Every finding on record at The Oaks Care Center

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff sanitized reusable medical equipment between each resident use, and performed hand hygiene after direct resident contact. Findings: Review of facility policy on 01/06/2026 at 1:30 p.m. titled Hand Hygiene Policy and Procedure dated 07/01/2020 revealed in part.Policy: Hand Hygiene shall be performed: (3) Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. (12) Before as appropriate and after coming in contact with a resident's intact skin (e.g. when taking a pulse, blood pressure, and lifting a resident). Observation of medication administration on 01/06/2026 from 8:20 a.m. until 8:45 a.m. revealed S3LPN used a wrist blood pressure cuff to monitor the blood pressure of multiple residents. Observation revealed the blood pressure cuff was not sanitized between uses on the residents. Observation revealed S3LPN did not perform hand hygiene between multiple residents during medication administration. Interview with S3LPN on 01/06/2026 at 8:47 a.m. confirmed she did not sanitize the wrist blood pressure cuff or perform hand hygiene between residents, but should have.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights for 2 (Resident #10 and Resident#12) of 20 Sampled Residents. The facility failed to: 1. Develop a focus of weight loss for Resident #10; and2. Develop a focus of depression for Resident # 12. Findings: Resident #10 Review of Resident #10's electronic health record revealed an admission date of 08/21/2020 with diagnoses which included: Alzheimer's disease, Schizoaffective Disorder, Dementia, Anxiety, Severe Intellectual Disabilities, Chronic Kidney Disease, Unspecified Severe Protein-Calorie Malnutrition, Dysphagia, and Vitamin Deficiency. Review of Resident #10's Quarterly MDS with an ARD of 11/04/2025 revealed that a BIMS was not conducted due to Resident #10 being rarely/never understood. Resident #10 was dependent on staff for all ADLs. Review of Resident #10's weight record revealed the following which represented a significant weight loss: 06/06/2025: 102.1 lbs. 07/08/2025: 98.8 lbs. 08:15:2025: 99 lbs. 09/08/2025: 98.5 lbs. 10/03/2025: 99 lbs. 11/07/2025: 95 lbs. 12/03/2025: 91.8 lbs. Review of Resident #10's weight note dated 12/03/2025 read in part. Current weight is 91.8 lbs. Resident newly triggering for weight loss of -10% from comparison weight 102.1 on 06/06/2025. Review of Resident #10's comprehensive care plan, initiated on 08/06/2024, revealed no documented problem statements, goals, or interventions addressing Resident #10's significant weight loss. Interview on 01/06/2026 at 2:45 p.m., S2 MDS Team Member revealed that MDS nurses are responsible for updating residents' comprehensive care plans. S2 MDS Team Member stated that care plans are reviewed and updated quarterly and as needed, including daily updates when warranted by a change in condition. S2 MDS Team Member stated that when a resident experiences significant weight loss, the issue should be reflected in the residents' care plan along with corresponding interventions. S2 MDS Team Member confirmed that the Resident #10's significant weight loss and related interventions were not listed in Resident #10's care plan, but should have been. Resident #12 Review of electronic health record for Resident #12 revealed an admission date of 03/13/2025 with diagnoses which included Depression and Anxiety. Review of Resident #12's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/04/2025 revealed a BIMS (Brief Interview Mental Status) of 12 indicating intact cognition. Resident #12 was on an antidepressant medication and had a diagnosis of depression. Review of Resident #12's current Care Plan revealed no focus for depression. During an interview on 01/07/2026 at 8:52 a.m. with S2MDS Team Leader revealed if a resident has a diagnosis of depression and received antidepressant medication, the Resident's care plan should reveal a focus of depression with appropriate interventions in place. S2MDS Team Leader confirmed Resident #12's diagnosis of depression was not care planned, but should have been.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. Total sample size was 20. Findings:Review of Resident #73's electronic health record revealed an admission date of 01/03/2017 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Mild Protein-Calorie Malnutrition, Generalized Osteoarthritis, Mild Cognitive Impairment, Dementia, Gout, and Encounter for Prophylactic Measures. Review of Resident #73's Quarterly MDS with an ARD of 10/09/2025 revealed a BIMS score of 1 indicating severe cognitive impairment. Resident #73 had bilateral upper extremity functional limitations in range of motion. Review of Resident #73's Physician's Order dated 08/04/2025 revealed in part. rolled gauze or hand roll to right hand every shift. Multiple observations of Resident #73 revealed that no rolled gauze or hand roll was present in Resident #73's hand. Observations occurred on the following dates and times:01/05/2026 at 1:30 p.m.01/06/2026 at 8:32 a.m.01/07/2026 at 9:46 a.m.01/07/2026 at 11:46 a.m.01/07/2026 at 1:47 p.m. On 01/07/2026 at 01:50 p.m., the surveyor accompanied S4LPN to Resident #73's room. S4LPN confirmed that the Resident #73 did not have a rolled gauze or hand roll present in her right hand at the time of observation, but should have. On 01/07/2026 at 01:53 p.m. An interview with S1DON confirmed that Resident #73 had a physician's order for a rolled gauze or hand roll to be applied to the right hand every shift. S1DON acknowledged that during multiple observations, Resident #73 did not have a rolled gauze or hand roll in place, but should have.

FACILITY Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to ingredients and portion size to ensure the nutritional adequacy of the meal for all 9 residents who received a puree diet. Findings: Review of the facility's policy titled: Preparation and Service of Pureed Diets read in part .Procedure 5: Follow recipes provided .Procedure: 6.A food thickener may be added to pureed foods to thicken the food to its desired consistency. In an interview during the initial kitchen tour at 8:43 a.m. on 09/16/2024, S3 Dietary Manager stated the facility had 9 residents being served a puree diet. In an observation on 09/16/2024 at 9:13 a.m., S4 Dietary [NAME] prepared puree pot roast and placed 1/2 of a roast in the blender with 6 pieces of bread, and approximately 1/2 pan of water in the blender to puree the roast. In an observation at 9:20 a.m., S4 Dietary [NAME] added 3 small cartons of whole milk to the 40 yam patties she placed in puree mixer and turned on the blender. At 9:30 a.m., S4 Dietary [NAME] put some cabbage in the blender. This surveyor asked how much cabbage she put in and she said, I just scooped some up. S4 Dietary [NAME] stated she used some of the juice the cabbage cooked in and then put some water in a pan and added it to the blender with the cabbage. During these observations, S4 Dietary [NAME] never measured the water before adding it to the pan and later the blender. Review of the recipe for puree pot roast revealed it required the use of water and food thickener bulk and did not require the use of bread. Review of the recipe for puree cabbage revealed it required the use of food thickener bulk and did not require the use of water. In an interview on 09/16/2024 at 4:10 p.m., S3 Dietary Manager confirmed S4 Dietary [NAME] did not follow the puree recipes, did not measure portion sizes according to puree recipe, and did not use food thickener bulk for recipes and should have.

Based on interview and record review, the facility failed to ensure services were provided to residents according to accepted standards of clinical practice for 2 (Resident #97 and Resident #102) out of a total sample of 30 residents. The facility failed to notify the physician when: 1. Resident #102 had blood glucose levels greater than 451 mg/dL as ordered. 2. Resident #97 had an unwitnessed fall. Findings: Review of a facility policy titled Change in Condition Policy and Procedure dated 08/27/2018 revealed in part . Procedure: 2. The licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition. Assessment may include but is not limited to: physical assessment findings, vital signs, blood glucose, oxygen saturation, etc. The licensed nurse will document assessment findings in the electronic medical record. 3. The resident's primary physician or designated alternate will be contacted promptly of a significant change in the resident's status. a. If unable to contact primary physician or designated alternate, the medical director is to be contacted. b. Document notification and any instructions/orders received in the electronic medical record and on the physician order as appropriate. Resident #102 Review of Resident #102's clinical record revealed an admitted [DATE] with diagnoses that included: Type 2 Diabetes Mellitus with Hyperglycemia; Hemiplegia And Hemiparesis following Cerebral Infarction Affecting Right Dominant; Unspecified Glaucoma; Apraxia following Cerebral Infarction; Aphasia following Cerebral Infarction; Dysarthria following Cerebral Infarction; and Hypertensive Heart And Chronic Kidney Disease with Heart Failure. Review of Resident #102's Quarterly MDS with an ARD of 06/29/2024 a BIMS score of 9, indicating moderate cognitive impairment. Resident #97's MDS revealed she required moderate assistance with eating and received seven days of insulin injections. Review of Resident #102's Care Plan with a Target Date of 10/16/2024 revealed in part .I have a diagnosis of Diabetes. Interventions: Administer my diet as ordered. Monitor my nutritional intake. Obtain my finger stick blood sugars as ordered. Administer my oral hypoglycemic agents as ordered. Observe me for signs of hypo/hyperglycemia. Monitor my blood sugar as ordered. Administer my insulin as ordered. Assess my response to the insulin changes and report to MD. Review of Resident #102's 08/2024 Medication Administration Record revealed in part . Order: Admelog Injection Solution. Inject as per sliding scale: if 60 - 200 = 0 units; 201 - 300 = 4 units; 301 - 400 = 8 units; 401 - 450 = 15 units; 451 - 999 = 20 units; 451-500 or above notify MD. Blood Glucose Levels: 08/01/2024 11:00 a.m. - 491 mg/dL 08/02/2024 11:00 a.m. - 492 mg/dL 08/02/2024 4:00 p.m. - 515 mg/dL 08/03/2024 11:00 a.m. - 471 mg/dL 08/04/2024 11:00 a.m. - 518 mg/dL 08/05/2024 11:00 a.m. - 543 mg/dL 08/06/2024 11:00 a.m. - 526 mg/dL 08/07/2024 11:00 a.m. - 490 mg/dL 08/07/2024 4:00 p.m. - 520 mg/dL 08/09/2024 4:00 p.m. - 503 mg/dL Review of Resident #102's 09/2024 Medication Administration Record revealed in part . Order: Admelog Injection Solution. Inject as per sliding scale: if 60 - 200 = 0 units; 201 - 300 = 6 units; 301 - 400 = 8 units; 401 - 450 = 15 units; 451 - 999 = 20 units; 451-500 or above notify MD. Blood Glucose Levels: 09/03/2024 11:00 a.m. - 464 mg/dL 09/04/2024 11:00 a.m. - 460 mg/dL 09/05/2024 11:00 a.m. - 467 mg/dL 09/05/2024 4:00 p.m. - 466 mg/dL 09/08/2024 11:00 a.m. - 466 mg/dL 09/09/2024 4:00 p.m. - 454 mg/dL 09/11/2024 11:00 a.m. - 455 mg/dL 09/11/2024 8:00 p.m. - 464 mg/dL 09/16/2024 11:00 a.m. - 456 mg/dL Review of Resident #102's Nursing Progress Notes from 08/01/2024 through 09/17/2024 revealed on the dates listed above there were no progress notes for notification of Resident #102's MD when her blood glucose levels were greater than 451 mg/dL. Interview on 09/18/2024 at 10:27 a.m. with S2 DON confirmed on the above listed dates when Resident #102's blood glucose levels were above 451 mg/dL the nurses did not document Resident #102's MD was notified, but they should have. S2 DON reported the nurses should have made a progress note in Resident #102's clinical record that the MD was notified. 51096 Resident #97 Review of the facility's policy and procedure dated 05/08/2018, and titled Incident and Accident read in part . Policy: Accidents are to be reported, investigated and followed up in a timely manner. Procedure: 1. Reporting of Incidents and Accidents: a. Any employee who witnesses or becomes aware of an incident or accident must report it to the designated departmental supervisor. 3. Medical attention (nurse) a. Assess all incident and accident victims. b. Notify Physician c. Notify family/ responsible party 4. Investigative Action: a. The nurse conducts an immediate investigation of any Incident and Accident. The nurse collects pertinent data and completes an incident entry form (including taking vital signs). 5. Incident and Accident Report: a. Complete an incident and accident report on any incidents or accidents, regardless of how minor the incident or accident may be. c. Documentation in the nurse's note must clearly define the incident and record the resident's vital signs. 6. Instructions for responding nurse: a. Incident or accident without head injury i. Notify family/ responsible party and physician, then document in the electronic medical record (EMR) ii. Complete incident and or accident report. iii. Document incident or accident follow-up notes in the electronic medical record (EMR) including vital signs for 72 hours. Equipment: 1. Incident and Accident Report 2. Vital Signs if applicable 3. Resident Chart 4. Electronic medical record (EMR) Review of Resident #97's clinical record revealed an admitted [DATE], with diagnoses which included other lack of coordination; hereditary and idiopathic neuropathy; muscle weakness, repeated falls, spondylolisthesis, vitamin D deficiency; osteomyelitis and other muscle spasms. Review of Resident #97's Quarterly MDS with an ARD/ Target date of 07/16/2024, revealed a BIMS score of 15; Cognitively intact. Resident #97 uses a wheelchair and requires substantial/maximal assistance with wheeling 150 feet, and wheeling 50 feet with two turns. Resident #97 requires partial/moderate assistance with chair/bed to chair transfers and changing from a sitting to standing position. Review of Resident #97's Care Plan revealed in part The resident is at risk for falls r/t Fall Hx, COPD, SOB, Anemia, Depression, Neuropathy, OA, and Psychotropic drug use. Interventions included: Place me on the fall program as appropriate; monitor for changes in my condition that may warrant increased supervision/ Assist and Notify MD and remind me to ask for assist with all ambulation. The resident requires staff assistance with ADL's related to Anemia, COPD, Depression, Neuropathy and OA. Interventions included: I require assistance with ambulation. I use a wheelchair for mobility and assist me with locomotion. Interview with Resident #97 on 09/16/2024 at 09:50 a.m., revealed that Resident #97 had a fall on Saturday, 09/14/2024 at the front of the facility. Resident #97 stated that she was outside visiting with her son. Resident #97 stated that her son left and she was sitting outside when her phone fell and as she attempted to reach down and pick it up, she slid out of the wheelchair onto her left shoulder. Resident #97 stated that she was outside on the ground for about 5 minutes when a visitor saw her on the ground and alerted staff. Resident #97 stated that about 5 nurses came outside to help her. The nurses checked her out and she had no injuries and was not in any pain. She was wheeled back into the facility. Resident #97 stated that she joked with staff that she would never reach for her phone again. Review of Resident #97's clinical record revealed no documentation of a fall on Saturday 09/14/2024; no Physician notification and no responsible party notification. Requested Incident report of resident's fall on Saturday, 09/14/2024 from S1Administrator. Interview with S2 DON on 09/17/2024 at 12:14 p.m. revealed that she was unaware that Resident #97 had a fall. She started the procedure to open an investigation. S2 contacted S8 LPN who was on duty Saturday via phone for more information concerning Resident #97's fall. Interview with S2 DON and S5 Regional QI Nurse on 09/18/2024 at 11:21 a.m. revealed that the physician and responsible party were not notified of Resident #97's fall and confirmed they should have. S2 DON stated that she was made aware of fall when it was brought to her attention by S1 Administrator after request for Incident report from this surveyor.

Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#109) of 30 sampled residents. The facility failed to implement appropriate infection control precautions for Resident #109. Findings: Review of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Policy: To follow CMS guidelines related to Enhanced Barrier Precautions, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. i. Wounds generally include chronic wounds, not short-lasting wounds such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. 1. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 2. EBP should be used for any resident who meets the above criteria, wherever they reside in the facility (resident room not in common area such as hallway, dining, or activity rooms). a. Outside the resident's room, EBP should be followed when performing transfers or assisting during bathing in a shared/ common shower room and when working with residents in the therapy gym. 4. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: a. Dressing b. Bathing/Showering c. Transferring d. Providing Hygiene e. Changing Linens f. Changing briefs or assisting with toileting g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy) h. Chronic Wound Care: any skin opening requiring a dressing. 5. PPE is to be applied prior to performing the high-contact resident activity according to below and before moving on to another resident: a. Perform hand hygiene b. Put on a gown and gloves c. After resident care, throw away gown and gloves in trash receptacle d. Perform hand hygiene Equipment: 1. EBP sign 2. Gloves and gown 3. Hand Sanitizer Review of Resident #109's clinical record revealed an admitted [DATE], with diagnoses which included encounter for other orthopedic aftercare; other acute osteomyelitis, right ankle and foot; aftercare following joint replacement surgery; local infection of the skin and subcutaneous tissue; and other fracture of right lower leg, subsequent encounter for closed fracture with routine healing. Review of Resident #109's Significant Change MDS with an ARD date of 08/09/2024, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #109 required supervision or touching assist with personal hygiene, upper body dressing; oral hygiene; and eating. Resident was Dependent for toileting. Resident required partial or moderate assistance for showering/ bathing; lower body dressing and putting on and taking off footwear. Resident had a surgical wound. Review of Resident #109's Care Plan revealed in part The resident has a leg infection (07/02/2024). Interventions included: Administer my medication as prescribed by my physician; monitor me for signs and symptoms of my infection getting worse and provide me treatment as ordered by my physician. The resident has a surgical site to right lateral malleolus (06/27/2024). Interventions included: I need wound care as ordered by my physician; monitor for changes in my skin status that may indicate worsening of my wound and notify the physician and turn and reposition me as appropriate. Review of Resident #109's Wound Assessment report dated 08/04/2024 revealed the resident had a non-pressure wound-surgical incision to right lower leg. Review of Resident #109's physician's orders dated 09/18/2024 at 8:20 a.m. revealed no order for Enhanced Barrier Precautions. Review of Resident #109's Care Plan dated 08/03/2024 revealed no care plan for Enhanced Barrier Precautions. Observation of Resident #109 on 09/16/2024 at 9:30 a.m. revealed Resident #109 sitting in wheelchair. PICC line noted to right arm, dressing clean, dry and intact, dated 09/12/2024 and wound vac on and connected to right ankle hanging on back of wheelchair. No Enhanced Barrier Precaution signage noted on door or near room. Observation of Resident #109 on 09/17/2024 at 9:06 a.m. revealed Resident #109 sitting up in bed. PICC line noted to right upper arm, dressing clean, dry and intact, dated 9/16/2024. Wound Vac on and connected to right ankle. No Enhanced Barrier precautions posted on room door, in room or near room. Observation of Resident #109 on 09/17/2024 at 1:42 p.m. revealed Resident #109 in bed. PICC line noted to right arm and wound vac on floor next to bed, on and connected to ankle. No Enhanced Barrier Precautions on door, in room or outside room door noted. Interview with S7 CNA on 09/17/2024 at 2:24 p.m. revealed she was aware of residents that are on Enhanced Barrier Precautions by orange sign on the resident's door. Observation and interview with Resident #109 on 09/18/2024 at 8:50 a.m. revealed Resident #109 lying in bed. PICC line observed to right arm, dressing clean dry and intact and wound vac sitting on floor, on and connected to right ankle. Resident #109 stated CNA's have not been wearing gowns when transferring resident to and from wheelchair or when performing toileting hygiene. Resident #109 stated tubing was disconnected by CNAs from wound vac during transfers. Enhanced Barrier Precaution sign now on resident's door. Interview with S6 LPN on 09/18/2024 at 9:04 a.m. revealed that she placed the sign on the Resident #109's door at some point on Tuesday, 09/17/2024.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #4, Resident #15, Resident #63, and Resident #70 ) of 4 sampled residents with MDS record over 120 days old. Findings: Review of the facility MDS transmission reports for Resident #4, Resident #15, Resident #63, and Resident #70 revealed the MDS Assessments with ARD of 07/18/2023 for all the above residents had not been transmitted until 08/17/2023. Interview on 08/23/2023 at 11:10 a.m. with S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator confirmed the above findings. S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator denied any technological issues that may have hindered transmission of the noted assessments. S11 LPN/MDS Team Leader revealed assessments should have been transmitted within 14 days of completion and had not been.

Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to ensure the bathroom wall and door in Room A were in good repair. Findings: Observation on 08/21/2023 at 12:38 p.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. Observation of the inside of the bathroom door revealed the door appeared shredded across the middle. Observation on 08/24/2023 at 10:30 a.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. The inside of the bathroom door appeared shredded across the middle of the door. Observation of Room A bathroom on 08/24/2023 accompanied by S2 DON revealed the above concerns remained present. Interview at the time of observation confirmed the door was peeling and damaged across the middle and lower corners. Two exposed screws were present below the wall grab bar and several small holes were present in the wall beside the commode. S2 DON stated staff were responsible for reporting areas in need of repair. S2 DON stated Room A's bathroom conditions should have been reported and repaired and had not been.

Based on observation, interview and record review the Facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (Resident #47) of 31 sampled Residents. The facility failed to provide a diet according to Resident #47''s food preferences. Findings: Review of Resident #47's medical record revealed an admitted [DATE] with diagnoses which included: Morbid Obesity, Functional Dyspepsia, Peripheral Vascular Disease, Atherosclerosis of Native Coronary Arteries and Bilateral Amputee. Review of a Quarterly MDS assessment with an ARD of 07/25/2023 revealed Resident #47 had a BIMS score of 15 indicating intact cognition. Review of August 2023 Physician orders revealed Resident #47 was on a regular no added salt, no red meats and no fried foods diet. Review of Resident #47's dietary card revealed a regular no added salt diet with dislikes of: cream corn, pork roast, mashed potatoes, pork ham, pork chop, pulled pork, cheese, scallop potatoes and smothered potatoes. Interview on 08/21/2023 at 9:39 a.m. with Resident #47 revealed he received foods he did not like or want on his tray at meal times. Resident #47 stated he had talked to the dietary staff several times about receiving foods he did not like on his tray, and it had not helped. Observation and interview on 08/21/2023 at 11:25 a.m. of Resident #47's lunch tray revealed he had mashed potatoes on his tray. Resident #47's dietary card revealed mashed potatoes was listed under dislikes for the resident. Resident #47 confirmed he did not like or want the mashed potatoes on his tray and he had informed dietary of this several times. Interview on 08/22/2023 at 11:18 a.m. with Resident #47 stated he recently received a pork chop on his tray and ate some of it because he thought it was turkey. Resident #47 stated he disliked pork because it made him feel dizzy. Interview on 08/24/2023 at 8:55 a.m. with Resident #47 revealed approximately 2 weeks ago he went to the kitchen to speak with S3 Dietary Manager regarding his food preferences and S3 Dietary Manger informed Resident #47 she was dumping trays and did not have time to talk to him. Interview on 08/24/2023 at 9:00 a.m. with S3 Dietary Manager stated Resident #47 did not like pork and should not get it on his tray. S3 Dietary Manager confirmed Resident #47 had gotten a barbecued pork chop on Sunday and he shouldn't have. S3 Dietary Manager confirmed Resident #47 should not have gotten mashed potatoes on his tray on 08/21/2023. S3 Dietary Manager confirmed Resident #47 came to speak with her approximately 2 weeks ago about his diet and she informed him she was busy dumping trays and didn't have time to talk to him.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 1 (Resident #81) of 1 resident sampled for misappropriation, in a total sample of 36 residents. The facility failed to prevent misappropriation of Resident #81's funds by S10 CNA. Findings: Review of the facility abuse policy revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. This policy applies to facility staff, other residents, family members or resident representatives, and anyone else present in our facility. 7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Review of Resident #81's clinical record revealed an admitted [DATE] with diagnoses that included Syringomyelia, Syringobulbia, Paraplegia, Neuromuscular Dysfunction of Bladder, and Pressure Ulcer of Left Buttock. Review of Resident #81's Quarterly MDS with ARD of 06/20/2023 revealed Resident #81 had a BIMS score of 15, indicating no cognitive impairment. Interview on 08/21/2023 at 10:18 a.m. with Resident #81 revealed a couple weeks ago Resident #81 had offered money to help S10 CNA out after S10 CNA told him she had fallen on hard times. Resident #81 stated S10 CNA declined to borrow the money. Resident #81 stated sometime after 2:00 p.m. he decided to check his account balance. Resident #81 stated after checking the last 4 withdrawals he noticed the last withdrawal was for $200.00 and had been transferred to a PayPal account. Resident #81 stated he reported the $200.00 transaction as fraud at that time and froze his card. Resident #8 stated a police report had been filed, and his son was notified. Interview on 08/23/2023 at 12:07 p.m. with S5 SSD revealed on 08/01/2023 Resident #81 called the nurses station to have the SSD go down to his room because his bank card was missing. S5 SSD stated she went to Resident #81's room, asked where the card was last seen, and searched Resident #81's room. S5 SSD stated Resident #81 told her I think that CNA (S10 CNA) took it, because she's the only one that's been in here, and because of the comment she made. S5 SSD stated she then went to S2 DON and S1 Administrator and reported the missing card. S5 SSD stated the police came to the facility and interviewed Resident #81. Interview on 08/23/2023 at 12:13 p.m. with S2 DON revealed on the evening of 08/01/2023, S5 SSD notified her that Resident #81's debit card was missing. S2 DON stated she interviewed Resident #81, and Resident #81 stated he had offered S10 CNA a loan because her ID and debit card were missing from her wallet. S2 DON stated she called S10 CNA and asked her about interactions between herself and Resident #81. S2 DON stated S10 CNA told her Resident #81 had offered to loan her money but she turned him down. S2 DON stated S10 CNA denied taking Resident #81's debit card. S2 DON stated she informed S10 CNA she was being suspended until the facility's investigation was complete. Interview on 08/23/2023 at 12:23 p.m. with S1 Administrator revealed on 08/08/2023 he contacted Resident #81's bank and spoke to a Liaison. S1 Administrator stated at that time he was informed by the bank liaison that $200.00 had been transferred from Resident #81's account to a CashApp account owned by S10 CNA. S1 Administrator stated S10 CNA was then terminated.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #46 and Resident #211) of 2 residents reviewed for respiratory care. The facility failed to: 1. Provide humidification in accordance to the resident person centered plan of care 2. Ensure respiratory equipment was properly stored Findings: Resident #46 Review of Resident #46's medical records revealed a diagnoses of Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety Disorder. Review of Resident #46's care plan with a review date of 09/27/2023 revealed Resident# 46 required oxygen therapy due to Chronic Obstructive Pulmonary Disease with facility interventions to provide humidification to oxygen therapy. An interview on 08/21/2023 at 11:30 a.m. with Resident #46 revealed she requested the facility add humidification to her oxygen concentrator multiple times because her nose became dry and irritated with oxygen usage without humidification. Resident #46 stated someone notified her (unsure of who) that the reason the facility could not add humidification to her oxygen was because they were unable to obtain distilled water. Observation on 08/22/2023 at 9:11 a.m. revealed Resident #46's humidification bottle for her oxygen concentrator was empty and her oxygen tubing was not attached. Resident #46 stated her nose was very dry and swollen. Resident #46 stated she had ask for her oxygen to be humidified several times but no one had been able to help. An interview on 08/23/2023 at 10:25 a.m. with S4 LPN confirmed Resident #46 did not have humidification connected to her oxygen concentrator and confirmed that she was care planned for humidification and it should have been applied. 44844 Resident #211 Facility's Policy on Nebulizer Machine Cleaning read in part .Procedure: (2) Store tubing, mouthpiece, and mask in plastic bag when not in use. Review of Resident #211's medical record revealed a diagnoses of Chronic Pulmonary Edema and Pneumonia. Resident #211 received Ipratropium BR 0.02% solution and Levalbuterol 1.25 MG/3ML solution one vial per nebulizer every 6 hours (breathing treatment). Observation and interview on 08/21/2023 at 10:14 a.m. revealed a nebulizer mask lying on Resident #211's bedside table uncovered with a brown hard substance on it. Resident #211 stated she used the nebulizer every day. Observation on 08/22/2023 at 9:10 a.m. revealed a nebulizer mask lying on Resident #211's bedside table uncovered. Observation and interview on 08/22/2023 at 9:14 a.m. accompanied by S2 DON revealed Resident #211's nebulizer mask lying on her bedside table uncovered. S2 DON confirmed Resident #211's nebulizer mask should have been in a plastic bag and it was not.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 113 Residents who receive meals prepared by the facility kitchen. Findings: Review of the facility's policy titled: Standardized Recipes read in part . Standardized recipes are used in preparation of food for control of quality, quantity, and uniformity of product. 2. A standardized recipe includes the following information: Yield and portion size. Review of the facility's policy titled: Portion Control read in part . Menus shall reflect standardized portion sizes to ensure nutritional adequacy of the diets, control production, and enhance food cost control efforts. 1. The established portion sizes for specific menu items are listed on the posted menu modification. 3. Employees are expected to follow established portions size for all menu items unless otherwise altered for nutrition care purposes or resident request. Review of the facility's approved 2023 Spring/Summer Menus revealed the facility was on week 3, day 2. Lunch menu consisted of: BBQ Pork Chop- 4oz, Homemade Potato Salad- 1/2 cup, Southern Style Green Beans (Substituted with Lima Beans)- 1/2 cup, French Bread- 1 each, Lemon Mousse-1 each, Beverage Choice and Water. Observation and interview on 08/21/2023 at 10:45 a.m. revealed the dietary workers in the kitchen began serving resident's lunch trays. S8 Dietary prepared a resident's lunch tray by placing a pork chop and a 4oz scoop of lima beans on the plate, she then passed the plate down the line to S9 Dietary who placed potato salad and a dessert on tray. Surveyor asked S3 Dietary Manager if the prepared tray was the complete serving size. S3 Dietary Manager confirmed the tray was completely prepared, and the worker was to place the tray on meal cart to be served to a Resident. Surveyor requested S3 Dietary Manager weigh the pork chop that was observed on the prepared tray. Observation and interview on 08/21/2023 at 10:48 a.m. revealed S3 Dietary Manager carried the pork chop to the kitchen's scale. S3 Dietary Manager weighed the pork chop, and the scale read 1.9 oz. S3 Dietary Manager confirmed the portion size served on this tray was not adequate to meet the minimum required portion size of 4 ounces, and the staff should have served 2 pork chops to meet the requirement. Telephone interview on 08/23/2023 at 2:25 p.m. with S7 Registered Dietician revealed she reviewed and signed off on all menus the facility utilized, which included portion sizes. S7 Registered Dietician stated S3 Dietary Manager informed her of the surveyor findings on 08/21/2023 and she had begun preparing an in-service to ensure proper serving sizes are served to residents. S7 Registered Dietician stated a typical daily requirement for protein would consist of; 1oz served for breakfast, 3 oz. served for lunch, and 2 oz. served for supper. S7 Registered Dietician stated the facility needed to update their menu's to reflect this. S7 Registered Dietician confirmed the 1.9 oz. of protein observed as prepared for a Resident on 08/21/2023 was insufficient and the weight needed to be closer to 3oz to meet requirement.

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. This deficient practice had the potential to affect the 113 residents that received meals prepared by the kitchen. Findings: Review of the facility's policy titled: Cleaning and Sanitizing Equipment read in part . All equipment is kept clean and food contact surfaces are cleaned and sanitized. Observation of the facility's kitchen on [DATE] at 8:25 a.m. accompanied by S3 Dietary Manager revealed: The kitchen's microwave was unsanitary with dried food splattered on the top and bottom. The dry food storage area contained 1 carton of thickened cranberry juice that had an expiration date of [DATE] on the shelf for use. Interview with S3 Dietary Manager on [DATE] at 8:35 a.m. confirmed the above findings. S3 Dietary Manager stated the microwave needed to be cleaned, and the shelf should not contain any expired items.

Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #19) of 36 sampled residents by failing to ensure she was free of facial hair. Findings: Review of Resident #19's medical records revealed she was admitted to the facility on [DATE] with diagnoses which included: Hyperlipidemia, Unspecified Mood disorder, Athsclerotic Heart Disease, Type 2 Diabetes Mellitus, Essential Hypertension, Unspecified Dementia, Alzheimer's disease and Anxiety Disorder. Review of Resident #19's Quarterly MDS with an ARD of 05/19/2023 revealed a BIMS score of 14 (indicating intact cognition). Resident #19 required physical assistance with 1-person physical assist for bed mobility, personal hygiene, bathing and toilet use. An interview and Observation on 08/21/2023 at 10:52 a.m. revealed Resident #19 sitting in dining room waiting for lunch with long facial hair on her chin and lip. Interview with Resident #19 revealed that she would like for her face to be shaved. An Observation and interview on 08/22/2023 at 11:21 a.m. with Resident #19 revealed her sitting in her wheelchair in the dining room with long facial hair on her chin and lip. Resident #19 revealed staff had not come to shave her and stated if I can find a razor I'll do it myself. An Interview with S4 LPN confirmed the long facial hair on Resident #19's chin and lip and that Resident #19 would like for it to be removed and it had not been done.

Based on observation, interview and record review, the Facility failed to ensure that Residents meals were distributed in a timely manner. This deficient practice had the potential to effect all Residents that are served meals in the dining room. Findings: A review of the Facility's Frequency of Meal policy read in part . 1. Meal service times for the Residents are as follows: a. Breakfast 7:15 a.m. b. Lunch 11:30 a.m. c. Dinner 5:15 p.m. An Interview on 04/03/2023 at 7:38 a.m. with Resident #3 revealed he was sitting in dining room awaiting breakfast. Resident #3 stated that he typically eats most meals in the dining room and at times has to wait for long periods of time to receive meals. Resident #3 stated that breakfast is typically the meal that he has to wait for longer times and that he often gets hungry while waiting. Staff interview on 04/03/2023 at 07:13 a.m. with S4 Dietary Staff revealed that breakfast meal trays are to begin being plated at 6:45 a.m. but were not because the eggs were not taken out of the freezer to defrost the night before. A breakfast observation in the dining room on 04/03/2023 revealed the first breakfast tray was served at 8:02 a.m. Interview on 4/03/2023 at 4:00 p.m. with S3 Dietary Manager confirmed that breakfast should have been served by the dietary staff in the dining room by 7:15 a.m. and was not served until 8:02 a.m.

Based on interviews and record review the Facility failed to ensure their grievance policy and procedure was followed for 2 Residents (Resident #1 and Resident #3) out of 5 sampled Residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) by failing to ensure prompt resolution of an allegation of missing property for Resident #1 and by failing to initiate a grievance for Resident #3. Findings: Resident #1 Review of the Facility's Grievance Policy and Procedure revealed in part . Policy: The Resident has the right to and the facility must make prompt efforts to resolve grievances. The facility grievance official/compliance liaison is the Administrator. Procedure: Follow-up/Resolution: The grievance official/compliance liaison or designee will follow-up with the complainant with a resolution within 5 business days of the date that the grievance was filed. NOTE: Depending on the nature of the grievance, establishing a resolution may take longer than 5 business days. In such cases: A. The grievance official/compliance liaison or designee shall update the complainant on the status of the investigation. Documentation: Document grievances made by a Resident, Resident family member, a visitor, volunteer, individual employee on the official Grievance form. Review of Resident #1's clinical record revealed an admitted [DATE] with diagnoses which included: Alzheimer's Disease, Dysphagia, Other Cerebral Infarction, Urinary Tract Infection and Pain, Unspecified. Review of Resident #1's SM5 MDS with an ARD of 02/16/2023 revealed Resident #1 had a BIMS score of 5 (indicating severe cognitive impairment). Resident #1's MDS revealed he required extensive assistance with 2 person physical assist with bed mobility, transfers and toilet use; extensive assistance of 1 person with dressing, personal hygiene and bathing and limited assistance of 1 person with eating. Review of the Facility's grievance log revealed Resident #1's responsible party filed a grievance on 03/09/2023 revealed in part . Resident #1 (son) reported his dad is missing 2 sweat suits. Telephone interview on 04/03/2023 at 10:23 with Resident #1's responsible party revealed Resident #1 had 2 sweat suits missing. Responsible party stated Resident #1 had been moved from one room to another room and during transport Resident #1's sweat suits came up missing. Responsible party revealed he and his brother washed Resident #1's clothes at home. Telephone interview on 04/03/2023 at 10:36 a.m. with second contact (Resident #1's son) revealed Resident #1 has had missing clothes in the past and that is the reason the family is washing his clothes now. Resident #1's son stated his dad changed rooms and his clothes came up missing when he moved. Resident #1's son revealed he reported the missing items to social services and to the laundry supervisor. Resident #1's son revealed the facility told him last week (the day of his care plan meeting dated 03/29/2023) they would reimburse him for the sweat suits after he provided the facility with a receipt. Resident #1's son stated the facility had not updated him on the grievance until 03/29/2023. Interview on 04/03/2023 at 11:50 a.m. with S1 Administrator revealed he was the grievance official. S1 Administrator stated he was aware of the grievance filed on 03/09/2023 in reference to 2 missing sweat suits for Resident #1. S1 Administrator stated Resident #1 had different family members washing his clothes and the facility was unable to verify if the 2 missing sweat suits were missing at the facility. S1 Administrator stated it was decided on 03/29/2023 during Resident #1's care plan meeting that the facility would reimburse Resident #1's son for the 2 missing sweat suits. S1 Administrator confirmed the grievance filed on 03/09/2023 with a resolution date on 03/29/2023. S1 Administrator confirmed this was not a prompt investigation and resolution to the allegation of missing property and he should have updated the complainant after 5 days of no resolution to the grievance. 46773 Resident #3 Review of Resident #3's clinical record revealed an admitted [DATE] with diagnoses which included: Generalized Osteoarthritis, Chronic Kidney disease, Heart Failure, Anxiety Disorder, Unspecified Dementia, Diabetes Mellitus, and Essential Hypertension. Review of Resident #3's MDS with an ARD of 03/12/2023 revealed a BIMS score of 15 (indicating cognitively intact). Resident #3's MDS revealed he required extensive assistance with 1-person physical assist with bed mobility, transfers, toilet use, dressing, personal hygiene and bathing. An interview on 4/03/2023 at 2:45 p.m. with Resident #3 revealed that he had been missing two blankets for a few months. Resident #3 stated that he had notified different staff members about the missing blankets but the facility had failed to find them or replace the missing items. Review of Resident Council Meeting minutes dated 02/06/2023 read in part: Resident #3 stated he had a few blankets missing. Review of Resident Council Meeting minutes dated 03/06/2023 read in part: Resident #3 stated he is still missing a few blankets. An interview on 04/03/2023 at 4:00 p.m. with S1 Administrator revealed that a grievance for Resident #3's missing blankets had not been initiated because he was unaware that the items were missing. S1 Administrator revealed that he is given the resident council minutes monthly and had received the minutes for February and March. S1 Administrator confirmed that a grievance for Resident #3's missing items was not initiated in a timely manner and it should have been.

Based on observation, interview and record review the Facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The Facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 105 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facilities approved menu revealed the facility is on cycle day 16. Lunch menu included: fried chicken -4oz, au gratin potato- 1/2 cup, veggie blend -1/2 cup, dinner roll -1 each, frosted cupcake-1 each, beverage choice. An observation and interview on 04/03/2023 at 10:50 a.m. revealed Resident #4's lunch tray being served. Resident #4 opened the tray and revealed a piece of fried chicken thigh, pasta salad, slice of wheat bread, carton of milk and a chocolate cupcake. At the time of observation Resident #4 stated the serving size of the chicken appeared small and requested it to be measured. An observation and interview on 04/03/2023 at 11:05 a.m. revealed S1Administrator carrying Resident #4's tray back into the kitchen and stated the chicken ordered from Sysco is premeasured and that 1 piece of chicken is given to each resident. An observation on 04/03/2023 at 11:11 am with S3 Dietary Manager revealed that all chicken was not measured prior to being cooked and the piece of chicken served to Resident #4 weighed 2.5oz. S3 Dietary Manager confirmed that the portion size given to Resident #4 is not adequate to the minimum required portion of 4oz.

Based on observation, interview and record review, the facility failed to use a mechanical lift and two person physical assistance during a transfer from the wheelchair to bed, as specified in the resident's person centered comprehensive plan of care, for 1(#96) of 4 sampled residents reviewed for accidents (#10, #76, #71 and #96), out of total sample of 33. This failed practice resulted in an actual harm situation on 07/18/2022 at 6:00 p.m., when Resident #96, who required a mechanical lift and two-person physical assistance for transfers, was transferred from the wheelchair to bed by S4CNA without using the mechanical lift and assistance of another staff member. Resident #96 hit her left lower leg on her wheelchair during the transfer, causing a laceration that measured 30cm in length. Resident #96 was transferred to theER on [DATE] at 6:30 p.m., and received 32 sutures to her left lower leg. Findings: Review of the facility's Transferring a Resident Policy and Procedure revealed in part .: Purpose: To provide the most effective means of moving a resident with diminished lower body sensation, weakness, immobility or injury. Policy: Residents will be transferred as safely as possible. Mechanical Lift Transfer procedure revealed in part .2. Consult with nurse for resident specific approaches as appropriate. Review of Resident #96's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], Type 2 Diabetes Mellitus with polyneuropathy, [CONDITION(S)], Muscle weakness, Lack of Coordination, Dementia, Depression, and Cognitive Communication Deficit. Review of Resident #96's Quarterly MDS with an ARD date of 07/05/2022 revealed a BIMS Summary score of 3 (which indicated severe cognitive impairment). Review of Resident #96's Functional Status revealed she required extensive physical assistance of two persons for bed mobility, and total dependence with two person physical assistance for transfers. Review of Resident #96's Person Centered Comprehensive Plan of Care revealed a problem of: Resident #96 required staff assistance x 1-2 with cueing, supervision and setup for ADL's and mobility related to her diagnoses of [CONDITION(S)], Dementia, Depression, Anxiety, Shortness of Breath and Impaired Cognition. Resident #96 was non-ambulatory. Interventions included: Resident #96 required a mechanical lift with transfers by two staff. Observation on 08/07/2022 at 9:30 a.m. revealed Resident #96 seated in a wheelchair beside her bed. She was wearing heel protectors. Her wheelchair had foam padding on the legs. There was a 4x4 gauze dressing noted to the outer part of her lower left leg dated 08/05/2022. There was also a clear dressing on her leg directly beneath the 4x4 gauze dressing. Interview of Resident #96 at that time revealed she did not remember how she injured her left leg. Review of Resident #96's Nurse's Note dated 07/18/2022 at 6:27 p.m., read as follows: S3LPN was summoned to Resident #96's room by S4CNA. Resident #96 was lying in bed with a laceration to the left shin. S4CNA stated Resident #96 hit her leg on her wheelchair during transfer. There was a small amount of blood noted. Resident #96 performed active range of motion within normal limits. Pain level was reported as 0/10. Doctor and RP notified. New order to transfer Resident #96 to hospital for evaluation and treatment. Review of Resident #96's Nurse's Note dated 07/19/2022 at 1:56 a.m. revealed the following: Resident #96 returned from the emergency room at 1:32 a.m. via stretcher for laceration of left lower leg. Resident #96 is alert and oriented. Resident #96 received 32 sutures to area per report taken from hospital. Resident #96 currently has a dressing to her left leg. Discharge orders are to clean the area with soap and water, and apply antibiotic ointment daily, and as needed. Remove sutures in 14 days. Telephone interview with S4CNA on 08/09/2022 at 2:35 a.m. revealed she was working the 2 p.m. to 10 p.m. shift on 07/18/2022 when the incident happened. S4CNA stated this was not her usual shift and this was not her usual hall. S4CNA stated Resident #96 was seated in her wheelchair beside her bed, and asked to be put to bed. S4CNA stated she transferred the resident to the bed by herself, and without using the mechanical lift. S4CNA stated she was aware that she can ask the staff nurse anything regarding a resident's plan of care including how residents are to be transferred. S4CNA stated she asked S3LPN how to transfer Resident #96 and was told to just pick her up. S4CNA stated when Resident #96 was back in bed, she noticed a small amount of blood on the leg of her pants, and immediately called the nurse. Interview with S10LPN on 08/09/2022 at 12:15 p.m. revealed she was the LPN staff nurse assigned to Resident #96 on 07/18/2022 on the 7:00 a.m. to 3:00 p.m. shift. S10LPN stated when she got off work at 3:00 p.m., Resident #96 was seated in her wheelchair beside her bed. S10LPN stated she saw the CNAs use the mechanical lift to transfer the resident to her wheelchair after lunch on 07/18/2022. She stated Resident #96 did not have an injury to her leg while she was on duty. S10LPN stated CNAs who are unsure of how to transfer a resident can refer to the CNA schedule binder, the kiosk, or ask the staff nurse. Interview with S3LPN on 08/09/2022 at 12:27 p.m. revealed she was the staff nurse on the 3:00 p.m. to 10:00 p.m. shift on 07/18/2022. S3LPN stated she was passing medication when S4CNA called her to Resident #96's room. Resident #96 was lying in bed when she arrived to the room, and there was a spot of blood on the left leg of Resident #96's pants. S3LPN stated when she pulled the residents pants off, she discovered a laceration. S3LPN stated she called the doctor and the RP, and then transferred Resident #96 to the emergency room for evaluation and treatment. S3LPN stated S4CNA did not ask her how Resident #96 was to be transferred from the chair to bed prior to the transfer. Interview with S2DON on 08/09/2022 at 3:30 p.m. revealed the CNAs are provided three resources to assist them with their duties: CNAs have access to the kiosk which provides information from resident's individual plan of care; the staff nurse has the information from the residents' care plan on their computer, and they are available to answer the CNAs questions regarding resident care; and the third resource is the schedule located at the nurse's station. Review of the schedule revealed a list of all residents in the facility who are to be transferred by two staff using a mechanical lift. S2DON stated S4CNA should have known how Resident #96 was supposed to be transferred, and she should not have transferred the resident without staff assistance, and without the mechanical lift.

Based on observation and interview, the facility failed to ensure garbage was disposed of properly. The total facility census was 105 residents. Findings: Observation on 08/07/2022 at 09:15 a.m. upon exiting the facility's kitchen accompanied by S6 Dietary Cook revealed three tied white trash bags, one tied black trash bag, an opened fast food bag labeled with contents scattered and multiple cigarettes butts scattered on the ground. Observation on 08/07/2022 at 09:15 a.m. of the facility's trash receptacles accompanied by S6 Dietary Cook revealed two large dumpsters partially enclosed in a wooden fenced in area. The lid to both dumpsters were open. There were multiple used dirty gloves and debris on the ground surrounded around both dumpsters. Interview with S6 Dietary Cook at the time of the observation confirmed the dumpster lids were open with dirty gloves and debris on the ground surrounding the dumpsters. S6 Dietary Cook further confirmed there were several tied trash bags, an opened fast food bag with contents scattered and multiple cigarette butts scattered on the ground. S6 Dietary Cook further confirmed the tied trash bags should have been placed in the dumpsters with the lids closed and was not done. Interview on 08/07/22 at 09:30 a.m. with S5 DM confirmed both of the dumpster lids were open and should have been closed. S5 DM further confirmed the trash bags should have been placed in the dumpsters with the lids closed but had not been done. Observation on 08/08/22 at 8:13 a.m. of the facility's trash receptacles accompanied by S5 DM revealed the lids to both dumpsters remained open with a trash bag overflowing off of the side of the dumpster closest to the kitchen door. Interview with S5 DM at the time of the observation confirmed that both of the dumpsters remained open and the dumpster closest to the kitchen was overflowing with a trash bag and should not have been. Interview on 08/10/2022 at 12:30 p.m. with S1 ADM revealed he had the lids to the dumpsters replaced yesterday due to them being damaged. He further revealed he was aware the lids to the dumpsters had been open and should not have been. Review of the facility's Waste Disposal policy revised 10/2018 in part revealed: Garbage containers are to be removed from the food preparation area before garbage containers are overfilled and are cleaned inside and outside daily. Outside storage areas are to be located away from the food production and storage areas, kept covered at all times, located on a nonabsorbent surface and kept clean of garbage and debris.

Based on observation, record review and interview, the facility failed to maintain infection control practices to prevent and control the spread of COVID - 19. The facility failed to discontinue indoor church services during a facility outbreak, and failed to ensure a delivery driver was screened before entering the facility, and wore a mask while onsite. This had the potential to affect all 110 residents in the facility. Findings: Interview with S1 Administrator on 08/25/2021 at 8:45 a.m. revealed he stated the facility did have residents who tested positive for COVID-19 residing on the facility's COVID-19 designated unit. He stated the facility also had staff who tested positive for COVID-19 and were currently off work on quarantine. S1 Administrator stated the facility was conducting outbreak testing twice a week. S1 Administrator provided a list of staff who tested positive for COVID-19 since July 1, 2021. Review of the list revealed there was a total of 10 staff on the list, and 2 of the staff remained out on quarantine. Interview with S2 DON on 08/25/2021 at 9:35 a.m. revealed she stated the facility was currently conducting outbreak testing. She stated they had two residents who tested positive for COVID-19 and were in the facility's COVID-19 designated unit. Review of a list provided by the facility revealed since July 1, 2021, they had three residents test positive for COVID-19 and one resident admitted with COVID-19 from another facility. Currently, two residents were residing on the COVID-19 unit and one was in the hospital. Observation in the kitchen area on 08/25/2021 at 10:40 a.m. revealed an unidentified male entered the back door of the kitchen pushing a [NAME] loaded with several boxes. He was not wearing a mask, and he pushed the [NAME] into a storage area in the kitchen. Interview at that time with Dietary Aides, #S3 and #S4, revealed they stated the male was a food delivery person. The delivery personnel then exited the storage area of the kitchen with the empty [NAME], walked through the kitchen area and exited out of the back door. Interview with #S3 Dietary Aide at 10:42 a.m. revealed she stated the delivery personnel was delivering food products, and she confirmed he was not wearing a mask. Interview revealed #S3 Dietary Aide was asked if the delivery personnel should be wearing a mask, and she stated she was not sure. She stated the facility came off of lock down about two weeks ago, and that was when they started allowing delivery personnel to enter the kitchen area. She stated before that, delivery personnel would leave the boxes outside and facility staff would bring them in the kitchen. Interview with #S3 Dietary Aide revealed they did not screen the delivery personnel before he entered the facility. Interview with S2 DON on 08/25/2021 at 10:45 a.m. revealed she stated everyone who entered the building should be screened and should be wearing a mask. She was not aware that delivery personnel were entering the kitchen area without a mask. She stated the Dietary Manager was out, and #S3 Dietary Aide was acting in her place. Further interview with S2 DON on 08/25/2021 at 11:15 a.m. revealed she provided a form titled In-service Log Form dated 08/25/2021, which she stated, was the facility's procedure for delivery drivers and vendors. The form revealed anyone entering the facility must enter through the main entrance and be screened. This includes vendors and delivery drivers. No delivery drivers are allowed to enter the facility. The delivery must be left outside and maintenance department will transport the delivery into the facility. Everyone in the facility must wear a face covering (KN95) at all times. On 08/26/2021 at 9:50 a.m., the facility announced overhead that there would be members from a local church who were coming in to conduct a church service in the activity room at 10:00 a.m. Interview with S2 DON on 08/26/2021 at 10:10 a.m. revealed she stated, to her knowledge, there were no outside visitors from local churches coming in the facility to hold church services. She stated there was a resident in the facility who would had been conducting some church services for the other residents. When asked about the announcement of visitors coming in today for church service, she stated she would check with the Administrator. Observation on 08/26/2021 at 10:15 a.m. revealed there were about 30 residents in the activity room for church service. All residents except three were wearing masks properly; however, there was not enough room for all residents to social distance. There was a male in front of the room, wearing a mask, who was talking to the residents, and there was a female who was seated at the piano and also wearing a mask. Interview with #S5 Unit Coordinator on 08/26/2021 at 10:20 a.m. revealed she stated she screened three members from a local church into the facility at 10:00 a.m. Review of the visitor log at that time revealed three visitor names were logged and documentation revealed they were from a local church. Review of the Visitor screening logs from August 2021 revealed church services were held by members from local churches in the facility's activity room on 08/05, 08/09, 08/12, 08/19, 08/20, 08/23, and 08/26/2021. Interview with S2 DON at 10:25 a.m. stated she spoke with the Administrator, and he stated he had been allowing staff from local churches to come into the facility and provide residents with church services. She stated he said he was allowing this visitation under the compassionate care section of the visitation guidelines. Interview with S6 Activity Director on 08/26/2021 at 12:05 p.m., revealed she stated they have been having church services with staff from outside churches coming into the facility since March 2021. She provided a form titled Activity Attendance which revealed a list of residents who attended the church service on 08/26/21. Documentation on the form revealed educated residents to wear mask all during service and to social distance. Additional documentation revealed the activity was Compassionate Care Services. There was a total of 31 residents' names listed on the form with 5 residents' names listed under a section titled refused to wear mask. Further interview with S6 Activity Director on 08/26/2021 at 12:05 p.m. revealed she stated there was not enough room for all the residents to be placed 6 feet apart from one another. She stated if any of the residents had a runny nose or cough, she placed them in the front or the back near the door so they would have easier access to exit the activity room if needed. Interview with S1 Administrator on 08/26/2021 at 1:00 p.m. revealed he confirmed he was allowing outside visitors to come into the facility and conduct church services even though the facility had positive cases of COVID-19 with staff and residents and the facility was conducting outbreak testing. S1 Administrator also stated the parish positivity rate was 10.1%. He stated he allowed the church services to be conducted by local church members due to the residents' request for church services, and he felt it was a form of compassionate care visitation under the visitation guidelines.

Based on record review, interview, and review of the facility's policy and procedure, the facility failed to ensure residents' environment remained as free of accident hazards as was possible. The facility failed to ensure a resident who was at high risk for fall and had a history of [REDACTED].#4). There was a total facility census of 96 according to the facility's Census and Condition of Residents. The facility failed to: 1. accurately assess a resident's fall risk (#4); 2. put interventions/approaches into place to prevent the resident from falling (#4); 3. monitor interventions/approaches to ensure they were being utilized (#4); and 4. reassess the interventions/approaches to ensure they were appropriate (#4). Resident #4 had a history of [REDACTED]. The physician ordered a low bed with fall mats in June, 2010. The resident was care planned for fall risk, low bed, floor mat and bed alarm. On 9/13/12 the resident was found sitting on the floor and appeared to have slid off her bed. On 9/15/12 the staff were called to the room, and the resident was found lying on her fall mat in the fetal position with her bed in the low position. The resident did not complain of pain or discomfort from the fall but stated that she had rolled out of bed. Documentation and staff interview did not reveal use of a bed alarm when the resident was found on the floor. On 12/14/12 the resident was found on the floor in front of her wheelchair, and stated that she had hit the back of her head on the floor. She had a skin tear noted to her left forearm and she was transported to the hospital by ambulance for evaluation and returned to the facility. Review of the facility's fall policy for high risk residents reflected various devices were suggested for use (wheelchair alarm, seat belt alarm, half rails, low bed with fall mat, scoop mattress, wedge cushion, positioning pillows (Bolsters) and equipment such as pommel cushions, self-releasing seat-belts, anti-tippers, lap buddys, lap trays etc.). Following resident #4's falls in September and December 2012, the facility did not conduct an assessment to determine the cause of the falls and put interventions into place. There were no interventions put into place in addition to the low bed, fall mat and bed alarm to prevent the resident from falling out of her bed and/or wheelchair. On 3/17/13 at 4:20 a.m. the resident's roommate called the nurses' station, and stated resident #4 was on the floor. When the nurse entered the room, the resident was lying on her right side, alongside the bed. The resident was alert, and staff did not move the resident until EMS arrived due to the amount of blood noted on the floor and coming from resident's head. As a result of the facility's lack of assessment and intervention, resident #4 experienced actual harm when she fell from her bed on 3/17/13 and sustained an avulsed laceration to her forehead that required surgical intervention. She also sustained a skin tear, hematoma to the right side of her forehead and swelling and bruising to her right hand. Findings: 1. Review of resident #4's closed record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's medical record and E Chart revealed she had a fall on 3/17/13, was transferred to the hospital and she did not return to the facility. Interview with S5CNA on 3/27/13 at 11:03 a.m. who was a long-term employee and cared for the resident several days per week, revealed the resident was unable to get out of bed on her own and her mode of ambulation was with a wheelchair. She stated she had to assist the resident into the wheelchair and into the bed from the wheelchair daily. She did acknowledge the resident had some symptoms of dementia. Further interview with S5 CNA on 3/27/13 at 11:03 a.m. revealed the resident was in an electric bed that was in it's lowest position and she usually had a fall mat in front of her bed. She stated that she had no other devices and did not use side rails on her bed. She denied the use of a bed or chair alarm but stated the resident had used one in the past; however, she had not used one in a long time. Review of the resident's current physician's orders [REDACTED]. Review of resident #4's departmental notes in her E chart revealed she had a fall on 9/13/12 at 7:24 a.m. in which she was found sitting on the floor and appeared to have slid off her bed. Documentation reflected the resident was unable to recall what happened and there were no injuries according to the notes. Review of the resident's departmental notes in her E chart dated 9/15/12 at 1:16 a.m. revealed staff were called to the room by a CNA. Documentation reflected the resident was found lying on her fall mat in the fetal position and her electric bed was in the low position. Documentation further reflected the resident did not complain of pain or discomfort from the fall but stated that she had rolled out of bed. She denied hitting her head during the fall and refused to be sent to the hospital for an evaluation. Review of the resident's care plan dated 9/12 revealed a problem of at risk for falls and a goal date of 10/12/12. It revealed the resident was to have a low bed with a floor mat and a bed alarm. Review of resident #4's MDS dated [DATE] revealed a Fall Risk Assessment had been completed and revealed the resident had no falls in the past 3 months; however, the resident had documented falls on 9/13/12 and 9/15/12 which had not been noted on the assessment. The resident was still considered a high risk for falls. Further review of documentation in the departmental notes on 9/13/12 and 9/15/12 revealed no mention of the use of a bed alarm or that it had been alarming when the resident was found on the floor. Interview with the S3 MDS Nurse on 3/27/13 at 9:50 a.m. also confirmed she could not find any documentation to reflect the resident had ever had a bed alarm placed on her bed. Further review of the departmental notes in resident #4's E Chart dated 12/14/12 at 3:34 p.m. revealed staff were called to the resident's room by her roommate. Documentation reflected she was found on the floor in front of her wheelchair and stated that she had hit the back of her head on the floor. She had a skin tear noted to her left forearm and she was transported to the hospital by ambulance for evaluation. Further review of the record revealed a scan of her brain revealed negative results, and she was transferred back to the facility. Review of Therapy Screening Form date 12/17/12 revealed PT, OT, and ST were not indicated at this time due to no recent changes. Further review following the resident's fall on 12/14/12 in the departmental notes revealed no documentation to reflect any new interventions had been introduced to prevent further falls for the resident. Review of notes provided by S2 DON on 3/28/13 regarding interventions done by the facility revealed documentation in the High Risk Meeting Minutes dated 12/21/12, the resident was to have a chair alarm as a new intervention, and on 12/28/12 the form indicated the intervention had been effective; however, there was no documentation in any of the departmental notes to reflect the resident had a chair alarm on her wheelchair and no documentation to reflect the device had been monitored to ensure it was actually being used for the resident. Further review of departmental notes dated 3/17/13 at 4:20 a.m. revealed the resident's roommate called the nurses' station, and stated resident #4 was on the floor. S4 LPN noted upon entry to the room, the resident was lying on her right side, alongside the bed with her head towards the head of the bed and her feet toward the foot of the bed. The notes further stated the resident was alert but she did not want to move the resident until EMS arrived due to the amount of blood noted on the floor coming from resident's head. The notes continued and at 4:30 a.m. an entry that EMTs had arrived and the resident was noted to have a skin tear and hematoma to the right side of her forehead. Her right hand was swollen and had discoloration. The resident was placed on a stretcher and a cervical collar was applied per the EMTs. In an interview with resident #R1 on 3/27/13 at 8:30 a.m. it revealed she was resident #4's roommate at the time of the fall on 3/27/13. She stated she found the resident on the floor when she got up to go to the bathroom that morning. She stated that the bathroom light was on and she saw she saw her on the floor and called for help. She further stated that her roommate was lying on the floor and she did not recall a fall mat being on the floor that day. In a telephone interview with S4 LPN on 3/27/13 at 8:35 a.m. she revealed that she was the one who responded to the room when summoned by the resident's roommate on 3/17/13. She documented the resident was found in the room, on the floor, and she also recalled that the resident was not on the fall mat when she was discovered. She added that the fall mat was in the room; however, she could not remember where it had been in relationship to the resident that morning. Review of the resident's hospital record obtained by the facility revealed the resident had a 10cm avulsed laceration to her forehead as a result of the fall and had surgery on 3/17/13 to repair the injury. Review of the resident's most current care plan with a goal date of 5/19/13 revealed a problem of at risk for falls. Review of her goals revealed she would not experience any injuries related to falls. Review of the interventions/approaches listed for the resident included to remind her to ask for assist for all ambulation, refer her for therapy evaluation as appropriate, monitor for changes in her condition that may warrant increased supervision/assistance, to refer her to restorative nursing program, use a wheelchair for mobility, and keep pathway in room free of clutter. Further review of the approaches revealed no other interventions even though the resident had a history of [REDACTED]. Review of resident #4's most recent MDS dated [DATE] revealed she remained at a high risk for falls. Review of the facility's Fall Prevention Program Policy and Procedure revealed if a resident triggered as high risk for falls they would have a care plan addressing goals and approaches. Review of the facility's Fall Protocol revealed under High Risk and (#4) revealed residents will be assessed for fall preventive devices as applicable. Review of suggested devices in the protocol revealed the following: wheelchair alarm, seat belt alarm, half rails, low bed with fall mat, scoop mattress, wedge cushion, positioning pillows (Bolsters) and equipment such as pommel cushions, self-releasing seat-belts, anti-tippers, lap buddys, lap trays etc. Interview with the DON on 3/27/13 at 8:50 a.m. revealed none of the suggested devices had been instituted for resident #4 to prevent her from falling out of the bed except a low bed with a fall mat, following the falls on 9/13/12 and 9/15/12. She also could not find any documentation to reflect when the resident's chair alarm had been discontinued. She also confirmed the resident had not been placed on a restorative program except for dining. Interview with the S1 Administrator on 3/28/13 at 8:20 a.m. revealed he and his staff did not think they needed to add any interventions/approaches for resident #4 because they believed her low bed and fall mat were enough to protect her from injury. They did not think they would be able to prevent the falls but thought her fall mat would be enough to prevent injury.

Based on record review and interview the facility failed to ensure it periodically conducted a comprehensive and accurate assessment of a resident who had experienced actual falls for 1 resident in a total sample of 8 residents investigated for falls (#4). There were a total of 96 residents residing in the facility according to the 802/Sample Roster Matrix provided by the facility. The facility failed to: 1. accurately assess a resident's fall risk; 2. put interventions/approaches into place to prevent the resident from falling; 3. monitor interventions/approaches to ensure they were being utilized; and 4. reassess the interventions/approaches to ensure they were appropriate. The lack of assessment resulted in actual harm for resident #4, when she fell from her bed on 3/17/13 and received a head injury with an avulsed laceration to her forehead requiring surgical intervention. Findings: Review of the facility's Fall Protocol under the heading Procedure revealed residents at high risk for falls would have their care plans updated. Under the sub Heading Equipment, the policy stated they would have a fall risk assessment, surveillance records if applicable, an investigation report and a care plan. Review of resident #4's record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of resident #4's E Chart and clinical record revealed she had a fall on 3/17/13, was sent to the hospital, and never returned to the facility. Interview with S5 CNA on 3/27/13 at 11:02 a.m. who was a long-term employee and cared for the resident several days per week, revealed the resident was unable to get out of bed on her own and her mode of ambulation was with a wheelchair. She stated she had to assist the resident into the wheelchair and into the bed from the wheelchair daily. She did acknowledge the resident had some symptoms of dementia. Further interview with S5 CNA 3/27/13 at 11:02 a.m. revealed the resident was in an electric bed, it was usually kept in it's lowest position, and she usually had a fall mat in front of her bed and no side rails. She further stated the resident never used her call light to ask for assistance, but added that she had worked with the resident a long time and anticipated her needs so that she didn't have a need for using it when she worked. She stated the resident had no other devices in use at the time she was discharged . She denied the use of a bed or chair alarm but stated the resident had used one in the past; however, it had been a long time ago. She did not recall when or why it had been discontinued. Review of the resident's current physician's orders [REDACTED]. Review of resident #4's departmental notes in her E Chart revealed she had a fall on 9/13/12 at 7:24 a.m. in which she was found sitting on the floor and appeared to have slid off her bed. The resident was unable to recall what happened and there were no injuries according to the notes. Review of the resident's departmental notes dated 9/15/12 at 1:16 a.m. revealed staff were called to the room by an unidentified CNA. Documentation revealed the resident was found lying on her fall mat in the fetal position and her electric bed was in the low position. The resident did not complain of pain or discomfort from the fall but stated that she had rolled out of bed. She denied hitting her head during the fall and refused to be sent to the hospital for an evaluation. Review of resident #4's MDS dated [DATE] revealed a Fall Risk Assessment had been completed and revealed the resident had no falls in the past 3 months; however, review of the resident's Incident Log confirmed the resident had falls on 9/13/12 and 9/15/12 which had not been noted on the MDS assessment. The resident was still considered a high risk for falls. In an interview with S3 MDS Nurse on 3/27/13 at 9:05 a.m. she confirmed the Fall Risk Assessment was incorrectly answered and confirmed the falls the resident had on 9/13/12 and 9/15/12 had not been included on the assessment and should have. Review of resident #4's care plan revealed a problem of at risk for falls and a goal date of 10/12/12. It revealed the resident was to have a low bed with a floor mat and a bed alarm. Review of documentation in the departmental notes on 9/13/12 and 9/15/12 revealed no mention of the use of a bed alarm or that it had been alarming when the resident was found on the floor. Further review of the departmental notes during 9/12, 10/12, and 11/12 revealed no documentation to reflect the facility was using a bed or chair alarm for the resident. Further review of resident #4's E Chart and medical record revealed no documentation to reflect an investigation of the resident's falls on 9/13/12 and 9/15/12 had been completed. Interview with S3 MDS Nurse on 3/27/13 at 9:50 a.m. also confirmed she could not find any documentation to reflect the resident had ever had a bed alarm placed on her bed after her falls on 9/13/12 and 9/15/12. Further review of the departmental notes dated 12/14/12 at 3:34 p.m. revealed staff were called to resident #4's room by her roommate (#R1). Resident #4 was found on the floor in front of her wheelchair. She stated that she had hit the back of her head on the floor. She had a skin tear noted to her left forearm and she was transported to the hospital by ambulance for evaluation. Further review of the record revealed a scan of her brain revealed negative results, and she returned to the facility. Review of resident #4's E Chart and medical record revealed no documentation to reflect an investigation of the resident's fall on 12/14/12 had been completed. Review of the departmental notes following the resident's fall on 12/14/12 revealed no documentation to reflect any new interventions had been tried after the resident fell . Review of notes provided by S2 DON on 3/28/13 regarding interventions done by the facility revealed documentation in their High Risk Meeting Minutes dated 12/21/12 that resident #4 was to have a chair alarm as a new intervention and on 12/28/12 the form indicated the intervention had been effective. However, there was no documentation in any of the departmental notes or clinical record to reflect the resident had a chair alarm on her wheelchair and no documentation to reflect the device had been monitored or surveillance initiated to ensure it was actually being used for the resident. Further review revealed no documentation of staff in-services related to the use of the new intervention. Review of departmental notes dated 3/17/13 at 4:20 a.m. revealed the resident's roommate (#R1) called the nurses' station, and stated resident #4 was on the floor. S4 LPN who responded to the call noted upon entry to the room the resident was lying on her right side, alongside the bed with her head towards the head of the bed and her feet toward the foot of the bed. The notes further stated the resident was alert but did not want to move the resident until EMS arrived due to the amount of blood noted on the floor coming from the resident's head. A 4:30 a.m. entry revealed EMTs had arrived and the resident was noted to have a skin tear and hematoma to the right side of her forehead. Her right hand was swollen and had discoloration. The resident was placed on a stretcher and a cervical collar was applied per the EMTs. In a telephone interview with S4 LPN on 3/27/13 at 8:35 a.m. she confirmed she was the staff who responded to resident #4's room when summoned by resident #4's roommate on the morning of 3/17/13. She documented resident #4 was found in the room, on the floor. Further interview with S4 LPN revealed that she also recalled the resident was not on the fall mat when she was discovered. She added that the fall mat was in the room somewhere; however, she could not remember where it had been in relationship to the resident that morning (3/17/13). Review of the resident's hospital record obtained by the facility revealed the resident had a 10 cm avulsed laceration to her forehead as a result of the fall and had surgery on 3/27/13 to repair the injury. Review of the resident's current care plan with a goal date of 5/19/13 revealed a problem of at risk for falls. Review of her goals revealed she would not experience any injuries related to falls. Review of interventions/approaches listed for the resident included to remind her to ask for assist for all ambulation, refer her for therapy evaluation as appropriate, monitor for changes in her condition that may warrant increased supervision/assistance, refer her to restorative nursing program, use a wheelchair for mobility, and keep pathway in room free of clutter. Further review of the approaches revealed no other interventions even though the resident had a history of [REDACTED]. Review of resident #4's MDS dated [DATE] revealed a Fall Risk Assessment had been completed and it reflected the resident remained at a high risk for falls. Interview with the S1 Administrator on 3/28/13 at 8:20 a.m. revealed he and his staff did not think they needed to add any interventions/approaches for resident #4 because they believed her low bed and fall mat were enough to protect her from injury. They did not think they would be able to prevent the falls but thought her fall mat would be enough to prevent injury.

Based on record review and interview the facility failed to ensure a resident was assessed relevant to her [DIAGNOSES REDACTED]. The facility failed to provide ongoing assessment of the resident's capillary blood sugar level, mental status changes and changes in condition after the nurse learned the resident's blood glucose level was greater than 625 for 1 of 2 diabetic residents admitted to the facility in the past 3 months in a total sample of 5 residents with a [DIAGNOSES REDACTED]. The facility failed to: 1. assess the resident's baseline mental status and failed provide a [DIAGNOSES REDACTED]. 2. assess routine capillary blood sugar levels as ordered by the physician and after the resident had a change in condition due to a blood glucose level of 625; 3. assess the resident's mental status after the family complained the resident was not herself and after the resident had a change in condition due to a blood glucose level of 625; 4. follow the written policy and procedure concerning Change in Condition which stated that a resident's change in condition would be assessed promptly and follow-up activity would occur in a timely fashion. The licensed nurse would assess the resident signs and symptoms including physical and mental status changes; Resident #3 was placed in Immediate Jeopardy on 10/01/10 at 3:00 p.m. when she was admitted to the facility after being transferred from another nursing home. The admitting nurse did not assess the resident's baseline mental status and did not include the [DIAGNOSES REDACTED]. The resident's MAR did not reflect that the resident was to receive capillary blood sugar monitoring and Insulin administration, and the resident did not receive capillary blood sugar monitoring or Insulin during her stay at the facility. Two days after admission (10/3/10), the resident's daughter complained that the resident was not herself and had a change in mental status, and the nurses failed to document an assessment and follow-up on of the resident's mental status. On 10/4/10 (approximately early afternoon) the nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625 from the early morning blood draw. The nurse did not assess the resident's mental status or blood sugar until at 7:00 p.m. she documented a capillary blood sugar of 188 and no mention of the mental status. There was no further documented assessment of the resident again until on 10/05/10 at approximately 1:10 p.m. when her daughter entered the facility, discovered the condition of her mother, demanded the physician be notified and her mother transferred out to the hospital. Resident #3 was transferred to the emergency room via ambulance (time not documented), assessed to have a blood glucose level of 1,262 and was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The other 110 residents in the facility who had the potential to require assessment due to changes in condition were at risk of potential for more than minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's were assessed routinely and after changes in condition. The deficient practice continues at a scope and severity of "E" for the other residents who had to potential to require physician notification. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: Review of the transferring facility's MAR dated 10/1/10 reflected the resident had a [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment conducted by S3LPN for resident #3 reflected she was admitted on [DATE] at 3:00 p.m. The assessment reflected only a [DIAGNOSES REDACTED]. Further review of the clinical record did not reflect a Nurses' Note or other documentation to describe the resident's mental status upon admission. Review of the handwritten admit physician's orders [REDACTED]. Review of Admit physician's orders [REDACTED]. Review of the MAR dated 10/1/10 did not reflect capillary blood glucose monitoring, Regular Insulin per sliding scale or [MEDICATION NAME] at bedtime. Review of the clinical record not did reflect documented evidence that the resident's capillary blood sugar had been monitored. Interview on 10/19/10 at 2:40 p.m. with S3LPN revealed she admitted the resident on 10/1/10 at 3:00 p.m., but she did not document the resident's mental status or the [DIAGNOSES REDACTED]. S4 stated she did not document these findings anywhere. S3 stated she gave a copy of the physician's orders [REDACTED]. S3 further stated she also handwrote a copy of the MAR and Diabetic Flowsheet. S3LPN stated that at 7:00 p.m. she reported to the night nurse, S5LPN, that the resident needed feeding via a feeding tube, required total assistance, was not very responsive, and that she needed accuchecks and Insulin. Further interview with S3LPN on 10/19/10 at 2:40 p.m. revealed she provided conflicting information and stated that she did not handwrite the sliding scale on the Diabetic Flowsheet until she returned to work the next day on 10/2/10. S3 stated that she also cared for the resident on the day shift of 10/2 and 10/3/10 from 7:00 a.m. to 7:00 p.m. S3 revealed that she assessed the resident's capillary blood sugar and administered Regular Insulin using the Diabetic Flowsheet. During the interview the resident's chart was review with S3LPN, and she was unable to produce documentation of capillary blood sugar monitoring or a Diabetic Flow sheet for the resident. Telephone interview with S5LPN on 10/20/10 at 8:55 a.m. revealed she cared for the resident on the night shift of 10/1, 10/2 and 10/3/10 from 7:00 p.m. to 7:00 a.m. S5 stated when she received report from S3LPN on 10/1/10 at 7:00 p.m., and the only thing S3 reported to her was the resident had a feeding tube, did not take many medications, and she was no problem. S5 stated that S3 did not tell her that the resident was a diabetic, and the resident's chart did not contain a Diabetic Flowsheet. S5 stated she did not check the resident's blood sugar or give Insulin because she did not have a MAR which reflected those measures were to be done for the resident. Interview with S2DON on 10/20/10 at 1:30 p.m. revealed on Sunday 10/3/10 she received a call from the facility (don't know which nurse) between 1:00 and 5:00 p.m. that the resident's daughter was at the facility complaining that the resident's cognitive status was not right. S2DON stated she informed the nurse to go by what the daughter said because "we" did not know the resident well enough to know if she was different or not. S2DON stated when she returned to work on Monday 10/4/10 she did not follow-up to see if the resident's mental status had been monitored. There was no documentation in the clinical record for 10/2, 10/3 or 10/4/10 to reflect the resident's mental status had been monitored. Review of Nurses' Notes dated "10/4/10 7a-7p" (no specific time) reflected the results from an early morning blood draw included a blood glucose level greater than 625. The note did not reflect an assessment of the resident's mental status or blood sugar. At 7:00 p.m. the Nurses' Notes reflected a capillary blood sugar of 188 and no mention of the resident's mental status. There was no further documented assessment of the resident until on 10/05/10 at 1:10 p.m. when orders were received to send the resident to the hospital for altered mental status and capillary blood sugar of 409. Interview on 10/19/10 at 1:18 p.m. with S4LPN revealed she first cared for resident #3 on 10/4/10 day shift from 7:00 a.m. to 7:00 p.m., and she never saw a Diabetic Flowsheet for the resident. S4 stated she did not know the resident was to receive blood sugar monitoring and Insulin administration, and when she reviewed the resident's MAR she did not see measures for blood sugar checks, Insulin administration or a [DIAGNOSES REDACTED]. S4 stated she did not remember or document the time that the technician called. S4 stated she placed a call to the nurse at the doctor's office and went and looked at the resident and she was asleep (time not noted), but she did not check her blood sugar or assess her mental status. S4LPN stated that at 5:00 p.m. the resident was still asleep, and she gave the resident her medications through the feeding tube, but she did not check her blood sugar. Further interview with S4LPN at that time revealed at 7:00 p.m. she checked the resident's blood sugar because she had not heard from the doctor's office, and it was 188. S4 stated she tried to stimulate the resident, but she would only mumble, and by not knowing the resident, she thought that was her usual mental status. S4 stated she gave report to the night shift nurse that the resident's morning blood sugar was 625, she was waiting for a return call from the doctor, and that she had gotten a blood sugar at 7:00 p.m. of 188. S4LPN stated at that time, that the next day (10/5/10) she reported to work at 7:00 a.m. and went to the resident's room around 8:30 a.m., called her name, but she did not mumble at that time. S4 stated she did not assess her blood sugar, and there was no Diabetic Flowsheet on the resident's MAR. S4 stated that around 12:00 noon the resident's daughter came in and asked how her mother had been doing with her blood sugar and Insulin, and S4 informed the daughter that she had not been checking the resident's blood sugar or giving her any Insulin because it was not listed on the MAR. S4 stated the daughter told her that her mother was not in her usual mental state, that she was usually more alert, and when her name was called she would respond. S4 stated the daughter wanted her mother's blood sugar checked (it was 409), and she transferred the resident out to the hospital per the daughter's request. A telephone interview was conducted with S7LPN on 10/21/10 at 1:10 p.m. which revealed she cared for resident #3 on the night shift of 10/4/10 from 7:00 p.m. to 7:00 a.m. S7 stated she did not receive much of a report on the resident. S7 stated S4LPN reported the resident was a new admit, and the resident did not do much at all. S7LPN stated she was not told that the resident had 625 blood glucose level. S7 stated she gave the resident her 8:00 p.m. medications and took her vital signs, but there was no Diabetic Flowsheet on the record nor was there a [DIAGNOSES REDACTED]. S7LPN stated she did not assess the resident's blood sugar nor give any Insulin. S7 stated she looked for the resident's admit paperwork but could not locate it. S7 stated she did not recall the resident having any distress, and she did not document on the resident's mental status. Review of the hospital Emergency Physician Record dated 10/5/10 at 1410 reflected the resident had a blood glucose level of 1,262, a clinical impression of [MEDICAL CONDITION], Hyperosmolar Coma, Dehydration and [MEDICAL CONDITION]. The record reflected her condition was critical, she was admitted . Review of the admitting physician's history and physical examination [REDACTED]. Review of the facility's policy and procedure concerning Change in Condition reflected a resident's change in condition would be assessed promptly and follow-up activity would occur in a timely fashion. The licensed nurse would assess the resident signs and symptoms including physical and mental status changes.

Based on record review and interview the facility failed to ensure a resident received the necessary care and services to attain the highest practicable level of physical and mental well-being for a diabetic resident (#3) after she was newly admitted to the facility for 1 of 5 sampled residents who had Diabetes Mellitus. Out of a total census of 111, 12 residents were admitted to the facility within the last 3 months, 2 of whom had Diabetes Mellitus. For Resident #3, the facility failed to: 1. conduct an initial nursing assessment during the admission process relevant to the resident's [DIAGNOSES REDACTED]. 2. include the resident's [DIAGNOSES REDACTED]. 3. ensure antidiabetic medications Regular Insulin per sliding scale and [MEDICATION NAME] appeared on the resident's MAR; 4. to communicate that the resident was a diabetic and needed blood glucose monitoring and administration of Insulin; 5. immediately consult with the physician on admit for dosage of Regular Insulin per sliding scale after a family member complained that the resident was not her self and had altered mental status and after the nurse was notified by the laboratory that the resident's blood glucose level was 625; 6. routinely assess the resident's capillary blood sugar, mental status changes and for changes in condition after the nurse was informed the resident's blood glucose level was 625; 7. administer Regular Insulin and [MEDICATION NAME] as ordered by the physician. 8. follow the written policy and procedure concerning Change in Condition which stated that a resident's change in condition would be assessed promptly and follow-up activity would occur in a timely fashion. The licensed nurse would assess the resident signs and symptoms including physical and mental status changes. The resident's primary physician would be consulted immediately of a significant change in resident's physical or mental status and every effort must be made to personally speak with the physician. Resident #3 was placed in Immediate Jeopardy on 10/01/10 at 3:00 p.m. when she was admitted to the facility and the admitting nurse did not identify and include on the initial nursing assessment that the resident was a diabetic and did not assess her baseline mental status. After admission the nurse did not ensure the resident's MAR reflected the resident was a diabetic, required capillary blood glucose testing, administration of 2 different types of Insulin (antidiabetic) medication. After admission the nurse did not ensure verbal communication to the night shift relief nurse that the resident was a diabetic, needed accuchecks and administration of Insulin. The admitting nurse did not consult with the primary physician to obtain specific sliding scale orders for accuchecks or dosage of Regular Insulin (which the admit nurse stated she administered without a physician's orders [REDACTED]. Interview with 2 of 4 nurses who worked day and/or night shifts from 10/1/10 to 10/5/10 revealed they did not perform capillary blood sugar testing for the resident, and 3 of 4 nurses revealed they did not administer any Insulin to the resident. When a family member complained 2 days after admission (10/3/10), that the resident was not herself and had a change in mental status, the nurse did not assess the resident or call the physician. When the DON returned to work on 10/4/10 she did not follow up on the resident's change in condition. On 10/4/10 (approximately early afternoon) the nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625 from the early morning blood draw. The nurse called the doctor's office but did not follow-up after she did not receive a return call from the doctor, did not assess the resident and did not report to the oncoming shift the resident's blood sugar level was 625. At 7:00 p.m. on 10/4/10 the nurse documented a capillary blood sugar of 188 with no mention of the resident's mental status. There was no further documented assessment of the resident again until on 10/05/10 at approximately 1:10 p.m. when her daughter entered the facility, discovered the condition of her mother, demanded the physician be notified and her mother transferred out to the hospital. Resident #3 was transferred to the emergency room via ambulance (time not documented), assessed to have a blood glucose level of 1,262, a clinical impression of Hyperosmolar Coma, [MEDICAL CONDITION], Dehydration and [MEDICAL CONDITION], and her condition was critical. The resident was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The deficient practice continues at a potential for more than minimal harm that is not immediate jeopardy (E) for all diabetic residents in the facility who could require physician consultation, assessment related to significant changes in condition, and administration of diabetic medication. The facility has not put a plan of action in place to ensure resident's physicians were consulted/notified, assessed routinely and for changes in condition and medications were administered as ordered. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: Review of the Admission Nursing Assessment for resident #3 dated 10/1/10 revealed the resident was transferred from another nursing facility and was accompanied by her family. Review of the transferring facility's MAR dated 10/1/10 reflected the resident had a [DIAGNOSES REDACTED]. Further review of the Admission Nursing Assessment reflected resident #3 was admitted to the facility on [DATE] at 3:00 p.m. by S3LPN. The assessment reflected only a [DIAGNOSES REDACTED]. Further review of the clinical record did not reflect a Nurses' Note or other documentation to describe the resident's mental status upon admission. Review of handwritten admit physician's orders [REDACTED]. Review of the Physician's Admit Orders dated 10/01/10 reflected finger stick blood sugar before meals and at bedtime, Regular Insulin per sliding scale and [MEDICATION NAME] at bedtime. The orders did not reflect specific sliding scale parameters for administration of Regular Insulin. There was no documentation in the clinical record to reflect the physician was consulted to obtain sliding scale orders for Regular Insulin administration. Review of the MAR dated 10/1/10 through 10/5/10 did not reflect entries for capillary blood glucose monitoring, administration of Regular Insulin per sliding scale or [MEDICATION NAME] at bedtime. Interview on 10/19/10 at 2:40 p.m. with S3LPN revealed she worked the day shift on 10/1/10 from 7:00 a.m. to 7:00 p.m. S3 stated she admitted resident #3 at 3:00 p.m. but did not document the resident's mental status or [DIAGNOSES REDACTED]. S3LPN stated she made a handwritten copy of the physician's orders [REDACTED]. S3 stated she also made a handwritten copy of the MAR and Diabetic Flowsheet. S3LPN stated that at 7:00 p.m. she reported to the night nurse, S5LPN, that the resident needed feeding via a feeding tube, required total assistance, was not very responsive, and that she needed accuchecks and Insulin. Further interview with S3LPN on 10/19/10 at 2:40 p.m. revealed she also cared for the resident on the day shift of 10/2 and 10/3/10 from 7:00 a.m. to 7:00 p.m. S3 stated that when she returned to work on 10/2/10 she realized that she had not written the sliding scale for Regular Insulin on the Diabetic Flowsheet, and she wrote it at that time. S3 stated that she assessed the resident's capillary blood sugar and administered Regular Insulin using the sliding from the transferring facility's documentation without calling the resident's primary physician to obtain specific sliding scale orders prior to administration. During the interview the resident's chart was review with S3LPN, and she confirmed there was no sliding scale ordered for Regular Insulin administration. S3 was unable to produce documentation of capillary blood sugar monitoring, Insulin Administration or a Diabetic Flow sheet for the resident. In a later interview with S3LPN on 10/20/10 at 10:30 a.m. she stated that S6 Medical Records clerk handed a printed copy of the MAR and Diabetic Flow sheet to her on the evening of 10/1/10 prior to S6 leaving for the weekend. Interview on 10/20/10 at 10:20 a.m. with S6 Medical Records clerk revealed she received a copy of the physician orders [REDACTED]. S6 stated that S3 stated that she would hand write the forms. S6 stated that she left for the weekend, and when she returned on Monday 10/4/10 she printed the MAR and Diabetic Flowsheet at that time. Telephone interview with S5LPN on 10/20/10 at 8:55 a.m. revealed she cared for the resident on the night shift of 10/1, 10/2 and 10/3/10 from 7:00 p.m. to 7:00 a.m. S5 stated when she received report from S3LPN on 10/1/10 at 7:00 p.m., the only thing S3 reported to her was the resident had a feeding tube, did not take many medications, and that she was no problem. S5 stated that S3 did not tell her that the resident was a diabetic, and the resident's chart did not contain a Diabetic Flowsheet. S5 stated that during her care of the resident, she did not check the resident's blood sugar or give Insulin because she did not have a MAR which reflected those measures were to be provided, and she did not review the physician's orders [REDACTED]. Interview with S2DON on 10/20/10 at 1:30 p.m. revealed on Sunday 10/3/10 she received a call from an unknown nurse at the facility between 1:00 and 5:00 p.m. that the resident's daughter was at the facility complaining that the resident's cognitive status was not right. S2DON stated she informed the nurse to go by what the daughter said because "we" did not know the resident well enough to know if her mental status was different or not. S3DON stated she told the nurse to contact the physician and let him know. Further interview with S2DON at that time revealed when she returned to work on Monday 10/4/10 she did not follow-up to see if the nurse had called the doctor concerning the resident's mental status or if the resident had been assessed after her mental status change. S3DON stated that she did not review the resident's clinical record, but she looked at the facility's 24 hour report, and there was nothing out of the ordinary listed for the resident. S3DON stated she went to the resident's room probably just before lunch, and the resident responded when she touched her arm by opening her eyes. There was no documentation in the clinical record to reflect the resident was assessed or the physician was consulted concerning her mental status after she was admitted to the facility. There was no documentation in Nurses' Notes after 10/1/10 at 3:00 p.m. until 10/4/10 at "7a - 7p". Review of Nurses' Notes dated "10/4/10 7a-7p" (no specific time documented) reflected the results from an early morning blood draw included a blood glucose level greater than 625 (normal range 80-115), and the nurse at the doctor's office was notified and instructed the facility nurse, S4LPN, to fax over a requisition to the doctor's office. The Nurses' Note reflected the blood glucose reading was given to the facility nurse by the laboratory technician. The note reflected doctor's office was faxed, and no new orders were given at that time. The note did not reflect an assessment of the resident's mental status or blood sugar. There was no documentation in the clinical record to reflect an attempt to follow-up with the doctor concerning the resident's blood glucose level of greater than 625. Review of Nurses' Notes dated 10/4/10 at 7:00 p.m. and documented by S4LPN reflected a capillary blood sugar of 188 and no assessment of the resident's mental status. There was no further documentation in Nurses' Notes until 10/05/10 at 1:10 p.m. which reflected a new order was received to send the resident to the hospital for altered mental status and capillary blood sugar of 409. Interview on 10/19/10 at 1:18 p.m. with S4LPN revealed she cared for resident #3 on 10/4/10 day shift from 7:00 a.m. to 7:00 p.m. and documented the time on the Nurses' Notes as "7a-7p". S4 stated the resident's blood was drawn early that morning (10/4/10) by the laboratory. The laboratory technician called and said she had a critical blood glucose level of 625 for the resident. S4 did not remember the time the technician called, but the laboratory results were faxed to the facility later that evening. S4LPN stated that she notified the nurse at the doctor's office (did not remember the nurse's name or the time she placed the call) and reported the resident's glucose level was 625. S4LPN stated that the doctor's nurse told her to fax the results to her on a requisition fax sheet, and no new orders were received. Further interview with S4 at that time revealed she went and looked at the resident, but she did not check her blood sugar or assess her mental status (the resident was asleep and S4 did not remember the time). S4LPN stated that at 5:00 p.m. the resident was still asleep, and she gave the resident her medications through the feeding tube, but she did not check her blood sugar. Further interview with S4LPN at that time revealed at 7:00 p.m. on 10/4/10 she still had not received a call back from the doctor, and she did not make another attempt to contact the doctor. S4 checked the resident's blood sugar because she had not heard from the doctor's office, and it was 188. S4 stated she tried to stimulate the resident, but she would only mumble, and by not knowing the resident, she thought that was her usual mental status. S4 stated she gave report to the night shift nurse that the resident's morning blood sugar was 625, she was waiting for a return call from the doctor, and that she had gotten a blood sugar at 7:00 p.m. of 188. Further interview with S4LPN at that time revealed the next day (10/5/10) she returned to work and cared for resident #3 again on the 7:00 a.m. to 7:00 p.m. shift. S4LPN stated that she did not follow-up with the physician concerning the resident's glucose level of 625 from the previous day. S4 stated she went to the resident's room around 8:30 a.m., called her name, but she did not mumble at that time. S4 stated she did not assess the resident's blood sugar. S4 stated that around 12:00 noon the resident's daughter came in and asked what was her mother's blood sugar was and how had she been doing with her Insulin. S4 stated that she told the daughter that she had not been checking her sugar or giving her mother any Insulin. S4 revealed the daughter then stated that her mother did not have her usual mental status, was usually more alert, and when she called her name she would usually respond. S4 stated the daughter wanted her mother's blood sugar checked, and it was 409. She called the doctor and reported the blood sugar of 409 and 625 the previous day, and orders were received to transfer the resident to the hospital. S4 stated that during her care for the resident, she did not check the resident's blood sugar or administer Insulin because there was no Diabetic Flowsheet on the resident's MAR, no measures for accuchecks or Insulin and no [DIAGNOSES REDACTED]. A telephone interview was conducted with S7LPN 10/21/10 at 1:10 p.m. which revealed she cared for resident #3 on the night shift of 10/4/10 from 7:00 p.m. to 7:00 a.m. S7 stated she did not receive much of a report on the resident. S7 stated S4LPN reported the resident was a new admit, and the resident did not do much at all. S7LPN stated she was not told that the resident had 625 blood glucose level. S7 stated she gave the resident her 8:00 p.m. medications and took her vital signs, but there was no Diabetic Flowsheet on the record nor was there a [DIAGNOSES REDACTED]. S7 stated she looked for the resident's admit paperwork but could not locate it. S7 stated she did not recall the resident having any distress, and she did not document on the resident that night. Review of the hospital Emergency Physician Record dated 10/5/10 at 1410 reflected the emergency room physician documented the resident had a blood glucose level of 1,262, a clinical impression of [MEDICAL CONDITION], Hyperosmolar Coma, Dehydration and [MEDICAL CONDITION]. The record reflected her condition was critical, and she was admitted . Review of the admitting physician's history and physical examination [REDACTED]. Review of the facility's Change in Condition reflected a resident's change in condition would be assessed promptly and follow-up activity would occur in a timely fashion. The licensed nurse was expected to assess the resident's signs and symptoms including physical and mental status changes. The resident's primary physician would be consulted immediately of a significant change in a resident's physical or mental status and every effort was expected to be made to personally speak with the physician.

Based on record review and interview the facility failed to provide care in accordance with the written physician's orders for a resident who was a diabetic and newly admitted to the facility for 1 of 5 sampled residents who had Diabetes Mellitus. Out of a total census of 111 12 residents were admitted to the facility within the last 3 months, 2 of whom had Diabetes Mellitus (#3). The facility failed to: 1. provide capillary blood sugar finger sticks and administer Regular Insulin and [MEDICATION NAME] as ordered by the physician. Resident #3 was placed in Immediate Jeopardy on 10/01/10 at 3:00 p.m. when she was admitted to the facility, when the admitting nurse did not identify and include on the resident's MAR that the resident was a diabetic, required capillary blood glucose testing and administration of Regular Insulin and [MEDICATION NAME] (antidiabetic) medications. The resident had admission Physician's Orders for Regular Insulin per sliding scale (without specific sliding scale parameters) and for [MEDICATION NAME]. After the resident was admitted on [DATE] at 3:00 p.m., the nurse did not ensure verbal communication to the night shift relief nurse that the resident was a diabetic and required administration of Insulin. The admitting nurse returned to work on the day shift of 10/2/10 from 7:00 a.m. to 7:00 a.m. and administered Regular Insulin to the resident without having specific sliding scale physician's orders. The clinical record did not contain documentation which evidenced the resident received either [MEDICATION NAME] or Regular Insulin from 10/1/10 to 10/5/10. Interview with 2 of 4 nurses who worked day and/or night shifts from 10/1/10 to 10/5/10 revealed they did not perform capillary blood sugar testing for the resident, and 3 of 4 nurses revealed they did not administer any Insulin to the resident. On 10/4/10 (approximately early afternoon) the facility nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625 from the early morning blood draw. The nurse did not review the resident's Physician's Orders to determined if the resident required antidiabetic medication. On 10/05/10 at approximately 1:10 p.m. the resident's daughter entered the facility to visit her mother and discovered the resident did not have her usual mental status. The resident's daughter asked the facility nurse how her mother was doing with her blood sugar and Insulin, and the nurse informed the daughter that the resident did not receive Insulin. The resident' daughter demanded that her mother's physician be notified, and that her mother be transferred out to the hospital. Resident #3 was transferred to the emergency room via ambulance (time not documented), assessed to have a blood glucose level of 1,262, a clinical impression of Hyperosmolar Coma, [MEDICAL CONDITION], Dehydration and [MEDICAL CONDITION], and her condition was critical. The resident was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The other 110 residents in the facility who had the potential of not receiving nursing care in accordance with the written plan of care and Physician's Orders were at risk of potential for more than minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's physicians were consulted/notified, assessed routinely and for changes in condition and medications were administered as ordered. The deficient practice continues at a scope and severity of "E" for the other residents who had the potential to require physician notification. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: Review of the Admission Nursing Assessment for resident #3 dated 10/1/10 revealed the resident was transferred from another nursing facility and was accompanied by her family. Review of the transferring facility's MAR dated 10/1/10 reflected the resident had a [DIAGNOSES REDACTED]. Review of handwritten Admit Physician's Orders dated 10/1/10 reflected the orders were transcribed by S3LPN but did not reflect the resident's [DIAGNOSES REDACTED]. The orders did not reflect a time or specific sliding scale parameters for administration of Regular Insulin. There was no documentation in the clinical record to reflect specific physician's orders for administration of Regular Insulin per sliding scale. Review of the clinical record and MAR dated 10/1/10 through 10/5/10 did not reflect entries for finger stick blood sugar, administration of Regular Insulin per sliding scale or [MEDICATION NAME] at bedtime. Interview on 10/19/10 at 2:40 p.m. with S3LPN revealed she worked the day shift on 10/1/10 from 7:00 a.m. to 7:00 p.m. S3 stated she admitted resident #3 at 3:00 p.m. but did not document the resident's [DIAGNOSES REDACTED]. S3LPN stated she made a handwritten copy of the Physician's Orders, MAR and Diabetic Flowsheet. S3LPN stated that at 7:00 p.m. she reported to the night nurse, S5LPN, that the resident required tube feedings, total assistance, accuchecks and Insulin administration. Further interview with S3LPN on 10/19/10 at 2:40 p.m. revealed she also cared for the resident on the day shift of 10/2 and 10/3/10 from 7:00 a.m. to 7:00 p.m. S3 stated that when she returned to work on 10/2/10 she realized that she had not written the sliding scale for Regular Insulin on the Diabetic Flowsheet, and she wrote it at that time. S3 stated that he administered Regular Insulin using the sliding scale from the transferring facility's documentation. S3 stated that she did not have specific sliding scale orders from the resident's primary physician prior to administration Regular Insulin. During the interview the resident's chart was review with S3LPN, and was unable to produce documentation for the administration of Regular Insulin or [MEDICATION NAME] or a Diabetic Flowsheet for the resident. Telephone interview with S5LPN on 10/20/10 at 8:55 a.m. revealed she cared for the resident on the night shift of 10/1, 10/2 and 10/3/10 from 7:00 p.m. to 7:00 a.m. S5 stated when she received report from S3LPN on 10/1/10 at 7:00 p.m., the only thing S3 reported to her was the resident had a feeding tube, did not take many medications, and that she was no problem. S5 stated that S3 did not tell her that the resident was a diabetic, and the resident's chart did not contain a Diabetic Flowsheet. S5 stated that during her care of the resident, she did not check the resident's blood sugar or give Insulin because she did not have a MAR which reflected those measures were to be provided, and she did not review the physician's orders for comparison to the MAR. Review of Nurses' Notes dated "10/4/10 7a-7p" (no specific time documented) reflected the results from an early morning blood draw included a blood glucose level greater than 625 (normal range 80-115). Review of Nurses' Notes dated 10/5/10 at 1:10 p.m. reflected the resident was transferred to the hospital for altered mental status and capillary blood sugar of 409. Interview on 10/19/10 at 1:18 p.m. with S4LPN revealed she cared for resident #3 on 10/4/10 day shift from 7:00 a.m. to 7:00 p.m., and the resident's blood was drawn early that morning (10/4/10) by the laboratory. S4LPN stated the laboratory technician called and said the resident had a critical high blood glucose level of 625. S4LPN stated that she did not administer any Insulin to the resident. S4LPN stated she returned next day (10/5/10) and cared for resident #3 again on the 7:00 a.m. to 7:00 p.m. shift. S4LPN stated that during her care of the resident, she did not check the resident's blood sugar or administer Insulin because there were no measures for accuchecks, Insulin administration or [DIAGNOSES REDACTED]. S4 stated that the resident did not have a Diabetic Flowsheet, and she (S4) did not look at the physician's orders to compare against the MAR. A telephone interview was conducted with S7LPN 10/21/10 at 1:10 p.m. which revealed she cared for resident #3 on the night shift of 10/4/10 from 7:00 p.m. to 7:00 a.m. S7 stated she did not receive much of a report on the resident. S7 stated S4LPN reported the resident was a new admit, and the resident did not do much at all. S7LPN stated she was not told that the resident had 625 blood glucose level. S7 stated she gave the resident her 8:00 p.m. medications and took her vital signs, but there was no Diabetic Flowsheet on the record nor was there a [DIAGNOSES REDACTED]. S7LPN stated she did not assess the resident's blood sugar nor give any Insulin to the resident. Review of the hospital Emergency Physician Record dated 10/5/10 at 1410 reflected the emergency room physician documented the resident had a blood glucose level of 1,262, a clinical impression of [MEDICAL CONDITION], Hyperosmolar Coma, Dehydration and [MEDICAL CONDITION]. The record reflected her condition was critical, and she was admitted . Review of the admitting physician's history and physical examination [REDACTED].

Based on record review and interview the facility failed to ensure accurate acquiring of a resident's routine medications by failing to obtain Lantus Insulin (antidiabetic), Asprin (anti-inflammatory) and Clonidine (antihypertensive) from the licensed pharmacist for 1 of 5 sampled residents newly admitted to the facility (#3). Out of a total census of 111 the facility currently had 12 residents who were admitted to the facility within the last 3 months. The facility failed to: 1. accurately and safely provide routine medications services by failing to obtain and provide Lantus Insulin, Asprin, and Clonidine through the services of a licensed pharmacist from 10/1/10 to 10/5/10. Resident #3 was placed in Immediate Jeopardy when she was admitted to the facility on [DATE] at 3:00 p.m., the DON checked her medications from the transferring facility, called the pharmacist and asked if it was ok to give them since they were labeled. The DON stated that the pharmacist said it was ok, and the DON placed the medications on the medication cart. The DON did not assure that all the resident's medications were ordered and received from the facility's licensed pharmacist. Asprin and/or Clonidine were administered to the resident using the medication packages from the transferring facility from 10/1/10 to 10/5/10, and the resident did not receive Lantus Insulin from 10/1/10 to 10/5/10. There was no record to reflect Lantus Insulin, Asprin and Clonidine were delivered to the facility from the licensed pharmacist. On 10/4/10 (approximately early afternoon) the facility nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625 from the early morning blood draw. On 10/05/10 at approximately 1:10 p.m. resident #3 was transferred to the emergency room via ambulance and upon arrival was assessed to have a blood glucose level of 1,262, a clinical impression of Hyperosmolar Coma, Hyperglycemia, Dehydration and Hypernatremia, and her condition was critical. The resident was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The other 110 residents in the facility who had the potential to require the use of a licensed pharmacist to acquire medications were at risk of potential for more than minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's medication were filled by the licensed pharmacist. The deficient practice continues at a scope and severity of "E" for the other residents who had to potential to require physician notification. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: Interview with the S2DON on 10/20/10 at 1:30 p.m. revealed when the resident arrived at the facility on 10/1/10 at 3:00 p.m., she had medication packages from the transferring facility. S2 stated she called the facility's pharmacist and asked if it was ok to give the medications from the transferring facility since they were labeled. S2 stated that the pharmacist said it was ok to give the medications, and she (S2DON) placed the medications on the medication cart under the resident's name. Review of the Consolidated Delivery Sheet dated 10/1/10 reflected Hydrochlorothiazide (diuretic), Lisinopril (antihypertensive) and Novolin R (antidiabetic) were received from the pharmacist for resident #3. The delivery sheet did not reflect Lantus Insulin, Asprin or Clonidine for the resident. Review of the MAR indicated [REDACTED]. The resident received Clonidine HCL 0.1mg once on 10/1/10 and on 10/5/10, and three times daily from 10/2/10 to 10/4/10. There was no documentation on the MAR to reflect the administration of Lantus Insulin. Interview with S8RN Corporate Nurse on 10/21/10 at 10:15 a.m. confirmed there was no documentation to reflect the facility received the resident's Lantus Insulin, Asprin or Clonidine from the licensed pharmacist.

Based on record review and interview the facility failed to ensure the resident's physician and/or family member were immediately consulted to clarify Insulin (antidiabetic) medication dosage (#3) and/or when a significant change in condition occurred (#3 and 1) for 2 of 5 sampled residents who had Diabetes Mellitus, admitted to the facility within the last 3 months and/or had a fall. Out of a total census of 111, 12 residents were admitted to the facility within the last 3 months, 2 of whom had Diabetes Mellitus and/or a fall. The facility failed to: 1. immediately consult with the resident's physician when there was a need for clarification of Regular Insulin dosage per sliding scale on admission, when a family member complained that the resident was not her self and had altered mental status and when the nurse was notified by the laboratory that the resident's blood glucose level was greater than 625 (#3); 2. immediately consult with the resident's family member when the nurse was notified by the laboratory that the resident's blood glucose level was greater than 625 (#3) and when a resident was transferred out to the hospital after a fall (#1) 3. follow the written policy and procedure concerning Change in Condition which stated the resident's primary physician would be consulted immediately of a significant change in a resident's physical or mental status making every effort to personally speak with the physician (#3), and the resident's designated medical contact would also be notified (#3 and 1). Resident #3 was placed in Immediate Jeopardy on 10/01/10 at 3:00 p.m. when she was admitted to the facility. The admitting nurse did not consult with the primary physician for specific orders for the administration of Regular Insulin per sliding scale which the admitting nurse stated that she administered without Insulin sliding scale orders. The staff nurse and the DON did not call the physician when a family member complained 2 days after admission (10/3/10) that the resident was not herself and had a change in mental status. On 10/4/10 (time unknown) the nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625, and the nurse placed a call to the nurse at the physician's office and faxed a copy of the lab results to the physician's office (time unknown). The facility's nurse did not speak to the physician, did not make a follow-up attempt to notify the physician, did not report to the DON or to the oncoming shift so they could make an attempt to follow-up with a call to the physician. On 10/05/10 at 7:00 a.m. the same facility nurse returned to work to care for resident #3, and she still did not follow-up with a call to the physician. The physician was not notified concerning resident #3's change in condition until 10/05/10 at approximately 1:10 p.m. when the resident's daughter entered the facility, discovered the condition of her mother, demanded the physician be notified and her mother transferred out to the hospital. Resident #3 was transferred to the emergency room via ambulance (time unknown). Upon arrival the resident was assessed to have a blood glucose level of 1,262 and was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The other 110 residents in the facility who had the potential to require physician consultation/notification of significant changes in condition were at risk of potential for more than minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's physicians were consulted/notified of changes in condition. The deficient practice continues at a scope and severity of "E" for the other residents who had potential to require physician notification. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: 1. Review of the Admission Nursing Assessment for resident #3 reflected the resident was admitted to the facility on [DATE] at 3:00 p.m. by S3LPN. The note reflected the resident was transferred from another nursing facility. Review of the Physician's Admit Orders dated 10/01/10 reflected Regular Insulin per Sliding Scale. The orders did not reflect specific sliding scale parameters for administration of Regular Insulin. There was no documentation in the clinical record to reflect the physician was consulted to obtain sliding scale orders for Regular Insulin administration. Interview on 10/19/10 at 2:40 p.m. with S3LPN revealed she worked the day shift on 10/1/10 from 7:00 a.m. to 7:00 p.m. and admitted resident #3 at 3:00 p.m. S3LPN stated stated she made a handwritten copy of the resident's physician's orders [REDACTED]. S3LPN stated she did not contact the physician to obtain specific sliding scale orders for administration of Regular Insulin. Further interview with S3LPN at that time revealed she also cared for the resident on the day shift of 10/2 and 10/3/10 from 7:00 a.m. to 7:00 p.m. S3 stated when she returned to work on 10/2/10 she realized that she had not written orders for sliding scale parameters for Regular Insulin. S3 stated that she performed the resident's accuchecks and gave Regular Insulin to the resident on 10/2/10 and 10/3/10 (no specific time stated). S3 stated she used the sliding scale which was reflected on the transferring facility's documentation without calling the resident's primary physician to obtain specific sliding scale orders prior to administration. Interview with S2DON on 10/20/10 at 1:30 p.m. revealed that on Sunday 10/3/10 she received a call from an unknown nurse at the facility between 1:00 and 5:00 p.m. that the resident's daughter was at the facility complaining that the resident's cognitive status was not right. S2DON stated that she informed the nurse to go by what the daughter said because "we" did not know the resident well enough to know if she was different or not. S3DON stated that she told the nurse to contact the physician and let him know. S2DON stated that when she returned to work on Monday 10/4/10 she did not follow-up to see if the nurse had called the doctor about the resident's mental status, and she (S2DON) did not call the doctor to report the resident's change in mental status. There was no documentation in the clinical record for 10/3 or 10/4/10 to reflect the resident's mental status or any contact with the physician concerning her mental status. Review of Nurses' Notes dated "10/4/10 7a-7p" (no specific time documented) reflected the results from an early morning blood draw included a blood glucose level greater than 625 (normal range 80-115), and the nurse at the doctor's office was notified with instructions to fax over a requisition to the doctor's office. The note reflected the blood glucose reading was given to the facility nurse by the laboratory technician. The note reflected doctor's office was faxed, and no new orders were given at that time. Nurses' Notes date 10/4/10 at 7:00 p.m. reflected no new orders from physician at this time. There was no documentation in the clinical record to reflect an attempt to follow-up with the doctor concerning the resident's blood glucose level greater than 625 after the "10/4/10 7a-7p" Nurses' Notes documentation. On 10/5/10 at 1:10 p.m. Nurses' Notes reflected the resident was sent to the hospital for a capillary blood sugar of 409 and altered mental status. Interview on 10/19/10 at 1:18 p.m. with S4LPN revealed she cared for resident #3 on 10/4/10 during the day shift from 7:00 a.m. to 7:00 p.m. S4 confirmed she documented the time on the Nurses' Notes as "10/4/10 7a-7p". S4 stated that the resident's blood was drawn that morning (10/4/10) by the laboratory. The laboratory technician called and said she had critical glucose level results of 625 for the resident, she did not remember the time, and the laboratory results was faxed to facility that evening. S4LPN stated that she notified the nurse at the doctor's office (did not remember the nurse's name or the time she placed the call) and told her the resident's glucose level was 625. S4LPN stated that the doctor's nurse told her to fax the results to her on a requisition fax sheet, and no new orders were received. S4 stated that she did not call the resident's daughter. Further interview with S4LPN at that time revealed at 7:00 p.m. on 10/4/10, she still had not received a call back from the doctor, and she did not make another attempt to contact the doctor. S4 stated that she gave report to the night shift nurse and told her about the glucose was 625, and she had not received a return call from the physician. Further interview with S4LPN at that time revealed the next day 10/5/10 she returned to work and cared for resident #3 again. S4LPN stated that she did not follow-up with the physician concerning the resident's glucose level of 625 from the previous day. S4 stated that around 12:00 noon the resident's daughter came in and asked what was her mother's blood sugar was and how had she been doing with her Insulin blood sugar. S4 stated that she told the daughter that she had not been checking her sugar or giving her mother any Insulin. S4 revealed the daughter then stated that her mother did not have her usual mental status, was usually more alert, and when she called her name she would usually respond. S4 stated that at that time she checked the resident's capillary sugar and it 409, she called the doctor and told him about the 409 and the previous 625 from the day before and he ordered to send her to the emergency room . Review of the hospital Emergency Physician Record dated 10/5/10 at 1410 reflected resident #3 had a blood glucose level of 1,262, a clinical impression of [MEDICAL CONDITION], Hyperosmolar Coma, Dehydration and [MEDICAL CONDITION]. The record reflected her condition was critical, and she was admitted . Review of the admitting physician's history and physical examination [REDACTED]. Review of the facility's policy and procedure revealed staff failed to follow the written policy for Change in Condition which reflected the resident's primary physician would be consulted immediately for a significant change in resident's physical or mental status and that every effort must be made to personally speak with the physician and the resident's designated medical contact. 2. Review of the Accumulative [DIAGNOSES REDACTED]. Review of Nurses' Notes dated 10/14/10 at 7:45 p.m. reflected the resident was sent to the hospital per doctor's orders. Review of Incident Follow-up Report dated 10/14/10 reflected the resident had a fall on 10/14/2010 at 6:40 p.m.. There was no documentation in the clinical record to reflect the resident's family had been notified of her fall or subsequent transfer to the hospital. Interview on 10/20/2010 at 11:15 a.m. with S2DON confirmed there was no documentation in the clinical record to reflect notification of the resident's family member when the resident was transferred out to the hospital on [DATE].

Based on record review and interview the facility failed to ensure the Registered Nurse (DON) directed nursing care and services by failing to clinically supervise the provision of nursing care to ensure nurses accurately conducted the admission assessment and on-going assessment of a resident, notified/consulted with the physician after a change in condition, clarified medication orders and administered medications as ordered by the physician. The nurses also failed to obtain medications from a licensed pharmacist for 1 of 2 diabetic residents admitted to the facility in the past 3 months in a total sample of 5 residents with a [DIAGNOSES REDACTED]. Resident #1 was not provided with an accurate assessment, notification of the physician of a change in condition, administration of medications, safe acquisition of medications from a licensed pharmacist and all nursing measures necessary to maintain her highest level of physical and mental well-being after she was admitted to the facility. Resident #1 was not provided an accurate initial nursing assessment during the admission process relevant to her [DIAGNOSES REDACTED]. Resident #1 was not provided routine ongoing assessment of her blood sugar level, administration of Insulin or onging assessment of her mental status when the nursing staff failed to ensure all of the resident's medications including Regular Insulin per sliding scale and [MEDICATION NAME] were transcribed correctly on the resident's MAR. Resident #1 was not provided timely notification and consultation of her physician after a family member complained that the resident was not her self and had altered mental status and after the nurse was notified by the laboratory that the resident's blood glucose level was 625. The DON failed to clinically supervise LPN'S to ensure: 1. Nurses conducted an admission assessment on 10/1/10 which included the resident's [DIAGNOSES REDACTED]. from a licensed pharmacist; 2. Nurses consulted immediately with the physician on admit (10/1/10) for dosage of Regular Insulin per sliding scale; after a family member complained that the resident was not her self and had altered mental status on 10/3/10; and after the nurse was notified by the laboratory that the resident's blood glucose level was greater than 625 on 10/4/10; 3. Nurses routinely assessed the resident's capillary blood sugar from 10/1/10 to 10/5/10, assessed her mental status after a family member complained that the resident was not her self on 10/3/10, and assessed her capillary blood sugar, mental status changes and for changes in condition after the nurse was informed the resident's blood glucose level was greater than 625 on 10/4/10; 4. Nurses administered Regular Insulin and [MEDICATION NAME] as ordered by the physician from 10/1/10 to 10/5/10; and 5. Nurses followed the written policy and procedure concerning Change in Condition. Resident #3 was placed in Immediate Jeopardy on 10/01/10 at 3:00 p.m. when she was admitted to the facility, and the admitting nurse did not identify and include on the initial nursing assessment that the resident was a diabetic and did not assess her baseline mental status. After admission the nurse did not ensure that the resident had a MAR indicated [REDACTED]. The admitting nurse did not consult with the primary physician to obtain specific sliding scale orders for accuchecks and dosage of Regular Insulin (which the admit nurse stated she administered without a physician's orders [REDACTED]. When a family member complained 2 days after admission (10/3/10), that the resident was not herself and had a change in mental status, the nurse did not assess the resident and call the physician. When the DON returned to work on 10/4/10 she did not follow up on the resident's change in condition. On 10/4/10 (approximately early afternoon) the nurse received a phone call from the laboratory that the resident's blood glucose level was greater than 625 from the early morning blood draw. The nurse called the doctor's office but did not follow-up after she did not receive a return call from the doctor, did not assess the resident and did not report to the oncoming shift the resident's blood sugar level was 625. At 7:00 p.m. on 10/4/10 the nurse documented a capillary blood sugar of 188 with no mention of the resident's mental status. There was no further documented assessment of the resident again until on 10/05/10 at approximately 1:10 p.m. when her daughter entered the facility, discovered the condition of her mother, demanded the physician be notified and her mother transferred out to the hospital. Resident #3 was transferred to the emergency room via ambulance (no time documented), assessed to have a blood glucose level of 1,262, a clinical impression of Hyperosmolar Coma, [MEDICAL CONDITION], Dehydration and [MEDICAL CONDITION], and her condition was critical. The resident was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The other 110 residents in the facility who had the potential to require physician consultation, accurate admission assessment, assessment related to significant changes in condition, administration of Insulin medication and acquisition of medications from a licensed pharmacist were at risk of potential for more than minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's physicians were consulted/notified of changes in condition. The deficient practice continues at a scope and severity of "E" for the other residents who had to potential to require physician notification. The facility has not put a QA system in place to ensure the deficient practice does not occur again. Findings: 1. Failure to ensure a resident received appropriate assessment, nursing care services and pharmaceutical services relevant to her [DIAGNOSES REDACTED]. The DON and nurses failed to follow the written Policy and procedure concerning admission of residents, change of shift and documentation by not conducting an admission assessment on 10/1/10 which included the resident's [DIAGNOSES REDACTED].#3). Review of the facility's written policy and procedure for Change of Shift revealed, "The change of shift report is needed to inform the oncoming shift of any problems that have occurred concerning any resident, and any changes in physicians orders that have occurred or been received." Review of the facility's written policy and procedure for Documentation on Admits revealed all residents admitted to the facility must have documentation in the Nurses' Notes to reflect the resident's [DIAGNOSES REDACTED]. Cross refer to F157, F272, F309 and F514 2. Failure to obtain the resident's medications from the licensed pharmacist: The DON and nurses failed to obtain the resident's [MEDICATION NAME], ASA and [MEDICATION NAME] from the licensed pharmacist upon admission to the facility on [DATE]. Cross refer to F425 3. Failure to assess a resident, consult with the physician, administer medications, and provide all measure of necessary to maintain the resident's highest level of well being: The DON and nurses failed to provide timely ongoing assessment of a resident from 10/1/10 to 10/5/10 after the resident was admitted , after she had a change in mental status and after her blood glucose level reported to be greater than 625; to consult with the physician on admission for clarification of Insulin dosage, when the family complained the resident had a change in mental statue, and when the resident's blood glucose level was greater than 625. Cross refer F157, F272, and F309 4. Failure to identify a lack of providing appropriate health care services: The DON and/or designee failed to identify through monitoring of clinical records, interview and communication with nursing staff that the resident was a diabetic, required monitoring of her Diabetic Flowsheet and did not received appropriate health care and treatment after her admission to the facility (#3). The clinical record for resident #3 had not been review by the nursing staff caring for her nor by the DON. Interview with the S2DON on 10/20/10 at 1:30 p.m. revealed the facility was currently monitoring the Diabetic Flowsheet documentation of each diabetic resident due to previous identified deficient practice in that area. S2 stated that nursing staff had been provided inservices on 9/7/10 and 9/8/10 concerning following the plan of care for diabetic residents. S2 sated that the nurses made copies daily of each diabetic resident's Diabetic Flowsheet, and she reviewed a percentage of the flowsheets. S2DON confirmed she did not know the resident did not have a Diabetic Flowsheet and did not receive accuchecks and Insulin until the surveyor asked. S2DON stated when the resident arrived on 10/1/10 at 3:00 p.m., she had some medications from the transferring facility, and she called the pharmacist and asked if it was ok to give them since they were labeled. S2 stated that the pharmacist said it was ok, and she placed the medications on the medication cart. S2DON stated the physicians's orders and MAR indicated [REDACTED]. S2DON stated she received a call from the nursing staff on 10/3/10 concerning the resident's mental status, but when she returned to work on 10/4/10 she did not follow-up on the condition of the resident and did not review the resident's clinical record. S2DON stated she read the 24 hour report sheet, and it did not reflect anything out of the ordinary. S2 stated that she was not informed by S4LPN on 10/4/10 that the resident's blood sugar was 625. S2DON stated that she did not know the role of the RN concerning the admission of resident's into the facility to ensure the plan of care was sufficient to meet the resident's needs. S2DON stated the LPN's conducted the admission assessments, but the RN only conducted the skin assessment. She stated that she did not know the system or policy for routinely investigating what happened to a resident once transferred out to the hospital. Cross refer to F157, F272, F309, F425, and F514