Every finding on record at The Waterton Healthcare & Rehabilitation

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of six residents (Resident #1) reviewed for misappropriation of property. The facility failed to report Resident #1's allegation of misappropriation of property to HHSC until approximately 60 hours after the incident occurred. This failure could place residents at risk of not receiving timely investigation into allegations of misappropriation of property. The findings included: A record review of Resident #1's face sheet, dated 08/20/2026, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute and chronic respiratory failure with hypoxia (when there is not enough oxygen in the blood), chronic obstructive pulmonary disease (a progressive lung disease that causes difficulty breathing), mucopurulent chronic bronchitis (a long term condition characterized by chronic cough with thick mucus), and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (plaque buildup in the heart). A record review of Resident #1's most recent Discharge Return Anticipated MDS assessment dated [DATE] indicated Resident #1's short term memory was okay and he was independent to make decisions regarding tasks of daily life. A record review of Resident #1's BIMS Evaluation dated 06/22/2026 at 1:47 PM indicated Resident #1 had a BIMS of 15, which indicated intact cognitive function. A record review of a grievance dated as received on 06/22/2026 indicated Resident #1 stated he had $322.00 before leaving for the hospital and reported this to the Therapy Program Manager and the SW. The grievance indicated on 06/23/2026 the individual designated to take action on this concern was the ADM, the concern was discussed during the morning meeting, and a self-report was completed. The grievance indicated it was not resolved, but was reported to HHSC, the police department was notified, and the money was not found signed by the SW on 06/23/2026 and the ADM on 07/01/2026. A record review of TULIP case details on 08/19/2026 at 4:32 PM indicated the report of misappropriation of property was received by HHSC on 06/24/2026. During an interview on 08/20/2026 at 10:35 AM, the Therapy Program Manager stated he was not told by Resident #1 about the missing money, but OT A told him and he reported it during a morning meeting. The Therapy Program Manager stated he was on his way to the morning meeting when OT A stopped him and told him of Resident #1's allegations. The Therapy Program Manager could not recall the specific date this occurred. The Therapy Program Manager stated the ADM was in the morning meeting. A telephone interview was attempted on 08/20/2026 at 10:40 AM to contact the SW, though she did not answer. During an interview on 08/20/2026 at 10:41 AM, OT A stated Resident #1 alleged misappropriation of property on the date she did his initial assessment upon his return from the hospital. OT A stated Resident #1 was flustered and did not want to participate in the assessment because he stated he had money missing from his wallet. OT A stated after reviewing her notes, it was 06/22/2026 that Resident #1 had his initial assessment and reported the alleged misappropriation of property. OT A stated she reported it to the Therapy Program Manager while he was in the morning meeting with department heads. OT A stated she had been trained on abuse, neglect, and exploitation and she told the Therapy Program Manager immediately after hearing the allegation. A record review of Resident #1's OT Evaluation indicated the OT assessment was dated 06/22/2026 signed at 10:55 AM by OT A. During an interview on 08/20/2026 at 11:19 AM, the ADM stated he did not remember who stated Resident #1 was missing money when he came back from the hospital, but it was reported during a morning meeting and that was when the investigation was initiated. The ADM stated he believed it was 06/24/2026 that he was notified of the alleged misappropriation and that was the day it was reported to HHSC. The ADM stated staff were aware of reporting to him allegations of abuse, neglect, or exploitation and that he was the one who would report it to HHSC. During a telephone interview on 08/20/2026 at 12:09 PM, Resident #1 stated he had $322 dollars in his wallet. Resident #1 initially stated he did not have the wallet at the hospital, then stated he did have the wallet at the hospital. Resident #1 stated he did not tell staff about the money in his wallet, but when he got back to the facility from the hospital, he reported the missing money to staff. During an interview on 08/20/2026 at 12:19 PM, the DON stated she could not recall the specific date that it was reported to her or the ADM that Resident #1 was missing money. The DON stated the ADM was not at work on 06/22/2026 and returned on 06/23/2026. The DON stated she did not recall if the alleged misappropriation was discussed in the morning meeting on 06/23/2026. The DON stated that allegations of misappropriation of property was to be reported to HHSC within 24 hours of the allegation. During an interview on 08/20/2026 at 12:46 PM, the ADM stated he was unsure, but he may not have been at the facility on 06/22/2026. The ADM stated 06/24/2026 would have been the first day he had been notified of the allegation of misappropriation as that was the day he reported it to HHSC. The ADM stated he did not feel there to be a risk to residents in this specific instance of an allegation of misappropriation of property. The ADM stated staff had been trained on abuse, neglect, and exploitation and reporting timelines. During an interview on 08/20/2026 at 12:53 PM, the Therapy Program Manager stated after thinking about it, it was during a clinical meeting that he reported Resident #1 telling OT A about the alleged misappropriation. The Therapy Program Manager stated he did not remember if the ADM was in the meeting or not. The Therapy Program Manager stated OT A told him at about 8:45 AM that Resident #1 made an allegation of misappropriation and he reported it during the clinical meeting at 9:00 AM and the morning meeting with department heads at 9:30 AM. The Therapy Program Manager stated he had been trained on abuse, neglect, and exploitation and that when a resident made an allegation of misappropriation of property, he was to notify the ADM. The Therapy Program Manager stated he knew it was the same day he notified the ADM and it was brought up in multiple morning meetings afterward following up. A record review of facility policy, most recently revised April 2025, titled Abuse: Prevention of and Prohibition Against indicated the following: .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Reporting/Response1. All allegations of abuse, neglect, or misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observations, interviews, and record review, 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 and transmission of communicable diseases and infections for 2 of 3 resident bathrooms (the shared bathroom of Resident #36 and Resident #40 and the shared bathroom of Resident #55 and Resident #62) reviewed for infection control. The facility failed to ensure antibacterial soap was provided in the shared bathroom of Resident #36 and Resident #40 and the shared bathroom of Resident #55 and Resident #62. This failure could place residents at risk for ineffective hand hygiene practices, which may contribute to the transmission of communicable diseases and cross-contamination among residents, staff, and visitors. The findings included: A record review of Resident #36's undated facesheet revealed she was a [AGE] year-old female most recently admitted to the facility on [DATE]. Resident #36 had diagnoses which included acute kidney failure (when the kidneys can no longer effectively filter waste and toxins from the blood), chronic obstructive pulmonary disease (a progressive lung disease which can cause difficulty breathing), and unspecified dementia. A record review of Resident #36's most recent Quarterly MDS dated [DATE] revealed a BIMS of 12, which indicated moderate cognitive impairment. Resident #36's MDS revealed she was independent with toileting hygiene. During an interview on 05/04/2026 at 9:59 AM, Resident #36 indicated she could not recall the last time there was soap in her bathroom. Resident #36 indicated she had been using shampoo to wash her hands after using the restroom. A record review of Resident #40's undated facesheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #40 had diagnoses which included acute on chronic diastolic (congestive) heart failure (a worsening of heart failure), end stage renal disease (the final stage of chronic kidney disease when the kidneys can no longer function adequately to sustain life without treatment), and type 2 diabetes. A record review of Resident #40's most recent Significant Change in Status MDS dated [DATE] revealed a BIMS of 7, which indicated severe cognitive impairment. Resident #40's MDS revealed she required partial/moderate assistance with toileting hygiene, was occasionally incontinent of urinary continence, and was always continent of bowel continence. During an interview on 05/04/2026 at 10:02 AM, Resident #40 indicated there had been no soap in the bathroom for at least days. Resident #40 indicated she used bar soap to wash her hands after using the restroom. An observation on 05/04/2026 at 9:46 AM indicated there was no antibacterial soap in the shared bathroom of Residents #36 and #40. During an observation on 05/04/2026 at 10:43 AM, housekeeping was observed cleaning the bathroom of Residents #36 and #40. During an observation on 05/04/2026 at 10:45 AM, there was no antibacterial soap observed in the bathroom of Residents #36 and #40. Record review of Resident #55's undated facesheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #55 had diagnoses which included unspecified dementia, diabetes, morbid obesity due to excess calories, muscle weakness, unspecified lack of coordination, and cognitive communication deficit. Record review of Resident #55's most recent Quarterly MDS dated [DATE] revealed a BIMS of 5, which indicated severe cognitive impairment. Resident #55's MDS indicated she was dependent on staff for toileting hygiene and was always incontinent with bowel and urinary continence. During an interview on 05/04/2026 at 10:08 AM, Resident #55 indicated she did not use the bathroom located within her room and she was unaware of any issues. Record review of Resident #62's undated facesheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #62 had diagnoses which included unspecified dementia, age-related physical debility, other lack of coordination, muscle weakness, unsteadiness on feet, and weakness. Record review of Resident #62's most recent Quarterly MDS dated [DATE] revealed a BIMS of 5, which indicated severe cognitive impairment. Resident #62's MDS indicated she was dependent on staff for toileting hygiene, utilized a wheelchair for mobility, and was always incontinent with bowel and urinary continence. An observation on 05/04/2026 at 10:05 AM indicated there was no antibacterial soap in the shared bathroom of Resident #55 and #62. An interview was attempted on 05/04/2026 at 10:10 AM with Resident #62, but she was unable to answer questions appropriately. During an observation on 05/04/2026 at 10:59 AM, housekeeping was observed cleaning the bathroom of Residents #55 and #62. During an observation on 05/04/2026 at 11:02 AM, there was no antibacterial soap observed in the bathroom of Residents #55 and #62. During an observation on 05/04/2026 at 3:43 PM, there was no antibacterial soap observed in the bathrooms of Residents #36, #40, #55, and #62. During an observation on 05/05/2026 at 8:30 AM, there was no antibacterial soap observed in the bathrooms of Residents #36, #40, #55, and #62. During an observation on 05/06/2026 at 8:42 AM, there was no antibacterial soap observed in the bathrooms of Residents #36, #40, #55, and #62. During an interview on 05/06/2026 at 8:56 AM, the Housekeeping Supervisor indicated it was the responsibility of housekeeping staff to ensure antibacterial soap was located in each resident's bathroom. The Housekeeping Supervisor indicated antibacterial soap was not in the dispenser because the dispenser needed to be replaced by maintenance. She indicated she had obtained pump bottles of antibacterial soap to be placed in resident bathrooms while they waited for maintenance. She indicated housekeeping should have notified her there was no antibacterial soap in these bathrooms. She indicated she believed gaps in communication to have created the problem of resident bathrooms not having antibacterial soap. The Housekeeping Supervisor recognized that it was a sanitation issue for residents, staff, and guests to not have antibacterial soap available in resident bathrooms for hand hygiene. During an interview on 05/06/2026 at 9:34 AM, Floor Tech A indicated he was filling in for housekeeping staff. Floor Tech A indicated he had just cleaned Resident #55 and #62's shared bathroom and noticed there was no antibacterial soap. Floor Tech A indicated he should have told the housekeeping supervisor and asked about the process on notifying her. Floor Tech A indicated it is a hygiene issue for residents, staff, and guests to not have antibacterial soap available in resident bathrooms for hand hygiene. During an interview on 05/06/2026 at 9:35 AM, CNA A indicated she provided care to Residents #36, #40, #55, and #62. CNA A indicated she washed her hands before and after providing direct care to residents, specifically incontinent care with Residents #55 and #62. CNA A indicated she utilized the nutrition room behind the nurses station to wash her hands due to the lack of soap in the resident's bathrooms. CNA A indicated she expected soap to be in the resident's bathrooms and she probably should have told housekeeping staff about the lack of soap. CNA A indicated the risk to residents for a lack of access to antibacterial soap for proper hand hygiene included the risk of infection. During an interview on 05/06/2026 at 9:41 AM, CNA B indicated he provided care to Residents #36, #40, #55, and #62. CNA B indicated he washed his hands before and after providing direct care to residents. CNA B indicated if there was no soap in the residents bathroom he utilized the nutrition room behind the nurses station to wash his hands. CNA B indicated he should have told somebody that there was no soap in the bathrooms, but that he got busy providing care to residents. During an interview on 05/06/2026 at 9:48 AM, LVN D indicated she was unaware of any issues with resident bathrooms. LVN D indicated she was unsure if CNAs were utilizing the nutrition room to conduct hand hygiene. LVN D indicated that a lack of antibacterial soap available in resident bathrooms for residents, staff, and guests could cause a risk of infection. LVN D indicated housekeeping was responsible for ensuring soap was in resident bathrooms and if she was notified she would have told the housekeeping supervisor. During an observation and interview on 05/06/2026 at 9:54 AM, the Life Safety Director was seen repairing the soap dispenser for Residents #55 and #62's shared bathroom. The Life Safety Director indicated he was unaware the soap dispensers were broken as a maintenance request had not been placed in the system. During an interview on 05/06/2026 at 10:03 AM, the Housekeeping Supervisor indicated she had notified the Life Safety Director that the soap dispensers were broken, but had not put in a request for maintenance. During an interview on 05/06/2026 at 10:43 AM, the DON indicated she expected CNAs to wash their hands prior to leaving a resident's room after providing direct care and she was aware of the issue with the lack of antibacterial soap in resident bathrooms. The DON indicated CNAs should have notified housekeeping about the lack of soap. The DON indicated she was unsure why CNAs would not have told housekeeping the resident bathrooms did not have soap. The DON indicated there is a risk of infection for residents, staff, and guests if they do not have access to antibacterial soap. During an interview on 05/06/2026 at 11:10 AM, the ADM indicated he had the expectation that broken equipment be fixed, supplies be replenished as needed, and staff to inform the maintenance director when things needed to be replaced. The ADM indicated he did not believe there was a risk to residents through staff as they were still able to conduct hand hygiene and guests had access to soap in the public restrooms, but indicated residents should not have to perform their own toileting function and not have a chance to wash their hands. A record review of a facility grievance dated 01/06/2026 revealed a complaint regarding a lack of toilet paper, hand soap in the bathroom dispenser, liners in the trash cans, and an unclean room. The facility grievance indicated the room was inspected and cleaned and toilet paper and paper towels were replenished. The facility grievance does not indicate soap was provided to the resident bathroom. A record review of the Maintenance Log dated 05/05/2025 through 05/05/2026 revealed no closed or open work orders related to fixing the soap dispensers. Record review of facility policy titled Infection Prevention and Control Program last revised 10/2022 indicated the following: 6. The facility will provide areas, equipment, and supplies to implement its Infection Control Program with the goal of:Ready availability of hand cleaning supplies and paper towels at each sink

Based on observations, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 3 resident bathrooms (the shared bathroom of Resident #55 and Resident #62) reviewed for environment. The facility failed to ensure Resident #55 and Resident #62's shared bathroom was free of water on the floor, wet towels, and flying insects. This failure could place residents at risk of an unsanitary environment which could lead to a decrease in quality of life. The findings included: Resident #55Record review of Resident #55's undated facesheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #55 had diagnoses which included unspecified dementia, diabetes, morbid obesity due to excess calories, muscle weakness, unspecified lack of coordination, and cognitive communication deficit. Record review of Resident #55's most recent Quarterly MDS dated [DATE] revealed a BIMS of 5, which indicated severe cognitive impairment. Resident #55's MDS indicated she was dependent on staff for toileting hygiene and was always incontinent with bowel and urinary continence. Resident #62Record review of Resident #62's undated facesheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #62 had diagnoses which included unspecified dementia, age-related physical debility, other lack of coordination, muscle weakness, unsteadiness on feet, and weakness. Record review of Resident #62's most recent Quarterly MDS dated [DATE] revealed a BIMS of 5, which indicated severe cognitive impairment. Resident #62's MDS indicated she was dependent on staff for toileting hygiene, utilized a wheelchair for mobility, and was always incontinent with bowel and urinary continence. An observation on 05/04/2026 at 10:05 AM indicated Residents #55 and #62's bathroom had water on the floor, wet towels and blankets surrounding the toilet and underneath the sink, and flying insects. During an interview on 05/04/2026 at 10:08 AM, Resident #55 indicated she did not use the bathroom located within her room and she was unaware of any issues. An interview was attempted on 05/04/2026 at 10:10 AM with Resident #62, but she was unable to answer questions appropriately. An observation on 05/04/2026 at 10:59 AM, housekeeping was observed cleaning the bathroom of Residents #55 and #62. During an observation on 05/04/2026 at 11:02 AM, the same towels remained on the wet floor and flying insects were still present in the bathroom of Residents #55 and #62. During an observation on 05/04/2026 at 3:43 PM, the same towels remained on the wet floor and flying insects were still present in the bathroom of Residents #55 and #62. During an observation 05/05/2026 at 8:30 AM, the same towels remained on the wet floor and flying insects were still present in the bathroom of Residents #55 and #62. During an observation on 05/06/2026 at 8:42 AM, the same towels remained on the wet floor and flying insects were still present in the bathroom of Residents #55 and #62. During an interview on 05/06/2026 at 8:45 AM, the Life Safety Director indicated a water line outside was being fixed and was causing water to come out from underneath the toilet in Resident #55 and #62's shared bathroom. The Life Safety Director indicated housekeeping should have been changing the towels and mopping up excess water. The Life Safety Director recognized the flying insects in the room but indicated he did not know what they were. The Life Safety Director declined to indicate any potential risk to residents due to the bathrooms sanitation. During an interview on 05/06/2026 at 9:05 AM, the Housekeeping Supervisor indicated CNA's were responsible for picking up the wet towels off the ground in the shared bathroom of Residents #55 and #62. The Housekeeping Supervisor indicated that after CNA's pick up the towels, housekeeping could then mop up the excess water in the bathroom. During an interview on 05/06/2026 at 9:38 AM, CNA A indicated she did provide some care to Residents #55 and #62. CNA A indicated she was aware of the towels on the floor in the shared bathroom and she understood housekeeping was to change the towels out daily. CNA A indicated she had not been told to change the towels, but that she does not regularly provide care to that room and CNA B does. During an interview on 05/06/2026 at 9:45 AM, CNA B indicated he provided care to Residents #55 and #62. CNA B indicated Residents #55 and #62 do not use the shared bathroom, but he would enter it to obtain wet rags for the residents to wash their faces with. CNA B indicated he was aware of the towels on the floor and he believed housekeeping to be responsible for ensuring they were changed regularly. CNA B indicated he had not observed any flying insects in the shared bathroom. During an interview on 05/06/2026 at 9:50 AM, LVN D indicated she had not been notified of any issues within the shared bathroom of Residents #55 and #62. LVN D indicated she was unaware who would be responsible for ensuring wet towels were not left on the floor, but that the CNA's should know who was responsible. During an interview on 05/06/2026 at 10:50 AM, the DON indicated she was aware of the toilet in the shared bathroom of Residents #55 and #62 leaking. The DON indicated when the toilet had been leaking housekeeping was to clean the room more often. The DON indicated if CNAs knew there were wet towels on the floor they should have removed them from the shared bathroom. The DON indicated she was unaware if the task of removing the towels was assigned to any specific staff member. The DON indicated she expected CNAs to notify her of the shared bathroom's appearance. The DON indicated she believed the flying insects observed in the shared bathroom to have been gnats. During an interview on 05/06/2026 at 11:15 AM, the ADM indicated Resident #55 and #62's shared bathroom had a leaking toilet due to current construction of a pipe. The ADM indicated he was unsure how long this had occurred. The ADM indicated he was unsure who initially placed the towels on the floor to soak up the excess water, but believed it likely to have been CNAs or housekeeping staff. The ADM indicated that anybody could have picked up the wet towels. A record review of an undated facility policy titled Physical Environment/Homelike Environment indicated the following: It is the policy of this facility that the facility must provide a safe, functional, and comfortable environment for residents. A record review of facility policy titled Environmental Services - Housekeeping last revised 2022 indicated the following: Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. Procedures:All rooms of residents will be cleaned regularly. These duties include:.c. Properly clean and disinfect the restroom which includes the toilet, sink, mirror, and floor.

Based on observation, interview, and record review, the facility failed to ensure the PICC line site was maintained consistent with professional standards of practice for 1 of 1 resident reviewed for PICC line care (Resident #69). The facility failed to ensure the Peripherally Inserted Central Catheter (PICC) line dressing change for Resident #69 were performed according to physician orders, infection prevention principles, and accepted standards of nursing practice. This failure could place the residents at risk for contamination, infection, interruption of therapy and adverse outcomes.Findings included: A record review of a face sheet dated 05/06/2026 indicated Resident #69 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included intraspinal abscess, streptococcal infection, depression, phlebitis (inflammation of a vein), and thrombophlebitis (inflammatory process causing a blood clot to form in a vein) of left moral vein, non-pressure chronic ulcer of back, muscle weakness, infection following a procedure (deep incisional surgical site), and cognitive communication deficit. A record review of Resident # 69's MDS dated [DATE] Section C0500: indicated Resident #69, had a BIMS score of 15 which indicated she was cognitively intact. MDS Section K Nutritional Status: indicated, an average fluid intake per day by IV (500 cc/day or less). MDS Section O-H1: indicated IV medications. MDS Section O: indicted IV access. A record review of the physician's orders dated 05/06/2026 indicated PICC Line care: Change PICC line dressing every 7 days. Apply Bio Patch with dressing change. Change dressing PRN if loose or soiled as needed. Order status Active. Order/Start Date 04/23/2026. A record review of a Care Plans dated initiated 04/27/2026 indicated, Resident # 69 was on antibiotic therapy related to infection. Interventions indicated: PICC line care per facility protocol. An observation on 05/04/2026 at 9:30AM Resident # 69's Peripherally Inserted Central Catheter (PICC) line site covered with a Bio patch (an antimicrobial dressing designed to reduce PICC line-associated infections), was intact. The dressing was dated 4/23/2026. An observation on 05/05/2026 at 8:30AM Resident # 69's PICC line site covered with a Bio patch dressing was intact. The dressing was dated 4/23/2026. During an interview with LVN A on 5/5/2026 at 2:30PM, LVN A stated Resident #69's PICC line and dressing changes were completed by the Charge nurse or the ADON. She said the risk of not changing the IV site dressing could increase infection at the site. During an interview with LVN B (wound care team) on 5/5/2026 at 3:30PM., she said Resident #69's PICC line dressing was to be changed every seven days by the Charge nurse, or ADON per facility protocol. She further said this failure could increase the risk of infection. During an interview with ADON on 5/5/2026 at 4:00PM., she said Resident #69 had a PICC line in the upper left arm and the dressing was to be changed every seven days by the trained nursing staff or the ADON. She said Charge nurses normally changed the PICC line dressing and notified her if unable to complete it. She further said this failure could put residents at risk for infection and bloodstream infection. During an interview with LVN C on 5/6/2026 at 9:30AM., she said Resident #69's PICC line dressing was changed late the previous afternoon by ADON and confirmed the date of change was overdue. She stated the nurses typically performed the PICC line dressing change and would notify ADON if they were unable to do so. She said the failure to complete IV dressing site changes could put the residents at risk for IV site infection. During an interview with DON on 5/6/2026 at 11:30AM., she said she expected the charge nurses and the ADON to follow Physician orders, infection prevention and the facility's central line/PICC line dressing changes policies and procedures. She said this included changing PICC line dressings every seven days or sooner if compromised, as failure to do so places residents at risk of infection and device complications. A review of the Facility's Infection Prevention and Control Policy and Procedure dated/revision June / 2021, January / 2022, and October / 2022 indicated: Policy: The elements of the infection prevention and control program consist of coordination /oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Goals: Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control. A review of the Facility's Central Vascular Access Device Peripherally Inserted Central Catheter (PICC). Dated May / 2021 Reviewed August / 2022 indicated: Dressing Change Policy: The transparent dressings are changed every 7 days or sooner when it becomes loosened to the point of compromising sterility or presents a risk of accidental dislodgment of the catheter. An accumulation of moisture, fluid, blood, or exudate could also be criteria for a dressing change. A review of the Facility 'PICC Dressing Change Procedure, dated, 8 /2022 indicated: .J. apply transparent dressing with insertion site centered in the dressing. M. Label dressing and discard used supplies appropriately.N. Chart the procedure.

Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 2 of 2 residents (Resident #3 and Resident #6) reviewed for medical records accuracy.The facility failed to ensure Resident #3's and Resident #6's OOH DNR records were complete and accurately signed and dated. This failure could place residents at risk for receiving resuscitation actions against their declared instructions. Findings included:1.A record review of Resident #3's face sheet dated 05/06/2026 indicated he was a [AGE] year-old male who admitted to the facility 11/20/2020. He had diagnoses which included cerebral infarction (a stroke), diabetes, and coronary heart disease (a progressive condition where plaque [fat, cholesterol, calcium) builds up in the heart's arteries, restricting blood flow).A record review of a quarterly MDS dated [DATE] noted Resident #3 had a BIMS score of 5 which indicated his cognition was severely impaired. A record review of Resident #3's EHR noted his profile was flagged with a DNR status.A record review of Resident #3's physician's orders dated 05/06/2026 reflected an order which read Do Not Resuscitate OOH DNR on chart and was dated 04/28/2025.A record review of Resident #3's care plan reflected he had elected a Do Not Resuscitate status with a goal to honor his Advance Directive. A record review of an OOH DNR form with witness signatures dated 01/20/2026 indicated the form was signed by Resident #3 but was not dated. Further review of the form indicated the physician's signature was undated also.2. A record review of Resident #6's face sheet dated 05/06/2026 indicated he was a [AGE] year-old male who admitted to the facility 04/05/2016. He had diagnoses which included myasthenia gravis (a chronic autoimmune neuromuscular disease characterized by fluctuating voluntary muscle weakness), diabetes, cerebral infarction (a stroke), chronic venous ulcer, PVD (peripheral vascular disease), memory deficit, and hypertension (high blood pressure). A record review of an annual MDS dated [DATE] noted Resident #6 had a BIMS score of 7 which indicated his cognition was severely impaired. A record review of Resident #6's EHR noted his profile was with a DNR status.A record review of Resident #6's physician's orders dated 05/06/2026 reflected an order which read DNR-DO Not RESUSCITATE and was dated 07/09/2025.A record review of Resident #6's care plan reflected he had elected a Do Not Resuscitate status dated as initiated on 01/25/2023 and revised on 02/15/2024. A record review of an OOH DNR form with witness signatures dated 01/20/2026 indicated the form was signed by Resident #6 but was not dated. Further review of the form indicated the physician's signature was undated also.During an interview on 05/05/2026 at 03:58 PM, the SW said she was responsible for ensuring OOH DNR forms were properly executed with dated signatures of both, the person requesting DNR status and the physician. She said Resident #3's and Resident #6's most recent OOH DNRs were not valid because of the missing dates and should not have been placed into their charts. The SW said incomplete and inaccurately executed OOH DNR forms could place residents at risk for receiving resuscitation actions against their desired wishes and/or instructions. A review of the facility's undated policy titled Advance Directives and Associated Documentation indicated the following: It is the policy of this facility to implement the resident decisions and directives that are in compliance with State and/or Federal Law and the policies of this facility.5. When the Advance Directive is completed: a. Review the Advance Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent. A review of the Instructions For Issuing An OOH-DNR Order provided on the Texas Department of State Health Services' OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH DNR) ORDER form included the following instructions: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A.A review of the official State of Texas website for obtaining an OOH DNR form indicated the following: An OOH DNR Order form must be properly executed in accordance with the instructions on the opposite side to be considered a valid form by emergency medical services personnel.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility did not obtain physician order's for wound care to her post-surgical incision sites during her stay at the facility from 3/28/26 to 4/8/26. LVN A did not obtain physician order's for the betadine (a widely used, non-stinging antiseptic that kills germs) she applied to Resident #1's post-surgical incision sights. The facility did not thoroughly assess and document Resident #1's post-surgical incision sites on 3/29/26 and 3/31/26. The facility did not assess and document Resident #1's post-surgical incision sites on 3/30/26and 4/1/26 through 4/8/26. The facility did not follow up to schedule Resident #1's post operative appointment with the orthopedic surgeon. Resident #1 was sent to the hospital on 4/8/26 and treated for dehiscence (surgical complication where a closed incision reopens) and infection of the left lateral incision ((incision to the outer aspect of the left knee extending above and below the knee). Resident #1 returned to her home with a wound vacuum in place. These failures could place residents at risk for deterioration and infection, complications of chronic health conditions and hospitalization. Findings included:Record review of Resident #1's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses of encounter for orthopedic aftercare and anticoagulants (commonly known as blood thinners, are medications that prevent or reduce blood clot formation by slowing down the body's clotting process). Record review of the admission MDS dated [DATE], indicated Resident #1 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for toileting, showering/bathing, dressing the upper/lower body, and putting on/taking off footwear. The MDS indicated Resident #1 required supervision with oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 was dependent on staff for all position changes ( rolling left to right; sit to lying, lying to sitting, sit to stand) and transfers. The MDS indicated Resident #1 was always incontinent of bowel and bladder. The MDS indicated Resident #1 had surgical wounds. Record review of Resident #1's care plan dated 4/2/26 indicated Resident #1 risk for pressure injury development. The care plan interventions included notifying the nurse of new areas of redness, blisters, bruises/discoloration; weekly head to toe skin assessment. The care plan did not address post surgical care or assessment to her post-surgical incision sites. Record review of the hospital wound/ostomy/assessment/care re-evaluation dated 3/27/26 documented Resident #1 had received an open reduction internal fixation of the tibia/fibula (a surgical procedure used to repair complex or displaced fractures of the shin bone [tibia] and/or the smaller lower leg bone [fibula]) (left leg) on 3/21/26 as well as an open reduction internal fixation of the right femur (thigh bone) on 3/23/26. The hospital wound/ostomy/assessment/care re-evaluation documented the following post-surgical incision sites: *Surgical incision to the left anterior measuring leg 15 cm in length and 1 cm in width closed with sutures. The document described the wound as approximated; moist; red with approximated edges (approximated wounds have edges that fit tightly together [e.g., closed by stitches, staples, or glue]) with scant serosanguineous drainage (a thin, watery wound discharge that is pale pink or light red, containing both blood [sanguineous] and serum [serous]). The document described the surrounding skin as edematous (issue that is abnormally swollen due to an excessive accumulation of fluid in intercellular spaces) and ecchymotic (describes a skin discoloration caused by ecchymosis-the medical term for a large bruise). *Surgical incision to the left lateral leg (incision to the outer aspect of the left knee extending above and below the knee) measuring leg 24 cm in length and 1 cm in width closed with sutures. The document described the wound as approximated; moist; purple with approximate edges with scant serosanguineous drainage. The document described the surrounding skin as edematous, ecchymotic and purple. * Surgical incision to the right lateral leg measuring leg 29 cm in length and 1 cm in width closed (with staples). The document described the wound as approximated; moist; with approximated edges with scant serosanguineous drainage. The document described the surrounding skin as edematous, ecchymotic and purple. Record review of the hospital after visit summary dated 3/28/26 for Resident #1 did not list any physician orders for her surgical sites. Record Review of Resident #1's progress note dated 3/29/26 at 9:23 a.m., documented as follows: *Skin issue #001- right lateral thigh- surgical wound- present on admission described as approximated, with no dehiscence, closed with staples, healing ridge, length of 35 cm and width of 1 cm. *Skin issue #002- left shin -noting two incision areas present on admission described as approximated, with no dehiscence, closed with sutures, healing ridge (a normal, firm, or bumpy area that develops beneath a surgical incision or wound as it heals), length of 17 cm and width of 1 cm. Further review revealed there was no measurement was provided for 2nd incision to left shin. Record Review of Resident #1's progress note dated 3/30/26 at 5:02 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN B. Record review of Resident #1's progress note dated 3/31/26 at 9:39 a.m. documented as follows: *Skin issue #001: right lateral thigh - surgical wound- present on admission described as approximated, with no dehiscence, closed with 29 staples, healing ridge, closed with 29 staples. The assessment indicated no measurements were obtained because the incisions were sporadically placed. *Skin issue #002: left shin- two incision areas present.11 sutures to left lower extremity, sutures to under 1st, 2nd and 3rd toes of the left foot, 27 sutures to left outer leg. No further assessment to left leg incisions were documented. This note was written by LVN A. Record Review of Resident #1's progress note dated 3/31/26 at 6:38 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN B. Record Review of Resident #1's progress note dated 4/1/26 at 5:00 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN B. Record Review of Resident #1's progress note dated 4/2/26 at 5:29 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN B. Record Review of Resident #1's progress note dated 4/3/26 at 5:53 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN B. Record Review of Resident #1's progress note dated 4/4/26 at 8:41 a.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN C.Record Review of Resident #1's progress note dated 4/4/26 at 8:45 a.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN C. Record Review of Resident #1's progress note dated 4/5/26 at 10:44 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN D. Record review of Resident #1's progress note dated 4/6/26 at 11:27 a.m., documented .Sutures under left 2nd toe and 3rd to came loose. Bleeding noted, bright red in color. (MD) here and observed with order rec. (received) to send to ER.Record review of the hospital after visit summary dated 4/6/26 for Resident #1 did not list any physician orders for her surgical sites.Record Review of Resident #1's progress note dated 4/6/26 at 10:56 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by LVN E. Record Review of Resident #1's progress note dated 4/7/26 at 5:07 p.m., indicated .skin issue: #001: skin issue has not been evaluated.skin issue: #002: skin issue has not been evaluated. This note was written by RN D. Record Review of Resident #1's progress note dated 4/8/26 at 11:34 a.m., documented .maceration (softening and breaking down of skin) noted to the left outer incision line. Record Review of the progress note dated 4/8/26 at 11:42 a.m., documented the MD had been notified of Resident #1's maceration of incision to left outer incision line. The progress note indicated Resident #1 was sent to the hospital at that time. Record review of the progress notes for Resident #1 from 3/28/26 to 4/8/26 revealed no additional assessments for Resident #1 post-surgical incision sites. Record review of the MAR/TAR for Resident #1 from 3/28/26 to 4/8/26 found no documented treatment or monitoring to any of Resident #1's surgical incisions. During an interview on 4/22/26 at 2:22 p.m., CNA F said she regularly took care of Resident #1 on the day shift. CNA F said LVN A was putting betadine on the surgical sites every day. During an interview on 4/23/26 at 9:40 a.m., LVN A said she took care of Resident #1 M-F on the 6:00 a.m. to 2:00 p.m. shift. LVN A said she applied betadine to each post-operative surgical site when she cared for her. LVN A said she could not recall who had given her the orders to apply the betadine. LVN A said she was unable to find documentation of communication with a provider in her phone regarding the betadine application. LVN A said if she had received an order it should have recorded in the EMR. LVN A said Resident #1's surgical incision were open to air when she arrived and there were no dressings. LVN A said Resident #1 was very swollen and her legs were weeping fluid from the incision sites since her admission. LVN A said staff were placing an absorbent pad under the legs and trying to position to keep the area dry. LVN A said the wound did not start looking like it was trying to open until 4/8/26. During an interview on 4/22/26 at 3:46 p.m., the Medical Director said he would not have provided treatment orders for Resident #1's surgical incisions and would expect the nurses to follow the orders from the hospital or from the orthopedic surgeon for those areas. The Medical Director said he was at her bedside and sent her to the ER on [DATE] because sutures on the left foot appeared to been open and the foot was bleeding. The Medical Director said Resident #1 was on anticoagulants and felt he could see tendon at the open area so he sent her out promptly. The Medical Director said he could not say he observed the other sights because the urgent concern was site to the left foot. During an interview on 4/23/26 at 6:09 a.m., RN D said she regularly took care of Resident #1 on the 10 p.m. to 6:00 a.m. shift. RN D said she did not recall Resident #1 having any treatment orders. RN D said she would have only performed treatment as it was needed if she did have orders because the routine care would not scheduled on her shift. RN D Resident #1 sites were open to air to her recollection. During an interview on 4/23/26 at 7:50 a.m., the DON said while the charge nurses were responsible for daily wound care, the facility had a wound manager. The DON said the wound manager role had been combined with the role of staffing coordinator and was being performed by LVN G. The DON said performance issues had been identified with LVN G in regard to failing to obtain treatment orders timely. The DON said it was felt a new person in the role would be essential to correcting these issues. The DON said on 3/18/26 LVN H had her first day in the position wound manager/staffing coordinator in conjunction with LVN G. The DON said LVN H quit without notice on 3/31/26. The DON said LVN G was now prn and had not worked in the facility since 3/23/26. The DON the facility hired a new nurse to fulfil the role of wound manager who started last week but since her first day of work has been out sick. The DON said she started in-services with her nurses regarding skin assessments on 4/2/26. The DON said nurses were in-serviced over obtaining treatment orders on 4/9/26 after finding there had been no treatment orders for Resident #1. The DON said the ADON had attempted to call and get treatment orders and schedule a follow up appointment for Resident #1 with the Orthopedic Surgeon [TT8] on 3/31/26 and could provide documentation. Record review[TT9] of the All Conversations: Appointment document dated 3/31/26 reflected the ADON had called and left a message on 3/31/26 at 12:24 pm with the Orthopedic Surgeon's clinic to schedule surgery follow-up. The document did not reflect a request for treatment orders. The document reflected the clinic attempted to return to the call to the ADON on 3/31/26 at 1:00 pm but received no answer or received a busy signal. Record review [TT10] of the All Conversations: Leg Swelling document dated 4/8/26 reflected the ADON had called and left a message on 4/8/26 at 10:20 a.m., with the Orthopedic Surgeon's clinic regarding Resident #1 leg swelling after surgery and ER advising to reach out to orthopedic surgeon. During an interview on 4/23/26 at 9:53 a.m., the ADON said she had not laid eyes on Resident #1 until 4/8/26. The ADON said she did call and leave a message to schedule her post- operative appointment but was not attempting to get any treatment orders as she was unaware there had been no orders obtained. The ADON said on 4/8/26 a family member was at the bedside and had pulled her into the room wanting to know what was being down for Resident #1's left leg incision (incision to the outer aspect of the left knee extending above and below the knee) because it looked like it was opening up. The ADON said she told the family member she was unfamiliar with what exactly was being done and she would get the nurse caring for her. The ADON said LVN A came into the room and told her she was about to notify the physician regarding Resident #1's leg because it started to look like it was opening up. The ADON said LVN A had also reported to her that Resident #1 had been sent to ER on [DATE] and was sent back to the facility. The ADON said she called the orthopedic surgeon's office again on 4/8/26 to notify the leg appeared to be opening up and Resident #1 was sent to the ER on [DATE] but discharged back to the facility. The ADON said they sent her out before receiving a return call. During[TT11] an interview on 4/22/26 at 2:41 p.m., Resident #1's family member reported she was now at home with a wound vacuum to the left leg (incision to the outer aspect of the left knee extending above and below the knee) and receiving wound care at home. An interview with LVN B was attempted via phone on 4/23/26 at 10:15 a.m. but was unsuccessful with no answer. An interview with LVN C was attempted via phone on 4/23/26 at 10:15 a.m. but was unsuccessful with no answer. [TT12] Record review of the facility policy and procedure titled Skin and Wound Monitoring and Management, revised April of 2025, stated .f. Skin and wound assessment on admission and readmission: A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented.A licensed nurse will assess/evaluate each pressure injury/and or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: 1) Measuring the skin injury; 2) Staging the skin injury (when the cause is pressure); 3) Describing the nature of the injury (e.g. pressure, stasis, surgical incision); 4) Describing the location of the skin alteration; 5) Describing the characteristics of the skin alteration.(g) Ongoing Skin and wound assessment.A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: 1) Measuring the skin injury; 2) Staging the skin injury (when the cause is pressure); 3) Describing the nature of the injury (e.g. pressure, stasis, surgical incision); 4) Describing the location of the skin alteration; 5) Describing the characteristics of the skin alteration; 6) Describing the progress with healing, and any barriers to healing which may exist; 7) Identifying any possible complications or signs/symptoms consistent with the possibility of infection.5. Treatment.b. Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after 14 days or any time the wound is worsening. 6. Monitoring a. Daily via medication administration and treatment administration records.

Based on interview and record review the facility failed to ensure accurate assessments were completed for 7 of 15 residents (Residents #9, #15, #20, #24, #25, #38, and #112) reviewed for accuracy of assessments. The facility failed to ensure (Residents #9, #15, #20, #24, #25, #38, and #112's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.Record review of Resident #9's face sheet for March 2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar type and anxiety. Record review of Resident #9's PASRR Level 1 screening done 05/01/2024 indicated she did not have a primary diagnosis of dementia and was positive for mental illness. Record review of Resident #9's PASRR Evaluation done 05/17/2024 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #9's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, bipolar disorder, and schizophrenia. 2. Record review of Resident #15's face sheet for March 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar type, insomnia, and schizophrenia. Record review of Resident #15's PASRR Level 1 screening done 08/17/2018 indicated she was positive for MI. Record review of Resident #15's PASRR Evaluation done 09/20/2022 indicated she was positive for MI. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #15's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had depression, bipolar disorder, and schizophrenia. 3. Record review of Resident #20's face sheet for March 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar type, mood disorder, anxiety, and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event). Record review of Resident #20's PASRR Level 1 screening done 11/20/2020 indicated he was positive for MI. Record review of Resident #20's significant change MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, schizophrenia, and post-traumatic stress disorder. 4. Record review of Resident #24's face sheet for March 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anxiety, depression and bipolar disorder. Record review of Resident #24's PASRR Level 1 screening done 09/02/2024 indicated she did not have a primary diagnosis of dementia and was positive for mental illness. Record review of Resident #24's PASRR Evaluation done 09/19/2024 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #24's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, bipolar disorder, and depression. 5. Record review of Resident #25's face sheet for March 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), depressive type, delusional disorder (a serious mental illness that causes people to have unshakable false beliefs for at least a month), anxiety, hoarding, and mild intellectual disabilities. Record review of Resident #25's PASRR Level 1 screening done 05/30/2019 indicated she did not have a primary diagnosis of dementia and was positive for mental illness and intellectual disabilities and developmental disabilities. Record review of Resident #25's PASRR Evaluation done 09/20/2024 indicated she was positive for intellectual and developmental disabilities and did qualify for specialized services and positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #25's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, psychotic delusions, and schizophrenia; under Other the resident had autistic disorder and mild intellectual disability. 6. Record review of Resident #38's face sheet for March 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included major depression, anxiety, insomnia, and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event). Record review of Resident #38's PASRR Level 1 screening done 01/26/2023 indicated she did not have a primary diagnosis of dementia and was positive for mental illness and intellectual disabilities and developmental disabilities. Record review of Resident #38's PASRR Evaluation done 01/27/2023 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #38's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, and post-traumatic distress disorder. 7. Record review of Resident #112's face sheet for March 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included major depression and anxiety. Record review of Resident #112's PASRR Level 1 screening done 04/05/2016 indicated he was positive for mental illness. Record review of Resident #112's PASRR Evaluation done 09/20/2022 indicated he was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. Record review of Resident #112's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety and depression. During an interview on 03/25/2025 at 3:45 PM, the MDS Coordinator said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said she also had a corporate resource person. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said she thought if the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and she was told to answer no because they were negative. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. 37495 42902 47723

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance and offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet for 1 of 4 residents (Resident #21) reviewed for nutrition. The facility failed to ensure Resident #21 received a health shake (nutritional supplement) on 03/24/25, 03/25/25, 03/26/25 and 2 desserts on 03/24/25, 03/25/25 with her meals as prescribed by the physician. These failures placed the resident at risk for weight loss, malnutrition, loss of energy, and decreased quality of life. Findings included: Record review of a face sheet dated 3/26/2025 indicated Resident #21 was a [AGE] year-old female who admitted on [DATE] with diagnoses which included dementia (decline in cognitive function that affects memory, thinking, and social abilities), major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest), iron deficiency (lack of iron in the body), vitamin D deficiency (lack of vitamin D in the body), muscle weakness, and abnormal weight loss. Record review of Resident #21's physician orders dated 03/26/2025 indicated she had an order, dated 02/24/2022, for a regular mechanical soft diet and to receive a health shake (nutritional supplement) with her meals and 2 desserts for lunch and dinner. Resident #21 had an order, dated 02/17/2025, for 4 ounces of house supplement four times a day. Record review of the comprehensive care plan dated 03/26/2025 for Resident #21 indicated she had a nutritional problem related to protein calorie malnutrition, history of abnormal weight loss, and vitamin deficiency initiated on 03/02/2022 and revised on 10/17/2023. Interventions included diet as ordered by the physician and RD to evaluate and make diet change recommendations as needed. Record review of a quarterly MDS dated [DATE] indicated Resident #21 made herself understood and usually understood others. Resident #21 had a BIMS score of 6 indicating she had severe cognitive impairment. The MDS indicated Resident #21 had significant weight loss of 5% or more in a month or loss of 10% in the last 6 months. The MDS indicated Resident #21's height was 62 inches and her weight was 98 pounds. Record review of the Resident #21's recorded weights indicated she weighed: 109.2 lbs. on 10/02/2024 103.6 lbs. on 11/15/2024 102.4 lbs. on 12/04/2024 98.2 lbs. on 02/12/2025 96.2 lbs. on 03/12/2025 Record review of a Quarterly Nutrition Progress Note dated 01/29/2025 indicated Resident #21 had no significant weight changes the past 3 months. Resident #21 received a regular mechanical soft diet, health shakes with meals and 2 desserts at lunch and dinner. Resident #21 received 4 ounces of house supplements three times a day. Resident #21 remained on supplements to maximize her nutrient intake. Record review of a Nutrition Progress Note dated 02/17/2025 indicated Resident #21 had significant weight loss of 10.1% in 4 months. Resident #21 received a regular mechanical soft diet, health shakes with meals and 2 desserts at lunch and dinner. Resident #21 remained on supplements to maximize her nutrient intake. RD recommendations indicated to increase house supplements to 4 ounces four times a day. Record review of Resident #21's noon meal ticket dated 03/24/2025 indicated, under tray instructions, health shake with all meals and no gravy. Resident #21's noon meal ticket did not indicate she was to receive 2 desserts at lunch and dinner. During an observation and interview on 03/24/2025 at 12:22 PM, there was a full case of Magic Cups in the kitchen freezer. The DM said she was responsible for ordering health shakes, Magic Cups, and other nutritional supplements from the food supplier. The DM said the supplier notified her a few weeks ago they did not have health shakes because the company who made them recalled them. The DM said Magic Cups are being substituted in place of health shakes until they are available again. During an observation of lunch service on 03/24/2025 at 12:55 p.m., Resident #21 was in the dining room eating lunch. There was an egg roll, orange chicken, broccoli, fried rice, and a cup of fruit cocktail for dessert on Resident #21's meal tray. Resident #21 did not receive a Magic Cup or a second dessert with her meal. During an observation on 03/25/2025 at 12:25 p.m., Resident #21 was eating lunch in the dining room. There was a roll, meatloaf, scallop potatoes, carrots, and a piece of white cake with icing for dessert on Resident #21's tray. Resident #21 did not receive a Magic Cup or a second dessert with her meal. During an observation and interview on 03/26/2025 at 7:35 a.m., Resident #21 was in her room eating breakfast. There was a piece of toast, scrambled eggs, ground sausage, and a bowl of oatmeal on Resident #21's tray. Resident #21 did not receive a Magic Cup with her meal. Resident #21 said breakfast was good, but her favorite thing was the toast. Resident #21 said there was no health shake or magic cup on her breakfast tray this morning. Resident #21 said she would drink a shake or eat an ice cream if it was on her meal tray. During an interview on 03/26/2025 at 1:41 p.m., CNA B said she had been employed at the facility for 2 months and worked the 6 a.m.-2 p.m. shift on the hall where Resident #21 resided. CNA B said Resident #21 usually ate breakfast in her room and lunch and dinner in the dining room. CNA B said Resident #21 has had weight loss and was supposed to get a health shakes with her meals. CNA B said she did pass out breakfast trays this morning but not to Resident #21. CNA B said she was not aware Resident #21 did not receive a health shake on her breakfast tray this morning. CNA B said the dietary staff were responsible for placing the health shakes on the meal trays and the nurses were supposed to check the diet orders and tray cards to ensure the residents were getting what was ordered. During an interview on 03/26/2025 at 1:41 p.m., CNA C said he had been employed at the facility for several years and worked the 6 a.m.-2 p.m. shift on the hall where Resident #21 resided. CNA C said Resident #21 usually ate breakfast in her room but ate lunch and dinner in the dining room. CNA C said Resident #21 received health shake with her meals due to weight loss. CNA B said he did not know if Resident #21 received a health shake this morning because he did not take her breakfast to her. CNA B said the dietary staff were responsible for placing the health shakes on the meal trays and the nurses were supposed to check the diet orders and tray cards to ensure the residents were getting what was ordered. During an interview on 03/26/2025 at 1:57 p.m., LVN A said she had been employed at the facility for 1 month and worked the 6 a.m.-2 p.m. shift on the hall where Resident #21 resided. LVN A said Resident #21 usually ate breakfast in her room but ate lunch and dinner in the dining room. LVN A said Resident #21 had an order to give health shakes with her meals due to weight loss. LVN A said if resident eats in the dining room the dietary staff are responsible for placing the health shakes on the meal trays and the nurses are supposed to check the diet orders and tray cards to ensure the residents were getting what was ordered. LVN A said the dietary staff do not usually put health shakes on the trays if a resident ate in their room and when that happens the nursing staff are then responsible for providing health shakes for the residents. LVN A said she did not know if Resident #21 received a health shake with her meal this morning because she did not pass out her tray or check on her until after she ate. LVN A said she was responsible for ensuring Resident #21 had received her health shakes with her meals. LVN A said a resident is at risk for weight loss if they do not receive health shakes or nutritional supplements as ordered. During an interview on 03/26/2025 at 2:22 p.m., the DON said the RD comes to the facility on ce a month and as needed and meets with her during that time to discuss residents with weight loss concerns. The DON said Resident #21's weight loss started when she was sick last month, and her appetite decreased. The DON said Resident #21 had an order for health shakes with meals to help stabilize her weight loss. The DON said if resident eats in the dining room the dietary staff are responsible for placing the health shakes on the meal trays and the nurses are supposed to check the diet orders and tray cards to ensure the residents were getting what was ordered. The DON said was not aware Resident #21 did not receive a health shake or 2 desserts for lunch on 03/24/25 and 03/25/25 or a health shake this morning. The DON said she expect residents to receive all nutritional supplements and diets as ordered by the physician. The DON said a resident is at risk for weight loss if they do not receive health shakes or nutritional supplements as ordered. Record review of the facility's policy on Nutrition Status Management revised on 12/2023 indicated, .2. Dietary Evaluation: .b. If there is a significant change in the resident's condition related to weight or nutrition, the RD will make recommendation to offer additional nutrition to those residents including all high-risk residents. Options include, but are not limited to, fortified cereal, large portions, between meal snacks, and commercial nutritional supplements.

Based on interview and observation, the facility failed to ensure the residents received mail for 2 of 7 confidential residents reviewed for right to forms of communication. The facility did not implement a system for delivering mail on Saturdays. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During a confidential interview, 2 of 7 residents said they know the mail was delivered on Saturday and if they have mail that comes in on Saturday, they want to get it on Saturday. During an interview on 1/30/2024 at 10:45 a.m., the Activity Director said she passes the weekend mail on Monday. She said when she comes to work on Monday, the residents mail was on her desk. She said she was not sure who puts it there, but she passes resident mail twice on Monday; the weekend mail held over from the weekend and the mail that come in on Monday. During an interview on 1/31/2024 at 9:55 a.m., Receptionist-A said she does not work on weekends, and she does not handle the mail on the weekend. She said Receptionist-B handles the weekend mail. During an interview on 1/31/2024 at 2:01 p.m., the Administrator said weekend Receptionist-B receives the weekend mail and gives it to the RN-C. He said, after RN-C receives the weekend mail, she passes it to the residents. During an interview on 1/31/2024 at 2:17 p.m., Receptionist -B said she does receive the mail on the weekend. She said when she gets the mail, she gives it to RN-C. She said she was not sure what RN-C does with the mail, after she gives it to her. During an interview on 01/31/2024 at 2:26 p.m., RN-C said she works the weekend, and the weekend mail was given to her by Receptionist-B. She said when she gets the weekend mail, she locks it in the medication room on the [NAME] Unit, to be passed out on Monday. She said she was not sure who picks the mail up from the medication room on Monday. During an interview with the Administrator on 02/01/2024 at 03:23 p.m., he said he does not have a policy related to resident's mail.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors for 1 of 3 sections (north side of the facility which is referred to as the Nile) of the facility reviewed for environmental conditions. The facility failed to provide an area for specialized therapy services that was conducive to the well-being of its residents by providing diathermy (a specialized therapy treatment that uses electric currents to generate heat) to a resident in a room used for storage. The facility failed to ensure the Nile section of the facility was maintained in a secure, practical, and sanitary manner due to the storage of items which included therapy equipment, carpet floor fan, dirty linen and trash barrels, wheelchairs and wheelchair parts, pressure reducing devices, large bag of trash, wall pictures, rolling stool, foot ottoman, folding table, folding chair, filing cabinet, beds, mattresses, oxygen concentrator and other miscellaneous items along both sides of the hall, in a room being utilized for specialized treatments, and by the nurses' station. These failures could place the residents, staff, and visitors at risk of receiving services, working, and visiting in an unsafe, unsanitary and uncomfortable environment. Findings included: During observations of the Nile section of the facility on 01/30/2024 at 10:20 AM reflected a resident sitting in her wheelchair in room [ROOM NUMBER], receiving diathermy (diathermy is an electrically induced heat or high frequency electromagnetic current form of physical therapy.) to her left shoulder area. A therapy staff person was sitting in a chair a few steps behind the resident. A bed with 2 mattresses on it were against the outer wall. A towel was noted lying on the floor against the side wall. There was a round table and a rectangular table in the room with empty drinking cups and miscellaneous papers noted on the tops of the tables. There were 2 (two) pieces of therapy equipment noted in the room, namely, an electrotherapy muscle stimulator (E-Stim) and the diathermy machine. There was an oxygen concentrator and a table with boxes stacked on it in the corner just inside the room. There was loose debris on the floor. The bathroom in room [ROOM NUMBER] was noted to have a small refrigerator sitting in the opening of the shower area with the doors of the refrigerator open and facing inward to the shower. A towel was noted lying on the floor along the base of the refrigerator. The door to the room was noted to be open throughout the survey. During observations of the Nile section of the facility (located on the north side of the facility) on 01/30/24 at 03:00 PM reflected empty resident rooms #'s 101- 107. The DON, ADON, HR, and DOR were using some of the empty rooms on this end of the facility for offices. Other offices in this area included the ADM and MDS Nurses offices. The therapy room and conference room were also located in this area. Residents, staff, and visitors were noted to have free access to the north end of the facility. During observations of the Nile section of the facility on 01/31/24 at 02:10 PM reflected multiple items along the east wall of the hall from the entrance into the area to the end of the building and included the following: 2 barrels used for dirty linen and trash, 6 varied sizes of framed wall pictures leaning against the wall, unused office chair, geri chair, 1 large utility cart with numerous w/c leg/foot rests, 1 large utility cart with cloth foot/heel protectors, on the shelves and w/c cushions and bolster cushion on top, knee caddy, green positioning wedge, 1 small orange cone, w/c with small plastic box on floor beside it with items in it, a container for papers needing shredding with hand weights and peg boards on top, and a red balloon on the floor. During observations of the Nile section of the facility on 01/31/24 at 02:15 PM reflected multiple items along the west wall of the hall from the entrance into the area to the end of the building and included the following: carpet blower fan for drying floors, black 3-drawer vertical filing cabinet, 2 large brown boxes stacked, portable set of stair/steps used by therapy, folding chair. 12 multiple types of walkers, wheelchair, square ottoman/footrest, 2 physical therapy stationary bikes, wheelchair cushion, and 1 large bag of trash. During observations of the wall along the back side of the nurses' station located in the center of the Nile section of the facility on 01/31/24 at 02:20 PM reflected a set of parallel bars and a small tote bag with plastic bowling pins in it. On the front side of the nurses' station was a coffee table with a wheelchair and rolling stool beside it. During an interview on 01/31/24 at 02:27 PM, the DOR said therapy uses room [ROOM NUMBER] for storage. She said therapy does not store equipment in the hall. When asked about the items along the walls of both sides of the hall, the DOR said the hall was cluttered with therapy equipment. She said the pictures located along the wall were in the room she was now using for an office. She said she moved them to the hall. She said the pictures should be put in room [ROOM NUMBER]. The DOR said therapy staff use room [ROOM NUMBER] for diathermy and E-Stim. She said residents receiving diathermy and E-stim were receiving therapy in a storage area (room [ROOM NUMBER]). She said therapy staff work with the residents in the hall at times. She said if residents need to go to the bathroom while receiving therapy, the therapy staff either take the resident to his or her room or to the bathroom in room [ROOM NUMBER].

Based on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 (Residents #1) residents reviewed for accidents. The facility failed to ensure adequate supervision for Resident #1 who was at risk for elopement. The facility staff were not aware Resident #1 was missing when he eloped on 09/18/23. The facility failed to ensure the function of Resident #1's Wander Guard Monitoring Bracelet was documented each shift for the month of July 2023, August 2023, and September 2023. The facility failed to ensure staff were trained on the facility's Wander System Policy/Procedure and Elopement Policy/Procedure. The facility staff were not aware which residents used a wander guard. An Immediate Jeopardy (IJ) was identified on 01/05/24. The IJ template was provided to the facility on [DATE] at 1:38 p.m While the IJ was removed on 01/06/24, the facility remained out of compliance at a scope of isolated and severity level with a potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk for harm, injury, or death due to elopement. Finding included: Record review of Resident #1's Face Sheet, dated 01/05/24 revealed Resident #1 was a [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that affects memory and other important mental functions), cognitive communication deficit (difficulty with understanding or producing language), aphasia following cerebral infarction (difficulty with comprehending or formulating language after a stroke), and history of falling. Resident #1 was discharged on [DATE] to a nursing facility. Record review of Resident #1's MDS dated [DATE] revealed he had severely impaired cognition and continuous inattention indicating he was easily distracted or had difficulty keeping track of what was being said. Record review of Resident #1's Care Plan dated 07/05/23 indicated he was at risk for a communication problem related to Alzheimer's Disease and history of stroke and interventions included anticipate and meet needs, assist with word finding as needed/appropriate and ensure/provide a safe environment. Resident #1 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness and interventions included document wandering behavior and monitor Wander Guard placement. Record review of Resident #1's physician's order dated 07/05/23 indicated an order to monitor placement and function of Wander Guard every shift; (+) = in place and function correctly, (-) = not working and replaced. Record review of Resident #1's Elopement/Wandering Evaluation dated 07/06/2023 at 08:25 a.m. indicated he had dementia and was disoriented. Resident #1 was at significant risk of getting to a potentially dangerous place (stairs, outside the facility). Resident #1 had a score of 11 indicating he was a high risk for elopement (Score ranges: Low risk: 0-9, High Risk:10-55). Record review of nursing note dated 07/07/23 at 10:03 a.m. indicated Resident #1 went to the front door and attempted to open it. When the alarm sounded he turned around and went back to his room. Record review of behavior note dated 07/29/23 at 09:26 a.m. indicated Resident #1 was pushing a resident in a wheelchair. They attempted to exit through the front door and the wander guard alarm alerted staff to the attempted elopement. Both residents were redirected, continue to wander throughout the facility and at risk for further elopement incidents. Record review of nursing note dated 08/13/23 at 6:44 p.m. indicated Resident #1 attempted to elope through the front door and was redirected back to his room. Record review of nursing note dated 09/18/23 at 8:58 p.m. by LVN C indicated she received a call from the police. Resident #1 walked to the store. A private citizen put him in their car and drove to a church where the police were sitting. The police brought him back to the facility. An elopement incident report dated 09/18/23 at 8:26 p.m. by LVN C indicated she received a call from the police who stated they had Resident #1. Resident #1 had walked to the store by a highway and a citizen brought him to them at a church. The police were sitting in the parking lot. Resident #1 was unable to give a description. Record review of facility Provider Investigation Report dated 09/23/2023 indicated on 09/18/23 at 6:01 p.m. Resident #1 was standing at the main entrance and a visitor let him out. Resident #1 walked to a store near the facility where an unknown individual drove him to a church parking lot where the police were at. The brought him back to the facility. An undated written interview statement by LVN D regarding Resident #1 elopement indicated she responded to the wander guard alarm then turned the alarm off after she looked and did not see anyone. LVN D assumed someone brought a wander guard resident into the building and they did not know the code because it happens so often. LVN D did not ask the nurses if anyone was missing because some employees do not know the wander guard code and set the alarm off when they bring residents in and out of the building. The facility determined a visitor let Resident #1 out and confirmed the findings. Record review of the facility's timeline for Resident #1's elopement indicated on 09/18/23 at 6:01 p.m. Resident #1 left the facility through the front door when a family member entered the door code and entered the facility. Resident #1 was seen on camera footage walking on the sidewalk in the front of the building at 6:14 p.m. and walking in the parking lot by the back door at 6:27 p.m The DON received a call from LVN D at 8:17 p.m. and was informed Resident #1 eloped. Record review of Resident #1's MAR for the month of July 2023, August 2023, and September 2023 revealed there was no documentation indicating his Wander Guard was in place and functioning or not working and replaced. Record review of www.timeanddate.com/sun for [NAME], Texas on 09/18/23 indicated sunset was 7:23 p.m. Record Review of CNA A's personnel file indicated she was hired on 10/18/23 and completed a web-based training for Wandering and Elopement on 10/20/23. There was no documented training for Wander System Monitoring Program. Record Review of NA B's personnel file indicated he was hired on 10/18/23 and completed a web-based training for Wandering and Elopement on 10/20/23. There was no documented training for Wander System Monitoring Program. During an interview on 01/04/24 at 12:55 p.m., NA B said residents at the facility who are at risk for elopement wore a wander guard bracelet which will alert staff by setting of the door alarm if they attempt leave. NA B said he did not know the residents that had a wander guard device on or what he needed to do if the wander guard alarm sounded but would ask the charge nurse or another CNA. NA B said he had worked at the facility almost 2 months and was not in-serviced on the facility's Elopement Policy or Wander System Monitoring Policy. NA B said this was his first shift back since the end of December 2023. During an interview on 01/04/24 at 1:01 p.m., CNA A said residents at the facility at risk for elopement wore a wander guard bracelet which will alert staff by setting of the door alarm if they attempt leave. CNA A said she did not know which residents had a wander guard device on. CNA A said she had worked at the facility for 2 months and was not in-serviced on the facility's Elopement Policy or Wander System Monitoring Policy. NA B said this was his first shift back since the end of December 2023. During an interview on 01/04/24 at 2:27 p.m., the DON said elopement trainings are conducted through a web-based company for new hires and annually after hire along with in-services at the facility when needed. The DON said the elopement training on web-based company was generalized and not specific to the facility's elopement policy. The DON said they do not train staff upon hire or annually on the facility's wander system policy. The DON said they had an in-service at the facility on the elopement policy and conducted elopement drills when Resident #1 eloped from the facility. The DON said LVN D responded to the wander guard alarm and turned it off when Resident #1 eloped on 09/18/23. The DON said LVN D should have accounted for the residents wearing wander guard bracelets and searched the facility grounds. LVN D did not follow the facility's elopement policy. The DON said Resident #1 would not have eloped if LVN D followed the elopement policy. The DON said she expected all staff to respond to the wander guard alarm, account for the residents and conduct a search inside the facility and outside on the grounds if a resident was unaccounted for. The DON said they had 5 residents wearing a wander guard bracelet. During an interview on 01/04/24 at 2:36 p.m., the ADON said elopement trainings are conducted through a web-based company for new hires and annually after hire along with in-services at the facility when needed. The ADON said the elopement training on the web-based company was generalized and not specific to the facility's elopement policy. The ADON said she was responsible to ensure all new hire trainings were completed. The ADON said they do not train staff upon hire or annually on the facility's wander system policy. During an observation and interview on 01/04/24 at 3:36 p.m., LVN C said she was the charge nurse and worked the 2 p.m.-10 p.m. shift on 09/18/23 when Resident #1 eloped. LVN C said at 8:15 p.m. the police called and informed her a private citizen found Resident #1 at a store then dropped him off to them at a church parking lot. LVN C said she had last seen Resident #1 at the facility around 5:30 p.m. during dinner and then at 8:26 p.m. when the police brought him back to the facility. LVN C said she did not know Resident #1 had eloped and was missing over 2 hours. LVN C said she never heard the wander guard system alarm go off during the time Resident #1 was missing. LVN C said she was in-serviced on the facility's Elopement Policy after Resident #1 had eloped. LVN C said she had not been in-serviced on the facility's Wander System Monitoring Policy. LVN C said she was responsible for monitoring a resident's wander guard bracelet for placement and function and documenting it on the resident MAR during her shift. LVN C said a plus (+) sign documented on the MAR indicates the wander guard was working during the shift and a negative (-) sign indicates it was not. LVN C was provided a copy of Resident #1's MARs for the month of July 2023, August 2023, and September 2023 and reviewed them. LVN C said Resident #1's MARs did not have a plus (+) or minus (-) sign documented on them. LVN C said there was no documentation Resident #1's wander guard was functioning properly. Record review of the facility's Elopement/Unsafe Wandering policy revised 06/2018 indicated, . It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement .Elopement is when a resident leaves the facility premises or a safe area without authorization .4. If a resident is missing it is a facility-wide emergency. The missing resident procedures will be initiated: .B. if the resident was not authorized to leave, institute a search of the premises. C. IF the resident is unaccounted for after a thorough search of the building and grounds, immediately notify: Administrator, Director of Nursing Services .D. Provide search teams with resident identification information and begin extensive search of the surrounding territory .12. Staff will be educated on proper identification, assessment, and treatment of residents with elopement risks. Education will be provided on orientation and annually thereafter. Record review of the facility's Wander System Monitoring Program policy revised 09/2007 indicated, It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents a wandering risk .All residents identified to be at risk for wandering will have a wander-monitoring bracelet. A monitoring notebook will be kept at each nurse's station identifying all residents currently using the wander monitoring system. Anytime an alarm sounds all staff is to respond and all wanderers will be accounted for. Procedures: .8. All staff is responsible to respond to alarm. 9. All new staff will be in-serviced regarding the Wander System during initial orientation. 10. All staff will be [NAME]-serviced annually .Basic Rules for Wanderer Management .6. Monitor each wanderer's wristband device each shift and record placement in the med sheet or other designated location .9. Check for that all wanderers are accounted for whenever an alarm sounds. Always assume that a second wanderer has left the facility at the same time. The Administrator was notified on 01/05/24 at 1:29 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 01/05/24 at 1:38 p.m The facility's Plan of Removal was accepted on 01/06/24 at 9:00 a.m. and included: Per the information provided in the IJ Template given on 01/05/24 at 13:38. The facility failed to follow the elopement policy and the facility failed to ensure adequate supervision for Resident #1 who was at risk for elopement. Resident #1 was found off the facility grounds in a parking lot. Facility failed to ensure the function of Resident #1 wander monitoring bracelet was documented each shift. Facility failed to ensure staff were trained on the facility's wander system/policy procedure and elopement policy/procedure. The identified resident was assessed by a licensed nurse on 9-18-2023 at 8:27 PM and found to have no injuries. The identified resident was placed on one-to-one monitoring on 9-18-2023 upon his return to the facility, until alternate placement was found at a facility with a secure unit on 9-20-2023 1. The Medical Director was notified of IJ on 01/05/24 at 1405. 2. Education initiated with all staff on elopement risk, elopement / unsafe wandering policy and procedure, wander guard system monitoring program policy and procedure. This education will be provided by the Clinical Resources, DON, ADON and cluster DON's. This training will be initiated on 01/05/24 and completed by 01/06/24. 3. All residents will be assessed for elopement risk 01/05/24 and all residents with wander guards will be assessed to assure that system is functioning and appropriate interventions and orders in place completed by DON and Clinical Resource on 01/05/24 by 1900. 4. Elopement drills will be completed with each shift starting on 01/05/24, and will continue with each shift by the clinical resources, DON, ADON, administrator and cluster DON's, cluster administrators until all staff have participated in an elopement drill to be completed by 01/08/23. Elopement drills will continue to be completed weekly x 4 weeks by the DON/ADON/Administrator or clinical resources. 5. All staff will complete a knowledge check on wander guard system and elopement policy procedure started on 01/05/24. This training will include the facility policy on elopement and use of the wander guard system to include monitoring, risk assessment and facility response. This training will be completed by 01/06/23 6. This training, elopement drill and knowledge check will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 7. An ad hoc QA meeting regarding items in the IJ template was completed on 01/05/24 at 1630. Attendees included the Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 8. Wanderguard elopement knowledge checks will be included in the orientation packet for new hires. 9. Wander guard system/doors will be checked daily by maintenance director, administrator, or weekend supervisor to assure proper functioning. On 01/06/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from a printed copy of a text message communication on 01/05/24 between the Administrator and the Medical Director. Interviews with 5 Licensed Nurses, 5 CNAs, 1 MA, 1 Dietary Staff, 1 Laundry Staff (on all shifts 8 a.m.- 5 p.m., 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. and Weekend Double) were performed on 01/06/24. All staff were able to correctly identify, elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. All staff said they completed a knowledge check on the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. During an interview on 01/06/24 at 10:39 a.m., the DON said she in-serviced the facility staff on elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. The DON said staff completed a knowledge check on the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures and will be included in the orientation packet for new hires. The DON said elopement drills were conducted and completed on each shift and will continue for each shift over the next 4 weeks. Record reviews on five resident charts wearing wander guard bracelets were completed on 01/06/24 to ensure wander guard function was documented each shift. There were no issues identified. Record review of in-services revealed staff were educated on elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. There were no issues identified. Record review of knowledge checks revealed staff completed the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures checks. There were no issues identified. Record review of Elopement Drills conducted revealed drills were completed on 01/05/24 during the 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shifts and the 6 a.m.-10 p.m. weekend double shift. There were no issues identified. Record review of the daily wander guard system/door log revealed checks were completed on 01/05/24 and 01/06/24. On 01/06/24 at 2:10 p.m., the Administrator was informed the IJ was removed; However, the facility remained out of compliance at a scope of isolated and severity level with a potential for more than minimal harm that is not immediate jeopardy.

Based on interview and record review, the facility failed to maintain accurate and complete clinical records in accordance with accepted professional standards and practices for 3 of 14 residents (Resident #s 42, 149, and 151)reviewed for accuracy of clinical information. Resident #s 42, 149, and 151's hard charts and electronic medical records (EMR) did not have corresponding information related to their code status. This failure could place residents at risk for incorrect information documented in the clinical records. Findings included: 1. Record review of the Physician orders for [DATE] indicated Resident #42 was a [AGE] year-old male readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #42 had moderate hearing issues, clear speech, was understood, and usually understood others; and he was cognitively intact with a BIMS of 14 out of 15. Record review of the care plan dated [DATE] indicated Resident #42 wished to remain a full code at this time with a goal of code status would be honored and he would be treated with dignity and respect for the next 90 days and interventions included: *Care plan team to meet with RP and myself to discuss a DNR and the use of artificial nutrition and hydration to maintain weight and other end of life decisions; *Staff will start CPR should [CONDITION(S)] occur and/or breathing independently cease, call 911 and transport to ER; *Staff will notify RP and myself of the right to request assistance in making new advance directives at anytime; and *Staff to notify MD and RP of any changes of condition. Record review of the EMR for Resident #42 from [DATE] through [DATE] indicated there was no code status listed. Record review of the hard chart indicated Resident #42 was a Full Code. During an interview on [DATE] at 09:00 a.m. the ADON said Resident #42 was a full code and she did not realize the EMR did not designate him as such. She said the EMR was primarily used for admission. She said the resident's hard chart was the chart the nurses used primarily for anything with the resident. She said it could be confusing for a new nurse or an agency nurse. 2. Record review of the Admission physician orders indicated Resident #149 was an [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #149's hard chart revealed that there was a blank baseline care plan form. There was no baseline care plan found in the EMR. Record review of the MDS revealed that it was in process for Resident #149. Record review of the hard chart for Resident #149 indicated she had an OOH-DNR signed by her on [DATE]. Record review of the hard chart for Resident #149 had no physician order indicating she was a DNR. Record review of the Advanced Directive information in the EMR dated [DATE] for Resident #149 indicated she had no Advance Directive information and CPR should be attempted. Record review of the EMR for Resident #149 had no physician order indicating she was a DNR. During an interview on [DATE] 09:00 AM the ADON said Resident #149 was a DNR. She said did not realize the EMR did not reflect the hard chart and there was no order for a DNR. 3. Record review of the Admission physician orders indicated Resident #151 was an [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the hard chart and EMR for Resident #151 revealed that there was no baseline care plan. Record review of the MDS for Resident #151 revealed that it was in process. Record review of the physician order dated [DATE] indicated Resident #151 had an OOH-DNR on the chart. Record review of the Advanced Directive information in the EMR dated [DATE] indicated Resident #151 had no Advanced Directive information and CPR should be attempted. Record review of Resident #151's hard chart indicated she was a full code. During an interview on [DATE] at 09:02 a.m. the ADON said she was responsible for the EMR and hard chart to match. She said Resident #151 was a full code and should not have a DNR order on her EMR chart. At exit, the facility was asked if there was additional information they would like to provide.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 2 of 2 residents (Resident #s 149 and 151)reviewed for the base line care plans. The facility did not complete a baseline care plan within 48 hours of admission and provide a summary for the resident or their Responsible Party (RP) for Resident #s 149 and 151. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff. Findings included: 1. Record review of the Admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS revealed that it was in process for Resident #149. Record review of Resident #149's hard chart revealed that there was a blank baseline care plan form. There were no baseline care plan found in the EMR. 2.Record review of the Admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS for Resident #151 revealed that it was in process. Record review of the hard chart and EMR for Resident #151 revealed that there was no baseline care plan. During an interview on 09/09/21 at 09:20 a.m. the MDS Nurse said it was her or the admitting nurse's responsibility for doing the baseline care plans. She said recently they had not been done. During an interview on 09/09/21 at 09:23 a.m. the ADON said the MDS Nurse was responsible for follow up of baseline care plans being done. During an interview on 09/09/21 at 11:15 a.m. the MDS Nurse said the baseline care plans were not done for Resident #s 149 and 151. She said baseline care plans were to be done within 48 hours of admission and a copy was to be provided to the family or resident. Record review of the Baseline Care Plan policy revised December 2016 indicated Policy Statement: A baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of the resident's admission. Policy Interpretation and Implementation:4. The resident and their representative will be provided a summary of the baseline care plan At exit, the facility was asked if there was additional information they would like to provide.

Based on observation, interview, and record review the facility failed to post the daily nurse staffing data at the beginning of each shift for 3 of 6 days (09/04/21, 09/05/21, 09/06/21) and did not included the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 9 of 9 months reviewed for staffing postings. The facility did not post the required staffing for 09/04/21, 09/05/21, and 09/06/21. The last one posted was 09/03/21. The facility did not include the required staffing with hours worked daily for January 2021 through September 09, 2021. These failures could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data. Findings included: 1. During an observation upon entrance to the facility on [DATE] at 08:30 a.m. the Daily Direct Care Staffing posting indicated a date of 09/03/21; there were no postings for 09/04/21, 09/05/21, or 09/06/21. During an interview on 09/09/21 at 01:41 p.m. the ADON said she posted the staffing posting after the morning meeting. She said the receptionist at the front was responsible for posting the staffing sheet on the weekends and holidays. She said she did not realize there was no updated ones since 09/03/21 when surveyors entered. During an interview on 09/09/21 at 04:20 p.m. the Receptionist said the ADON posted the staffing posting daily. She said the ADON posted it on the weekend also. 2. Record review of the Daily Direct Care Staffing sheets for January 2021 through September 09, 2021 indicated there were no actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LVNs, or CNAs on the posting. During an interview on 09/09/21 at 01:41 p.m. the ADON said she did not know she needed to place the hours on the staffing sheets also. At exit, the facility was asked if there was additional information they would like to provide.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 6 residents reviewed for care plans. (Resident #1) The facility did not assess or follow physician orders for wound care to left buttocks, right buttocks, coccyx, left and right foot for Resident #1. The facility did not implement interventions to promote the healing of multiple unstageable pressure injuries and wounds to Resident #1 according to the comprehensive care plan. These failures could place residents at risk for unmet care needs due to lack of implementation and following orders. Findings include: Record review of consolidated physician orders dated March 2021 indicated Resident #1 was [AGE] years old, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] indicated Resident #1 sometimes made herself understood, understood others, and was cognitive severe impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility and transfers; total dependence with dressing, eating, toileting, personal hygiene and bathing. The assessment indicated Resident #1 was at risk of developing pressure injuries and had three unstageable pressure injuries that were present on admission. Record review of the care plan updated on 3/4/21 indicated Resident #1 had skin concerns and the facility will monitor her skin weekly, document and report any changes in skin condition to physician and responsible party as occurring; perform treatments as per physician orders, document, report progress to physician every two weeks and as needed; clean unstageable wound to left buttocks with normal saline, apply Santyl (wound care supplies) to wound bed and cover with ABD pad (wound care supplies) daily and PRN; may have pressure reducing mattress; may have pressure reducing cushion to wheelchair; clean unstageable wound to right buttock with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN; clean unstageable wound to coccyx with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN; apply skin prep to the top of left and right foot daily. Record review of the hospital history and physical dated 2/10/21 indicated Resident #1 had been admitted to the hospital on 2/9/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order dated 3/1/21 indicated a skin assessment will be performed every 7 days and PRN. Record review of clinical file revealed there were no weekly skin assessments done between 3/1 and 3/22. Record review of the physician order dated 3/3/21 indicated the treatment order for Resident #1's coccyx was to clean with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN. Record review of the physician order dated 3/3/21 indicated the treatment order for the top of Resident #1's left, and right foot was to apply skin prep daily. Record review of a dietician/nursing/physician communication form dated 3/10/21 indicated recommendations; continue by mouth water intake; goal 1500 ml/50 oz per day, choose one of two formula options ([MEDICATION(S)] 1.5 @ 95 ml/hr.- peg tube feeding), increase formula rate from current, give 1 [MEDICATION(S)] packet (vitamin supplement). Record review of the physician order dated 3/17/21 indicated the treatment order for Resident #1's right buttock was to clean with [MEDICATION(S)] and cover with ABD pad daily and PRN. Record review of the physician order dated 3/17/21 indicated the treatment order for Resident #1's left buttock was to clean with [MEDICATION(S)] and cover with ABD pad daily and PRN. Record review of the physician order dated 3/24/21 indicated the treatment order for the top of Resident #1's left, and right foot was to clean with normal saline, apply collagen patch (wound care supplies) to open area and cover with protective dressing (wound care supplies). Record review of a wound evaluation and management summary dated 3/3/21 completed by the wound care doctor indicated Resident #1 had a: *unstageable deep tissue injury of the left buttock measured 8 centimeter in length, 8 centimeters in width and not measurable. *unstageable deep tissue injury of the right buttock measured 8 centimeter in length, 8 centimeters in width and not measurable. *unstageable deep tissue to coccyx measured 2 centimeter in length, 2 centimeters in width and not measurable. *wound of the left dorsal foot measured 1 centimeter in length, 5 centimeters in width and not measurable *wound of the right foot measured 1 centimeter in length, 5 centimeters in width and not measurable *recommendation: off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; low air mattress Record review of a wound evaluation and management summary dated 3/10/21 completed by the wound care doctor indicated Resident #1 had a: *unstageable deep tissue injury of the left buttock measured 8 centimeter in length, 10 centimeters in width and not measurable. *unstageable deep tissue injury of the right buttock measured 12.5 centimeter in length, 12 centimeters in width and not measurable. *unstageable deep tissue to coccyx measured 2 centimeter in length, 2 centimeters in width and not measurable. *wound of the left dorsal foot measured 1 centimeter in length, 5 centimeters in width and not measurable *wound of the right foot measured 1 centimeter in length, 5 centimeters in width and not measurable *recommendation: off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; low air mattress *dressing treatment plan indicated the order for Santyl was discontinued to Resident #1 coccyx. Record review of a wound evaluation and management summary dated 3/17/21 completed by the wound care doctor indicated Resident #1 had a: *unstageable deep tissue injury of the left buttock measured 8 centimeter in length, 10 centimeters in width and not measurable. *unstageable deep tissue injury of the right buttock measured 10 centimeter in length, 12 centimeters in width and not measurable. *unstageable deep tissue to coccyx measured 2 centimeter in length, 2 centimeters in width and 0.8 centimeters in depth. *wound of the left dorsal foot measured 1 centimeter in length, 1 centimeter in width and not measurable *wound of the right foot measured 1 centimeter in length, 1 centimeter in width and not measurable *recommendation: off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; low air mattress *dressing treatment plan indicated the order for Santyl was discontinued to Resident #1 coccyx, left and right buttocks. Record review of a wound evaluation and management summary dated 3/24/21 completed by the wound care doctor indicated Resident #1 had a: *unstageable deep tissue injury of the left buttock measured 8 centimeter in length, 10 centimeters in width and not measurable. *unstageable deep tissue injury of the right buttock measured 12 centimeter in length, 13 centimeters in width and not measurable. *unstageable deep tissue to coccyx measured 2 centimeter in length, 2 centimeters in width and 0.8 centimeters in depth. *wound of the left dorsal foot measured 4 centimeter in length, 2 centimeter in width and not measurable *wound of the right foot measured 4 centimeter in length, 1.5 centimeter in width and not measurable *recommendation: off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; low air mattress *dressing treatment plan indicated the order for Santyl was continued for right buttocks but discontinued to Resident #1 coccyx and left buttocks; discontinue to the skin prep to the wound of the right and left foot and apply a collagen sheet to areas. Record review of a treatment administration record dated 3/1/21-3/31/21 indicated Resident #1 wound care to her left buttocks was to cleanse with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN. Resident #1 received this wound care starting 3/3/21 to 3/29/21 but did not receive the ordered treatment. Record review of a treatment administration record dated 3/1/21-3/31/21 indicated Resident #1 wound care to her sacrum was to cleanse with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN. Resident #1 received this wound care starting 3/3/21 to 3/29/21 but did not receive the ordered treatment. Record review of a treatment administration record dated 3/1/21-3/31/21 indicated Resident #1 wound care to her right buttocks was to cleanse with normal saline, apply Santyl to wound bed and cover with ABD pad daily and PRN. Resident #1 received this wound care starting 3/3/21 to 3/29/21 but did not receive the ordered treatment. Record review of a treatment administration record dated 3/1/21-3/31/21 indicated Resident #1 wound care to her the top of her left and right foot was to apply skin prep daily. Resident #1 received wound care starting 3/3/21 to 3/12/21 but did not receive treatment from 3/13/21 to 3/22/21. During an interview on 4/10/21 at 2:14 p.m., LVN G said he was able to assist with reposition every 2 hours when he cared for Resident #1. LVN G said Resident #1 heels was always floated. During an interview on 4/10/21 at 2:33 p.m., LVN A said she was aware that the wound care doctor discontinued wound care order regarding Santyl on 3/10, 3/17 and added the Santyl back on 3/24 for Resident #1 right buttock. LVN A said she believe there is a different treatment administration record but was not able to provide a copy. LVN A said she does not know why she discontinued the wound care order to the top of Resident #1 left and right foot on 3/12/21. LVN A said skin assessments should be completed weekly. LVN A said the facility does not have a wound care nurse at this time. During an interview on 4/10/21 at 2:48 p.m., the wound care doctor said not discontinuing the Santyl or applying skin prep to Resident #1 wounds would not have caused harmed. The wound care doctor said the wound healing expectation is unrealistic due to the comorbidities and immobility. The wound care doctor said these two things alone make the wounds unavoidable and prognosis to worsens. He said Resident #1 is a hospice candidate. During an interview on 4/10/21 at 3:00 p.m., CNA H said Resident #1 was turn and reposition every 2 hours and heels floated when she cared for her. CNA H said Resident #1 required 2 persons assist. During an interview on 4/10/21 at 3:56 p.m., LVN B said the nurse that make rounds with wound care doctor is responsible for updating the TAR (treatment administration record). LVN B said skin assessments should be completed weekly and documented. During an interview on 4/10/21 at 4:09 p.m., LVN C said the wound care orders and TAR should be updated by the nurse that round with the wound care doctor. LVN C said he was aware that Resident #1 wound care orders were changed mid-month. LVN C said he did not provide the wound care he signed off on the TAR 3/27 and 3/28. He said I use [MEDICATION(S)] instead. LVN C said he was not aware that the Santyl was discontinued. LVN C said if he had of reviewed the orders, he would have realized the Santyl was discontinued and he should have still applied the skin prep to her feet. LVN C said he did not apply the skin prep to the top of Resident #1 left and right foot after 3/12/21. LVN C said 90% of the time the nurses skin assessments are done the opposite day of the wound care doctor, sometimes it may fall on a Wednesday when the wound care doctor here but that is rare. LVN C said by completing weekly skin assessment nurses can identify new wounds and the progress of the other wounds. During an interview on 4/10/21 at 4:28 p.m. the DON said the charge nurse that receives the order is responsible for updating the TAR with current treatments. The ADON is responsible for checking orders daily making sure they are carried out. The DON said she goes in and spot check to see if there is an issue with updating orders but obviously there is one, she said. The DON said she expect the orders to be updated and discontinued as new physician orders come through. The DON said the charge nurse is responsible for completing the weekly skin assessments. The DON said the nurses complete their skin assessments the same day the wound care doctor come. The DON said she spoke with the admission nurse today that admitted Resident #1 and explained to her that a skin assessment needs to be completed on admission and weekly thereafter. The DON said she cannot find Resident #1 skin assessments. The DON said her and the ADON are responsible for ensuring that the skin assessments are completed weekly by reviewing the charts to make sure the assessments are completed. During an interview on 4/10/21 at 4:41 p.m., the ADON said she expect the charge nurse that is rounding with the wound care doctor to update the TAR to his treatment plan. The ADON said the charge nurse should write the order on a telephone physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/10/21 at 5:40 p.m., RN D said skin assessments are completed every seven days and as needed. RN D said the skin assessments usually does not fall on the day the wound care doctor come unless it is that Resident day for a skin assessment to be completed. During an interview on 4/10/21 at 5:43 p.m., LVN E said skin assessments are completed once a week. LVN E said there is a schedule to tell what day assessments should be completed for each resident. LVN E said she does not complete her skin assessments on the same day the wound care does his. LVN E said it is important to complete skin assessments to see if the wounds are improving or identify new wounds. During an interview on 4/10/21 at 5:56 p.m., LVN F said skin assessments are done every week on certain days. LVN F said the assessments are not done the same day as the wound care doctor unless it falls on that day. LVN F said it is important to complete them to identify any changes and report to the physician. During an interview on 4/10/21 at 6:03 p.m., the administrator said he expect the charge nurses to discontinue the old order and updated the TAR to the physician treatment plan. The administrator said he expect the ADON to monitor the changes and ensure the correct orders are been implemented. The administrator said he imagined the skin assessments should be done weekly and document the findings in the chart. The administrator said the nursing managers is responsible for ensuring the assessments are completed. A facility policy titled Medication and Treatment orders revised 7/2016: Orders for medications and treatments will be consistent with principles of safe and effective order writing . verbal orders must be recorded immediately in the resident's chart by the person receiving the order .

Based on observation, interview and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on 1 of 3 units in the facility (Olympus unit) reviewed for resident call system. The facility did not ensure the call light panel was visible at the nurse's station, or that the audible alarm was sounding when a call light was activated on the unit. This could place residents at risk of being unable to obtain assistance in the event of an emergency. Findings included: During an observation and interview on 3/2/21 at 12:30 p.m., the maintenance director activated the call light in the shower room of the Olympus unit at surveyor request. The light in the hall illuminated, but there was no audible alarm. The maintenance director said the call light system was supposed to beep at the nurse's station and display the room number when a call light was activated. The maintenance director said he could not locate the call light panel for the Olympus unit. The maintenance director said the call light panel was about the size of a telephone and was usually on the counter at the nurse's station. During an observation and interview on 3/2/21 at 12:35 p.m., LVN A found the call light panel in a cabinet and placed it on the counter. LVN A said the call light system was messed up, but she did not know how long the system had been like that. LVN A said residents had not been provided with any other means of calling for assistance. During an observation and interview on 3/2/21 at 12:40 p.m., the maintenance director plugged in the call light panel. The shower room call light was tested again and functioned correctly including an audible alarm at the nurse's station. During an interview on 3/2/21 at 12:50 a.m., CNA B said no one had told her that the call light system was not working correctly. During an interview on 3/2/21 at 1:05 p.m., the maintenance director said no one had reported any problems with the call light system to him, and he was unaware the system was not functioning correctly. He said the normal operation of the call light system would include an illuminated light in the hall, a room number displayed on the call light panel and an audible alarm. The maintenance director said it was now working correctly, and it appeared that the only problem was that the call light panel had not been plugged in. The maintenance director said when maintenance issues were identified, staff should complete a work order via an electronic system, but most of the time he learned about issues by word of mouth. During an interview on 3/2/21 at 1:15 p.m., the administrator said he was unaware of any issues with the call light system, and that no one had reported any issues to him. He said 31 residents resided on the Olympus unit. During an interview on 3/2/21 at 2:52 p.m., the DON said she was unaware of any problems with the call light system on the Olympus unit. During an observation and interview on 3/2/21 at 3:24 p.m., a light was illuminated outside room [ROOM NUMBER], indicating the call light had been activated. room [ROOM NUMBER] was not displayed on the call light panel, and there was no audible alarm. LVN C said she had notified the maintenance director that the call light was not working correctly, and that if a call light was on, it should be beeping. During an interview on 3/2/21 at 3:27 p.m., the maintenance director said he thought a component (cable) of the call light panel was faulty and that he would replace it. A policy titled Answering the Call Light, revised October 2010, stated the purpose of the procedure is to respond to the resident's requests and needs. The policy indicated: *be sure the call light is plugged in at all times *report all defective call lights to the nurse supervisor promptly

Based on observation, interview and record review the facility failed to ensure an infection control policy and procedure designated to provide a safe and sanitary environment and to prevent the development and transmission of infectious diseases was implemented for 8 of 13 residents reviewed for infection control. (Residents #1, #2, #3, #4, #5, #6, #11, and #12) Staff did not wear N95 masks while providing care for residents on the COVID-19 unknown status unit. (Residents #11 and #12) CNAs D and E did not perform hand hygiene before or after resident contact with checking incontinent residents. (Residents #1, #2, #3, #4, #5, and #6) These failures could place residents who required assistance with incontinent care at risk for cross contamination and place residents at risk for exposure to infectious diseases. Findings included: 1. A policy titled COVID-19, Prevention and Control, revised 9/25/20, indicated a facility statement, .Isolation (Full PPE including N95 or higher, face shield/googles, gloves, & gown) (a) All new admissions (b) All re-admissions (c) Residents who have spent one or more nights away from the facility . .All new admissions will be placed in observation with transmission-based precautions for 14 days. Staff will wear a N95 or higher mask, gown, & gloves during care of the resident .Readmissions or Residents who have spent more than one night away from the facility are considered residents with an unknown COVID-19 status. A new, 14-day, quarantine period will begin upon readmission to the facility . During the entrance conference interview on 03/02/21 at 11:25 AM, the administrator said staff were now wearing surgical masks with no confirmed COVID-19 positives in the building within the last 14 days. During the entrance conference interview on 03/02/21 at 11:25 AM, the DON said there were residents with unknown COVID-19 status that were recent admissions on the Napolean unit. During an interview on 3/02/21 at 4:37 PM, LVN F said required personal protective equipment (PPE) for providing care on the unknown COVID-19 status unit she worked on included a surgical mask, gloves, gown, and face shield. She said if a resident was COVID-19 positive a N95 mask would be worn. During an interview on 3/03/21 at 5:45 AM, LVN G said staff wear a surgical mask for new residents (unknown COVID-19 status), because there were no positive COVID-19 residents in the building. During an observation on 03/03/21 at 8:42 AM, an unidentified staff member entered room [ROOM NUMBER] with Resident #s 11 and 12 (COVID-19 unknown unit), wearing a surgical mask. During an interview on 03/03/21 at 10:25 AM, the Regional Nurse said staff were wearing surgical masks with no confirmed positives in the building within the last 14 days. She said staff were switching back to N95s today (3/3/21) and were working on N95 in-services. She said staff should be wearing N95, gown, gloves, and face shield when entering unknown status resident rooms. During an interview on 3/03/21 at 10:43 AM, the DON said staff started wearing surgical masks when there were no confirmed positives in the building for at least 14 days. She said she had a conversation this morning with staff and they were now wearing N95's. She said staff should don N95, gown, gloves, and face shield or goggles when entering unknown status resident rooms. During an interview on 03/03/21 at 12:07PM, the DON identified seven residents on the resident roster with unknown COVID-19 status to include Residents: #7, #8, #9, #10, #11, and #12, and #13. 2. A policy titled Handwashing/Hand Hygiene, revised August 2010, included a policy statement stating the facility considers hand hygiene the primary means to prevent the spread of infections. The policy indicated: *all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors *wash hands with soap and water when hands are visibly soiled *use an alcohol based hand rub *before and after going on duty *before and after direct contact with residents *before moving from a contaminated body site to a clean body site during resident care *after contact with a resident's intact skin *after contact with objects in the immediate vicinity of the resident *after removing gloves Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand hygiene During an observation on 3/3/21 at 5:00 a.m., without performing hand hygiene, CNA D donned gloves and touched Resident #1's bed linens, brief and skin during an incontinent check. CNA D removed her gloves and donned new gloves without performing hand hygiene. CNA D performed an incontinent check on Resident #2 (roommate of Resident #1), then removed her gloves and performed hand hygiene. During an observation on 3/3/21 at 5:05 a.m., CNA D performed hand hygiene, donned gloves and touched Resident #3's bed linens, brief, and skin during an incontinent check. CNA D discarded the gloves and exited the room without performing hand hygiene. During an observation on 3/3/21 at 5:10 a.m., CNA D, without performing hand hygiene, donned new gloves and touched Resident #4's bed linens, brief, and skin during an incontinent check. CNA D discarded the gloves and donned new gloves without performing hand hygiene. CNA D then touched Resident #5's (roommate of Resident #4) bed linens, brief and skin during an incontinent check. CNA D discarded her gloves, and exited the room without performing hand hygiene. During an interview on 3/3/21 at 5:20 a.m., CNA D said hand hygiene could be washing hands with soap and water or using hand sanitizer. CNA D said hand hygiene should occur before going into a resident's room and when you come out, as well as between residents if providing care to both residents. CNA D said she did not perform hand hygiene between caring for residents during the observed incontinent round because her hands were broken out from using hand sanitizer so often. She said she had not told anyone at the facility that her hands were broken out from using hand sanitizer. CNA D said the facility had provided in-services on hand hygiene. During an observation on 3/3/21 at 5:26 a.m., without performing hand hygiene, CNA E entered Resident #6's room, donned gloves, and performed incontinent care for Resident #6. CNA E touched Resident #6's soiled brief, bed linens, and skin during the incontinent care. CNA E did not change gloves or sanitize her hands after removing the soiled brief and before applying a clean brief. CNA E placed the soiled brief and linens in a bag, then removed gloves and did not performing hand hygiene. CNA E emptied a trash can, picked up used drinking glasses and exited the room without performing hand hygiene. CNA E placed the trash bag in a larger bin, compressing the contents of the trash can with an ungloved hand so the lid would close. CNA E lifted the lid to the dirty linen bin with an ungloved hand and placed the soiled linen in the bin. CNA E carried the dirty glasses in one hand and went to the front door to let an oncoming staff member in the facility, then carried the dirty glasses to the kitchen. CNA E then performed hand hygiene with hand sanitizer. During an interview on 3/3/21 at 5:45 a.m., CNA E said hand hygiene could be washing hands with soap and water or using hand sanitizer. CNA E said hand hygiene should occur before and after going into a resident's room, if hands become soiled, or in between glove changes. CNA E said gloves should be changed and hand hygiene performed during incontinent care after cleaning the resident and removing the soiled brief and before applying a new brief. CNA E said she should have changed gloves and performed hand hygiene in between dirty and clean when performing incontinent care for Resident #6, and did not do so because she was nervous. During an interview on 3/3/21 at 10:45 a.m., the DON said hand hygiene could include washing hands with soap and water or using hand sanitizer. The DON said hand hygiene should occur before providing resident care and after, while providing care, before meals, after toileting or eating. The DON said hand hygiene should occur between glove changes. The DON said when providing incontinent care staff should change gloves and sanitize hands between dirty and clean. The DON said hand hygiene should occur before they leave the room or as soon as possible after leaving the room.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for 5 of 9 residents reviewed for infection control related to COVID-19 ([MEDICAL CONDITION] that is spread from person to person causing mild to severe respiratory symptoms). (Resident #s 1, 2, 3, 4, and 5) The facility did not: *ensure staff wore proper PPE when entering Resident #1, #2 and #3's rooms, who were new admission residents on quarantine. *make PPE readily available near the entrance of Resident #4 and #5's room. *place signage outside of Resident #4's room identifying transmission-based precautions, instructions for use of PPE, or instructions to see the nurse before entering the room. This failure could place residents at risk for developing COVID-19 or other infections. Findings included: A face sheet dated 08/19/20 indicated Resident #1 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A COVID-19 results summary dated 08/12/20 for Resident #1 indicated Resident #1 was tested for COVID-19 on 08/09/20 and it was not detected (negative). An MDS dated [DATE] indicated Resident #1 understood others, made her needs known, was cognitively intact, required extensive assistance with ADLs and was incontinent of bowel and bladder During an observation on 08/14/20 at 1:10 p.m., Resident #1's room was located on the designated quarantine hall or area or whatever. Something showing she was on quarantine. An isolation cart was sitting outside of Resident #1's room stocked with isolation gowns and gloves. The DON and CNA B were wearing N-95 face masks and donned isolation gowns and gloves before entering Resident #1's room. The DON and CNA B did not don a face shield or goggles before entering Resident #1's room. During an interview on 08/14/20 at 1:52 p.m., CNA B said it was her first day back in the facility since February 2020 and she did not know if the facility provided face shields to staff. During an interview on 08/14/20 at 3:36 p.m., the DON said when staff entered a room of a newly admitted resident, they should wear a N-95 mask, isolation gown, face shield or goggles, and gloves. She said staff were provided face shields and they were stored in the beauty shop. She said she sometimes forgot to don a face shield before entering a new admission quarantine room. During an observation on 08/14/20 at 1:16 p.m., LVN A was wearing a N-95 face mask and donned an isolation gown and gloves before entering Resident #1's room. LVN A did not don a face shield or goggles before entering Resident #1's room. During an interview on 08/14/20 at 1:25 p.m., LVN A said residents that were new admissions were placed on quarantine for 14 days. She said when staff entered a resident's room on quarantine, they should don a N-95 mask, isolation gown, face shield, and gloves. She said the facility provided staff with face shields. A face sheet dated 08/06/20 indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A COVID-19 results summary dated 08/07/20 for Resident #2 indicated Resident #2 was tested for COVID-19 on 08/05/20 and it was not detected (negative). An MDS dated [DATE] indicated Resident #2 understood others, made her needs known, and was cognitively intact. She required extensive assistance with ADLs and was incontinent of bowel and bladder. A face sheet dated 08/11/20 indicated Resident #3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital to post acute care facility transfer COVID-19 assessment dated [DATE] indicated Resident #3 was not tested for COVID-19 because he did not meet the CDC testing criteria. An MDS dated [DATE] indicated Resident #3 understood others, made his needs known, and was cognitively intact. He required extensive assistance with most ADLs and was incontinent of bowel and bladder. During an observation on 08/14/20 at 1:37 p.m., an isolation cart was sitting outside of Resident #2 and Resident #3's room stocked with isolation gowns and gloves. Resident #2 and #3's room was located on in the quarantine area. The ADON was wearing a N-95 face mask and entered Resident #2 and #3's room. The ADON did not don an isolation gown, gloves, face shield or goggles before entering Resident #2 and #3's room. The ADON did not provide care to Resident #2 or Resident #3. The ADON exited Resident #2 and #3's room. During an interview on 08/14/20 at 2:11 p.m., the ADON said staff should wear a N-95, isolation gown, face shield or goggles, and gloves when entering a resident's room on quarantine. During an observation on 08/14/20 at 1:49 p.m., CNA B, CNA C, and CNA D were wearing N-95 face masks. CNA B, CNA C, and CNA D entered Resident #2 and #3's room with gloves. CNA B, CNA C, and CNA D did not don an isolation gown, face shield, or goggles before entering the room. Staff wore gloves when entering the room and closed the door. During an observation on 08/14/20 at 1:53 p.m., CNA B, CNA C, and CNA D exited Resident #2 and #3's room and were not wearing and isolation gown, face shield or goggles, or gloves. During an interview on 08/14/20 at 1:53 p.m., CNA B said it was her first day back in the facility since February and she did not know if Resident #2 and #3 were on quarantine. She said she did not know if the facility provided face shields to staff. During an interview on 08/14/20 at 1:54 p.m., CNA C said she just started working at the facility and she did not know if Resident #2 and #3 were on quarantine. She said she did not know if she was provided a face shield. During an interview on 08/14/20 at 1:56 p.m., CNA D said she did not wear an isolation gown or a face shield into Resident #2 and #3's room because she thought they were off of quarantine. A face sheet dated 08/10/20 indicated Resident #4 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A COVID-19 results summary dated 08/12/20 for Resident #4 indicated the resident was tested for COVID-19 08/09/20 and it was not detected (negative). An MDS dated [DATE] indicated Resident #4 usually understood others, made her needs known, and had severely impaired cognition. She required extensive assistance with ADLs and was incontinent of bowel and bladder. A face sheet dated 08/11/20 indicated Resident #5 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #5 understood others, made her needs known, and was cognitively intact. She required supervision assistance with ADLs and was continent of bowel and bladder. During an observation on 08/14/20 at 2:26 p.m., there was no isolation cart outside of Resident #4's quarantine room. There was no signage outside of Resident #4's room identifying transmission-based precautions, instructions for use of PPE, or instructions to see the nurse before entering the room. During an observation and interview on 08/14/20 at 4:21 p.m., Resident #5 was in her room and said she returned a few days ago from a hospital stay. There was no isolation cart outside of Resident #5's room. An in-service dated 06/23/20 conducted by the DON indicated full PPE, including N-95 mask and face shield, must be worn when entering the rooms of new admissions. Staff would be assigned a face shield and N-95 mask. Face shields must be cleaned after exiting the resident's room. Masks and face shields would be stored in the beauty shop in a bag labeled with the staff member's name. During an observation on 08/14/20 at 2:18 p.m., face shields were in paper bags with staff names on the paper bags in the beauty shop. During an interview on 08/14/20 at 3:36 p.m., the DON said regardless if a resident admitted with a negative COVID-19 test, the resident was placed on a 14-day quarantine if they were a new admission or readmission. She said all staff wore N-95 masks while in the facility. She said when staff entered a room of a newly admitted resident, they should wear a N-95 mask, isolation gown, face shield or goggles, and gloves. She said staff were provided face shields and they were stored in the beauty shop. She said she sometimes forgot to don a face shield before entering a new admission quarantine room. The DON said Resident #4 recently moved to another room but Resident #4 and #5 should have isolation carts near their rooms. During an interview on 08/19/20 at 12:20 p.m., the administrator said Resident #2 and Resident #5 were tested for COVID-19 on 08/15/20 and they were waiting on the results. A COVID-19 policy revised 08/14/20 indicated .isolation (full PPE including N-95 or higher, face shield/goggles, gloves, and gown) for all new admissions, all readmissions, and residents who have spent one or more nights away from the facility .all new admissions will be placed in observation with transmission-based precautions for 14 days. Staff will wear an N-95 or higher mask, gown, and gloves during care of the resident .residents who have spent more than one night away from the facility are all considered residents with an unknown COVID-19 status. A new 14-day quarantine period will begin upon readmission to the facility .

Based on interview and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and needs of the residents in accordance with the comprehensive assessment for 6 of 6 residents reviewed for activities. (Residents #20, #21, #23, #53 and #56) The facility did not provide ongoing activities on the weekends. This failure could place residents at risk of being depressed and a decreased quality ife. Findings included: During a group interview on 12/17/19 at 10:30 a.m., Residents #20, #21,#23, #53 and #56 said there were no organized activities on Saturdays and Sundays. The residents complained of occasional boredom because of the lack of activities. They said the AD left some games on a table on Olympic Hall for the residents to play on their own. Resident #53 said the weekends were the longest two days because there was nothing to do. Resident #53, 21 and 56 said they had each notified the Activity Director (AD) or staff at some point but nothing was ever done. During an interview on 12/18/19 at 9:02 a.m., Activity Director (AD) said she only worked Monday through Friday as the AD. She said for the weekend activities, she leaves word search puzzles and a few games on a table on Olympic hall for the residents to do independently. During an interview on 12/18/19 at 9:15 a.m., the administrator said he was not aware the residents were not happy with the lack of activities being done on the weekend. He said if the residents were not happy then they would need to make changes. During an interview on 12/18/19 at 10:17 a.m., the DON said she acknowledged watching TV was not an activity. She said there was not a staff assigned to assisting with activities on the weekends. The activity calendar for December, 2019 documented the following: *Sunday 12/1/19, 12/8/19, 12/15/19, 12/22/19, & 12/29/19 - 9:30am - Worship Service - Rev. Doud 11am - Inspiration Network Channel 42 *Evening table games *Saturday 12/7/19 & 12/14/19 - Independent activities 10am - Word Search 2 p.m. - Puzzles, Dominoes, classic TV, Movies The activity calendar for November, 2019 documented the following: *Sunday 11/3/19, 11/10/19, 11/17/19, & 11/24/19 - 9:30 a.m. - Worship Service - Rev. Doud 11 a.m. - Inspiration Network Channel 42 *Evening table games *Saturday 11/2/19, 11/9/19, 11/16/19, 11/23/19, & 11/30/19 - Independent activities 10 a.m. - Word Search 2 p.m. - Puzzles, Dominoes, classic TV, Movies The activity calendar for October, 2019 documented the following: *Sunday 10/6/19, 10/13/19, 10/20/19 & 10/27/19 - 9:30 a.m. - Worship Service - Rev. Doud 11 a.m. - Inspiration Network Channel 42 *Evening table games* Relaxation *Saturday 10/5/19, 10/12/19, 10/19/19 & 10/26/19 - Independent activities 10 a.m. - Word Search 2 p.m. - Puzzles, Dominoes, classic TV, Movies The activity calendar for September, 2019 documented the following: *Sunday 9/1/19, 9/8/19, 9/15/19, 9/22/19 & 9/29/19 - 9:30 a.m. - Worship Service - Rev. Doud 11 a.m. - Inspiration Network Channel 42 Relaxation *Saturday 9/7/19, 9/14/19, 9/21/19 & 9/28/19 - Independent activities Word Search Puzzles, Dominoes, classic TV, Movies ALL DAY Undated activity director job description indicated on page 1 of 4 Job Summary: The director of activities delivers a quality program of activities that is designed to meet the needs of the individuals and groups, and functions as a team member of the multidisciplinary team. .On page 2 of 4 #14. Develops an ongoing program of meaningful activities, designed to meet the needs and interests of each resident, and is responsible for the implementation of programs. Revised Activities and social services policy dated December, 2006 indicated Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility . #7 Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays. During an interview on 12/18/19 at 4:58 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on interview and record review, the facility failed to transmit the resident assessment within the required time frame for 2 of 2 discharged residents reviewed for data encoding and transmission. (Residents #1 and #2). The facility did not submit a discharge MDS for Residents #1 and #2. This failure could affect residents who discharged from the facility at risk of not having their assessments transmitted timely. Findings included: 1. A face sheet dated 12/18/19 indicated Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The clinical record for Resident #1 indicated the discharge MDS dated [DATE] was completed but not submitted. During an interview on 12/18/19 at 10:11 a.m., the MDS nurse said Resident #1 was discharged from the facility on 07/27/19 and the discharge MDS was not transmitted because she did not upload the batch. She said Resident #1's discharge MDS should have been uploaded for transmission on 08/01/19, but it was grouped in the wrong batch. The MDS nurse said she just emailed the corporate MDS nurse and the administrator. She said the corporate MDS nurse would have to transmit it because of the facility's current computer system limitations. 2. A face sheet dated 12/18/19 indicated Resident #2 admitted to the facility on [DATE] and discharged on [DATE]. Resident #2's [DIAGNOSES REDACTED]. The clinical records for Resident #2 indicated the discharge MDS dated [DATE] was never completed and therefore not submitted. During an interview on 12/18/19 at 10:16 a.m., the MDS nurse said Resident #2 was discharged from the facility on 10/06/19 and the discharge MDS was still not completed. The MDS nurse said she was responsible for completing and submitting the MDS. She said she needed to get it done. She said she did not know how that slipped by her. She said the discharge MDS was from October, so it could not be submitted. She said she was going to get Resident #2's records from the medical records department and complete the discharge MDS immediately and it would be submitted today. She said neither one of the discharge MDS would be on a verification report because the one for Resident #2 was not completed and the one for Resident #1 was not successfully transmitted. During an interview on 12/18/19 at 10:57 a.m., the DON said the MDS should be transmitted within the required timeframes. During an interview on 12/18/19 at 02:30 p.m., the administrator said the MDS should be transmitted within the required timeframes. A policy statement for MDS completion and submission timeframes revised (MONTH) (YEAR) indicated the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. A policy statement for electronic transmission of the MDS revised (MONTH) 2010 indicated all MDS assessments and discharge and reentry records will be completed and electronically encoded into the facility's information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulation governing the transmission of MDS data. During an interview on 12/18/19 at 4:58 p.m., the administrator and staff were asked for any additional information at exit and no additional information was provided.

Based on observation, interview and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 resident reviewed for accidents. (Resident #1) CNA A performed a Hoyer lift transfer without assistance of another staff member resulting in a major injury for Resident #1. This failure could place residents who required Hoyer transfers at risk for neglect and/or injury. Findings included: Physician orders [REDACTED].#1 admitted [DATE] was [AGE] year-old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was severely impaired cognitively and required extensive 2-person assistance with transfers. The MDS indicated Resident #1 had pain that was rated severe over the last 5 days. A care plan initiated 7/16/19 and last updated 10/17/19 indicated Resident #1 had deficits with ADLs, the approach included .staff to assist with ADLs with extensive/dependent assist, transfer with Hoyer lift x 2 staff . The care plan also indicated Resident #1 was at risk for falls, the goal was for the resident to be free from any falls and would not experience any injuries related to falls. A provider investigation report dated 10/16/19 indicated this incident occurred on 10/14/19 at 6:00 p.m. and was reported to the state on 10/15/19. The report alleged CNA A did not follow proper procedure for transferring Resident #1 with a Hoyer lift and the resident fell . The resident was transferred to the hospital on [DATE] and returned with a head injury, left hip dislocation, left knee dislocation and closed left hip femoral fracture. A mobile x-ray was ordered and completed on 10/15/19, facility notified the physician. The facility administered pain medication for 3 days duration and then on a PRN (as needed) basis. A hospital discharge report dated 10/14/19 indicated Resident #1 was admitted on [DATE] with a chief complaint of fall. The hospital [DIAGNOSES REDACTED]. A hospital radiology report dated 10/14/19 indicated Resident #1 had an acute fracture to the proximal left femur (upper thigh bone), possibly intertrochanteric (between the trochanters, which are bony protrusions on the femur (thighbone). No definite fracture in bony pelvis. The femoral head (highest part of the thigh bone) appeared displaced laterally from the acetabulum (socket of the hip bone). A radiology report dated 10/15/19 of bilateral (both) hips with pelvis indicated Resident #1 had a dislocated left hip joint with underlying left proximal femoral deformity. An incident report dated 10/14/19 indicated CNA A and CNA B were transferring Resident #1 from wheelchair to bed with assist of the Hoyer lift. During the transfer the top sling came off the lift. CNA A grabbed onto the resident while CNA B lowered the resident to the ground. Resident #1 was placed on the floor on top of the Hoyer lift legs. Resident #1 voiced no pain. A head to toe assessment was completed and resident was lifted X4 staff. During an interview on 11/5/19 at 11:22 a.m., Resident #1 said there was only one person to transfer him with the Hoyer lift, he said CNA A dropped him. Resident #1 said it was not only until after he was dropped that CNA B and LVN C can into the room to help him. A typed statement dated 10/15/19 at 5:15 p.m. by the administrator, indicated she called CNA [NAME] CNA A indicated she did not follow protocol when transferring Resident #1 using the Hoyer lift, resulting in a fall. During a telephone interview on 11/5/19 at 10:41 a.m., CNA B said she was not in the room during the Hoyer transfer of Resident #1. CNA B said she was approached by LVN C to write a statement indicating she was in the room during the Hoyer transfer. During an interview on 11/5/19 at 2:00 p.m., the DON said all Hoyer transfers were to be completed with 2 staff at all times. The DON said all staff had been in-serviced and completed return demonstration. A lifting machine, using portable policy revised 12/2013 indicated two (2) nursing assistance are required to perform this procedure

Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect for 1 of 4 residents reviewed for accidents. (Resident #1) CNA A performed a Hoyer lift transfer without assistance of another staff member resulting in a major injury for Resident #1. This failure could place residents who required Hoyer transfers at risk for neglect and/or injury. Findings included: Physician orders [REDACTED].#1 admitted [DATE] was [AGE] year-old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was severely impaired cognitively and required extensive 2-person assistance with transfers. The MDS indicated Resident #1 had pain that was rated severe over the last 5 days. The pain limited the resident's day to day activities. The MDS indicated Resident #1 had a fall since admission with no injury. A care plan initiated 7/16/18 and last updated 10/17/19 indicated Resident #1 had deficits with ADLs, the approach included .staff to assist with ADLs with extensive/dependent assist, transfer with Hoyer lift x 2 staff . The care plan also indicated Resident #1 was at risk for falls, the goal was for the resident to be free from any falls and would not experience any injuries related to falls. The care plan also indicated Resident #1 had potential for pain related to contractures. A goal was to assess the cause of pain and alleviate by administering medication, treatments, relaxation techniques as needed. A provider investigation report dated 10/16/19 indicated this incident occurred on 10/14/19 at 6:00 p.m. and was reported to the state on 10/15/19. The report alleged CNA A did not follow proper procedure for transferring Resident #1 with a Hoyer lift and the resident fell . The resident was transferred to the hospital on [DATE] and returned with a head injury, left hip dislocation, left knee dislocation and closed left hip femoral fracture. A mobile x-ray was ordered and completed on 10/15/19, facility notified the physician. The facility administered pain medication for 3 days duration and then on a PRN (as needed) basis. A hospital discharge report dated 10/14/19 indicated Resident #1 was admitted on [DATE] with a chief complaint of fall. The hospital [DIAGNOSES REDACTED]. A hospital radiology report dated 10/14/19 indicated Resident #1 had an acute fracture to the proximal left femur (upper thigh bone), possibly intertrochanteric (between the trochanters, which are bony protrusions on the femur (thighbone). No definite fracture in bony pelvis. The femoral head (highest part of the thigh bone) appeared displaced laterally from the acetabulum (socket of the hip bone). A radiology report dated 10/15/19 of bilateral (both) hips with pelvis indicated Resident #1 had a dislocated left hip joint with underlying left proximal femoral deformity. An incident report dated 10/14/19 indicated CNA A and CNA B were transferring Resident #1 from wheelchair to bed with assist of the Hoyer lift. During the transfer the top sling came off the lift. CNA A grabbed onto the resident while CNA B lowered the resident to the ground. Resident #1 was placed on the floor on top of the Hoyer lift legs. Resident #1 voiced no pain. A head to toe assessment was completed and resident was lifted X4 staff. During an interview on 11/5/19 at 11:22 a.m., Resident #1 said there was only one person to transfer him with the Hoyer lift, he said CNA A dropped him. Resident #1 said it was not only until after he was dropped that CNA B and LVN C can into the room to help him. A typed statement dated 10/15/19 at 5:15 p.m. by the administrator, indicated she called CNA [NAME] CNA A indicated she did not follow protocol when transferring Resident #1 using the Hoyer lift, resulting in a fall. During a telephone interview on 11/5/19 at 10:41 a.m., CNA B said she was not in the room during the Hoyer transfer of Resident #1. CNA B said she was approached by LVN C to write a statement indicating she was in the room during the Hoyer transfer. During an interview on 11/5/19 at 2:00 p.m., the DON said all Hoyer transfers were to be completed with 2 staff at all times. The DON said all staff had been in-serviced and completed return demonstration. A lifting machine, using portable policy revised 12/2013 indicated two (2) nursing assistance are required to perform this procedure The Abuse policy dated 2019 indicated neglect includes but not limited to the failure to provide goods and services necessary to avoid physical harm .

Based on interview and record review, the facility failed to ensure residents were protected from neglect for 1 of 9 residents reviewed for neglect. (Resident # 1) The facility did not respond to a change in condition when Resident #1 was found unresponsive. Resident #1 had a low finger stick blood sugar (FSBS) reading of 68 (normal range 70-100) but was administered [MEDICATION NAME] 15 units. Approximately 4 ½ hours later, Resident #1 was unresponsive and sent to the hospital with a FSBS reading of 36. Resident #1 was admitted to the intensive care unit (ICU) and intubated. An Immediate Jeopardy was identified on 06/05/18. The Immediate Jeopardy was removed on 06/06/18; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 8 residents who were diabetics at risk for neglect, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], (from the hospital) with [DIAGNOSES REDACTED]. The hospital discharge orders (to the facility) dated 06/01/18 indicated Resident #1 was ordered [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) 4-20 units 3 times a day with meals. The transcribed physician orders [REDACTED].#1 was [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, with no sliding scale. [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) before meals and at night, per sliding scale. The administration instructions for Resident #1's [MEDICATION NAME] indicated .inject 15 units subcutaneously 3 times a day before meals and inject subcutaneously per sliding scale before meals and at bedtime . According to https://www.drugs.com/[MEDICATION NAME].html accessed on 6/11/18 indicated .[MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood . The clinical records for Resident #1 dated 06/01- 06/18 indicated no care plan to address diabetes. The clinical records for Resident #1 dated 06/01- 06/18 indicated no MDS assessment. The MAR indicated [REDACTED]. Resident #1's FSBS at 11:30 a.m. was 60 and [MEDICATION NAME] was held due to the low blood sugar. A nursing note dated 06/03/18 at 12:27 p.m., documented by LVN A indicated Resident #1 was non-responsive due to low blood sugar. Blood sugar at 11:30 a.m. was 60. Glucose gel was administered with no response after 30 minutes. Resident #1's blood sugar dropped to 48. The emergency medical service (EMS) was called to transfer resident to hospital. Physician and family were notified. The EMS checked Resident #1's blood sugar and it was 36. During an interview on 06/04/18 at 2:53 p.m., LVN A said she admitted Resident #1 to the facility on [DATE] and transferred her to the hospital on [DATE]. She said on 06/03/18 she checked Resident #1's blood sugar between 6:30 a.m. and 7:30 a.m. and it was 68. LVN A said Resident #1 was alert but acted slower than normal. She said Resident #1 was non-verbal. She said she administered the ordered 15 units of [MEDICATION NAME] at that time. LVN A said she checked on Resident #1 an hour and a half later and noticed her breakfast was untouched. She said she attempted to encourage Resident #1 to eat, but Resident #1 was less responsive than she was earlier that morning. LVN A said she checked Resident #1's blood sugar at 11:30 a.m. it was 60. She said Resident #1 was unresponsive and diaphoretic. (excessive or profuse sweating) She said she administered oral glucose and rechecked her blood sugar. She said Resident #1's blood sugar was 48. LVN A said she performed a sternal rub and Resident #1 did not respond. She said EMS was called and transferred her to the hospital. LVN A said she thought about holding Resident #1's 15 units of [MEDICATION NAME] at 6:30 a.m., but Resident #1 was in and out of being alert and she thought it would be ok to give. She said the pharmacy did not send Humalog because they said Humalog and [MEDICATION NAME] were basically the same. LVN A said the order for Humalog was per sliding scale and the order for [MEDICATION NAME] was 15 unit 3 times a day with no sliding scale. She said Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. At https://www.healthline.com/health/diabetes/humalog-[MEDICATION NAME] accessed 6/20/18 indicated .Drug feature differences .Both Humalog and [MEDICATION NAME] help lower and stabilize your blood sugar when used as prescribed. But there are a few differences between the drugs. For example, there are differences in who can take the drugs, when you can take them, and the dosage. So, these drugs are not interchangeable . The EMS records for Resident #1 dated 06/03/18 indicated paramedics arrived at the facility at 12:08 p.m. Facility staff said Resident #1's blood sugar was just checked, and it was 42. Resident #1 was completely unresponsive. Staff said Resident #1 was given 15 units of insulin at approximately 7:00 a.m. today but the resident had not eaten breakfast. Blood sugar was checked again and was 36. Resident #1's oxygen saturation was 88%, blood pressure was 134/57, and her Glascow Coma Scale (eye opening response, verbal response, and motor response) was 3 (3-totally unresponsive). Once in ambulance, Resident #1's blood sugar rose to 144, but resident was still unresponsive. The hospital records dated 06/03/18 indicated Resident #1 arrived at the hospital on [DATE] at 12:50 p.m. The records indicated Resident #1 was found to be unresponsive, low blood sugar, and in acute hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen levels) at the facility. Resident #1 was intubated (insertion of a tube into the airway) after arriving to the ED. Resident #1 .reportedly had a blood sugar in the 60's this morning and was given 15 units of insulin and her blood sugar dropped to 38. Resident #1 and most likely sustained a significant [MEDICAL CONDITIONS] event . During an interview on 06/05/18 at 8:49 a.m., Resident #1's hospital Intensive Care Unit (ICU) nurse said she had been Resident #1's nurse since her admission on 06/03/18. She said Resident #1 was currently under sedation and on a ventilator. She said Resident #1's sedation was discontinued on 06/04/18 but was restarted after Resident #1 began grimacing. She said Resident #1 was still unresponsive after medical sedation was temporarily discontinued on 06/04/18. During an observation on 06/05/18 at 9:05 a.m., Resident #1 was lying in the hospital bed. She was intubated and unresponsive. During an interview on 06/05/18 at 11:50 a.m., Resident #1's physician said on the evening of 06/02/18, she visited with Resident #1 at the facility. She said Resident #1 was sitting in her room eating dinner. The physician said Resident #1 was alert and they discussed Resident #1's therapy and Resident #1 answered her questions appropriately. She said she received a message on 06/03/18 from the facility that Resident #1 was being transferred to the hospital. Resident #1's physician said the facility should have gotten clarification on the insulin orders. Resident #1's physician said [MEDICATION NAME] should not have been administered if the blood sugar was 68. She said Resident #1's insulin orders should have had parameters. During an interview on 06/05/18 at 12:15 p.m., the pharmacy assistant director said the pharmacy received medication orders on 06/01/18 for Resident #1. He said the orders were for [MEDICATION NAME] 15 units 3 times a day before meals, [MEDICATION NAME] 35 units at night, and Humalog per sliding scale. He said he spoke with Resident #1's nurse, unable to recall her name, and asked for order clarification because Humalog and [MEDICATION NAME] were basically the same drug. He said the nurse told him to send [MEDICATION NAME] and they would use it for both the 15 units and the sliding scale. During an interview on 06/05/18 at 10:05 a.m., CNA B said she worked on 06/03/18 with Resident #1. She said she arrived at approximately 7:30 a.m. and CNA C notified her that Resident #1 was unresponsive. She was told LVN A was aware of Resident #1's change of condition. CNA B said she had not worked with Resident #1 before and did not know her baseline. She said she went into Resident #1's room at approximately 8:00 a.m. and Resident #1 was sleeping. She said Resident #1's arms were limp, and she could not wake her up. She said Resident #1's breakfast tray was untouched in her room. CNA B said she immediately notified LVN A of Resident #1's condition and LVN A said Resident #1 was always like that. CNA B said LVN A did not get up to assess Resident #1. CNA B said she and CNA C went back into Resident #1's room at approximately 11:00 a.m. and Resident #1 continued to be unresponsive and her eyes were rolled back in her head. CNA B said she notified LVN D (charge nurse on another unit) about Resident #1's condition. She said LVN D told her to perform a sternal rub on Resident #1. CNA B said she performed a sternal rub on Resident #1 and Resident #1 did not respond. She said Resident #1 had labored breathing. CNA B said she went to LVN A and asked if Resident #1 was a diabetic and was told yes. CNA B said she asked LVN A if she was going to check Resident #1's blood sugar and LVN A said yes. CNA B said LVN A checked Resident #1's blood sugar and it was 60. LVN A gave Resident #1 oral glucose, but there was no change in Resident #1's condition. She said at approximately 12:00 p.m., she and CNA C went to RN E and notified her of Resident #1's condition. CNA B said RN E immediately went into Resident #1's room and checked her oxygen level and blood sugar. CNA B said Resident #1's blood sugar was in the 40s. She said RN E performed a sternal rub and Resident #1 did not respond. CNA B said RN E told her and CNA C to stay with Resident #1 while she called EMS. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 06/05/18 at 12:29 p.m., CNA C said she worked on 06/03/18 with Resident #1. CNA C said 06/03/18 was the first time she worked with Resident #1. She said at approximately 6:30 a.m. she was making her rounds and Resident #1 was sleeping in her bed. She said she was not alarmed because several residents slept past 6:30 a.m. and did not know Resident #1's baseline. CNA C said at approximately 7:30 a.m. she took Resident #1 her breakfast tray. She said she could not wake up Resident #1. She said she immediately notified LVN A about Resident #1's condition. She said LVN A said, she was always like that and did not assess Resident #1. CNA C said her, and CNA B went into Resident #1's room around 11:00 a.m. and Resident #1 was still sleeping and unresponsive. She said CNA B notified LVN D about Resident #1's condition. She said she and CNA B applied wet rags and ice to try to wake Resident #1, but she did not respond. During an interview on 06/05/18 at 3:19 p.m., LVN D said she worked on 06/03/18. She said at approximately 11:00 a.m., CNA B asked her if she knew anything about Resident #1. LVN D said she did not know Resident #1. She said CNA B told her about Resident #1's condition and that she tried to tell LVN A but LVN A blew her off. LVN D said she asked CNA B if Resident #1 was diabetic and CNA B said yes. LVN D said she told CNA B to get LVN A and they both should go into Resident #1's room and perform a sternal rub. LVN D said she did not go assess Resident #1 because she was busy with her own residents. During an interview on 06/05/18 at 2:27 p.m., RN E said on 06/03/18 at 11:58 a.m., CNAs B and C notified her about Resident #1's condition. She said she asked the CNAs if they notified LVN A about Resident #1's condition and they said they already did and LVN A said Resident #1 was fine. RN E said she immediately went into Resident #1's room and the resident had labored breathing and was unresponsive. She said Resident #1's oxygen saturation was 87%. She said after oxygen was applied, Resident #1's oxygen saturation went up to 96%. RN E said she performed a sternal rub on Resident #1 and she did not respond. She said the CNAs told her that Resident #1 was diabetic. RN E said she checked Resident #1's blood sugar and it was 43. She said LVN A was at the nursing station on the phone and she hollered at her to call Resident #1's physician. She said she told the CNAs to stay with Resident #1 while she called EMS. She said when EMS arrived, they checked Resident #1's blood sugar and it was 36. She said LVN A did not seem concerned about Resident #1's condition. During an interview on 06/06/18 at 1:20 p.m., CNA F said she worked with Resident #1 on 06/02/18 from 10:00 p.m. to 06/03/18 at 6:00 a.m. She said Resident #1 was alert and able to verbalize her needs. She said the last time she checked on Resident #1 was on 06/03/18 at 5:30 a.m. CNA F said Resident #1 was sleeping, but she woke her up to ask Resident #1 if she needed anything and she checked her for incontinence. She said Resident #1 awoke easily, said good morning to her, and told her she did not need anything. The abuse prohibition policy dated (YEAR) indicated .neglect includes but not limited to the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . The undated change of condition policy indicated .assess the resident's need for immediate care, do not leave the resident alone, assess the resident and notify the physician of the resident's condition, compare the resident's current condition to their prior level of function, and monitor resident's condition frequently until stable . The sliding scale insulin protocol dated 2007 indicated .residents with a blood sugar less than or equal to 130 would not be administered insulin . The administrator was notified on 06/05/18 at 3:38 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 06/05/18 at 7:21 p.m., and included: 1. A list of all residents with orders for Insulin administration will be reviewed/audited to ensure inclusion of hypoglycemic protocol per physician. For those residents whose orders did not address parameters and treatment of [REDACTED]. Completed by DON and designee 06/05/18 5:00 pm. 2. All residents receiving Insulin will be assessed by the DON and/or her designee for signs and symptoms of [DIAGNOSES REDACTED]. Any abnormal findings will be reported to the attending physician and the family will be notified. Completed by DON and designee 06/05/18 6:00pm. 3. Consultant Pharmacist will be notified and asked to visit facility as soon as possible to review recent order changes and assist with monitoring compliance with hypoglycemic protocols. Completed 6/5/18 at 5:20 pm by the Regional Nurse Consultant. Visit scheduled for Thursday, (MONTH) 7, (YEAR). 4. Education: A. Nursing Care of the Resident with Diabetes Mellitus (Policy) B. Insulin Administration (Policy) C. Obtaining a Fingerstick Glucose Level (policy) D. New orders received on current residents related to hypoglycemic protocols E. CNA education regarding immediately reporting delayed nurse provided resident assessment to adjacent unit nurse or nurse manager. Education of all nurses initiated on 6/4/18 and will be complete by the end of Wednesday, (MONTH) 6, (YEAR) 6:00pm by DON or designee. Any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON will ensure nurses hired after 6/5/2018 will receive training in the above stated policies related to diabetic management of residents prior to beginning work on the floor. 5. Compliance to be monitored through random observations and interviews of license nurses by DON and /or her designee at least q day x 2 wks. Residents' records requiring Insulin administration will be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. 6. Concerns/Issues will be reported to the QAPI committee monthly. On 06/06/18, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 06/06/18 at 1:02 p.m., the regional nurse said all diabetic residents' orders were reviewed by the DON and insulin parameters were added. She said the DON assessed all diabetic residents for signs and symptoms of [DIAGNOSES REDACTED] with no concerns found. She said the DON and ADON in-serviced staff on order clarification, charting on new admissions and changes of condition every shift for the first 72 hours, blood sugar checking and parameters, insulin administration, reporting and responding to changes of condition. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on 06/06/18. The regional nurse said the nurses would be monitored through random observations and interviews by the DON and /or her designee of license nurses by at least daily for two weeks. She said residents' records requiring Insulin administration would be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. During an interview on 06/06/18 at 2:01 p.m., the ADON said he in-serviced staff on symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. He said staff were in-serviced on recognizing change of condition, responding to change of condition, documentation, and insulin parameters. During interviews on 06/06/18 from 1:30 p.m. to 4:23 p.m., 7 nurses (2 from day shift, 2 from evening shift, and 3 from night shift) and 10 CNAs (4 from day shift, 4 from evening shift, and 2 from night shift) were interviewed and said they received training on change of condition and who to notify when there was a change of condition. The nurses said they received training on medication parameters, documentation on new admissions/change of condition, insulin administration, and responding to changes of condition. On 06/06/18 at 4:26 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 06/04/18 at 3:07 p.m, the DON provided a list that indicated 8 residents were diabetics.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 9 residents reviewed for neglect. (Resident # 1) The facility did not respond to a change in condition when Resident #1 was found unresponsive. Resident #1 had a low finger stick blood sugar (FSBS) reading of 68 (normal range 70-100) but was administered [MEDICATION NAME] 15 units. Approximately 4 ½ hours later, Resident #1 was unresponsive and sent to the hospital with a FSBS reading of 36. Resident #1 was admitted to the intensive care unit (ICU) and intubated. An Immediate Jeopardy was identified on 06/05/18. The Immediate Jeopardy was removed on 06/06/18; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 8 residents who were diabetics at risk for neglect, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: The abuse prohibition policy dated (YEAR) indicated .neglect includes but not limited to the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . The undated change of condition policy indicated .assess the resident's need for immediate care, do not leave the resident alone, assess the resident and notify the physician of the resident's condition, compare the resident's current condition to their prior level of function, and monitor resident's condition frequently until stable . The sliding scale insulin protocol dated 2007 indicated .residents with a blood sugar less than or equal to 130 would not be administered insulin . Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], (from the hospital) with [DIAGNOSES REDACTED]. The hospital discharge orders (to the facility) dated 06/01/18 indicated Resident #1 was ordered [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) 4-20 units 3 times a day with meals. The transcribed physician orders [REDACTED].#1 was [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, with no sliding scale. [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) before meals and at night, per sliding scale. The administration instructions for Resident #1's [MEDICATION NAME] indicated .inject 15 units subcutaneously 3 times a day before meals and inject subcutaneously per sliding scale before meals and at bedtime . According to https://www.drugs.com/[MEDICATION NAME].html accessed on 6/11/18 indicated .[MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood . The clinical records for Resident #1 dated 06/01- 06/18 indicated no care plan to address diabetes. The clinical records for Resident #1 dated 06/01- 06/18 indicated no MDS assessment. The MAR indicated [REDACTED]. Resident #1's FSBS at 11:30 a.m. was 60 and [MEDICATION NAME] was held due to the low blood sugar. A nursing note dated 06/03/18 at 12:27 p.m., documented by LVN A indicated Resident #1 was non-responsive due to low blood sugar. Blood sugar at 11:30 a.m. was 60. Glucose gel was administered with no response after 30 minutes. Resident #1's blood sugar dropped to 48. The emergency medical service (EMS) was called to transfer resident to hospital. Physician and family were notified. The EMS checked Resident #1's blood sugar and it was 36. During an interview on 06/04/18 at 2:53 p.m., LVN A said she admitted Resident #1 to the facility on [DATE] and transferred her to the hospital on [DATE]. She said on 06/03/18 she checked Resident #1's blood sugar between 6:30 a.m. and 7:30 a.m. and it was 68. LVN A said Resident #1 was alert but acted slower than normal. She said Resident #1 was non-verbal. She said she administered the ordered 15 units of [MEDICATION NAME] at that time. LVN A said she checked on Resident #1 an hour and a half later and noticed her breakfast was untouched. She said she attempted to encourage Resident #1 to eat, but Resident #1 was less responsive than she was earlier that morning. LVN A said she checked Resident #1's blood sugar at 11:30 a.m. it was 60. She said Resident #1 was unresponsive and diaphoretic. (excessive or profuse sweating) She said she administered oral glucose and rechecked her blood sugar. She said Resident #1's blood sugar was 48. LVN A said she performed a sternal rub and Resident #1 did not respond. She said EMS was called and transferred her to the hospital. LVN A said she thought about holding Resident #1's 15 units of [MEDICATION NAME] at 6:30 a.m., but Resident #1 was in and out of being alert and she thought it would be ok to give. She said the pharmacy did not send Humalog because they said Humalog and [MEDICATION NAME] were basically the same. LVN A said the order for Humalog was per sliding scale and the order for [MEDICATION NAME] was 15 unit 3 times a day with no sliding scale. She said Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. The EMS records for Resident #1 dated 06/03/18 indicated paramedics arrived at the facility at 12:08 p.m. Facility staff said Resident #1's blood sugar was just checked, and it was 42. Resident #1 was completely unresponsive. Staff said Resident #1 was given 15 units of insulin at approximately 7:00 a.m. today but the resident had not eaten breakfast. Blood sugar was checked again and was 36. Resident #1's oxygen saturation was 88%, blood pressure was 134/57, and her Glascow Coma Scale (eye opening response, verbal response, and motor response) was 3 (3-totally unresponsive). Once in ambulance, Resident #1's blood sugar rose to 144, but resident was still unresponsive. The hospital records dated 06/03/18 indicated Resident #1 arrived at the hospital on [DATE] at 12:50 p.m. The records indicated Resident #1 was found to be unresponsive, low blood sugar, and in acute hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen levels) at the facility. Resident #1 was intubated (insertion of a tube into the airway) after arriving to the ED. Resident #1 .reportedly had a blood sugar in the 60's this morning and was given 15 units of insulin and her blood sugar dropped to 38. Resident #1 and most likely sustained a significant [MEDICAL CONDITIONS] event . During an interview on 06/05/18 at 8:49 a.m., Resident #1's hospital Intensive Care Unit (ICU) nurse said she had been Resident #1's nurse since her admission on 06/03/18. She said Resident #1 was currently under sedation and on a ventilator. She said Resident #1's sedation was discontinued on 06/04/18 but was restarted after Resident #1 began grimacing. She said Resident #1 was still unresponsive after medical sedation was temporarily discontinued on 06/04/18. During an observation on 06/05/18 at 9:05 a.m., Resident #1 was lying in the hospital bed. She was intubated and unresponsive. During an interview on 06/05/18 at 11:50 a.m., Resident #1's physician said on the evening of 06/02/18, she visited with Resident #1 at the facility. She said Resident #1 was sitting in her room eating dinner. The physician said Resident #1 was alert and they discussed Resident #1's therapy and Resident #1 answered her questions appropriately. She said she received a message on 06/03/18 from the facility that Resident #1 was being transferred to the hospital. Resident #1's physician said the facility should have gotten clarification on the insulin orders. Resident #1's physician said [MEDICATION NAME] should not have been administered if the blood sugar was 68. She said Resident #1's insulin orders should have had parameters. At https://www.healthline.com/health/diabetes/humalog-[MEDICATION NAME] accessed 6/20/18 indicated .Drug feature differences .Both Humalog and [MEDICATION NAME] help lower and stabilize your blood sugar when used as prescribed. But there are a few differences between the drugs. For example, there are differences in who can take the drugs, when you can take them, and the dosage. So, these drugs are not interchangeable . During an interview on 06/05/18 at 12:15 p.m., the pharmacy assistant director said the pharmacy received medication orders on 06/01/18 for Resident #1. He said the orders were for [MEDICATION NAME] 15 units 3 times a day before meals, [MEDICATION NAME] 35 units at night, and Humalog per sliding scale. He said he spoke with Resident #1's nurse, unable to recall her name, and asked for order clarification because Humalog and [MEDICATION NAME] were basically the same drug. He said the nurse told him to send [MEDICATION NAME] and they would use it for both the 15 units and the sliding scale. During an interview on 06/05/18 at 10:05 a.m., CNA B said she worked on 06/03/18 with Resident #1. She said she arrived at approximately 7:30 a.m. and CNA C notified her that Resident #1 was unresponsive. She was told LVN A was aware of Resident #1's change of condition. CNA B said she had not worked with Resident #1 before and did not know her baseline. She said she went into Resident #1's room at approximately 8:00 a.m. and Resident #1 was sleeping. She said Resident #1's arms were limp, and she could not wake her up. She said Resident #1's breakfast tray was untouched in her room. CNA B said she immediately notified LVN A of Resident #1's condition and LVN A said Resident #1 was always like that. CNA B said LVN A did not get up to assess Resident #1. CNA B said she and CNA C went back into Resident #1's room at approximately 11:00 a.m. and Resident #1 continued to be unresponsive and her eyes were rolled back in her head. CNA B said she notified LVN D (charge nurse on another unit) about Resident #1's condition. She said LVN D told her to perform a sternal rub on Resident #1. CNA B said she performed a sternal rub on Resident #1 and Resident #1 did not respond. She said Resident #1 had labored breathing. CNA B said she went to LVN A and asked if Resident #1 was a diabetic and was told yes. CNA B said she asked LVN A if she was going to check Resident #1's blood sugar and LVN A said yes. CNA B said LVN A checked Resident #1's blood sugar and it was 60. LVN A gave Resident #1 oral glucose, but there was no change in Resident #1's condition. She said at approximately 12:00 p.m., she and CNA C went to RN E and notified her of Resident #1's condition. CNA B said RN E immediately went into Resident #1's room and checked her oxygen level and blood sugar. CNA B said Resident #1's blood sugar was in the 40s. She said RN E performed a sternal rub and Resident #1 did not respond. CNA B said RN E told her and CNA C to stay with Resident #1 while she called EMS. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 06/05/18 at 12:29 p.m., CNA C said she worked on 06/03/18 with Resident #1. CNA C said 06/03/18 was the first time she worked with Resident #1. She said at approximately 6:30 a.m. she was making her rounds and Resident #1 was sleeping in her bed. She said she was not alarmed because several residents slept past 6:30 a.m. and did not know Resident #1's baseline. CNA C said at approximately 7:30 a.m. she took Resident #1 her breakfast tray. She said she could not wake up Resident #1. She said she immediately notified LVN A about Resident #1's condition. She said LVN A said, she was always like that and did not assess Resident #1. CNA C said her, and CNA B went into Resident #1's room around 11:00 a.m. and Resident #1 was still sleeping and unresponsive. She said CNA B notified LVN D about Resident #1's condition. She said she and CNA B applied wet rags and ice to try to wake Resident #1, but she did not respond. During an interview on 06/05/18 at 3:19 p.m., LVN D said she worked on 06/03/18. She said at approximately 11:00 a.m., CNA B asked her if she knew anything about Resident #1. LVN D said she did not know Resident #1. She said CNA B told her about Resident #1's condition and that she tried to tell LVN A but LVN A blew her off. LVN D said she asked CNA B if Resident #1 was diabetic and CNA B said yes. LVN D said she told CNA B to get LVN A and they both should go into Resident #1's room and perform a sternal rub. LVN D said she did not go assess Resident #1 because she was busy with her own residents. During an interview on 06/05/18 at 2:27 p.m., RN E said on 06/03/18 at 11:58 a.m., CNAs B and C notified her about Resident #1's condition. She said she asked the CNAs if they notified LVN A about Resident #1's condition and they said they already did and LVN A said Resident #1 was fine. RN E said she immediately went into Resident #1's room and the resident had labored breathing and was unresponsive. She said Resident #1's oxygen saturation was 87%. She said after oxygen was applied, Resident #1's oxygen saturation went up to 96%. RN E said she performed a sternal rub on Resident #1 and she did not respond. She said the CNAs told her that Resident #1 was diabetic. RN E said she checked Resident #1's blood sugar and it was 43. She said LVN A was at the nursing station on the phone and she hollered at her to call Resident #1's physician. She said she told the CNAs to stay with Resident #1 while she called EMS. She said when EMS arrived, they checked Resident #1's blood sugar and it was 36. She said LVN A did not seem concerned about Resident #1's condition. During an interview on 06/06/18 at 1:20 p.m., CNA F said she worked with Resident #1 on 06/02/18 from 10:00 p.m. to 06/03/18 at 6:00 a.m. She said Resident #1 was alert and able to verbalize her needs. She said the last time she checked on Resident #1 was on 06/03/18 at 5:30 a.m. CNA F said Resident #1 was sleeping, but she woke her up to ask Resident #1 if she needed anything and she checked her for incontinence. She said Resident #1 awoke easily, said good morning to her, and told her she did not need anything. The administrator was notified on 06/05/18 at 3:38 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 06/05/18 at 7:21 p.m., and included: 1. A list of all residents with orders for Insulin administration will be reviewed/audited to ensure inclusion of hypoglycemic protocol per physician. For those residents whose orders did not address parameters and treatment of [REDACTED]. Completed by DON and designee 06/05/18 5:00 pm. 2. All residents receiving Insulin will be assessed by the DON and/or her designee for signs and symptoms of [DIAGNOSES REDACTED]. Any abnormal findings will be reported to the attending physician and the family will be notified. Completed by DON and designee 06/05/18 6:00pm. 3. Consultant Pharmacist will be notified and asked to visit facility as soon as possible to review recent order changes and assist with monitoring compliance with hypoglycemic protocols. Completed 6/5/18 at 5:20 pm by the Regional Nurse Consultant. Visit scheduled for Thursday, (MONTH) 7, (YEAR). 4. Education: A. Nursing Care of the Resident with Diabetes Mellitus (Policy) B. Insulin Administration (Policy) C. Obtaining a Fingerstick Glucose Level (policy) D. New orders received on current residents related to hypoglycemic protocols E. CNA education regarding immediately reporting delayed nurse provided resident assessment to adjacent unit nurse or nurse manager. Education of all nurses initiated on 6/4/18 and will be complete by the end of Wednesday, (MONTH) 6, (YEAR) 6:00pm by DON or designee. Any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON will ensure nurses hired after 6/5/2018 will receive training in the above stated policies related to diabetic management of residents prior to beginning work on the floor. 5. Compliance to be monitored through random observations and interviews of license nurses by DON and /or her designee at least q day x 2 wks. Residents' records requiring Insulin administration will be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. 6. Concerns/Issues will be reported to the QAPI committee monthly. On 06/06/18, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 06/06/18 at 1:02 p.m., the regional nurse said all diabetic residents' orders were reviewed by the DON and insulin parameters were added. She said the DON assessed all diabetic residents for signs and symptoms of [DIAGNOSES REDACTED] with no concerns found. She said the DON and ADON in-serviced staff on order clarification, charting on new admissions and changes of condition every shift for the first 72 hours, blood sugar checking and parameters, insulin administration, reporting and responding to changes of condition. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on 06/06/18. The regional nurse said the nurses would be monitored through random observations and interviews by the DON and /or her designee of license nurses by at least daily for two weeks. She said residents' records requiring Insulin administration would be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. During an interview on 06/06/18 at 2:01 p.m., the ADON said he in-serviced staff on symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. He said staff were in-serviced on recognizing change of condition, responding to change of condition, documentation, and insulin parameters. During interviews on 06/06/18 from 1:30 p.m. to 4:23 p.m., 7 nurses (2 from day shift, 2 from evening shift, and 3 from night shift) and 10 CNAs (4 from day shift, 4 from evening shift, and 2 from night shift) were interviewed and said they received training on change of condition and who to notify when there was a change of condition. The nurses said they received training on medication parameters, documentation on new admissions/change of condition, insulin administration, and responding to changes of condition. On 06/06/18 at 4:26 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 06/04/18 at 3:07 p.m, the DON provided a list that indicated 8 residents were diabetics.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and based on the comprehensive assessment for 1 of 9 residents reviewed for assessment. (Resident #1) The facility did not respond to a change in condition when Resident #1 was found unresponsive. Resident #1 had a low finger stick blood sugar (FSBS) reading of 68 (normal range 70-100) but was administered [MEDICATION NAME] 15 units. Approximately 4 ½ hours later, Resident #1 was unresponsive and sent to the hospital with a FSBS reading of 36. Resident #1 was admitted to the intensive care unit (ICU) and intubated. An Immediate Jeopardy was identified on 06/05/18. The Immediate Jeopardy was removed on 06/06/18; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 8 residents who were diabetics at risk for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], (from the hospital) with [DIAGNOSES REDACTED]. The hospital discharge orders (to the facility) dated 06/01/18 indicated Resident #1 was ordered [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) 4-20 units 3 times a day with meals. The transcribed physician orders [REDACTED].#1 was [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, with no sliding scale. [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) before meals and at night, per sliding scale. The administration instructions for Resident #1's [MEDICATION NAME] indicated .inject 15 units subcutaneously 3 times a day before meals and inject subcutaneously per sliding scale before meals and at bedtime . According to https://www.drugs.com/[MEDICATION NAME].html accessed on 6/11/18 indicated .[MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood . The clinical records for Resident #1 dated 06/01- 06/18 indicated no care plan to address diabetes. The clinical records for Resident #1 dated 06/01- 06/18 indicated no MDS assessment. The MAR indicated [REDACTED]. Resident #1's FSBS at 11:30 a.m. was 60 and [MEDICATION NAME] was held due to the low blood sugar. A nursing note dated 06/03/18 at 12:27 p.m., documented by LVN A indicated Resident #1 was non-responsive due to low blood sugar. Blood sugar at 11:30 a.m. was 60. Glucose gel was administered with no response after 30 minutes. Resident #1's blood sugar dropped to 48. The emergency medical service (EMS) was called to transfer resident to hospital. Physician and family were notified. The EMS checked Resident #1's blood sugar and it was 36. During an interview on 06/04/18 at 2:53 p.m., LVN A said she admitted Resident #1 to the facility on [DATE] and transferred her to the hospital on [DATE]. She said on 06/03/18 she checked Resident #1's blood sugar between 6:30 a.m. and 7:30 a.m. and it was 68. LVN A said Resident #1 was alert but acted slower than normal. She said Resident #1 was non-verbal. She said she administered the ordered 15 units of [MEDICATION NAME] at that time. LVN A said she checked on Resident #1 an hour and a half later and noticed her breakfast was untouched. She said she attempted to encourage Resident #1 to eat, but Resident #1 was less responsive than she was earlier that morning. LVN A said she checked Resident #1's blood sugar at 11:30 a.m. it was 60. She said Resident #1 was unresponsive and diaphoretic. (excessive or profuse sweating) She said she administered oral glucose and rechecked her blood sugar. She said Resident #1's blood sugar was 48. LVN A said she performed a sternal rub and Resident #1 did not respond. She said EMS was called and transferred her to the hospital. LVN A said she thought about holding Resident #1's 15 units of [MEDICATION NAME] at 6:30 a.m., but Resident #1 was in and out of being alert and she thought it would be ok to give. She said the pharmacy did not send Humalog because they said Humalog and [MEDICATION NAME] were basically the same. LVN A said the order for Humalog was per sliding scale and the order for [MEDICATION NAME] was 15 unit 3 times a day with no sliding scale. She said Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. At https://www.healthline.com/health/diabetes/humalog-[MEDICATION NAME] accessed 6/20/18 indicated .Drug feature differences .Both Humalog and [MEDICATION NAME] help lower and stabilize your blood sugar when used as prescribed. But there are a few differences between the drugs. For example, there are differences in who can take the drugs, when you can take them, and the dosage. So, these drugs are not interchangeable . The EMS records for Resident #1 dated 06/03/18 indicated paramedics arrived at the facility at 12:08 p.m. Facility staff said Resident #1's blood sugar was just checked, and it was 42. Resident #1 was completely unresponsive. Staff said Resident #1 was given 15 units of insulin at approximately 7:00 a.m. today but the resident had not eaten breakfast. Blood sugar was checked again and was 36. Resident #1's oxygen saturation was 88%, blood pressure was 134/57, and her Glascow Coma Scale (eye opening response, verbal response, and motor response) was 3 (3-totally unresponsive). Once in ambulance, Resident #1's blood sugar rose to 144, but resident was still unresponsive. The hospital records dated 06/03/18 indicated Resident #1 arrived at the hospital on [DATE] at 12:50 p.m. The records indicated Resident #1 was found to be unresponsive, low blood sugar, and in acute hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen levels) at the facility. Resident #1 was intubated (insertion of a tube into the airway) after arriving to the ED. Resident #1 .reportedly had a blood sugar in the 60's this morning and was given 15 units of insulin and her blood sugar dropped to 38. Resident #1 and most likely sustained a significant [MEDICAL CONDITIONS] event . During an interview on 06/05/18 at 8:49 a.m., Resident #1's hospital Intensive Care Unit (ICU) nurse said she had been Resident #1's nurse since her admission on 06/03/18. She said Resident #1 was currently under sedation and on a ventilator. She said Resident #1's sedation was discontinued on 06/04/18 but was restarted after Resident #1 began grimacing. She said Resident #1 was still unresponsive after medical sedation was temporarily discontinued on 06/04/18. During an observation on 06/05/18 at 9:05 a.m., Resident #1 was lying in the hospital bed. She was intubated and unresponsive. During an interview on 06/05/18 at 11:50 a.m., Resident #1's physician said on the evening of 06/02/18, she visited with Resident #1 at the facility. She said Resident #1 was sitting in her room eating dinner. The physician said Resident #1 was alert and they discussed Resident #1's therapy and Resident #1 answered her questions appropriately. She said she received a message on 06/03/18 from the facility that Resident #1 was being transferred to the hospital. Resident #1's physician said the facility should have gotten clarification on the insulin orders. Resident #1's physician said [MEDICATION NAME] should not have been administered if the blood sugar was 68. She said Resident #1's insulin orders should have had parameters. During an interview on 06/05/18 at 12:15 p.m., the pharmacy assistant director said the pharmacy received medication orders on 06/01/18 for Resident #1. He said the orders were for [MEDICATION NAME] 15 units 3 times a day before meals, [MEDICATION NAME] 35 units at night, and Humalog per sliding scale. He said he spoke with Resident #1's nurse, unable to recall her name, and asked for order clarification because Humalog and [MEDICATION NAME] were basically the same drug. He said the nurse told him to send [MEDICATION NAME] and they would use it for both the 15 units and the sliding scale. During an interview on 06/05/18 at 10:05 a.m., CNA B said she worked on 06/03/18 with Resident #1. She said she arrived at approximately 7:30 a.m. and CNA C notified her that Resident #1 was unresponsive. She was told LVN A was aware of Resident #1's change of condition. CNA B said she had not worked with Resident #1 before and did not know her baseline. She said she went into Resident #1's room at approximately 8:00 a.m. and Resident #1 was sleeping. She said Resident #1's arms were limp, and she could not wake her up. She said Resident #1's breakfast tray was untouched in her room. CNA B said she immediately notified LVN A of Resident #1's condition and LVN A said Resident #1 was always like that. CNA B said LVN A did not get up to assess Resident #1. CNA B said she and CNA C went back into Resident #1's room at approximately 11:00 a.m. and Resident #1 continued to be unresponsive and her eyes were rolled back in her head. CNA B said she notified LVN D (charge nurse on another unit) about Resident #1's condition. She said LVN D told her to perform a sternal rub on Resident #1. CNA B said she performed a sternal rub on Resident #1 and Resident #1 did not respond. She said Resident #1 had labored breathing. CNA B said she went to LVN A and asked if Resident #1 was a diabetic and was told yes. CNA B said she asked LVN A if she was going to check Resident #1's blood sugar and LVN A said yes. CNA B said LVN A checked Resident #1's blood sugar and it was 60. LVN A gave Resident #1 oral glucose, but there was no change in Resident #1's condition. She said at approximately 12:00 p.m., she and CNA C went to RN E and notified her of Resident #1's condition. CNA B said RN E immediately went into Resident #1's room and checked her oxygen level and blood sugar. CNA B said Resident #1's blood sugar was in the 40s. She said RN E performed a sternal rub and Resident #1 did not respond. CNA B said RN E told her and CNA C to stay with Resident #1 while she called EMS. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 06/05/18 at 12:29 p.m., CNA C said she worked on 06/03/18 with Resident #1. CNA C said 06/03/18 was the first time she worked with Resident #1. She said at approximately 6:30 a.m. she was making her rounds and Resident #1 was sleeping in her bed. She said she was not alarmed because several residents slept past 6:30 a.m. and did not know Resident #1's baseline. CNA C said at approximately 7:30 a.m. she took Resident #1 her breakfast tray. She said she could not wake up Resident #1. She said she immediately notified LVN A about Resident #1's condition. She said LVN A said, she was always like that and did not assess Resident #1. CNA C said her, and CNA B went into Resident #1's room around 11:00 a.m. and Resident #1 was still sleeping and unresponsive. She said CNA B notified LVN D about Resident #1's condition. She said she and CNA B applied wet rags and ice to try to wake Resident #1, but she did not respond. During an interview on 06/05/18 at 3:19 p.m., LVN D said she worked on 06/03/18. She said at approximately 11:00 a.m., CNA B asked her if she knew anything about Resident #1. LVN D said she did not know Resident #1. She said CNA B told her about Resident #1's condition and that she tried to tell LVN A but LVN A blew her off. LVN D said she asked CNA B if Resident #1 was diabetic and CNA B said yes. LVN D said she told CNA B to get LVN A and they both should go into Resident #1's room and perform a sternal rub. LVN D said she did not go assess Resident #1 because she was busy with her own residents. During an interview on 06/05/18 at 2:27 p.m., RN E said on 06/03/18 at 11:58 a.m., CNAs B and C notified her about Resident #1's condition. She said she asked the CNAs if they notified LVN A about Resident #1's condition and they said they already did and LVN A said Resident #1 was fine. RN E said she immediately went into Resident #1's room and the resident had labored breathing and was unresponsive. She said Resident #1's oxygen saturation was 87%. She said after oxygen was applied, Resident #1's oxygen saturation went up to 96%. RN E said she performed a sternal rub on Resident #1 and she did not respond. She said the CNAs told her that Resident #1 was diabetic. RN E said she checked Resident #1's blood sugar and it was 43. She said LVN A was at the nursing station on the phone and she hollered at her to call Resident #1's physician. She said she told the CNAs to stay with Resident #1 while she called EMS. She said when EMS arrived, they checked Resident #1's blood sugar and it was 36. She said LVN A did not seem concerned about Resident #1's condition. During an interview on 06/06/18 at 1:20 p.m., CNA F said she worked with Resident #1 on 06/02/18 from 10:00 p.m. to 06/03/18 at 6:00 a.m. She said Resident #1 was alert and able to verbalize her needs. She said the last time she checked on Resident #1 was on 06/03/18 at 5:30 a.m. CNA F said Resident #1 was sleeping, but she woke her up to ask Resident #1 if she needed anything and she checked her for incontinence. She said Resident #1 awoke easily, said good morning to her, and told her she did not need anything. The undated change of condition policy indicated .assess the resident's need for immediate care, do not leave the resident alone, assess the resident and notify the physician of the resident's condition, compare the resident's current condition to their prior level of function, and monitor resident's condition frequently until stable . The sliding scale insulin protocol dated 2007 indicated .residents with a blood sugar less than or equal to 130 would not be administered insulin . The administrator was notified on 06/05/18 at 3:38 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 06/05/18 at 7:21 p.m., and included: 1. A list of all residents with orders for Insulin administration will be reviewed/audited to ensure inclusion of hypoglycemic protocol per physician. For those residents whose orders did not address parameters and treatment of [REDACTED]. Completed by DON and designee 06/05/18 5:00 pm. 2. All residents receiving Insulin will be assessed by the DON and/or her designee for signs and symptoms of [DIAGNOSES REDACTED]. Any abnormal findings will be reported to the attending physician and the family will be notified. Completed by DON and designee 06/05/18 6:00pm. 3. Consultant Pharmacist will be notified and asked to visit facility as soon as possible to review recent order changes and assist with monitoring compliance with hypoglycemic protocols. Completed 6/5/18 at 5:20 pm by the Regional Nurse Consultant. Visit scheduled for Thursday, (MONTH) 7, (YEAR). 4. Education: A. Nursing Care of the Resident with Diabetes Mellitus (Policy) B. Insulin Administration (Policy) C. Obtaining a Fingerstick Glucose Level (policy) D. New orders received on current residents related to hypoglycemic protocols E. CNA education regarding immediately reporting delayed nurse provided resident assessment to adjacent unit nurse or nurse manager. Education of all nurses initiated on 6/4/18 and will be complete by the end of Wednesday, (MONTH) 6, (YEAR) 6:00pm by DON or designee. Any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON will ensure nurses hired after 6/5/2018 will receive training in the above stated policies related to diabetic management of residents prior to beginning work on the floor. 5. Compliance to be monitored through random observations and interviews of license nurses by DON and /or her designee at least q day x 2 wks. Residents' records requiring Insulin administration will be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. 6. Concerns/Issues will be reported to the QAPI committee monthly. On 06/06/18, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 06/06/18 at 1:02 p.m., the regional nurse said all diabetic residents' orders were reviewed by the DON and insulin parameters were added. She said the DON assessed all diabetic residents for signs and symptoms of [DIAGNOSES REDACTED] with no concerns found. She said the DON and ADON in-serviced staff on order clarification, charting on new admissions and changes of condition every shift for the first 72 hours, blood sugar checking and parameters, insulin administration, reporting and responding to changes of condition. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on 06/06/18. The regional nurse said the nurses would be monitored through random observations and interviews by the DON and /or her designee of license nurses by at least daily for two weeks. She said residents' records requiring Insulin administration would be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. During an interview on 06/06/18 at 2:01 p.m., the ADON said he in-serviced staff on symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. He said staff were in-serviced on recognizing change of condition, responding to change of condition, documentation, and insulin parameters. During interviews on 06/06/18 from 1:30 p.m. to 4:23 p.m., 7 nurses (2 from day shift, 2 from evening shift, and 3 from night shift) and 10 CNAs (4 from day shift, 4 from evening shift, and 2 from night shift) were interviewed and said they received training on change of condition and who to notify when there was a change of condition. The nurses said they received training on medication parameters, documentation on new admissions/change of condition, insulin administration, and responding to changes of condition. On 06/06/18 at 4:26 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 06/04/18 at 3:07 p.m, the DON provided a list that indicated 8 residents were diabetics.

Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 1 resident reviewed for insulin administration. (Resident #1) The facility did not respond to a change in condition when Resident #1 was found unresponsive. Resident #1 had a low finger stick blood sugar (FSBS) reading of 68 (normal range 70-100) but was administered [MEDICATION NAME] 15 units. Approximately 4 ½ hours later, Resident #1 was unresponsive and sent to the hospital with a FSBS reading of 36. Resident #1 was admitted to the intensive care unit (ICU) and intubated. An Immediate Jeopardy was identified on 06/05/18. The Immediate Jeopardy was removed on 06/06/18; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 8 residents who were diabetics at risk for neglect, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], (from the hospital) with [DIAGNOSES REDACTED]. The hospital discharge orders (to the facility) dated 06/01/18 indicated Resident #1 was ordered [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) 4-20 units 3 times a day with meals. The transcribed physician orders [REDACTED].#1 was [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, with no sliding scale. [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) before meals and at night, per sliding scale. The administration instructions for Resident #1's [MEDICATION NAME] indicated .inject 15 units subcutaneously 3 times a day before meals and inject subcutaneously per sliding scale before meals and at bedtime . According to https://www.drugs.com/[MEDICATION NAME].html accessed on 6/11/18 indicated .[MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood . The clinical records for Resident #1 dated 06/01- 06/18 indicated no care plan to address diabetes. The clinical records for Resident #1 dated 06/01- 06/18 indicated no MDS assessment. The MAR indicated [REDACTED]. Resident #1's FSBS at 11:30 a.m. was 60 and [MEDICATION NAME] was held due to the low blood sugar. A nursing note dated 06/03/18 at 12:27 p.m., documented by LVN A indicated Resident #1 was non-responsive due to low blood sugar. Blood sugar at 11:30 a.m. was 60. Glucose gel was administered with no response after 30 minutes. Resident #1's blood sugar dropped to 48. The emergency medical service (EMS) was called to transfer resident to hospital. Physician and family were notified. The EMS checked Resident #1's blood sugar and it was 36. During an interview on 06/04/18 at 2:53 p.m., LVN A said she admitted Resident #1 to the facility on [DATE] and transferred her to the hospital on [DATE]. She said on 06/03/18 she checked Resident #1's blood sugar between 6:30 a.m. and 7:30 a.m. and it was 68. LVN A said Resident #1 was alert but acted slower than normal. She said Resident #1 was non-verbal. She said she administered the ordered 15 units of [MEDICATION NAME] at that time. LVN A said she checked on Resident #1 an hour and a half later and noticed her breakfast was untouched. She said she attempted to encourage Resident #1 to eat, but Resident #1 was less responsive than she was earlier that morning. LVN A said she checked Resident #1's blood sugar at 11:30 a.m. it was 60. She said Resident #1 was unresponsive and diaphoretic. (excessive or profuse sweating) She said she administered oral glucose and rechecked her blood sugar. She said Resident #1's blood sugar was 48. LVN A said she performed a sternal rub and Resident #1 did not respond. She said EMS was called and transferred her to the hospital. LVN A said she thought about holding Resident #1's 15 units of [MEDICATION NAME] at 6:30 a.m., but Resident #1 was in and out of being alert and she thought it would be ok to give. She said the pharmacy did not send Humalog because they said Humalog and [MEDICATION NAME] were basically the same. LVN A said the order for Humalog was per sliding scale and the order for [MEDICATION NAME] was 15 unit 3 times a day with no sliding scale. She said Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. At https://www.healthline.com/health/diabetes/humalog-[MEDICATION NAME] accessed 6/20/18 indicated .Drug feature differences .Both Humalog and [MEDICATION NAME] help lower and stabilize your blood sugar when used as prescribed. But there are a few differences between the drugs. For example, there are differences in who can take the drugs, when you can take them, and the dosage. So, these drugs are not interchangeable . The EMS records for Resident #1 dated 06/03/18 indicated paramedics arrived at the facility at 12:08 p.m. Facility staff said Resident #1's blood sugar was just checked, and it was 42. Resident #1 was completely unresponsive. Staff said Resident #1 was given 15 units of insulin at approximately 7:00 a.m. today but the resident had not eaten breakfast. Blood sugar was checked again and was 36. Resident #1's oxygen saturation was 88%, blood pressure was 134/57, and her Glascow Coma Scale (eye opening response, verbal response, and motor response) was 3 (3-totally unresponsive). Once in ambulance, Resident #1's blood sugar rose to 144, but resident was still unresponsive. The hospital records dated 06/03/18 indicated Resident #1 arrived at the hospital on [DATE] at 12:50 p.m. The records indicated Resident #1 was found to be unresponsive, low blood sugar, and in acute hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen levels) at the facility. Resident #1 was intubated (insertion of a tube into the airway) after arriving to the ED. Resident #1 .reportedly had a blood sugar in the 60's this morning and was given 15 units of insulin and her blood sugar dropped to 38. Resident #1 and most likely sustained a significant [MEDICAL CONDITIONS] event . During an interview on 06/05/18 at 8:49 a.m., Resident #1's hospital Intensive Care Unit (ICU) nurse said she had been Resident #1's nurse since her admission on 06/03/18. She said Resident #1 was currently under sedation and on a ventilator. She said Resident #1's sedation was discontinued on 06/04/18 but was restarted after Resident #1 began grimacing. She said Resident #1 was still unresponsive after medical sedation was temporarily discontinued on 06/04/18. During an observation on 06/05/18 at 9:05 a.m., Resident #1 was lying in the hospital bed. She was intubated and unresponsive. During an interview on 06/05/18 at 11:50 a.m., Resident #1's physician said on the evening of 06/02/18, she visited with Resident #1 at the facility. She said Resident #1 was sitting in her room eating dinner. The physician said Resident #1 was alert and they discussed Resident #1's therapy and Resident #1 answered her questions appropriately. She said she received a message on 06/03/18 from the facility that Resident #1 was being transferred to the hospital. Resident #1's physician said the facility should have gotten clarification on the insulin orders. Resident #1's physician said [MEDICATION NAME] should not have been administered if the blood sugar was 68. She said Resident #1's insulin orders should have had parameters. During an interview on 06/05/18 at 12:15 p.m., the pharmacy assistant director said the pharmacy received medication orders on 06/01/18 for Resident #1. He said the orders were for [MEDICATION NAME] 15 units 3 times a day before meals, [MEDICATION NAME] 35 units at night, and Humalog per sliding scale. He said he spoke with Resident #1's nurse, unable to recall her name, and asked for order clarification because Humalog and [MEDICATION NAME] were basically the same drug. He said the nurse told him to send [MEDICATION NAME] and they would use it for both the 15 units and the sliding scale. During an interview on 06/05/18 at 10:05 a.m., CNA B said she worked on 06/03/18 with Resident #1. She said she arrived at approximately 7:30 a.m. and CNA C notified her that Resident #1 was unresponsive. She was told LVN A was aware of Resident #1's change of condition. CNA B said she had not worked with Resident #1 before and did not know her baseline. She said she went into Resident #1's room at approximately 8:00 a.m. and Resident #1 was sleeping. She said Resident #1's arms were limp, and she could not wake her up. She said Resident #1's breakfast tray was untouched in her room. CNA B said she immediately notified LVN A of Resident #1's condition and LVN A said Resident #1 was always like that. CNA B said LVN A did not get up to assess Resident #1. CNA B said she and CNA C went back into Resident #1's room at approximately 11:00 a.m. and Resident #1 continued to be unresponsive and her eyes were rolled back in her head. CNA B said she notified LVN D (charge nurse on another unit) about Resident #1's condition. She said LVN D told her to perform a sternal rub on Resident #1. CNA B said she performed a sternal rub on Resident #1 and Resident #1 did not respond. She said Resident #1 had labored breathing. CNA B said she went to LVN A and asked if Resident #1 was a diabetic and was told yes. CNA B said she asked LVN A if she was going to check Resident #1's blood sugar and LVN A said yes. CNA B said LVN A checked Resident #1's blood sugar and it was 60. LVN A gave Resident #1 oral glucose, but there was no change in Resident #1's condition. She said at approximately 12:00 p.m., she and CNA C went to RN E and notified her of Resident #1's condition. CNA B said RN E immediately went into Resident #1's room and checked her oxygen level and blood sugar. CNA B said Resident #1's blood sugar was in the 40s. She said RN E performed a sternal rub and Resident #1 did not respond. CNA B said RN E told her and CNA C to stay with Resident #1 while she called EMS. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 06/05/18 at 12:29 p.m., CNA C said she worked on 06/03/18 with Resident #1. CNA C said 06/03/18 was the first time she worked with Resident #1. She said at approximately 6:30 a.m. she was making her rounds and Resident #1 was sleeping in her bed. She said she was not alarmed because several residents slept past 6:30 a.m. and did not know Resident #1's baseline. CNA C said at approximately 7:30 a.m. she took Resident #1 her breakfast tray. She said she could not wake up Resident #1. She said she immediately notified LVN A about Resident #1's condition. She said LVN A said, she was always like that and did not assess Resident #1. CNA C said her, and CNA B went into Resident #1's room around 11:00 a.m. and Resident #1 was still sleeping and unresponsive. She said CNA B notified LVN D about Resident #1's condition. She said she and CNA B applied wet rags and ice to try to wake Resident #1, but she did not respond. During an interview on 06/05/18 at 3:19 p.m., LVN D said she worked on 06/03/18. She said at approximately 11:00 a.m., CNA B asked her if she knew anything about Resident #1. LVN D said she did not know Resident #1. She said CNA B told her about Resident #1's condition and that she tried to tell LVN A but LVN A blew her off. LVN D said she asked CNA B if Resident #1 was diabetic and CNA B said yes. LVN D said she told CNA B to get LVN A and they both should go into Resident #1's room and perform a sternal rub. LVN D said she did not go assess Resident #1 because she was busy with her own residents. During an interview on 06/05/18 at 2:27 p.m., RN E said on 06/03/18 at 11:58 a.m., CNAs B and C notified her about Resident #1's condition. She said she asked the CNAs if they notified LVN A about Resident #1's condition and they said they already did and LVN A said Resident #1 was fine. RN E said she immediately went into Resident #1's room and the resident had labored breathing and was unresponsive. She said Resident #1's oxygen saturation was 87%. She said after oxygen was applied, Resident #1's oxygen saturation went up to 96%. RN E said she performed a sternal rub on Resident #1 and she did not respond. She said the CNAs told her that Resident #1 was diabetic. RN E said she checked Resident #1's blood sugar and it was 43. She said LVN A was at the nursing station on the phone and she hollered at her to call Resident #1's physician. She said she told the CNAs to stay with Resident #1 while she called EMS. She said when EMS arrived, they checked Resident #1's blood sugar and it was 36. She said LVN A did not seem concerned about Resident #1's condition. During an interview on 06/06/18 at 1:20 p.m., CNA F said she worked with Resident #1 on 06/02/18 from 10:00 p.m. to 06/03/18 at 6:00 a.m. She said Resident #1 was alert and able to verbalize her needs. She said the last time she checked on Resident #1 was on 06/03/18 at 5:30 a.m. CNA F said Resident #1 was sleeping, but she woke her up to ask Resident #1 if she needed anything and she checked her for incontinence. She said Resident #1 awoke easily, said good morning to her, and told her she did not need anything. The undated change of condition policy indicated .assess the resident's need for immediate care, do not leave the resident alone, assess the resident and notify the physician of the resident's condition, compare the resident's current condition to their prior level of function, and monitor resident's condition frequently until stable . The sliding scale insulin protocol dated 2007 indicated .residents with a blood sugar less than or equal to 130 would not be administered insulin . The administrator was notified on 06/05/18 at 3:38 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 06/05/18 at 7:21 p.m., and included: 1. A list of all residents with orders for Insulin administration will be reviewed/audited to ensure inclusion of hypoglycemic protocol per physician. For those residents whose orders did not address parameters and treatment of [REDACTED]. Completed by DON and designee 06/05/18 5:00 pm. 2. All residents receiving Insulin will be assessed by the DON and/or her designee for signs and symptoms of [DIAGNOSES REDACTED]. Any abnormal findings will be reported to the attending physician and the family will be notified. Completed by DON and designee 06/05/18 6:00pm. 3. Consultant Pharmacist will be notified and asked to visit facility as soon as possible to review recent order changes and assist with monitoring compliance with hypoglycemic protocols. Completed 6/5/18 at 5:20 pm by the Regional Nurse Consultant. Visit scheduled for Thursday, (MONTH) 7, (YEAR). 4. Education: A. Nursing Care of the Resident with Diabetes Mellitus (Policy) B. Insulin Administration (Policy) C. Obtaining a Fingerstick Glucose Level (policy) D. New orders received on current residents related to hypoglycemic protocols E. CNA education regarding immediately reporting delayed nurse provided resident assessment to adjacent unit nurse or nurse manager. Education of all nurses initiated on 6/4/18 and will be complete by the end of Wednesday, (MONTH) 6, (YEAR) 6:00pm by DON or designee. Any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON will ensure nurses hired after 6/5/2018 will receive training in the above stated policies related to diabetic management of residents prior to beginning work on the floor. 5. Compliance to be monitored through random observations and interviews of license nurses by DON and /or her designee at least q day x 2 wks. Residents' records requiring Insulin administration will be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. 6. Concerns/Issues will be reported to the QAPI committee monthly. On 06/06/18, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 06/06/18 at 1:02 p.m., the regional nurse said all diabetic residents' orders were reviewed by the DON and insulin parameters were added. She said the DON assessed all diabetic residents for signs and symptoms of [DIAGNOSES REDACTED] with no concerns found. She said the DON and ADON in-serviced staff on order clarification, charting on new admissions and changes of condition every shift for the first 72 hours, blood sugar checking and parameters, insulin administration, reporting and responding to changes of condition. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on 06/06/18. The regional nurse said the nurses would be monitored through random observations and interviews by the DON and /or her designee of license nurses by at least daily for two weeks. She said residents' records requiring Insulin administration would be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. During an interview on 06/06/18 at 2:01 p.m., the ADON said he in-serviced staff on symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. He said staff were in-serviced on recognizing change of condition, responding to change of condition, documentation, and insulin parameters. During interviews on 06/06/18 from 1:30 p.m. to 4:23 p.m., 7 nurses (2 from day shift, 2 from evening shift, and 3 from night shift) and 10 CNAs (4 from day shift, 4 from evening shift, and 2 from night shift) were interviewed and said they received training on change of condition and who to notify when there was a change of condition. The nurses said they received training on medication parameters, documentation on new admissions/change of condition, insulin administration, and responding to changes of condition. On 06/06/18 at 4:26 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 06/04/18 at 3:07 p.m, the DON provided a list that indicated 8 residents were diabetics.

Based on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary medications for 1 of 9 residents reviewed for insulin medications. (Resident #1) The facility did not respond to a change in condition when Resident #1 was found unresponsive. Resident #1 had a low finger stick blood sugar (FSBS) reading of 68 (normal range 70-100) but was administered [MEDICATION NAME] 15 units. Approximately 4 ½ hours later, Resident #1 was unresponsive and sent to the hospital with a FSBS reading of 36. Resident #1 was admitted to the intensive care unit (ICU) and intubated. An Immediate Jeopardy was identified on 06/05/18. The Immediate Jeopardy was removed on 06/06/18; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 8 residents who were diabetics at risk for neglect, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], (from the hospital) with [DIAGNOSES REDACTED]. The hospital discharge orders (to the facility) dated 06/01/18 indicated Resident #1 was ordered [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) 4-20 units 3 times a day with meals. The transcribed physician orders [REDACTED].#1 was [MEDICATION NAME] (fast-acting insulin)15 units 3 times a day before meals, with no sliding scale. [MEDICATION NAME] (long [MEDICATION NAME] insulin) 35 units at night, and Humalog (fast acting insulin) before meals and at night, per sliding scale. The administration instructions for Resident #1's [MEDICATION NAME] indicated .inject 15 units subcutaneously 3 times a day before meals and inject subcutaneously per sliding scale before meals and at bedtime . According to https://www.drugs.com/[MEDICATION NAME].html accessed on 6/11/18 indicated .[MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood . The clinical records for Resident #1 dated 06/01- 06/18 indicated no care plan to address diabetes. The clinical records for Resident #1 dated 06/01- 06/18 indicated no MDS assessment. The MAR indicated [REDACTED]. Resident #1's FSBS at 11:30 a.m. was 60 and [MEDICATION NAME] was held due to the low blood sugar. A nursing note dated 06/03/18 at 12:27 p.m., documented by LVN A indicated Resident #1 was non-responsive due to low blood sugar. Blood sugar at 11:30 a.m. was 60. Glucose gel was administered with no response after 30 minutes. Resident #1's blood sugar dropped to 48. The emergency medical service (EMS) was called to transfer resident to hospital. Physician and family were notified. The EMS checked Resident #1's blood sugar and it was 36. During an interview on 06/04/18 at 2:53 p.m., LVN A said she admitted Resident #1 to the facility on [DATE] and transferred her to the hospital on [DATE]. She said on 06/03/18 she checked Resident #1's blood sugar between 6:30 a.m. and 7:30 a.m. and it was 68. LVN A said Resident #1 was alert but acted slower than normal. She said Resident #1 was non-verbal. She said she administered the ordered 15 units of [MEDICATION NAME] at that time. LVN A said she checked on Resident #1 an hour and a half later and noticed her breakfast was untouched. She said she attempted to encourage Resident #1 to eat, but Resident #1 was less responsive than she was earlier that morning. LVN A said she checked Resident #1's blood sugar at 11:30 a.m. it was 60. She said Resident #1 was unresponsive and diaphoretic. (excessive or profuse sweating) She said she administered oral glucose and rechecked her blood sugar. She said Resident #1's blood sugar was 48. LVN A said she performed a sternal rub and Resident #1 did not respond. She said EMS was called and transferred her to the hospital. LVN A said she thought about holding Resident #1's 15 units of [MEDICATION NAME] at 6:30 a.m., but Resident #1 was in and out of being alert and she thought it would be ok to give. She said the pharmacy did not send Humalog because they said Humalog and [MEDICATION NAME] were basically the same. LVN A said the order for Humalog was per sliding scale and the order for [MEDICATION NAME] was 15 unit 3 times a day with no sliding scale. She said Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. At https://www.healthline.com/health/diabetes/humalog-[MEDICATION NAME] accessed 6/20/18 indicated .Drug feature differences .Both Humalog and [MEDICATION NAME] help lower and stabilize your blood sugar when used as prescribed. But there are a few differences between the drugs. For example, there are differences in who can take the drugs, when you can take them, and the dosage. So, these drugs are not interchangeable . The EMS records for Resident #1 dated 06/03/18 indicated paramedics arrived at the facility at 12:08 p.m. Facility staff said Resident #1's blood sugar was just checked, and it was 42. Resident #1 was completely unresponsive. Staff said Resident #1 was given 15 units of insulin at approximately 7:00 a.m. today but the resident had not eaten breakfast. Blood sugar was checked again and was 36. Resident #1's oxygen saturation was 88%, blood pressure was 134/57, and her Glascow Coma Scale (eye opening response, verbal response, and motor response) was 3 (3-totally unresponsive). Once in ambulance, Resident #1's blood sugar rose to 144, but resident was still unresponsive. The hospital records dated 06/03/18 indicated Resident #1 arrived at the hospital on [DATE] at 12:50 p.m. The records indicated Resident #1 was found to be unresponsive, low blood sugar, and in acute hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen levels) at the facility. Resident #1 was intubated (insertion of a tube into the airway) after arriving to the ED. Resident #1 .reportedly had a blood sugar in the 60's this morning and was given 15 units of insulin and her blood sugar dropped to 38. Resident #1 and most likely sustained a significant [MEDICAL CONDITIONS] event . During an interview on 06/05/18 at 8:49 a.m., Resident #1's hospital Intensive Care Unit (ICU) nurse said she had been Resident #1's nurse since her admission on 06/03/18. She said Resident #1 was currently under sedation and on a ventilator. She said Resident #1's sedation was discontinued on 06/04/18 but was restarted after Resident #1 began grimacing. She said Resident #1 was still unresponsive after medical sedation was temporarily discontinued on 06/04/18. During an observation on 06/05/18 at 9:05 a.m., Resident #1 was lying in the hospital bed. She was intubated and unresponsive. During an interview on 06/05/18 at 11:50 a.m., Resident #1's physician said on the evening of 06/02/18, she visited with Resident #1 at the facility. She said Resident #1 was sitting in her room eating dinner. The physician said Resident #1 was alert and they discussed Resident #1's therapy and Resident #1 answered her questions appropriately. She said she received a message on 06/03/18 from the facility that Resident #1 was being transferred to the hospital. Resident #1's physician said the facility should have gotten clarification on the insulin orders. Resident #1's physician said [MEDICATION NAME] should not have been administered if the blood sugar was 68. She said Resident #1's insulin orders should have had parameters. During an interview on 06/05/18 at 12:15 p.m., the pharmacy assistant director said the pharmacy received medication orders on 06/01/18 for Resident #1. He said the orders were for [MEDICATION NAME] 15 units 3 times a day before meals, [MEDICATION NAME] 35 units at night, and Humalog per sliding scale. He said he spoke with Resident #1's nurse, unable to recall her name, and asked for order clarification because Humalog and [MEDICATION NAME] were basically the same drug. He said the nurse told him to send [MEDICATION NAME] and they would use it for both the 15 units and the sliding scale. During an interview on 06/05/18 at 10:05 a.m., CNA B said she worked on 06/03/18 with Resident #1. She said she arrived at approximately 7:30 a.m. and CNA C notified her that Resident #1 was unresponsive. She was told LVN A was aware of Resident #1's change of condition. CNA B said she had not worked with Resident #1 before and did not know her baseline. She said she went into Resident #1's room at approximately 8:00 a.m. and Resident #1 was sleeping. She said Resident #1's arms were limp, and she could not wake her up. She said Resident #1's breakfast tray was untouched in her room. CNA B said she immediately notified LVN A of Resident #1's condition and LVN A said Resident #1 was always like that. CNA B said LVN A did not get up to assess Resident #1. CNA B said she and CNA C went back into Resident #1's room at approximately 11:00 a.m. and Resident #1 continued to be unresponsive and her eyes were rolled back in her head. CNA B said she notified LVN D (charge nurse on another unit) about Resident #1's condition. She said LVN D told her to perform a sternal rub on Resident #1. CNA B said she performed a sternal rub on Resident #1 and Resident #1 did not respond. She said Resident #1 had labored breathing. CNA B said she went to LVN A and asked if Resident #1 was a diabetic and was told yes. CNA B said she asked LVN A if she was going to check Resident #1's blood sugar and LVN A said yes. CNA B said LVN A checked Resident #1's blood sugar and it was 60. LVN A gave Resident #1 oral glucose, but there was no change in Resident #1's condition. She said at approximately 12:00 p.m., she and CNA C went to RN E and notified her of Resident #1's condition. CNA B said RN E immediately went into Resident #1's room and checked her oxygen level and blood sugar. CNA B said Resident #1's blood sugar was in the 40s. She said RN E performed a sternal rub and Resident #1 did not respond. CNA B said RN E told her and CNA C to stay with Resident #1 while she called EMS. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 06/05/18 at 12:29 p.m., CNA C said she worked on 06/03/18 with Resident #1. CNA C said 06/03/18 was the first time she worked with Resident #1. She said at approximately 6:30 a.m. she was making her rounds and Resident #1 was sleeping in her bed. She said she was not alarmed because several residents slept past 6:30 a.m. and did not know Resident #1's baseline. CNA C said at approximately 7:30 a.m. she took Resident #1 her breakfast tray. She said she could not wake up Resident #1. She said she immediately notified LVN A about Resident #1's condition. She said LVN A said, she was always like that and did not assess Resident #1. CNA C said her, and CNA B went into Resident #1's room around 11:00 a.m. and Resident #1 was still sleeping and unresponsive. She said CNA B notified LVN D about Resident #1's condition. She said she and CNA B applied wet rags and ice to try to wake Resident #1, but she did not respond. During an interview on 06/05/18 at 3:19 p.m., LVN D said she worked on 06/03/18. She said at approximately 11:00 a.m., CNA B asked her if she knew anything about Resident #1. LVN D said she did not know Resident #1. She said CNA B told her about Resident #1's condition and that she tried to tell LVN A but LVN A blew her off. LVN D said she asked CNA B if Resident #1 was diabetic and CNA B said yes. LVN D said she told CNA B to get LVN A and they both should go into Resident #1's room and perform a sternal rub. LVN D said she did not go assess Resident #1 because she was busy with her own residents. During an interview on 06/05/18 at 2:27 p.m., RN E said on 06/03/18 at 11:58 a.m., CNAs B and C notified her about Resident #1's condition. She said she asked the CNAs if they notified LVN A about Resident #1's condition and they said they already did and LVN A said Resident #1 was fine. RN E said she immediately went into Resident #1's room and the resident had labored breathing and was unresponsive. She said Resident #1's oxygen saturation was 87%. She said after oxygen was applied, Resident #1's oxygen saturation went up to 96%. RN E said she performed a sternal rub on Resident #1 and she did not respond. She said the CNAs told her that Resident #1 was diabetic. RN E said she checked Resident #1's blood sugar and it was 43. She said LVN A was at the nursing station on the phone and she hollered at her to call Resident #1's physician. She said she told the CNAs to stay with Resident #1 while she called EMS. She said when EMS arrived, they checked Resident #1's blood sugar and it was 36. She said LVN A did not seem concerned about Resident #1's condition. During an interview on 06/06/18 at 1:20 p.m., CNA F said she worked with Resident #1 on 06/02/18 from 10:00 p.m. to 06/03/18 at 6:00 a.m. She said Resident #1 was alert and able to verbalize her needs. She said the last time she checked on Resident #1 was on 06/03/18 at 5:30 a.m. CNA F said Resident #1 was sleeping, but she woke her up to ask Resident #1 if she needed anything and she checked her for incontinence. She said Resident #1 awoke easily, said good morning to her, and told her she did not need anything. The undated change of condition policy indicated .assess the resident's need for immediate care, do not leave the resident alone, assess the resident and notify the physician of the resident's condition, compare the resident's current condition to their prior level of function, and monitor resident's condition frequently until stable . The sliding scale insulin protocol dated 2007 indicated .residents with a blood sugar less than or equal to 130 would not be administered insulin . The administrator was notified on 06/05/18 at 3:38 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 06/05/18 at 7:21 p.m., and included: 1. A list of all residents with orders for Insulin administration will be reviewed/audited to ensure inclusion of hypoglycemic protocol per physician. For those residents whose orders did not address parameters and treatment of [REDACTED]. Completed by DON and designee 06/05/18 5:00 pm. 2. All residents receiving Insulin will be assessed by the DON and/or her designee for signs and symptoms of [DIAGNOSES REDACTED]. Any abnormal findings will be reported to the attending physician and the family will be notified. Completed by DON and designee 06/05/18 6:00pm. 3. Consultant Pharmacist will be notified and asked to visit facility as soon as possible to review recent order changes and assist with monitoring compliance with hypoglycemic protocols. Completed 6/5/18 at 5:20 pm by the Regional Nurse Consultant. Visit scheduled for Thursday, (MONTH) 7, (YEAR). 4. Education: A. Nursing Care of the Resident with Diabetes Mellitus (Policy) B. Insulin Administration (Policy) C. Obtaining a Fingerstick Glucose Level (policy) D. New orders received on current residents related to hypoglycemic protocols E. CNA education regarding immediately reporting delayed nurse provided resident assessment to adjacent unit nurse or nurse manager. Education of all nurses initiated on 6/4/18 and will be complete by the end of Wednesday, (MONTH) 6, (YEAR) 6:00pm by DON or designee. Any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON will ensure nurses hired after 6/5/2018 will receive training in the above stated policies related to diabetic management of residents prior to beginning work on the floor. 5. Compliance to be monitored through random observations and interviews of license nurses by DON and /or her designee at least q day x 2 wks. Residents' records requiring Insulin administration will be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. 6. Concerns/Issues will be reported to the QAPI committee monthly. On 06/06/18, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 06/06/18 at 1:02 p.m., the regional nurse said all diabetic residents' orders were reviewed by the DON and insulin parameters were added. She said the DON assessed all diabetic residents for signs and symptoms of [DIAGNOSES REDACTED] with no concerns found. She said the DON and ADON in-serviced staff on order clarification, charting on new admissions and changes of condition every shift for the first 72 hours, blood sugar checking and parameters, insulin administration, reporting and responding to changes of condition. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on 06/06/18. The regional nurse said the nurses would be monitored through random observations and interviews by the DON and /or her designee of license nurses by at least daily for two weeks. She said residents' records requiring Insulin administration would be reviewed at least 3 times a week for the next 90 days during the morning Clinical meeting then at least weekly as part of the Standards of Excellence (SOE) meeting. During an interview on 06/06/18 at 2:01 p.m., the ADON said he in-serviced staff on symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. He said staff were in-serviced on recognizing change of condition, responding to change of condition, documentation, and insulin parameters. During interviews on 06/06/18 from 1:30 p.m. to 4:23 p.m., 7 nurses (2 from day shift, 2 from evening shift, and 3 from night shift) and 10 CNAs (4 from day shift, 4 from evening shift, and 2 from night shift) were interviewed and said they received training on change of condition and who to notify when there was a change of condition. The nurses said they received training on medication parameters, documentation on new admissions/change of condition, insulin administration, and responding to changes of condition. On 06/06/18 at 4:26 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 06/04/18 at 3:07 p.m, the DON provided a list that indicated 8 residents were diabetics.

Based on interview and record review the facility failed to ensure accurate pharmaceutical services and administering of all drugs to meet the needs of each resident for 1 of 5 residents reviewed for medication administration. (Resident #1) The facility did not administer Resident #1 the stool softener and laxative as ordered for 4 days. Resident #1 complained of nausea and vomiting and abdominal pain for 4 days. The resident was hospitalized with a bowel obstruction which required surgical intervention. This failure could place 17 post-surgical residents at the facility at risk for harm. Findings included: Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents reviewed for medication errors. (Resident #1) The facility did not administer Resident #1 stool softeners and laxatives as ordered for 4 days. Resident #1 complained of nausea and vomiting and abdominal pain for 4 days. The resident was hospitalized with a bowel obstruction. This failure could place 17 post-surgical residents at the facility at risk for not receiving the intended therapeutic effect of their medications. Findings included: The admitting orders dated 05/04/17 indicated Resident #1 was to take oxycodone (narcotic pain medication known to cause opioid induced constipation) 10mg 1 tablet every 4 hours as needed for pain and docusate calcium (stool softener) 240mg 1 capsule every day as needed for constipation. A nursing note dated 05/05/16 at 10:51 p.m., electronically signed by LVN A, indicated Resident #1 complained of constipation and said she had not had a bowel movement since Monday 05/01/17. LVN A notified the NP and was given orders to start Colace (stool softener) 100 mg twice daily routinely and milk of magnesia (laxative) 30ml daily as needed. Nursing notes indicated LVN A administered Resident #1 the milk of magnesia, but not the Colace. During an interview on 05/16/17 at 2:13 p.m., LVN A said she received the orders from the NP to give Resident #1 the milk of magnesia and Colace on 05/05/17. She said she administered both medications, but was unable to locate the documentation of her administering the medication. She said she could not find documentation of the medications ordered by the NP on the May 2017 MAR for Resident #1. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The CNA Flow sheet dated May 2017 showed no bowel movements for Resident #1. During an interview on 05/16/17 at 11:50 a.m., CNA C said she cared for Resident #1 while she was at the facility. She said she remembered Resident #1 complaining of being constipated. She said she informed LVN B of the resident's complaint. CNA C said Resident #1 never had a bowel movement while she was caring for her. Nursing notes dated 05/07/17 at 8:55 p.m. indicated Resident #1 complained of constipation and the'as needed' docusate calcium was given for her complaint of constipation. The resident said she felt sick at her stomach, but did not vomit. The NP was notified and the facility noted they would continue to monitor the resident. A nursing note dated 05/08/17 at 5:54 a.m. indicated, This morning patient was very uncomfortable. Resident #1 said she had not had a bowel movement in a week. The nursing note indicated an as needed Colace was given to the resident. A nursing note dated 05/08/17 indicated at 8:15 a.m. staff reported Resident #1 was vomiting brown colored vomit in a basin. The resident's vital signs were 104/76 (blood pressure), 80 (heart rate). Resident #1 also complained of constipation, saying she had not had a bowel movement in 1 week. The NP and physician were notified. A new order was received for Zofran (anti-nausea medication) 4 mg 1 every 6 hours as needed, Fleet enema 1 every day as needed, and laboratory panels ordered for the next morning. The MAR indicated [REDACTED]. During an interview on 05/16/17 at 2:13 p.m., LVN B said she looked at Resident #1's May 2017 MAR, but was unable to locate the routine Colace 100mg and the milk of magnesia 30ml daily as needed. LVN B said she cared for Resident #1 on her shift on the day of 05/08/17 and Resident #1 told her she had not had a bowel movement in a week. She said she obtained orders to give Resident #1 an enema and after the enema was given, Resident #1 had a bowel movement. A nursing note dated 05/09/17 indicated at 2:45 p.m. Resident #1 complained of nausea. Resident #1 said she vomited twice that day, but continued to feel nauseous. Resident #1 said she felt bloated and gassy. Resident #1 was given Magnesium Citrate and her vitals were taken 185/92 (blood pressure), 90 (pulse). The NP was notified of her condition. At 3:25 p.m. the physician was notified due to Resident #1 began complaining of severe abdominal pain, and broke into a cold sweat. Resident #1's vitals signs were 175/89 (blood pressure), 94 (pulse). The notes indicated new orders received to give Resident #1 Phenergan (anti-nausea medication) 12.5 mg every 6 hours as needed for nausea/vomiting and to order a stat abdominal x-ray. At 7:30 p.m., EMS was called to transport Resident #1 to the hospital. The history and physical of Resident #1's hospital records dated 05/09/17 indicated a CT scan of the abdomen and pelvis showed evidence of a small bowel obstruction. Hospital Physician notes dated 05/15/17 recommended Resident #1 for exploratory laparotomy to be conducted (05/15/17) for treatment of [REDACTED]. The CMS 670 dated 05/16/17 indicated 17 residents had post-surgical needs.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents reviewed for medication errors. (Resident #1) The facility did not administer Resident #1 stool softeners and laxatives as ordered for 4 days. Resident #1 complained of nausea and vomiting and abdominal pain for 4 days. The resident was hospitalized with a bowel obstruction. This failure could place 17 post-surgical residents at the facility at risk for not receiving the intended therapuetic effect of medications. Findings included: The admitting orders dated 05/04/17 indicated Resident #1 was to take [MEDICATION NAME] (narcotic pain medication known to cause opioid induced constipation) 10mg 1 tablet every 4 hours as needed for pain and [MEDICATION NAME] calcium (stool softener) 240mg 1 capsule every day as needed for constipation. A nursing note dated 05/05/16 at 10:51 p.m., electronically signed by LVN A, indicated Resident #1 complained of constipation and said she had not had a bowel movement since Monday 05/01/17. LVN A notified the NP and was given orders to start [MEDICATION NAME] (stool softener) 100 mg twice daily routinely and milk of magnesia (laxative) 30ml daily as needed. Nursing notes indicated LVN A administered Resident #1 the milk of magnesia, but not the [MEDICATION NAME]. During an interview on 05/16/17 at 2:13 p.m., LVN A said she received the orders from the NP to give Resident #1 the milk of magnesia and [MEDICATION NAME] on 05/05/17. She said she administered both medications, but was unable to locate the documentation of her administering the medication. She said she could not find documentation of the medications ordered by the NP on the May 2017 MAR for Resident #1. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The CNA Flow sheet dated May 2017 showed no bowel movements for Resident #1. During an interview on 05/16/17 at 11:50 a.m., CNA C said she cared for Resident #1 while she was at the facility. She said she remembered Resident #1 complaining of being constipated. She said she informed LVN B of the resident's complaint. CNA C said Resident #1 never had a bowel movement while she was caring for her. Nursing notes dated 05/07/17 at 8:55 p.m. indicated Resident #1 complained of constipation and the'as needed' [MEDICATION NAME] calcium was given for her complaint of constipation. The resident said she felt sick at her stomach, but did not vomit. The NP was notified and the facility noted they would continue to monitor the resident. A nursing note dated 05/08/17 at 5:54 a.m. indicated, This morning patient was very uncomfortable. Resident #1 said she had not had a bowel movement in a week. The nursing note indicated an as needed [MEDICATION NAME] was given to the resident. A nursing note dated 05/08/17 indicated at 8:15 a.m. staff reported Resident #1 was vomiting brown colored vomit in a basin. The resident's vital signs were 104/76 (blood pressure), 80 (heart rate). Resident #1 also complained of constipation, saying she had not had a bowel movement in 1 week. The NP and physician were notified. A new order was received for [MEDICATION NAME] (anti-nausea medication) 4 mg 1 every 6 hours as needed, Fleet enema 1 every day as needed, and laboratory panels ordered for the next morning. The MAR indicated [REDACTED]. During an interview on 05/16/17 at 2:13 p.m., LVN B said she looked at Resident #1's May 2017 MAR, but was unable to locate the routine [MEDICATION NAME] 100mg and the milk of magnesia 30ml daily as needed. LVN B said she cared for Resident #1 on her shift on the day of 05/08/17 and Resident #1 told her she had not had a bowel movement in a week. She said she obtained orders to give Resident #1 an enema and after the enema was given, Resident #1 had a bowel movement. A nursing note dated 05/09/17 indicated at 2:45 p.m. Resident #1 complained of nausea. Resident #1 said she vomited twice that day, but continued to feel nauseous. Resident #1 said she felt bloated and gassy. Resident #1 was given Magnesium [MEDICATION NAME] and her vitals were taken 185/92 (blood pressure), 90 (pulse). The NP was notified of her condition. At 3:25 p.m. the physician was notified due to Resident #1 began complaining of severe abdominal pain, and broke into a cold sweat. Resident #1's vitals signs were 175/89 (blood pressure), 94 (pulse). The notes indicated new orders received to give Resident #1 [MEDICATION NAME] (anti-nausea medication) 12.5 mg every 6 hours as needed for nausea/vomiting and to order a stat abdominal x-ray. At 7:30 p.m., EMS was called to transport Resident #1 to the hospital. The history and physical of Resident #1's hospital records dated 05/09/17 indicated a CT scan of the abdomen and pelvis showed evidence of a small bowel obstruction. Hospital Physician notes dated 05/15/17 recommended Resident #1 for exploratory laparotomy to be conducted (05/15/17) for treatment of [REDACTED]. The CMS 670 dated 05/16/17 indicated 17 residents had post-surgical needs.

Based on observation, interview and record review the facility failed to provide care and services in accordance with the comprehensive assessment to ensure: *pain relief for 1 of 5 residents reviewed for pain (Resident #1), and *as much normal bladder function as possible was restored for 2 of 2 residents reviewed for catheters. (Resident #s 1 and 5) Resident #1 was identified by pain assessment, nursing assessment, and the comprehensive assessment as having pain. The resident was in pain during treatments to pressure ulcers and ADLs. Resident #1 did not have pain medications or interventions in place to prevent pain and the physician was not notified. Resident #s 1 and 5 did not have medical justification, physician orders [REDACTED]. This failure contributed to Resident #1's unrelieved pain and could place 12 residents at risk for unrelieved pain and a decline in their functional levels. This failure could place 3 residents at risk of infection and damage to the bladder. Findings included: An Admission Nursing assessment dated [DATE] indicated Resident # 1 was admitted on this date. The assessment indicated the resident had pain at an intensity of distressing. An interim plan of care dated 6/20/12 indicated Resident #1 triggered for pressure sores. Physician orders [REDACTED]. There were no orders for pain medication or a catheter. The orders did not indicate a justification for the catheter. A nursing note dated 6/23/12 indicated Resident #1 was admitted to the hospital. Resident #1's nursing home admission orders [REDACTED]. She had wound care orders for a [MEDICATION NAME] dressing to the right and left side of the sacrum of the buttocks every 3 days and as needed. There was an order to paint left great toe and heel with [MEDICATION NAME] every day. A pain assessment dated [DATE] indicated Resident #1 had moderate pain. She had occasional moan or groan, facial grimacing, tense, fidgeting, and unable to console or distract. An admission MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and was totally dependent on staff for all ADLs. The MDS indicated the resident expressed pain with facial expressions and protective body movements. She had frequency of pain 1 or 2 days in the last 5 days. The MDS indicated the resident had a catheter. Resident #1's TAR dated July 2012 indicated treatment to the sacrum was administered 13 times, to the right side of the buttock 10 times, to the left side 9 times, to the left heel 22 times and to the left great toe, 24 times. Resident #1's CAA summary dated 7/20/12 indicated pain triggered and the resident had urinary incontinence and an indwelling catheter. The summary indicated a care plan should be developed for pain and urinary incontinence and an indwelling catheter. Resident #1's care plan dated 7/27/12 listed problems of pain and pressure sore-potential or development of pressure sores. A goal was the resident would display decreased behaviors of inadequate pain control as evidenced by grimacing or groaning. There were no interventions listed for the resident's pain and pressure sores. During an interview on 7/27/12 at 12:52 p.m. the MDS coordinator said Resident #1 did not have a care plan with interventions to address pain or pressure sores prior to today. The MDS coordinator said the treatment nurse usually developed care plans for pressure sore interventions. During an interview on 7/27/12 at 12:25 p.m., LVN D said Resident #1 was in pain when she was moved. During observations of Resident #1 on 7/27/12 the following was noted: *At 8:57 a.m. CNA A and D transferred the resident with the Hoyer lift. Resident #1 moaned in pain when her arm was adjusted. They tried to calm her. *At 9:15 a.m. the resident had her eyes closed and appeared to be asleep; Resident #1 had a catheter. She jerked her foot and moaned when the treatment nurse measured her great toe. The treatment nurse said " I know it hurts ". The DON was present during the observation. *At 9:30 a.m. the resident moaned and groaned when she received her treatment to the buttocks. The treatment nurse and the DON said they did not know if she had received anything for pain. During an interview on 7/27/12 at 9:32 a.m., CNA A said Resident #1 was in pain "all the time " . She said she did not think the resident wanted to get up because it "hurt her too bad " . During an interview on 7/27/12 at 2:28 p.m. the DON said Resident #1 did not have an order for [REDACTED]. The DON said she did not know why the physician had not been contacted in regard to pain. The DON said she had heard Resident #1 moan in pain during the treatment of [REDACTED].#1's pain or pressure sores. During an interview on 7/27/12 at 4:16 p.m. LVN B said Resident #1 complained of pain anytime you move her. She said she had done her treatments on the weekend and the resident showed signs of pain during the treatments. She said she asked the daughter about Resident #1's pain but had never contacted the physician. During an observation and interview on 7/27/12 at 4:25 p.m. Resident #1 moaned from pain when LVN B moved Resident #1's hand. Resident #1 said she was in pain. During the exit conference on 7/27/12 at 5:00 p.m. the ADON said she received an order on today from the physician for pain medication and the catheter for Resident #1. She said she wrote the orders at that time. A telephone order dated 7/27/12 at 3:50 p.m. said give Resident #1 Acetamin 160 mg/5 ml give 20 ml by mouth every 4 to 6 hours for pain as needed and Foley catheter for [MEDICAL CONDITION] and Foley catheter care per shift and as needed. The Pain-Clinical Protocol dated April 2009 indicated " 1. The physician and staff will identify individuals who have pain or who were at risk for having pain. a. This includes a review of each person's known [DIAGNOSES REDACTED]. " " 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care, ambulation, or repositioning. " 2. Physician orders [REDACTED]. Some of his [DIAGNOSES REDACTED]. Resident #5 did not have a diagnosis, medical justification, or a physician order [REDACTED]. An interim plan of care dated 4/30/12 indicated Resident #5 triggered for Foley catheter but there were no interventions. During an observation on 7/27/12 at 12:01 p.m. Resident #5 had a catheter. During an interview at 12:52 p.m. on 7/27/12, the MDS coordinator said Resident #1 and #5 did not have care plans prior to today to address their catheters. During an interview on 7/27/12 at 2:28 p.m. the DON and ADON said Resident #1 and Resident #5 did not have medical justification for the catheter, physician orders [REDACTED]. The Urinary and Renal Conditions: Treatment and Management policy dated April 2007 stated: " If a resident is admitted from the hospital with a newly placed indwelling catheter the attending physician and staff will evaluate the potential for removing it, depending on the current condition and the rationale for its original placement. The physician will identify situations where an indwelling catheter are indicated and will document why other alternatives are not feasible. The staff and the physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible. There should be documentation of resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence." CMS 672 dated 7/27/12 indicated 12 residents on pain management and 3 residents with catheters.

Based on observation, interview and record review the facility failed to provide necessary care and services to prevent development and worsening of pressure sores for 1 of 4 residents reviewed for pressure sores. (Resident #1) Resident #1 was admitted to the facility on [DATE] with 2 unstageable pressure sores on the left great toe and heel. The resident developed a new unstageable pressure sore on the left second toe. The resident did not receive a wound consultation as ordered. The resident experienced pain during treatment to the pressure sores and the pain was not treated. The facility did not develop a care plan to address the resident's pressure sores and pain until 7/27/12. The DON and facility staff did not know what the bed settings were supposed to be or how to operate the bed. This failure contributed to the development of new pressure sores and worsening of existing pressures sores for Resident #1 and could place 3 residents with pressure sores at risk for development of new pressure sores and worsening of existing pressures. Findings included: An Admission Nursing assessment dated [DATE] indicated Resident #1 was admitted on this date. The assessment indicated the resident had pain at an intensity of distressing. An interim plan of care dated 6/20/12 indicated Resident #1 triggered for pressure sores. An admission order from the hospital dated 6/20/12 indicated Resident #1 required a wound care consult. Physician orders [REDACTED]. A pain assessment dated [DATE] indicated Resident #1 had moderate pain with occasional moan or groan, facial grimacing, tense, fidgeting, and unable to console or distract. An admission MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and she was totally dependent on staff for all ADLs. The MDS indicated the resident expressed pain with facial expressions and protective body movements. She had frequency of pain 1 or 2 days in the last 5 days. The MDS indicated the resident had 2 Stage II pressure sores and 2 unstageable pressure sores on admission. Resident #1's CAA summary dated 7/20/12 indicated pain and pressure sores triggered and a care plan should be developed. Resident #1's nursing home admission orders [REDACTED]. She had wound care orders for a [MEDICATION NAME] dressing to the right and left side of the sacrum and buttocks every 3 days and as needed. There were orders to paint the left great toe and heel with [MEDICATION NAME] every day. A weekly pressure sore record dated 6/20/12 indicated Resident #1 had the following pressure sores: *left buttocks Stage II 4 x 1.8 cm the wound bed was red beef with normal surrounding tissue, *right buttocks Stage II 6 x 4 cm the wound bed was red beefy with normal surrounding tissue, *sacrum Stage II 2 x 2 cm the wound bed was red beefy with normal surrounding tissue, *left heel, unstageable 3.5 x 5.7 cm wound bed was red and black, and *left great toe, unstageable 2 x 2 cm the wound bed was black with black surrounding tissue. A nursing note dated 6/23/12 indicated Resident #1 was admitted to the hospital. A weekly pressure sore record dated 7/2/12 indicated Resident #1 had the following pressure sores: *left buttocks, Stage II 3.5 x 1.5 cm the wound bed was red beef with normal surrounding tissue, *right buttocks, Stage II 6 x 3.5 cm the wound bed red beefy with normal surrounding tissue, *left heel, unstageable 3.5 x 5.7 cm wound bed was red and black, and *left great toe, dry gangrene, unstageable 2 x 2 cm the wound bed was black. *There was no documentation of a pressure sore to the left second toe. Laboratory report dated 7/3/12 indicated Resident #1's [MEDICATION NAME] (marker of nutritional status and wound management) level was 9 (expected range 20-40). A complaint form dated 7/26/12 indicated the family complained Resident #1 was not getting proper treatment to her pressure sores. A physician telephone order dated 7/26/12 indicated Resident #1 was to have a wound care appointment to evaluate and treat. During an observation and interview on 7/27/12 at 9:15 of Resident #1 the following was noted: *The resident had her eyes closed and appeared to be asleep. The resident's bed was set on normal pressure. The DON said she did not know what the bed settings were supposed to be. Resident #1 jerked her foot and moaned when the treatment nurse measured her great toe. The treatment nurse said "I know it hurts". The DON was present during the observation. *left heel unstageable, 5.5 x 2.7 cm the eschar area measured 4.5 x 2 cm. The DON described the area as neurotic tissue with a pink wound bed, yellow slough and loose eschar, no odor with some wetness that may or may not be drainage. *left great toe, 1/6 x 1.2 cm unstageable, the DON described the wound ad dark necrotic area with hard eschar and the wound was dark with a dark surrounding ridge. *left second toe 0.8 x 1.5 cm unstageable, the DON described it as a darken area and a hard nail bed. The DON said the pressure sore was a new area. Resident #1's July 2012 TAR indicated treatment to the sacrum was administered 13 times, to the right side of the buttock 10 times, to the left side 9 times, to left heel 22 times and to the left great toe 24 times. Resident #1's care plan dated 7/27/12 listed problems of pain and pressure sore-potential or development of pressure sores. A goal was the resident would display decreased behaviors of inadequate pain control as evidenced by grimacing or groaning. There were no interventions listed for the resident 's pain and pressure sores. During an interview on 7/27/12 at 12:52 p.m. the MDS coordinator said Resident #1 did not have a care plan with interventions to address pain or pressure sores prior to today. The MDS coordinator said the treatment nurse usually developed care plans for pressure sore interventions. During an interview on 7/27/12 at 2:28 p.m. the DON said Resident #1 did not have an order for [REDACTED]. The DON said she did not know why the physician had not been contacted in regard to pain. The DON said she heard Resident #1 moan in pain during the treatment of [REDACTED].#1's pain or pressure sores. The DON said Resident #1 had an order for [REDACTED]. The DON said the 6/20/12 admission physician orders [REDACTED]. She said she did not know why the order was not completed. The DON said the physician was contacted on 7/26/12 in regard to Resident #1's pressure sores. He gave an order for [REDACTED]. During an interview on 7/27/12 at 4:16 p.m. LVN B said Resident #1 complained of pain anytime you move her. She said she had done her treatments on the weekend and the resident showed signs of pain during the treatments. She said she asked the daughter about Resident #1's pain but had never contacted the physician. The Ulcers/Skin Breakdown-Clinical Protocol dated April 2007 stated: "The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or wound treatment. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions." The Pain Protocol dated April 2009 indicated: "The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes person's known [DIAGNOSES REDACTED]. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated for example wound care, or repositioning." The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 8/7/12 indicated the following: "Common Definition of Pressure Ulcers A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated." "Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body's natural (biological) cover" and should not be removed." The CMS 672 dated 7/27/12 indicated 4 residents with pressure sores.