Medical Records. She stated Resident #1's hospital records from February were not uploaded into his medical record. She stated after reviewing Resident #1's uploads she was not able to find the file which should be labeled hospital transfer. She stated the medical records clerk was not available for interview. The Administrative Services Manager stated she did audits of medical records. She stated Resident #1's transferring hospital would send records to Admissions. Stated Admissions will upload the medical records. She stated alternatively the resident could have been transferred to the facility with the documents. She stated they would then upload them into the computer. She stated the timeframe for upload was dependent on the physician. She stated the physicians wanted the medical records available at the nurse's station to review. She stated after the physician had an opportunity to review, medical records would take them and usually upload them within a couple of days. The Administrative Services Manager stated timely upload of medical records into the computer was important for communication and continuity of care. During an interview on 3/17/2025 at 2:18 p.m., the DON stated her expectation was for medical records to be uploaded into the resident's medical records within 24-48 hours after they receive them. She stated they had been located and were now uploaded for review (after surveyor intervention). She stated the facility waited for a provider signature and then the documents were uploaded. She stated the Administrative Services Manager was responsible for ensuring it happened. She stated it was important so have the medical records available for review as needed for resident care. Record review of a facility policy, titled Maintenance of Electronic Medical Records (undated) revealed: This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. II. a. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was individualized specifically for to meet the resdient's needs for the diagnosis of diabetes mellitus based on physician order. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans. The findings included: Record review of Resident #1 face sheet dated 3/14/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it)and acute on chronic diastolic congestive heart failure(the heart's main pumping chamber becomes stiff and unable to fill properly). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment and required substantial and/or total dependence for ADL care. The assessment indicated the resident used insulin injections daily. Record review of Resident #1's Order Summary Report for March 2025 revealed: -3/07/2025 for accuchecks before meals and at bedtime related to diabetes mellitus .notify MD/NP for blood glucose less than 100 or greater than 350. -03/07/2025 accuchecks (blood glucose) at 2:00 am to monitor for low blood sugar levels, one time a day, notify MD/NP for blood glucose less than 100 or greater than 350. -3/07/2025 Insulin Lispo 100 units/ml inject per sliding scale 151-200 (give) 3 units, 201-250 (give) 5 units, 251-300 (give) 7 units, 301-350 (give) 9 units, 351-400 (give) 11 units subcutaneously before meals and at bedtime related to diabetes mellitus without complications, notify MD/NP for blood glucose less than 100 or greater than 350. -2/27/2025 glipizide oral tablet by mouth 3 times a day for diabetes -12/12/2025 Januvia oral tablet 100 mg, give one tablet by mouth one time a day related to type 2 diabetes mellitus without complications -12/11/2025 glucagon emergency injection kit 1 mg, inject 1 mg intramuscularly as needed for low blood sugar for blood glucose less than 70 mg/dl and patient has no IV access and unresponsive or unable to take oral substance . Record review of Resident #1's Care Plan for diabetes mellitus initiated on 3/13/2025 revealed the resident had diabetes with hypoglycemic episodes (incidents of low blood glucose) with interventions which included fasting serum blood sugar as ordered by a physician and diabetes medication as ordered by doctor. Januvia, glipizide, Lispro, monitor/document for side effects and effectiveness. The care plan did not included physician ordered parameters for notification of blood glucose levels or what steps to take for the resident if the levels were outside of parameters or what symptoms to monitor for low blood sugar). During an interview on 3/17/2025 at 1:06 p.m., the MDS Coordinator stated Resident #1 went to the hospital on 2/11/2025 and was readmitted on [DATE]. She stated on 3/17/2025 his care plan was redone. She stated the MDS Coordinator was responsible for revision of care plans. She stated she learned about changes during morning clinical meetings. After reviewing Resident #1's care plan for diabetes, she stated fasting blood glucose meant accuchecks, not fasting lab glucose readings. She stated she does not put specifics to the resident's care or specifics related to diabetes because those things are listed in his physician orders. She stated she does not include frequency of blood glucose monitoring or notification of physician related to blood glucose because those are also in his physician orders. She stated if staff needed to review how to care for Resident #1, they should review his physician orders. She stated the goal for his diabetes care plan was for Resident #1 to have no complications related to diabetes. She stated again, the nurses should review the physician orders for specifics. The MDS Coordinator stated she had been completing MDS assessments and care plans for the last three years. She stated she was trained by attending classes throughout the year and was taught by another MDS Coordinator. She stated she did not typically put care that was listed in physician orders in the care plan. During an interview on 3/17/2025 at 2:18 p.m., the DON stated accuracy and frequency of blood glucose, monitoring of symptoms, and 100% documentation, especially refusals of care should be documented in the care plan. The DON stated to her knowledge Resident #1 did not have refusals of care. The DON stated it was important to have accurate documentation of the resident's care plan to ensure treatment of the resident with the right interventions. Record review of a facility policy, titled Care Plans-Comprehensive dated May 2024 revealed: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological will be developed for each resident. 5. Care Plans are revised as changes in the resident's condition dictate.

Based on interviews and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 13 residents (Resident #1) reviewed for diabetic medical interventions. The facility failed to ensure Resident #1 had supporting orders for his diagnosis of diabetes mellitus upon admission to the facility from the hospital on 05/29/2024 and led to Resident #1 not being assessed for daily blood sugar levels for the months of June 2024, August 2024, and September 2024, resulting on 10/18/2024, a hemoglobin A1C (HbA1c, a blood test that shows what your average blood sugar level was over the past two to three months) lab level of 9.9% (A1c normal level below 5.7; diabetes level = 6.5 or higher) and a finger stick blood sugar assessments of 300 at 06:00 AM and 453 at 06:00 PM (A healthy (normal) fasting blood glucose level for someone without diabetes is 70 to 99 mg/dL (3.9 to 5.5 mmol/L). Values between 50 and 70 mg/dL (2.8 to 3.9 mmol/L) for people without diabetes can be normal). The noncompliance was identified as PNC. The IJ began on 05/29/2024 and ended on 10/18/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for harm by complications of high blood sugar levels. The findings included: A record review of Resident #1' admission record dated 01/03/2025, revealed an admitted [DATE] with diagnoses which included diabetes mellitus type II (the body's resistance to utilizing blood sugar and leading to high levels of blood sugar with disease complications), and congestive heart failure (A heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath, and swelling). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had received insulin injections during the last 7 day look back period, 7 = record the number of days that insulin injections were received during the last 7 days A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male admitted for long term care, assessed with a BIMS score of 00 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 06/14/2024 revealed a focus for diabetes, (Resident #1) will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/26/2024 . For BS< 70 and unable to consume nutrition orally give glucagon. Position resident on side to prevent aspiration. Staff to remain with resident at all times. Repeat BG in 15 min if the resident is able and willing to consume nutrition, repeat finger stick BG and re-treat every 15 minutes until BG > 70 or without symptoms. Date Initiated: 05/03/2024. Give diabetic meds as ordered and report any adverse reactions to md. Date Initiated: 01/26/2024. A record review of Resident #1's May 2024 physicians' orders revealed the physician had prescribed for Resident #1 to be monitored for blood sugar levels, For BG <70 and unable to consume nutrition orally: *give glucagon *position resident on side to prevent aspiration STAFF TO REMAIN WITH RESIDENT AT ALL TIMES Repeat BG in 15 sic(minute)s, if the resident is able and willing to consume nutrition, repeat finger stick BG, and re-treat every 15 minutes until BG >70 mg/dL without symptoms every 15 minutes as needed for Hypoglycemia and unable to swallow If the resident is not able or willing to consume nutrition within 15 minutes, give another dose of glucagon, and call for emergency help, i.e., 911. For Blood Glucose < 70mg/dL and is able to take orally. Give 15 Grams Carbohydrates of either from the following: *1/2 cup fruit juice or regular soda * 1TBSP honey, sugar, syrup, or jelly * 4-5 Saltine Crackers REMAIN WITH RESIDENT AT ALL TIMES REPEAT BG AND RE-TREAT EVERY 15 MINUTES UNTIL BG > 70 AND WITHOUT SYMPTOMS every 15 minutes as needed for hypoglycemia BG < 70 mg/DL and able to swallow fluids If more than 1 hour until next meal/snack, give 15 grams of carbohydrates with ~5 grams protein: e.g., 1/2 sandwich with 1 TBSP peanut/nut butter*, 3 graham crackers with 1 TBSP peanut/nut butter * A record review of Resident #1's May 2024 physicians' orders revealed the physician had prescribed for Resident #1 to receive insulin injections and oral medications daily, (insulin lispro brand name) Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2U; 201 - 250 = 4U; 251 - 300 = 6U; 301 - 350 = 8U; 351 - 400 = 10U Call MD if Blood Sugar is >400, subcutaneously two times a day for Diabetes Mellitus related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Call MD if greater than 400. (Brand name linagliptin) Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS A record review of Resident #1's June 2024 physicians' order summary dated 01/01/2025 revealed Resident #1 diagnoses of diabetes with no orders for insulin lispro, no orders for monitoring blood sugar levels, no orders for oral linagliptin for diabetes interventions. A record review of Resident #1's nursing progress notes revealed on 05/22/2024 LVN C Documented Resident #1 was sent out to another hospital due to swelling complications, Resident returned from hospital via stretcher accompanied by EMT's and (Resident #1's Representative). Resident abdomen noted to be distended and edema noted to BLE. Resident also noted to have non-productive cough. DON notified (hospital) representative of residents' arrival and condition and suggested resident to be sent out to (name of hospital) Hospital for eval and treat. Report called to Nurse (RN Name) RN. Resident transported via (name of ambulance) ambulance service on stretcher accompanied by EMT's and (Resident #1's Representative). A record review of Resident #1's nursing progress notes revealed on 05/29/2024 LVN C documented, Resident arrived from (Name of hospital) Hospital approximately 2140 (09:40 PM) via (name of ambulance) ambulance on a stretcher accompanied by (Resident #1's Representative) and two EMT's. Resident was admitted to hospital for fluid volume overload. Resident transferred to bed. Breath sounds even and unlabored with productive cough. No c/o pain or discomfort. Skin assessment entered. Consents signed by daughter. VS are BP 113/65, T 97.8, P 66, rr 17, o2 96% on RA. On call notified of residents' arrival. Bed in lowest position, call light in reach. During an interview on 12/31/2024 at 11:50 AM LVN D stated she was the charge nurse for sage home and had been employed at the facility for the past 4 years. LVN D stated she was the nurse for Resident #1 and had been his nurse for the 6:00 AM to 2:00 PM shift during May 2024 to now (December 2024). LVN D stated Resident #1 was diagnosed with diabetes and was prescribed anti-diabetic medications with daily finger blood sugar checks in May 2024, specifically sliding scale insulin lispro. LVN D stated when Resident #1 came back from the hospital and was admitted he did not have diabetic orders nor interventions. LVN D stated she believed Resident #1 was not prescribed diabetic interventions due to post hospitalization changes. LVN D stated she was not aware of Resident #1's diabetic orders and interventions until October 2024. LVN D stated Resident #1's blood sugar levels were high and were addressed with accuchecks and oral medications. During an interview on 12/31/2024 at 12:40 PM the Administrator stated DON A was the DON in May and June 2024. The Administrator stated the current DON B was the DON. The Administrator stated Resident #1 was admitted to the facility from the hospital at the end of May 2024 and in October 2024 DON B received a complaint from Resident #1's Veteran's Social Worker and the NP. The Administrator stated she and DON B began an investigation and DON B reported the incident to the state agency. The Administrator stated she was disappointed that DON A had not reviewed Resident #1's admission records to reveal no evidence for interventions and or supports for Resident #1's diagnosis of diabetes. During an interview on 01/01/2025 at 12:30 PM LVN C stated she was the nurse on duty when Resident #1 return from the hospital on 05/29/2024 and she was the nurse who reviewed Resident #1's hospital discharge orders for medications and treatments. LVN C stated she had called the on-call physician and given a report on Resident #1 and received orders to continue hospital discharge medications and treatments. LVN C stated she had not given the on-call physician a report of Resident #1's May 2024, diagnosis of diabetes with medications and monitoring, which included twice a day blood sugar monitoring with finger sticks, sliding scale insulin injections, and an oral linagliptin, a diabetes control medication. LVN C stated she had not reconciled, reviewed, and compared the previous orders for diabetes and the current hospital discharge orders for the diagnosis of diabetes and stated, I report to the on-call physician the discharge hospital orders . we are strict about following hospital discharge orders. LVN C stated she had not communicated to the MD, The NP, DON A, nor the ADON, that she had not reconciled, reviewed, and compared the previous orders for diabetes and the current hospital discharge orders for the diagnosis of diabetes. During an interview on at the previous DON, DON A, stated he was the DON at the facility during May 2024 through July 2024 and he and the interdisciplinary team, which included the Administrator and the ADON, daily reviewed the 24-hour report and new admissions for safety. DON A stated he could not recall the morning meetings from June 2024 but did state the tools utilized to review residents for safety would include a review of the 24-hr. report, nursing, notes, and previous orders and current orders. DON A stated the person responsible to ensure Resident safety with reconciliation of physician orders was the ADON. During an interview on 01/01/2025 at 10:30 AM NP stated he was the NP for Resident #1, and he was aware Resident #1 was a diabetic with twice a day blood-sugar checks, sliding scale insulin injections and oral anti-diabetic medications. NP stated he had not received a report from the nursing staff that Resident #1 had not received daily finger stick to assess for blood sugar levels, had not received daily sliding scale insulin injections, nor received the daily oral anti-diabetic medication for 4 months. NP stated he had ordered blood labs to reveal blood sugar levels that were within acceptable levels for an [AGE] year-old male who had just returned from the hospital recovering from an on-going clostridium difficile infection complicated by chronic heart failure disease. NP stated he believed the interventions for Resident #1's underlying diabetes were effective as evidenced by the blood glucose labs he had ordered and thus had not ordered any further interventions until he followed up with an HbA1c blood lab in October 2024 which revealed a high blood sugar level of 9.9%. NP stated he then intervened with oral anti-diabetic medications, laboratory tests, and daily blood sugar finger sticks which resulted in a managed blood sugar level. During an interview on 12/31/2024 at 12:10 PM, the Medical Director stated he was aware Resident #1 was treated at the hospital in May 2024 for complications of a clostridium difficile infection complicated by CHF. The MD stated he was not aware Resident #1 was admitted from the hospital in May 2024 without interventions for his diabetes and, at a minimum, should have been assessed daily for blood sugar levels. The medical director stated the risk to Resident #1 would have been complications of hyperglycemia (high levels of sugar in the blood). The MD stated clinically it was understandable for Resident #1 to not have high blood sugar levels during the episodes where he was recovering from the clostridium difficile infection, not eating, due to nausea, vomiting, and diarrhea. The MD stated Resident #1 responded to the infection treatments, recovered, and began eating again and thus contributed to the gradual increase in blood sugar levels without monitoring. During an interview on at the administrator stated Resident #1 was being seen and cared for by the MD and the NP and were focused on the serious infection of clostridium difficile and Resident #1 was assessed for blood sugar levels which were within normal limits. The administrator stated the NP and the MD did intervene with further interventions to manage Resident #1's diabetes and blood sugar levels when in October 2024 the resulted A1c lab revealed a high result. The administrator stated the facility provided care for Resident #1, Resident #1 had recovered from the infection, and the facility continued to provide quality care for Resident #1. A record review of the facility's Abuse, Neglect and Exploitation Policy dated April 2024, revealed, PURPOSE: To establish a uniform policy and procedures for reporting and responding to abuse, neglect, exploitation (ANE), and misappropriation of resident property. It is the policy of (The Facility) to provide protection for the health, welfare and rights of each resident residing in its facilities. The following procedures have been developed with the intent to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The procedures will include at a minimum the following elements: screening, training, prevention, identification, investigation, protection, and reporting/response. An evaluation of the facilities ANE policy will be conducted through the facility's Quality Assurance and Performance Improvement Committee (QAPI) as appropriate. A record review of the United States Centers for Disease Control's websites : https://www.cdc.gov/diabetes/treatment/your-diabetes-care-schedule.html and https://www.cdc.gov/diabetes/diabetes-testing/monitoring-blood-sugar.html . Accessed 01/11/2025. Titled Your Diabetes Care Schedule and Monitoring Your Blood Sugar revealed, Every day, Blood sugar checks. Check up to several times a day as directed by your doctor. Keep a record of your numbers and share with your health care team during your next visit. And Key points, monitoring your blood sugar is the most important thing you can do to manage diabetes. Importance of monitoring, many factors like food choices, medicines, and physical activity cause your blood sugar to change throughout the day. Some change is normal, but when your blood sugar is too high or too low, this can cause problems. Monitoring will help you figure out what affects your numbers, find patterns, and adjust as you go. By checking regularly you'll be more likely to achieve your blood sugar target ranges. Monitoring also helps your health care team make decisions about your diabetes care plan. Your doctor will tell you when and how often to check your blood sugar levels. A record review of the facility's in-services revealed an in-service dated 10/25/2024 titled, Medication Reconciliation revealed, Residents often receive new medications or have changes made to their existing medications at times of transitions in care-upon hospital admission, transfer from one unit to another during hospitalization , or discharge from the hospital to home or another facility. Although most of these changes are intentional, unintended changes occur frequently for a variety of reasons. For example, hospital-based clinicians might not be able to easily access patients' complete pre-admission medication lists or may be unaware of recent medication changes. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrect dosages. These discrepancies place patients at risk for adverse drug events, which have been shown to be one of the most common types of adverse events after hospital discharge. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care. Further review revealed 13 out of 13 nurses received the in-service. A record review of the facility's diabetic Resident Audit for safety and medication reconciliation report revealed 10 out of 10 residents diagnosed with diabetes were reviewed on 10/24/2024 without complications. During an interview on 01/02/2025 at 5:27 PM RN E stated she was prn all shift - and she would SBAR (Situation Background Assessment and Recommendation) the doctor to include a review of the past discharge orders and compare them to the new hospital orders. RN E stated she would call the on call and or doctor. During an interview on 01/02/25 at 5:42 PM RN F stated she would review discharge hospital orders and would check previous orders and sbar the doctor and document in the progress notes. RN F stated she works the 7:00 AM to 3:00 PM shift. During an interview on 01/02/2025 at 6:35 PM RN G stated she would call and fax the hospital discharge orders and her recommend orders from the residents' previous orders to the on-call physician, for example Resident discharge to, where he went, and came back, Resident had diabetes upon admission with labs and I added an A1c. RN G stated she worked double shift on weekends. During an interview on 01/02/2025 at 6:46 PM LVN D stated she works 7:00 AM - 3:00 PM shift and would reconcile orders to include new orders from the hospital compared to all previous discharge orders and sbar the doctor to include all diagnoses and their interventions and make recommendations to the doctor. During an interview on 12/31/2024 at 3:49 PM Resident #2's representative stated Resident #2 was well cared for at the facility and was satisfied with her safety and treatment. During an interview on 01/02/2025 at 11:50 AM Resident #3's representative stated she was satisfied with Resident #3's care to include diabetes management and dignified and respectful care. A record review of the facility's Audit of Diabetic Residents dated 10/24/2024, revealed 10 of 10 residents with diagnoses of diabetes were reviewed for safety to include diabetic medications and interventions. The noncompliance was identified as PNC. The IJ began on 05/29/2024 and ended on 10/18/2024. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews the facility failed to ensure the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for 1 of 8 residents (Resident #2) reviewed for abuse, neglect, and or exploitation. The facility failed to ensure residents were free from physical abuse on 09/30/2024, while Resident #2 was laying on her bed CNA H placed a pillow over Resident #2's face and stated, Pillow Therapy! The noncompliance was identified as PNC. The noncompliance began on 09/30/2024 and ended on 10/01/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for harm by abuse. The findings included: A record review of Resident #2's admission record, dated 12/31/2024, revealed an admitted [DATE] with diagnoses which included chronic obstructive pulmonary disease, anxiety, and hemiplegia and hemiparesis. A record review of Resident #2's quarterly MDS, dated [DATE], revealed Resident #2 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 14 which indicated no cognitive impairment. further review revealed Resident was asked Over the last 2 weeks, have you been bothered by any of the following problems? . feeling down, depressed, or hopeless? . yes . 2-6 days . trouble falling asleep or staying asleep, or sleeping too much? Yes . frequency 1 day A record review of Resident #2's care plan, dated 12/31/2024, revealed Resident #2 had a focus for COPD, (Resident #2) has COPD complication with episodes of SOB, sleep apnea, And interventions which included monitor for signs and symptoms of depression . monitor for signs and symptoms of anxiety A record review of the facility's email record, dated 09/30/2024, revealed the DON D emailed the state agency, Hello, I am self-reporting an incident that occurred today at 1730 (5:30 PM). It was brought to my attention by CNA B that he witnessed CNA H place a pillow over a resident's head stating, pillow therapy. Statements have been received from CNA B, the resident, while in presence of her (Representative) and the alleged perpetrator CNA H. Ms. CNA H described this action as part of a running joke between her and the resident. Resident in question is housed in (name of hall) household room (number), Thank you, (DON), RN. A record review of the facility's CMS form 3613 Provider Investigation report dated 10/01/2024 revealed an incident date of 09/302024 with an alleged perpetrator of CNA H. Further review revealed, Description of the allegation: (CNA B) witness sic(ed) (CNA H) place a pillow over the Resident's head stating it is pillow therapy A record review of CNA B's witness statement dated 10/02/2024 revealed, a typical day in (name of neighborhood in the facility) CNA H cares for residents who either do not have the best memory or cannot communicate efficiently (rooms within the home) this has been going on for a while. I am concerned about our resident's safety only because if she was so comfortable with giving (Resident #2) pillow Therapy while I was in the room it makes me wonder what she is or is capable of doing while I am not in the room watching her. A record review of the facility's schedule dated 09/30/2024 revealed CNA H and CNA B were scheduled to work the 3:00 PM to 11:00 PM schedule for Resident #2's home within the facility. Interviews with CNA B and CNA H were attempted without success, CNA B and CNA H were no longer employed by the facility. An interview with Resident #2 representative was attempted without success. During an interview on 1/3/2025 at 9:23 AM LVN J stated she had received a report from DON I that CNA H had held a pillow over Resident #2's face and she immediately assessed Resident #2 without injury and communicated the findings to the physician and Resident #2's representative. During an interview on 12/30/2024 at 03:05 PM the Administrator stated the facility investigated an allegation of abuse for Resident #2. The Administrator stated on September 30th, 2024, the interim DON I received a report that CNA H placed a pillow over Resident #2's face. The Administrator stated the facility's staff Education Coordinator then interviewed CNA H in which she admitted the action took place in jest. The facility suspended CNA H and reported the allegation of abuse to the state agency. The Administrator stated Resident #2 and peer residents were assessed for safety and no one was evidenced harmed. The Administrator stated the staff received an in-service for ANE prevention on 10/01/2024. The Administrator stated CNA H was terminated for the incident. A record review of the facility's in-service, dated 10/01/2024, titled, Abuse, Neglect, Exploitation, conducted by DON I revealed training for staff prevention and reporting alleged abuse, neglect, and or exploitation. Further review revealed 47 employees received the in-service. A record review of the facility's employee roster, dated 09/30/2024, revealed 47 employees. During an interview on 01/06/2025 at 11:10 AM DON I stated CNA H was interviewed on 09/30/2024 and she admitted she was jokingly placed the pillow over Resident #2's face and was sincerely sorry for the misjudgment. The DON I stated CNA H was immediately suspended, and Resident #2 and peer residents were assessed for safety with no one evidencing injury or reports of abuse, neglect, and or exploitation. During an interview on 12/31/2024 at 3:49 PM Resident #2's representative stated Resident #2 was well cared for at the facility and was satisfied with her safety and treatment. During an interview on 01/02/2025 at 11:50 AM Resident #3's representative stated she was satisfied with Resident #3's care to include diabetes management and dignified and respectful care. Record reviews of the facility's investigations revealed peer residents were reviewed for safety with and documented with questionnaires which revealed no evidence of alleged ANE and all the staff received an in-service for ANE prevention and reporting allegations of ANE. A record review of the facility's Abuse, Neglect, and Exploitation Policy, dated April 2024, revealed, PURPOSE: To establish a uniform policy and procedures for reporting and responding to abuse, neglect, exploitation (ANE), and misappropriation of resident property. POLICY: It is the policy of (the facility) to provide protection for the health, welfare and rights of each resident residing in its facilities. The following procedures have been developed with the intent to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The procedures will include at a minimum the following elements: screening, training, prevention, identification, investigation, protection, and reporting/response. An evaluation of the facilities ANE policy will be conducted through the facility's Quality Assurance and Performance Improvement Committee (QAPI) as appropriate.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #12, Resident #28, and Resident #44) reviewed for care plans. The facility failed to ensure Residents #12, #28 and #44 care plans reflected their need or placement on a secured memory care unit. This deficient practice places residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #12's face sheet, dated 05/09/2024, revealed Resident #12 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and metabolic encephalopathy. Record review of Resident #12's Admission assessment, dated 04/07/2024, revealed Resident #12's BIMS score was 00 for severe cognitive impairment. Record review of Resident #12's care plan with an initiated date of 04/09/2024 and a targeted date 07/07/2024, revealed no care plan addressing Resident #12's need or placement on a secured/memory care unit. Record review of Resident #12's Consent for Admission to [name of unit] Secured Household dated 04/05/2024 revealed acknowledgment of resident placement on the secured household signed by Resident #12's legal representative. Observation on 05/7/2024 at 10:00 a.m. revealed Resident #12 on the secure/memory care unit tearful and staff providing her with her animated stuffed cat. Record review of Resident #28's face sheet, dated 05/08/2024, revealed Resident #28 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #28's Quarterly assessment, dated 03/20/2024, revealed Resident #28's BIMS score was 00 for severe cognitive impairment. Record review of Resident #28's care plan with a revision date of 03/25/2024 and a targeted date 06/20/2024, revealed no care plan addressing Resident #28's need or placement on a secured/memory care unit. Record review of Resident #28's Consent for Admission to [name of unit] Secured Household dated 09/15/2023 revealed acknowledgment of resident placement on the secured household signed by Resident #28's legal representative. Observation on 05/07/2024 at 9:55 a.m. revealed Resident #28 in her bed with bed in the lowest position and fall mats to both sides on the secure/memory care unit. Record review of Resident #44's face sheet, dated 05/09/2024, revealed Resident #44 was admitted on [DATE] with diagnoses which included: Parkinson's disease without dyskinesia, without mention of fluctuations, and dementia in other diseases classified elsewhere, unspecified severity, with agitation. Record review of Resident #44's Admission assessment, dated 03/04/2024, revealed Resident #44's BIMS score was 00 for severe cognitive impairment. Record review of Resident #44's care plan with an initiated date of 03/04/2024 and a targeted date 06/04/2024, revealed no care plan addressing Resident #44's need and or placement on a secured/memory care unit. Record review of Resident #44's Consent for Admission to [name of unit] Secured Household dated 03/13/2024 revealed acknowledgment of resident placement on the secured household signed by Resident #44's legal representative. Observation on 05/10/2024 at 11:10 a.m. revealed Resident #44 sitting in a recliner in the living room on the secure/memory care unit. During an interview on 05/10/2024 at 11:29 a.m. with Resident Assessment Coordinator she reviewed Resident #12, Resident #28, and Resident #44's care plans and stated the residents did not have a care plan for the secure/memory care unit. She further stated residents did not necessarily need a care plan for the use of the unit due to many other behaviors having been care planned. Resident Assessment Coordinator stated the secure/memory care unit would not typically be a focus on its own. She further stated the facility realized the residents could not come off the unit on their own but could come off the unit with an escort so did not feel it was a problem. During an interview on 05/10/2024 at 12:50 p.m. the ADM stated she did not know if the secure/memory care unit would be care planned or more the resident's diagnoses. The ADM further stated Alzheimer's and dementia would be the focus, not necessarily the specific household. During an interview on 05/10/2024 at 2:01 p.m. the DON stated residents on the secure/memory care unit would have a special care plan with the reason for the need. The DON further stated the Resident Assessment Coordinators were usually responsible for the care plans. The DON stated the importance of the care plans was so the staff when caring for the residents would be aware of any special needs. Record review of the facility's Care Plan - Comprehensive policy, effective February 2024, revealed Purpose: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological will be developed for each resident. III Procedure: #3 Each resident's Comprehensive Care Plan has been designed to; a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on resident's strengths. d. Reflect treatment goals and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in preventing or reducing declines in the resident's functional status and or functional levels.

Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for enteral feeding tubes in that: LVN C did not check for residual volume prior to medication administration, did not flush the enteral feeding tube per physician's orders and administered the flush and medications with the syringe plunger instead of via gravity flow to Resident #12. These deficient practices could place residents receiving enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #12's face sheet, dated 5/9/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of the sacrum, gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), aphasia (a disorder that impacts speech and the ability to communicate), severe protein-calorie malnutrition, and gastrostomy status (feeding tube). Record review of Resident #12's most recent admission MDS assessment, dated 4/7/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #12's Order Summary Report, dated 5/9/24 revealed the following: - [Enteral] Open system container or gravity feeding - Change feeding administration set daily; label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials, every shift, with order date 4/3/24 and no end date - Check and record residuals every shift. Contact physician if residual exceeds 100 ml every shift, with order date 4/3/24 and no end date - Flush 5-10 ml of water in between each medication every shift, with order date 4/6/24 and no end date - Flush feeding tube with 20 ml to 30 ml of water before and after medication administration every shift with order date 4/3/24 and no end date - Flecainide 150 mg, give 75 mg via PEG-Tube one time a day for A-Fib, hold for heart rate less than 60, with order date 4/6/24 and no end date - Multiple Vitamin, give 1 tablet via PEG-Tube one time a day for supplement, with order date 4/4/24 and no end date - Docusate Sodium 100 mg, give 1 tablet via PEG-Tube two times a day for constipation, with order date 4/10/24 and no end date - Lyrica 75 mg, give 1 capsule via PEG-Tube two times a day for neuropathic pain, with order date 4/3/24 and no end date - Metoprolol 25 mg tablet, give 1 tablet via PEG-Tube one time a day for hypertension - May crush medication per pharmacy, HOLD: Systolic blood pressure less than 110 AND Heart Rate less than 60, with order date 4/4/24 and no end date - Calcium Carbonate Oral Wafer, give 500 mg via PEG-Tube in the morning for supplement, with order date 4/10/24 and no end date Record review of Resident #12's comprehensive care plan, revision date 4/10/24 revealed the resident required tube feeding related to dysphagia (difficulty swallowing), resisting eating, swallowing problem and failure to thrive with interventions that included to check tube placement and gastric contents/residual volume per facility protocol and record; hold feed if greater than 100 cc aspirate and report to MD. Further review of the comprehensive care plan revealed to flush the feeding tube with 20 ml to 30 ml of water before and after medication administration and the resident was dependent with tube feeding and water flushes; see MD order for current feeding orders. Observation on 5/9/24 at 8:09 a.m., during the medication pass, revealed LVN C opened the port to Resident #12's feeding tube, and did not check for residual prior to administering the initial water flush. LVN C then pushed 60 ml of water instead of the ordered 20 ml to 30 ml with the syringe plunger instead of by gravity flow. LVN C continued with the medication pass and administered Flecainide, Multiple Vitamin, and Docusate Sodium all by pushing the medications with the syringe plunger instead of by gravity flow. LVN C, when administering the Multiple Vitamin, mixed the medication with 60 ml of water, instead of the ordered 5 ml to 10 ml. LVN C completed the medication pass and administered the final flush of 40 ml, instead of the ordered 20 ml to 30 ml with the syringe plunger instead of by gravity flow. During an interview on 5/9/24 at 8:31 a.m., LVN C stated she had checked Resident #12 for residual earlier at 7:40 a.m. when she administered Lyrica, Metoprolol, and Calcium Carbonate prior to observation by the State Surveyor beginning at 8:09 a.m. LVN C stated, medications given back-to-back via a feeding tube did not need to be checked for residual again. LVN C revealed she had administered an additional amount of water flush because Resident #12 was not taking fluids. LVN C stated she did not usually push the medications with the syringe plunger but, with Resident #12's feeding tube I have to be more forceful; we are supposed to do it by gravity as much as possible, I do but you have to be more rigorous with flushing. During an interview on 5/9/24 at 2:36 p.m., the DON stated, pushing the flush and the medications with the syringe plunger could traumatize the stomach. The DON revealed, he was not aware staff were pushing fluids and medications with the syringe plunger instead of by gravity flow. The DON stated it was his expectation staff were following policy and the policy was to administer water and medications with a syringe via gravity flow. The DON stated, must check for residual to ensure the feeding tube was patent, every time you open the peg tube port and introduce a medication or feeding, you must check for residual prior. The DON further stated, if there was a blockage you are only forcing fluids to go in and you want to make sure the digestive tract was working, and things are flowing out of the stomach. Record review of the facility policy and procedure, titled Administering Medications Through an Enteral Tube, effective date August 2023 revealed in part, .PURPOSE To ensure residents receiving nutritional and/or hydration support via PEG-Tube receives safe medication administration according to MD orders and within nursing standards of practice .For gastrostomy tubes, check .gastric contents .Pull back gently on the syringe to aspirate stomach content .Flush tubing with 15 to 30 ml warm water (or prescribed amount) .remove syringe and clamp/close tubing .Reattach syringe (without plunger) to the end of the tubing .Administer medication by gravity flow .Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion .When the last of the medication begins to drain from the tubing, flush the tubing with 30 to 50 ml of water at room temp (or prescribed amount) .

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 4 of 8 residents (Residents #12, #28, #33, and #44) reviewed for accuracy of medical records. Facility failed to ensure Residents #12, #28, #33 and #44 had physician orders for admission to the locked memory care unit. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #12's face sheet, dated 05/09/2024, revealed Resident #12 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and metabolic encephalopathy. Record review of Resident #12's Admission assessment, dated 04/07/2024, revealed Resident #12's BIMS score was 00 for severe cognitive impairment. Record review of Resident #12's care plan with an initiated date of 04/09/2024 and a targeted date 07/07/2024, revealed Resident #12 had a Focus: [resident's name] has an ADL self-care performance deficit r/t Confusion, Dementia . Record review of Resident #12's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #12 to be admitted to the locked memory care unit. Observation on 05/7/2024 at 10:00 a.m. revealed Resident #12 on the secure/memory care unit tearful and staff providing her with her animated stuffed cat. Record review of Resident #28's face sheet, dated 05/08/2024, revealed Resident #28 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #28's Quarterly assessment, dated 03/20/2024, revealed Resident #28's BIMS score was 00 for severe cognitive impairment. Record review of Resident #28's care plan with a revision date of 03/25/2024 and a targeted date 06/20/2024, revealed Resident #28 had a Focus: [resident's name] has an ADL self-care performance deficit r/t Confusion, Dementia . and a Focus: [resident's name] does have Risk for Wandering/Elopement Identified. Record review of Resident #28's physician order summary report, dated, 05/08/2024, revealed no orders for Resident #28 to be admitted to the locked memory care unit. Observation on 05/07/2024 at 9:55 a.m. revealed Resident #28 in her bed with bed in the lowest position and fall mats to both sides on the secure/memory care unit. Record review of Resident #33's face sheet, dated 05/09/2024, revealed Resident #33 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #33's Significant Change assessment, dated 04/09/2024, revealed Resident #33's BIMS score was 00 for severe cognitive impairment. Record review of Resident #33's care plan with a revision date of 04/18/2024 and a targeted date 07/09/2024, revealed Resident #33 had a Focus: [resident's name] has a history of wandering (moving with no rational purpose, seemingly oblivious to needs or safety .Interventions: Re-assess [resident's name] for placement in a specially designed therapeutic unit per facility protocol. Record review of Resident #33's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #33 to be admitted to the locked memory care unit. Observation on 05/07/2024 at 11:50 a.m. revealed Resident #33 sitting in the dining room on the secured/memory care unit waiting for his lunch. Record review of Resident #44's face sheet, dated 05/09/2024, revealed Resident #44 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and Parkinson's disease without dyskinesia, without mention of fluctuations. Record review of Resident #44's Admission assessment, dated 03/04/2024, revealed Resident #44's BIMS score was 00 for severe cognitive impairment. Record review of Resident #44's care plan with an initiated date of 03/04/2024 and a targeted date 06/04/2024, revealed Resident #44 had a Focus: [resident's name] has impaired cognitive function/dementia with impaired thought processes r/t Dementia, Impaired decision making, Short term memory loss. Record review of Resident #44's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #44 to be admitted to the locked memory care unit. Observation on 05/10/2024 at 11:10 a.m. revealed Resident #44 sitting in a recliner in the living room on the secure/memory care unit. During an interview on 05/10/2024 at 11:10 a.m. LVN C stated the DON usually did the orders for the unit and residents had orders prior to being moved to the unit. During an interview on 05/10/2024 at 11:17 a.m. the DON stated Residents #12, #28, #33 and #44 did not have orders, however residents just needed to have consents and did not require orders to be admitted to the unit. The DON further stated the residents also had to have a diagnosis of Alzheimer's disease or dementia. During an interview on 05/10/2024 at 12:50 p.m. the ADM stated residents needed a diagnosis of Alzheimer's or dementia but did not necessarily have to have an order to be placed on the memory care unit. The ADM further stated consents were required prior to residents being placed on this unit. Record review of the facility's policy titled Physician Medication Orders, effective date, January 2023, revealed IV. Dementia Protocol: 3. The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia (to included assignment to memory care unit, as need) based on pertinent clinical guidelines and regulatory expectations.

Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 6 residents (Resident #10) reviewed for advanced directives, in that: The facility failed to ensure Resident #10's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and had the physician's license number which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #10's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, lack of coordination, cognitive communication deficit, reduced mobility, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and chronic respiratory failure with hypoxia (hypoxemic respiratory failure indicates not enough oxygen in your blood, but your levels of carbon dioxide are close to normal). Record review of Resident #10's most recent admission MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #10's Order Summary Report, dated [DATE] revealed the following: - OOH-DNR, with order date [DATE] and no end date [DATE] 04:34 PM Record review of Resident #10's OOH DNR document, uploaded into the electronic record on [DATE] revealed the document was missing the physician's license number and the date of signature. Record review of Resident #10's. Order summary report revealed order for OOH DNR with order date [DATE]. During an interview on [DATE] at 1:04 p.m., the SW revealed she was responsible for initiating OOH-DNR for those residents who requested DNR status. The SW stated she followed the OOH-DNR document process from beginning to end and then the document was uploaded into the computer by the medical records clerk. The SW confirmed Resident #10's OOH-DNR was incomplete because it was missing the physician's license number and date which made the document invalid. The SW further revealed Resident #10 would be considered full code status (all resuscitation procedures will be provided to keep a person alive) because of the invalid OOH-DNR. The SW stated, the OOH-DNR was time sensitive and would need to be addressed immediately and the process would have to be started over again. A facility policy regarding Advance Directives was requested but not received by the time of the exit. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.

Based on observation, interview, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 of 1 resident (Resident #14) reviewed for residents' rights, in that: The facility failed to ensure LVN E locked the Medication Cart Computer screen and left Resident #14's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Record review of Resident #14's face sheet, dated 5/10/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility), hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), dysphagia, mood disorder (feelings of distress, sadness or symptoms of depression, and anxiety), lack of coordination and chronic pain. Observation on 5/9/24 at 4:27 p.m. revealed the Medication Cart Computer screen was left open, unattended, and facing the hall with Resident #14's health information exposed from 4:27 p.m. to 4:36 p.m. During an interview on 5/9/24 at 4:36 p.m., LVN E revealed she had left the Medication Cart Computer Screen unattended to answer the phone and did not close the screen on the computer. LVN E stated, can't do that because it was a HIPAA violation. During an interview on 5/10/24 at 10:27 a.m., the DON revealed it was his expectation staff were to clear or push the walkaway button on the computer screen to protect resident information and was considered a HIPAA violation. Record review of the facility policy and procedure titled, HIPAA Security Agreement, undated, revealed in part, . (the Facility) considers maintaining the security and confidentiality of protected health information (PHI) a matter of its higher priority. All those granted access to this information must agree to the standards set forth in this Computer and Information Usage Agreement .Understand that the information accessed through all (Facility) computer(s) and information systems contains sensitive and confidential patient care .information which should only be disclosed to those authorized to receive it .

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 Residents (Resident #54) whose MDS records were reviewed for accuracy. Resident #54's Quarterly MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #54's face sheet dated 5/08/2024 revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included: Angina Pectoris (chest pain), Atherosclerotic Heart Disease of Native Coronary Artery (plaque buildup that causes the inside of the arteries to narrow over time), Type II Diabetes (a disease that occurs when your blood sugar is too high). Record review of Resident #54's Discharge MDS assessment, dated 02/17/2024, revealed under section for identification, Discharge Status was coded as being discharged to Short-Term General Hospital. Record review of Resident #54's discharge progress note, dated 2/17/2024 11:04:25, showed Resident DC Home with Spouse, Resident breathing even and unlabored, Resident DC at baseline. Spouse Took all belonging During an interview on 05/09/2024 at 12:58 pm with LVN H, MDS Nurse - she verified the MDS indicated the resident was discharged to a General Short-Term Hospital. When asked where the resident was discharged to, she replied we've already established that. LVN H then stated, I'm correcting it now. During a phone interview on 5/10/24 at 10:34 am - LVN D stated she had written the discharge progress note for Resident #54 and verified the resident was discharged home and that her family member picked her up. She stated that the resident was not discharged to another facility. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 15 (Resident #1) residents reviewed for wound care in that: 1. The facility failed to ensure prompt wound care when a new wound to Resident #1's left and right lower leg was discovered on 11/21/23. The Wound Care Nurse D was first notified of the wounds on 11/28/23. 2. While performing Resident #1's left heel and right lower extremity wound care on 2/27/24, Wound Care Nurse D did not perform Resident #1's wound care as ordered by the physician. This deficient practice could affect residents who receive wound care and place them at risk for delayed wound healing. The findings were: 1. Record review of Resident #1's face sheet, dated 2/27/24, revealed Resident #1's latest admission was 9/6/23 with diagnoses of senile degeneration of brain [loss of intellectual ability associated with old age], not elsewhere classified, encounter for palliative care [specialized medical care for people living with serious and long-term illnesses], pressure-induced deep tissue damage of left hip, pressure ulcer of left heel, stage 3, and pressure ulcer of other site, unstageable. Record review of Resident #1's significant change MDS, dated [DATE], revealed Resident #1 had a BIMS of 7, signifying severe cognitive impairment. Record review of Resident #1's skin evaluation form, dated 11/21/23 and written by LVN A, revealed new skin issue described as an abrasion located on the right lower leg with the wound measurements 9.5 cm (length) x 3 cm (width) x 3 cm (depth). There was another new skin issue described as an abrasion located on the right lower leg with the wound measurements 9.5 cm (length) x 3 cm (width) x 0 cm (depth). There was nothing in this evaluation form indicating the Wound Care Nurse D, Wound Care NP C, or a physician was notified. Record review of Resident #1's nursing progress notes from 11/1/23 to 11/30/23, revealed the following nursing progress notes: - Nursing Progress Note written by LVN A, dated 11/21/23: Skin Issue: #001: New. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 3 . Skin Issue: #002: New. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 0. There was no mention of notifying Wound Care Nurse D or Wound Care NP C. - Nursing Progress Note written by Wound Care Nurse D, dated 11/22/23: Stage 4 Pressure Ulcer to Sacrum [tail bone area] assessed by Wound NP and Treatment Nurse. Current wound measurements this visit: 8.0x9.0x1.5cm and presents with undermining from 9 o'clock to 12 o'clock and tunneling [when the wound forms passageways underneath the surface of the skin] 2cm deep. Upon further assessment of wound Moderate amount of green serosanguineous [thin, watery discharge that contains a small amount of blood] drainage observed to wound bed with no foul odor. There was no mention of treating any wounds to Resident #1's right and left leg. - Nursing Progress Note written by LVN A on 11/28/23: Skin Issue: #001: No Change. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 3 . Skin Issue: #002: Needs Review. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 0. There was no mention of notifying Wound Care Nurse D or Wound Care NP C. - Nursing Progress Note written by Wound Care Nurse D on 11/29/23: Lower Extremity presents with Unstageable pressure ulcer measuring 10.0x3.5xUTDcm. Moderate amount of serosangenous [sic] drainage with foul odor noted, erythematous [red] and purple in color with slough [the yellow/white material in the wound bed] and eschar [a collection of dry, dead tissue within a wound] observed . Right Lower Extremity has developed an unstageable Pressure Ulcer measuring 7.0x4.0xUTD with mild amount of serous drainage [clear fluid that leaks out of wounds], intact eschar, and purple in color. Record review of a wound care progress note, dated 11/29/23 and written by Wound Care NP C, revealed: seen today for wound care follow up new ulcers noted to . bilateral LE [lower extremities.] Record review of Resident #1's all physician orders, obtained on 2/27/24, revealed the first wound care order for either of Resident #1's legs was the following order dated on 11/30/23: Left Lower Extremity Unstageable Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS [Normal Saline which is a mixture of sodium chloride and water used to cleanse wounds, flushing lines, and treating dehydration]/Wound Cleanser, pat dry Primary dressing: Santyl [a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin] Secondary dressing: Dakins [an antimicrobial solution used for wound care] soaked gauze 1/4 strength Secured With: Dry dressing every day shift. Observation on 2/27/24 at 10:27 a.m. revealed Resident #1 was in bed. Resident #1's heels were lifted from the bed with pillows. No heel-lifting boots were seen in the room. During an interview on 2/28/24 at 10:14 a.m., Resident #1's RP stated she was satisfied with the care of the facility and denied any concerns of neglect. Resident #1's RP stated she recalled that Resident #1's leg wounds first began in before December 2023. Resident #1's RP stated at the time Resident #1 wore heel-lifting boots and Resident #1 did not want to reposition his legs. Resident #1's RP stated sometimes if the staff reposition Resident #1's legs, Resident #1 will move his legs back to the same position. During an interview on 2/29/24 at 2:43 p.m., LVN A stated she was not currently employed by the facility and her previous position at the facility was an LVN A. LVN A stated when a wound was found she would notify Wound Care Nurse D and then Wound Care Nurse D would obtain wound care orders from either the wound care physician or the resident's physician. LVN A stated, [Resident #1] had abrasions [a minor injury where the skin rubs off] on either side of the outer part of his calves. They started as redness. I did contact [Wound Care Nurse D] and she said to just keep him clean and dry and open to air. So we didn't. We didn't write an order for that. And then I believe the wounds . maybe within a week and a half, the wounds became worse. [Wound Care Nurse D] got wound care orders for that. LVN A stated she could not remember specific dates related to the onset or the treatment of Resident #1's wounds. LVN A stated she notified Wound Care Nurse D when Resident #1's lower leg wounds first appeared but she did not recall if Resident #1's physician was notified. During an interview on 2/29/24 at 10:17 a.m., Wound Care Nurse D stated when a staff member found a new wound, the staff member would notify the wound care nurse soon as the wound is found. Wound Care Nurse D stated the wound care physician or the wound care nurse practitioner would typically be notified immediately if within business hours or by 8:00 a.m. the next day. Wound Care Nurse D stated, As soon as I'm notified I would give [the staff] a . standing order from our nurse practitioner just to clean it, bandage it up, or I'll go and evaluate [the wound] right away . It's not that I don't get involved [with abrasions], but we typically like to monitor . We do implement either a xeroform [a special type of wound dressing] or skin prep [a liquid that forms a protective barrier to help reduce friction during the removal of tapes and films from the skin depending on the severity of the abrasion. Normally we would treat the abrasion. When asked if an abrasion would typically require a physician notification or a wound care order, Wound Care Nurse D stated, yes. Wound Care Nurse D stated Resident #1's lower leg wounds began towards the end of November and she was first notified of the wound on . 11/28/23. Wound Care Nurse D stated she was informed the wounds were abrasions. Wound Care Nurse D stated she first saw Resident #1's wounds on 11/29/23. Wound Care Nurse D stated, [Resident #1] was using the [heel-lifting] boots. I know [the wound] started on the left leg. And from what I understood, they [the nurses] used a dressing basically on that leg. It was in the end of November, [the wound] started out as unstageable. Wound Care Nurse D stated the cause of the wounds to Resident #1's lower legs was the heel-lifting boots he wore at the time, which had since been discontinued. During an interview on 2/29/24 at 1:05 p.m., Wound Care NP C stated Resident #1 was one of her patients. Wound Care NP C stated Resident #1 had poor blood flow to his legs and Resident #1 was also prone to wounds because he was physically weak. When asked how soon she would like to be notified if a resident had a new wound, Wound Care NP C stated, It depends on the wound. If it's something [the staff] can manage, they're perfectly capable of it . But most of the time the new residents . [Wound Care Nurse D] will call me promptly. Wound Care NP C stated she would prefer to be notified within 24 hours. Wound Care NP C stated on 11/22/23 she saw Resident #1 and treated his sacral wound. Wound Care NP C stated Resident #1 refused examination of his legs. Wound Care NP C stated she first saw Resident #1's lower leg wounds on 11/28/23 and implemented wound care orders for his lower leg wounds at that time. When asked if she believed the delay in notification may have worsened his lower leg wounds, Wound Care NP stated, There's multiple factors and I can't say for sure. During an interview on 3/1/24 at 11:23 a.m., the DON stated he expected abrasions to be reported to Wound Care Nurse D as soon as possible, then Wound Care Nurse D will decided if the wound required wound care orders. The DON was aware new wounds were discovered on Resident #1's lower legs on 11/28/23, but he did not realize that LVN A did not report the wounds to the wound care nurse or the wound care practitioner until he was reviewing documentation on 12/5/23. The DON stated LVN A noted Resident #1 had abrasions to his lower legs on 11/21/23. The DON stated Resident #1 had poor circulation and would frequently refused wound care treatments and would also refuse turning. The DON stated ultimately, LVN A failed to report the abrasions. The DON stated, The root cause revealed the irritation was caused by the [heel-lifting] boots so after that the resident was followed and treated by the wound care nurse practitioner. We discontinued the [heel-lifting] boots so we off-load his heels in pillows. We in-serviced the CNAs and nurses on the use and care of residents with those boots. And we started doing the shower sheets. Even though he refused care, I found it hard to believe no one saw that. And they gave those to the wound care coordinator. When asked if the facility had a process to ensure residents' providers were notified of new wounds, the DON stated, we do that during the morning clinical meeting. We'll find out in the skin assessment and if [the staff] are reporting the problem. When asked what sort of negative affects could occur if providers were not notified of new wounds, the DON stated, they [the residents] won't receive the proper orders and treatments. During an interview on 3/4/24 at 9:27 a.m., LVN E stated she recalled seeing Resident #1's lower leg wounds when they first began in November 2023, but could not recall the specific dates. LVN E stated, I don't remember when, but I know the treatment nurse was there . I think it was a deep tissue injury. We'd turn him, but a lot of the times he would not allow us to turn him. During a follow-up interview on 3/4/24 at 9:43 a.m., Wound Care Nurse D stated on 11/22/23 she and Wound Care NP C treated Resident #1's sacrum and they had noted a deep tissue injury to Resident #1's left heel. Wound Care Nurse D stated Resident #1's had heel protection boots on during the treatment on 11/22/23 and the boots hid the dressing which covered Resident #1's lower leg wounds. Wound Care Nurse D stated she did not check Resident #1's legs because when she and Wound Care NP C treat a resident's wounds, they are only focused on the wounds they are aware of. During an interview on 3/8/24 at 2:10 p.m., Physician F stated he was not informed when Resident #1's wounds first began but cannot recall exactly when he was notified. Physician F stated the wound care nurse did not notify him of Resident #1's lower leg wounds. When asked if there could have been a different outcome if he was notified of Resident #1's leg wounds sooner, Physician F stated, There are times where I've recommended things and [Resident #1's Medical Power of Attorney] has not gone along with my suggestions. And . [Resident #1] will frequently be very angry with the staff if they attempt to even to touch him. So the real question is going to be the chicken or the egg. Who is really responsible for him for not getting the care he needed? Is it the staff or was it because he was recalcitrant [uncooperative] in regards of letting the staff do what they need to do? I have no way of knowing that. Record review of a facility policy titled, Wound Care, dated January 2024 revealed the following: The facility does not have the capability to manage complex wounds, Stage 2 or above. These are referred to a contract specialty wound care group which provides clinical evaluation and treatment plans and therapies through the services of one or more providers under the contract . If the Charge Nurse is the staff member entering the order into [the facility's electronic medical system] she/he will notify [Wound Care Nurse D] of the need for the referral as soon as possible. Record review of a facility policy titled, change in a Resident's Condition, dated December 2024, revealed the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .a need to alter the resident's medical treatment significantly. 2. Record review of Resident #1's physician orders, obtained on 2/27/24 revealed the following wound care orders: - Left Heel Stage 3 Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS/Wound Cleanser, Pat dry Primary dressing: Anasept [an antibiotic liquid used in wound care that helps prevent infection] Secured With: Dry Dressing every evening shift every Mon, Wed, Fri. - Right Lower Extremity Stage 4 Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS/Wound Cleanser, pat dry Primary dressing: Anasept Secondary dressing: Dakins [an antimicrobial solution used for wound care] soaked gauze Secured With: ABD Pad [a highly absorbent dressing that provides padding and protection for large wounds], Kerlix [a type of bandage roll], and tape every evening shift every Mon, Wed, Fri. Observation on 2/27/24 11:48 a.m. revealed Wound Care Nurse D began the treatment to Resident #1's left heel. Wound Care Nurse D cleansed Resident #1's left heel with gauze soaked in wound cleanser, which used the last of her gauze soaked in wound cleanser. Wound Care Nurse D removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D next painted Resident #1's left heel with betadine (which was not part of the wound care orders for this wound) and pat the betadine dry. Wound Care Nurse D removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D completed the rest of wound care for Resident #1's left heel. Wound Care Nurse D did not obtain more gauze soaked in wound cleanser. Wound Care Nurse D then began the treatment to Resident #1's right lower leg. Wound Care Nurse D removed the old dressing on Resident #1's right lower leg, removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D cleansed Resident #1's right lower leg wound with Dakins solution (which was not part of the wound care orders for this wound) and applied Anacept. Wound Care Nurse D then completed the rest of the wound care for Resident #1's right heel. During an interview on 2/27/24 at 12:27 p.m., Wound Care Nurse D stated, I know I put the betadine first [on Resident #1's left heel] and then I realized it was a mistake. I was just a little confused. After I caught it, I realized it was supposed to be the Anacept . I cleansed [Resident #1's right lower leg], dried it, applied the Anacept and the Dakins. Wound Care Nurse D stated she was supposed to use the wound cleanser for Resident #1's right lower leg wound, but she ran out of wound cleanser. When asked what sort of negative affects could happen to the residents if their wound care wasn't done appropriately, Wound Care Nurse D stated, it could delay the healing. During an interview on 3/1/24 at 11:23 a.m., when asked if the facility had a quality assurance process to ensure wound care was done per properly, the DON stated when the nurse practitioner rounded, the facility was able to follow if the wounds are getting better. The DON stated wounds are also discussed in the facility's clinical morning meeting. When asked what sort of negative effects could occur to the residents if they did not receive their wound care properly, the DON stated, the wound will deteriorate or get worse. Record review of a facility policy titled, Wound Care, dated January 2024 revealed the following: DRESSING CHANGE PREPARATION . 1. Verify there is a physician's order for the procedure . 3. Assemble the equipment and supplies needed.