Every finding on record at Tishomingo Comm Living Center

Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of five (5) residents who were at risk for elopement and wandering, Resident #68.On 12/10/25, at approximately 2:53 PM a member of the facility staff reported in the staff meeting that Resident #68 was found inside the pharmacy across the street. At 2:55 PM Resident # 68 was located by facility staff, approximately 100 yards away from the facility across a busy two-lane street inside the pharmacy where he was observed standing, laughing and conversing with the pharmacy staff. The temperature at the time was cloudy and 55 degrees; the resident was dressed in lace up tennis shoes, pants and a long sleeve shirt.The facility's failure to provide adequate supervision to prevent the elopement of Resident #68 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death.The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 12/10/25 and existed at 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity (S/S) of J.The SA notified the facility's Administrator of the IJ and SQC on 12/15/25, at 3:30PM and provided the Administrator with the IJ template.Based on the facility's implementation of corrective actions on 12/11/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 12/12/25, prior to the SA's first entrance on 12/15/25.Findings include:Record review of facility Elopement/Unsafe Wandering Plan dated 02/07/2012 revealed, Policy: It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life and safe environment.Procedures. Risk Evaluation: An evaluation of the resident's risk for unsafe wandering or elopement is to be conducted on admission, quarterly, after a significant change in condition, and after an incident of elopement. Identification: Residents at risk will have some type of identifier on their person. Plan of Care: If a resident is identified at risk for elopement or unsafe wandering, a preventative plan of care is to be implemented at the time the risk is identified. Unsafe wandering and/or elopement potential is to be entered into the ADL (activity of daily living) system and ADL plan of care.Supervision: Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as necessary. Facility Systems: Systems such as alarms, Wander guard systems and special locks/keypads as allowed by state and local authorities will be utilized to the extent possible.Record review of the admission Record for Resident #68 revealed the facility admitted the resident on 12/5/25 and the resident had diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery with Other Forms of Angina Pectoris, Type 2 Diabetes Mellitus with Hyperglycemia, Dementia in Other Diseases Classified Elsewhere, Severe, with Other Behavioral Disturbance, Alzheimer's Disease with Late Onset, and Chronic Obstructive Pulmonary Disease, Unspecified.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 12/5/25 for Resident #68 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment.Record review of the Quarterly Wander Evaluation dated 12/6/2025 revealed Resident #68 was a wander/elopement risk.During an interview on 12/15/25 at 11:30 AM Licensed Nursing Home Administrator (LNHA) described her understanding of the incident involving Resident #68. She stated she first became aware of the elopement when the Business Office Manager (BOM) came into their staff meeting to alert them that Resident #68 was inside the pharmacy across the street from the facility. She said this occurred at 2:53 PM on 12/10/25. She stated that Social Services, Activities Director, and the Director of Nursing immediately left the facility to go across the street to the pharmacy. She stated that at 2:55 PM, Social Services, Activities Director, and the Director of Nursing walked into the pharmacy where Resident #68 was observed standing, laughing and conversing with the pharmacy staff. She confirmed that Resident #68 was returned to the facility at 3:00 PM. During an interview on 12/16/25 at 10:54 AM, Pharmacy Technician stated she works at the pharmacy across the street from the facility. She reported that between approximately 2:30 PM and 3:00 PM she had just delivered medications to the facility. She stated that she entered the facility through a side door that was unlocked. After she dropped off the medications, she was sitting in her car in the parking lot when a male individual flagged her down and walked up to her car window. She stated the individual asked if she could give him a ride to (proper name of a nearby town), stating he was a good person, loved the Lord, and only needed to be dropped off at the city limits. She stated he told her his name and offered her $350 to provide the ride. She reported she declined his offer and drove away. She further stated that after leaving the facility parking lot, she realized the individual was a resident of the facility and remembered his name as that of a resident that she had just delivered medications for to the facility. She contacted her boss at the pharmacy, who instructed her to return to the facility and let the staff know about the possible elopement. While she was in route back to the facility and on the phone with her boss, she was informed that the resident had just walked into the pharmacy. Additionally, she stated she turned around and went back to the facility and told them that the resident had been in the parking lot when she was outside and he was now across the street inside the pharmacy. During an interview on 12/16/25 at 11:12 AM, Licensed Practical Nurse (LPN) #1 revealed that she worked at the front nursing station on the day of the elopement. She reported that the resident repeatedly attempted to go to the exit door and stated that he needed to go home to his wife. LPN #1 stated that she placed a chair at the nursing station and had the resident sit beside her. She reported that Resident #68, for the most part, remained seated at the nurses' station. She offered him magazines to look at and allowed him to watch videos on her phone. She stated that she conducted visual checks at least every hour. LPN #1 stated that the resident was already listed in the facility's elopement book as being at risk for elopement. She confirmed that she had no idea how the resident had gotten through the locked door and got outside of the building and stated, We think he probably walked out with a visitor. She reported that the facility currently has five residents on elopement precautions. She stated that she maintained her own visual list of the resident's location, checking his whereabouts every 30 minutes to one hour. LPN #1 reported that when the resident returned following the elopement, he was confused and restless, and the facility initiated one-to-one observation. She stated that after the elopement incident, the facility provided education to staff regarding elopement precautions. LPN #1 stated that her shift was from 6:00 AM to 6:00 PM. She reported that at 6:00 PM, the night shift nurse assumed care of the resident, and the resident remained on one-to-one observation.During an interview on 12/16/25 at 11:20 AM, Certified Nursing Assistants (CNA) #1 and #2 both stated that although they do usually work the hall where Resident #68 resides, they were interviewed regarding training implemented after the elopement incident. They both confirmed that Resident #68 was anxious and exit seeking prior to his elopement. Both CNAs stated that they were off duty on the day of the elopement. CNAs #1 and #2 stated that since the elopement, the facility had implemented new training and protocols for residents at risk of elopement. They reported that CNAs are required to document every 30 minutes for residents identified as being at risk for elopement and listed in the facility's elopement book. They stated that documentation is completed every 30 minutes in the computer charting system.During an interview on 12/16/25 at 11:24 AM, the Director of Nursing (DON) stated that she knew the resident prior to admission and reported that she did not anticipate the elopement. She stated, I've known him for a long time prior to this, and reported that she did not recall any prior wandering behavior. The DON stated that during a staff meeting, the BOM notified staff that the resident had eloped and was located at the drugstore across the street from the facility. She reported that the drugstore staff, that made a delivery to the facility, first noticed the resident outside of the facility. The DON stated that a staff member from the drugstore returned inside the facility and notified staff. The DON stated that she, along with the Activities Director and the Social Worker, got into a car and went across the street to retrieve the resident. She reported that when they arrived, the resident appeared happy to see them and did not appear distressed or aware that he had done anything wrong. She stated that the resident told her he was trying to get to where his wife was, and she stated that I told him that his wife was coming to the facility and he returned to the facility without difficulty. The DON stated that the resident was wearing lace-up tennis shoes, pants, and a long-sleeved shirt. She reported that the weather was cool but not frigid. The DON further stated that once the facility became aware of the elopement, staff immediately checked all doors and windows and completed a headcount of all residents. She reported that after the resident returned to the facility, staff completed a body audit to ensure he was not injured. She stated that the facility contacted a local business to install a keypad on the front door. The DON reported that the facility conducted in-service education on elopement and abuse. She stated that once the issue was identified, the resident was placed on one-to-one observation, with one staff member assigned to continuously monitor the resident to prevent further elopement.During an interview on 12/16/25 at 11:34 AM, Social Services (SS) #1 reported that prior to the elopement, she had not observed exit-seeking behaviors for this resident. She stated that on the day of the elopement, she observed the resident standing in a resident's doorway at approximately 2:39 PM while she was walking to a meeting. SS #1 stated that once staff were notified of the elopement, she and other staff immediately got into a vehicle and went to the drugstore across the street to retrieve the resident. She reported that the resident appeared happy to see staff. She stated that the resident may have made a comment at the drugstore about needing to get to his wife. SS #1 stated that after the resident returned to the facility, several interventions were implemented. She reported that the facility had installed a new lock on the front door. She stated that going forward, the front door must be physically opened by staff using a keypad code. She reported that after 5:00 PM, the facility limits access to one entrance only, and individuals must be buzzed out by staff. SS #1 stated that family members were notified of these changes, including the limitation to one entrance after 5:00 PM and on weekends, to more closely monitor all comings and goings. SS #1 stated that when the resident first arrived at the facility, he was constantly pacing, but she believed he had calmed down somewhat since admission. She reported that on the day of the elopement, the resident was dressed in street clothes and was wearing a jacket. She stated that the jacket covered his identification bracelet, and she could see how a visitor might mistake him for another visitor rather than a resident. SS #1 stated that she believed the resident may have exited the building behind a visitor. She reported that on the first night of his admission, the resident paced throughout the facility and was unable to remain still. She stated that staff had CNAs follow behind him throughout that first night. SS #1 stated that when the drugstore clerk first observed the resident, he was standing on the sidewalk and had not traveled far from the facility before staff became aware of his location.During an interview on 12/16/25 at 11:41 AM, LPN #2 stated that she was working at the back nursing station on the same hall as the resident on the day of the elopement. She reported that she had been talking with the resident about his past work as a game warden and stated that the resident engaged in conversations with different people. She reported that the resident was trying to find his house and talking about how he needed to get home and check on his wife. LPN #2 stated, I don't know how he got out. Maybe someone was coming in and he slipped out. She further stated that nurses document on residents identified as wanderers every hour. She reported that nursing documentation includes the resident's location and behaviors and that this hourly documentation was already in place at the time of the elopement. She stated that the change implemented after the elopement was that CNAs are now required to document every 30 minutes. She reported that CNAs document every 30 minutes, while nurses continue to document hourly on the resident's behaviors and location.On 12/15/25 at 2:30 PM observed that the facility front lobby is a separate area from where the resident rooms are and the residents reside. There is a set of double doors with a coded, locked entrance to enter the area where the resident rooms are found. Prior to this incident on 12/10/25 the front lobby area was unsecured, and the multiple entrance and exits were unlocked and unsecured. Observation on 12/15/25 at 2:35 PM revealed that the exits and entrances in the front lobby are coded and locked now and you must have a code to leave the building or be let into the building. Observation revealed the distance from the facility to the pharmacy, where the resident was found, was approximately one hundred yards. The pharmacy is located across the street from the facility, and the resident would have crossed a busy two-lane street with no cross walks with speed limits of 35 miles per hour to have reached the pharmacy parking lot.Record review of the local weather history according to Custom Weather, Inc., for the facility for 2:53 PM on 12/10/25 revealed the temperature was fifty-seven (57) degrees Fahrenheit, passing clouds with zero (0) precipitation, eighteen (18) mile per hour winds. Corrective Action PlanOn 12/15/25 at 3:30 PM the State Agency presented an Immediate Jeopardy [NAME] which notified the Administrator of the facility that the facility failed to ensure Resident #68, who has a BIMS score of 3 (cognitively impaired) was adequately supervised to prevent elopement.On 12/10/25 at 2:53 PM it was reported to administrator that Resident #68 was noted in the drug store located across from the facility, asking for a ride to see his wife. Staff members assisted residents safely back inside the facility. Decision was made to report and start investigation.Notifications:Son Responsible Party notified by phone on 12/10/25 at 3:23 PMMedical Director notified 12/10/25 with no new ordersState Department of Health notified on 12/10/25 at 5:28 PMRegional Director of Operations/Regional Nurse Consultant 12/10/25 per phoneDirector of Nursing, Assistant Director of Nursing, Social Services, notified 12/10/25 in personOmbudsman notified 12/10/25 per phonePolice Department 12/10/25 at 3:40 PM Immediate Actions:1. Body Audit: with no negative findings performed on 12/10/252. Resident #68 placed on 1:1 on 12/10/253. 100% head count of residents on 12/10/254. Door codes changed at all entrances 12/10/25 by maintenance director.5. Education of all staff started on 12/10/25 on wandering/elopement and completed 12/10/25. No staff will be allowed to work until in-services are complete.6. Education to all staff on not providing the code to anyone other than staff. Education began on 12/10/25 and was completed on the same day by the Director of Nursing.7. Magnetic lock doors activated at front lobby entrance doors on 12/10/25.8. 100% audit of elopement books completed, noted that these were up to date and updated 12/10/25 by Social Services director. No negative findings were noted with this audit.9. All residents in the Elopement book were placed on 1-hour visual checks per nursing and 30-minute visual checks per Certified Nursing Assistants on 12/10/25.10. Elopement drill completed on 12/11/25 by maintenance director.11. Emergency Quality Assurance and Performance Improvement meeting with Medical Director and Interdisciplinary team on 12/11/25.12. 100% psychosocial orders put into place for all residents on 12/10/25.13. Wandering/elopement evaluation form completed for 100% of all residents on 12/11/25.14. All families were notified of the new entrance process into the facility on [DATE].15. Checked all doors and windows on 12/10/25 by the Maintenance Director. Continued Monitoring:1. Code W drills will be done weekly x (times) 4 weeks then monthly and as needed (PRN) starting on 12/11/25.2. Newly hired staff will be trained on the wandering/elopement prevention plan starting on 12/11/25.3. Residents will be assessed for elopement risk on admission, quarterly, and with any significant changes starting on 12/11/25.4. Resident continues 1-hour visual checks per nursing and is now placed on 30-minute visual checks for Certified Nursing Assistants (CNA)s starting 12/10/25.5. Social Services to audit the elopement/wander book weekly x 4 weeks, then biweekly x 4 weeks, then monthly thereafter starting 12/10/25.6. Minimum Data Set Nurse to audit wander/elopement care plans weekly x 4 weeks, then biweekly x 4 weeks starting 12/10/25. Timeline:At 2:45 PM LPN was doing rounds and visualized resident speaking to another resident on nursing station 1 hallway while she was sitting in her doorway. Resident #68 was dressed in pants, a long sleeve jacket, and lace up shoes. The nurse continued to make rounds while the residents visited with one another. Numerous staff members wrote statements of visualizing the resident on the hall around the same time frame.At 2:50 PM Pharmacy Tech with local pharmacy arrived at the facility and came inside to deliver meds.At 2:53 PM The Business office manager came into our staff meeting to alert us that Resident #68 was inside the pharmacy.At 2:55 PM Social Services, Activities Director, and the Director of Nursing walked into the pharmacy where the Resident #68 was observed standing, laughing and conversing with the pharmacy staff.At 2:57 PM Resident #68 willingly came with us back to the facility.At 3:00 PM Resident #68 was back and safely inside the facility. Facility alleged that all corrective actions were implemented on 12/11/25 and the Immediate Jeopardy removed on 12/12/25.On 12/15/25, the SA validations were made onsite during the complaint investigation through interviews, observations and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 12/12/25, prior to the SA entrance on 12/15/25.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 4th Quarter 2025. Findings Include:Record review of the facility policy titled, Staffing Hours-Monitoring of Policy and Procedure undated, revealed, Purpose: To assure the facility staffing meet federal and state guidelines. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2025 (July 1-September 30), revealed the facility triggered on this report for excessively low weekend staffing.During an interview on 12/17/2025 at 3:20 PM, the Administrator revealed that after auditing the low weekend staffing data, she discovered that the data submitted to PBJ was inaccurate. She revealed that both she and the Director of Nurses (DON) had worked some weekends, and their salary hours were not accurately converted to hourly. The Administrator also revealed that, after further investigation into the excessively low weekend staffing, it was discovered that there was a data entry error with their vendor Paylocity, which failed to capture all employees who worked during the time period in question.

Based on staff interview, record review, and facility policy review, the facility failed to provide written notification to the resident/representative regarding bed hold when the resident was sent to the hospital for two (2) of two residents reviewed for hospitalization. Resident #1 and Resident #65Findings Include: Review of the facility policy titled, Bed hold Policy and Procedure revealed Policy: Before the facility transfers a resident to the hospital or allows a resident to go on therapeutic leave, written information should be provided to the resident and family member or legal representative specifying the following information: (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the facility; and (ii) The policies regarding bed-hold periods, which should be consistent .In the case of an emergency transfer, a written notification should be given to the family, surrogate, or representative within 24 hours of the transfer. A copy of the notice should be sent with the resident in the transferring paperwork. Resident #1 Review of Resident #1's Health Status Note, dated 11/24/25, revealed that the Medical Director (MD) ordered the resident be sent to emergency room (ER) for treatment and evaluation. Record review of the Transfer/Discharge Notice Form revealed that Resident #1 was transferred/discharged to the hospital on [DATE]. During an interview on 12/18/25 at 9:25 AM, the Business Office Manager (BOM) confirmed that the facility did not provide a written bed-hold notice to the resident or the resident's representative at the time of transfer. She acknowledged that she is responsible for ensuring the written bed hold notifications are sent to the resident/resident representative when a resident is transferred to the hospital. She confirmed that the bed hold policy, which includes the reserve bed payment, was not sent for Resident #1 and Resident #65. During an interview on 12/18/25 at 10:25 AM, the Administrator confirmed that whenever a resident is discharged or transferred, they are supposed to receive a notification of bed-hold, including the amount, so the resident or resident representative will know how much they will need to pay to hold their bed. Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that include, Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, and Dysphagia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/17/25 revealed Resident #1 is rarely/never understood. Resident #65 Review of Resident #65's Health Status Note, dated 10/08/25, revealed that the MD ordered the resident be sent to ER for treatment and evaluation. Record review of the Transfer/Discharge Notice Form revealed that Resident #65 was transferred/discharged to the hospital on [DATE]. Record review of the admission Record revealed Resident #65 was admitted to the facility on [DATE] with a diagnosis that included Metabolic Encephalopathy. Record review of Resident #65's MDS with ARD of 10/08/25 revealed Resident #65's BIMS was incomplete, as the majority of cognitive interview questions were marked not assessed, and no BIMS summary score (0-15 or 99) was entered.

Based on resident and staff interviews and record review, and the facility policy the facility failed to notify the provider of an increase in blood pressure for one (1) of three (3) residents reviewed for blood pressure monitoring. Resident #55 Findings include: Record review of facility policy titled, Blood Pressure, Measuring dated 8/25/24, revealed, Hypertension is usually defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg). Hypertension should be reported to the physician. Record review of facility policy titled, Notification of Changes in a Resident's Condition or Status, undated, revealed, It is the policy of this facility to inform the resident, consult with his or her physician, and notify, consistent with his/her authority, the resident's representative of changes in the resident's condition and/or status. The policy also revealed, 1. Nursing services shall be responsible for notifying the resident's attending physician when: . b. There is a significant change in the resident's physical, mental, or psychosocial status . f. Notification is deemed necessary or appropriate in the best interest of the resident. Record review of facility policy titled, Change in a Resident's Condition or Status, dated 8/2023, revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a . d. significant change in the resident's physical/emotional mental condition. Record review of Vital Signs In service dated March 14, 2008, revealed, Vital signs are important indicators of how well the vital organs of the body such as the heart and lungs are functioning. Changes in vital signs are a good indicator of a person's health. Blood Pressure shows how well the heart is working. The normal range for the systolic is between 100 - 140 and 60 to 90 for the diastolic. Always report abnormal or changes in vital signs to the nurse. During an interview on 7/30/24 at 8:50 AM, Resident #55 revealed he had hypertension and his blood pressure had been elevated several times recently and he wondered if his medications had been changed. He stated he had mentioned this to the nurses and had been told they would continue to monitor his blood pressure. On 7/30/24 at 11:15 AM, an interview with the Director of Nursing (DON) revealed she had not been able to determine for certain how this resident's blood pressure readings were not reported, but it appeared the vital signs may have been entered by the Certified Nursing Assistants (CNA)'s and the nurses did not monitor these values closely enough. She confirmed the nurses should monitor the blood pressure values and should notify the provider if the blood pressure is not within the normal parameters and document this into the resident's record and there was a failure in this process. She stated the facility did not have a standing order on when to notify the physician, but they used the attached Vital Signs In service for acceptable parameters and anything outside those values should be reported. The DON confirmed the facility failed to notify the physician of changes of the resident's condition that could have indicated a clinical complication or led to devastating results such as a stroke. She stated notification to the provider should be done for each resident with a change of their clinical condition to ensure proper treatment was given. During a phone interview on 7/31/24 at 9:30 AM, Resident #55's Medical Doctor revealed on admission, she was concerned that the resident had some hypotensive episodes and his blood pressure was within normal limits at that time and no blood pressure medications were ordered at the facility. She stated she was uncertain, but thought she had been notified of his increased blood pressure once and treatment was given, but she was not aware of any other times she was notified due to increased blood pressure. She stated if she had been notified of other times Resident #55 had increased blood pressure, she would have made changes, as needed. Record review of Resident #55's Weights and Vitals Summary revealed multiple blood pressure values that exceeded the facility's policy's definition of hypertension of 140/90. Record review of increased values over the past eight days included: 7/21/24 - 177/125; 7/22/24 - 164/91; 7/22/24 - 170/55; 7/23/24 - 175/93; 7/23/24 - 187/98; 7/24/24 - 174/123; 7/25/24 - 170/116; 7/26/24 - 160/100; 7/29/24 - 160/90; 7/29/24 - 186/128; 7/30/24 - 152/95. Review of resident's record revealed none of these blood pressure values had been reported to the provider. Record review of Resident #55's Admission Record revealed the facility admitted the resident on 4/9/24. Diagnosis included an admission diagnosis of hypertension. Record review of Resident #55's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/16/24 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated this resident was cognitively intact.

Based on resident and staff interviews and record review, the facility failed to notify the resident's representative in writing and the Ombudsman of the emergency transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization . Resident #22 Findings include: Record review of letter dated 7/31/24 on facility letterhead revealed, The facility does not have a policy that states the Responsible Party and/or Ombudsman must be notified in writing of Emergency Transfers. During an interview on 07/29/24 at 11:55 AM, Resident #22 revealed she had been in the hospital recently but she did not remember the date of this. An interview with the Administrator on 7/30/24 at 2:10 PM, revealed the notification to the Ombudsman was not provided and the written notification to Resident #22's representative was not provided. She stated the Medical Records Nurse was the person responsible for this and failed to send these notifications due to the resident returning within a few hours of leaving facility and her name was accidentally removed from the transfer list. She confirmed the notifications were needed to ensure the required people were aware of an emergency transfer and the facility failed to provide the notifications as required to the resident's representative and to the Ombudsman. On 7/31/24 at 8:15 AM, an interview with the Medical Records Nurse revealed she was responsible for the notifications to the Ombudsman and to the resident's representative. She stated the resident only stayed at the hospital briefly and her name was inadvertently removed from the transfer system and therefore, she overlooked it. She confirmed it was an oversight on her part and she was making an additional check list so this would not occur again. Record review of Progress Note dated 5/2/24 at 11:29 AM, revealed, . MD notified and order to send to ER for evaluation and treatment. Record review of Physician's Orders revealed there was not an order to send to the emergency room . Record review of letter on facility letterhead dated 7/31/24 revealed, We are unable to provide the Physician Order in Point Click Care to send resident to the ER to be evaluated and treated on 5/2/24. Attached is a letter from the Medical Doctor (proper name of Resident #22's physician) verifying that she gave a verbal telephone order to the nurse on duty to send this resident to the ER to be evaluated and treated. Record review of letter from Resident #22's physician revealed, Nurse at (proper name of facility) was given verbal orders over the telephone to send resident (proper name of Resident #22) to the emergency department after a fall on 5/2/24. Record review of Resident #22's Admission Record revealed the facility admitted the resident on 12/20/23. Diagnoses included heart failure, type 2 diabetes mellitus, dementia, hypertension, and repeated falls. Record review of Resident #22's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/12/24, revealed a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment.

Based on staff interview, record review and the facility policy the facility failed to develop a care plan for a resident with a history of hypertension for one (1) of 19 care plans reviewed. Resident #55 Findings included: Record review of facility policy titled, Care Plans, Comprehensive Person-Centered, dated 11/22, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed, 7. The comprehensive, person-centered care plan . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . e. reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. An interview with Resident #55 on 7/30/24 at 8:50 AM revealed he had a history of hypertension and his blood pressure had been high several times recently and the staff informed him they would continue to monitor this. Record review of Resident #55's care plan revealed there was no care plan for hypertension or for a history of hypertension. An interview on 7/31/24 at 8:30 AM, with the Minimum Data Set (MDS) Registered Nurse (RN)revealed she was responsible for MDS entries and care plan development. She stated when this resident was admitted , she failed to list hypertension since he was not actively receiving treatment for hypertension. She stated the diagnosis of history of hypertension should have been added and she failed to do this. With this diagnosis, parameters and interventions would have been added to the care plan. She confirmed the care plan should address the resident's needs and preferences and guide the staff in the care of the resident and it was human error that she failed to address the resident's history of hypertension. During an interview on 7/31/24 at 9:15 AM, the Director of Nursing (DON) confirmed the resident had a history of hypertension and the facility failed to develop a care plan with interventions for the staff to use as a guide for care. She stated a care plan would have offered interventions and parameters's for the resident's blood pressure monitoring. Record review of Resident #55's Admission Record revealed the facility admitted the resident on 4/9/24. Diagnosis included an admission diagnosis of hypertension. Record review of Resident #55's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/16/24 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated this resident was cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to prevent the possibility of an accident while administering medications for one (1) of four (4) residents observed for medication administration. Resident #34 Findings Include: Review of the facility policy titled, Medication Administration-General Guidelines with a revision date of 8/25/14 revealed under Procedure .#1. Preparation: e. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing . An interview and observation on 07/29/24 at 10:44 AM with Resident #34 revealed that her only problem was a huge pill they give her, and she cannot swallow it. She stated it gets stuck in her throat and she just has to let it dissolve. She revealed she told the nurse this morning, but she told her it would not be much longer, and she would not have to take them anymore. An interview on 7/30/24 at 8:00 AM with Licensed Practical Nurse (LPN) #1 confirmed that Resident #34 had complained in the past that the Amoxicillin tablet was big but had never asked to have it split or crushed. An observation on 7/30/24 at 8:05 AM revealed LPN #1 administered the following medications. 1.) Amlodipine Berate 5 mg (milligram) PO one time per day 2.) Metoprolol 50 mg PO one time per day 3.) Potassium 99 mg PO one time per day 4.) Cholecalciferol 1000 units =2 tabs (tablets) one time per day 5.) Amoxicillin 875/125 mg PO BID 6.) Phenytoin 100 mg PO BID 7.) [NAME] lax 1 scoop=17 gm (gram) with water one time per day An observation and interview on 7/30/24 at 8:05 AM revealed LPN #1 ask Resident #34 if she would like for her to break the Amoxicillin in half since it was so big. The resident stated yes please that thing gets stuck in my throat, and it just sits there all day. An interview on 7/30/24 at 8:20 AM with LPN #1 revealed when Resident #34 had complained of the pill being so big in the past, she had not offered to split the pill. She stated that she should have offered to split it or get an order to crush it. She stated that the residents last swallow test was good, but again that is a big pill, and she could have choked. An interview on 7/30/24 at 10:50 AM with the Director of Nurses (DON) admitted that if Resident #34 was complaining of the pill being too big then the nurse should have offered to have split the pill, because she could have choked. An interview on 07/30/24 at 3:11 PM with the Consultant Pharmacist revealed there would have been no problem crushing that Amoxicillin. An interview on 07/30/24 03:17 PM with the DON confirmed that the Amoxicillin could have been crushed or the nurse could have called and got an order for liquid. An interview on 8/1/24 at 8:50 AM with LPN #1 confirmed that she attended the in-service about what medications were crushable, but she just did not think about crushing Resident #34's large antibiotic pill, because none of her other medications were getting crushed. Record review of the facility in-services revealed an in-service on 6/4/24 that included crushable medications and was attended by LPN #1. Record review of Resident #34's Physicians orders revealed an order dated 7/23/24 for Amoxicillin-Pot Clavulanate Tablet 875-125 MG (Milligrams). Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) related to Urinary Tract Infection, site not specified for 7 (seven) days. Record review of Resident #34's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Wedge Compression Fracture of First Lumbar Vertebra, Subsequent encounter for fracture with routine healing.

Based on interview, facility and hospital record review, and facility policy review the facility failed to ensure a baseline careplan was developed for a resident with Diabetes resulting in death for one (1) of six (6) resident records reviewed; Resident #1. During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to accurately transcribe physician's orders, reconcile, and verify physician's orders resulting in the omission of an insulin order. Resident #1's physician ordered long-acting insulin was not administered for five days following admission on [DATE] at approximately 4:49 PM, and the resident had to be transferred to the emergency roiagnom on [DATE] at 5:10 AM. The resident had a blood sugar of 764 mg/dl (milligrams/deciliter) at 5:38 AM and resulted in death of the resident at 6:35 AM with a diagnosis of diabetic ketoacidosis (DKA). The facility's failure to accurately transcribe physicians orders, reconcile and verify physicians orders to prevent Diabetic Ketoacidosis as a result of the omission of an insulin order and failure to develop and implement a baseline care plan for diabetes to safeguard against adverse events that are most likely to occur right after admission. This failure resulted in the death of Resident #1 and placed other residents with significant medication orders at risk of developing a situation that was likely to cause serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 5:00 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE] and the IJ removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Care Plan Comprehensive, undated, revealed, 5. A baseline care plan is developed upon the residents' admission. The baseline care plan is used to help develop the comprehensive care plan. An interview on [DATE] at 11:02 AM with the Medical Records Nurse revealed that she confirmed that Minimum Data Set (MDS) nurse is responsible for care plans being put in the resident's record, but each department also does some of their own and if a resident is admitted on the weekend or at night then the nurse supervisor or admitting nurse is responsible for all the resident's care plans. And that a resident's care plans should match the physician orders and diagnoses. She confirmed that by not checking the admission orders and verifying the medical record was accurate that they also failed to develop a base line care plan for diabetes which might would have caught that the Lantus had been omitted. An interview on [DATE] at 11:15 AM with the DON confirmed that the baseline care plan had a yes or no question regarding if the resident was a diabetic and Resident #1's was marked yes, but there were no care instructions regarding diabetes. She revealed that the resident did not have a comprehensive care plan regarding the diagnosis of diabetes, but she should have and confirmed that the facility had policies in place to prevent this from happening, but the process broke down. She revealed she could not say why the process broke down except it was a high stress week but that is no excuse. An interview on [DATE] at 1:06 PM with the MDS nurse revealed that she is part of the interdisciplinary team and receives an email from social services regarding new admissions. She revealed she is responsible for getting the baseline care plan in the resident's record after admission within 48 hours, but the facility does it in 24 hours. She revealed that if a resident is admitted at night or on the weekend then the nurse supervisor would be responsible for putting the care plans in. She revealed the resident's care plan needed to match the orders and the diagnosis and the purpose of the care plan is to know what kind of care the resident needs. She revealed that if she was in the building when a resident was admitted and saw a diagnosis of diabetes then she would try to get the care plan opened as soon as possible (ASAP). She stated, You need to know if someone is a diabetic. She revealed that she was not at work when Resident #1 was admitted on [DATE] and did not return to work until [DATE]. She stated that in her absence the DON and ADON would have been responsible for the care plans, and she felt like within 5 days the resident's diabetic care plan should have been done. An interview on [DATE] at 1:20 PM with the DON revealed that she did not do a care plan for Resident #1 while the MDS nurse was out during the week of [DATE]. She revealed she thought the Corporate MDS person was the backup to the MDS nurse when she was out and thought that person was going to do the care plans, but confirmed a care plan should have been completed and confirmed that a lot of breakdowns of their system occurred. Record review of Resident #1's admitting orders from the hospital dated [DATE] revealed the following orders regarding her diagnosis of diabetes; Lantus 20 units subcutaneous (sub-Q) daily, Humalog 300 units/3 milliliter (ml) solution per sliding scale protocol-corrective low-dose regimens; fingerstick blood glucose of ,d+[DATE] -2 units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, ,d+[DATE] 12 units sub-Q, greater than 400 mg/dl-14 units sub-Q, This review revealed that Lantus 20 unit subcutaneous was last given on [DATE] at 8:57 AM. Record review of Resident #1's facility physicians orders revealed there was no order for Lantus 20 units subcutaneous daily on her Medication Administration Record (MAR). Record review of Resident #1's preliminary certificate of death revealed the Cause of death to be cardiac arrest due to or as a consequence of ketoacidosis, due to or because of diabetes mellitus, received by the facility via fax on [DATE] at 12:04 PM. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's and Type 2 Diabetes. Record review of Resident #1's MDS with an Assessment Reference Date (ARD) of [DATE] revealed in Section I, a diagnosis of Diabetes and in Section C a Brief Interview for Mental Status score (BIMS) of 11, which indicated the resident was moderately cognitively impaired. Review of the Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: 1. On [DATE], at 4:50 am, the Night Shift Registered Nurse (RN) #1 was in a resident ' s room providing care in the room next door when she heard a loud thump x 2. She immediately went to the adjoining room which was resident #1's and upon entering the room, RN #1 observed that Resident #1 was lying on the floor and then attempted to stand up from the floor, when she fell backwards hitting her head prior to RN #1 being able to intervene. Resident # 1 was transferred to the emergency room (ER), (proper name of hospital) per resident's Medical Doctor, at 5:10 am on [DATE].2023. Resident # 1 blood sugar was last checked on [DATE] per Evening Shift Licensed Practical Nurse (LPN), resulting in blood sugar of 388 mg/dl with Humalog 12 units administered Subcutaneous to Right Upper Quadrant of Abdomen per LPN. Blood Sugar at (Proper name of hospital) ER was 764. Resident expired at (Proper name of hospital)ER on [DATE] at 0635 am. Upon investigation on [DATE], of the incident, a chart review was performed, and it was observed that an insulin order, Lantus insulin 20 units every night, was omitted. 2. An Emergency QA meeting was held on [DATE], at 16:12 PM with Regional Director of Operations (DO), Regional Nurse Consultant (RNC), Director of Nursing/Infection Preventionist (DON/IP), Nursing Home Administrator (NHA), and Facility Medical Director (FMD). To prevent this from happening in the future and going forward the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3. Starting on [DATE], and ending on [DATE], the RNC and all resident physicians assessed all resident orders and revised with no negative outcomes. 4. Starting on [DATE] at 1700 the DON/IP started the following processes in which nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. ADON was suspended on [DATE] pending investigation per NHA. 1 on 1 In-service with ADON for admission processes, medication errors, and order entry was performed by NHA, RDO, and RNC on [DATE]. The ADON returned to work on [DATE]. 6. Monitoring Procedures started on [DATE] and included the IDT Clinical team (DON/IP, ADON, MR, and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. On [DATE], the RNC performed 1 on 1 in-service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in-service on diabetic orders, Medical Director (MD) notification, incident care plans, and new employee orientation with DON/IP. On [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. On [DATE], the SA validated the facilities Removal Plan by staff interviews, record reviews, review of the Quality Assurance sign in sheet and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ on [DATE]. The SA validated through interview on [DATE] with the Administrator and DON and record review that the initial investigation was started the morning of [DATE] by the Administrator and the DON including interview of team members that were in the facility at that time. The SA validated through interview on [DATE] with the Administrator, DON, medical director, and record review of the sign in sheets that a Quality Assurance meeting was completed on [DATE] at 4:12 PM. Discussion and an immediate plan including initiation of the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. The SA validated through interviews on [DATE] with the DON and Administrator and record reviews that the RNC and all resident physicians assessed all resident orders and blood sugars and revised with no negative outcomes. The SA validated through interviews and record reviews on [DATE] with the DON, RNC, ADON, Medical Records Nurse, RN #1 and MDS nurse and review of in-service sign in sheets that nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. The SA validated through interviews and record reviews on [DATE] with the DON and ADON that the ADON was suspended following the investigation on [DATE] and returned to work on [DATE] after being in-serviced on the admission process, medication errors and order entry. The SA validated through interviews and record reviews on [DATE] with the DON, Administrator, ADON, Medical Records Nurse and the MDS Nurse that monitoring procedures started on [DATE] and included the Interdisciplinary (IDT) Clinical team (DON/Infection Preventionist (IP), ADON, Medical Records (MR), and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. The SA validated through interviews and record reviews on [DATE] with the RNC and DON and review of in-service sign in sheets that on [DATE] the RNC performed 1 on 1 in service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in service on diabetic orders, MD notification, incident care plans, and new employee orientation with the DON/IP and on [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. The SA validated on [DATE] that all corrective actions to remove the IJ had been completed and the IJ removed on [DATE].

Based on staff interview, record review and facility policy review the facility failed to ensure a resident was free from significant medication errors as evidenced by insulin being omitted from a resident's record for one (1) of six (6) medication orders reviewed. Resident #1 During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to accurately transcribe physician's orders, reconcile, and verify physician's orders resulting in the omission of an insulin order. Resident #1's physician ordered long-acting insulin was not administered for five days following admission on [DATE] at approximately 4:49 PM, and the resident had to be transferred to the emergency roiagnom on [DATE] at 5:10 AM. The resident had a blood sugar of 764 mg/dl (milligrams/deciliter) at 5:38 AM and resulted in death of the resident at 6:35 AM with a diagnosis of diabetic ketoacidosis (DKA). The facility's failure to accurately transcribe physicians orders, reconcile and verify physicians orders to prevent Diabetic Ketoacidosis as a result of the omission of an insulin order and failure to develop and implement a comprehensive care plan regarding the care needed for the diagnosis of diabetes resulted in the death of Resident #1 and placed other residents with significant medication orders at risk of developing a situation that was likely to cause serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 5:00 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Preventing and Detecting Adverse Consequences with a revision date of [DATE] revealed under Policy .The facility employs a system to assure that medication usage is evaluated on an ongoing basis. When a resident has a change in condition, medication-related problems are considered, Significant medication-related problems are assess, document and reported as appropriate to the resident ' attending physician, the pharmacy, the consultant pharmacist and the Food and Drug Administration Med/Watch Program or USP/ISMP Medication Error Reporting Program (when applicable).This review revealed under Procedures, F .In the event of a significant medication related error or adverse consequence, immediate actions is taken, as necessary, to protect the resident's safety and welfare, Significant is defined as .2.) Requiring hospitalization .6.) Life threatening .7.) Resulting in death .G. The attending physician is notified promptly of any significant error or adverse consequence . Review of the facility policy titled, Medications on Admission, Reconciliation of with a revision date of [DATE] revealed Purpose .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility . During an interview on [DATE] at 10:30 AM, the Administrator revealed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes, fell and hit her head on [DATE] and was sent to the emergency room (ER) where she passed away. She revealed that during the investigation of the incident the staff discovered that the residents order of Lantus had been omitted. The Director of Nurses (DON) stated in an interview on [DATE] at 11:45 AM, that Resident #1 was admitted to the facility on [DATE] with a diagnosis of Diabetes. She confirmed the resident was on a sliding scale of insulin and had been receiving that when needed. She confirmed that the order for Lantus had been omitted when the ADON entered the orders, and that omission was found after the resident fell and went to the hospital on [DATE]. She revealed that the orders should have been verified by someone, but that did not happen. She revealed that the facility has a policy and procedure in place to prevent this from happening, but the system broke down. On [DATE] at 1:00 PM, with the Assistant Director of Nurses (ADON), during an interview confirmed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that she entered the Resident #1's orders into her facility medical record and did not realize that the order for Lantus had been left off until the DON and the Administrator informed her on [DATE]. She stated, I do recall taking verbal report from the nurse at the hospital before the resident was admitted and she told me that the resident was a brittle diabetic that tends to drop quickly. An interview on [DATE] at 6:57 PM via telephone, Registered Nurse (RN) #1 revealed she was the nurse on duty the night that Resident #1 had to go to the ER. She revealed she was not aware that the resident was supposed to be taking Lantus because there was no order until the DON notified her. The Medical Records nurse revealed during an interview on [DATE] at 11:02 AM that she was given Resident #1's record to review her admission orders, but there was a lot going on that week with Case Mix and Survey that it got pushed back on her end and that is how the system failed for her personally. She stated, I realized she was on my list to review, survey left on Thursday, and I was going to look at her record on Monday [DATE]. She revealed that orders need follow-up verification and that is what she is supposed to do to make sure there are no errors. She stated, I knew that was my responsibility to verify orders. I didn't realize that not doing that would have resulted in in this. She revealed that the Administrator told her that even when they have other things going on that I have to put admissions first. On [DATE] at 12:32 PM, in an interview with the DON she revealed that medications are ordered from the pharmacy based on the orders that are entered in the resident's electronic record. She revealed that since Resident #1 did not have an order in the computer system for Lantus, it was not ordered. The Administrator reported during an interview on [DATE] at 4:55 PM, that she felt like the week this happened with Resident #1 was the perfect storm, with case mix and survey both going on, but that is no excuse. She revealed that medical records was helping with case mix due to MDS being off and it just fell through. She revealed that she and the team have learned a lot from this and hates that it happened. Record review of the incident investigation revealed that RN #1 was in the neighboring resident room providing care to another resident and heard a loud thump followed by another softer thump in Resident #1's room. RN #1 then went to Resident #1's room and observed the resident on the floor against the wall leaning against the dresser and before the nurse could get to the resident the resident attempted to get up and fell backwards hitting her head on the dresser and wall. RN #1 observed that the resident ' s eyes were open, and she was scooting across the floor but unable to follow simple instructions, track objects or respond verbally. RN #1 called Doctor #1 and received an order to send the resident to the ER for evaluation and treatment and 911 was notified. RN #1 then notified the DON and attempted to notify the Resident Representative (RR) with a phone message being left. This review revealed the resident left the facility around 5:10 AM via ambulance and at approximately 6:50 AM RN #1 was notified by the RR that the resident had passed away at the ER. The facility then received a follow-up call from the ER confirming that the resident had passed away. Record review of Resident #1's admitting orders from the hospital revealed the following orders regarding her diagnosis of diabetes; Lantus 20 units subcutaneous (sub-Q) daily, Humalog 300 units/3ml solution per sliding scale protocol-corrective low-dose regimens; fingerstick blood glucose of ,d+[DATE] -2 units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, ,d+[DATE] 12 units sub-Q, greater than 400 mg/dl-14 units sub-Q. Documentation revealed the last time Lantus 20 units subcutaneously was administer to Resident #1 was on [DATE] at 8:57 AM. Record review of Resident #1's electronic record revealed Lantus 20 units subcutaneous daily was omitted from the physician orders. Record review of Resident #1's documented blood sugars since admission revealed Resident #1's blood sugar had been checked 18 times and 14 of those were above 141 requiring insulin per physician's ordered sliding scale. The documented blood sugars were as follows: [DATE] @ 5:13 PM = 159 [DATE] @ 8:47 PM = 141 [DATE] @ 7:20 AM = 129 [DATE] @ 11:50 AM =116 [DATE] @ 4:21 PM = 128 [DATE] @ 9:04 PM = 270 [DATE] @ 7:23 AM = 308 [DATE] @ 12:06 PM = 329 [DATE] @ 4:56 PM = 253 [DATE] @ 8:13 PM = 217 [DATE] @ 7:57 AM = 398 [DATE] @ 1:25 PM = 284 [DATE] @ 6:36 PM = 393 [DATE] @ 9:46 PM = 377 [DATE] @ 7:47 AM = 399 [DATE] @ 12:50 PM = 188 [DATE] @ 4:38 PM = 374 [DATE] @ 9:37 PM = 388 Record review of Resident #1's ER visit on [DATE] revealed a bedside glucose of High Critical-Very abnormal high collected at 5:34 AM and a comprehensive Metabolic Panel glucose result of 764 mg/dl collected at 5:38 AM. Record review of the written statement given by the ADON revealed (Resident #1's proper name) was admitted on Monday and in report I was told she was a brittle diabetic with a history of DKA and her blood sugars dropped at night. While putting in her orders I was notified of another admission coming while also trying to secure staffing. I remember I needed clarification for her Lantus but do not recall what pulled me away from finishing her admission and this statement was signed by the DON. Review of the typed statement signed by the Medical Records Nurse read as follows: I was unable to review admissions during the week beginning [DATE] due to assisting with State mix review and state survey. Afterwards, Information Technology (IT) was working on my computer due to problems with my email. Friday, I reviewed the admission for [DATE]; assisted with advance directive clarifications, cleared/audited forms, and worked on filing and putting documents on charts. Record review of Resident #1's preliminary certificate of death received by the facility via fax on [DATE] at 12:04 PM revealed the cause of death to be cardiac arrest due to or as a consequence of ketoacidosis, due to or as a consequence of diabetes mellitus. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's and Type 2 Diabetes. Record review of Resident #1's Minimum Data Set with an Assessment Reference Date of [DATE] revealed in Section I, a diagnosis of Diabetes and in Section C a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired, Review of the Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: 1. On [DATE], at 4:50 am, the Night Shift Registered Nurse (RN) #1 was in a resident ' s room providing care in the room next door when she heard a loud thump x 2. She immediately went to the adjoining room which was resident #1 ' s and upon entering the room, RN #1 observed that Resident #1 was lying on the floor and then attempted to stand up from the floor, when she fell backwards hitting her head prior to RN #1 being able to intervene. Resident # 1 was transferred to the emergency room (ER), (proper name of hospital) per resident ' s Medical Doctor, at 5:10 am on [DATE].2023. Resident # 1 blood sugar was last checked on [DATE] per Evening Shift Licensed Practical Nurse (LPN), resulting in blood sugar of 388 mg/dl with Humalog 12 units administered Subcutaneously to Right Upper Quadrant of Abdomen per LPN. Blood Sugar at (Proper name of hospital) ER was 764. Resident expired at (Proper name of hospital)ER on [DATE] at 0635 am. Upon investigation on [DATE], of the incident, a chart review was performed, and it was observed that an insulin order, Lantus insulin 20 units every night, was omitted. 2. An Emergency QA meeting was held on [DATE], at 16:12 PM with Regional Director of Operations (DO), Regional Nurse Consultant (RNC), Director of Nursing/Infection Preventionist (DON/IP), Nursing Home Administrator (NHA), and Facility Medical Director (FMD). To prevent this from happening in the future and going forward the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3. Starting on [DATE], and ending on [DATE], the RNC and all resident physicians assessed all resident orders and revised with no negative outcomes. 4. Starting on [DATE] at 1700 the DON/IP started the following processes in which nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. ADON was suspended on [DATE] pending investigation per NHA. 1 on 1 In-service with ADON for admission processes, medication errors, and order entry was performed by NHA, RDO, and RNC on [DATE]. The ADON returned to work on [DATE]. 6. Monitoring Procedures started on [DATE] and included the IDT Clinical team (DON/IP, ADON, MR, and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. On [DATE], the RNC performed 1 on 1 in-service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in-service on diabetic orders, Medical Director (MD) notification, incident care plans, and new employee orientation with DON/IP. On [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. On [DATE], the SA validated the facilities Removal Plan by staff interviews, record reviews, review of the Quality Assurance sign in sheet and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ on [DATE]. The SA validated through interview on [DATE] with the Administrator and DON and record review that the initial investigation was started the morning of [DATE] by the Administrator and the DON including interview of team members that were in the facility at that time. The SA validated through interview on [DATE] with the Administrator, DON, medical director, and record review of the sign in sheets that a Quality Assurance meeting was completed on [DATE] at 4:12 PM. Discussion and an immediate plan including initiation of the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. The SA validated through interviews on [DATE] with the DON and Administrator and record reviews that the RNC and all resident physicians assessed all resident orders and blood sugars and revised with no negative outcomes. The SA validated through interviews and record reviews on [DATE] with the DON, RNC, ADON, Medical Records Nurse, RN #1 and MDS nurse and review of in-service sign in sheets that nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. The SA validated through interviews and record reviews on [DATE] with the DON and ADON that the ADON was suspended following the investigation on [DATE] and returned to work on [DATE] after being in-serviced on the admission process, medication errors and order entry. The SA validated through interviews and record reviews on [DATE] with the DON, Administrator, ADON, Medical Records Nurse and the MDS Nurse that monitoring procedures started on [DATE] and included the Interdisciplinary (IDT) Clinical team (DON/Infection Preventionist (IP), ADON, Medical Records (MR), and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. The SA validated through interviews and record reviews on [DATE] with the RNC and DON and review of in-service sign in sheets that on [DATE] the RNC performed 1 on 1 in service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in service on diabetic orders, MD notification, incident care plans, and new employee orientation with the DON/IP and on [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. The SA validated on [DATE] that all corrective actions to remove the IJ had been completed and the IJ removed on [DATE].

Based on staff interviews, record review and facility policy review the facility failed to ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for one (1) of 10 residents reviewed (six (6) sampled residents and four (4) unsampled residents). Resident #1 During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to accurately transcribe physician's orders, reconcile, and verify physician's orders resulting in the omission of an insulin order. Resident #1's physician ordered long-acting insulin was not administered for five days following admission on [DATE] at approximately 4:49 PM, and the resident had to be transferred to the emergency roiagnom on [DATE] at 5:10 AM. The resident had a blood sugar of 764 mg/dl (milligrams/deciliter) at 5:38 AM and resulted in death of the resident at 6:35 AM with a diagnosis of diabetic ketoacidosis (DKA). The facility's failure to accurately transcribe physicians orders, reconcile and verify physicians orders to prevent Diabetic Ketoacidosis as a result of the omission of an insulin order and failure to develop and implement a comprehensive care plan regarding the care needed for the diagnosis of diabetes resulted in the death of Resident #1 and placed other residents with significant medication orders at risk of developing a situation that was likely to cause serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 5:00 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE] and the IJ removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Conformity with Laws and Professional Standards with a revision date of [DATE], revealed, Policy Statement .Our facility operates and provides services in compliance with current federal, state and local laws and regulations, codes and professional standards of practice that apply to our facility and types of services provided . Review of the facility policy titled, Medications on Admission, Reconciliation Of with a revision date of [DATE] revealed, Purpose . The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. During an interview with the Administrator on [DATE] at 10:30 AM, revealed that Resident #1 was admitted to the facility on [DATE] with a diagnosis of diabetes, fell and hit her head on [DATE] and was sent to the emergency room (ER) where she passed away. She revealed that during the investigation of the incident the staff discovered that the residents order for Lantus daily had been omitted from her admission orders. During an interview with the Director of Nurses (DON) on [DATE] at 11:45 AM, she confirmed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that the resident's order for Lantus had been omitted when the Assistant Director of Nursing (ADON) entered the physician orders, and that omission was found after the resident fell and went to the hospital and died on [DATE]. She revealed that the orders should have been verified by someone, but that did not happen, and she is not sure why. She revealed that the facility has a policy and procedure in place to prevent this from happening and this was a system breakdown. In an interview with the ADON on [DATE] at 1:00 PM, confirmed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that she entered the resident's orders in the facility medical record and did not realize that the order for Lantus had been left off until the DON and the Administrator informed her on [DATE]. She stated, I do recall taking verbal report from the nurse at the hospital before the resident was admitted and she told me that the resident was a brittle diabetic that tends to drop quickly. She revealed that she or the DON enter the admission orders for residents and then when we they are finished, they give it to Medical Records for her to verify. She revealed she gave the record to someone to verify but does not recall who. She confirmed that she was suspended from work on [DATE] while they completed their investigation and returned to work on [DATE] and was also in-serviced about medication entry, medication errors, the admission process and care plans. During a phone interview on [DATE] at 6:57 PM, Registered Nurse (RN) #1 revealed she was Resident #1's nurse the night she had to go to the ER. She stated that she was in the resident's room next door to Resident #1's room providing care to another resident and heard two loud thumps coming from Resident #1's room. She went to Resident #1's room and found her lying on the floor between the wall and the dresser and she told the resident to hang on and she would get some help, then she called for assistance from another staff member. She stated that the resident attempted to get up before she could get to her and almost made it to her knees then fell back again and hit her head on the dresser. She revealed that after the resident fell the second time and hit her head, she started scooting across the floor and was shaking. She stated that the resident said something that was not understandable and made eye contact with her, but it did not seem like she was understanding simple commands. She revealed that she immediately notified Doctor #1 who gave her the order to send her out to the ER. She then called 911, the DON and attempted to reach the resident's Resident Representative (RR) but did not get an answer. She revealed that the resident had been able to walk without assistance since admission and had not showed any signs of problems with her blood sugar since she had come on shift at 10:00 PM. She confirmed that the RR had called the facility and notified her that the resident had passed away at the ER and then she received a call from the ER verifying that the resident had passed away. She stated that she was not aware that the resident was supposed to be taking Lantus every day because there was no order in the medical record until the facility notified her during the investigation. During an interview on [DATE] at 11:02 AM, with the Medical Records Nurse revealed that she was given Resident #1's medical record to review her admission orders, but there was she was so busy that week that it got pushed back on her end and that is how the system failed for her personally. She stated, I realized she was on my list to review, and I was going to look at her record on Monday [DATE]. She revealed that orders needed follow-up verification and that is what she is supposed to do to make sure there are no errors. She stated, I knew that was my responsibility to verify orders. I didn't realize that not doing that would have resulted in in this (death). She stated she was in-serviced after the incident occurred regarding the admission process, verifying orders and care plans. She stated that the Administrator told her that even when we have other things going on that I must put admissions first. She confirmed that Minimum Data Set (MDS) is responsible for care plans being put in resident's record, but each department also does some of their own and if a resident is admitted on the weekend or at night then the nurse supervisor or admitting nurse is responsible for all the resident's care plans. And that a resident's care plans should match the physician orders and diagnoses. She confirmed that by not checking the admission orders and verifying the medical record was accurate that they also failed to develop a base line care plan for diabetes which might would have caught that the Lantus had been omitted. In interview with the DON on [DATE] at 11:15 AM, she stated she was in serviced by the Registered Nurse Consultant (RNC) following the death of Resident #1 regarding medication errors, doctor notification and care plans. She confirmed that the baseline care plan had a yes or no question regarding if the resident was a diabetic and Resident #1's was marked yes, but there were no care instructions regarding diabetes. She revealed that the resident did not have a comprehensive care plan regarding the diagnosis of diabetes, but she should have and confirmed that the facility had policies in place to prevent this from happening, but the process broke down. She revealed she could not say why the process broke down except it was a high stress week but that is no excuse. During an interview on [DATE] at 12:32 PM, with the DON revealed that medications are ordered from the pharmacy based on the orders that are entered in the computer system. She stated that since Resident #1 did not have an order in the computer system for Lantus, it was not ordered from the pharmacy. On [DATE] at 1:06 PM, during an interview with the MDS nurse revealed that she is a member of the interdisciplinary team and receives an email from social services regarding new admissions. She revealed she is responsible for getting the baseline care plan in the resident's record after admission within 48 hours, but the facility does it in 24 hours. She revealed that if a resident is admitted at night or on the weekend then the nurse supervisor would be responsible for putting the care plans in. She revealed the resident's care plan needed to match the orders and the diagnosis and the purpose of the care plan is to know what kind of care the resident needs. She revealed that if she was in the building when a resident was admitted and saw a diagnosis of diabetes then she would try to get the care plan opened as soon as possible (ASAP). She stated, You need to know if someone is a diabetic. She revealed that she was not at work when Resident #1 was admitted on [DATE] and did not return to work until [DATE]. She stated that in her absence the DON and ADON would have been responsible for the care plans, and she felt like within 5 days the resident's diabetic care plan should have been done. In interview on with the DON [DATE] at 1:20 PM, she confirmed that Resident #1 did not have a care plan regarding her diagnosis of Diabetes. She revealed that she did not do a care plan for Resident #1 while the MDS nurse was out during the week of [DATE]. She revealed she thought the Corporate MDS person was the backup to the MDS nurse when she was out and thought that person was going to do the care plans, but confirmed a care plan should have been completed and confirmed that a lot of breakdowns of their system occurred. During an interview on [DATE] at 1:42 PM, with the Registered Nurse Consultant (RNC) revealed that the facility has 21 days to get the comprehensive care plans in the resident's record. When the State Agent asked if she felt like a resident with a diagnosis of diabetes and receiving insulin should have a care plan regarding that diagnosis sooner than 21 days, she smiled but did not respond. An interview on [DATE] at 1:47 PM with RN #2 revealed she was the previous DON at the facility. She revealed that if she sees that a resident is getting blood glucose checks then she checks to make sure they have a care plan. An interview on [DATE] at 4:55 PM, with the Administrator revealed she felt like the week this happened with Resident #1 was the perfect storm, with case mix and survey both going on, but that is no excuse. She revealed that medical records were helping with case mix due to MDS being off and it just fell through. She revealed that she and the team have learned a lot from this and hates that it happened. Record review of the incident investigation revealed that RN #1 was in the neighboring resident room providing care to another resident and heard a loud thump followed by another softer thump in Resident #1's room. RN #1 then went to Resident #1 ' s room and observed the resident on the floor against the wall leaning against the dresser and before the nurse could get to the resident the resident attempted to get up and fell backwards hitting her head on the dresser and wall. RN #1 observed that the resident' eyes were open, and she was scooting across the floor but unable to follow simple instructions, track objects or respond verbally. RN #1 called Doctor #1 and received an order to send the resident to the ER for evaluation and treatment and 911 was notified. RN #1 then notified the DON and attempted to notify the Resident Representative (RR) with a phone message being left. This review revealed the resident left the facility around 5:10 AM via ambulance and at approximately 6:50 AM RN #1 was notified by the RR that the resident had passed away at the ER and then received a follow-up call from the ER confirming that the resident had passed away. Record review of Resident #1 ' s admitting orders from the hospital revealed the following orders regarding her diagnosis of diabetes; Lantus 20 units subcutaneous daily, Humalog 300 units/3ml solution per sliding scale protocol-corrective low-dose regimens; fingerstick blood glucose of ,d+[DATE] -2 units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, ,d+[DATE] 12 units sub-Q, greater than 400 mg/dl-14 units sub-Q, This review revealed that the last time that Resident #1 received Lantus 20 units subcutaneously was on [DATE] at 8:57 AM. Record review of Resident #1's facility physicians orders revealed there was no order for Lantus 20 units subcutaneous daily. Record review of the written statement given by the ADON revealed (Resident #1's proper name) was admitted on Monday and in report I was told she was a brittle diabetic with a history of DKA and her blood sugars dropped at night. While putting in her orders I was notified of another admission coming while also trying to secure staffing. I remember I needed clarification for her Lantus but do not recall what pulled me away from finishing her admission and this statement was signed by the DON. Review of the typed statement signed by the Medical Records Nurse read as follows: I was unable to review admissions during the week beginning [DATE] due to assisting with State mix review and state survey. Afterwards, Information Technology (IT) was working on my computer due to problems with my email. Friday, I reviewed the admission for [DATE]; assisted with advance directive clarifications, cleared/audited forms, and worked on filing and putting documents on charts. Record review of Resident #1's care plans revealed the resident was indicated to have diabetes on the baseline care plan with no care instructions and there was no comprehensive care plan related to the resident's diagnosis of diabetes. Record review of Resident #1's documented blood sugars since admission revealed the resident's blood sugar had been checked 18 times and 14 of those were above 141 mg/dl requiring insulin per physician's ordered sliding scale. The documented blood sugars were as follows: [DATE] @ 5:13 PM = 159 [DATE] @ 8:47 PM = 141 [DATE] @ 7:20 AM = 129 [DATE] @ 11:50 AM =116 [DATE] @ 4:21 PM = 128 [DATE] @ 9:04 PM = 270 [DATE] @ 7:23 AM = 308 [DATE] @ 12:06 PM = 329 [DATE] @ 4:56 PM = 253 [DATE] @ 8:13 PM = 217 [DATE] @ 7:57 AM = 398 [DATE] @ 1:25 PM = 284 [DATE] @ 6:36 PM = 393 [DATE] @ 9:46 PM = 377 [DATE] @ 7:47 AM = 399 [DATE] @ 12:50 PM = 188 [DATE] @ 4:38 PM = 374 [DATE] @ 9:37 PM = 388 Record review of Resident #1's ER visit on [DATE] revealed a bedside glucose of High Critical-Very abnormal high collected at 5:34 AM and a comprehensive Metabolic Panel glucose result of 764 collected at 5:38 AM. Record review of Resident #1's preliminary certificate of death revealed the cause of death to be cardiac arrest due to or as a consequence of ketoacidosis, due to or as a consequence of diabetes mellitus received by the facility via fax on [DATE] at 12:04 PM. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's and Type 2 Diabetes. Record review of Resident #1's Minimum Data Set with an Assessment Reference Date of [DATE] revealed in Section I, a diagnosis of Diabetes and in Section C a Brief Interview for Mental Status (BIMS) of 11 which indicated the resident was moderately cognitively impaired, Review of the facilities Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: 1. On [DATE], at 4:50 am, the Night Shift Registered Nurse (RN) #1 was in a resident's room providing care in the room next door when she heard a loud thump x 2. She immediately went to the adjoining room which was resident #1's and upon entering the room, RN #1 observed that Resident #1 was lying on the floor and then attempted to stand up from the floor, when she fell backwards hitting her head prior to RN #1 being able to intervene. Resident # 1 was transferred to the emergency room (ER), (proper name of hospital) per resident ' s Medical Doctor, at 5:10am on [DATE].2023. Resident # 1 blood sugar was last checked on [DATE] per Evening Shift Licensed Practical Nurse (LPN), resulting in blood sugar of 388 mg/dl with Humalog 12 units administered Subcutaneously to Right Upper Quadrant of Abdomen per LPN. Blood Sugar at (Proper name of hospital) ER was 764. Resident expired at (Proper name of hospital)ER on [DATE] at 0635 am. Upon investigation on [DATE], of the incident, a chart review was performed, and it was observed that an insulin order, Lantus insulin 20 units every night, was omitted. 2. An Emergency QA meeting was held on [DATE], at 16:12 PM with Regional Director of Operations (DO), Regional Nurse Consultant (RNC), Director of Nursing/Infection Preventionist (DON/IP), Nursing Home Administrator (NHA), and Facility Medical Director (FMD). To prevent this from happening in the future and going forward the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3. Starting on [DATE], and ending on [DATE], the RNC and all resident physicians assessed all resident orders and revised with no negative outcomes. 4. Starting on [DATE] at 1700 the DON/IP started the following processes in which nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. ADON was suspended on [DATE] pending investigation per NHA. 1 on 1 In-service with ADON for admission processes, medication errors, and order entry was performed by NHA, RDO, and RNC on [DATE]. The ADON returned to work on [DATE]. 6. Monitoring Procedures started on [DATE] and included the IDT Clinical team (DON/IP, ADON, MR, and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. On [DATE], the RNC performed 1 on 1 in-service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in-service on diabetic orders, Medical Director (MD) notification, incident care plans, and new employee orientation with DON/IP. On [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. On [DATE], the SA validated the facilities Removal Plan by staff interviews, record reviews, review of the Quality Assurance sign in sheet and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ on [DATE]. 1. The SA validated through interview on [DATE] with the Administrator and DON and record review that the initial investigation was started the morning of [DATE] by the Administrator and the DON including interview of team members that were in the facility at that time. 2. The SA validated through interview on [DATE] with the Administrator, DON, medical director, and record review of the sign in sheets that a Quality Assurance meeting was completed on [DATE] at 4:12 PM. Discussion and an immediate plan including initiation of the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3/ The SA validated through interviews on [DATE] with the DON and Administrator and record reviews that the RNC and all resident physicians assessed all resident orders and blood sugars and revised with no negative outcomes. 4. The SA validated through interviews and record reviews on [DATE] with the DON, RNC, ADON, Medical Records Nurse, RN #1 and MDS nurse and review of in-service sign in sheets that nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. The SA validated through interviews and record reviews on [DATE] with the DON and ADON that the ADON was suspended following the investigation on [DATE] and returned to work on [DATE] after being in-serviced on the admission process, medication errors and order entry. 6. The SA validated through interviews and record reviews on [DATE] with the DON, Administrator, ADON, Medical Records Nurse and the MDS Nurse that monitoring procedures started on [DATE] and included the Interdisciplinary (IDT) Clinical team (DON/Infection Preventionist (IP), ADON, Medical Records (MR), and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. The SA validated through interviews and record reviews on [DATE] with the RNC and DON and review of in-service sign in sheets that on [DATE] the RNC performed 1 on 1 in service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in service on diabetic orders, MD notification, incident care plans, and new employee orientation with the DON/IP and on [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. The SA validated on [DATE] that all corrective actions to remove the IJ had been completed and the IJ removed on [DATE].

Based on interviews, facility and hospital record review, and facility policy review, the facility failed to provide services to meet professional standards by failing to ensure the accuracy and reconciliation of a resident's physician orders for medications for a resident with Diabetes resulting in death for one (1) of six (6) resident records reviewed; Resident #1. During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to accurately transcribe physician's orders, reconcile, and verify physician's orders resulting in the omission of an insulin order. Resident #1's physician ordered long-acting insulin was not administered for five days following admission on [DATE] at approximately 4:49 PM, and the resident had to be transferred to the emergency roiagnom on [DATE] at 5:10 AM. The resident had a blood sugar of 764 mg/dl (milligrams/deciliter) at 5:38 AM and resulted in death of the resident at 6:35 AM with a diagnosis of diabetic ketoacidosis (DKA). The facility's failure to adhere to professional standards and accurately transcribe physician's orders, reconcile and verify physician's orders, and prevent Diabetic Ketoacidosis from the omission of an insulin order, lead to the death of Resident #1 and placed other residents with significant medication orders at risk of a situation that was likely to cause serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 5:00 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE] and the IJ removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Conformity with Laws and Professional Standards with a revision date of ,d+[DATE], revealed under, Policy Statement .Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes and professional standards of practice that apply to our facility and types of services provided. The Administrator revealed during an interview on [DATE] at 10:30 AM, that Resident #1 was admitted on [DATE] with a diagnosis of diabetes. On [DATE], the resident fell and hit her head and was sent to the emergency room (ER) where she passed away. She revealed that during the investigation of the incident the staff discovered that the resident's order for Lantus daily had been omitted from her admission orders. The Director of Nurses (DON) confirmed during an interview on [DATE] at 11:45 AM, that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that the order for Lantus had been omitted when the Assistant Director of Nursing (ADON) entered the physician orders, and that omission was found after the resident fell and went to the hospital and died on [DATE]. She revealed that the orders should have been verified by someone, but that did not happen, and she is not sure why. She revealed that the facility has a policy and procedure in place to prevent this from happening and this was a system breakdown. The Assistant Director of Nurses (ADON) confirmed in an interview on [DATE] at 1:00 PM, that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that she entered the resident's orders into her facility medical record and did not realize that the order for Lantus had been left off until the DON and the Administrator informed her on [DATE]. She stated, I do recall taking verbal report from the nurse at the hospital before the resident was admitted and she told me that the resident was a brittle diabetic that tends to drop quickly. She revealed that she or the DON enters the admission orders for residents and then when we they are finished, they give it to Medical Records for her to verify. She revealed she gave the record to someone to verify but does not recall who. She confirmed that she was suspended from work on [DATE] while they completed their investigation and returned to work on [DATE] and was in-serviced about medication entry, medication errors, the admission process and care plans. Registered Nurse (RN) #1 revealed during a phone interview on [DATE] at 6:57 PM, she was the nurse on duty the night that Resident #1 had to go to the ER. She revealed that the resident had been able to walk without assistance since admission and had not showed any signs of problems with her blood sugar since she had come on shift at 10:00 PM. She confirmed the resident fell and had to go to the ER. She confirmed that the Resident Representative (RR) had called the facility and notified her that the resident had passed away at the ER and then she received a call from the ER verifying that the resident had passed away. She stated that she was not aware that the resident was supposed to be taking Lantus every day because there was no order in the medical record until the facility notified her during the investigation. Interview on [DATE] at 11:02 AM with the Medical Records Nurse revealed that she was given Resident #1's medical record to review her admission orders, but there was so much going on that week that it got pushed back on her end and that is how the system failed for her personally. She stated, I realized she was on my list to review, and I was going to look at her record on Monday [DATE]. She revealed that orders needed follow-up verification and that is what she is supposed to do to make sure there are no errors. She stated, I knew that was my responsibility to verify orders. I didn't realize that not doing that would have resulted in in this (death). She stated she was in-service after the incident occurred regarding the admission process, verifying orders and care plans. She stated that the Administrator told her that even when we have other things going on that I must put admissions first. Interview on [DATE] at 4:55 PM with the Administrator revealed she felt like the week this happened with Resident #1 was the perfect storm, but that is no excuse. She revealed that medical records were helping with case mix due to MDS being off and it just fell through. Record review of Resident #1's admitting orders from the hospital dated [DATE] revealed the following orders regarding her diagnosis of diabetes; Lantus 20 units subcutaneous (sub-Q) daily, Humalog 300 units/3 ml solution per sliding scale protocol-corrective low-dose regimens; fingerstick blood glucose of ,d+[DATE] -2 units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, ,d+[DATE] 12 units sub-Q, greater than 400 mg/dl-14 units sub-Q, This review revealed that Lantus 20 unit subcutaneous was last given on [DATE] at 8:57 AM. Record review of Resident #1's facility physicians orders revealed there was no order for Lantus 20 units subcutaneous daily on her Medication Administration Record (MAR). Record review of the written statement given by the ADON revealed (Resident #1's proper name) was admitted on Monday and in report I was told she was a brittle diabetic with a history of Diabetic Ketoacidosis (DKA) and her blood sugars dropped at night. While putting in her orders I was notified of another admission coming while also trying to secure staffing. I remember I needed clarification for her Lantus but do not recall what pulled me away from finishing her admission. and this statement was signed by the DON. Review of the typed statement signed by the Medical Records Nurse read as follows: I was unable to review admissions during the week beginning [DATE] due to assisting with State mix review and state survey. Afterwards, Information Technology (IT) was working on my computer due to problems with my email. Friday, I reviewed the admissions for [DATE]; assisted with advance directive clarifications, cleared/audited forms, and worked on filing and putting documents on charts. Record review of Resident #1's documented blood sugars since admission revealed the resident's blood sugar had been checked 18 times and 14 of those were above 141 requiring insulin per physician's ordered sliding scale. The documented blood sugars were as follows: Record review of Resident #1's ER visit on [DATE] revealed a bedside glucose of High Critical-Very abnormal high collected at 5:34 AM and a comprehensive Metabolic Panel glucose result of 764 collected at 5:38 AM. Record review of Resident #1's preliminary certificate of death revealed the Cause of death to be cardiac arrest due to or as a consequence of ketoacidosis, due to or because of diabetes mellitus, received by the facility via fax on [DATE] at 12:04 PM. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's and Type 2 Diabetes. Record review of Resident #1's MDS with an Assessment Reference Date (ARD) of [DATE] revealed in Section I, a diagnosis of Diabetes and in Section C a Brief Interview for Mental Status score (BIMS) of 11, which indicated the resident was moderately cognitively impaired. Review of the facilities Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: 1. On [DATE], at 4:50 am, the Night Shift Registered Nurse (RN) #1 was in a resident's room providing care in the room next door when she heard a loud thump x 2. She immediately went to the adjoining room which was Resident #1's and upon entering the room, RN #1 observed that Resident #1 was lying on the floor and then attempted to stand up from the floor, when she fell backwards hitting her head prior to RN #1 being able to intervene. Resident # 1 was transferred to the emergency room (ER), (proper name of hospital) per resident's Medical Doctor, at 5:10 am on [DATE].2023. Resident # 1 blood sugar was last checked on [DATE] per Evening Shift Licensed Practical Nurse (LPN), resulting in blood sugar of 388 mg/dl with Humalog 12 units administered Subcutaneous to Right Upper Quadrant of Abdomen per LPN. Blood Sugar at (Proper name of hospital) ER was 764. Resident expired at (Proper name of hospital)ER on [DATE] at 0635 am. Upon investigation on [DATE], of the incident, a chart review was performed, and it was observed that an insulin order, Lantus insulin 20 units every night, was omitted. 2. An Emergency QA meeting was held on [DATE], at 16:12 pm with Regional Director of Operations (DO), Regional Nurse Consultant (RNC), Director of Nursing/Infection Preventionist (DON/IP), Nursing Home Administrator (NHA), and Facility Medical Director (FMD). To prevent this from happening in the future and going forward the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3. Starting on [DATE], and ending on [DATE], the RNC and all resident physicians assessed all resident orders and revised with no negative outcomes. 4. Starting on [DATE] at 1700 the DON/IP started the following processes in which nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. ADON was suspended on [DATE] pending investigation per NHA. 1 on 1 In-service with ADON for admission processes, medication errors, and order entry was performed by NHA, RDO, and RNC on [DATE]. The ADON returned to work on [DATE]. 6. Monitoring Procedures started on [DATE] and included the IDT Clinical team (DON/IP, ADON, MR, and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. On [DATE], the RNC performed 1 on 1 in-service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in-service on diabetic orders, Medical Director (MD) notification, incident care plans, and new employee orientation with DON/IP. On [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. State Agency (SA) Validation: On [DATE], the SA validated the facilities Removal Plan by staff interviews, record reviews, review of the Quality Assurance sign in sheet and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ on [DATE]. The SA validated through interview on [DATE] with the Administrator and DON and record review that the initial investigation was started the morning of [DATE] by the Administrator and the DON including interview of team members that were in the facility at that time. The SA validated through interview on [DATE] with the Administrator, DON, medical director, and record review of the sign in sheets that a Quality Assurance meeting was completed on [DATE] at 4:12 PM. Discussion and an immediate plan including initiation of the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. The SA validated through interviews on [DATE] with the DON and Administrator and record reviews that the RNC and all resident physicians assessed all resident orders and blood sugars and revised with no negative outcomes. The SA validated through interviews and record reviews on [DATE] with the DON, RNC, ADON, Medical Records Nurse, RN #1 and MDS nurse and review of in-service sign in sheets that nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. The SA validated through interviews and record reviews on [DATE] with the DON and ADON that the ADON was suspended following the investigation on [DATE] and returned to work on [DATE] after being in-serviced on the admission process, medication errors and order entry. The SA validated through interviews and record reviews on [DATE] with the DON, Administrator, ADON, Medical Records Nurse and the MDS Nurse that monitoring procedures started on [DATE] and included the Interdisciplinary (IDT) Clinical team (DON/Infection Preventionist (IP), ADON, Medical Records (MR), and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. The SA validated through interviews and record reviews on [DATE] with the RNC and DON and review of in-service sign in sheets that on [DATE] the RNC performed 1 on 1 in service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in service on diabetic orders, MD notification, incident care plans, and new employee orientation with the DON/IP and on [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. The SA validated on [DATE] that all corrective actions to remove the IJ had been completed and the IJ removed on [DATE].

Based on staff interview, record review and facility policy review the facility failed to ensure resident's medical records were accurately and completely documented on a newly admitted resident. Resident #1's admitting physician's orders were not transcribed correctly or implemented for one (1) of six (6) resident medication records reviewed. Resident #1 During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to accurately transcribe physician's orders, reconcile, and verify physician's orders resulting in the omission of an insulin order and develop a comprehensive care plan regarding the care needed for the diagnosis of diabetes for Resident #1. Resident #1's physician ordered long-acting insulin was not administered for five days following admission on [DATE] at approximately 4:49 PM and the resident had to be transferred to the emergency roiagnom on [DATE] at 5:10 AM. The resident had a blood sugar of 764 mg/dl (milligrams/deciliter) at 5:38 AM and resulted in death of the resident at 6:35 AM with a diagnosis of diabetic ketoacidosis (DKA). The facility's failure to accurately transcribe physicians orders, reconcile and verify physicians orders to prevent Diabetic Ketoacidosis as a result of the omission of an insulin order resulted in the death of Resident #1 and placed other residents with significant medication orders at risk of developing a situation that was likely to cause serious injury, harm, impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 5:00 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Medication on Admission, Reconciliation of with a revision date of [DATE] revealed Purpose .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility . General Guidelines .#2. Medication reconciliation reduces medication errors and enhance resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process . Review of the facility policy titled Medical Record Audits with a revision date of [DATE] revealed Policy Statement .It is the policy of this facility to conduct on going audits and monitoring for completion, timeliness and accuracy of the resident's medical record, This review revealed under Procedure .#1 Audits will be conducted on the resident's medical record according to the following schedule: a. Upon Admission/Readmission . An interview on [DATE] at 10:30 AM, with the Administrator revealed that Resident #1 was admitted on [DATE] with diagnoses that included diabetes, fell and hit her head on [DATE] and was sent to the emergency room (ER) where she passed away. She revealed that during the investigation of the incident the staff discovered that the residents order of Lantus had been omitted. An interview on [DATE] at 11:45 AM, with the Director of Nurses (DON) confirmed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes Mellitus. She confirmed that the resident's Lantus order had been omitted when the Assistant Director of Nurses (ADON) entered the orders, and that omission was found after the resident fell and went to the hospital on [DATE]. She revealed that the orders should have been verified by someone, but that did not happen, and she is not sure why. She revealed that the facility has a policy and procedure in place to prevent this from happening, but this was a system breakdown. An interview on [DATE] at 1:00 PM, with the ADON confirmed that Resident #1 was admitted on [DATE] with a diagnosis of Diabetes. She confirmed that she entered the resident's orders into her facility medical record, but did not realize that the order for Lantus had been left off until the DON and the Administrator informed her on [DATE]. She stated, I do recall taking verbal report from the nurse at the hospital before the resident was admitted and she told me that the resident was a brittle diabetic that tends to drop quickly. She revealed that she or the DON enters the admission orders for the residents and then when we they are finished, they give it to Medical Records Department for Verification. She stated that she gave the record to someone to verify but does not recall who and stated she recalled that survey was going on that week, so we were busy getting information for them, but that is no excuse. She confirmed that she was suspended from work on [DATE] while they completed their investigation and returned to work on [DATE] and was also in-serviced about medication entry, medication errors, the admission process and care plans. A telephone interview on [DATE] at 6:57 PM, with Registered Nurse (RN) #1 revealed she was the nurse on duty the night that Resident #1 had to go to the ER. She revealed she was not aware that the resident was supposed to be taking Lantus until the DON notified her during the investigation, because there was no order. An interview on [DATE] at 11:02 AM, with the Medical Records Nurse revealed that she was given Resident #1's record to review her admission orders, but there was so much going on that week with Case Mix and Survey that it got pushed back on her end and that is how the system failed for her personally. She stated, I realized she was on my list to review. Survey left on Thursday and I was going to look at her record on Monday [DATE]. She revealed that orders need follow-up verification and that is what she is supposed to do to make sure there are no errors. She stated, I knew that was my responsibility to verify orders. I didn't realize that not doing that would have resulted in in this. She revealed she did receive an in-service after the incident occurred regarding the admission process, verifying orders and care plans. She stated that the Administrator told her that even when we have other things going on that I have to put admissions first. An interview on [DATE] at 11:15 AM, with the DON, confirmed the facility had policies in place to prevent this from happening, but the process broke down. She revealed she could not say why the process broke down except it was a high stress week with both survey and case mix present, although that is no excuse. She revealed that the process for entering admission orders was that the DON or ADON received the orders from social services who gets them from the doctor or hospital, enters them and then one of us or medical records verifies the orders. An interview on [DATE] at 4:55 PM, with the Administrator revealed she felt like the week this happened with Resident #1 was the perfect storm, with case mix and survey both going on, but that is no excuse. She revealed that medical records were helping with case mix due to MDS being off and it just fell through and stated that she and the team have learned a lot from this and hates that it happened. Record review of Resident #1's admitting orders from the hospital revealed the following orders regarding her diagnosis of diabetes; Lantus 20 units subcutaneous (sub-Q) daily, Humalog 300 units/3ml solution per sliding scale protocol-corrective low-dose regimens; fingerstick blood glucose of ,d+[DATE] -2 units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, [DATE] units sub-Q, ,d+[DATE] 12 units sub-Q, greater than 400 mg/dl-14 units sub-Q. Documentation revealed that Lantus 20 units was last administered to Resident #1 on [DATE] at 8:57 AM prior to admission to the facility. Record review of Resident #1's facility physicians orders revealed there was no order for Lantus 20 units subcutaneous daily. Record review of the written statement given by the ADON revealed (Resident #1's proper name) was admitted on Monday and in report I was told she was a brittle diabetic with a history of DKA and her blood sugars dropped at night. While putting in her orders I was notified of another admission coming while also trying to secure staffing. I remember I needed clarification for her Lantus but do not recall what pulled me away from finishing her admission. This statement was signed by the DON. Review of the typed statement signed by the Medical Records Nurse read as follows: I was unable to review admissions during the week beginning [DATE] due to assisting with State mix review and state survey. Afterwards, Information Technology (IT) was working on my computer due to problems with my email. Friday, I reviewed the admission for [DATE]; assisted with advance directive clarifications, cleared/audited forms, and worked on filing and putting documents on charts. Record review of Resident #1's documented blood sugars since admission revealed Resident #1's blood sugar had been checked 18 times and 14 of those were above 141 requiring insulin per physician's ordered sliding scale. The documented blood sugars were as follows: [DATE] @ 5:13 PM = 159 [DATE] @ 8:47 PM = 141 [DATE] @ 7:20 AM = 129 [DATE] @ 11:50 AM =116 [DATE] @ 4:21 PM = 128 [DATE] @ 9:04 PM = 270 [DATE] @ 7:23 AM = 308 [DATE] @ 12:06 PM = 329 [DATE] @ 4:56 PM = 253 [DATE] @ 8:13 PM = 217 [DATE] @ 7:57 AM = 398 [DATE] @ 1:25 PM = 284 [DATE] @ 6:36 PM = 393 [DATE] @ 9:46 PM = 377 [DATE] @ 7:47 AM = 399 [DATE] @ 12:50 PM = 188 [DATE] @ 4:38 PM = 374 [DATE] @ 9:37 PM = 388 Record review of Resident #1's ER visit on [DATE] revealed a bedside glucose of High Critical-Very abnormal high collected at 5:34 AM and a comprehensive Metabolic Panel glucose result of 764mg/dl collected at 5:38 AM. Record review of Resident #1's preliminary certificate of death received by the facility fax on [DATE] at 12:04 PM, revealed the cause of death to be cardiac arrest due to or as a consequence of ketoacidosis, due to or as a consequence of diabetes mellitus. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's and Type 2 Diabetes. Record review of Resident #1's Minimum Data Set with an Assessment Reference Date of [DATE] revealed in Section I, a diagnosis of Diabetes and in Section C a Brief Interview for Mental Status (BIMS) of 11 which indicated the resident was moderately cognitively impaired. Review of the facilities Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: 1. On [DATE], at 4:50 am, the Night Shift Registered Nurse (RN) #1 was in a resident's room providing care in the room next door when she heard a loud thump x 2. She immediately went to the adjoining room which was resident #1 ' s and upon entering the room, RN #1 observed that Resident #1 was lying on the floor and then attempted to stand up from the floor, when she fell backwards hitting her head prior to RN #1 being able to intervene. Resident # 1 was transferred to the emergency room (ER), (proper name of hospital) per resident ' s Medical Doctor, at 5:10am on [DATE].2023. Resident # 1 blood sugar was last checked on [DATE] per Evening Shift Licensed Practical Nurse (LPN), resulting in blood sugar of 388 mg/dl with Humalog 12 units administered Subcutaneously to Right Upper Quadrant of Abdomen per LPN. Blood Sugar at (Proper name of hospital) ER was 764. Resident expired at (Proper name of hospital)ER on [DATE] at 0635 am. Upon investigation on [DATE], of the incident, a chart review was performed, and it was observed that an insulin order, Lantus insulin 20 units every night, was omitted. 2. An Emergency QA meeting was held on [DATE], at 16:12 PM with Regional Director of Operations (DO), Regional Nurse Consultant (RNC), Director of Nursing/Infection Preventionist (DON/IP), Nursing Home Administrator (NHA), and Facility Medical Director (FMD). To prevent this from happening in the future and going forward the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. 3. Starting on [DATE], and ending on [DATE], the RNC and all resident physicians assessed all resident orders and revised with no negative outcomes. 4. Starting on [DATE] at 1700 the DON/IP started the following processes in which nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. 5. ADON was suspended on [DATE] pending investigation per NHA. 1 on 1 In-service with ADON for admission processes, medication errors, and order entry was performed by NHA, RDO, and RNC on [DATE]. The ADON returned to work on [DATE]. 6. Monitoring Procedures started on [DATE] and included the IDT Clinical team (DON/IP, ADON, MR, and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. 7. On [DATE], the RNC performed 1 on 1 in-service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in-service on diabetic orders, Medical Director (MD) notification, incident care plans, and new employee orientation with DON/IP. On [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. On [DATE], the SA validated the facilities Removal Plan by staff interviews, record reviews, review of the Quality Assurance sign in sheet and review of in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ on [DATE]. The SA validated through interview on [DATE] with the Administrator and DON and record review that the initial investigation was started the morning of [DATE] by the Administrator and the DON including interview of team members that were in the facility at that time. The SA validated through interview on [DATE] with the Administrator, DON, medical director, and record review of the sign in sheets that a Quality Assurance meeting was completed on [DATE] at 4:12 PM. Discussion and an immediate plan including initiation of the DON/IP, Assistant Director of Nursing (ADON), Medical Records (MR), and Minimum Data Set Nurse (MDS) as a team will perform an admission audit and review all orders the day after admission and any orders received within 24 hours of admitting to the facility. On the weekend, the Weekend RN Supervisor/Charge Nurse, DON/IP, or ADON will perform the admission audit. The SA validated through interviews on [DATE] with the DON and Administrator and record reviews that the RNC and all resident physicians assessed all resident orders and blood sugars and revised with no negative outcomes. The SA validated through interviews and record reviews on [DATE] with the DON, RNC, ADON, Medical Records Nurse, RN #1 and MDS nurse and review of in-service sign in sheets that nurses were not allowed to work until in serviced on: Glucometer check offs, Inservice on Policy for Medication Administration of Insulin Injections, Inservice on Admission Policy, Inservice on Diabetic Resident Review, Inservice on Medication Management, Inservice on Abuse and Neglect, Inservice on Fingerstick Glucose Procedure, Inservice on Observing and Reporting to MD, Inservice on Charting Errors, Inservice on Medication Reconciliation, and Inservice on Diabetes Policies and Procedures. These in services and check offs concluded on [DATE] at 1900. The SA validated through interviews and record reviews on [DATE] with the DON and ADON that the ADON was suspended following the investigation on [DATE] and returned to work on [DATE] after being in-serviced on the admission process, medication errors and order entry. The SA validated through interviews and record reviews on [DATE] with the DON, Administrator, ADON, Medical Records Nurse and the MDS Nurse that monitoring procedures started on [DATE] and included the Interdisciplinary (IDT) Clinical team (DON/Infection Preventionist (IP), ADON, Medical Records (MR), and MDS) implementing admission checklist sheets that includes all medications, parameters orders, Code Status documentation, Immunization History and needs, and ancillary orders on new admissions that are reviewed and left in a binder during morning clinical meetings held daily at 9 am. Monitoring procedures for diabetic residents started on [DATE] and the first Weekly review of diabetic residents was performed by DON/IP on [DATE] with no new findings noted. In the event that findings need correction, the DON/IP will report directly to the FMD Immediately. The SA validated through interviews and record reviews on [DATE] with the RNC and DON and review of in-service sign in sheets that on [DATE] the RNC performed 1 on 1 in service with MDS on care plans. On [DATE], the RNC performed 1 on 1 in service on diabetic orders, MD notification, incident care plans, and new employee orientation with the DON/IP and on [DATE], the RNC performed 1 on 1 in service on care plans and diabetic orders with Medical Records. The SA validated on [DATE] that all corrective actions to remove the IJ had been completed and the IJ removed on [DATE].

Based on observation, staff interview and facility policy review the facility failed to store food in a manner that meets professional standards as evidenced by unlabeled and undated food in the refrigerator, dry food stored uncovered and resident nourishment refrigerators with resident snacks that were unlabeled or undated for two (2) of four (4) survey days. Findings include: Record review of the facility policy titled, Food Storage with a revision date of [DATE] revealed . Procedure .2. All foods or food items not requiring refrigeration shall be stored above the floor, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backfill or contamination by condensation leakage, rodents, or vermin. All package food, canned foods or food items stored shall be kept clean and dry at all times . 9. All leftover foods are to be stored in covered containers, dated, & labeled. Cooked leftovers are to be used reheating to 180 degrees Fahrenheit. If not used by the third (3rd) day, they are to be discarded. Cooked foods are to be reheated on (1) time only. Cold leftovers not used by the third (3rd) day are to be discarded . Record review of a typed statement on facility letterhead, dated [DATE], and signed by the Administrator revealed (Proper Name of Facility) follows state and federal regulations regarding nourishment refrigerators and the dating of food for the resident. The facility does not have a separate policy. An observation and interview on [DATE] at 10:15 AM, during the initial tour of the kitchen revealed a plastic container of diced tomatoes in the refrigerator with no date or label on the container. Dietary Staff #3 confirmed that the unlabeled container was diced tomatoes, did not have a label or date, and should have. Dietary Staff #3 put a label on this container with a date for [DATE]. When the State Agent (SA) asked the staff member if she put the tomatoes in that container in the refrigerator she stated, No, I've not even used any tomatoes. I have no idea when they were put in the refrigerator. When the SA asked what she was putting on the label, she stated, They are good for 3 days then confirmed she did not know when they were put in the refrigerator. She revealed that since she did not know when they were put in the refrigerator then she could not verify they were still good and if they were not and were served to the residents then that could make them sick. An observation on [DATE] at 10:00 AM, with the Dietary Manager (DM) revealed an opened 5-pound bag of powdered sugar that was more than half full being stored in an open cardboard box with one piece of lose plastic wrap laid over the top of the box. The DM revealed that the opened bag of powdered sugar stored in this manner could attract pests and rodents to the sugar. The DM confirmed the powdered sugar was not stored properly and should be stored in an airtight container. An interview on [DATE] at 2:20 PM, with the Dietary Manager (DM) confirmed that each meal cart included snacks for the residents and if they are not used and need refrigerated then they are put in the nutrition refrigerator near each nurse's station. She revealed as far as she knew the nursing staff were responsible for cleaning those refrigerators and throwing out expired foods and confirmed that the dietary department does not keep those refrigerators clean. An observation and interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 2:50 PM, of the nutrition refrigerator for the 200 nurses station revealed there were nutrition shakes, salsa dip, an opened root beer can, a plastic bowl with food inside. None of the food items were labeled or dated. CNA #1 confirmed this was the refrigerator that held resident snacks. She confirmed that the refrigerator had both resident and staff food inside with no labels or dates. She stated that she is not sure, but thinks it is supposed to be only resident's food kept in this refrigerator and that the nightshift CNAs are responsible for cleaning the refrigerators. An observation and interview on [DATE] at 3:00 PM, of the nutrition refrigerator on the 100-hall revealed three cold cut sandwiches with meat and cheese wrapped in plastic wrap with no date or label. One of the sandwiches was half eaten, a plastic bowl with food, a pitcher of water, a gallon jug of tea, and nutrition shakes with no labels, dates, or names. An interview with Licensed Practical Nurse (LPN) #3 confirmed that the nutrition refrigerators are supposed to only hold resident food and snacks. LPN #3 reported that the night shift CNAs are responsible for cleaning and checking the temperature. She stated that all staff are responsible for cleaning and labeling and removing any out-of-date food. She confirmed that there was both resident and staff food in the refrigerator with no labels or dates. She confirmed that if the cold cut sandwiches had been served to a resident with no date, then it could make them sick. An interview on [DATE] at 3:10 PM, with the Administrator confirmed that resident food in the nutrition refrigerators on the halls should be labeled and dated and that if out of date food was served to a resident, then it could make them sick. An interview on [DATE] at 3:30 PM, with the Director of Nurses (DON) confirmed that only resident food is supposed to be kept in the snack refrigerators near each nurse's station. The DON stated that food should be dated and that night shift CNAs are supposed to clean the refrigerator and check temperatures. If out-of-date food were served to a resident then it could make them sick.

Based on staff interview, record review and facility policy review the facility failed to ensure that the Dietary Manager (DM) had completed required training for dietary management after one year of full-time employment for four (4) or four (4) survey days observed. Findings include: Record review of the facility policy Dietary Manager with a revision date of June 1, 2000 revealed Policy Statement: It is the policy of this facility that the day-to-day functions of the dietary department be under the supervision of a qualified dietary manager . An interview on 5/17/23 at 2:20 PM, with the DM and the Registered Dietician (RD) revealed that the Dietary Manager had been in that position since 5/2022 and had not completed her DM certification course. The DM revealed that she was hired by another Administrator and when the new Administrator started, they discussed the need for her to get her certification, but nothing was ever done. The RD revealed she comes to the facility two times per month. The DM revealed she had one day of training at a sister facility with the Dietary Manager before she started working at this facility full time. The DM revealed that she had no prior experience in a nursing facility. An interview on 5/17/23 at 2:40 PM, with the Administrator revealed she had not been made aware when she started in August of 2022 that the Dietary Manager had not completed her DM certification course. She is not sure when or how she finally discovered that. She revealed that she sent the information to their corporate office around April of this year to get approval for funding to pay for the DM to take the certification course and confirmed that the DM will start her course sometime this month. An interview on 5/18/23 at 10:30 AM, with the Administrator confirmed that 12 months was too long to wait to get the DM signed up for her certification course. She revealed that she and the DM had discussed the certification course and that the DM had agreed to pay for it with her own personal credit card and get reimbursement back from the company later. She stated she failed to follow up with her and that was her responsibility. Record review revealed that the DM's hire date was 5/9/22.

Based on staff interview, record review, and policy review the facility failed to develop a care plan for cardio-pulmonary resuscitation code status (Resident #30 and Resident #51) and implement a care plan by failing to change a humidifier bottle and tubing, and ensuring a resident received humidified oxygen (Resident # 17) for three (3) of 24 resident reviewed. Findings include: A review of the facility policy titled, Care Plan-Comprehensive, revealed Policy Statement: It is the policy of the facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs . Findings Include: Resident #30 A review of Resident #30's care plan titled, I am A CPR status with a review date of [DATE] revealed, Goals I will receive all measures of comfort care, and life sustaining treatment through each review during nursing home stay. A review of the Advance Health Care Directive signed [DATE] by Resident #30 revealed Part one (1)- Power of Attorney of Health Care: I designate the following individual as my agent to make decisions for me naming (Proper Name) the sister. Part two (2)-Instructions for Health Care: (6) End-Of-Life Decisions: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:(a) Choice Not to prolong Life. A review of the Advance Directive with Social Services staff on [DATE] at 9:10 AM confirmed the Advance Directives stated that Resident #30 does not wish to prolong life, and confirmed the facility failed to develop the appropriate Code Status Care plan revealing Resident #30's care plan should read Do Not Resuscitate (DNR). A review of the Advance Directive and care plan for Resident #30 with the Administrator on [DATE] at 9:36 AM confirmed the Advance Directive did not match the care plan and revealed Resident #30 should be care planned as a DNR. An interview with LPN #1 on [DATE] at 11:14 AM revealed the purpose of the comprehensive care plan is to direct staff on the type of individualized care a resident need. An interview with the Director of Nursing (DON) on [DATE] at 9:56 AM, revealed the physician's orders, and the care plan should match and confirmed the care plan directs the type of care the resident may need. Record review of the Admission Record revealed that the facility admitted Resident #30 to the facility on [DATE] with diagnoses of Cerebral Palsy. Record review of the MDS Section C with an ARD of [DATE], revealed that Resident #30 had a BIMS score of 10 which indicated that the resident was moderately cognitively impaired. Resident #51 Record review of Resident #51's care plan revealed a care plan initiated [DATE] for DNR status. Record review of the Advance Health-Care Directive dated [DATE] and signed by Resident #51 revealed the instructions for health care which indicated the resident's wishes for choice to prolong life. I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards. This copy indicated this choice to prolong life was changed to choice not to prolong life. This was the copy that was changed when State Agency was in the facility requesting the Advance Directive for this resident. During an interview with the Medical Record's Licensed Practical Nurse on [DATE] at 12:05 PM, she stated there was a mistake in the documentation for this resident and the Code Status form and order did not match the resident's wishes according to the Advance Directive she signed. She confirmed that Resident #51 chose to have CPR performed and this was not indicated on her orders, Code Status form, or care plan and this could have led to her wishes not being honored. An interview with Resident #51 on [DATE] at 3:20 PM, revealed the staff discussed the Advance Directive with her on admission and today. She stated if something happens to her, she wants a full code. She stated, I would hope they would do something to help me live. I hope they wouldn't just turn around and walk out the door and leave me there. An interview with the Administrator on [DATE] at 4:00 PM, revealed she verified with the resident what her preference was for her Advance Directive and the resident wanted CPR performed as indicated on the Advance Directive signed by the resident on admission. She confirmed the care plan failed to indicate the resident's preference for CPR since it stated resident had a DNR status. She confirmed the importance of the care plan reflecting the resident's preferences for care and the facility failed to ensure an accurate care plan for this resident. Record review of the Admission Record revealed Resident #51was admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus, Heart Failure, and Stage 3 Chronic Kidney Disease. Record review of admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed resident with a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. Record review of the most recent quarterly MDS with ARD of [DATE] revealed a BIMS of 8 which indicated moderate cognitive impairment. Resident #17 An observation of Resident #17 on [DATE] at 11:00 AM, revealed the oxygen (O2) humidifier bottle dated [DATE] with no date on tubing connected to the humidifier. An observation of Resident #17 on [DATE] at 2:08 PM, revealed an empty O2 Humidifier bottle with date of [DATE] and no date to tubing connected to the humidifier bottle. An interview with the Director of Nursing (DON) on [DATE] 2:12 at PM confirmed Absolutely the oxygen humidifier bottle and tubing for Resident #17 should have been changed every week and more if needed and confirmed with the date [DATE] on the humidifier bottle that there was no way it had been changed. The DON went on to say possible complications from failing to change the humidifier bottle and tubing is possible respiratory infections. The DON reviewed the oxygen care plan and confirmed the staff was not following the care plan. Record review of Resident # 17's care plan titled, I use oxygen therapy r/t (related to) shortness of breath, with a review date of [DATE], revealed Interventions: Change Humidifier bottle and tubing weekly and prn (as needed) .Oxygen settings: O2 via nasal prongs at 2 liters continuous. Humidified . An interview with LPN #1 on [DATE] at 11:14 AM, she revealed the purpose of the comprehensive care plan is to direct staff on the type of individualized care a resident's needs and confirmed staff were not following Resident #17's oxygen care plan. Record review of the Admission Record revealed that the facility admitted Resident #17 to the facility on [DATE] with diagnoses of Chronic Obstructive pulmonary disease and sleep disorder. Resident #30 Record review of Resident #30's Care Plan Detail dated [DATE], revealed I am a CPR status . Goals I will receive all measures of comfort care, and life sustaining treatment through each review during nursing home stay . A review of the Advance Health Care Directive signed [DATE] by Resident #30 revealed Part one (1)- Power of Attorney of Health Care: I designate the following individual as my agent to make decisions for me naming (Proper Name) the sister. Part two (2)-Instructions for Health Care: (6) End-Of-Life Decisions: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:(a) Choice Not to prolong Life. A phone interview with Resident #30's sister who is the designated Durable Power of Attorney (POA) on [DATE] at 6:00 PM, she confirmed she was the POA and confirmed her brother's Living Will states he does not want CPR. She went on to say her brother has been chronically ill for a long time with Cerebral Palsy and she confirmed she has made no changes to his code status. Record review of the Advance Directive with Social Services staff on [DATE] at 9:10 AM, confirmed the Advance Directives stated that Resident #30 does not wish to prolong life, and confirmed the facility failed to develop the appropriate Code Status Care plan revealing Resident #30's care plan should read Do Not Resuscitate (DNR). Record review of the Advance Directive and care plan for Resident #30 with the Administrator on [DATE] at 9:36 AM, confirmed the Advance Directive did not match the care plan and revealed Resident #30 should be care planned as a DNR. The Administrator went on to reveal concerns of failing to identify and follow Resident #30's Advance Directives if the facility was not following his wishes and staff would have performed CPR. An interview with LPN #1 on [DATE] at 11:14 AM, revealed the purpose of the comprehensive care plan is to direct staff on the type of individualized care a resident need. An interview with the DON on [DATE] at 9:56 AM, revealed the physician's orders, and the care plan should match and confirmed the care plan directs the type of care the resident may need. Record review of the Admission Record revealed that the facility admitted Resident #30 to the facility on [DATE] with diagnoses of Cerebral Palsy. Record review of the MDS Section C with an ARD of [DATE], revealed that Resident #30 had a BIMS score of 10 which indicated that the resident was moderately cognitively impaired. 47157

Based on observation, staff interview, record review and facility policy review the facility failed to change an oxygen (O2) humidifier bottle and tubing weekly as ordered for one (1) of four (4) residents reviewed for oxygen therapy. Resident #17 Findings include: Record review of the facility policy titled, Oxygen Education, with a date of September 12, 2013, revealed . Important facts: All tubing is changed once a week and clearly marked with the days date . Record review of the facility policy titled, Oxygen Administration, with a Procedure revised date of August 25, 2014, revealed . Steps in the Procedure . 9 . Be sure there is water in the humidifying jar (if used) and that the water level is high enough that the water bubbles as oxygen flows through .11. Periodically re-check the water level in the humidifying jar . An observation of Resident #17 on 5/15/23 at 11:00 AM, revealed the O2 humidifier bottle dated 4/18/23 with no date on tubing connected to the humidifier. An observation of Resident #17 on 5/16/23 at 2:08 PM, revealed an empty O2 humidifier bottle with date of 4/18/23 and no date to tubing connected to the humidifier bottle. An interview with Licensed Practical Nurse (LPN) #1 on 5/16/23 2:10 at PM, confirmed the oxygen humidifier bottle was empty with a date of 4/18/23 and confirmed there was no date on the oxygen tubing for Resident #17. LPN #1 revealed the humidifier bottle and tubing should be changed weekly and dated to prevent possible infections and to ensure moisturization of the oxygen to prevent drying and nasal discomfort and sores in the nose. An interview with the Director of Nursing (DON) on 5/16/23 2:12 at PM, she confirmed Absolutely the oxygen Humidifier bottle and tubing for Resident #17 should have been changed every week and more if needed. She revealed with the date 4/18/23 on the humidifier bottle there was no way it had been changed. The DON went on to say possible complications from failing to change the humidifier bottle and tubing is possible respiratory infections. Record review of the Order Summary Report with active orders as of 5/17/23 revealed an order dated 10/20/2019 Change humidifier bottle and O2 tubing weekly and prn (as needed) every night shift every Fri (Friday). Record review of the Treatment Administration Record (TAR) for April 2023 and May 2023 for Resident #17 revealed Change humidifier bottle and O2 tubing weekly and prn (as needed) every night shift every Fri (Friday). The TAR was initialed and signed off as the humidifier bottles and O2 tubing as being changed every Friday night. Record review of the Admission Record revealed that the facility admitted Resident #17 to the facility on [DATE] with diagnoses of Chronic Obstructive pulmonary disease and sleep disorder. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/23 revealed in Section C Resident #17 had a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #17 was unable to complete the interview.

Based on staff interview, record review and review of the statement regarding the facility's policy, the facility failed to submit a change in status for a Level II PASARR (Pre Admission Screening and Resident Review) referral for one (1) of four (4) residents reviewed. Resident # 46. Findings Include: Record review of facility policy titled, Admission Criteria, dated 4/25/23, revealed, Our facility admits only residents who's medical and nursing care needs can be met. The policy also revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. Record review of the signed Administrator's note on facility letterhead dated 5/17/23 revealed, (Proper name of facility) follows state regulations regarding Pre-Admission Screening and Resident Review Level II submissions and resubmissions. The facility does not have a separate policy. An interview with the Licensed Social Worker (LSW) on 5/17/23 at 2:00 PM, revealed Resident #46 was admitted to the facility on [DATE]. She stated she had a Preadmission Screen dated 6/19/19 and at that time it was determined that she was appropriate for nursing facility placement. The LSW confirmed that Resident #46 was diagnosed with Paranoid Personality Disorder and Delusional Disorder in November 2021, a significant status change form should have been submitted for a Level II, but it was not. She stated she was responsible for submitting these and this one fell through the cracks and she failed to submit it. She stated the purpose of submitting these changes accurately was to ensure the resident was appropriate for nursing home placement and for the resident to receive recommended services. An interview with the Administrator on 5/17/23 at 4:00 PM, revealed the significant status change for the determination of a Level II was required but it was not done. She stated each time a resident had a new mental illness diagnosis, a status change should be submitted. She confirmed the facility failed to submit the status change for a Level II, and therefore, the resident was not reassessed for being appropriate for nursing home placement or for interventions recommended for the resident's mental health. Record review of the Preadmission Screening revealed this was done on 6/19/19 and revealed active medical conditions of Anxiety disorder and Depression. Record review of the Notice of Negative Level 1 Screen Outcome dated 6/8/2020 revealed .nursing facility placement is appropriate for you. Record review of the Admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Paranoid Personality Disorder (diagnosed on [DATE]), Recurrent Depressive Disorders, Anxiety Disorder, and Delusional Disorders (diagnosed on [DATE]). Record review of Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/8/23, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact.

Based on observation, staff and resident interviews, and facility policy review the facility failed to respect the dignity of a resident as evidenced by not completely covering the resident's naked body while transporting the resident to the shower for one (1) of 67 resident's observed, Resident #33 Findings Include: Record review of the facility policy titled, Dignity and Respect with no revision date revealed under Procedure .#4 Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. An observation on 05/17/23 at 3:36 PM, revealed Certified Nurse Assistant (CNA) #2 pushing Resident #33 down the hall in a shower chair covered in the front with a white facility blanket and no covering over his bare buttocks, which were visible from the back side of the chair as he was being pushed down the hallway. An interview on 5/17/23 at 3:38 PM, with CNA #2 revealed she did not realize that Resident #33 was not covered in the back but knows they should be because that is an invasion of the resident's privacy, and she has been taught by the staff that she should make sure they are completely covered. An interview on 5/17/23 at 3:41 PM, with Licensed Practical Nurse (LPN) #3 confirmed that a resident should be completely covered when they are taken to the shower. She stated, Please tell me you did not see that on this hall, because we just talked about that with the staff. When the State Agent (SA) confirmed that she had seen a resident's bare buttocks in a shower chair going down the hall, she confirmed that was a dignity issue and should not have happened. An interview on 5/17/23 at 4:00 PM, with the Administrator confirmed that the resident's bare buttocks being exposed while being taken to the shower in a shower chair is not respecting the resident's dignity. An interview on 5/18/23 at 8:40 AM, with Resident #33 revealed he was not aware until a couple of days ago that he was not completely covered when they took him to the shower. Record review revealed the facility had an in-service titled Dignity and Respect on 3/30/23 and CNA #2 had attended. Record review of Resident #33's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Record review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident is cognitively intact.

Based on record review, resident interview, staff interview, and facility policy review the facility failed to ensure a resident's Advance Directives were honored as evidenced by the facility did not correctly implement the resident's decision on the correct code status for two (2) of 24 resident's reviewed (Resident # 30 and # 51) and failed to have a copy of the Advanced Directive on the medical record for two (2) of 24 residents reviewed. (Resident # 45 and #58) Findings Include: A review of the facility policy titled, Advance Directives, reviewed ,d+[DATE], revealed, Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .Determining Existence of Advance Directive .2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .If the Resident has an Advance Directive . 2. The director of nursing services (DOS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident medical record and plan of care 3. The resident's wishes are communicated to the resident direct care staff and physician by placing the advance directive in a prominent, accessible location in the medical record and discussing resident wishes in care planning meetings . Resident #30 A review of Resident #30's profile screen in the Electronic Medical Record (EMR) revealed code status: CPR (cardiopulmonary resuscitation). A record review of the Order Summary Report with active orders as of [DATE], revealed a physician's orders for Resident #30 with an order date of [DATE] for CPR. A continued review of discontinued Code Status orders revealed CPR for all the orders since admission [DATE]. A review of the Advance Health Care Directive signed [DATE] by Resident #30 revealed Part one (1)- Power of Attorney of Health Care: I designate the following individual as my agent to make decisions for me. naming his sister . Part two (2)-Instructions for Health Care: (6) End-Of-Life Decisions: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:(a) Choice: Not to prolong Life. A phone interview with Resident #30's sister who is the designated Durable Power of Attorney (POA) on [DATE] at 6:00 PM, confirmed she was the POA and confirmed her brother's Living Will stated he does not want CPR. She went on to say her brother has been chronically ill for a long time with Cerebral Palsy and she confirmed she has made no changes to his code status. A review of the advance directive physician's orders with Social Service staff on [DATE] at 9:10 AM, confirmed the advance directives stated that Resident # 30 does not wish to prolong life, and the physician's orders have Resident # 30 as wanting CPR. A continued review of all social notes, progress notes with the social services staff revealed there was no documentation of Resident #30 or POA changing the Advance Directive and confirmed the facility only reviewed the code status after admission if there had been a change and she would have the resident or designee complete a new advance directive code status form. A review of the advance directive and code status order with the Administrator on [DATE] at 9:36 AM, confirmed the Advance Directive did not match the code status order and revealed Resident #30 should be a DNR (Do Not Resuscitate). An interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:14 AM, she revealed she looks at the code status order and the code status listed on the resident profile in the electronic record to know what the code status is. A review of the EMR for Resident #30 under tab labeled Code Status revealed, a red sheet of paper reading Full Code, no copy of the advance directive was located on the paper chart. Record review of the Admission Record revealed that the facility admitted Resident #30 to the facility on [DATE] with diagnoses of Cerebral Palsy. Record review of the Minimum Data Set (MDS) Section C with an ARD of [DATE], revealed that Resident # 30 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that she was moderately cognitively impaired. Resident #51 An interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:10 AM, revealed if a resident had a cardiac or respiratory arrest, she would first check the initial profile screen in the computer which would indicate if a resident was a full code status where cardiopulmonary resuscitation (CPR) would be performed or a do not resuscitate (DNR) status where CPR would not be performed. She stated if a DNR status was indicated, she would verify that with the handwritten physician order in the paper chart, which is in the sheet protector sleeve with the red code status sheet. She stated if both of those indicated a DNR status, a full code with CPR would not be done. She opened the computer to Resident #51's initial profile page and stated that a DNR status was indicated. She then checked the paper chart and noted the handwritten physician order with the red code status sheet for DNR status. She confirmed that if Resident #51 had a cardio-pulmonary arrest, CPR would not be performed. An interview with the Licensed Social Worker (LSW) on [DATE] at 11:40 AM, revealed that when State Agency (SA) asked for a copy of Resident #51's Advance Directive, she realized that the Advance Directive did not match the physician's order, so she spoke with the Administrator to ask about correcting the form. She stated the Administrator told her she could correct by marking through the incorrect information, adding the correct information, and initialing the change. She stated the copy she gave the State Agency (SA) was the changed copy and not the original copy. She revealed that on admission, she filled out the information with the resident's representative and with the resident. The resident's representative came in prior to the resident arriving at the facility and filled out all the paperwork except for the Advance Directive and the resident's representative signed for a DNR on the code status form. When the resident arrived, the Advance Directive was discussed with the resident and the section to prolong life was marked and this was signed by the resident. She stated she did not note the discrepancy until the SA asked for a copy of the Advance Directive and at that time it was changed to what she thought was correct which was a DNR status that matched the DNR status form signed by the resident's representative and the physician's order. The LSW confirmed this information should have been verified with the resident to ensure the Physician's Orders, the Advance Directive, and the Code Status form all matched and indicated the resident's wishes for her code status. An interview with the Medical Record's Licensed Practical Nurse on [DATE] at 12:05 PM, revealed if a resident had a cardio-pulmonary arrest, she would check the profile page of the computer and if a DNR was indicated, she would verify this with the handwritten order in the resident's paper chart. She stated if both areas indicated DNR, CPR would not be done. She stated there was a mistake in the documentation for this resident and the Code Status form and order did not match the resident's wishes according to the Advance Directive she signed. She confirmed that Resident #51 Advanced Directive paperwork revealed that the resident wished to have CPR performed and this was not indicated on her orders, Code Status form, or care plan and this could have led to Resident #51's wishes not being honored. An interview with LPN #3 on [DATE] at 3:10 PM revealed if a resident has a cardio-pulmonary arrest, she will first check the computer for their code status and verify this with the paper chart code status alert sheet. She stated if the resident was listed as a DNR in the computer chart and it matched with the handwritten physician's order in the paper chart, CPR would not be done. She stated that she would not typically look on the actual paperwork for the Advance Directive, but she felt certain that the computer code status, the code status alert form in the paper chart, and the physician's handwritten order (if a DNR) in the paper chart would indicate the resident's wishes. She stated, That would be horrible if something different was done from what the family and the resident wanted done. An interview with Resident #51 on [DATE] at 3:20 PM revealed the staff discussed the Advance Directive with her on admission and again today and she confirmed that if something happened to her, she wanted a full code. She stated, I would hope they would do something to help me live. I hope they won't just turn around and walk out the door and leave me there. An interview with the Administrator on [DATE] at 4:00 PM, revealed she verified with the resident what her preference was for her Advance Directive and the resident wanted CPR performed as indicated on the Advance Directive signed by the resident on admission. She confirmed the facility failed to accurately document the resident's choice for her Advance Directive care related to end of life wishes. Record review of the Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus, Heart Failure, and Stage 3 chronic kidney disease. The face sheet revealed an Advance Directive with code status of DNR. Record review of the Advance Health-Care Directive dated [DATE] and signed by Resident #51 revealed the instructions for health care which indicated the resident's wishes for Choice to prolong life. I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards. This copy indicated this choice to prolong life was changed to choose not to prolong life. This was the copy that was changed when the SA was in the facility requesting the Advance Directive for this resident and the LSW changed it to match what the family had signed on admission. Record review of Code Status form, undated, signed by the Resident Representative revealed choice for Do Not Attempt Resuscitation. Record review of electronic Physician's Orders revealed an order for DNR dated [DATE]. Record review of red Code Status sheet in the paper chart revealed Resident #51's code status of DNR. Record review of handwritten and signed Physician's Order dated [DATE] revealed DNR. Record review of the computer profile page for Resident #51 revealed the code status of DNR. Record review of a statement from Resident #51 with the Administrator as witness dated [DATE], revealed, I want my code status to be CPR. I fully understand what will occur and wish to be a full code. Record review of admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed resident with a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. Record review of quarterly MDS with ARD of [DATE] revealed a BIMS of 8 which indicated moderate cognitive impairment. 44804 Resident #45 An interview on [DATE] at 4:00 PM, with Social Services revealed Resident #45 did not have a signed Code Status Form because the staff had been trying to catch the resident's representative to sign the Code status paperwork. An interview on [DATE] at 9:20 AM, with Social Services confirmed that Resident #45 did not have an Advanced Directive for code status signed but should have and revealed she should have documented that she was not able to get the resident representative to sign the Advance Directive for end of life wishes for the resident. An interview on [DATE] at 9:45 AM, with the Administrator confirmed it is the facility staff's responsibility to make sure follow-up is completed regarding the resident's wishes for their care. Record review revealed Resident #45 did not have a copy of her Advance Directive on her record, but the record review revealed that the medical record had a red piece of paper in the record that indicated the resident's code status is Do Not Resuscitate (DNR) but it was not signed by the responsible party. Record review of Resident #45's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review of Resident #45's MDS with an ARD of [DATE] revealed under Section C a BIMS score of 04, which indicates the resident is severely cognitively impaired. Resident #58 An interview on [DATE] at 4:00 PM, with Social Services revealed Resident #58 did not have an Advanced Directive code status form signed until today but that the resident should have had one on his medical record. An interview on [DATE] at 9:20 AM, with Social Services revealed that the reason Resident #58 did not have an Advanced Directive code status form signed prior to yesterday [DATE] was because he refused to sign it. She revealed there is no documentation that the resident refused to sign the Advance Directive and she confirmed that she is responsible for following up and getting the Advance Directives signed on admission and the purpose of the Advance Directive is to make sure the resident's wishes for care and code status are known and implemented. An interview on [DATE] at 4:30 PM, with Resident #58 revealed the staff came to him yesterday and asked him to sign a paper regarding if he wanted Cardiopulmonary Resuscitation (CPR) or not. He revealed the staff had never mentioned him signing a paperwork regarding his choice of CPR before yesterday. An interview on [DATE] at 9:08 AM, with the Director of Nurses (DON) revealed that the Advanced Directives let the staff know the resident's end of life care wishes and the importance of updating the code status is to make sure the staff knows the correct code status based on the resident's wishes. Record review revealed Resident#58 did not have a signed Advance Directive on his record and social services had not revised the resident's code status on the record after code status changes had occurred. Record review of Resident #58's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Kidney Disease Stage 3 Unspecified. Record review of Resident #58's MDS with an ARD of [DATE], revealed under Section C a BIMS score of 10, which indicated the resident is moderately cognitively impaired. 47157

F563 S/S=E Based on record review, facility observation, resident interviews, and Responsible Party/Power of Attorney (POA) interviews, the facility failed to allow three (3) of five (5) residents reviewed to visit with family and friends in their private rooms. Residents #3; #4; and #5, were restricted by the facility to limited visitation and not allowed to visit in their private rooms per requests. Facility policy review entitled Resident Rights Revised and implemented on Nov. 28, 2016 stated, The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to resonable clinical and safety restrictions and the resident 's right to deny or withdraw consent at any time. On 07/12/21 at 3:30PM an observation on entrance to the facility observed that the front door to the facility was locked and visitors were required to ring the door bell to be escorted in to the facility by staff and lead to the front desk to have temperatures taken by staff and to sign in to the facility and answer Covid 19 questionaire. Interview on 07/12/2021 at 4:00 P.M. with the facility administrator (ADM) revealed that the current visitation policy was through pre-arranged appointments and that the visitors were encouraged to visit outside, in the front lobby, or in the community room that was set aside specific for visitation. The Administrator stated that the visitation policy and procedure had been revised and updated two weeks prior to 07/12/2021 to extend visitation and to allow in-room visitation but that the facility had not implemented this new policy yet. The ADM confirmed that all of the bedrooms for residents in the facility were private rooms. The ADM stated that currently the facility was providing visitation to the facility residents as outlined in the Covid 19 Guidelines. The ADM stated that the goal of the facility was always to protect the residents. The ADM confirmed that the facility had no current cases of Covid 19 and that the last reported case at the facility was April 30, 2021. The ADM confirmed that the county has a current Covid infection rate of less than 10% and that most all of the facility residents have had at least one vaccine for Covid, but that it was her hopes to offer the vaccinations in-house. The ADM confirmed that at the current time [MEDICATION(S)] Pharmacy was providing the vaccinations for Covid 19 per facility requests. Interview on 07/12/2021 at 4:45 P.M. with the Director of Nursing (DON) revealed that the visitation policy had been revised and updated two weeks prior to 07/12/2021 to dismiss the 14 day quarantine after residents went out of the facility. The DON confirmed that currently residents visitors must call ahead in advance and schedule a visit with the residents either outside, in the front lobby, or in the Community Room. Residents that are on palliative care and/or bedfast, and/or openly refuse to leave their rooms, may have visitors in their rooms, but at this time that is the only in-room visits that they are allowing. The DON stated that the facility strongly encouraged the residents and visitors to visit per a schedule. The DON confirmed that all resident rooms were private rooms. An observation and interview on 07/13/2021 at 10:15 A.M. with Resident #5 revealed that she had been at the facility for approximately three (3) months and that she had not been allowed to have any visits from her family in her room. Resident #5 stated that she was limited to two (2) 45 minute pre scheduled visits per week and that her daughter would come on one day and the other day her daughter in law would come visit. Resident #5 stated that her family had never seen or visited her in her room. Resident #5 stated that her family would have to call the facility and make an appointment with the staff to pre-arrange visits. Resident #5 stated that she was allowed to visit in the facility lobby or outside. Resident #5 stated that she had not seen or visited with her grandchildren since she was admitted to the facility in the past three months. Resident #5 stated that she had been in another facility in another city and that her home was close to her current nursing home facility. Resident #5 had requested a transfer from the prior nursing home to come to (proper name of facility) in order to be where her family lived, have a private room, and to be able to visit with her family more often. She also stated that she would love to visit with her family in her private room but that she is not allowed to and must go outside or to the front lobby. Resident #5 asked the State Agency Surveyor to please see what we could do to allow visitors in her private room. Resident #5 stated that she was tired of non-private visits in the lobby and not having access to her grandchildren. She stated that the facility would not allow her to go out of the facility for a short stay to visit family unless she quarantined for 10-14 days upon return. Record review for Resident #5 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) dated [DATE]revealed a Brief Interview of Mental Status (BIMS) score of 10, which indicated mild cognitive impairment. Observation and Interview on 07/13/2021 at 10:35 A.M. with Resident #3, revealed that she was sitting alone in her private room in a chair. She stated that she had not had any visitors in her room. She stated that her daughter worked at the facility and she did visit with her. Resident #3 explained the visitation policy to the SA as no in-room visits are allowed and all visits had to be pre-arranged and were limited to two (2) visits per week either outside or in the front lobby. Record review for Resident #3 revealed that she was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had a Minimum Data Set (MDS) dated [DATE] that documented her Brief Interview of Mental Status (BIMS) score of 11, which indicated mild cognitive impairment. Observation and Interview on 07/13/2021 at 11:00 A.M. with Resident #4, revealed that she was alert and oriented and was sitting alone in her private room in a wheelchair. Resident stated that she had been a resident in the facility for almost two (2) years. Resident #4 stated that she would love to visit with her family in her private room, but was not allowed to due to the facility requiring that all visitation was to be pre-arranged by making an appointment with the facility to visit outside or in the lobby. Resident #4 became tearful when she expressed her desire to be re-united with her husband. Resident #4 stated that it would be most desirable to have visits in her private room with her husband. Resident #4 cried as she discussed visitation with the State Agency. Record review of resident #4 revealed that she was admitted to the facility on [DATE], and originally on 01/06/2020. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 had a Minimum Data Set (MDS) dated [DATE] that documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated that resident #4 was fully cognitively intact with no cognitive deficits. Interview on 07/13/2021 at 12:20 P.M. with the Activities Coordinator (AC), revealed that she had been employed as the Activities Coordinator (AC) since March 2021. She stated that the current visitation policy for the residents in the facility was arranged via pre-scheduled appointments twice weekly. She stated that the facility policy was for visitation to take place in the lobby or outside. She stated that some of the residents that were not able to come to the lobby or outside were allowed limited visits in their rooms through pre-arranged appointments. The AC confirmed that all the residents had private rooms in the facility and had no room mates. She stated that she was not aware of any cases of Covid 19 in the facility since she began work in March 2021 and she confirmed that currently there were no visits allowed in the residents rooms. Interview on 07/13/2021 at 12:30 P.M. with the Power of Attorney (POA) daughter of resident #5, revealed that she wanted her mother to be allowed to receive visits in her private room at the facility. The POA stated that Resident #5 had been admitted to the facility on [DATE] and that she (the POA) had not been allowed to see her mother's (resident #5's) room. The POA stated that she had requested to visit in her mother's room and was denied. The POA stated that since 05/11/2021 she had to call the facility staff and schedule a pre-arranged appointment to visit with her mother. The POA stated that she and her family were only allowed two (2) 45 minute visits each week. The visits must take place in the front lobby or outside of the building. The POA stated that resident #5 was transferred from another nursing home to be close to family. The POA stated that on 07/09/21 she had spoken with Social Services Designee/Admissions (SSD), and had asked to see her mother's room. The SSD told the POA no you can not go to resident #5's room and you have already visited long enough today. The SSD told the POA that she would take a picture of resident #5's room and send it to her if she wanted to see what it looked like. The SSD told the POA that she was following the current visitation policy as outlined by the facility, and if she wanted to call the administrator and ask questions, she was welcome to call the ADM. The POA stated that she called the facility administrator, and left a message to please call her back and as of 07/13/2021 at 12:30 P.M. the POA had not heard from the facility administrator (ADM) and had not yet been allowed to visit in resident #5's room. The POA stated that she was considering moving her mother, yet again, in order to visit her in her room and to be able to go out on a pass without having to quarantine for 14 days. The POA stated that she had called several other facility's in the area and all of them were allowing in-room visits and were not limiting the time for visitors and were not quarantining residents for 14 days after they go out on pass. Interview on 07/13/2021 at 1:00 P.M. with the Social Services Designee/Admissions Coordinator (SSD) revealed that she had talked to resident #5's daughter (POA) about the visitation policy on 07/09/21 and had referred her to the facility administrator (ADM). The SSD stated that the current visitation policy was limited to two (2) 45 minute per week visits for each resident and they had to be pre-arranged by calling ahead for a scheduled appointment. The visitation areas were limited to the lobby, to outside, and in the community room. The SSD stated that on 07/09/2021 that resident #5 had already been in the lobby visiting with her daughter (POA) and at the end of their visitation time the POA asked SSD to visit in the resident's room and the SSD told POA of resident #5 that she had used her visitation time for that day and that there was no in room visitation allowed; and if she had further questions about the visitation policy she was welcome to call the facility administrator. The SSD stated to the surveyor that she couldn't understand why resident #5's daughter (POA) waited until the end of her visit to ask to go see resident #5's room? The SSD stated that she had been employed at the facility for 4 ½ years and stated that the current visitation policy only allowed in-room visits for palative care and hospice care. Also, the SSD stated, If a resident just refuses to leave their room we will allow in-room visits. The SSD stated that she was doing what she felt was right for the residents and she truly thought that limiting the residents in-room visitation was the right thing to do. The SSD stated that it had been a difficult task for the facility staff to schedule all the visitation appointments for the residents.

Based on record review, staff interview and policy review the facility failed to properly monitor a resident at risk for falls which resulted in an injury for one (1) of seven (7) residents reviewed (Resident #1). Also based on observation, staff interview and facility policy review the facility failed to prevent the potential for accidents and hazards by having elevated water temperatures between 115 degrees Fahrenheit-123 degrees Fahrenheit for two (2) of three (3) days of survey. Findings include: Resident #1 Record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 12/30/2013, revealed Brief Interview for Mental Status score was five (5) which indicated, cognitive status was severely impaired. The functional status was a one (1) and two (2) person assist with activities of daily living (ADL) and walk in the room or corridor did not occur. Review of the facility's policy entitled, "Fall Risk Management" dated February 22, 2012, stataed "residents will be assessed for fall risk potential. Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness during care planning and as needed." Review of Resident #1 Incident Report dated 02/09/14 at 11:30 AM documented, "Observed patient (pt) lying on floor at bedside with hands and head up attempting to get up, bed alarm sounding. Hematoma with abrasion to left (L) eyebrow area, approximately (approx.) 2x2cm in size, small amount (amt) blood noted." " Measures taken to prevent reoccurrences: Get pt in Geri-chair (G/C) at desk around others, (unable to read) et (and) does not attempt to get up as often et (and) can be monitored more (with a line drawn through more). Conclusion: Pt attempted to get out of bed without (s with line over it) assistance et fell at bedside." Review of Resident #1 Incident Reports revealed the following falls on 11/29/13 at 8:10 PM, 12/21/13 at 4:15PM, 01/31/14 at 11 PM, 02/11/14 at 9:50 PM unwitnessed fall in resident room. Resident #1 also had witnessed falls on 12/18/13 at 1:30 PM, 02/23/14 PM in the dining room, and 01/06/14 at 6 PM in the activity room. Review of Resident #1 Fall Risk Evaluation dated 11/12/13, 11/29/13, 12/06/13, 12/18/13, 12/21/13, 12/26/13, 01/07/14, 02/01/14, 02/11/14, and 02/24/14, revealed a total score of 18-20 which represents Resident #1 was a high risk for fall. A score of 10 or above represents HIGH RISK. Record review of Resident #1's chart revealed that on January 6, 2014, Resident #1 slipped from his geri-chair onto the floor. Staff's documentation indicated that the alarms under the resident did not sound because the alarms were not plugged in securely. The record indicated that on January 31, 2014, the resident was found on the floor after getting out of bed without assistance. Documentation indicated that the bed alarms did not sound and were noted to be unplugged. Review of the care plan and chart failed to indicated that measures were implemented after the January 6, 2014, fall; to assure securing and plugging of the alarms was done to alert staff of the potential for Resident #1 to fall, which did occur on January 31, 2014. Interview with Licensed Practical Nurse (LPN) #4 on 02/27/14 at 4:55 PM confirmed Resident #1's fall with injury, but does not remember much else about the day (02/09/14). Interview with the Director of Nursing on 02/27/14 at 5:35 PM confirmed Resident #1 had a fall with injury on 02/09/14 and Resident #1 was moved closer to nurses' station. Facility Environmental Review Review of facility policy entitled Weekly Water Temperature Checklist-Notes, not dated revealed,"Resident room water temperatures should be no less than 100 degrees and no more than 115 degrees. If water temperatures exceed 115 degrees, check water heater for that area and adjust or repair ASAP. If water temperatures exceed 115 degrees, temperature must be recorded daily on each shift until adjustments have been made and temperatures are back to normal. If temperature exceeds 115 degrees, notify Administrator and the Safety Director immediately." Observation on 02/25/14 at 10:35 AM with RN #1 revealed: Water temperature measured 100 degrees F (fahrenheit) in resident room 177. Water temperature measured 108 degrees F in resident room 181. Water temperature measured less than 60 F degrees in resident room 188. Water temperature measured less than 60 F degrees in resident room 190. Water temperature measured less than 60 F degrees in resident room 173. Observation on 02/25/14 at 10:35 AM with Licensed Practical Nurse (LPN) #5 revealed: Water temperature measured 76 degrees F in resident room 144. Water temperature measuredc87 degrees F in resident room 145. Water temperature measured 95 degrees F in resident room 146. Water temperature measured 96 degrees F in resident room 147. Water temperature measured 92 degrees F in resident room 151. Water temperature measured 99 degrees F in resident room 159. Water temperature measured 90 degrees F in resident room 161. Observation on 02/27/14 at 10:10 AM with Maintenance #1 revealed during recheck of water temperatures with facility thermometer: Water temperature measured 121.1 degrees F in residents room 323. Water temperature measured 123.2 degrees F in resident room 177. Water temperature measured 119.4 degrees F in resident room 181. Water temperature measured 98.0 degrees F in resident room 144. Water temperature measured 98.1 degrees F in resident room 145. Water temperature measured 99.3 degrees F in resident room 146. Water temperature measured 99.3 degrees F in resident room 147. Water temperature measured 97.1 degrees F in resident room 151. Water temperature measured 99.1 degrees F in resident room 152. Water temperature measured 89.1 degrees F in resident room 158. Water temperature measured 89.9 degrees F in resident room 163. Water temperature measured 121.1 degrees F in resident shower room station 1. Water temperature measured 98.2 degrees F in resident shower room station 2. Water temperature measured 120.4 degrees F in resident shower room station 3. Interview on 02/25/14 at 10:35 AM with Maintenance #1 regarding water temperatures who stated, "We have a new circulating pump. We have had the pump for several weeks but have not had time to install it." Maintenance #1 further stated, "We check water temps every Monday." During interview on 02/27/14 at 10:10 AM with Maintenance #1 about water temperatures, he stated, "They should be between 100-115." (degrees Fahrenheit) Interview on 02/27/14 at 10:40 AM with Maintenance #1 who stated, "That (water temperature) just blows my mind. They (temperatures) have never been that high. Station 1 shares the kitchen (water heater), station 2 is the further away from one (water heater) and station 3 has its own (water heater). I check 2 rooms on each hall every Monday like I was told."

Based on record review, staff interview and policy review, the facility failed to revise a care plan after multiple falls for one (1) of 13 Residents reviewed (Resident #1). Findings include: Resident #1 Record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 12/30/2013, revealed Brief Interview for Mental Status score was five (5) which indicated, cognitive status was severely impaired. The functional status was a one (1) and two (2) person assist with activities of daily living (ADL) and walk in the room or corridor did not occur. Review of the facility's policy entitled, "Care Plans----Comprehensive" dated June 1, 2000 stated "It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. Procedure #2 the comprehensive care plan had been designed to: (a) incorporate identified problem area, (b) incorporate risk factors associated with identified problems, (d) reflects treatment goals and objectives in measurable outcome, etc ." Review of the facility's policy entitled, "Fall Risk Management" dated February 22, 2012, documented, that "residents will be assessed for fall risk potential. Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness during care planning and as needed." Review of Resident #1 care plan updated 10/14/13 documented, "Resident has a potential for falls R/T (related to) history of falls. 11/29/13, 12/06/13, 12/18/13, 12/21/13, 02/11/14, 02/23/14 actual fall no injury, and 02/09/14 actual fall with abrasion to eyebrow area. Approaches: Geri-chair, bed/chair alarm and landing mat beside bed. The care plans had no evidence of re-evaluation and no new interventions/approaches after the falls. Record review of Resident #1's chart revealed that on January 6, 2014, Resident #1 slipped out of his geri-chair onto the floor. Staff documented that the bell alarm under the resident was not plugged in securely. The record indicated that on January 31, 2014, the resident was found on the floor after getting out of bed without assistance. Documentation indicated that the bed alarms did not sound and were noted to be unplugged. The care plan failed to address the importance of assuring the equipment was secured and working properly. Interview with the Director of Nursing (DON) on 02/27/14 at 2:30 PM revealed the DON said, "About the care plans, it should be updated after each fall."

Based on observation, record review and facility policy review, the facility failed to provide sufficient staff to meet the needs of the residents that resulted in a fall with injury for one (1)of fifteen (15) days of staffing reviewed. On the date of 02/09/14, five Certified Nursing Assistant's (CNAs) were indicated as scheduled to work on the 6AM to 2PM shift, but after review of the timecards for that day, four CNAs were clocked in and working. Resident #1 received a fall with injury during that shift. Review of facility policy, dated June 1, 2000, and entitled, STAFFING, stated, "This facility maintains adequate staff on each shift to assure that the resident's needs are met. Inquiries concerning staffing should be referred to the director of nursing services, personnel director, and/or to the administrator." Interview with the Director of Nursing (DON) on 02/27/14 at 4:00PM, DON confirmed that five (5) CNAs were scheduled to work and four (4) were working on the 6:00AM to 2:00PM shift, while five (5) were posted on the staffing grid for that day on 02/09/14. DON stated, "I've got somebody (CNA) to start the first week of March, but we just haven't had anybody." DON also confirmed that staffing has been an issue for several months now. Interview with CNA #2 on 02/27/14 at 5:00PM stated, "Honestly, we have been short staffed a lot lately. If anybody calls in, we don't have anybody to help." Observation and review of timecards and staffing grid for the date of 02/09/14 confirmed findings that five (5) CNAs were on the schedule, but four (4) CNAs were indicated on the timecards and working on the 6:00AM to 2:00PM shift for that date.