Every finding on record at Tweeten Lutheran Health Care Center

Based on observation, interview, and document review the facility failed to notify the physician of hypoglycemic (low blood sugar) episodes, ensure insulin was safely administered, and provide rescue medication per facility protocol during a severe hypoglycemic episode for 1 of 4 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a severe hypoglycemic episode after repeated hypoglycemia episodes earlier in the day and was subsequently found unresponsive and required emergency medical care and hospitalization. In addition, the facility failed to notify the physician immediately of hypoglycemic episodes for 2 of 4 residents (R1, R2). The immediate jeopardy (IJ) began on 5/15/26 when it was identified that R1 had hypoglycemic episodes during the day, continued to receive insulin, proceeded to have a severe hypoglycemic episode, and needed to be hospitalized . On 6/5/26 at 4:32 p.m., the administrator and infection control/quality nurse (IC-Q) were notified of the IJ. The IJ was removed on 6/6/25 at 12 p.m., after it was verified the facility implemented an acceptable removal plan. However, non-compliance remained at a lower scope and severity of D, no actual harm, with a potential for more than minimal harm. Findings include: According to the Mayo Clinic a normal fasting (before eating) blood sugar reading would be 80-120 milligrams/deciliter (mg/dl). R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included: -Administer medications per physician orders. Nursing staff will dispense and administer all medications. -Monitor blood sugars per physician orders. Notify provider of out-of-range blood sugars per facility policy. R1's physician orders with a start date of 5/13/26 directed the following: -Check blood sugar four times a day at 7:00 a.m.; 11:00 a.m.; 4:00 p.m.; and 9:00 p.m. -Insulin Glargine (long-acting) insulin 100 units/milliliter (ml): administer 15 units subcutaneously (under the skin) daily in the morning. -Novolog (rapid acting) insulin U (units)-100 insulin: administer ten units every morning. -Novolog insulin U-100 insulin: administer six units subcutaneous with lunch. -Novolog insulin U-100: administer twelve units subcutaneously with evening meal. -For signs/symptoms of hypoglycemic reaction initiate the 15/15 protocol. Check blood sugar, if less than 60, give 15 grams (g) of carbs (carbs only), 4 oz of orange juice; regular pop; glucose tablets; 1 tablespoon of jelly/jam/sugar/honey. Wait 15 minutes, then test again. If blood sugar does not increase repeat 15 g of carbs and wait 15 minutes and test again. If unable to consume a snack, provide oral glucose gel. If blood sugar does not show improvement after two rounds (30 minutes) or becomes unresponsive, seek medical help. -If unable to administer oral glucose gel, administer Glucagon (emergency medication used to treat severe hypoglycemia) 1-unit subcutaneously/intramuscular (SQ/IM). Recheck blood sugar after administration. Notify provider of gel/glucose use. R1's progress note dated 5/15/26 at 2:01 p.m., identified R1's blood sugar reading had been extremely fluctuating and point of care testing (POCT) had to be done x2 so that insulin could be administered after meals (post prandial) when readings indicated better figures. Review of R1's record dated 5/15/26 between 6:00 a.m. and 3:00 p.m. identified recorded blood sugars did not reflect fluctuating blood sugars according to the progress note, instead the record noted at the following: -9:47 a.m. blood sugar reading was 181 milligram/deciliter (mg/dl). -1:17 p.m. blood sugar reading was 251 mg/dl. Review of R1's Medication Administration History for 5/15/26 identified the following administrations: -Glargine insulin: ten units administered at 9:47 a.m. (physician order was for fifteen units). R1's record did not identify a physician order for reduction of the insulin by 5 units nor a documented rationale for the lower dose. -Novolog insulin administered ten units at 9:47 a.m. -Novolog insulin: administered six units at 1:17 p.m. Review of R1's blood glucose monitor was not set to the correct date and time. On 6/5/26 at 2:07 p.m., Infection Control/Quality nurse (IC-QN) reviewed the meter, the actual date and time were determined and recorded blood sugars were validated. R1's meter identified at on 5/15/26 at 12:04 p.m. R1's blood sugar was 55 mg/dl. Between 12:04 p.m. and 1:17 p.m. when the meter identified R1's blood sugar was 251 mg/dl, there was no indication R1's blood sugar was rechecked every 15-minutes according to physician orders. In addition, review of R1's record did not include an assessment for signs and symptoms of hypoglycemia, no indication the 15/15 protocol was followed, and no indication the physician was notified. R1's physician assistant (PA) nursing home note dated 5/15/26 at 1:30 p.m. identified R1 had been seen for a new admission visit. Blood sugars were reviewed and there was no hypoglycemia documented. Insulin and semaglutide (a medication used to treat diabetes) will be continued as ordered. Blood sugar does not need to be checked at bedtime, and they can be checked three times per day before meals. R1's progress note dated 5/15/26 at 3:47 p.m., identified R1 had been seen by physician assistant (PA) for new admission. New orders to check blood sugar three times per day before meals. Bedtime blood sugar check was not necessary. In review of R1's record there was no indication the orders were transcribed into the medical record, nor notification to the provider of R1's blood sugar of 55 mg/dl. R1's afternoon blood glucose meter recorded on 5/15/26 blood sugars were reviewed on 6/5/26 in combination with record values in the electronic health record (EHR). The meter identified at 4:47 p.m. R1's blood sugar was 70 mg/dl, however the EHR did not identify this value. R1's record did not include an assessment for signs and symptoms of hypoglycemia after R1's meter identified the blood sugar of 70 nor evident the physician was notified. R1's EHR identified the next recorded blood sugar was obtained at 6:37 p.m. when her blood sugar was 97 mg/dl. R1's MAR identified at 6:38 p.m. R1 was administered 12 units of Novolog insulin even though post prandial blood sugar was only 97 mg/dl. R1's EHR at 9:20 p.m. documented the blood sugar as LOW. R1's meter identified LOW at 9:30 p.m. During an interview on 6/5/26 at 12:54 p.m., blood glucose monitor manufacturer (BGM)-A stated a reading of LOW on the monitor indicated the blood sugar reading was less than 20 mg/dl. During an interview on 6/5/26 at 2:07 p.m., IC-QN verified R1's blood glucose monitor by comparing the EHR had two blood sugars taken on 5/15/26 at 12:04 p.m. with a value of 55 mg/dl and at 4:47 p.m., with a value of 70 mg/dl. IC-QN explained that neither of the values had been entered into R1's EHR and that R1 had received all of her doses of insulin that day and should not have received the noon or evening dose until the physician had been notified first. R1's progress note dated 5/15/26 at 9:59 p.m., included that R1 was taken to (the hospital) at 9:40 p.m. after an unresponsive episode due to hypoglycemia. Writer went into R1's room to apply bedtime body creams and found R1 lying in bed unresponsive. Point of care testing (POCT) indicated R1's blood sugar was low and there were no numerical numbers. Glucagon gel was applied and paramedics came and administered intramuscular (IM) glucagon and took R1 to the hospital. R1's emergency department (ED) nursing note dated 5/15/26, identified R1 had been brought in via emergency management services (EMS) after an unresponsive episode. When EMS picked her up her blood pressures were in the 40's systolic, blood sugar was in the 60's. R1 did not eat much for dinner and was very diaphoretic (sweaty). Glucagon (emergency medicine used to treat severe hypoglycemia) was given via intramuscular on scene. Last blood sugar was 89. R1's hospital note dated 5/15/26 at 10:36 p.m., identified R1 presented in the ED from the nursing home with hypoglycemia. R1 reported recent episodes of low blood sugar, sweating, and difficulty eating at the nursing home. R1 was admitted for ongoing hypoglycemia and borderline blood pressure, with concern that nursing home was insufficient for current acuity. Decision to admit was based on clinical instability and need for close monitoring and interventions, including intravenous glucose. ED course showed at 2:45 a.m., R1 developed recurrent hypoglycemia and had to be administered D50 (50% dextrose-sugar water) and had to be placed on a dextrose drip. R1 reported that earlier in the evening her blood sugar read 70, after she was advised to eat. R1 had consumed cottage cheese and attempted to eat melon but found it too hard to chew. Her last substantial meal was half a bacon, lettuce and tomato sandwich from the previous day. After returning to her room, she began to experience shaking and sweating, which she recognized as symptoms of hypoglycemia. R1 reported her daughter-in-law provided a nutritional drink, but symptoms worsened before she could consume it. R1 received 1 liter of intravenous fluids and a D50 injection in the ambulance prior to arrival. R1's hospital admission history and physical note dated 5/16/16, identified R1 was found unresponsive and diaphoretic at the facility and was found to be critically hypoglycemic, hypotensive, and anemic. R1 was admitted for management of hypoglycemia, hemoglobin monitoring, and acute kidney injury. Acute kidney injury suspected to be pre-renal (a medical condition occurring in the circulatory system before reaching the kidneys) etiology in setting of poor oral intake, blood loss anemia. R1 reported holding diuretics and blood pressure medication since her admission due to sepsis and acute kidney injury. During an interview on 6/4/26 at 1:36 p.m., R1 stated she had an episode a while ago where her blood sugar bottomed out and had to be sent to the hospital. R1 recalled being told around 5:00 p.m. that her blood sugar was around 70 mg/dl and the nurse told her to go and eat, and he would recheck it after she ate. R1 explained she then went to the dining room and really was not hungry, so she only ate a part of a sandwich and a little bit of cottage cheese. R1 then returned to her room after the meal but did not recall if the nurse came back to check on her or take her blood sugar. R1 stated she must have gone unresponsive and had to be taken to the ED, but it must have happened so fast, because she did not recall having any symptoms prior to that episode. R1 had heard the ambulance crew needed to give her glucose injection and she did not wake up until she got to the ED. R1 thought the nurse had given her less insulin on that day due to her blood sugar being low but did recall exactly. During an interview on 6/5/26 at 11:44 a.m., PA stated she had seen R1 for a new admission round on 5/15/26 and had not been notified of any hypoglycemic blood sugar readings during rounds. PA stated she had access to R1's electronic health record (EHR) and reviews blood sugars by looking at the documented vital signs. PA stated if she had been notified of R1's blood sugars of 55 mg/dl before lunch, she would have had the nurse hold the scheduled insulin and kept a close eye on R1's blood sugars that day. PA further explained when the nurse identified R1's low blood sugars but continued to administer R1's scheduled insulin without notification to a physician put R1 in harm's way and put her at risk for serious harm, impairment or even could have caused death. During an interview on 6/8/26 at 2:08 p.m., registered nurse (RN)-A stated he had checked R1's blood sugar on 5/15/26 before lunch and her reading was 55 mg/dl, however, could not recall if R1 had any hypoglycemic symptoms at that time. RN-A then instructed R1 to go and eat her noon meal due to her blood sugar being low. RN-A retook R1's blood sugars around 1:17 p.m. and found her blood sugar to be 251mg/dl, so RN-A stated he administered R1's insulin at that time. RN-A further explained before supper time R1's blood sugar reading was 70 mg/dl, so he also told R1 to go eat the meal, however, did not verify how much R1 ate during the meal, and he would check her blood sugar after she ate, which then he took a blood sugar at 6:37 p.m., which was 97 mg/dl. RN-A then administered R1 her 12 units of Novolog. RN-A explained R1's fasting blood sugar values before she ate would be considered hypoglycemic but believed he could base the insulin dosing on the after the meal blood sugar. RN-A explained that at around 9:30 p.m., he was notified by an aide that something was wrong with R1. RN-A went to R1's room immediately, where he found her lying in bed unresponsive. R1's blood sugar was taken and read LOW- there were no numbers registering on the glucose monitor. RN-A stated he immediately looked in the medication cart but could not find the rescue glucagon injection. Then licensed practical nurse (LPN)-B assisted him in trying to find the medication but was unable to locate the glucagon infection either. RN-A then went to find jam and honey and began to rub it on R1's oral mucosa (the mucous membranes lining the skin inside of the mouth, including cheeks and lips) to raise the blood sugar. LPN-B then found the oral glucose gel in the med room, so he then RN-A placed it in R1's oral mucosa also. RN-A reported that when the substances were applied in R1's mouth, R1 remained unresponsive and was unable to swallow. RN-A explained that is all I could do, since I could not find the medication, she needed. RN-A stated he was agency staff and had been working at the facility for the past 3 months but had never been shown where the location of the emergency kit and also was not aware of the hypoglycemic protocol. During an interview on 6/4/26 at 4:25 p.m., licensed practical nurse (LPN)-B stated she had worked at the facility on 5/15/26 when R1 was found unresponsive. LPN-B was passing medication when she heard a nursing assistant come out of R1's room and tell registered nurse (RN)-A that something was wrong with R1. RN-A then went into R1's room when LPN-B observed RN-A leaving and re-entering R1's room multiple times. When LPN-B entered R1's room she observed R1 to be pale and unresponsive. RN-A then informed LPN-B that R1's blood sugar was LOW and RN-A could not find the glucagon pen. LPN-B then called 911 and attempted to assist RN-A to find the glucagon pen, however, was unable to locate it. LPN-B explained she had not been shown during orientation of the location but knew it would be in the medication room however her badge did not work to enter the room. LPN-B then went to get RN-A to open the medication room door and both LPN-A and RN-A attempted to look for the glucagon injection but still was unable to locate it. LPN-B further explained she was finally able to locate the glucose gel and gave it to RN-A. When LPN-B heard R1's blood sugar was reading low and was unresponsive, she was aware she needed to have the glucagon injection quickly to avoid death. LPN-B stated when emergency management systems (EMS) arrived they had taken R1's blood sugar and continued to read LOW so they administered a glucagon injection and took her to the emergency department. LPN-B stated when EMS left the facility with R1, R1 remained unresponsive. During an interview on 6/5/26 at 12:08 p.m., nursing assistant (NA)-A stated she had been asked to sit with R1 on 5/15/26 because the nurses were having a tough time finding the glucose injection to give R1 because her blood sugar was too low. When NA-A entered R1's room she was pale and completely un-responsive. It was kind of scary to see her like that, I thought she might die. NA-A could not recall the exact time she sat with R1, but soon after RN-A returned to R1's room and applied some sort of gel on her gums then EMS arrived to take R1 to the hospital. Review of facility investigation notes dated 5/18/26 and 6/5/26 identified although the facility identified issues with licensed staff's awareness of the location of the glucagon there was no indication the facility completed an analysis of what led to R1's hypoglycemic event that had resulted in unconsciousness and hospital admission. The investigative notes dated 6/5/26 identified the facility met with RN-A to discuss R1's hypoglycemia episode. RN-A reported after R1 became unresponsive and her blood sugar reading was low, he was unable to locate the glucagon, so he located honey and rubbed it on her oral mucosa. Another nurse had already called 911 and when they arrived, they administered IM glucagon. Investigative notes on 6/5/26 identified an undated statement from RN-A that included R1 was found unresponsive when he went to administer bedtime body creams. R1's blood sugars had been extremely fluctuating blood sugar reading throughout the day. The writer searched and could not locate the glucagon. Two nurse managers were called to assist in its location and there was no solution. The writer rubbed honey and jam in R1's oral mucosa. A few minutes later the oral glucagon gel was found and administered to the resident. 911 had already been called for assistance. Vital signs were taken and blood sugar readings indicated low on the glucometer. When emergency personnel came, they administered IM glucagon and left to take R1 to the hospital. R1 was still unresponsive at the time she was taken to hospital around 9:45 p.m. As a result of the facility investigation that identified staff being unable to locate emergency medications used to treat a severe hypoglycemia reaction, the following education was provided to staff beginning 5/18/26: -Staff provided the Management of Hypoglycemia Policy to read; instructed staff that nurses should respond to blood sugars less than 70 mg/dl according to the policy; instruction on the location of the glucagon injection (located in the medication room in an emergency kit). -Instructed staff that providers should be notified whenever glucagon is administered and/or 911 is called for appropriate follow up care. -Instructed staff that if residents are unresponsive or responding poorly, they should not be given anything orally to prevent choking, During an interview on 6/4/26 at 2:14 p.m., LPN-A stated she was agency nursing staff, and it had only been her 3rd or 4th day working at the facility. LPN-A was unable to articulate the facility protocol for a resident with a hypoglycemic episode. LPN-A stated if she identified a diabetic resident unresponsive, she would first check the blood sugar, and if the reading showed a reading of low, she would quickly give oral glucose gel to bring the blood sugar up. LPN- A stated she would give the glucose oral gel, even if the resident could not swallow, because the oral glucose gel would just absorb in their oral mucosa. LPN-A explained she would not give the unconscious resident the glucagon injection, because she believed it would be above her scope of practice as an LPN to administer this medication. During an interview on 6/5/26 at 11:20 a.m., LPN-D stated after R1's hypoglycemic episode the facility printed off the policy and wanted the staff to read it and then sign the paper that they read it. LPN-D stated she did not receive any education on the policy for treatment of hypoglycemia or been shown the exact location of the emergency glucose injection and believed this medication is kept in the refrigerator but was not exactly sure. During a return phone call on 6/9/26 at 9:23 a.m., case manager RN-B stated she had assisted in the investigation after R1's unresponsive/hypoglycemic episode on 5/15/26. RN-B stated she had been informed by RN-A on 5/18/26 that R1has episodes of hypoglycemia, but when she reviewed R1's vitals she had not identified any low blood sugars on 5/15/26 so she had instructed R1 to place the low values in the EHR. RN-B did not review the values on the machine nor look at the administration history to see if RN-A had administered R1 insulin at the appropriate time and she should have completed this to determine if R1 received insulin when she was not supposed to. RN-B was not aware R1 had blood sugar values of 55 mg/dl before lunch, nor a blood sugar of 70 mg/dl before supper and with values like that R1's insulin should have been held, and the physician should have been notified. During an interview on 6/5/26 at 4:16 p.m., medical director (MD) stated she had not been notified of the hypoglycemic event that happened with R1 on 5/15/26. MD explained if she had been notified of the event, she would have worked with the facility to determine a root cause of the hypoglycemic event and assisted with the education of staff. MD explained that oral glucose gel or anything orally should have never been given to an unconscious resident due to the risk of choking. MD also explained the facility should have ensured all staff had been trained in the location of any emergency medication to ensure that there was not a delay in administration. R2 R2's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus and long-term use of insulin. R2's Annual MDS dated [DATE], identified moderate cognitive impairment, had no behaviors, no rejection of cares, took insulin injections 7 out of 7 days during the assessment. R2's health condition focus care plan dated 2/18/20, identified R2 had a diagnosis of diabetes mellitus type 2. Goal to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Interventions as follows:-Monitor blood sugars per provider orders. Notify provider of out-of-range blood sugars per facility policy. Dated 4/8/24.-Administer medications per providers orders. Dated 4/8/24. R2's physician orders identified the following orders:-Check blood sugar three times per day. Notify physician on next business day on blood sugars less than 50 mg/dl or greater than 450 mg/dl. -Lantus (long-acting insulin): administer 7 units with meals. Hold for blood sugars less than 90 mg/dl three times per before meals. -Lantus insulin: administer 7 units every morning. Dated 8/29/25.-Lantus insulin: admininster17 units every evening. Dated 3/6/26 with a stop date of 6/5/26. -Lispro insulin (rapid acting): administer 5 units with meals (three times per day). Dated 5/15/26.-Lispro insulin per sliding scale (a method used to manage blood glucose levels by adjusting the insulin dose based off blood glucose levels) three times per day before meals: If blood sugar is 200 to 249-give 2 units; if blood sugar is 250-299-give 4 units; if blood sugar is 300-349-give 6 units; if blood sugar is greater than 349-give 8 units. Dated 10/22/25. -Give glass of orange juice halfway through night shift to help blood sugars from dropping prior to breakfast. Dated 6/29/25.-Give resident toast with peanut butter at bedtime. Dated 6/23/23. Review of R2's Medication Administration Record (MAR), identified on 5/12/26, and 5/15/26 R2 did not receive the orange juice during the night shift. R2's progress note dated 5/11/26, identified R2 verbalized to another staff that she was not feeling good. Blood sugars were checked at 9:05 p.m., and the 15/15 protocol initiated. 15 grams of carbs, orange juice and peanut butter jelly toast given. Blood sugar rechecked and was 85 at 9:20 p.m. R2 stated she felt better. R2's blood glucose readings with low values for the month of 5/26 included:-5/11/26 at 9:05 p.m. was 47 mg/dl.-5/11/26 at 9:20 p.m. was 85 mg/dl.-5/12/26 at 5:15 p.m. was 60 mg/dl. Review of R2's medical record from 5/11/26 through 5/14/26, did not indicate the physician had been notified of R2's low blood sugar readings. R2's progress note dated 5/15/26, identified R2 was seen by physician assistant and gave new orders to reduce Lispro insulin to 5 units three times per day and hold for blood sugars less than 90 mg/dl or not going to eat. Follow up if any blood sugars are low. R2's PA progress note dated 5/15/26, identified R2 had some recent hypoglycemia with one blood sugar of 47 at the time of the evening meal and one blood sugar of 60 at bedtime. Plan was for type 2 diabetes was her last hemoglobin A1C was probably too well controlled too well controlled for her age and comorbidities [sic]. Long-acting insulin was reduced with the A1C of 6.0 and still having some hypoglycemia. New orders to reduce Lispro insulin to from 7 units to 5 units three times per day with meals and hold for blood sugars less than 90 mg/dl or if she is not going to eat. Insulin glargine and sliding scale left as ordered. Follow up if there is recurrent hypoglycemia. Review of R2's MAR for month of May 2026, identified R2's Lispro insulin was held on 5/18/26 at 4:45 p.m.; 5/20/26 at 7:30 a.m.; 5/31/26 at 11:30 a.m. R2's medical record reviewed from 5/18/26 through 6/5/26, identified the following low blood sugar readings:-5/18/26 at 4:55 p.m. was 85 mg/dl. -5/20/26 at 8:09 a.m. was 77 mg/dl.-5/20/26 at 4:55 p.m. was 85 mg/dl.-5/31/26 at 11:32 a.m. was 79 mg/dl. -5/31/26 at 5:07 p.m. 191 mg/dl. -6/5/26 at 3:37 a.m. was 65 mg/dl. Review of R2's record from 5/18/26 through 5/31/26 did not identify the physician had been updated on R2's low blood sugar readings. R2's progress note dated 5/31/26 at 10:58 a.m., identified R2 was extremely tired today. When in to get blood sugar resident stated she was ready to get up staff was told resident fell back asleep [sic]. Asked resident why she was so tired and her response was I think they gave me too many sleeping pills. Resident was up in wheelchair. Glucose check was 79 before lunch and was sent to dining room for lunch. Although R2's record showed symptoms of hypoglycemia of feeling tired, a recheck blood sugar was not identified in R2's chart until 5/31/26 at 5:07 p.m. During an interview and observation on 6/5/26 at 9:46 a.m., LPN-C stated she had been informed during report from LPN-B that R2 had a low blood sugar in the middle of the night around 3:37 a.m., with a value of 65 mg/dl. LPN-C reviewed R2's progress notes and did not identify any documentation of any symptoms during the low blood sugar and also reviewed R2's vitals and did not identify a recheck R2's blood sugar 15 minutes later. LPN-C stated LPN-B told her she gave R2 orange juice and a half a peanut butter sandwich when she identified the low blood sugar. LPN-C verified on R2's blood glucose monitor that a blood sugar had been rechecked 30 minutes after the value of 65 mg/dl and was listed as 110 mg/dl. LPN-C explained R2's blood sugar should have been checked 15 minutes after the snack had been given and the physician should have been notified, however, did not see any notification in the progress notes. During an interview on 6/8/26 at 10:05 a.m., LPN-B stated on 6/5/26 at around 3:37 a.m., R1 had reported she was not feeling well and wanted her blood sugar taken. LPN-B explained when she had taken R2's blood sugar at that time she got a result of 65 mg/dl, she gave R2 some orange juice and a half of a peanut butter sandwich and rechecked R2's blood sugar about 30 minutes after giving the carbohydrates and the result was 110 mg/dl. LPN-B explained she had not documented R2 symptoms, the re-check of R2's blood sugar, nor notified the physician of R2's hypoglycemic reaction and was not aware of the facility protocol of notifying physician. LPN-B believed since R2's blood sugar improved she did not need to notify the physician. R2's progress note dated 6/5/26 at 4:21 p.m., identified a new order for glargine insulin to reduce evening dose to 16 units and continue 7 units in the morning. Follow up on blood sugar on Tuesday 6/9/26. R2's physician orders identified an order for Lantus insulin: give 16 units every evening. Dated 6/5/26. During an interview on 6/5/25 at 9:46 a.m., LPN-C stated it was reported to her that in the middle of the night R2 had a low blood sugar. LPN-C reviewed R2's record and identified R2 had a blood sugar of 68 mg/dl. LPN-C then reviewed R2's blood glucose monitor and identified a blood glucose was obtained (with an incorrect date of 4/8/26 at 4:03 a.m. reading on the monitor) of 68 mg/dl. LPN-C stated the blood glucose machine showed another reading 30 minutes later at 4:33 a.m. (30 minutes later, incorrect time) of 110 mg/dl. LPN-C stated per the facility protocol R2's blood sugar should have been rechecked 15 minutes later to ensure it did not drop any lower, however, according to the glucose monitor it did not appear to be done per protocol. During an interview on 6/5/26 at 9:54 a.m., R1 stated she had woken up in the middle of the night and did not feel well. R2 explained she felt shaky and just off. R2 stated she called for the nurse, and she came in and took her blood sugar and told her it was low and proceeded to give her a peanut butter sandwich and some orange juice. During an interview on 6/5/26 at 11:44 a.m., PA stated she was on-call last night and had not been notified of R2's hypoglycemic episode on 6/5/26 and should have been notified to review R2's blood sugars to possibly make an adjustment in her insulin dosing. PA will review R2's blood sugars during rounds today and make the adjustments. PA further explained by the facility not contacting her to inform of her blood sugars being low had the possibility of causing a severe hypoglycemic reaction. During an interview on 6/5/26 at 4:16 p.m., MD stated when R2 had a hypoglycemic reaction in the middle of the night, the physician should have been notified immediately to possibly make adjustments to her insulin order to attempt to prevent future hypoglycemic reactions. Review of facility Standing Orders dated 6/25/24, identified under blood sugars the following:-Nurse may check blood glucose on any resident at any time if they feel it is indicated.-If resident is having nausea/vomiting or decreased nutritional intake, nurse may hold oral diabetic medications and/or insulin until oral intake is tolerated. Notify provider immediately if medication is held.-For signs/symptoms of hypoglycemia (low blood sugar) reaction, initiate the following protocol: check blood sugar; If blood sugar is less than 60, provide resident with snack (such as 4 ounces of milk, 4 oz. of orange juice; 2 graham crackers). If unable to consume a snack, provide oral glucose gel; If unable to consume oral glucose gel, administer Glucagon 1 unit subcutaneously/intramuscular. Recheck blood sugar after administration. Notify the provider of gel/glucagon use. Review of the facility's Management of Hypoglycemia Policy/Protocol dated 2/26, identified the following are symptoms of hypoglycemia:Weakness; restlessness; tachycardia (fast heartrate); pale/cool/moist skin; excessive perspiration; irritability/bizarre behavior; blurred vision; headaches; numbness of the tongue; more severe (stupor, unconscious and or convulsions) and coma. Management of Hypoglycemia:The following is a suggested protocol that should not be implemented without the approval of the Medical Director and Director of Nursing. If there is already a protocol in place, disregard this and follow the existing approved protocol instead.Classification of hypoglycemia:Level 1 hypoglycemia: blood glucose is less than 70 mg/dl but greater than 54 mg/dl.Level 2 hypoglycemia: blood glucose less than 54 mg/dlLevel 3 hypoglycemia: blood glucose: altered mental status and/or physical status requiring assistance for treatment of hypoglycemia.For Level 1 hypoglycemia (less than 70 mg/dl)Give the resident an oral form of rapidly absorbed glucose (15-20 grams).Notify the provider immediately.Remain with the resident.Recheck blood glucose in 15 minutes.If blood glucose is within established reference range, provide the resident with a meal or snack. If blood glucose is greater than established reference range administer diabetic me[TRUNCATED]

Based on interview and document review the facility failed to investigate immediately a cause of hypoglycemia (low blood sugar) for 1 of 4 residents (R1) reviewed for insulin administration. Findings include:R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included:Administer medications per physician orders. Nursing staff will dispense and administer all medications.Monitor blood sugars per physician orders. Notify provider of out-of-range blood sugars per facility policy. R1's physician orders with a start date of 5/13/26 directed the following:Check blood sugar four times a day at 7:00 a.m.; 11:00 a.m.; 4:00 p.m.; and 9:00 p.m.Insulin Glargine (long-acting) insulin 100 units/milliliter (ml): administer 15 units subcutaneously (under the skin) daily in the morning. Novolog (rapid acting) insulin U (units) 100 insulin: administer ten units every morning.Novolog insulin U-100 insulin: administer six units subcutaneous with lunch. Novolog insulin U-100: administer twelve units subcutaneously with evening meal. For signs/symptoms of hypoglycemic reaction initiate the 15/15 protocol. Check blood sugar, if less than 60, give 15 grams (g) of carbs (carbs only), 4 oz of orange juice; regular pop; glucose tablets; 1 tablespoon of jelly/jam/sugar/honey. Wait 15 minutes, then test again. If blood sugar does not increase repeat 15 g of carbs and wait 15 minutes and test again. If unable to consume a snack, provide oral glucose gel. If blood sugar does not show improvement after two rounds (30 minutes) or becomes unresponsive, seek medical help.If unable to administer oral glucose gel, administer Glucagon (emergency medication used to treat severe hypoglycemia) 1-unit subcutaneously/intramuscular (SQ/IM). Recheck blood sugar after administration. Notify provider of gel/glucose use. R1's progress note dated 5/15/26 at 2:01 p.m., identified R1's blood sugar reading had been extremely fluctuating and point of care testing (POCT) had to be completed twice so that insulin could be administered after meals (post prandial) when readings indicated better figures. R1's progress note dated 5/15/26 at 9:59 p.m., included R1 was taken to hospital at 9:40 p.m., after an unresponsive episode due to hypoglycemia. Writer went into R1's room to apply bedtime body creams and found R1 lying in bed unresponsive. POCT indicated, low, and there were no numerical numbers. Glucagon gel was applied and paramedics came and administered intramuscular (IM) glucagon and took R1 to the hospital. R1's hospital note dated 5/15/26 at 10:36 p.m., identified R1 presented in the emergency department (ED) from the nursing home with hypoglycemia. R1 reported recent episodes of low blood sugar, sweating, and difficulty eating at nursing home. R1 was admitted for ongoing hypoglycemia and borderline blood pressure, with concern that nursing home was insufficient for current acuity. Decision to admit was based on clinical instability and need for close monitoring and interventions, including intravenous glucose. ED course showed at 2:45 a.m., R1 developed recurrent hypoglycemia and had to be administered D50 (50% dextrose-sugar water) and had to be placed on a dextrose drip. R1 reported that earlier in the evening her blood sugar read 70, after she was advised to eat. R1 had consumed cottage cheese and attempted to eat melon but found it too hard to chew. Her last substantial meal was half a bacon, lettuce and tomato sandwich from the previous day. After returning to her room, she began to experience shaking and sweating, which she recognized as symptoms of hypoglycemia. R1 received 1 liter of intravenous fluids and a D50 injection in the ambulance prior to arrival. R1's blood glucose meter recorded on 5/15/26, blood sugars were reviewed on 6/5/26, in combination with record values in the electronic health record (EHR). The meter identified at 4:47 p.m., R1's blood sugar was 70 mg/dl, however the EHR did not identify this value. R1's record did not include an assessment for signs and symptoms of hypoglycemia after R1's meter identified the blood sugar of 70 nor evidence the physician was notified. R1's EHR identified the next recorded blood sugar was not obtained at 6:37 p.m. when her blood sugar was 97 mg/dl. R1's MAR identified at 6:38 p.m. R1 was administered 12 units of Novolog insulin even though post prandial blood sugar was only 97 mg/dl. R1's EHR at 9:20 p.m. documented the blood sugar as LOW. R1's meter identified LOW at 9:30 p.m. Review of R1's blood glucose monitor was not set to the correct date and time. On 6/5/26 at 2:07 p.m., Infection Control/Quality nurse (IC-QN) reviewed the meter, the actual date and time were determined and recorded blood sugars were validated. R1's meter identified at 12:04 p.m. R1's blood sugar was 55 mg/dl. Between 12:04 p.m. and 1:16 p.m. when the meter identified R1's blood sugar was 251 mg/dl there was no indication R1's blood sugar was rechecked every 15-minutes according to physician orders. In addition, review of R1's record did not include an assessment for signs and symptoms of hypoglycemia, no indication the 15/15 protocol was followed, and no indication the physician was notified. During an interview on 6/5/26 at 2:07 p.m., IC-QN verified R1's blood glucose monitor by comparing the EHR had two blood sugars taken on 5/15/26 at 12:04 p.m. with a value of 55 mg/dl and at 4:47 p.m., with a value of 70 mg/dl. IC-Q explained that neither of the values had been entered into R1's EHR and that R1 had received all of her doses of insulin that day. IC-QN stated R1 should not have received the noon or evening dose until the physician had been notified. During an interview on 6/8/26 at 3:53 p.m., former director of nursing (F-DON) stated she was the acting DON at the time of R1's hypoglycemic/unresponsive episode on 5/15/26, however, she had not been involved in the investigation to determine the cause of R1's hypoglycemia. F-DON further explained that a consultant and the case manager did the investigation and the education with the staff. During a return phone call on 6/9/26 at 9:23 a.m., registered nurse case manager (RN)-CM stated she assisted in the investigation after R1's unresponsive/hypoglycemic episode on 5/15/26. RN-CM stated she was informed by RN-A on 5/18/26, that R1has episodes of hypoglycemia, but when she reviewed R1's vitals she had not identified any low blood sugars on 5/15/26 so she had instructed R1 to place the low values in the EHR. RN-CM did not review the values on the machine nor look at the administration history to see if RN-A had administered R1 insulin at the scheduled times and she should have completed this to determine if R1 received insulin when she was not supposed to. RN-CM was not aware R1 had blood sugar values of 55 mg/dl before lunch, nor a blood sugar of 70 mg/dl before supper and with values like that R1's insulin should have been held, and the physician should have been notified. Review of the facility's Abuse Potential/Vulnerable Adult/Quality Assurance and Performance Improvement (QAPI) Review Policy dated 3/26, identified the following:It is the policy of the facility that all incidents will be investigated even if not reportable and results of investigation will be documented. This included the following:-Taking steps to prevent further potential abuse.-Reporting the alleged violation and investigation within required time frames.-Conducting a thorough investigation of the alleged violation.-Revising the resident care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Procedure:The investigation is the process used to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. This information gathered is given to administration.

Based on interview and document review the facility failed to ensure nurses were competent in their skill level to identify a hypoglycemic (low blood sugar) episode and safely administer insulin for 1 of 1 resident (R1) reviewed for insulin administration. Findings include: R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included: Administer medications per physician orders. Nursing staff will dispense and administer all medications. Monitor blood sugars per physician orders. Notify provider of out-of-range blood sugars per facility policy. R1's progress note dated 5/15/26 at 2:01 p.m., identified R1's blood sugar reading had been extremely fluctuating and point of care testing (POCT) had to be done x2 so that insulin could be administered after meals (post prandial) when readings indicated better figures. R1's afternoon blood glucose meter recorded on 5/15/26, blood sugars were reviewed on 6/5/26, in combination with record values in the electronic health record (EHR). The meter identified at 4:47 p.m. R1's blood sugar was 70 mg/dl, however the EHR did not identify this value. R1's record did not include an assessment for signs and symptoms of hypoglycemia after R1's meter identified the blood sugar of 70 nor evident the physician was notified. R1's EHR identified the next recorded blood sugar was not obtained at 6:37 p.m., when her blood sugar was 97 mg/dl. R1's MAR identified at 6:38 p.m. R1 was administered 12 units of Novolog insulin even though post prandial blood sugar was only 97 mg/dl. R1's EHR at 9:20 p.m. documented the blood sugar as LOW. R1's meter identified LOW at 9:30 p.m. During an interview on 6/5/26 at 2:07 p.m., IC-QN verified R1's blood glucose monitor by comparing the EHR had two blood sugars taken on 5/15/26 at 12:04 p.m., with a value of 55 mg/dl and at 4:47 p.m., with a value of 70 mg/dl. IC-Q explained that neither of the values had been entered into R1's EHR and that R1 had received all of her scheduled doses of insulin that day and should not have received the noon or evening dose until the physician had been notified first. R1's progress note dated 5/15/26 at 9:59 p.m., included R1 was taken to hospital at 9:40 p.m. after an unresponsive episode due to hypoglycemia. Writer went into R1's room to apply bedtime body creams and found R1 lying in bed unresponsive. POCT indicated R1's blood sugan was LOW and there were no numerical numbers. Glucagon gel was applied and paramedics came and administered intramuscular (IM) glucagon and took R1 to the hospital.During an interview on 6/8/26 at 2:08 p.m., registered nurse (RN)-A stated he had checked R1's blood sugar on 5/15/26, before lunch and her reading was 55 mg/dl. RN-A could not recall if R1 had any hypoglycemic symptoms at that time. RN-A then instructed R1 to eat her noon meal due to her blood sugar being low. RN-A retook R1's blood sugars around 1:17 p.m., R1's blood sugar was 251mg/dl, so RN-A stated he administered R1's insulin at that time. RN-A further explained before supper R1's blood sugar reading was 70 mg/dl, so he also told R1 to eat the meal and he would re-check her blood sugar after she ate. RN-A checked R1's blood sugar at 6:37 p.m., which was 97 mg/dl. RN-A then administered 12 units of Novolog to R1. RN-A explained, R1's fasting blood sugar values before she ate would be considered hypoglycemic but believed he could base the insulin dosing on the after the meal blood sugar. RN-A explained, at approximately 9:30 p.m., he was notified by an aide that something was wrong with R1. RN-A went to R1's room immediately, where he found her lying in bed unresponsive. R1's blood sugar was taken and read LOW- there were no numbers registering on the glucose monitor. RN-A stated he immediately looked in the medication cart but could not find the rescue glucagon injection. Then licensed practical nurse (LPN)-B assisted him in trying to find the medication but was unable to locate the glucagon injection either. RN-A then went to find jam and honey and began to rub it on R1's oral mucosa (the mucous membranes lining the skin inside of the mouth, including cheeks and lips)to raise the blood sugar. LPN-B then found the oral glucose gel in the medication room, so he then placed it in R1's oral mucosa also. RN-A reported, when the substances were applied in R1's mouth, R1 remained unresponsive and was unable to swallow. RN-A explained, that is all I could do, since I could not find the medication, she needed. RN-A stated he was agency staff and had been working at the facility for the past three months but had never been shown where the location of the emergency kit and also was not aware of the hypoglycemic protocol. RN-A explained he was unaware that a blood sugar of 55 indicated hypoglycemia nor that the facility protocol indicated a specific treatment for a blood sugar of this value. RN-A explained any medication had a window of an hour before and an hour after, so when he had R1 eat her meal and he re-checked R1's blood sugar, he thought he could give the scheduled dose because her blood glucose value was in the normal range. RN-A stated he thought R1 would be just fine. RN-A stated he had not had any training on how to safely administer insulin nor had any competencies on this skill from the facility. RN-A further explained, when he first started working at the facility he had only been showed a basic layout of the facility, but not had any competencies completed by the facility. Review of RN-A's supplemental nursing staffing agency employee form dated 11/11/25, identified RN-A was able to perform blood glucose monitoring, performing fingerstick, use of blood glucose meter device, and use of visual blood glucose strips independently. Although RN-A's employee file identified RN-A was able to perform independently, had knowledge of diabetes and hypoglycemia, there was no competency completed by the facility to identify RN-A was deemed to be competent in those skills. During an interview on 6/8/26 at 2:45 p.m., IC-QN stated she was responsible to complete any competency of the nurses in the facility, however, had not completed a competency on RN-A because she believed an agency nurse had these competencies completed by the agency before being allowed to work in the facility, however, had not reviewed any documentation of competency the agency had completed. IC-QN explained she should have completed the competency on all staff and not relied on the competency documentation the agency completed. Review of the facility's Building Competency Evaluations Policy dated 2/26, identified the purpose of the policy was to define and set expectations regarding a system to evaluate and verify competency of nursing service personnel in the facility to assure resident safety and to attain the highest practicable physical, [NAME], and psychosocial well-being of each resident. Competency needs will be identified based on resident assessments, individualized plan of care, resident acuity, resident diagnoses and unique resident needs. The competency process will assess the knowledge and skills of the nursing staff in the specific skill being assessed. This process will include verification of education and competence for certification or licensure upon hire and on an ongoing basis to substantiate evidence of proficiency and skill for quality resident care. Orientation: New employee orientation, in-service education and verification of skills will be completed upon hire for all nursing services personnel. Follow up evaluation of understanding and competency will be obtained with post-test skills check list.

Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record for 2 of 3 residents (R1, R2) who were noted to have missing blood sugar values in their record. Findings include:R1R1's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus, sepsis, heart failure, and hypertensive chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors, no rejection of care, required insulin injections and hypoglycemic medications (including insulin). R1 required supervision/touching assistance from staff for transfers. R1's care plan dated 5/1/26, identified R1 had a diagnosis of diabetes mellitus. R1's goal was to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Corresponding interventions dated 5/13/26 included: -Administer medications per physician orders. Nursing staff will dispense and administer all medications.-Monitor blood sugars per physician orders. Notify provider of out-of-range blood sugars per facility policy. R1's physician orders with a start date of 5/13/26 directed the following: -Check blood sugar four times a day at 7:00 a.m.; 11:00 a.m.; 4:00 p.m.; and 9:00 p.m. R1's progress note dated 5/15/26 at 2:01 p.m., identified R1's blood sugar reading had been extremely fluctuating and point of care testing (POCT) had to be done x2 so that insulin could be administered after meals (post prandial) when readings indicated better figures. Review of R1's record dated 5/15/26 between 6:00 a.m. and 3:00 p.m., identified recorded blood sugars did not reflect fluctuating blood sugars according to the progress note, instead the record noted at the following: 9:47 a.m. blood sugar reading was 181 milligram/deciliter (mg/dl). 1:17 p.m. blood sugar reading was 251 mg/dl. R1's physician assistant (PA) nursing home note dated 5/15/26 at 1:30 p.m., identified R1 had been seen for a new admission visit. Blood sugars were reviewed and there was no hypoglycemia (low blood sugar) documented. Insulin and semaglutide (a medication used to treat diabetes) will be continued as ordered. Blood sugar does not need to be checked at bedtime, and they can be checked three times per day before meals. R1's progress note dated 5/15/26 at 9:59 p.m., included R1 was taken to hospital at 9:40 p.m. after an unresponsive episode due to hypoglycemia. Writer went into R1's room to apply bedtime body creams and found R1 lying in bed unresponsive. Point of care testing (POCT) indicated low and there were no numerical numbers. Glucagon gel was applied and paramedics came and administered intramuscular (IM) glucagon and took R1 to the hospital. Review of R1's record dated 5/15/26 between 6:00 p.m. and 9:30 p.m., indicated:6:38 p.m. blood sugar reading was 97 mg/dl. 9:20 p.m. blood sugar reading was LOW. During an observation and interview on 6/5/26 at 2:07 p.m., Infection Control/Quality nurse (IC-QN) verified on R1's blood glucose monitor (which was not set to the correct date and time) by comparing R1's meter along with the electronic health record (EHR) that R1's blood sugar recorded in the meter on 5/15/26 at 12:04 p.m. of 55 mg/dl and at 4:47 p.m., with a value of 70 mg/dl. was not recorded in R1's EHR. During an interview on 6/8/26 at 2:08 p.m., registered nurse (RN)-A stated on 5/15/26 he had checked R1's blood sugar before lunch and got a value of 55 mg/dl and before supper R1's blood sugar was 70 mg/dl, however, had not recorded either value into R1' s EHR because RN-A stated he believed that there was only one section to record the value in the medication administration record (MAR). RN-A stated he did not add the blood sugar results to the vitals section. During an interview on 6/5/26 at 11:44 a.m., PA stated she had seen R1 for a new admission visit on 5/15/26 and had not been notified of any hypoglycemic blood sugar readings during rounds. PA stated she had access to R1's electronic health record (EHR) and reviews blood sugars by looking at the documented vital signs. PA further explained by not having all the blood sugar values entered into R1's EHR, she was not able to accurately review R1's blood sugars to make adjustments to her insulin due to having episodes of hypoglycemia. R2 R2's face sheet dated 6/8/26, identified diagnoses of diabetes mellitus and long-term use of insulin. R2's Annual MDS dated [DATE], identified moderate cognitive impairment, had no behaviors, no rejection of cares, took insulin injections seven out of seven days during the assessment. R2's health condition focus care plan dated 2/18/20, identified R2 had a diagnosis of diabetes mellitus type 2. Goal to effectively manage health conditions along with nursing staff as evidenced by no acute exacerbation of condition. Interventions as follows:Monitor blood sugars per provider orders. Notify provider of out-of-range blood sugars per facility policy. Dated 4/8/24. Administer medications per providers orders. Dated 4/8/24. R2's medical record reviewed on 6/5/26 identified R2's blood sugar at 3:37 a.m. was 65 mg/dl. During an interview and observation on 6/5/26 at 9:46 a.m., licensed practical nurse (LPN)-C stated she was informed during report from LPN-B that R2 had a low blood sugar in the middle of the night around 3:37 a.m., with a value of 65 mg/dl. LPN-C reviewed R2's progress notes and did not identify any documentation of any symptoms during the low blood sugar and also reviewed R2's vitals and did not identify a recheck R2's blood sugar 15 minutes later. LPN-C stated LPN-B told her she gave R2 orange juice and a half a peanut butter sandwich when she identified the low blood sugar. LPN-C verified on R2's blood glucose monitor that a blood sugar had been rechecked 30 minutes after the value of 65 mg/dl and was listed as 110 mg/dl. LPN-C reviewed R2's medical record and did not identify R2's blood sugar had been recorded in the record 30 minutes after 3:37 a.m., and stated this value should have also been entered into R2's record to show R2's response after intervention. During an interview on 6/8/25 at 2:45 p.m., IC-QN stated her expectation for the nurse was to ensure that all blood sugars become a part of the resident's medical record to ensure the record is complete and accurate. IC-QN further explained by not entering all of the vitals into a resident's chart this could not prevent the physicians from identifying concerns when reviewing a chart and could miss serious concerns. Review of the facility's Management of Hypoglycemia Policy dated 2/26, identified the following for documentation: Document the resident's blood glucose before intervention. Note blood sugar after each administration of rapid acting glucose and the follow up blood sugar. Record the resident's level of consciousness before and after intervention. Document provider instructions. Requested a policy on complete and accurate medical record but did not receive.

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded high risk issues related to pressure ulcers by developing and implementing action plans for process improvement. This deficient practice had the potential to affect all 33 residents that resident in the facility. Review of QAPI minutes from December 2025 through March of 2025 identified across all months the facility consistently collected and reported data related to pressure ulcers; however, the documents did not address or include root cause analysis, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, and monitoring if interventions for effectiveness. Quality documents included the following: The December QAPI meeting demonstrated the facility had a process for collecting and reporting quality data across multiple departments. Specific measures were identified, including 2 bruises and a medication error involving incorrect medication administration, infection control data showing 4 total infections (2 pneumonia, 2 UTI), 19 audits completed, PPE compliance at 87.7%, and 63.9% influenza vaccination rate, and nursing audit findings including 6.57% of call lights not answered timely and bowel/bladder documentation completion rates between 67% and 89.7%. Additional clinical indicators were identified through MDS review, including areas flagged at or above threshold such as falls, antipsychotic medication use, UTI, worsened bowel/bladder function, and increased ADL assistance, with additional triggered areas including pressure ulcers, falls with major injury, anxiety/hypnotic use, behavioral symptoms, and excess weight loss. There was no evidence of prioritization of which of these identified risks represented the highest concern, no documented root cause analysis to determine underlying system contributors (e.g., staffing, care processes, environment, or documentation practices), and no indication that interdisciplinary action plans were developed in response to the identified measures. Additionally, the meeting did not reflect assignment of responsibility, implementation timelines, or a structured plan for re-evaluation to determine effectiveness of any interventions. Despite identification of these multiple clinical risk indicators, the facility did not document analysis of the underlying causes of the identified concerns, prioritization of high-risk areas such as pressure ulcers, or development of an action plan or performance improvement activity, and the meeting did not reflect interdisciplinary interventions or a structured approach to monitor effectiveness of any changes.The January QAPI meeting continued to reflect collection and reporting of quality indicators, including 14 falls for December exceeding the facility goal of 9 or less, 10 bruises (1 reportable). Infection prevention identified 5 infections with 20% compliance with gown usage and 60% glove compliance, while nursing services demonstrated decline in documentation with bowel and bladder documentation ranging from 37.8% to 76.7%, and identified CNA documentation and charting as needing improvement. Pharmacy data identified increased antipsychotic and antidepressant use above national averages, and MDS indicators continued to flag falls, psychotropic use, UTIs, ADL decline, and mobility decline, with pressure ulcers again noted as a triggered area below 75%. Despite repeated identification of these concerns from the prior month, there was no documentation of root cause analysis, prioritization, or action planning, and no evidence that pressure ulcers or other recurring risks were addressed through a formal performance improvement processThe February QAPI meeting demonstrated continued monitoring of clinical indicators across departments. Nursing reports identified 12 falls for January with a goal of 5 or less, including 1 major injury and 1 VA-reportable event, as well as 12 skin events for the month, nonreportable, 8 bruises with 1 reportable. Infection prevention identified 8 infections total, 9 residents on advanced barrier precautions, 100% compliance on gowns, 86% compliance with hand hygiene, 100% compliance with gloves, 40% compliance with masks, and 18 audits conducted with 83.9% compliance. Nursing services identified 7.48% of call lights not answered within 10 minutes and bowel and bladder documentation completed between 22.9% and 92.6%, with notation that weekly skin audits were compliant but wound management still needed work. MDS/CASPER data identified areas flagged at or above 75% including falls, antipsychotic medication use, UTI, new or worsened bowel/bladder, increased ADL help, and decline in independent mobility, with additional areas triggered below 75% including pressure ulcers, falls with major injury, antianxiety/hypnotic use, depression symptoms, behavior symptoms affecting others, and excess weight loss. Despite continued identification of skin integrity concerns and pressure ulcers across multiple data sources, the facility did not document analysis of contributing factors, prioritization of skin integrity or pressure ulcer risk, or development and implementation of an action plan, and the meeting did not reflect evaluation of the effectiveness of any interventions or sustained performance improvement efforts.The March QAPI meeting continued to reflect ongoing identification of clinical and operational concerns. Nursing reports identified 12 falls for February with a goal of 5 or less, including 1 major injury and 1 VA-reportable event, as well as 13 skin events reported for the month, none reportable, 2 bruises, and 1 medication error involving a missed dose due to misreading an order. Infection prevention and control identified 6 infections total (3 cellulitis/soft tissue, 2 UTI, and 1 pneumonia), with 8 residents on enhanced barrier precautions and 66.6% compliance on gowns. Nursing services identified 5.5% of call lights not answered within 10 minutes, noted as an improvement from the prior month, and bowel and bladder documentation ranging between 22.9% and 92.6%. Pharmacy services reported the facility remained above national benchmarks for antianxiety, antipsychotic, and antidepressant medications. Additional concerns identified during the meeting included communication gaps. MDS/CASPER data continued to identify areas flagged at or above 75%, including falls, antipsychotic medication use, UTI, new or worsened bowel/bladder, increased ADL assistance, and decline in independent mobility, with additional triggered areas below 75% including pressure ulcers, falls with major injury, antianxiety/hypnotic use, depression, behavioral symptoms affecting others, and excess weight loss. Despite repeated identification of pressure ulcers and skin integrity concerns across multiple months, the facility did not document root cause analysis, prioritization of this recurring issue, or development of corrective action plans, and there was no evidence of monitoring for effectiveness or sustained system changes to address these concerns.During an interview on 4/2/26 at 5:16 p.m., the facility infection preventionist/quality assurance nurse (IPQA) stated she has been in the position for 3 months and received minimal training in the QAPI process and was not able to articulate how the committee functioned, unsure of her role, and what was required in accordance with the regulations. After a recent complaint survey, IPQA requested education from the director of nursing (DON) so that she could ensure an affective quality program however the DON told the IPQA not to worry because a QAPI program was already in place. The IPQA stated the facility did have a quality assurance committee that meets monthly. During the meeting a power point was shared with all the members to enter their collected data. Although data was collected and presented at the information doesn't go anywhere else. The root cause for high incident rates is not analyzed. The committee identified pressure ulcers as a problem area however attributed the increased pressure injury rate to improved nursing documentation. The IPQA could not provide a written action plan for any areas identified during the meeting that were discussed. A policy titled Quality Assurance and Performance Improvement revised 3/2024 indicated the following: The purpose of a Quality Assurance and performance Improvement plan is to identify, track, organize, analyze, and improve healthcare outcomes at the facility towards a healthy populations of residents and staff, who are functioning at their best possible ability level. A QAPI process is based on five key elements, design and scope, governance and leadership, feedback, data systems and monitoring, performance improvement, systematic analysis and systemic action. The facilities QAPI program is designed to address root cause and systems in all areas of clinic care, resident life, quality of live, quality of care, environment, and to every practicable extent promote a high quality of life and offering of choices to our residents. It is imperative that in design the QAPI plan is accessible and understood by all staff to be an integral part of the facility function. Clinical care quality as addressed in our QAPI program with interdepartmental team involvement to meet residents needs. We assess performance of clinical care through audit clinical records internally, monitor delivery of care, mentoring and orientation processes, track care outcomes through standardized reports ( CASPER, MNQI, MN nursing home compare, CMS five star system including PBJ data), state survey results. The administrator and board of directors are responsible and accountable for the develoment, implementation, and monitoring of the QAPI program. The facility has a designated QAPI nurse staff member who is responsible for assisting with change efforts, guiding system improvements, conducting training, promoting initiatives, devlopement policies and protocols, establishing continuity, reviewing reports and research, and setting facility culture expectations for quality, while ensuring resident rights and choice are paramount. As an affiliate facility in the {managing health system}, the QAPI nurse accesses the {health system} survey readiness and quality improvement departmental contacts for mentorship and support leadership as reasonable. Feedback, systems, and monitoring: The facility utilizes a system that monitors care and services in all areas and draws data from multiple sources. Some data sources include: input from stakeholders, adverse events, performance indicators, survey findings, and complaints. Adverse events are reported through electronic charting system and include pressure ulcerations. Performance indicators include quality reports, five start rating reports, trending form data, and continuous readiness rounding results. Survey Findings are useful to set a clear path from noncompliance to compliance and awareness. Survey data is received, a plan of correction put into place and tracking created to ensure we achieve improvement based on this feedback. Complaints it is the facilities goal to create an environment where complaints and be brought freely and problem solving an be undertaken withing our setting. when a complaint is made, the facility works closely with regulators to address concern when appropriate, provide any necessary data to support or refute quality issue, engage fully to correct concern, focus on systems toward improvement in quality, and follow concern to ensure correction and improvement will occur Performance improvement projects: A performance improvement project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide. It involves gathering information to clarify issues or problems and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. The facility conducts performance improvement projects based on a system focused approach and designed to address systems across the care and service areas provided. A PIP should lead to change and guide corrective actions within systems, across affected departments and groups, and impact the quality of life and quality of care for those in the resident community. When feedback is obtained which shows an area my qualify for improvement efforts the facility will take into consideration that concern and determine where to focus efforts. With input from leadership and stakeholders, the facility selects opportunity for improvement. In choosing a performance improvement project, the facility prioritizes focus areas based on high risk to resident or staff safety, high volume problem prone areas, poor quality outcome compared to bench marking. A project plan is intended to assist in focusing a project by setting the goals, scope, time frame, milestones, team roles, and responsibilities. The QA committee will chose a PIP team that is interdisciplinary involved in the processes or work to be improved, and lead by a qualified person who is able to direct the work. PIP progress is recorded in minutes of PIP meetings. Systematic analysis and systemic action.: identifying root cause is the first step in improving performance of a system failure. After identifying root causes, the facility seeks to implement changes and corrective actions that result in lasting improvements. Linking interventions to the root cause will be the most likely method to prevent further recurrence of the problem. To be effective, changes should target the elimination of mitigation of the root causes, offer long term solutions, and have a positive impact on other processes or systems. Interventions are to be achievable, objective and measurable. The facility may use the following models to guide discussion, thinking and processes towards identifying root cause: root cause analysis outlines, plan-do-study-act review. When appropriate, a pilot test of a broad change will be made, feedback obtained, and used to determine if the change is effective. When interventions are enacted, the ongoing response and measure of the effectiveness are to be included on the PIP document or in the format of minutes and assignments.

Based on observation, interview, and document review the facility failed to provide resident preference for positioning for 1 of 1 resident (R4) who was reviewed for pressure ulcers. Findings Include:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but is able if prompted or given times. R4 has unclear speech, with slurred or mumbled words. R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue, usually over bony prominences, caused by prolonged pressure, friction, or shear). R4's care plan titled bilateral heel and low back pain that does interfere with day-to-day activities and sleep dated 2/26/23, interventions included:-administer medications as ordered, monitor for effectiveness-if R4 should show or verbalize symptoms of pain, investigate cause and explore interventions to relieve discomfort-monitor for signs and symptoms of pain including facial grimacing, crying, or tearfulness, guarding, or posturing, or verbally stating pain or discomfort. During an observation on 3/31/26 at 9:28 a.m., R4 looked visibly uncomfortable, rocking back and forth, trying to move his feet, and slight grimace. During an observation on 3/31/26 at 10:18 a.m., R4 put on his call light. Nursing assistant (NA)-E responded to R4's call light. R4 asked NA-E to reposition his feet; NA-E stated his feet needed to stay where they are; did not reposition his feet per his request. NA-E told resident to sit back and relax, R4 stated he was uncomfortable. NA-E again told resident to lean back in his chair. R4 touched his legs and asked again to have his legs and feet repositioned. NA-E stated again his feet needed to stay where they were; refused his request for a position change. During an interview on 3/31/26 at 1:01 p.m., NA-E stated she did not remember refusing to assist R4 with a requested position change. NA-E stated R4 would be unable to reposition himself without assistance. NA-E stated it is important to assist R4 because he is unable to reposition himself and she wants him to be comfortable. During an interview on 3/31/26 at 1:07 p.mp, licensed practical nurse (LPN)-A stated R4 was unable to reposition himself; requiring assistance from facility staff. LPN-A stated a refusal to reposition him would be inappropriate; the resident request to reposition should be honored. LPN-A stated she would expect staff to assist him with repositioning if he requested it. LPN-A stated it is important R4 is comfortable, and his positioning preferences should be honored. During an interview on 3/31/26 at 1:20 p.m., registered nurse (RN)-D stated it was inappropriate for staff to refuse repositioning to R4. RN-D stated she would expect staff to reposition R4 upon his request. RN-D confirmed R4 needs assistance for all repositioning. RN-D stated it was important to honor R4's requested positioning and preferences. A facility policy titled Resident Rights and Guidelines for All Nursing Procedures dated 02/25, facility staff received training regarding resident freedom of choice. A facility policy titled Activities of Daily Living, supporting dated 02/25, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to carry out ADL's independently.

Based on interview and document review the facility failed to timely provide the required liability and appeal rights notices prior to discharge from Medicare Part A services for 1 of 3 residents (R40) reviewed for beneficiary notices.R40's last day of covered Medicare Part A Skilled Services was 3/4/26, as identified on the form CMS-20052 (SNF [skilled nursing facility] Beneficiary Protection Notification Review). The form also indicated the faciilty/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. Section 2 indicated the Notice of Medicare Non-Coverage (NOMNC, form CMS-10123) was not issues because Resident discharge immediately after LCD.R40's progress notes dated 2/26/26 recorded as a late entry on 3/2/26 indicated a last covered date from physical therapy on 3/2/26 and occupational therapy on 3/3/26 with R40 discharging home 3/4/26. On 3/3/26 the progress notes indicated R40's family will arrive on 3/4 to bring R40 home on discharge. On 3/4/26 progress notes indicated discharge paperwork was discussed with R40's family and R40 was discharged home. The progress notes do not indicate R40's POA received the required NOMNC. R40's physical therapy discharge summary signed 3/2/26 indicated R40 will continue to need stand by assist to ensure he has assistance with all mobility. Discharge instructions indicated R40's daughter understood R40 was a fall risk and will have 24 hour care. Discharge reason indicated therapist decision. R40's occupational therapy Discharge summary dated [DATE] indicated R40 will require continued 24 hour care with assist of family with all activities of daily living and safety with front wheeled walker transfers recommended to live with daughter . R40's Notice of Medicare Non-Coverage (NOMNC, form CMS-10123) was requested but not received. During an interview on 4/1/26 at 9:28 a.m., family member (FM)-A stated R40 was discharged from the facility due to preference and funding reasons. FM-A was unfamiliar with a NOMNC and questioned if the from was send in the mail from Medicare or from the facility. FM-A was not aware of the option to appeal Medicare coverage ending. During an interview on 4/1/26 at 9:55 a.m. the business office representative ([NAME]) stated when the facility knows a resident's LCD is approaching, they issue a NOMNC a couple days before. During a follow-up interview on 4/1/26 at 2:04 the [NAME] stated the facility did not issue the NOMNC due to R40 discharging home and there was confusion if the NOMNC need to be issued or not. The [NAME] stated the NOMNC should have been issued. A NOMNC policy was requested but not received.

Based on observation, interview and document review, the facility failed to obtain careplanned baseline side effect monitoring for 1 of 2 residents (R15) reviewed for antipsychotic medication use.Findings include: R15's face sheet indicated an admission date of 10/17/25. R15's quarterly Minimum Data Set (MDS) dated [DATE] indicated R15 was moderately cognitively impaired however could not complete the assessment. R15 also exhibited fluctuating disorganized thinking with daily behaviors not directed at others. The MDS also indicated R15 takes antipsychotic (medication used to treat mental health conditions), antianxiety, and antidepressants. R15's diagnoses included vascular dementia with moderate psychotic disturbances, psychotic disorder, and non-traumatic brain dysfunction.R15's medication administration record indicated R15 received olanzapine (antipsychotic medication) 5 milligrams (mg) every morning from admission [DATE]) until 10/19/25. From 10/20/25 until 11/5/25 R15 received Olanzapine 5 mg twice a day. From 11/5/25-1/20/26 R15 received olanzapine 10 mg twice a day. Starting 1/20/26 R15 received olanzapine 5 mg in the morning and 10 mg in the evening. R15's pharmacy review care plan dated 10/17/25 indicated R15 was receiving an antipsychotic medication and should have an assessment for tardive dyskinesia (abnormal involuntary movements) per physician.R15's medical record does not contain a baseline tardive dyskinesia assessment. During an interview on 4/1/26 at 12:05 p.m., the facility nursing manager, registered nurse (RN)-A, stated resident's who receive antipsychotic medications have abnormal involuntary movement scale (AIMS) assessment [an assessment done to measure symptoms of tardive dyskinesia] done on admission and every 6 months. RN-A confirmed R15 medical records did not indicate an AIMS assessment was done and confirmed R15 should have had a baseline AIMS assessment done upon admission. A policy titled Psychotropic Drug Use dated 2/2025 indicated baseline Tardive dyskinesia assessment will be completed with re-assessment every six months and as needed for antipsychotic medications.

Based on observation, interview, and document review the facility failed to monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 2 of 2 residents (R4, R24) reviewed for pressure ulcers. Findings include: R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue, usually over bony prominences, caused by prolonged pressure, friction, or shear). R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but is able if prompted or given times. R4 has unclear speech, with slurred or mumbled words. R4's care plan stated R4 is at risk for pressure injury related to poor nutrition, immobility, Braden score of 15, and unstageable pressure injury due to a deep tissue injury to right heel. Interventions included: -2/24/26: apply barrier ointment to right heel twice daily and allow to dry, left heel resolved/dry, apply ointment twice daily. Off-load heels when in bed. [NAME] boots on at all times. -1/21/26: apply barrier ointment to buttocks/ coccyx -12/22/25: Repositioning: turn and reposition every 2 hours when in bed (sign posted in room). Off-load heels when in bed. Up in wheelchair during the day repositioning when in chair every 2 hours. [NAME] boots on at all times R4's physician orders identified the following: -monitor right heel area of skin alteration for changes, if area appears larger in size or skin breaks open, notify charge nurse/nurse manager/hospice nurse, monitor and measure area with weekly skin checks until it is healed -apply barrier ointment to right heel twice per day, allow to dry. Left heel resolved/dry, apply barrier ointment twice per day. Off-load heels when in bed. [NAME] boots on at all times. R4 progress notes dated 3/23/26 at 12:47 p.m., right heel (central) unstageable deep tissue injury on the right heel measuring 0.5 cm x 0.5cm, depth unable to be measured. No exudate or odor present. Tissue is closed/resurfaced. Surrounding skin is pink, blanchable, and shows mild scaling. Wound base remains slightly discolored. No undermining, tunneling, or sinus tracts noted. During observation on 3/31/26 at 8:13 a.m., R4 was sitting in his Broda chair in the dining hall, R4 did not have the protective green boots on his lower extremities. During observation on 3/31/26 at 9:09 a.m., R4 was sitting in his Broda chair in his room, R4 did not have the protective green boots on his lower extremities. Protective green boots were sitting on R4's bed. During observation on 3/31/26 at 9:35 a.m., social services (SS)-B asked facility staff to assiste her with repositioning R4. Nursing assistant (NA)-E assisted with repositioning R4, the protective green boots were not applied. During observation on 3/31/26 at 10:18 a.m., R4 put on his call light to ask staff to reposition his lower legs. NA-E responded to R4's call light, R4 told her his legs were uncomfortable and asked to have them moved. NA-E declined to move his legs. NA-E instead brought resident down to activity; did not apply protective green boots. During observation on 3/31/26 at 10:24 a.m., licensed practical nurse (LPN)-A approached R4 to administer medication. LPN-A did not offer and/or apply protective green boots. During observation on 3/31/26 at 11:36 a.m., NA-E took R4 from the activity to the dining room for lunch; did not stop at R4's room to apply protective green boots. During an interview on 3/31/26 at 1:01 p.m., NA-E stated she was unsure if R4 was supposed to wear the protective green boots all the time. NA-E stated she could look at R4's care plans to find out. NA-E stated R4 had pressure ulcers on both heels but thinks they are both healed. During an interview on 3/31/26 at 1:07 p.m., LPN-A stated R4 had an unstageable pressure injury on both heels; stating they are both now healed. LPN-A stated he was supposed to have barrier cream applied twice per day every day and have protective green boots all the time. LPN-A confirmed she did not put his protective green boots on until after lunch today. LPN-A stated it was important for R4 to wear protective green boots all the time because his pressure injuries, while healed, are still very fragile and could worsen very quickly. During an interview on 3/31/26 at 1:20 p.m., registered nurse (RN)-D stated she was unsure what interventions R4 had in place; she would review his care plan if she had questions. RN-D stated R4 was care-planned to wear protective green boots all the time. RN-D stated R4 had provider orders to wear protective green boots all the time. RN-D stated R4 was non-ambulatory so he should have the protective green boots on all the time, regardless of being in the Broda chair or in bed. During an interview on 4/1/26 at 2:10 p.m., physician assistant (PA)-B stated she expected facility staff to implement all care-planned interventions; to include protective green boots. PA-B stated she expected facility staff to follow provider orders; to include protective green boots. PA-B stated R4 is non-ambulatory so he should have the protective green boots on all the time. PA-B stated the importance of protective green boots is to provide cushion to his fragile skin on both his ankles. PA-B stated he would be at risk of re-developing pressure ulcers on both his heels without the protective green boots. R24 R24's quarterly Minimum Data Set, dated [DATE] indicated R24 had moderate cognitive impairment, long and short-term memory problems, impaired decision making, and disorganized thinking. R24 also had no physical or verbal behaviors, wandering, or rejection of care. The MDS also indicated R24 required set up for eating, substantial assist for oral hygiene and was dependent on staff for other activities of daily living. R24 was at risk for pressure injuries an used pressure reducing devices to bed and chair. R24's care plan updated 3/26/26 indicated R24 was at risk for pressure injury due to impaired bed mobility, and bowel/bladder incontinence. Interventions included: pressure off-loading [NAME] on both feet in bed and no shoes until pressure injury is healed. R24's medication administration record indicated Offload heels while in bed, Use heel boots when they are available every shift starting 3/25/26 with no documentation of refusals. During observation on 3/30/26 at 1:14 p.m. and 4:35 p.m., R24 was seated in the wheelchair with heel boots on both feet. During observation on 3/31/26 at 1:02 p.m., R24 was lying on his right side in bed with a pillow behind his back. Heel boots were observed on the top shelf in R24's closet. During observation and interview at 1:04 p.m., registered nurse (RN)-B stated R24 is very picky and frequently refuses cares. RN-B confirmed R24 had a pressure injury to his left heel that is not open. Staff monitor the area and encourage off-loading of pressure. During observation, R24 was laying on his right side in bed sleeping with a small pillow under his right leg however his foot was touching the bed. R24's left leg was crossed over the right with the outside of his left foot touching the top of his right foot. RN-B stated staff keep R24's feet elevated and R24 refuses to wear the offloading boots. RN-B removed R24's socks. A raised blister-like area containing a tanish fluid was observed on the outside of R24's left heel. The raised area was hardened resembling a callous. RN-B removed and applied R24's socks twice. R24 slept through the procedure. RN-B placed the pillow under R24's right leg and R24's left leg naturally crossed over the right placing area of the blister in close contact to the top of R24's foot. RN-B confirmed it appeared the blistered area was in close contact to the top of R24's foot. RN-B covered R24 with blankets and did not attempt to apply heel boots. Heel boots observed on the top shelf of R24's closet. During an interview on 3/31/26 at 1:25 p.m., nursing assistant (NA)-A stated R24 gets overstimulated easily and prefers to keep to himself. R24 has a habit of refusing cares and staff frequently have to reapproach. NA-A stated R24 wears tubigrips (compression sleeves used to treat swelling) during the day and heel boots at night. NA-A stated R24 just started using the heel boots due to a sore on his foot and has never refused them to her knowledge. When asked if R24 wears the heel boots every time he is in bed or just at night, NA-A read R24's care plan and stated I'll have to go talk to the nurse to see if he needs them on now. During a follow-up interview on 3/31/26 at 2:40 p.m., NA-B stated R24 wears the heel boots all the time now. During an interview on 3/31/26 at 3:41 p.m., the infection preventionist/quality assurance nurse (IPQA) stated on 3/25/26 the charge nurse on duty sent an email informing of the pressure injury to R24's left heel. The next morning, the IPQA assessed the wound and found a surface-level hard calloused area that looked like a deep tissue injury. R24's care plan was updated to include not wearing shoes until area is healed and to wear heel boots every time R24 is laying down. During an interview on 3/31/26 at 3:54 p.m., facility case manager registered nurse (RN)-A stated R24 is not to wear shoes until the pressure injury is healed and should wear heel boots on both feet while in bed. RN-A confirmed NA-A had asked about the boots and confirmed R24 should have had them on when in bed. A facility policy titled Pressure Ulcer/Skin Breakdown dated 02/26, the purpose of this policy is to reduce or prevent the occurrence or worsening of pressure ulcers/skin breakdown and outline the provision of care designed to promote healing.

Based on observation, interview, and document review, the facility failed to follow manufacturer's instructions for safe operation of mechanical sit-to-stand lift and/or implement policies to ensure safety and supervision while attached to a sit-to-stand lift for 1 of 1 (R20) resident reviewed for lift safety.Findings include:R20's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R20 had no hearing impairment, speech is clear and intelligible, ability to understand others, and moderate cognitive impairment. Additionally, R20 was dependent on staff for toileting, dressing, and positioning from sitting to standing and chair to bed.R20's care plan dated 2/6/26 stated R20 has limited mobility with interventions including:-assist of 1 staff for transfers using EZ Stand (brand of sit-to-stand mechanical lift) for all transfers, XL harness, do not use leg strap per resident request-informed of risks vs. benefits, resident voiced understanding Additionally, R20's care plan dated 2/6/26 stated R20 was a risk for falling with interventions including:-assure he is in a safe position prior to assisting with EZ lift and that all safety measures regarding equipment are in place as directed-give R20 verbal reminders not to ambulate/transfer without assistanceR20's care plan dated 5/19/25 stated R20 had limited ability to toilet self with interventions included assist of 1 using EZ stand to commodeDuring an observation on 3/30/26 at 1:03 p.m., nursing assistant (NA)-F assisted R20 from his recliner chair to his commode using an EZ stand. NA-F did not disconnect R20's harness from the lift and exited the room. During an observation on 4/1/26 at 9:30 a.m., NA-A assisted R20 from his recliner chair to his commode using an EZ stand. NA-A did not disconnect R20's harness from the lift and exited the room. During an interview on 4/1/26 at 10:55 a.m., NA-A stated she did not think R20 had a safety assessment to remain attached to the EZ stand during toileting. NA-A stated it wasn't really an issue to leave him hooked up because he was probably safe. NA-A stated R20 had slipped out of the EZ stand previously during toileting. NA-A stated R20 was probably still safe to be left alone while still hooked up to the EZ stand. NA-A stated it might be a good idea to complete a safety assessment to make sure R20 would be safe to remain on the EZ stand during toileting.During an interview on 4/2/26 at 1:23 p.m., registered nurse (RN)-C stated generally residents should not be left on the EZ stand while on the commode or toilet. RN-C stated some residents prefer to leave the EZ stand hooked up and in front of them, so they have something to hold on toDuring an interview on 4/2/26 at 12:51 p.m., RN-D stated residents should not be left on the EZ stand unless directly visualized by staff. RN-D stated residents were at risk of injury if left in the EZ stand during toileting. The manual for the Drive EZ Sit to Stand lift indicated:How to transfer the Patient to the desired surface1.Have the wheelchair, bed or commode ready: If transfer the patient to a commode, position the patient over the commode.2. Press the (M1) DOWN button and lower the patient onto the desired surface.3. Lock the rear swivel casters of lift.4. Unhook the sling from all attachment points on the lift.5. Instruct the patient to lift their feet off the footplate.6. Remove the sling from around the patient.7. Pull the lift away from the wheelchair, bed or commode. A facility policy titled Fall Prevention date 10/22, fall assessments will be tailored to the specific risks identified. The risk factors will include fall history, review of medications, evaluation of factors that may predispose resident to falls, medical conditions, functional and psychological factors that may increase fall risk, environmental factors such as lighting and room layout, and modifiable fall risk factors and interventions. Additionally, fall prevention includes securing equipment, and providing a safe environment. curing equipment, and providing a safe environment.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R4) who was at risk for dehydration had hydration available and within reach.Findings include:Findings include:R4's diagnosis included Parkinson's (progressive neurological disorder leading to movement difficulties), dementia with Lewy bodies (buildup of proteins that lead to a decline in mental abilities, visual hallucinations, language difficulties, and impaired reasoning), pressure ulcer of right heal (injuries to skin and underlying tissue, usually over bony prominences, caused by prolonged pressure, friction, or shear).R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], resident has severe cognitive impairment, is dependent on facility staff for toileting, showering/bathing, dressing, personal hygiene, and position changes and transfers. R4 requires set up/clean up assistance with eating and oral hygiene. R4 is usually understood but has difficulty communicating some words or finishing thoughts but is able if prompted or given times. R4 has unclear speech, with slurred or mumbled words.R4's care plan dated 1/2/25, R4 is at risk for dehydration related to comorbidities, poor coordination, tremors, decreased fluid intake, interventions included:-avoid fluids with diuretic effect (coffee, tea, grapefruit juice)-keep fluids accessible-assist with fluids as needed-encourage fluids to 2000cc per day, offer variety of juices, gelatins, soups, popsicles-assess dehydration (dizziness, change in mental status, decreased urinary output, concentrated urine, poor skin turgor, dry cracked lips, dry mucus membranes, sunken eyes, constipation, fever During an observation on 03/31/26 at 9:09 a.m., R4 was sitting in his room directly in front of the television. R4's water pitcher was sitting on his side table next to the bed, not within his reach. During an observation on 3/31/26 9:35 a.m., social services (SS)-B entered R4's room for her scheduled visit. SS-B spent approximately 4 minutes with R4 and left the room. SS-B did not move R4's water within reach and did not offer him hydration.During an observation on 3/31/26 at 10:18 a.m., R4 put his call light on, nursing assistant (NA)-E answered the call light. NA-E told R4 she was taking him to the activity; she did not offer him any hydration before leaving his room.During an observation on 3/31/26 at 11:35 a.m., activity assistant (AA)-A returned R4 to his room after the activity. AA-A placed R4 in his room directly in front of the television. R4's water pitcher was sitting on his side table next to the bed, not within his reach. AA-A left R4's room as R4 asked her for root beer. AA-A did not address R4's request for hydration.During an observation on 3/31/26 at 11:41 a.m., NA-E entered R4's room and she told him she was taking him to the dining hall for lunch. R4 again asked for root beer; NA-E told him no and took him to the dining hall. During an observation on 3/31/26 at 12:57 p.m., R4 was sitting in his room directly in front of the television. R4's water pitcher was sitting on his side table next to the bed, not within his reach.During an interview on 3/31/26 at 1:07 p.m., licensed practical nurse (LPN)-A stated R4 cannot move within his room. LPN-A stated R4 needed his water within reach of his chair to be able to drink his water without assistance. During an interview on 3/31/26 at 1:20 p.m., registered nurse (RN)-D stated she was not familiar with the hydration care plan interventions in place for R4. RN-D confirmed R4 had a care plan intervention to keep fluids accessible. RN-D stated this means his hydration should be within arm's length regardless of where he is sitting. Additionally, RN-D stated R4 had a care plan intervention that staff should encourage fluids up to 2000cc per day. RN-D stated this means staff should be offering hydration to him anytime they are in his room. RN-D stated it is important to offer R4 hydration whenever interacting with him because he is at high risk of dehydration.A facility hydration policy was requested and not received.

Based on observation, interview and records review, the facility failed to ensure that a resident who is a trauma survivor received culturally competent, trauma-informed care by accounting for resident's preference for 1 of 1 resident (R2) reviewed for Trauma informed care.Findings include R2's quarterly Minimum Data Set (MDS) assessment, dated, 2/13/2026 indicated intact cognition, R2 needed substantial assistance with toileting, dressing and personal hygiene. R2's diagnoses include PTSD, anxiety disorder. R2's [NAME] Trauma Informed Care Assessment was completed on 1/08/2026, indicated yes to history of physical, verbal or sexual abuse. Triggers listed: time of the day, nightmares. Things that help cope: talk to staff, call someone, and get a hug or hand massage. Based on nursing assistant documentation and facility staffing record review, a male staff member provided personal cares for R2 on 3/20/2026, 3/28/2026 and 3/29/2026. During an interview on 03/30/2026 4:19 p.m., R2 stated she had requested no male staff members to provide assistance with activities of daily living due to a history of post-traumatic stress disorder, and that request had not consistently been honored. R2 had communicated her need for no male staff members because of her PTSD to social service designee (SD) and all staff members. R2 stated it is frustrating, they all know about my story, who else do I need to tell?. The other day, one guy walked in here while I was half naked to help me. R2 was teary eye by the end of the interview. During an interview on 3/31/2026 5:46 p.m., nursing assistant, (NA)-D, a male staff member, confirmed he had provided cares to R2 the previous week while he was aware of R2's request for no male staff member to provide personal cares. NA-D stated, when I went in the room, she did not ask me to leave so I did her cares. During an interview an 04/02/2026 3:20 p.m., NA- A, a female staff member, stated was told by R2 of the request of no male staff member provided personal care due to history of trauma. During an interview on 3/31/2026 2:07p.m., NA-C, a female staff member stated was aware of R2's request for no male staff member to provide personal cares due to history of trauma. NA- C stated had received the information from a nursing report and was also told by R2 due to the history of trauma. During an interview on 3/31/2026 2:09p.m., registered nurse (RN)-B, stated awareness of R2's request for no male staff member to provide personal cares due to history of trauma. RN-B was knowledgeable from communication with other staff members and was unsure if that intervention was identified in the care plan. During an interview on 04/02/2026 3:18 p.m., RN-C stated awareness of R2 request for no male staff member assistance with activities of daily living, and that intervention was not identified in the care plan. During an interview on 3/31/2026 2:30 p.m., registered nurse case manager, RN-A stated was aware of R2 's request for no male staff member to provide personal cares. RN- A reviewed R2's care plan and confirmed R2 's request for no male staff members was not on the care plan. RN-A stated, she had a rough go of things in the past, and I can see why she would request it. During an interview on 3/31/2026 2:39 P.m., SD confirmed, was aware of R2's trauma history since admission and completed the [NAME] Trauma Informed Care Assessment dated 1/08/2026. Facility policy titled Trauma Informed Care last revised 10/2022, next review 02/2026 states, in situations where a trauma survivor is reluctant to share their history, we are still responsible to try to identify triggers which may retraumatize the resident and develop a care plan intervention which minimize or eliminate the effect of trigger on the resident .

Based on observation, interview and record review, the facility failed to obtain routine dental services and dental services that were requested by 2 of 2 residents (R2, R25) reviewed for routine/emergency dental services.Findings include: R25's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated moderate cognitive impairment and diagnoses included, unspecified dementia without behavioral disturbance, Chronic cough, interstitial pulmonary disease (a group of disorder that causes inflammation and scarring of lung tissues). R25's physician orders included: Biotene Moisturizing Mouth (Saliva stimulant), take every hour as needed for dry mouth (dated 5/20/2025), Mechanical soft Diet, ground meat, low sodium (dated 12/1/2025), may crush medications dated (12/13/2023.) R25's oral cavity assessment dated [DATE] indicated R25 was seen 3 years ago by a dental care provider, had an upper partial, denture appliance in good condition, had some missing teeth, no referral necessary and only wanted to be seen if having a problem. R25 's Speech therapy treatment note dated 11/5/2025 indicated, R25 had loose fitting partials. R25's oral assessment dated [DATE] indicated, R25 was seen 3 years ago by a dental care provider, had an upper partial, denture appliance in good condition, had some missing teeth, no referral necessary, no referral necessary and only wanted to be seen if having a problem. Oral assessment did not identify loose partial. During an interview on 3/30/2026 at 3:13 p.m., R25 stated, had requested dental services due to his upper partial fitting loosely. They said, they will get it set and let my wife know at the last care conference meeting at end of February I think. During an interview registered nurse case manager, RN-(A) on 3/31/2026 11:31 a.m., registered nurse (RN) -A stated, R25 did request a dental appointment during the care conference in February. RN-A reported being in the process of contacting R25 's spouse to check on availability to take R25 to a dental appointment.R25 record review showed no documentation regarding dental appointment requests initiated or attempts made by RN-A to make a dental appointment for R25. During an observation on 4/1/2026 at 12:37 p.m., R25 wheeled self from the dining room toward his room, then stopped, turned his wheeled chair around and proceeded back toward the dining room. R25 was asked the reason for returning to the dining room and R25 stated I forgot my upper partial in there, I took it out to eat, it starts to float when you are trying to chew, and it is not comfortable. I think they are trying to set something up. R2 R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no oral concerns identified and diagnoses, included myotonic muscular dystrophy, chronic diastolic (congestive) heart failure, dry mouth, Gastro-esophageal reflux disease. R2's [NAME] Oral Cavity observation dated completed on 2/10/2026 identified no concerns. During an interview on 03/30/2026 12:52 p.m., R2 expressed the desire to be seen by a dentist due to sensitivity with hot, cold food and some missing teeth. R2 stated to have communicated the request to staff a while ago, last fall. During an interview on 03/31/2026 11:40 a.m., registered nurse, case manager RN-(A), confirmed the request made by R2 last fall, and stated to be working on getting an appointment/ referral set up for R2. RN-A stated, social service designee was also assisting with the process of scheduling a dental appointment for R2. During an interview on 3/31/2026 2:35p.m., SD stated, We were working on getting an appointment /referral set up for her, last fall. The facility policy titled: Dental Services, reviewed on 02/2025, indicates, Routine dental services means an annual inspection of oral cavity for signs of disease, diagnosis, of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedure.

Based on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 1 resident (R20) reviewed for enhanced barrier precautions (EBP), additionally the facility failed to ensure shared resident equipment was disinfected between uses, and the facility failed to ensure proper placement of a catheter bag for 1 of 1 resident (R11) reviewed for catheter use.Findings include: R20's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R20 had no hearing impairment, speech is clear and intelligible, ability to understand others, and moderate cognitive impairment. Additionally, R20 was dependent on staff for toileting, dressing, and positioning from sitting to standing and chair to bed.R20's care plan dated 2/6/26 stated R20 has limited mobility with interventions including:-assist of 1 staff for transfers using EZ Stand for all transfers, XL sling, do not use leg strap per resident request-informed of risks vs. benefits, resident voiced understandingAccording to the Center for Disease Control (CDC) R20 required additional personal protective equipment (PPE) requiring Enhanced Barrier Precaution (EBP) isolation. EBP are designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes; they require gown and glove use during high-contact resident care activities. High-contact resident care activities include dressing, bathing, toileting, hygiene, transfers, and bed making.During an observation on 3/30/26 at 1:26 p.m., nursing assistant (NA)-F approached R20's room to answer the light call. NA-F failed to apply the appropriate PPE prior to entering; R20's room door had an Enhanced Barrier Protection isolation sign posted. After entering, NA-F assisted R20 from his recliner chair to the commode via EZ stand; assisting him with removal of lower clothing and handed R20 an empty urinal once he was seated. NA-F left room once R20 was seated.During observation on 3/3026 at 1:28 p.m., NA-F returned to R20's room to assist him with transferring from commode to recliner chair. Prior to entering, NA-F failed to apply the appropriate PPE. Upon exiting NA-F did not disinfect the EZ Stand after use. NA-F placed the EZ stand back in the hall for next use.During observation on 3/30/26 at 1:38 p.m., NA-F came down the hall and grabbed the same EZ stand (that had not been disinfected) and took it to another room to use. The EZ stand was not disinfected prior to using it with second resident.During an interview on 3/30/26 at 1:35 p.m., NA-F stated she was unsure the reason R20 was in EBP. NA-F stated since the EBP sign was posted on the R20's door, she should have put the appropriate PPE on before entering. NA-F stated she should have disinfected the EZ stand after using it with R20. NA-F stated it is important to use the appropriate PPE to prevent the spring of infections from residents to residents. NA-F stated all equipment should be disinfected after use, again, to prevent the spread of infection.During observation on 4/2/26 at 10:43 a.m., NA-G and NA-B entered room [ROOM NUMBER] with a facility lift to assist resident with a transfer from chair to bed. NA-G exited the room with the facility lift, placed in hall outside room, did not disinfect lift after use. NA-B exited room, performed hand hygiene, and grabbed the same facility lift and took it down the hall to 131 to transfer resident from chair to bed, did not disinfect lift before using it with next resident.During observation on 4/2/26 at 11:01 a.m., NA-G and NA-B exited room [ROOM NUMBER], neither had disinfected lift prior to placing it in empty room [ROOM NUMBER].During an interview on 4/2/26 at 11:25 a.m., NA-B stated she should have disinfected the lift equipment after using it with the residents in room [ROOM NUMBER] and 131. NA-B stated all shared equipment should be disinfected after every use before placing it in the hall for re-use. NA-B stated disinfection of equipment is important, so you don't spread infection from resident to resident.During an interview on 4/2/26 at 11:32 a.m., NA-G stated she should have made sure to disinfect the lift equipment after they used it with the residents in room [ROOM NUMBER] and 131. NA-G stated it is important to disinfect lift equipment after every use to prevent the spread of infection. R11R11's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R11 was cognitively intact, dependent on staff for toileting, dressing, and position changes. R11 had a diagnosis of benign prostatic hyperplasia (BPH (enlarged prostate that compresses the urethra) with obstructive and reflux uropathy (urine backs up into bladder and kidneys causing damage) requiring a urinary catheter.During an observation and interview on 4/2/26 at 11:43 a.m., NA-G looked inside R11's room, NA-G stated R11's catheter bag should not be laying directly on the facility floor; the catheter bag should be inside a dignity bag or hung on the chair next to him. The catheter bag is not supposed to be on the floor because this could increase the risk of infection for the R11. During an interview on 4/2/25 at 12:51 p.m., registered nurse (RN)-D stated it is an expectation that all staff apply the proper PPE based on the door placard hanging on the resident door. RN-D stated staff must still apply PPE even if they think the resident has been removed from isolation precautions, if the door placard is still in place. The charge nurse or infection preventionist will remove the door placards when they are no longer needed. If the door placard is still in place on resident door, staff are required to continue the appropriate PPE. Additionally, it is a facility expectation that all shared equipment is disinfected after every use. RN-D stated catheter bags are not to be laying directly on the floor; catheter bags should be placed inside a dignity bag or hung on the chair or bed the resident is sitting on. RN-D stated catheter bags left directly on the floor increase the resident risk of infection.During an interview on 4/2/26 at 1:17 p.m., infection preventionist and quality assurance (IPQA) stated it is an expectation that staff apply the correct PPE based on the resident's door placard. IPQA stated the standard of practice is to wear the proper PPE until the placard has been removed by the charge nurse or herself. IPQA further stated, it is an expectation that all facility shared equipment is disinfected after every use before placing the equipment back in the hall for its next use. Additionally, IPQA stated all catheter bags should be placed in a dignity bag and hung on the chair the resident is seated in. IPQA stated the catheter bags should not be directly laying on the floor. IPQA stated the dignity bags are provided by the facility; and are used to prevent the spread of infection. A facility policy titled Enhanced Barrier Precautions (EBP) dated 10/25, EBP precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. EBP signage should be posted on the door or wall outside of the resident room. A facility policy titled Shared Equipment Sanitary Use dated 09/25, lifts and stands that are used must be cleaned with disinfectant before being taken for use outside of that room. A facility policy titled Catheter Care dated 11/25, infection control; be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and document review the facility failed monitor, comprehensively assess, and develop and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R4) reviewed for pressure ulcers. Findings include:R4's face sheet dated 12/19/25, identified diagnoses of dementia (a severe decline in mental abilities) and Parkinson's Disease (a progressive brain disorder leading to movement issues like tremors, stiffness, and slowness).R4's skin risk assessment with Braden (a healthcare tool for pressure ulcer risk) dated 9/8/25, identified R4 was not at risk for pressure ulcers.R4's Annual Minimum Data Set (MDS) dated [DATE], identified R4 received hospice services, needed maximum assistance for bed mobility/transfers, at risk for pressure ulcers, had one stage one pressure ulcer and had moderately impaired cognition.R4's pressure ulcer focus care plan dated 12/8/23, identified R4 was at risk for pressure injury related to poor nutrition, immobility, chairfast and had skin breakdown on heels and coccyx. Goal of R4's skin to remain intact. Corresponding interventions dated 12/8/23 included: -Air mattress to bed and cushion in Broda wheelchair to reduce pressure when lying or sitting.-Inspect skin with cares. Report and signs of skin breakdown (sore, tender, red, or broken areas) to charge nurse. Notify physician of problems. Lotion skin with cares. -Keep clean and dry as possible. -Weekly total body skin assessments to be performed and documented by charge nurse.-apply skin prep to both heels twice daily and allow to dry and bilateral heel protectors on when in bed. Initiated on 12/2/25. R4's skin alteration form dated 11/24/25, identified that R4 had non-blanchable redness on left heel and right buttocks. Left heel measured 2.5 x 1.0 and right buttocks measured 1.5 x 1.5; the report did not identify the unit of measurement nor any other wound characteristics. Intervention of boots to be ordered by hospice and always worn. Summary of investigation identified heels were being offloaded with pillow and boots to be ordered by hospice. R4's record did not identify documentation of offloading of pillow prior to identification of left heel redness on 11/24/25.Hospice situation, background, assessment, response (SBAR) note dated 11/24/25, identified left heel had non-blanchable bruising measuring 2.5 centimeters (cm) x 1.0 cm; large blister on right heel measuring 5.0 cm x 6.0 cm. R4's hospice note did not identify any other wound characteristics, however ordered skin barrier spray to both heels twice daily and heel boots on at all times. R4's Wound Management Detailed Report dated 11/24/25, identified R4's left heel had a purple bruise that measured 2.5 cm x 1.0 cm. R4's wound management report did not identify any other wound characteristics such as pain, surrounding skin, and drainage. The wound management detailed report did not include the intervention of heel boots that was identified in the skin alteration form and review of R4's care plan indicated the care plan was not revised to include the intervention until 12/2/25 (8 days after the wound was identified).R4's progress note dated 12/1/25, identified a hospice note due to a worsening right heel blister, with less fluid filled, purple in areas, less painful to R4. R4's Wound Management Detailed Report dated 12/4/25, identified left heel wound measured 8.0 cm x 2.0 cm and purple in color. Although the wound had increased from 2.5 cm x 1.0 cm the evaluation identified the wound was stable. R4's wound management report lacked a comprehensive wound assessment that included color, drainage, tissue type, odor, and pain and did not address pressure relieving interventions nor treatments being utilized. R4's progress note dated 12/10/25, indicated a new wound was found on R4's right heel that measured 7.5 x 3.5 (did not identify unit of measurement) and left heel was 4.0 x 2.0 (did not identify unit of measurement). Will order air mattress due to pressure wounds on heels. R4's record did identify a corresponding comprehensive wound assessment of either heel wound. During an interview on 12/19/25 at 11:21 a.m., registered nurse case manager (RN-CM) stated staff nurses are performing the comprehensive wound assessments for all wounds on a resident's scheduled bath day, however, the assessment are not reviewed to ensure the wounds are not worsening, the appropriate treatments/pressure relieving measures are being utilized.During an observation and interview on 12/19/25 at 1:05 p.m. R4 had green heel boots on both feet. RN-CM stated R4's right heel had an unstageable pressure ulcer that measured 3.5 cm x 7.0 cm, dry, covered in eschar (a thick, dark, leathery layer of dead tissue that forms over wounds), dark color, not blistery in appearance; R4's left heel was an unstageable pressure ulcer that measured 2.0 cm x 1.6 cm, dry, brown discolored, not really boggy but feels mushy over the wound, surrounding skin pink, no edema around it, skin intact with no pain. RN-CM could not articulate any further details of the description of right or left heel appearance. RN-CM R4's wounds were being treated with skin prep (a spray that creates a breathable protective film on the skin to shield it from friction) twice daily to both heels, heel protectors and an air mattress. R4's Wound Management Detailed Report dated 12/19/25 at 1:30 p.m. identified R4 had a pressure ulcer on left heel that was first identified on 11/24/25 as a bruise. Report identified area appears to be pressure ulcer not a bruise. Wound description of measurements of 1.6 cm c 2.0 cm with no depth, no exudate, no odor, stage identified as unstageable-slough and/or eschar, 50 % of necrotic tissue, surrounding skin pink/normal, skin is more brown than black and heel feels slightly mushy but not really boggy.During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R4's left heel that was identified on 11/24/25 did not have a comprehensive assessment, proper wound identification, nor weekly comprehensive assessment by a registered nurse to determine wound improvement/progression. During an interview on 12/19/25 at 1:48 p.m., physician assistant (PA) stated any resident that is determined to be a high risk for developing a pressure ulcer should have interventions in place to prevent the development of a pressure ulcer and any resident admitted to the nursing home without a pressure ulcer should not develop a pressure ulcer and if the resident is admitted with or develops a pressure ulcer that the pressure ulcer is managed to heal with interventions put in place by the facility.Review of the facility's Prevention of Pressure Ulcers/Injuries policy dated 2/25, indicated the following:Skin Inspection:-A head to toe skin inspection on all residents is completed weekly by a licensed nurse in alignment with bathing to identify any signs of developing pressure injuries, inspect pressure points, wash the skin after each episode of incontinence, moisture dry skin daily, and reposition resident as indicated on care plan.-A resident with a wound present a comprehensive wound assessment will be completed by a registered nurse weeklyPrevention:-Moisture: keep skin clean, dry, and free of exposure to urine and fecal matter.-Nutrition: use a screening tool to determine if resident is at risk for under nutrition. Skin inspection: -a head to toe skin inspection on all residents will be completed on admission, daily with cares, and weekly by licensed nurse in alignment with bathing. Residents with a wounds: -For those residents that have a wound present, a comprehensive wound assessment will be completed by a registered nurse weekly.

Based on interview and document review the facility failed to immediately respond to elopement when 1 of 1 resident (R1) activated an exit alarm and walked outside off the facility property without appropriate clothing for temperature of 1 degree/windchill of -7 degrees. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 1 of 3 residents (R8) reviewed for accidents.Findings include:R1's face sheet dated 12/18/25, identified diagnosis of mild cognitive impairment, chronic kidney disease (condition where kidneys have been damaged), and history of neoplasm (cancer) of the breast.R1's progress note dated 12/2/25, identified R1 had been admitted and had a history of wandering out of her home and nursing aware that if R1 needed to be admitted to the secured memory care unit this can be done. R1's elopement evaluation dated 12/2/25, identified R1was ambulatory, had a risk factor of being cognitively impaired, poor decision-making skills, displayed behaviors that may indicate an attempt to leave may be forthcoming. R1 was identified as an elopement risk, and an exit alarm was placed. R1's progress note dated 12/2/25, identified wander/elopement alarm applied to left ankle for safety.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had daily wandering behaviors, was independent for transfers and ambulation without the use of any mobility devices, had moderate cognitive impairment, and used a wander/elopement alarm daily.R1's vulnerable adult focus care plan dated 12/4/25, identified R1 was vulnerable due to admission, cognitive, and physical limitations, and required assistance to safety in the event of a harmful situation. Goal of resident assisted to safety in the event of a harmful situation. Interventions as followed: assist Resident to safety in the event of a harmful situation; Exit alarm bracelet applied to body due to safety concerns to alert staff of any attempt to exit building without assistance. Check twice daily for placement and functioning device. Change exit alarm bracelet every 80 to 90 days.R1's progress note dated 12/13/25 at 3:56 p.m., identified R1 left the facility out of the front door, alarm sounded, but stated patio door. R1 was up the block from the facility, when aide was searching for resident, R1 saw the aide, called her by name, and then walked back to the facility with staff. R1 was wearing sweatshirt and pants and no injuries observed. R1 was moved to secured unit upon return to the facility. According to Houston County (KMNEITZE3-weather station) the temperature on 12/13/25 at 3:00 p.m. had an actual temperature of 1 degree with a wind chill of -7 degrees. During a facility tour on 12/17/25 at 2:36 p.m., the front facility exit needed to pass through two doors to come out to a parking lot: the parking lot with a small decline towards the street with a curb at the end of the parking lot. The street running in front of the building to the left sloped downwards towards a field; the street running to the right of the parking lot had a steeper slope with a curve at the end that went uphill to another block; near the curve in the road there was a grocery store parking lot to the right and beyond the parking lot was a highly traveled highway; the sidewalk/street going up to the next block had a steep incline with a curb on the right side; the house in which R1 had been found was 3/4 way down the block and on the left side of the street which had concrete steps in the front of the house with 3 steps. R1's behavioral symptom focus care plan dated 12/16/25, identified R1 experienced wandering behavior, seeks out exit doors, was at risk for elopement. The corresponding intervention directed staff to assess resident for placement in a specifically designed therapeutic unit. During an interview on 12/17/25 at 11:37 a.m., nursing assistant (NA)-A stated she had been in the secured unit on 12/13/25. Around 3:00 p.m. she opened the unit door to go into the general population area; she heard the exit alarms sounding and saw licensed practical nurse (LPN)-A running in the hallway. LPN-A informed NA-A that the patio door exit alarm was sounding and that she believed R1 had went out that door. NA-A looked in the patio area for R1 but did not see her. NA-A then returned into the facility and observed LPN-A coming down the hallway and informed her R1 was on the street in the front of the building about a block away. NA-A went outside to get R1 but by the time NA-A went outside to that location, R1 was not there. NA-A then walked down the street to the left of the building where she saw a person walking on the street, however, when she got closer, she identified it was not R1. NA-A then went the opposite way and continued around the corner up the hill and still had not located R1. NA-A then began walking down the street and about 15 minutes after she began looking for R1, she observed R1 (in only a long sleeve shirt and pants) walking down some steps in front of a house. When R1 saw NA-A she called out NA-A's name and walked towards NA-A through the snow. NA-A stated R1's face was red, her hands were very cold, she then ambulated back to the facility with NA-A with no issue. During an interview on 12/17/25 at 12:19 p.m., licensed practical nurse (LPN)-A stated around 3:00 p.m. on 12/13/25, she heard an exit alarm sound, and immediately went to the alarm panel which identified it was the patio door by the dining room. LPN-A immediately ran to the patio door and did not observe R1 outside the area or notice any footprints in the snow. Nursing assistant (NA)-A arrived shortly after and went outside to look in the patio area first. LPN-A then went to the front door where she was able to see R1 standing about a block away near a tree on the road. LPN-A stated she did not attempt to go outside to bring R1 back into the facility because it was really cold out and I did not have a coat. Instead, she walked away from the window and door where she could visualize R1 to get another staff member to assist R1 back into the facility, however, when LPN-A returned to the window R1was not there. LPN-A stated after she had located a staff member to go outside, she went back to the same window however R1 was no longer standing where she was. Nursing assistant (NA)-A walked around outside to locate R1, found her coming down a stairway at a house on the next block up the hill and brought R1 back into the facility. LPN-A stated she assessed R1 for any injuries and did not observe any and she was just cold. LPN-A stated R1 was then placed in the secured unit after discussion with management for safety. During an interview on 12/17/25 at 12:36 p.m., trained medication aide (TMA)-A stated she had not received any education regarding prevention of elopement or what to do if a resident elopes, however, TMA-A stated if she observed a resident outside after an elopement, she would immediately go outside to attempt to get the resident back inside. During an interview on 12/17/25 at 12:50 p.m., director of nursing (DON) stated R1 had an exit alarm bracelet placed on admission because she was an elopement risk. R1 was independent in the facility and had a history of setting off the exit alarms due by getting close to the doors. DON further stated LPN-A should have exited the building immediately after locating R1on the street and brought her back into the facility. During an interview on 12/17/25 at 1:11 p.m., licensed social worker (LSW) stated after a resident elopement and the resident is located outside of the facility, staff would need to attempt to get the resident immediately and not take eyes off the resident. By taking eyes off of R1 this could have put R1 at risk for getting injured. During an interview on 12/17/25 at 2:55 p.m., NA-B stated R1 had a history of wandering throughout the facility and would go near the exit doors at times, but had not seen R1 attempt to exit the facility and if a resident had been observed outside after an elopement she would immediately go outside and attempt to get the resident back into the facility. Staff should not take eyes off of the person, because in the short time that they are not seen they could have the potential to get farther away and could get hurt. During an interview on 12/17/25 at 4:45 p.m., administrator stated that after an exit alarm goes off and a resident had been observed outside of the facility the staff member that observes the resident should have gone outside immediately to attempt to get the resident back to safety. LPN-A should not have been concerned about not having a coat on, because R1 also did not have a coat on, and it was so cold that day R1 went outside. Review of the facility's Wandering and Elopement Policy dated 2/25, identified the facility will work to ensure the safety of the residents under their care. The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Implementation:-If a resident is identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Strategies may include receiving a Wandergard (name brand for an exit alarm) bracelet; placing a resident in a room farther from exits and need for frequent monitoring; photos of the resident should be updated annually.Missing Resident: If a resident is missing initiate the elopement/missing resident emergency procedure.-staff will check with the charge nurse and check the leave of absence book to see if the resident signed out of the building.-If the resident is not authorized to leave the, initiate a search of the building and premises. This includes to check with all on-duty staff and identify when they were last seen, where they were last seen, and what were they wearing. Designate staff to check resident room and bathrooms, therapy areas, common areas, patio/courtyard, clinic area, kitchen, and immediate surrounding areas outside. R8's face sheet dated 12/19/25, identified diagnoses of malignant neoplasm (cancer) of the lung and brain. R8's admission Minimum Data Set (MDS) dated [DATE], identified R8 needed maximum assist for transfers and bed mobility, had a fall 2-6 months prior to entry and had moderate cognitive impairment.R8's fall risk assessment dated [DATE], identified R8 was at risk for falling due to impaired balance and needing assistance. R8's fall focus care plan dated 10/13/25, identified R8 was at risk for falling related to impaired mobility and balance. Interventions dated 10/13/25 were as followed: -assure resident is wearing eyeglasses and that they are clean and in good repair.- assure the floor is free of glare, liquids, foreign objects, provider proper, well-maintained footwear, encourage use of environmental devices such as hand grips, hand rails, etc.-give resident verbal reminders not to ambulate/transfer without assistance.-keep bed at proper height-monitor overall condition for underlying infection that could contribute to altered mental status, weakness, and overall increased risk for falling. -provide resident an environment free of clutter. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Encourage resident to assume a standing position slowly. Leave night light on in room. R8's fall investigation event dated 10/6/25 at 11:17 p.m., identified R8 had an unwitnessed fall in the bathroom. R8 stated she needed to go to the bathroom, self-transferred, became weak and fell to the floor. Root cause of the fall identified as confused/forgetful. Associated interventions directed staff to toilet at regular intervals, increase assistance and surveillance, increase in staff assistance as appropriate in the early morning, to and from toilet, during all transfers, during ambulation. Interdisciplinary team (IDT) review determined potential factors that contributed to the fall were increased weakness, new environment, forgetfulness. Intervention to be taken to prevent further falls were to remind resident to use call lights and 30-minute checks. Although the fall investigation event indicated potential causal factors of toileting needs, there was no comprehensive assessment to determine R1's toileting needs, no comprehensive assessment that identified how 30-minute checks were determined, and no indication R8's care was revised. R8's fall investigation event dated 10/20/25 at 8:43 p.m., identified R8 was found on the floor by bed and had attempted to get into bed without assistance. Root cause identified as mood/behavior. IDT review identified R8 not aware of limitations and an intervention of sign placed in room to remind to call for help and 15-minute checks at bedtime. There was no other information pertaining to why R8 was attempting to get out of bed and did not identify if the care plan had been followed prior to R8's fall. Although the fall investigation event indicated potential causal factors of R8 wanting to go to bed, this was not addressed in the care plan interventions. R8's care plan was revised on 10/22/25 to include 15-minute checks from 6:00 p.m. to 9:00 p.m., however, did not include sign placed in room to remind R8 to call for help. During an observation on 12/19/25 at 10:30 a.m., R8 was in her room, a sign was located near R8's head of her bed that read call for help. R8 stated she the sign helped her remember to ask for help, but at times she still forgets to ask for help. During an interview on 12/19/25 at 10:15 a.m., licensed practical nurse (LPN)-A stated staff document the 15-minute checks for R8 on paper and then it scanned into the electronic health record. LPN-A confirmed the care plan was not revised to include the sign prompting R1 to call for help but stated the sign was placed shortly after R8 fell on [DATE]; she could not articulate an exact date of when the sign was posted. R8's fall investigation event dated 10/25/25 at 8:27 a.m., identified R8 had an unwitnessed fall in her room. R8 stated she wanted to be toileted and could not locate her call light due to being on her right side when call light was on her left side. Root cause of fall was identified as toileting status/need. Interventions to provide staff assistance in the early a.m. and after meals; increase staff assistance as appropriate in the early morning to and from toilet, during all transfers and during ambulation; increase assistance and surveillance; remind resident to stay in bed and ask for assistance when in need of transfer. The fall investigation did not address if the care plan was followed prior to the fall. Although the fall investigation event indicated potential causal factors of call light placement and toileting needs, there was no comprehensive assessment to determine R1's toileting needs and no indication R8's care was revised. R8's fall investigation event dated 11/5/25 at 6:45 p.m., identified R8 was found on the floor in her room by the bathroom door. Cause of fall was identified as confusion/lack of remembering to call for help. Root cause of fall was not marked off. Interventions left blank. IDT review identified potential factors that could have contributed to the fall were cancer and chronic pain. Interventions added to place R8 on 30-minute checks with offer of bathroom use or transfer to bed at appropriate times. Although the fall investigation event indicated potential causal factors of toileting needs, there was no comprehensive assessment to determine R1's toileting needs and no indication R8's care was revised. R8's fall investigation event dated 11/10/25 at 6:45 p.m., identified R8 had an unwitnessed fall in her room near her bathroom. R8 was in her wheelchair and was attempting to get into bed with wheelchair brakes unlocked. Cause of fall were identified that R8 attempted self-transfer to bed from wheelchair, wheelchair brakes not locked, wearing regular socks without non-skid grippy material. Root cause of the fall was identified as physical function and footwear. Interventions of increase assistance and surveillance and reduce risk of injury (i.e., low bed, floor mat, nonslip socks, lower or remove side rails). Although the fall investigation event indicated potential causal factors toileting needs, wheelchair brakes not being locked and inappropriate footwear there was no indication R8's care plan was revised to include associated interventions. ----review your statement for accuracy R8's fall investigation report dated 11/29/25 at 2:45 a.m., identified R8 was found on the fall mat beside her bed on her left side. R8 stated she was attempting to get up to the bathroom. R8's fall prevention interventions on report of hourly rounding and signs visible from bed. There was no indication of a comprehensive analysis to identify causal factors and R8's care plan was not revised until 12/18/25 which was 19 days after the fall occurred. R8's fall investigation report dated 12/17/25 at 3:05 p.m., identified R8 was found sitting on the floor in her room. R8 stated she was attempting to plug in her cell phone and leaned forward to pick up her charger on the floor and slid out of the wheelchair. There was no indication of a comprehensive analysis to identify causal factors and no indication R8's care plan was revised. During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R8's falls had been looked at to attempt to do a deep dive of her falls, however, facility had only been looking at bits and pieces of the reasons R8 had been having repeat falls and not the whole picture to determine appropriate interventions were in place. Review of the facility's Falls and Fall Risk, Managing Policy dated 2/25, identified the facility will identify interventions related to resident's specific risks and causes to try and prevent the resident from falling and minimize the complications from falling.Resident centered approaches to managing falls and fall risk:-the staff with the input of the attending physician will implement a resident centered fall prevention plan to reduce the specific risks factors of falls for each resident at risk or with history of falls. -if a systemic evaluation of a residents fall risk identifies several possible interventions, the staff may choose to prioritize interventions.-if falling reoccurs despite initial interventions, staff will implement additional of different interventions or indicate why the current approach remains relevant. Monitoring Subsequent falls and fall risk:-the staff will monitor and document Each resident's response to interventions intended to reduce falling or the risk of falling.-If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved.-If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.-The staff and or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk of falling or injury due to falls.

Based on interview and document review the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours a day in a 24-hour period for one day between 11/1/25 through 12/18/25. This had the potential to affect all thirty-six residents residing in the facility. Findings include:Review of facility posted nurse staffing information and daily nurse staff posting from 11/1/25 through 12/18/25, identified the following:-On 12/13/25, the facility posted nurse staffing information indicated one RN was working the day shift, however, the daily schedule did not have evidence of a RN working eight consecutive hours in that 24-hour period. During an interview on 12/18/25 at 12:14 p.m., director of nursing (DON) stated the 12/13/25 facility posted nurse staffing had identified that RN was on the day shift for 8 hours, however, the nurse schedule identified that only licensed practical nurses were on the schedule during that 24 hour period and that the facility did not have RN coverage for the date of 12/13/25. Review of the facility's Nurse Staffing Hours policy dated 11/25, identified that that facility will post the total number of hours and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift, however, the policy did not identify the facility to have a RN coverage for eight consecutive hours in a 24-hour period.

Based on interview and document review the facility failed to immediately investigate injuries of unknown source according to the facility's abuse prohibition policy for 2 of 2 residents (R7, R6) reviewed for injuries of unknown origin.Findings include R7's face sheet dated 12/19/25, identified diagnoses of Alzheimer's disease (a progressive neurological disorder characterized by worsening memory loss) and Parkinson's disease (a progressive brain disorder leading to movement issues). R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was dependent for transfer and had moderate cognitive impairment.R7's progress note dated 11/21/25, indicated a bruise of unknown origin was found on R7's right breast and that R7 denied abuse. In review of R7's record and facility incident reports there was no other information pertaining to how or when R7 would have received the bruise to her breast nor was it evident staff interviews were completed. R6's face sheet dated 12/19/25, identified diagnoses of heart failure (a condition in which heart doesn't pump blood as well as it should), diabetes mellitus (a condition that affects how the body uses sugar as fuel), and atrial fibrillation (irregular heartbeat causing rapid, inefficient pumping). R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 was dependent with toileting hygiene/transfers and had intact cognition. R6's progress note dated 12/18/25 at 6:45 a.m., identified a dark black and blue bruise about the size of a half dollar noted to the right side of the rectum. R6 claimed it was from having a bowel movement the other day. R6 denied abuse and or pain. In review of R6's record and facility incident reports there was no other information pertaining to the bruise to R6's rectum nor staff interviews completed. During an interview on 12/18/25 at 2:30 p.m., director of nursing (DON) stated a bruise found on a breast or anal region of a resident would be considered suspicious for abuse and should have had an investigation begin immediately, however, an investigation was not initiated after R7 nor R6's bruises were discovered. Review of the facility's Abuse Potential/Vulnerable Adult/Quality Assurance Performance Improvement Policy dated 7/25, identified the following:Investigation Abuse Policy Requirements identified that it is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknow source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. All incidents will be investigated eve if not reportable and the results of the investigation will be documented. Procedure: The investigation is the process used to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to the administration. -Investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. Injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma.

Based on interview and document review, the facility failed to immediately report injuries of unknown origin to the administrator and failed to report to the State Agency (SA) within the required reporting guidelines for 2 of 2 residents (R7, R6) reviewed for an injury of unknown origin. Findings include:Based on interview and document review, the facility failed to immediately report injuries of unknown origin to the administrator and failed to report to the State Agency (SA) within the required reporting guidelines for 2 of 2 residents (R7, R6) reviewed for an injury of unknown origin. Findings include:R7's face sheet dated 12/19/25, identified diagnoses of Alzheimer's disease (a progressive neurological disorder characterized by worsening memory loss) and Parkinson's disease (a progressive brain disorder leading to movement issues). R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was dependent for transfer and had moderate cognitive impairment.R7's progress note dated 11/21/25, identified a bruise was found on R7's right breast of unknown origin and that R7 denied abuse. During an interview on 12/18/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated she had discovered R7's bruise on her right breast on 11/21/25 and was of an unknown origin, however, believed the bruise was from the sit to stand lift and because R7 denied being abused she did not report it to the administrator immediately, but had sent an email notification a few hours after it was discovered. During an interview on 12/18/25 at 2:30 p.m., director of nursing (DON) stated a bruise found on a breast of a resident would be considered suspicious for abuse and should have been reported to the SA within two hours. R7's bruise was not investigated nor reported to the SA. R6's face sheet dated 12/19/25, identified diagnoses of heart failure, diabetes mellitus, and atrial fibrillation. R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 was dependent with toileting hygiene/transfers and had intact cognition. R6's progress note dated 12/18/25 at 6:45 a.m., identified a dark black and blue bruise about the size of a half dollar noted to the right side of the rectum. R6 claimed it was from having a bowel movement the other day. R6 denied abuse and or pain. During an interview on 12/18/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated she identified a new bruise near R6's anal region at 6: 45 a.m., however, did not notify the director of nursing nor the administrator immediately of the findings. LPN-A stated a bruise located near the anal region would be considered suspicious, but believed since R6 believed the bruise came from having a bowel movement a few days earlier and said he had not been abused she waited to send an email at a later time to inform the administration of the bruise.Review of the facility's Abuse Potential/Vulnerable Adult/QAPI review policy dated 7/25, identified reporting and response Abuse policy requirements identified that is was the policy of the facility that allegations involving abuse no later than 2 hours after the allegation is made.

Based on interview and document review the facility failed to assure baseline line care plan for falls was continuously evaluated and updated to reflect interventions that were identified as a result of fall investigations for 1 of 2 resident (R2) reviewed for falls.Findings include:R2's face sheet dated 12/19/25, identified diagnoses of neurocognitive disorder with Lewy bodies (a progressive brain disorder causing decline in memory) and polyneuropathy (numbness, tingling or burning feeling in hands and feet). R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 was independent in bed mobility, needed supervision/touching assistance for transfers, had severe cognitive impairment, had fall in the last month prior to admission, had two falls since admission with no injury.R2's baseline care plan dated 12/4/25, identified R2 had been newly admitted to the facility and requires assistance from staff. Goal to be free from injury. Corresponding interventions as followed: call light or pendant should be within reach at all times, keep area clean and free from clutter; keep frequently used personal items close by and within reach; resident will be orientated to call light on admission to facility and may be issued a pendant for use in the facility if appropriate. R2's baseline care plan did not identify R2's level of risk for falling. R2's progress note dated 12/7/25 at 5:00 p.m., identified R2 fell in the dining area, due to not realizing he was weak and stood up from wheelchair with brakes not on. R2 was placed on one to one this shift for fall prevention. R2's Fall Investigation Event dated 12/7/25 at 5:19 p.m., identified R2 had a witnessed fall in the dining room after attempted self-transfer from wheelchair. Interventions to increase staff assistance as appropriate; R2 needs one to one supervision; assist to toilet, during all transfers, during ambulation/wheelchair. R2's baseline care plan had not been updated to reflect the fall prevention interventions that were added to the fall investigation event.R2's Fall Investigation Event dated 12/8/25 at 8:30 a.m., identified R2 had a witnessed fall in the dining room after attempting to stand up. Interventions to instruct resident to change positions slowly, increase staff assistance as appropriate in the early morning, to and from toilet, during all transfers, during ambulation.; increase in assistance and surveillance. R2's baseline care plan had not been updated to reflect the fall prevention interventions that had been added to the fall investigation event. During an interview on 12/19/25 at 12:15 p.m., director of nursing (DON) stated R2 was identified as a high fall risk on admission and at time of admission a baseline care plan was created in the electronic health record (EHR), however, did not identify R2's risk for falls nor appropriate fall prevention interventions to mitigate the risk for future falls. Review of the facility's Baseline Care Plan Policy dated 2/25, identified the baseline care plan is to be developed and implemented within 48 hours of admission to promote continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Implementation: -Upon admission the facility will begin the process of developing a baseline care plan will be completed within 48 hours of admission/readmission.-Information for the baseline care plan will be based upon admission/readmission orders, information from the transferring provider and discussion with the resident and resident representative. -The care plan will include at the minimum the following information: initial goals, physician orders, dietary orders, therapy services, social services, instructions needed to provide effective and person centered care that meets professional standards of quality of care, address resident health and safety concerns to prevent decline or injury such as elopement or fall risk.

Based on observation, interview, and document review the facility failed to ensure insulin was safely administered by following the rights of medication administration prior to administering insulin for 2 of 4 residents (R1 and R2). This resulted in an immediate jeopardy for R1 who required hospitalization for blood glucose monitoring and intravenous dextrose (sugar solution) to return to baseline, and a likelihood of serious harm for R2. The immediate jeopardy (IJ) began on [DATE] when licensed practical nurse (LPN)-A injected R1 with 40 units of rapid-acting insulin instead of the prescribed 40 units of long-acting insulin, resulting in R1 being sent to the emergency room (ER) for monitoring and treatment of severe hypoglycemia (low blood sugar). The administrator and interim director of nursing were notified of the IJ on [DATE] at 5:37 p.m., which was identified at the scope and severity of J, ISOLATED. The IJ was removed on [DATE] at 12:18 p.m., but non-compliance remained at the lower scope and severity of D, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R1R1's face sheet dated [DATE], identified diagnoses of diabetes and chronic kidney disease (a disease of the kidneys leading to failure). R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 received insulin injections and was cognitively intact. Review of R2's insulin physician orders from [DATE] to [DATE] were as follows:Start date of [DATE]: Aspart (rapid-acting) insulin, give per sliding scale (method for controlling blood sugar levels by adjusting insulin doses) before meals and at bedtime.Start date of [DATE]: Glargine (long-acting) insulin to give 40 units twice daily. R1's progress note dated [DATE] at 10:51 p.m., identified R1 had been given the wrong insulin. R1 was given 40 units of the fast acting instead of the prescribed 40 units of long-acting insulin. The ambulance was called and R1 had been given some carbohydrates. R1's blood sugar level was 117 milligrams/deciliter (mg/dl) when the ambulance arrived. R1's Safety Event-Medication Error report dated [DATE], identified R1 had been given 40 units of Aspart insulin rather than the ordered 40 units of glargine. R1 was given a snack and sent to ER via ambulance to hospital. Measures to prevent reoccurrence was noted for staff to double-check the medication administration record (MAR) with a second nurse for insulin orders. R1's progress note dated [DATE] at 11:34 p.m., identified the ER nurse called the facility and stated R1 was doing well. Their last blood sugar was about 90 mg/dl after administering glucose and sandwiches, and R1 would be coming back to the facility shortly. R1's progress note dated [DATE] at 3:34 a.m., identified the ER called and informed R1 was being admitted to the hospital due to their blood sugar dropping rapidly. R1's ER note dated [DATE], identified R1 arrived in the ER following an accidental injection of 40 units of rapid-acting insulin instead of the correct ordered 40 units of long-acting insulin. Emergency management services (EMS) reported R1's blood glucose taken 10 min prior to arrival in the ER had dropped from 117 mg/dl to 86 mg/dl. R1's Initial blood glucose taken in the ER at 9:04 p.m., was 59 mg/dl. R1 had to be given intravenous (IV) dextrose (sugar water). R1's blood sugar was taken again at 9:29 p.m It was 142 mg/dl. The ER physician's plan was to continue to monitor R1's glucose every 20 minutes for possible additional doses of dextrose. R1 had a large drop in persistently low glucose with symptoms of tremors and diaphoresis (sweating) and had to be given a second dose of IV dextrose. During this time R's blood glucose ranged from low 60's mg/dl to high 100's mg/dl. R1 was started on a continuous IV dextrose drip and staff checked R1's glucose regularly. At 12:44 a.m., R1 had a low blood glucose and had to be given a third dose of IV dextrose. R1's blood sugar at 2:00 a.m., was 97 mg/dl, but it continued to trend down to 72 mg/dl at 2:30 a.m Despite attempts to control R1's blood sugars by giving both IV dextrose and eating a meal, R1's blood sugar continued to drop. R1 subsequently became symptomatic for hypoglycemia. R1 was admitted to the hospital for blood glucose monitoring and laboratory (labs). R1's hospital Discharge summary dated [DATE], identified R1 had been seen in the ER on [DATE], after mistakenly being given 40 units of Aspart insulin rather than 40 units of glargine insulin and subsequently developed hypoglycemia. R1 had been kept in the ER additional time due to the half-life of Aspart. However, he had refractory hypoglycemia (low blood sugar that is prolonged and resistant to standard treatments) after this time period. Labs were drawn and identified R1 had an acute kidney injury due to poor oral intake and certain medications. R1 improved and was discharged back to skilled nursing facility. During an interview on [DATE] at 3:57 p.m., with the licensed practical nurse (LPN)-A stated on the evening of [DATE], she drew up R1's insulin. She had a trained medication aide (TMA) verify the units, however, noted she did not have the TMA verify in the MAR that the medication was correct. LPN-A then proceeded to administer the insulin to R1. When LPN-A was about to sign-off the insulin in the MAR, this is when LPN-A discovered the incorrect insulin had been given to R1. R1 was supposed to get 40 units of glargine. LPN-A had administered 40 units of Aspart instead. LPN-A proceeded to call an ambulance for R1 to send them to the ER for monitoring. LPN-A agreed she had not performed the proper rights of medication administration before administering the insulin to R1 and this is what caused the medication error. During an interview on [DATE] at 1:34 p.m., the IDON stated R1's medication error on [DATE], was considered a significant medication error. If LPN-A had followed the rights of medication administration, this kind of error would have not occurred. R1 could have died. During an interview on [DATE] at 2:46 p.m., the physician assistant (PA)-A stated R1's medication error of receiving 40 units of rapid-acting insulin versus the ordered 40 units of the long-acting insulin could have had a bad outcome for [R1]. For a resident that received this type of insulin when not ordered, it could cause severe hypoglycemia (low blood sugar) and a complication of death could be possible. PA-A stated her expectation for insulin/and or any medication administration would be for nursing to ensure all the correct checks are performed before a resident receives the medication to ensure they receive the correct medication and dose. During an interview on [DATE] at 3:33 p.m., the consulting pharmacist (RPh) stated when R1 received 40 units of rapid-acting insulin instead of the prescribed 40 units of long-acting insulin, this was a significant medication error because this type of insulin would have dropped R1's blood sugar rapidly. That error had the potential to cause serious injury or even death. The outcome could have bad for R1. During an interview on [DATE] at 1:11 p.m., R1 stated he was given the wrong insulin by mistake by LPN-A and had to be sent to the ER after it happened. I could have died from this kind of error, but very grateful I made it through it. R2R2's medication administration record (MAR), identified on [DATE] at 7:00 a.m., R2 had been administered four units of insulin lispro (fast-acting) insulin by LPN-B; however, the order read to hold the insulin if R2's blood sugar was less than 90 mg/dl. LPN-B and a trained medication aide (TMA)-A signed R2's order in the MAR as the double check the medication had been given appropriately and as ordered. Review of the [DATE], When is the best time to administer Humalog insulin article, located at https://www.drugs.com/medical-answers/best-time-administer-humalog-insulin-3560120/, identified Humalog should be injected within 15 minutes before eating a meal or immediately after eating a meal. Humalog is a rapid-acting insulin that is used to help control blood sugar in people with diabetes. Insulin is most commonly administered as a subcutaneous (under the skin) injection. Humalog is a brand name for insulin lispro, a rapid-acting insulin. R2's face sheet dated [DATE], identified diagnosis of diabetes mellitus. R2's Annual MDS dated [DATE], identified R2 received insulin injections and had moderate cognitive impairment. Review of R2's physician orders for blood sugar checks and insulin were as follows:Start date of [DATE]: check blood sugars t3 times per day and to notify physician next business day if less than 50 mg/dl or greater than 450 mg/dl. Special instruction to chart any symptoms/or lack of hypoglycemia if blood sugar is less than 80 mg/dl or blood and chart symptoms of hyperglycemia (high blood sugar level) if blood sugar above 300 mg/dl.Start date of [DATE]: Lispro (a rapid acting insulin) insulin give per sliding scale 3 times per day with meals.Start date of [DATE]: Lispro insulin give 4 units twice daily with meals and hold for blood sugar less than 90 mg/dl. Start date of [DATE]: Lispro insulin give seven units daily with noon meal-hold for blood sugar less than 90 mg/dl.Start date of [DATE]: Glargine (long-acting) insulin give seven units in the morning and twenty units in the evening.Two nurses or 1 nurse and a trained medication aide (TMA) were to check the medication and dose before administering. R2's vital signs (VS) documentation identified on [DATE] at 6:38 a.m., R2 had a blood sugar of 55 mg/dl. The VS documentation did not identify any further blood sugars were taken until 11:25 a.m. R2's progress notes or assessments data did not identify staff performed an assessment of potential or actual hypoglycemia symptoms, or if R2 had been given any carbohydrates. During an interview on [DATE] at 9:44 a.m., LPN-B identified on [DATE] she had obtained R2's blood sugar at 6:33 a.m., with a result of 55 mg/dl which was way too low for a diabetic person. LPN-B further stated she had not rechecked R2's blood sugar prior to administering R2's morning insulin, and stated R2's insulin was supposed to be held according to the order. LPN-B stated she had R2's insulin order verified by a TMA, prior to administering it to R2. During an interview on [DATE] at 11:31 a.m., R2 stated did not recall being told by the nurse that her blood sugar was low in the morning of [DATE] and she stated That is really low for me and she normally would eat something and/or have juice even if she was not having symptoms. During an interview on [DATE] at 1:34 p.m., the IDON stated on [DATE], R2's insulin order had been signed-off by LPN-B and a TMA-A for the 7:00 a.m. dose, even though the order was to hold if R2's blood sugar was less than 90 mg/dl. The IDON considered this a significant medication error that had the potential to cause serious hypoglycemia. When LPN-B took R2's blood sugar and it was 55 mg/dl, LPN-B should have followed the facilities hypoglycemia protocol. R2 should have been given carbohydrates, had her blood sugar rechecked and been closely monitored, and the physician notified. During interview [DATE] at 7:16 a.m., registered nurse (RN)-A stated she would take R1 and R2's blood sugar levels around 6:50 a.m. on the days she worked. She would document those levels in the VS documentation at that time. RN-A then records the results later when she administers insulin, around breakfast time at 8:00 a.m She does not recheck blood sugar levels prior to any administration at 8:00 a.m., nor does she document the time when the checks were performed in order to reflect actual times of the blood sugar levels taken. RN-A agreed blood sugar levels for a resident could drop in the time between the blood sugar was taken and the insulin being administered. This could put the residents at risk for hypoglycemia. During an interview on [DATE] at 3:33 p.m., the RPh stated a blood sugar of 55 mg/dl was significantly low and would indicate hypoglycemia. Rapid- acting insulins should be administered right after a blood sugar is checked and right before a meal. If the insulin had been administered based off the values that were obtained that far in advance (6:50 a.m.), that could result in severe hypoglycemia and/or unnecessary doses of insulin. During an interview on [DATE] at 10:04 a.m., the interim director of nursing (IDON) stated all blood sugars should be taken as close to mealtime and the actual insulin administration. The facility initially identified the root cause of R1's medication error to be the medication had not been identified correctly. The facility then began adding a second nurse or TMA to verify all insulin orders prior to administration. After the error of R2's insulin order being administered against physician order even with a second verification, s the root cause of the errors was the rights of medication administration were not being followed by staff. The IDON noted she was in the process of beginning education with all the licensed nursing staff immediately. The immediate jeopardy that began on [DATE] was removed on [DATE] when it was verified, the facility implemented the following:Reviewed policy and identified current policy met standards of practice.Facility will not use vials of insulin and will only use insulin pens.Rapid-acting insulin pens were marked with a red sticker to identify different type of insulinInsulin reference guides were attached to top of all medication carts.All like residents who received insulin had records reviewed to ensure they did not receive insulin in error.Education to all nursing staff was provided on the medication administration rights, standards of monitoring, and following physician orders with a return demonstration and quiz. Facility policy titled Insulin Administration dated 10/22, identified the purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Preparation included the following:Only appropriately licensed or certified personnel shall draw and administer insulin.Only the person who draws up the insulin for injection can inject it.The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician order.The nurse shall notify the director of nursing services and attending physician of any discrepancies, before giving the insulin.

Based on interview and document review the facility failed to ensure a comprehensive nutritional assessment was completed and further failed to identify, comprehensively assess and monitor for signs/symptoms of dehydration for 1 of 3 residents (R1) reviewed for change in condition. The facility's failures resulted in harm when R1 required a 3 day hospitalization for profound hypernatremia and hypovolemia. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of congestive heart failure, hypernatremia (a condition where there is too much sodium in the blood that can be caused by diarrhea and not drinking enough fluids) and hyperosmolality (a condition where the blood has a high concentration of salt, glucose and other substances which draws water out of the body's organs). R1 was always continent of bowel and bladder with no special diet. R1 received diuretics. R1's order summary dated 10/8/24, identified R1 had an order to receive torsemide 20 milligrams (mg) twice a day for heart failure. Additional orders to receive docusate sodium (emollient laxative that draws water and fat into your stool, making it softer and easier for stool to pass) give 100 mg twice a day for constipation. R1's Nutritional Therapy assessment dated [DATE] identified R1 was obese with no recent weight change, received a regular diet, used an adaptive divided plate with Dycem, mugs with lids and straws and built-up utensils. R1's food and fluid were adequate to meet estimated needs. Nutritional needs estimation did not identify how many calories, protein, or the amount of fluids R1 would need daily. R1's nutritional assessment did not identify R1 was on diuretics. R1's Bowel and Bladder Observation dated 10/11/24, identified R1 typically had a fluid intake of 501 to 1000 milliliters (ml)/daily. R1's discharge-return anticipated MDS assessment dated [DATE], identified R1 was frequently incontinent of bowel, received a mechanically altered diet and diuretics. Review of R1's record did not include a comprehensive assessment that identified R1's risk for dehydration, nor did the care plan address goals and interventions to prevent or mitigate R1's risk for dehydration related to (but not limited to) level of assistance, diuretic usage, change in diet to thickened liquids, and requiring assistance with eating. R1's care plan identified a problem dated 10/15/24, nutritional status potential for significant wight change and malnutrition. Intervention dated 11/11/24 to provide a pureed diet with nectar thickened liquids, provide feeding assistance when in an upright position in the wheelchair, not in the bed or recliner and complete oral cares after meals due to observed residue in mouth. An additional problem dated 10/30/24, R1 was limited in the ability to toilet self-related to immobility, weakness, and deconditioning, was frequently incontinent of bowel and bladder with a long-term goal to have a Bowel Movement (BM) every 3 days. Interventions included to monitor and record BM every shift and administer docusate sodium, Citrucel (bulk-forming laxative), and Miralax (osmotic laxative) per provider orders and to monitor the effectiveness of the medication. An additional intervention was to encourage fluids and reminder to drink fluids in between meals. R1's Vital report for fluid intake identified total fluid intakes each day for October and November 2024 however, in review of R1's record between 10/8/24 through 10/28/24, revealed the record did not include assessments/evaluations to ensure appropriate fluid balance and/or evident R1 was monitored for signs/symptoms of dehydration. Documented intakes included: 10/8/24: 200 ml 10/9/24: 960 ml 10/10/24: 840 ml 10/11/24: 990 ml 10/12/24: 650 ml 10/13/24: 420 ml R1's hospital discharge summary identified R1 was hospitalized from 10/13/24 at 5:25 p.m. to 10/16/24,and returned to the facility at 2:45 p.m. R1 was hospitalized for severe hypotension (when blood pressure drops dangerously low), acute respiratory failure with hypoxia (when your lungs suddenly fail to adequately oxygenate the blood leading to a dangerously low level of oxygen in the blood) due to a choking/aspiration event and was discharged with new diet orders for nectar thickened liquids and soft and bite sized diet. 10/16/24: 120 ml 10/17/24: 240 ml 10/18/24: 460 ml 10/19/24: 540 ml 10/20/24: 672 ml 10/21/24: 440 ml 10/22/24: 640 ml 10/23/23: 0 ml R1's hospital discharge summary identified R1 was hospitalized from 10/23/24 at 10:00 a.m. to 10/29/24 and returned to the facility at 1:00 p.m. R1 was hospitalized for profound hypernatremia and stupor secondary to poor oral intake and hypovolemia (a condition where the body loses too much fluid, such as blood or water which can lead to organ malfunction or failure), R1's torsemide was discontinued due to hypovolemia and may be restarted at a later date if needed. R1 will need to be offered water by staff every 4 to 6 hours, R1 may not ask for water so it needs to be offered. R1's Nutrition Reassessment dated [DATE] identified R1 received mechanical soft diet with thickened liquids. R1's current intake at meals was 50 to 74%. Food and fluid intake adequate to meet R1's needs was not identified and the assessment did not include an evaluation of R1's daily fluid consumption. R1's bowel and bladder record reviewed between 11/2/24 through 11/13/24 identified R1 had 17 large loose stools. R1's Vital report for fluid intake identified total fluid intakes each day for October and November 2024 however, in review of R1's record between 10/29/24 through 11/13/24, revealed the record did not include assessments/evaluations to ensure appropriate fluid volume balance and/or evident R1 was monitored for signs/symptoms of dehydration. Additionally, the record did not include documentation R1 was offered fluids every 4-6 hours per the hospital discharge summary dated 10/29/24. Documented intakes included: 10/29/24: 0 ml 10/30/24: 1,150 ml 10/31/24: 300 ml 11/1/24: 240 ml 11/2/24: 950 ml 11/3/24: 0 ml 11/4/24: 0 ml 11/5/24: 320 ml 11/6/24: 520 ml 11/7/24: 605 ml 11/8/24: 0 ml 11/9/24: 350 ml 11/10/24: 320 ml 11/11/24: 0 ml 11/12/24: 580 ml 11/13/24: 560 ml R1's Speech therapy (ST) Evaluation and Plan of treatment dated 11/11/24 identified R1 had a diagnosis of dysphagia (difficulty swallowing) required assist with eating and recommendations were to receive nectar thickened liquids with pureed consistencies. During a phone interview on 11/26/24 at 2:02 p.m., family member (FM)-A identified she was R1's guardian. FM-A indicated R1 had previously lived in a group home and had gotten COVID and had four hospitalization s since 9/25/24. FM-A stated the first and second time R1 had problems with her breathing, the third time she had high sodium levels and stated she didn't think R1 was getting enough to drink. FM-A stated after one of R1's hospitalization s she had to be on thickened liquids and didn't think the staff were offering the fluids like they should have been and R1 needed help with drinking fluids. During an interview on 11/26/24 at 4:26 p.m., nursing assistant (NA)-A identified R1 had a pureed diet and thickened liquids and needed assist with eating. NA-A stated she was not aware that fluids needed to be encouraged with R1 until the day she passed away on 11/13/24. NA-A stated the kitchen staff would pick up R1's lunch trays and document the fluids given. NA-A further stated R1 typically did not drink her fluids well. During an interview on 11/27/24 at 9:30 a.m., NA-B indicated R1 was on pureed foods and thickened liquids and stated R1 typically didn't eat much preferred desserts but would drink. NA-B stated initially R1 did not like thickened liquids but once we explained why she had to have thickened she would drink, she liked the thickened juice. During an interview on 11/27/24 at 1:51 p.m. licensed practical nurse (LPN)-B indicated low fluid intake along with loose stools can lead to dehydration and an electrolyte imbalance. LPN-B stated R1 was not drinking enough and was having several loose stools which can lead to dehydration. LPN-B stated she was unsure they had a system in place to monitor fluid intake unless a resident was on a fluid restriction. LPN-B indicated R1 was not being monitored for dehydration. During an interview on 11/27/24 at 12:54 p.m., LPN-A stated R1's care plan did not identify R1 was at risk for dehydration and did not identify the amount of fluids R1 would need daily to prevent dehydration. LPN-A indicated from 11/3/24 to 11/10/24, R1 received less than 600 ml of fluids daily and and 15 large loose stools would place R1 at risk for dehydration. During an interview on 11/27/24 at 1:44 p.m., dietary aide (DA)-A stated the nursing staff are responsible to document flood and fluid intake for their residents. On unit 2 the kitchen staff are responsible to document the food and fluid intake in the resident medical record. The residents who ate in their rooms, dietary would pick up the resident trays and document how much they ate based on what was left on their tray. During an interview on 11/27/24 at 1:15 p.m., dietary manager (DM)-A stated R1's admission nutritional assessment was not comprehensive and did not include R1 was administered diuretic medications, also did not identify the amount of calories and fluids R1 would need daily. DM-A stated she would start getting worried if a resident was not drinking 400 ml per meal. DM-A explained from 11/3/24 to 11/13/24, R1's fluid intake was less than 600 ml daily along with over 15 loose stools during that time, she would worry about dehydration. DM-A was unsure if R1's intakes were being monitored or who would be responsible for that. During a phone interview on 12/2/24 at 12:10 p.m., registered dietician (RD)-A stated a nutritional assessment was completed on all residents upon admit, with significant changes and annually. RD-A stated she did not comprehensively assess R1 for the amount of fluid intake she would need daily and did not develop a care plan for R1's risk for dehydration. RD-A stated typically the average resident would need 1500 ml per day to stay hydrated and verified that R1 was receiving less than 600 ml daily for 10 days prior to R1's death along with over 15 large loose stools. RD verified R1 was admitted with torsemide and taking this medication would put R1 at risk for dehydration and then was hospitalized from 10/23/24 to 10/29/24 for severe hypernatremia and was receiving thickened liquids due to difficulty swallowing, these factors put her at higher risk for dehydration. RD-A stated R1's body was losing fluids faster than she could take in and stated R1 should have been monitored for dehydration. During an interview on 11/27/24 at 2:03 p.m., interim director of nursing (IDON) indicated the facility did not currently have a system in place to monitor residents for fluid intake unless a resident was on a fluid restriction. IDON indicated R1's fluid intake was less than 600 ml daily for about 10 days along with over 15 large loose stools which had a high potential to lead to dehydration, the provider should have been notified right away. During a phone interview on 12/2/24 at 2:18 p.m., physician assistant (PA)-A stated any resident who had loose stools, bowel medications should be held, if loose stools continue for two days the provider should be notified to address this. PA-A further stated in conjunction with R1's lack of fluids and chronic loose stools could lead to dehydration which can cause hypernatremia, which is a condition where the level of sodium in the blood is too high. PA-A stated R1 would be at high risk for dehydration with low fluid intake, loose stools and recent history of hypernatremia, facility should be closely monitoring residents like this a reporting it to the provider. Facility policy Dehydration Nutrition Interventions dated 9/2024, included Individuals at risk for dehydration will be identified and provided with sufficient fluid intake to maintain proper hydration and health. Implementation: Each individual will receive sufficient amounts of fluid based on individual need and personal preference to prevent dehydration and maintain health. 1. Risk factors for and/or clinical signs of dehydration will be identified through routine nursing assessments. 2. Adequate fluids should be offered based on a comprehensive nutrition assessment of factors affecting fluid needs and fluid intakes. 3. Fluids should be provided based on each individual's beverage preferences and physician's orders for fluid consistency. 4. If fluids intake is not adequate to meet needs, an IV or enteral feeding tube may be recommended. Facility policy Encouraging and Restricting Fluids dated 7/2024 included: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy directed staff on the protocol to encourage fluids and documentation requirements. The documentation requirements directed staff to record any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin Further directing staff to notify the supervisor if the resident refuses. Facility policy Comprehensive Medical Nutrition Therapy assessment dated ,d+[DATE] included The RDN will complete a comprehensive medical nutrition therapy assessment for each individual that is referred or identified. The purpose of nutrition assessment is to obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance.

Based on interview and document review the facility failed to identify and implement physician orders for a therapeutic textured diet with interventions for safe swallowing for 1 of 3 residents (R1) who received the wrong textured diet for seventeen days, resulting in hospitalization with aspiration pneumonia, lung abscess, sepsis, and hospice care for one of one resident (R1). The immediate jeopardy (IJ) began on 5/1/23, when R1 had a provider visit and R1 was diagnosed with dysphagia and required a pureed diet with thickened liquids, the order was not acknowledged or implemented by the facility resulting in R1's transfer to emergency room (ER) and hospitalization from [DATE] to 5/16/23. The administrator and director of nursing (DON) were notified of the IJ on 5/24/23, at 4:47 p.m. The immediacy was removed on 5/25/23, at 11:30 a.m. but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's hospital,Speech Pathology Inpatient Evaluation, dated 4/19/23, identified R1 was referred for a bedside swallow evaluation nursing requested due to poor oral intake. The evaluation identified R1 had four trials given for thin liquids, one trial of bite size solids and easy to chew solids; R1 had delayed throat clearing, change in vital signs, and wet vocal quality. Suspect pharyngeal stasis (residue in the throat after swallowing) and suspected delayed initiation of swallow. After three trials of pureed food and mildly thicken liquids resulting in normal limited speech therapy recommendations were mildly thick liquids, pureed foods, crush medications with puree, upright with all oral intake and remain upright for 30 - 60 minutes after meals, eat/feed slowly, small bites/sips, nursing to provide assistance as needed. Plan: A Video fluoroscopic Swallow Study (VFSS) will need to be performed prior to diet consistency upgrades to rule out aspiration or if a decline in swallowing status observed by medical staff. R1's admission provider visit dated 4/25/23, indicated R1 was admitted to the facility for rehab following a hospitalization with a right sided pleural effusion that was thought to be secondary to an autoimmune disease. The visit note did not address R1's diagnoses of dysphagia or diet texture recommendations from her hospitalization and not evident the facility identified or provided R1 required a textured therapeutic diet upon admission to the facility. R1's physician order dated 4/24/23, included regular carb-controlled diet. Further clarified to include low sodium according to the Dietary Communication Order dated 4/25/23. R1's admission, Minimum Data Set (MDS), dated [DATE], identified R1 had diagnoses of downs syndrome, acute respiratory failure with hypoxemia (lower than normal oxygen levels) and gastroesophageal reflux disease (GERD). R1 had severe cognitive impairment and required supervision with eating. MDS identified R1 did not have any issues with swallowing/choking and did not identify R1's diagnosis of dysphagia. R1's physician visit dated 5/1/23, indicated during R1's hospital stay from 4/12/23 to 4/24/23, R1 had a speech therapy eval completed to rule out aspiration. Evaluation included findings of moderate oral pharyngeal dysphagia. Recommendations included level 2 mildly thickened liquids and level 4 pureed solids. Meds should be taken crushed with pureed foods. Remain upright as possible for all oral intake and remain upright for 30-60 minutes after meals, eat slowly, and take small bites and sips. Good potential for rehab and SLP (speech language pathologist) re-evaluation can be completed to see if we can advance diet if R1 continues to do well. In review of R1's physician orders, progress notes, and dietary documentation after the physician acknowledged R1's dysphagia diagnosis, dietary requirements for pureed diet, and interventions were transcribed into the facilities EMR (electronic medical record). Between 5/1/23 to 5/11/23, R1 did not receive the correct diet nor safe swallowing interventions to prevent or mitigate risk of aspiration according to the 5/1/23 physician visit note. During an interview on 5/24/23, at 12:55 p.m. the director of nursing (DON) was not aware R1 had a diagnosis of dysphagia nor the orders that had been identified in the 5/1/23 physician visit note. When R1 was admitted , the hospital discharge paperwork did not identify R1's diagnosis of dysphagia or include R1's speech evaluation and recommendations. DON stated I didn't know anything about it [5/1/23 physician acknowledgement of dysphagia diagnoses and textured diet order] until you [surveyor] brought it to my attention. DON explained the charge nurse would usually bring the residents visit notes/orders back for her to look at. DON was not sure what happened with R1's 5/1/23, visit or who reviewed it. R1's progress notes dated 5/11/23, at 6:45 a.m. indicated R1 was having diarrhea and nausea. At 11:30 p.m. R1's entire bed was wet from perspiration. R1's blood sugar was elevated, the physician was notified with orders to give insulin. At 11:36 p.m. R1 began to complain of chest pain and stated, my heart hurts. Family and physician notified and R1 was sent to the emergency department. R1's hospital palliative care visit note dated 5/12/23, identified visit diagnosis as abscess of lung with sepsis. R1 had a large right lung abscess that had not responded to antibiotics nor intervention, had progressed, and was very high risk for a surgical candidate. Shared concerns with family members that R1 was nearing the end of life and could not tolerate any aggressive treatments. Family was supportive of hospice. R1's after visit summary (AVS) dated 5/16/23, indicated R1 had a hospitalization from [DATE] to 5/16/23, with diagnoses of right lung abscess with aspiration pneumonia with a fluid collection measuring 7.4 centimeters (cm) x 4.3 cm x 5.5 cm. R1 was placed on end-of-life comfort cares. R1's Dietary Communication Order dated 5/16/23, included pureed diet with nectar thickened liquids. During an interview on 5/24/23, at 10:09 a.m. cook (C)-A, confirmed through documentation that R1 was on a low sodium diet with regular texture when she was first admitted . R1 did not receive pureed diet until 5/16/23, according to our kitchen records During an interview on 5/24/23, at 9:44 a.m. nursing assistant (NA)-A stated when R1 first got here she was a on a regular diet, then she went to the hospital, and currently on a pureed diet with thickened liquids. During an interview on 5/24/23, at 9:46 a.m. NA-B stated when R1 first got here she was a on a regular diet, then one day she was weak and shaky. R1 was sent to the hospital, she was diagnosed with aspiration pneumonia. When R1 returned from the hospital she was on hospice and needed a pureed diet with thickened liquids. During an interview on 5/24/23, at 9:48 a.m. NA-C stated when R1 first got here she was a on a regular diet, then she got aspiration pneumonia and went to the hospital. R1 came back from the hospital on hospice and was on pureed diet. During an interview 5/24/23, at 12:35 p.m. licensed practical nurse (LPN)-A indicated when we have new admissions the case manager reviews all of the admission paperwork and enters the orders into the EHR. The floor nurses were responsible for the assessments. Following a physician visit/appointment, a nurse needed to go through the visit notes and transcribe the orders and any care plan changes into EHR (electronic health record). LPN-A was not aware why R1's orders for pureed diet and thickened liquids were missed from the 5/1/23 appointment. During an interview on 5/24/23, at 12:46 p.m. speech therapist (ST)-A, stated she never received referral for R1 upon her initial admitted . ST-A stated if textured diets were not followed, it could result in aspiration pneumonia which could lead to sepsis and death. Aspiration can occur when pharyngeal (throat) secretions, food, or gastric (stomach) secretions enter the larynx (tube that leads to the lungs) and trachea and can descend into the lungs, having a diagnosis of GERD can play a role in this as well increasing the risk of aspiration. When the secretions are trapped in the lungs bacteria starts to form which leads to pneumonia. Silent aspiration happens when the cough reflex is not present. During an interview on 5/24/23 at 3:53 p.m. DON confirmed R1 should have been on a pureed diet and thickened liquid diet on her admitted [DATE]. DON acknowledged R1 started declining on 5/11/23, was sent to the ER and was hospitalized for aspiration pneumonia with sepsis and returned to the facility with hospice 5/16/23, as a result of further decline related to aspiration pneumonia. Facility policy, undated, National Dysphagia Level 1: Pureed Nutritional Therapy, indicated this diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close to complete supervision and alternate feeding methods may be required. Facility policy, Physician services, revised 10/2022, indicated the medical care of each resident is under the supervision of a Licensed physician. Physician visits the physician will review the residents total program of care, including medications and treatments at each visit. Facility policy, Nursing admission/Readmission Policy and Guidelines, revised 10/2022, indicated 4. Assure the facility receives appropriate medical records prior to or upon the resident admission. Preadmission/Preadmission: 1. Prior to the admission or readmission, the referring entity and/or attending physician must provide the facility with information related to the immediate care of the resident. An interdisciplinary discussion will occur in the facility involving no less than the social security designee (SSD) and nursing leadership team, but may include the medical director, pharmacy, or any other appropriate entity to best decide if the facility can safely and effectively meet the needs of the potential admission based on the information received. If needed a nurse-to-nurse call may be made to assist in the decision to take the individual as a resident of the facility. The immediate jeopardy that began on 5/1/23, was removed on 5/25/23, when it was verified, the facility implemented the following: -identified residents at risk for aspiration to ensure appropriate diets were given -reviewed physician visit notes for any missed orders for textured diets -Review and revised policies and procedures -Reviewed/revised care plans as appropriate -Educated all nursing staff on reading physician visits and transcribing orders from provider visits

Based on observation, interview and document review, the facility failed to completely inform 1 of 1 residents (R18) of their medical condition. This resulted in actual psychosocial harm for R18, when R18 had been erroneously informed he had a terminal diagnosis, and 2-3 weeks to live, without a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R18's admission Minimum Data Set (MDS) dated [DATE], identified R18 was cognitively intact, did not exhibit behavioral symptoms or depression, was considered medically complex with problems including [CONDITION(S)], concerns related clotting disorder, end-stage-kidney disease requiring hemodialysis, and diabetes mellitus among other diagnosis. R18 did not have a pressure ulcer at that time, and the MDS did not indicate R18 had a terminal condition. R18's medical provider's note dated 3/18/22, written by a physician's assistant (PA)-A, included, R18 had been admitted to the facility following hospitalization due to concerns of a stroke and was found to have several blood clots in veins but not a stroke. R18 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 had been active since admission to the facility, going to [CONDITION(S)], but also on outings with family and friends, and R18 was hoping to discharge back to his home soon. PA-A recommended R18 decrease his outings and spend more time in therapy in order to meet his goal of returning home. The note did not indicate R18 had a wound at that time, nor did it indicate R18 was in a terminal condition. R18's medical provider's note dated 4/6/22, written by a medical doctor (MD)-A, identified R18 was on [CONDITION(S)] for [CONDITION(S)] and receiving physical therapy for strengthening. R18 had diabetic [CONDITION(S)] associated with type 2 diabetes mellitus (kidney damage from diabetes). R18 had been admitted to the facility for generalized weakness, but was improving and the plan was to discharge home. There was no mention of skin problems, or anything to indicate R18 was in a terminal condition. R18's medical providers noted dated 4/12/22, written by PA-A, identified R18 had developed a skin lesion on the right inner gluteal cleft of his buttocks, and some superficial skin breakdown of the gluteal cleft. PA-A wrote the lesion was not open, but was indurated (hard swelling) and approximately 2 cm in length by 0.5 cm in width. A very small opening was noted, but PA-A was unsure if this was related. At that time there was no warmth or redness and no drainage and PA-A indicated this area might be a cyst, and warm packs were ordered to be applied three times per day. PA-A indicated R18 should be seen at the clinic for evaluation if his condition worsened. A Telephone Encounter note dated 4/18/22 indicated PA-A had received communication from the facility that R18's wound had some spreading redness and an open area. PA-A provided an order to start [MEDICATION(S)] (antibiotic) 100 mg two times per day and [MEDICATION(S)]/[MEDICATION(S)] (antibiotic) 800-160 mg once daily in the evenings. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's medical provider's note dated 4/19/21, written by PA-A indicated R18 was complaining of pain in the gluteal lesion, and PA-A remarked there was the possibility that R18 had developed an abscess. The note indicated PA-A discussed the case with MD-A and the decision was made to incise the wound and drain the cite which was then accomplished. Treatment orders were provided. On 4/19/22, 2:20 p.m. a registered nurse (RN)-A sent an email to a contracted wound care nurse, RN-E, with a picture of R18's wound, asking for an opinion on the wound and the treatment decisions. RN-E replied at 4:09 p.m. he was in agreement with the treatment plan. On 4/21/22, at 10:09 a.m. RN-A sent another email to RN-E (with a copy to PA-A and MD-A) with an updated picture of R18's wound, but with no other information about the wound. RN-A wrote, he is declining so I thought maybe a Kennedy ulcer? [A Kennedy Terminal Ulcer is a skin wound that appears in some people during their final weeks of life, it is a failure of skin as an organ as the organs shut down] A reply from RN-E came at 10:21 a.m. and said, I guess it's a terminal ulcer. No further emails were provided and no indication that PA-A or MD-A had acknowledged receipt or replied to the email correspondence. R18's progress note dated 4/21/22, at 3:39 p.m. included, R [right] buttock has deteriorated within the last week. Now measures approximately 5 cm long by 3 cm wide There is a hole due to I&D [incision and drainage] on Tuesday, the hole opening measures 0.5 cm and is 3 cm deep at this time. Consultation to wound care nurse completed and the wound appears to be a Kennedy Ulceration. It is a butterfly shape and has yellow stringy slough at this time. [R18 name] was told about this change and what a Kennedy Ulceration is. He understands and all question answered. Called [family member- FM-A] and all questions were answered. [R18] was very upset and saddened by this news. R18's progress note dated 4/22/22, at 4:59 a.m. included, Resident alert and oriented, able to make needs known and uses call light appropriately. Tearful at start of shift after finding out about Kennedy ulcer. Family here at 1900 [7:00 p.m.] and visited until 2300 [11:00 p.m.] Resident slept poorly throughout the night. Voiced that he is worried about dying. R18's progress note dated 4/22/22, at 10:20 a.m. included, Family here at facility at 0900 [9:00 a.m.] for a meeting regarding [R18's] wound. Per Wound Nurse yesterday [R18's] wound appears to be a terminal ulcer. Discussed with family, what the ulcer is, what the next steps are, what to continue etc. [R18] was understanding, family was understanding. All questions answered. [R18] chooses to continue with [CONDITION(S)] at this time until he physically cannot go to [CONDITION(S)] anymore. He is going to stay here and continue course as is at this time. A communication note dated 4/22/22, from R18's [CONDITION(S)] call center, indicated a call was received from RN-A: [R18] had a care conference today to inform patient and family of terminal wound on buttocks. Patient wishes to continue [CONDITION(S)] as long as he can. Use of cushioned blue chair at [CONDITION(S)] to promote comfort. Will forward to care team for pt [patient] update. A communication note dated 4/22/22, from R18's [CONDITION(S)] case manager RN-F, included the following: Told by POD [front line [CONDITION(S)] staff] that [R18] wanted to talk with someone to get more information about his new diagnosis. As chart review found little other than a new gluteal ulcer/abscess, call placed to [facility] to ask for more information. Per [licensed practical nurse (LPN)-A], [R18] was diagnosed yesterday with a Kennedy ulcer, and there had been a family conference today to talk about the poor prognosis (likely 2-3 weeks to live?) As writer unfamiliar with Kennedy ulcer, looked up information and noted that wound bears uncanny resemblance to [CONDITION(S)] wound [a rare, but serious kidney complication where the calcium builds up inside blood vessels of the fat and skin]. Writer asked [PN-A] to please view information about [CONDITION(S)] and to ask her team if they considered this as a diagnosis. Also asked if there had been any biopsies taken, which might prove or disprove either diagnosis. [PN-A] will follow up with [facility] while writer asks Nephrologist to review as well. R18's nephrologist, MD-B, wrote several communication notes dated 4/22/22 which indicated: Would need skin biopsy to see whether this is [CONDITION(S)] or not. Wound clinic consult order placed. After RN-F replied to say it would be two weeks before an appointment could be made, MD-B wrote, I have placed consult for wound clinic. As discussed with you today please see if anyone can see him in the Wound Clinic sooner to comment on whether this ulcer is really Kennedy ulcer or not. He is in nursing home and they are discussing about end of life cares. A communication note dated 4/25/22 from RN-F indicated, Received call back from [RN-A]. They have doctor rounds with [R18] today, and will reassure patient and family that all departments are working together as a team to make accurate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's medical provider's note dated 4/26/22, written by PA-A indicated R18 had presumed [CONDITION(S)] of the right buttock. PA-A remarked on concerns that the appearance of the wound might have represented a terminal ulcer, but PA-A wrote that R18's pain was improving, he was mentally clear, eating well and his wound was much improved. PA-A wrote that Nephrology had stopped medications with calcium due to a concern for calciphlylaxis as the etiology of the wound. A medical provider's note dated 4/28/22, written by a wound specialist, MD-C indicated R18 was being seen for the wound on his right gluteal cleft. MD-C wrote that chart notes document a concern for a Kennedy terminal ulcer and Nephrology was concerned for calcipylaxis. MD-C wrote that R18 came to the appointment with (FM-A), and indicated (FM-A) reported frustration that R18 had been given a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD-C's note indicated the wound, appears to have started as a skin/soft tissue infection around April 12th, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/2/22, at 4:38 p.m. R18 stated he had a wound on his buttocks which required he spend most of his time in bed. R18 expressed sadness about this since he enjoyed going out to stock sales and riding in the country. R18 stated he had hoped to go home soon, but would not be able to since his wound required dressing changes several times per day, and a visiting nurse could only come a few times a week. R18 said his wound had, started as a little pimple and rapidly progressed, and was now a stage IV pressure wound. R18 stated he wasn't sure anyone knew what was going on with his wound, but he had been to the wound clinic now and felt things might be improving. R18 had been provided a pressure reducing mattress for his bed, a different chair for [CONDITION(S)] and had been instructed to stay off the wound as much as possible. During a telephone interview on 5/4/22, at 9:11 a.m. RN-F stated the [CONDITION(S)] team had been aware that R18 had a sore on his buttocks. RN-F said she could not recall getting any calls from the facility about the wound, but had an expectation that the facility would call to provide updates. RN-F stated she knew of the wound because R18 had kept her apprised of his condition. RN-F then stated R18 had arrived to [CONDITION(S)] one day (unsure of date) in tears and overwhelmed and said they [facility] told him he was going to die. RN-F stated R18 told her he had a Kennedy ulcer. RN-F stated the renal team was concerned, as the wound looks similar to a wound [CONDITION(S)] patients can get [not a terminal ulcer]. RN-F stated the reason they had, weighed in on it was because it was a, big deal, and a, shock for R18. RN-F said R18 told her the facility had held a care conference to tell him he was terminal and would have to make end of life decisions. RN-F stated the renal team contacted their physician MD-B, who was reported to have said R18 needed a second opinion and ordered a referral to the wound care clinic. During an interview on 5/4/22, at 10:19 a.m. the facility director of social services (SW) stated R18 had initially planned a short term stay at the facility, and wanted to return to his home. SW stated they had discussed what type of referrals he would need to go home, including home modifications, nursing care and meal preparation. However, R18 had had some setbacks with a wound. SW stated RN-A had kept her up to date on what was happening with the wound, that it was a terminal wound and RN-A had set up a meeting with the family. SW said the family was very private so it was determined that it was not necessary for the entire interdisciplinary team to meet with the family, but just to have RN-A since they would need to, talk about sensitive things. SW did not know if a physician had determined R18 to be terminally ill, but stated, there was a wound specialist who looked at the wound, [RN-A] reached out to the wound specialist and he took a look at it. SW stated she had provided RN-A with some pamphlets to give the family on decision making and resources for end of life. During an interview on 5/4/22, at 10:15 a.m. R18 stated he had attended a meeting at the facility where he was told, his condition was terminal. R18 stated, I thought I was going to die. R18 expressed concern about FM-A who was very upset about what they had been told. R18 stated he thought he was going to have to make a decision about whether or not to continue his [CONDITION(S)] treatment, saying, I understood with a wound like that, well, it goes pretty quick and I thought I would have more time! R18 expressed this sudden terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 was observed to shake his head, and look down at his lap with a sad countenance. During an interview on 5/4/22, at 10:49 a.m. RN-A stated, I am not a certified wound nurse, but I am the one who monitors wounds. RN-A stated she had communicated with PA-A regarding the changes in R18's wound, and PA-A had provided treatment that included warm packs, antibiotics and opening the wound up. On 4/20/21, RN-A had been doing wound rounds, and, pretty much overnight, there was thick yellow slough [slough is dead tissue in the wound caused by inflammation]. RN-A stated she had contacted the nurse consultant RN-E and said, He mentioned it could have been a Kennedy ulcer or a terminal ulcer. RN-A said R18 went to [CONDITION(S)] on Friday 4/22/21 and the nurse manager there thought there was an aspect of calcification. RN-A said that nurse, MD-B and PA-A decided R18 should go to the wound clinic for an evaluation. RN-A stated she had never seen a Kennedy ulcer, but that RN-E had. RN-A said, RN-E had only seen R18's wound in a picture after it had gotten worse. RN-A stated a physician had not provided a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated she provided them with resources for making decisions, including information about hospice care. RN-A stated, I discussed the potential for this to be a terminal ulcer, and I said I wasn't certified and hoped I was wrong. RN-A reported the family was, shocked and wanted to know why she thought it was a terminal ulcer. She said she told them she had reached out to a wound specialist about it. RN-A stated she had called [CONDITION(S)] to discuss the meeting, but said she had not documented this, and was unsure of who she spoke with. During a telephone interview on 5/4/22, at 11:21 a.m. PA-A stated she had been away from work during the time the 4/21/22, email had been sent from RN-A asking if the ulcer might be a Kennedy terminal ulcer. PA-A became aware the wound appeared to be worse after her return to work, and also becoming aware R18 and family had been told he had a terminal ulcer. PA-A stated a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . PA-A stated the communication to a resident of a terminal condition would be, distressing, adding, he did not have a terminal illness! PA-A stated such news would be, shocking and upsetting. PA-A expressed frustration with how things had been handled by the facility and stated, I came back from being gone and had to clean up that mess. When interviewed on 5/04/22, 3:38 p.m. The facility director of nursing (DON) stated , Luckily, he is better than was thought, but I understand, there was an emotional toll. A facility policy titled [NAME] Care Center: Palliative/End-of-Life Care-Clinical Protocol, dated 9/20/21 indicated the purpose was to provide end of life care according to the standards of practice set forth. The policy indicated, the physician will help identify or verify underlying causes of a resident's decline and it is not uncommon for patients to have potentially treatable conditions or have potential for improved function and quality of life that has not been identified or treated adequately. In addition, the policy indicated, the physician will advise the resident/patient, family and facility staff about the prognosis and overall medical plan periodically, including any impact of significant changes of condition.

Based on interview and document review the facility failed to ensure residents were free of mental abuse when a resident photograph with demeaning language was shared on social media for 1 of 1 resident (R1), reviewed for allegations of mental abuse. In addition, the facility failed to immediately report, thoroughly investigate and protect residents from possible further abuse for 1 of 1 resident (R1) with incident of mental abuse. Although non-compliance was present at the time of the event, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance immediate jeopardy for R1. The past noncompliance IJ began on [DATE]. The IJ was removed and the deficient practice was corrected by [DATE], when the alleged perpetrator (AP) had no further contact with residents at the facility and a thorough investigation and re-education to all staff on abuse prohibition, vulnerable adults, and cell phone policies was completed. Findings include: Facility Reported Incident (FRI) submitted to the State Agency on [DATE], at 5:46 p.m. identified allegations of emotional or mental abuse that occurred on [DATE]. The description of the incident included, Received notification today that a snap chat was sent of R1 [name of resident] with a caption stating: This mother [OBSCENITY] is bound and determined he is getting in the dining room Snap Chat was sent out by one of the Registered nurses working. R1's Face Sheet identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had severe cognitive impairment and indicated R1 did not have any behaviors. The MDS indicated R1 did not walk, required extensive assistance from one staff member for locomotion on and off the unit and required assistance from two staff members for transfers. R1's care plan dated [DATE], identified R1 as a vulnerable adult related to physical limitations and would require physical assistance from staff in the event of a harmful situation. R1's goal was will not be maltreated and will be assisted to safety in the event of a harmful situation. Corresponding intervention was Assist to safety in the event of a harmful situation. Encourage resident to report any maltreatment. During an interview on [DATE], at 11:00 a.m. scheduling coordinator (SC) stated she had received a snap chat from RN-A on a Friday morning before breakfast within the last month (could not recall the date) of R1 wedged in-between the chairs staff use to block the entrance of the dining room until meal service was ready. SC stated the photo had a caption that said This mother [OBSCENITY] is bound and determined to get into the dining room. SC indicated she studied the photo, did not save it, and within minutes of receiving the photo she went to the director of nursing's (DON) office to report the photo as a HIPAA [Health Insurance Portability and Accountability Act] (a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information) violation. SC stated the social worker (SW) entered the office shortly after; SW indicated they had received the same snap chat from RN-A. SC stated as they (SC and SW) conversed about the picture, SC said the DON was preoccupied on the computer and never asked any questions or commented on their discussion. SC didn't think DON was paying attention to them and didn't really hear what they were talking about. SC indicated she did not report the photograph to the administrator per facility policy when she felt the DON was not paying attention to the conversation. SC stated she was not aware if RN-A had sent the picture to anyone else inside or outside of the facility. SC stated the photograph resurfaced on [DATE], when the human resources director requested a written statement pertaining to unrelated performance concern she had knowledge of for RN-A and included the inappropriate snap chat photo details RN-A sent to her and SW in the report. SC stated she was then called by the administrator on [DATE] and had to complete education and take a test on vulnerable adults, abuse reporting, and cell phone usage/social media. During an interview on [DATE], at 11:49 a.m. social worker (SW) stated she had received a snap chat photo of R1 from RN-A sometime in the middle of May; she could not recall the date. SW stated she was at home when she received the photo, quickly glanced at it long enough to recognize R1 and that he was not in his room and did not save the picture. SW stated she could not recall if the photo had a caption or what the caption said. SW stated at first, she though it was a HIPAA violation, but then dismissed the thought because the photo was sent between staff members. SW stated she was in the DON's office at the same time SC was. SW stated she and SC discussed the photo in the DON's office however, DON was doing something on his computer and did not think he heard or was paying attention to their conversation. SW was not aware if RN-A had sent the picture of R1 to anyone else inside or outside the facility, and was not aware of any other photos taken by RN-A or other staff members without the resident(s) consent. SW indicated she had not reported the picture to administrator per facility policy. SW stated she received re-education on abuse policies, social medical, and cell phone usage on [DATE]. During an interview on [DATE], at 1:23 p.m. DON said he recalls the SC and SW coming into his office, however, does not recall the conversation they were having. DON indicated his office is often a hub of activity and chatter between staff members. DON stated while SC and SW were in his office he was busy trying to analyze timecards and was not paying attention to the conversation between SC and SW. DON stated he became aware of the photograph of R1 on [DATE] when he was contacted and interviewed by the administrator. DON stated the administrator had been made aware by a statement written by SC. DON stated he had not seen the photograph because neither SC nor SW saved the picture from snap chat, found SC and SW very credible witnesses and their reports of receipt of photograph from RN-A was valid. DON stated the investigation did not identify anyone else who had received the picture from RN-A or any photos of residents taken or sent by staff members without the resident's consent. DON stated the photo should have been reported to the administrator immediately as an allegation of abuse, personal cell phones were not allowed, and the picture should not have been taken without consent. DON stated the investigation and re-education of all staff members was completed on [DATE]. DON stated RN-A has not been in the facility since [DATE] and her employment was terminated on [DATE]. During an interview on [DATE], at 3:15 p.m. administrator stated she became aware of the allegation on [DATE], by the HR director who had become aware of the allegation on [DATE], via written statement by SC. Administrator stated the HR director didn't immediately report the allegation to her because he wanted to validate some of the information that SC wrote. Administrator stated she immediately educated the HR director on reporting immediately of allegations of abuse/exploitation. Administrator stated SC and SW should have reported the allegations to her immediately and not the DON per the facility reporting policy. Administrator stated after she became aware of the allegation, she initiated the investigation. Administrator stated neither SC or SW saved the photograph, and it could not be determined when SC or SW received the photograph other than within the last month or so. Administrator stated she interviewed SC, SW, staff, and residents and concluded the photograph of R1 was not sent to any other staff members employed at the facility, no other staff members had taken photos of residents without consent, and this incident was a one-time occurrence. Administrator stated she provided immediate re-education to all staff on [DATE], that included: Cell phone policy, social media policy, abuse policy, and restraint policy. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: a thorough investigation and re-education to all staff on abuse prohibition, vulnerable adults, and cell phone policies was completed. Facility policy Plan for Abuse Prevention and Reporting last revised [DATE], included it is the policy of [NAME] Care Center to maintain an environment where residents are free from abuse, neglect, exploitation, and misappropriation of resident property. Internal Reporting: Employees must always repot any abuse or suspicion of abuse, or suspicion of crime immediately to the administration. ***Note: failure to report can make employee just as responsible for the abuse in accordance with state law. Facility policy Social Media dated [DATE], included Inappropriate Usage: Inappropriate usage of social networking while at work includes, but is not limited to: Any activity or communication that involves the transmission of or access to sexually orientated, obscene, discriminatory, harassing, defamatory, false, inaccurate, abusive, profane, pornographic, threatening, racially offensive, or otherwise biased, discriminatory or illegal material. Resident's right to privacy and confidentiality: Examples include, but not limited to images or recordings being kept, shared or disseminated via social media by staff taking unauthorized photographs of resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity. Resident Abuse: posting or disclosure of any resident in a way that demeans or humiliates a resident, regardless of whether the resident provided consent or regardless of the resident's cognitive status. Examples include, but are not limited to photographs or recordings being kept, shared or disseminated via social media of derogatory statements directed to a resident, showing a body part without the residents face whether it is the chest, limbs, or back, labeling resident's pictures and/or providing comments in a demeaning manner . and showing the resident in a compromised position. Violations: suspected or known violations of policy or law shall be reported the employees supervisor/manager, the administrator, or human resources.

Based on observation, interview and document review, the facility failed to complete a comprehensive assessment and monitor for healing and signs of a non-pressure related skin impairment (surgical incision). In addition, the facility failed to notify the physician when the incision dehisced, when there were signs/symptoms of infection, and when there was an increased associated pain for 1 of 1 residents (R28) reviewed for hospitalization . The facility's failures resulted in harm for R28 when she had to be hospitalized for [REDACTED]. Findings include: During an interview on 11/18/19, at 2:20 p.m. R28 sat in her room in her wheelchair. R28 stated she was admitted to the facility after having surgery on her back. R28 stated she had not been at the facility very long when a nurse and her family member noticed that her incision was red, causing her to be sent back to the hospital where it was identified she had an infection in her back which was treated with intravenous antibiotics. R28 could not recall how long she had been in the hospital, but remembered she had been readmitted with a wound vac. R28's hospital discharge summary dated 10/24/19, identified R28's principal [DIAGNOSES REDACTED]. Orthopedic recommendations/instructions included: -If any general questions call the orthopedic service; the summary included contact numbers for during business day and for off-hours. -Your incision is closed with sutures. You need to have these removed 2 weeks post the surgery date or by our service or by your home town physician or nurse practitioner or physician assistant. -Leave the operative dressing in place for 3-4 days. The incision should be inspected daily for signs and symptoms of infection. Once there is 2 consecutive days without drainage your incision can be open to air. Apply a dressing only if brace or clothes irritating the incision. -Complications sometimes occur and we need to know about them so as to manage them correctly. Please contact us if you develop any of the following symptoms: fever (greater than 38.5 C/101 F; drainage from your wound; increased incisional pain; new numbness or tingling not present before you left the hospital. Call us if you experience loss of bowel or bladder control; increased warmth or redness at the incision, excessive vomiting, chills, night sweats. R28's Resident Face Sheet, indicated R28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R28's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R28 did not have cognitive impairment and required extensive assistant from two or more staff for transfers, bed mobility, and toileting. The MDS indicated R28 had a surgical wound that required surgical wound care. Physician orders included: -Weekly skin check done by nurse. Complete skin sheet in chart and a progress note (start date (10/24/19) -Leave the operative dressing in place for 3-4 days. The incision should be inspected daily for signs and symptoms of infection. Once there is 2 consecutive days without drainage you incision can be open to air (start date 10/24/19, stop date 11/12/19.) -Remove sutures 2 weeks after surgery (start and stop date 10/26/19) -[MEDICATION NAME]-pot (potassium) clavulanate (antibiotic) 875-125 milligrams (mg) every twelve hours (start date 11/12/19, stop date 11/22/19) -Call Dr.(name of surgeon) service if the resident's incision develops increasing redness, drainage, or skin breakdown or if facility is concerned about the incision or clinical status (start date 11/12/19). -Cleanse incision with wound cleaner. Apply sterile 4 x 4 gauze and tape. Change daily (start date 11/15/19, stop date 11/21/19) -Change wet to dry dressing every morning and evening. 1. Swab wound beds with diluted hydrogen peroxide 1:1 2. pack with sterile saline soaked gauze making sure wet gauze sits only on wound bed and not on surrounding tissue 3. Cover with absorbent dressing and secure (start date 11/20/19) R28's base line care plan dated 10/24/19, included, Resident has had spinal surgery related to fracture of lumbar vertebra, and associated goal was R28 would achieve highest level of mobility. Corresponding interventions included, monitor for pain, occupational therapy and follow recommendations, physical therapy, wear back brace except when lying in bed, and provide adequate rest periods. R28's care plan for newly admitted to the facility dated 10/24/19, directed staff to notify charge nurse of any skin irregularities. The care plan revised 11/12/19, included R28 developed an infection in the incision in her back and was hospitalized . The care plan directed staff to administer antibiotics per order, evaluate/record/report effectiveness/adverse side effects. Monitor and record any complaints of pain/itching/discomfort, and observe and report signs [MEDICAL CONDITION]. Treat incision per MD order with application of wound vac. R28's admission Skin Risk Assessment with Braden Scale dated 10/24/19, identified R28 to have a surgical wound and required surgical wound care, no specific information about the wound or treatment was included in the assessment. section. The interventions for skin care included: inspect skin daily, weekly skin assessments, monitor pain and administer pain medications/treatments as ordered. In the section Indicate Care Plan Action Taken, initiate care plan was checked. R28's progress note dated 10/24/19, included Back incision covered with Prineo (is a topical mesh and skin adhesive that forms a strong bond across opposed wound edges allowing the normal healing process to occur)which is like tape and not to be removed until it falls off. R28's progress note dated 10/26/19, indicated R28's incision had small amount of bleeding at the 3rd suture site with no other drainage, redness, or signs and symptoms of infection. R28's progress note dated 10/27/19, indicated R28's sutures had been removed on 10/26/19, per physician order. The note also indicated skin was intact with no signs and symptoms of infection. R28's progress notes on 10/28 and 10/29/19, indicated R28's incision was intact with no signs and symptoms of infection. R28's progress note dated 10/30/19, included resident has a small opening to back incision with scant (sic) amount of drainage, cleanse area with Saline then applied dry dressing. Review of R28's record lacked evidence of a comprehensive wound assessment, lacked evidence of physician and/or orthopedic service notification, and lacked evidence of care plan revision or treatment plan for the open wound. The treatment administration record and/or physician orders did not identify physician or nursing orders for treatment of [REDACTED]. R28's progress note dated 10/30/19, at 4:07 p.m. indicated physician assistant (PA) discontinued R28's order for as needed [MEDICATION NAME] (narcotic pain medication). R28's progress note dated 10/31/19, at 3:18 a.m. indicated R28 refused to get out of bed except to go to the bathroom; consistently rated her back pain 5-6/10 (0 no pain, and 10 worse pain) and was administered scheduled [MEDICATION NAME] every 4 hours. The note also indicated R28's incision was intact with the exception of small area on her low back. R28's progress note dated 10/31/19, indicated R28 did not complain of pain while lying in bed, and received scheduled [MEDICATION NAME] every 4 hours. Lumbar incision in intact with no tape or dressing covering. Small amount of serosanguinous drainage noted on incontinent product at waistline lower back. Covered with [MEDICATION NAME] dressing to protect from rubbing. R28's progress note dated 11/1/19, at 9:22 a.m. included Weekly skin inspection completed after shower. Long incision mid back well healed other than where undergarment rubs at waistline. A subsequent note at 2:39 p.m. indicated R28 continued to receive scheduled [MEDICATION NAME] and Admits to having more pain again today than she did yesterday. R28's progress note dated 11/2/19, at 2:47 a.m. indicated R28 reported as long as she wasn't moving did not have pain. At 5:17 p.m. progress note included R28 sitting in recliner smiling but tells this writer that her back really hurts still but stomach was feeling better. R28's progress note dated 11/3/19, at 2:43 a.m. included Resident complains of increased pain throughout the day today rating her pain at 8/10 this evening. A note at 10:34 a.m. included, Dressing was changed to the incision area on lower back that is open. Scant drainage on the dressing that was removed and small amount of purulent drainage oozing during cleansing at the small of back. The note also indicated R28 refused to wear back brace and rated back pain 5-6/10 with minimal movement. At note at 1:40 p.m. indicated at 11:45 a.m. R28 rated her back pain at 8/10; R28 told the nurse that it was too painful to each lunch and PT (physical therapy) here at 1300 (1:00 p.m.) and transferred her into bed too painful to participate in therapy. Continues to refuse to wear back brace. R28's progress note dated 11/3/19, at 11:16 p.m. included R28, Rating back pain at 8/10 when administering evening meds, including [MEDICATION NAME], states best rate is about 6/7, largely not effective to relieve pain in low back. Low back is assessed to find most of incision intact except inferior portion, which is open and has some scant purulent drainage; ABD (soft absorbent padded dressing) applied to area. R28's progress note dated 11/4/19, at 3:47 a.m. indicated R28 rated pain 8/19, was cooperative with positioning side-to-side; R28 grimaced and showed signs of pain during repositioning. Progress note at 3:07 p.m. indicated R28 ate both meals in her room, complained of back pain with movement. The note indicated the dressing to R28's back was changed and it was draining. The note did not identify type and amount of drainage, size of wound, or dressing that was applied. R28's progress note dated 11/5/19, at 2:54 a.m. included, Resident c/o (complained of) significant back pain 8/10, she is receiving [MEDICATION NAME] every 4 hours for pain. R28's progress note dated 11/5/19, at 11:24 a.m. indicated R28 was seen by physician assistant (PA) for uncontrolled back pain and purulent drainage from incision. PA received orders to transfer R28 to hospital and was transferred by ambulance at 11:30 a.m. R28's physician visit dated 11/5/19, indicated reason for visit was to follow-up on pain after lumbar spinal fusion. The note included, Pain uncontrolled with scheduled [MEDICATION NAME] and [MEDICATION NAME] cream, so on (MONTH) 30th I authorized 5 mg scheduled every 4 hours. Despite this, pain has been severe. Nurses report that (R28) cannot wear her back brace because of pain, and she has been unable to participate in therapy because of the pain. Physical examination identified at the distal (lower) aspect of midline lumbar back incision, there is an area about 2 cm in length that is slightly open with serous drainage present around the wound and on the overlying dressing. No significant [DIAGNOSES REDACTED] surrounding the back incision The note further indicated that because of the degree of pain, new opening in incision with purulent drainage R28 would transfer to hospital for direct hospital admission. During an interview on 11/21/19, at 2:56 p.m. R28 stated she had a lot of back pain before going back to the hospital. R28 stated there were times she could not eat because she was in so much pain. R28 stated the pain progressively got worse and then out of control. R28 stated she did not recall seeing a physician after her incision opened up. Hospital progress note dated 11/5/19, at 2:30 p.m. included, Over the lumbar region there are two open areas, one approximately 2.0 cm long and one approximately 0.5 cm long. There is granulation tissue visible in each open area. The note indicated the larger wound had a depth of approximately 1.0 cm and the small had a depth of approximately 0.5 cm; purulent drainage was not observed during probing. The note also indicated there was scattered [DIAGNOSES REDACTED] (redness) around the superior opening. An orthopedic spine note indicated laboratory results were indicative of infectious process associated with the openings in the healing incision. Hospital note indicated the wound vac (vacuum) was applied on 11/12/19, the back incision remained open with purulent material and the larger of the two openings appeared to be shallower than initial presentation. Hospital discharge summary indicated R28 was administered intravenous antibiotics during hospital course and was discharged back to the facility on oral antibiotics and wound vac in place. The hospital discharge summary also included orders for the wound vac to stay in place until 11/16/19, then begin daily dressing changes with 4 x 4 gauze and paper tape, instructed to keep the incision dry, and to keep the surgical service updated with period photos. The instructions also included, The rehab facility should call the (name of doctor) service if the patient's incision develops increasing redness, drainage, or skin breakdown or if the facility is otherwise concerned about the patient's incision or clinical status. R28's progress note dated 11/12/19, at 1:00 p.m. indicated R28 returned from the hospital with a wound vac in place over her back incision. R28's re-admission assessment dated [DATE], indicated R28 has a surgical incision on mid [MEDICATION NAME] back that was 15 centimeters long. The assessment indicated the incision was not observed because it was covered with a surgical dressing. R28's progress note dated 11/13/19, at 1:00 p.m. indicated the charge nurse had notified spinal surgeon with message of wound vac not working, and had not received any orders. A subsequent note at 1:09 p.m. indicated the wound vac had been working effectively earlier that morning, Is now without a seal, unable to remedy this. Wound vac removed from back site; incision redressed with sterile gauze. Incision intact, couple of drops blood seen, macerated looking, no redness, no odor. R28's Skin Integrity assessment dated [DATE], identified R28's surgical incision to her lower mid back that was 5.0 cm x 1.0 cm x 0.2 cm, and was 100% slough. The assessment also indicated that the drainage was purulent with no odor, and the surrounding tissue was macerated. The assessment indicated no referrals were necessary and directed to continue with current plan of care. R28's progress note dated 11/14/19, at 11:33 a.m. indicated the wound vac would be reapplied when available. R28's progress note dated 11/15/19, indicated weekly skin inspection was completed, Incision mid back is open and macerated at the small of back. Review of progress notes did not address a return communication and/or orders from the surgical service for wound treatments. R28's record lacked evidence of a verbal order for the treatment that was entered into the electronic health record on 11/15/19. During an observation on 11/19/19, at 8:36 a.m. physical therapist (PT)-A was in R28's room, R28 was in the middle of a transfer from her bed to her wheelchair in a hospital gown which exposed R28's open wounds that were on her spine of her lower back. R28's gauze dressing that had come off laid on the bed; the dressing had a baseball-sized area of bloody drainage. PT-A stated to RN-D and RN-F the dressing had fallen off. RN-A washed hands, donned gloves, and cleaned the upper wound which measured about 2-3 centimeters (cm) in length, about 0.2- 0.3 cm in width and 0.2-0.5-0.75 cm in depth; wound had thick white slough along the inside wound edges. Just below that wound was about 0.5 cm- cm x 0.2-0.4 mm (was unable to appreciate depth) appeared as a slit and had bloody drainage, which RN-A cleaned gently. RN-A covered the wounds with a gauze cover dressing. RN-A indicated that the slough had been inside of the wound and was not able to remove any of the slough during cleansing. RN-A indicated the PA would be notified of wound status today. Progress note dated 11/19/19, at 11:19 a.m. indicated PA had seen R28 and floor nurse was calling the surgeon related to the incision and dressing change. A subsequent progress note at 3:49 p.m. included, Her wound was cleansed this morning. It is not red, abnormally painful, or [MEDICAL CONDITION]. She has serosanguinous drainage on her bandage. Dressing was changed. Concern for no improvement in wound status was brought to the attention of (name of PA) who further recommended contacting her orthopedic surgeon. (Name of surgeon)office was called, (name of doctor) replied. He has requested pictures of the wound in order to recommend new dressing orders. Verbal consent was obtained from resident for photo exam, we will forward these pictures on to him and follow up tomorrow R28's record reviewed from 11/13/19 to 11/21/19, did not include assessment of the lower smaller wound. Progress note dated 11/20/19, at 1:00 p.m. included back dressing was changed, scant amt (sic) red serous dry drainage. Approximately 1.5 cm distal (lower) incision with slight gaping. No redness R28's physician's orders indicated that new orders were obtained for the dressing on 11/20/19, however R28's treatment administration record indicated the dressing was not changed per physician; documentation identified the reason as unable, no further explanation was documented in the record. During an interview on 11/21/19, at 10:37 a.m. registered nurse (RN)-A reviewed R28's record; RN-A verified R28's surgical incision was not comprehensively assessed upon admission, and indicated the site should have been further evaluated and the physician contacted prior to suture removal. RN-A confirmed there was not a comprehensive assessment completed after the incision opened and the physician was not contacted even when the incision had drainage and R28 had increased pain. RN-A stated the physician should have been notified after the incision opened, after the incision had purulent drainage, and when R28 had an increase in pain. RN-A indicated the medical provider had not seen R28 until 11/5/19, then R28 was directly admitted to the hospital after the medical provider contacted the surgical service. RN-A stated when R28 came back from the hospital, the wound vac would not keep a seal, so it was removed. RN-A stated a wound assessment was completed after it was removed, however one had not been completed since. RN-A stated when dressings were changed at the minimum the nurse should be looking for changes and documenting drainage, odor, surrounding skin integrity, and description of the wound bed. RN-A verified R28's care plan had not been revised after the incision opened or after the wound vac was removed. RN-A indicated the care plan should have been updated with the changes to the wound. During an interview on 11/21/19, at 12:50 p.m. the director of nursing (DON)stated comprehensive assessments should have been completed upon admission, when the wound opened up, and with any change to the wound. The DON indicated stated if since the incision had been draining, prior to suture removal there should have been further evaluation, and the provider should have been contacted. required further evaluation and potentially the provider contacted. The DON stated there should have been thorough documentation when the dressings were changed that at a minimum including: color, odor, amount of drainage, what everything looked like, signs and symptoms of infection, type of dressing, and how the resident tolerated the dressing change. DON stated the physician should have been contacted when the incision opened, when the incision showed signs and symptoms of infection, and when R28 had increase in pain. DON stated there should have been a base line care plan developed upon admission, base line updated when the incision opened, and the care plan changed when the wound vac was no longer used. During an interview on 11/22/19, at 8:51 a.m. physician assistant (PA)-A stated she had not been made aware of when the incision opened and there was purulent drainage and increased pain until 11/5/19. PA-A stated, I would have expected them to call me and let me know. PA-A stated in hind sight, she should have been made aware of the condition of the incision before the sutures were removed. PA-A indicated she would also expect the wound to be comprehensively assessed and documented. The facility's undated??? Policy, Notification of Changes included: 1) The nurse will immediately notify the resident, resident's physician and the resident representative(s) for B) A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complications and C) a need to alter treatment significantly The facility's 2/27/19 policy Skin Integrity, included: Implementation 1) adhere to the client's individualized skin and/or wound management plan. 2) Reporting to case managers of any abnormalities to the residents skin or wound area ( .signs of dehiscence) 3) Documentation of abnormal observations made in progress notes and what was done about it. Assessment and Recognition: 3) The nurse shall document/report the following: a) full assessment of pressure ulcer/skin injury including: iii) Describe the wound as partial thickness or full thickness iv) Length/width/depth vi) Presence of drainage vii) Odor viii) method of debridement x) wound edges xi) surrounding tissues xii) indicators of infection xii) complaints of pain. The policy also included Skin Inspection: a head to toe inspection completed on all residents will be completed upon admission, daily with cares by caregivers, and weekly by a licensed nurse in alignment with bathing. A ii) any new findings are document in the Skin Integrity Observation. Treatment and Management- 1) The practitioner will order pertinent wound treatments.

Based on observation, interview and record review, the facility failed to ensure allegations of abuse were identified timely, failed to ensure appropriate actions was taken to immediately provide residents protection, and failed to thoroughly investigate allegations of abuse for 1 of 1 resident (R35). R35 was physically forced to the bathroom by a registered nurse (RN)-D and subsequently exhibited escalating behaviors, yelling for someone to call the police, and aggression towards RN-D by trying to choke, bite and scratch RN-D. The allegation was not immediately reported and the facility failed to protect the additional 34 residents residing in the facility, by allowing RN-D to continue to work in the facility the following day without having thoroughly investigated the alleged abuse. The IJ began on 1/1/19, when it was determined there was an allegation of staff to resident abuse which was not immediately reported, R35 was allegedly forced to go to the bathroom against her will by RN-D, who pulled the resident to the bathroom, resulting in R35 exhibiting escalating behaviors. In addition RN-D continued to work the floor, placing all 34 residents residing in the facility at risk for abuse. The administrator, director of nursing (DON), and social services (SS) director were notified of the IJ at 5:35 p.m. on 1/10/19. The IJ was removed on 1/11/19, at 3:15 p.m. but noncompliance remained at the lower scope and severity of a pattern, with potential for more than minimal harm (Level F). The findings include: R35's current face sheet identified an admitted [DATE], and included [DIAGNOSES REDACTED]. R35's care plan dated 12/28/18, indicated a problem: I (R35) am forgetful and can get agitated when I (R35) don't understand what I should be doing. Goal: I (R35) will function at my best ability possible. Approach: Avoid confrontations. Gain trust and agreement before proceeding with activity. Establish rapport before introducing tasks to be done. Monitor for and take steps to avoid over stimulating, chaotic, loud environment which can contribute to resident feeling anxious, confused, agitated and restless. An additional problem identified in the care plan dated 12/28/18, I (R35) sometimes experience bladder incontinence. Goal: I (R35) would like my bladder incontinence to improve. Approach: I (R35) need 1 person assistance for transfers related to toileting and 1 person assistance for hygiene related to toileting. A progress note dated 1/1/19, at 8:33 p.m. for R35 included: .NA (nursing assistant) and I (writer of note) could smell a foul odor and had attempted multiple times to assist resident with toileting needs as she had a BM (bowel movement). She (R35) was sitting at the dining room table sleeping. We asked her politely to come with us so we could get her cleaned up for bed. We helped her up and assisted her back to the bathroom where she proceeded to hit, pinch, and bite at staff and then grabbed nurse by the throat and also squeezed nurse's hands. We were able to get resident to sit down and pants changed but she would not stand for us to assist in cleaning her bottom. Her pants were changed but she still has BM on her bottom at this time. Has been asked again and just walks the other way and glares at staff. Will let settle and try to attempt assist again before the shift is over. An undated, document 5 Day Incident Report, identified the above incident occurred on 1/1/19, at 8:30 p.m. and indicated an allegation of physical abuse-conduct intended to produce pain/injury or rough handling had occurred by RN-D towards R35. A description of the incident identified by the reporting staff included: resident (R35) soiled self at evening meal. NA-C attempted to assist resident back to bedroom for cares. Resident was not responding to NA-C's prompts to go back to her bedroom. At this time it was reported that RN-D intervened stating, just make her, and grabbed resident under arms and pulled resident into her bedroom, resident responded by yelling at RN-D to stop .leave me alone. Resident began to exhibit behaviors in response to RN-D's intervention, as evidenced by RN-D's progress note, .proceeded to hit, pinch, and bite at staff, and then grabbed nurse by the throat and also squeezed nurse's hands. RN-D's approach was unsuccessful, and left the room, resident behavior subsided and NA-C was able to provide cares at this time. Action taken to protect resident was RN-D was placed on suspension following DON (director of nursing) notification of the incident and while undertaking investigation. Witness information: NA-C, activity aide (AA)-B, and RN-D. An undated, Initial Internal Investigation form, completed by the DON revealed an incident had occurred on 1/1/19: R35 refused cares through the afternoon shift. NA-C approached R35 and attempted to get her to come with her, holding R35's hands in her own. RN-D approached R35 and grabbed her by the arm, proceeding to pull R35 towards her bathroom. NA-C was reported to have told RN-D to give R35 time and not hurry her. During this time R35 was reported to yell leave me alone .call the police .call the police. R35 continued to hold onto NA-D's hands until they reached the bathroom, at which time R35 let go and proceeded to push RN-D up against the wall with her hands around her throat. R35 let go of RN-D and staff was able to direct her into the bathroom where she continued to express resistance. Staff attempted to explain that they needed to clean her up. RN-D left the bathroom and NA-C was able to clean R35 as she calmed down. The Statements obtained: licensed practical nurse (LPN)-A came to my office, during our discussion, I inquired whether she knew what NA-C had wanted to talk to me about. She stated that while working together overnight on 1/2-1/3/19, at 2:00 a.m. NA-C was talking to LPN-A during rounds. In this conversation, NA-C told LPN-A that during the evening of 1/1/2019, staff were having difficulties toileting R35, and RN-D was rough getting R35 to her room to get her cleaned and NA-C wanted to talk to me about it. LPN-A went on to report that RN-D had talked to RN-A about the incident and told her NA-D is probably going to report this on me anyway. LPN-A stated she believed NA-C knew it was not okay, but was not sure of the degree of conduct. Discussed abuse reporting expectations of charge nurses and VA (vulnerable adult) reporting with LPN-A. Internal Investigation also indicated, Procedural violations: Mistreatment, see VA policy as well as a Summary of findings: RN-D was terminated from employment on 1/10/19. R35's care plan updated on 1/4/19, identified a problem: I (R35) have had difficulty finding the bathroom and have had accidents. I (R35) do not like to be told what to do and when to do it. Goal identified, resident will not exhibit socially inappropriate/disruptive behavior as evidenced by using the bathroom. I (R35) will cooperate with staff helping me. Approaches identified to allow the resident to have control over situations, if possible, maintain a calm environment and approach the resident and label the bathroom with, The Can, as this is what I call it. During observation on 1/7/19, at 3:56 p.m. R35 was wearing a pink t-shirt with a red sweater and tan pants. R35 was noted to be well groomed and was sitting up to the table in the dining area eating a cookie and having a cup of coffee. During phone interview on 1/08/19, at 3:18 p.m. NA-C stated, I have worked here for 2 years. On 1/1/18, I worked the evening shift, and around 4 p.m. I could smell R35 had been incontinent of BM. Several attempts were made to assist R35 to be cleaned up, but she kept refusing. At 8 p.m., R35 continued to refuse. I was told by RN-D, we have to make this happen, (R35) needs to be cleaned up. R35 was sitting at the table in the dining room when RN-D tried to get R35 to go to the bathroom and R35 refused. RN-D then grabbed R35 under her left arm and dragged her to the tub room with a toilet since that was closest. We offered R35 a shower or bath, but R35 refused. RN-D did get R35 on the shower chair. RN-D was trying to do pericare while R35 was scratching, yelling and trying to bite RN-D. Then RN-D told R35, we have to clean you, you are full of BM! R35 was very upset, and told RN-D that she was going to call the cops on her. R35 yelled for RN-D to leave and RN-D finally did leave. R35 then yelled for me to leave, so I did. I did give her some toilet paper in hopes she would use it. When NA-C was asked if the incident was reported to the administrator NA-C said, at the time I was not sure if this incident was abuse or neglect. I did not report it right away because I was not sure if it was anything. NA-C said it was reported 2 days later in the afternoon. NA-C further said, I feel like (RN-D) could have potentially hurt (R35), the way she grabbed (R35's) arm. (R35) just kept trying to get away. I feel (RN-D) could have used a gait belt or something. I don't think she intended to hurt (R35), I mean she talked nice to her, but she shouldn't have grabbed her under the arm like that. During a phone interview on 1/10/19, at 9:35 a.m. RN-D stated, On 1/1/19, around 2 p.m. we were trying to toilet (R35) because she had a visible BM in her pants with no brief or underwear on, so we approached her multiple times to get her cleaned up and (R35) kept refusing. Around p.m. (R35) was sleeping at the table in the dining room with her head in her hands, I then tried to reason with (R35) about getting the BM cleaned up. So (NA-C) and I assisted (R35) to stand, and (R35) was trying to refuse. I had her right hand in my left hand and right forearm was on her lower back and (NA-C) was on the right side and she had her left arm underneath (R35's) right arm pit. Then we guided her down the hallway as (R35) was swearing at us. We were calm and tried to explain to her that she needed to be cleaned up and we brought her to the tub room. (R35) busted free from (NA-C), and (R35) grabbed the door to the tub room with her right hand, then I let go of (R35's) right hand and I was able to go under (R35's) right hand to break it free from the door, then (R35) grabbed onto my neck and pushed me up against the wall and had both of her hands around my neck. I was able to get under (R35's) hands and break free from that. (NA-C) helped (R35) get in the shower chair, and she pulled down (R35's) pants. (R35) was still very upset kicking, hitting, and biting at me, this went on for about three minutes, and then I decided if one person was in there it might be better. So I left a washrag and towel in (R35's) sight hoping she would clean herself up, and I stepped out of the room. (NA-C) was still in the room with (R35). I sat outside the door in case they were to need some help. Eventually, (NA-C) walked out, I am not sure if (R35) even got cleaned up. We did attempt time and time again with no success. RN-D verified she had worked the following day then stated, they suspended me on 1/3/19 over the phone, and I was fired yesterday over the phone, they said they did the investigation on this and sent it to the State. During phone interview on 1/10/19, at 2:33 p.m. AA-B verified she worked on 1/1/19, during the evening and was sitting on the couch with a couple of the male residents when RN-D and NA-C were trying to care for R35. AA-B said NA-C had her hand in R35's hand and RN-D was pushing R35 from behind. AA-B said, As they were walking by, (R35) stated 'are you getting a free show?' then told me to call the police. RN-D was pushing R35 from behind to get her in the bathroom. AA-B further stated, I wasn't sure what the protocol here is. (RN-D) and (NA-C) got (R35) in the tub room and I could hear (R35) screaming. I felt bad because they were forcing her go into the bathroom and she did not want to. (NA-C) was gentler, but she got forced to go in by (RN-D). If that was my parent, I wouldn't want them to be forced like that. Further, AA-B said she did not report this incident to anyone. During interview on 1/10/19, at 3:43 p.m. the Administrator stated, I was notified on 1/3/19, around 3-4 p.m. by the DON, about the staff to resident abuse with (RN-D) and (R35). The administrator verified the investigation was completed, and the DON had talked to everyone she needed to, So it is done. The outcome of the investigation was that we felt (RN-D's) approach to how she brought (R35) down the hallway was not appropriate, we blamed it on mistreatment. (R35) was saying 'no' and responded with aggression, so we figured that was the dementia resident saying 'no'. The administrator verified no other residents were interviewed and the only staff interviewed were the witnesses to the alleged abuse incident. The administrator also verified RN-D had worked the day after the incident, but was then suspended the following day 1/3/19, via phone, and had been terminated 1/9/19, via phone. During interview on 1/10/19, at 4:11 p.m. the DON stated, I was first notified of the 1/1/19 incident on the morning of 1/3/19, because (NA-C) left a note from the night before on my desk to please call when I had time. (LPN-A) had stopped in and talked to me about (NA-C) having concerns about (RN-D) rough handling a resident. I called (NA-C) on 1/3/19, around 1 p.m (NA-C) divulged to me that (R35) was resistive to being cleaned up with multiple approaches and came out to the dining room and was visibly soiled for 3-4 hours or so. (NA-C) said (RN-D) grabbed (R35) by the arm to bring her to the bathroom. (R35) was escalating, saying 'leave me alone', yelling 'call the cops' and 'get away from me'. The DON stated, You should never force someone to do something, and verified that through her investigation it was determined R35 was forced into the bathroom to get pericare completed, and that RN-D was rough with R35 and forced her to do something she did not want to do. The DON reported NA-C and AA-B were not quite sure whether this situation would be considered abuse, so I reeducated them on 1/4/19. The DON verified NA-C reported the incident to LPN-A who was the charge nurse. However, LPN-A did not report the incident to the state agency, which the DON said she should have. The DON stated she had notified the administrator of the alleged abuse on 1/3/19, in the afternoon and added, My investigation for this incident was completed yesterday (1/9/19). The DON also verified RN-D had worked on 1/2/19, and verified she had not interviewed any other residents or staff members in regards to RN-D and any alleged rough handling or abuse. The DON then stated, I could see that (RN-D) could be intimidating to other staff, but not to the residents. We terminated (RN-D), because it is against our policy and procedure to put your hands on a resident with dementia and force them into doing something they do not want to do. If a resident is telling you 'no', yelling and telling you they do not want it, you need to take a step back. I feel like the staff need more education on what abuse really is. We do online abuse training, but we should be doing more intense training maybe with scenarios so they are sure to understand what abuse really is. Review of facility nursing work schedule revealed that RN-D worked on 1/1/19, the day of the abuse incident and worked again the following day, 1/2/19. The IJ that began on 1/1/19, at 8:30 p.m. was removed on 1/11/19, at 1:28 p.m. when it could be verified the facility had implemented an acceptable removal plan including: interviews with all interviewable residents regarding allegations of abuse, conducting skin checks for non-interviewable residents, review of residents' behaviors to determine any behavioral changes, provided training to staff re., abuse prevention and reporting, and staff could verify what constituted abuse and what to report. In addition, the facility reviewed and revised their internal reporting processes and terminated R-D from employment. The facility's 11/7/17 policy and procedure Plan for Abuse Prevention and the Reporting, included: It is the policy of Gundersen Tweeten Care Center to maintain an environment where residents are free from abuse, neglect exploitation, and misappropriation of resident property. Abuse includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. An owner, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. Definitions: Mistreatment means inappropriate treatment or exploitation of a resident. Internal reporting-employees must always report any abuse or suspicion of abuse immediately to the administrator. Note: Failure to report can make an employee just as responsible for the abuse in accordance with State law.

Based on observation, interview and record review, the facility failed to assess and implement fall interventions, and operate equipment safely to minimize the risk of falls for 1 of 3 residents (R1) with a risk of falls. This resulted in actual harm when R1 sustained a head injury when falling from a standing lift. Findings include: R1 ' s medical record was reviewed. R1 had [DIAGNOSES REDACTED]. R1 was dependent on staff to assist with all activities of daily living and transferred using a standing lift. The manufacturer's instructions standing lift is a mechanical lift used for transfers which position the resident's feet on a platform and use a harness to hold the upper body in place to safely lift the resident. The lift is moved to allow the resident to be lowered to a chair or other surface when the resident is too weak to stand and transfer on their own. The facility's Event Report dated 1/20/16 indicated that R1 was transferred with the standing lift from sitting on the side of the bed to a wheelchair. The nursing assistant was alone and did not attach the waist belt around the resident, and did not attach the foot strap around the resident's calves. During the lift R1 fell out of the lift to the floor and struck his head on the floor. The nurse assessed the resident and provided first aid to the injuries. The facility policy titled Safe Patient Handling dated 6/1/2015 indicated that one to two staff should be used to ensure safety when using the stand, and resident's plan of care should be followed. The manufacturer's operator instructions dated 6/2014 indicated that prior to lifting the For the safety of the patient, securely fasten the safety strap around the patient's torso. Secure the buckle and pull the strap to tighten. An interview with the floor registered nurse (RN-M) on 2/1/2016 at 101 am revealed that she went to the room of R1 on 1/20/16 at 8:00 a.m., R1 was on the floor and had bleeding from a cut on the back of the head and swelling around the cut. The family and physician were notified, and planned to keep R1 at the facility and have the physician see him that day. The nurse did fifteen minute checks and hourly neurological checks which were stable, and stated R1 had neck and head pain which was relieved with medications. An interview with the nursing assistant (NA- L) on 1/26/16 at 11:45 a.m. indicated that the aide had received training and had completed numerous mechanical sit to stand lift transfers. NA-L stated that on 1/20/16 at 8:00 a.m., she had forgot to fasten the waistband by clipping the safety strap and did not use the foot strap to secure R1 in the lift according to manufacturer's instructions and training the facility had provided. NA-L stated the resident fell out of the lift to the floor striking his head. She immediately got the nurse to assess the resident's injuries. An interview with the Director of Nursing (DON) was conducted on 1/25/16 at 3:00 p.m. indicated that NA-L was trained in orientation and had performed numerous transfers without any injuries. She stated the procedure that was trained and the policy of the facility was not followed. R1 was observed to be transferred by 2 nursing assistants on 1/25/16 at 12:15 p.m. from the recliner to the bed using a full lift with a sling, and on 1/26/16 at 8:15 a.m. The nursing assistant care sheets(undated) direct the staff to use the standing lift and assist of 1 or 2 staff. The care plan for R1 dated 6/1/2015 indicated that R1 was to transfer with the assist of 1 to 2 staff and the standing lift. An interview with the case manager (RN-I) was conducted on 1/26/16 at 8:50 a.m., she stated that the care plan for R1 had not been updated since the fall, she thought that physical therapy had assessed and the full lift was being used. The physical therapist was interviewed at 10:30 a.m. and stated there had not been a referral for assessment for R1. An interview with the (DON) was conducted on 1/26/16 at 12:30 p.m. revealed the the care plan could only be updated by the case managers, and had not been done for R1. She verified that the Nursing Assistant care sheets were not always up to date, and that a white board and 24 hour report should also be reviewed by the NA for updates. She was aware that communication to the nursing assistants was inconsistent.

Based on interview and document review, the facility failed to ensure changes in clinical status, including significantly elevated blood sugars and/or results that were a change of condition, were promptly reported to the physician for 1 of 5 residents (R61) reviewed who had diabetes. The lack of clinical monitoring and failure to notify the physician resulted in an Immediate Jeopardy (IJ) situation with the potential to affect 5 current diabetic residents who required blood glucose monitoring. The deficient practice resulted in actual harm for R61 who required emergency medical interventions on [DATE], and later expired. The immediate jeopardy began on [DATE] at 12:25 a.m. when the facility failed to promptly notify the physician of an elevated blood sugar, and was identified on [DATE]. The administrator and director of nursing were notified of the immediate jeopardy on [DATE], at 6:47 p.m. The immediate jeopardy was removed on [DATE], at 3:00 p.m. but non-compliance remained at the lower scope and severity of a G (isolated, with actual harm that is not immediate jeopardy.) Findings include: R61's record was reviewed and according to the admission sheet, R61 had been admitted to the facility on [DATE]. A hospital discharge summary dated [DATE], indicated R61 had been hospitalized prior to admission to the nursing home with an infection and had required a peripherally inserted central catheter (PICC) for infusion of [MEDICATION NAME] (ancef) (an antibiotic medication) until [DATE]. In addition, the hospital discharge summary indicated the resident was to maintain blood glucose (a test that measures the amount of a type of sugar in your blood) goal of ,[DATE] mg (milligrams)/dl (deciliter) due to advanced age, a HgbA1c (hemoglobin A1c, test used as a standard tool to determine the blood sugar control for patients with diabetes over a three month period), and indicated on [DATE] R61's HgbA1c measured 9.5 percent (%) (reflecting an indication of not having good control of blood sugar readings) with the goal for the HgbA1c of 8% due to advanced age. The discharge summary also indicated the resident had been taking [MEDICATION NAME] N (intermediate-acting insulin with a slower onset of action and a longer duration of activity, up to 24 hours) twice daily prior to admission to the hospital and that while hospitalized , R61 had experienced an episode of [DIAGNOSES REDACTED] (low blood sugar) and that her insulin dose would likely require adjustment. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE]; indicated R61 had a BIMS (Brief Interview for Mental Status) score of 13, indicating R61 was cognitively intact. A review of R61's Medication Administration Record [REDACTED]"HI". The manufacturer's guidance for the glucose meter the facility utilized (Assure Platinum), was reviewed and indicated that a "HI" reading indicated the blood glucose reading was at or above 600 mg/dl. The manufacturer directions also indicated the blood glucose should be retested with a new test strip when there was a "HI" reading, and that the health care professional should be contacted. Although the progress notes indicated R61's physician had been contacted for readings over 400 mg/dl, and had given orders for additional insulin coverage and monitoring, the notes indicated the physician had not been notified of the "HI" reading identified on [DATE] at 12:25 a.m. A nursing progress note entry written by registered nurse (RN)-C dated [DATE] at 9:42 a.m., indicated R61's blood sugar reading reading had registered as "HI" at 7:00 a.m. that morning and that the physician had been notified and had ordered 5 units of [MEDICATION NAME] (short acting insulin) to be administered, and to recheck the resident's blood sugar at 8:00 a.m.. The progress note indicated the reading had been "HI" again at 8:00 a.m., that another call had been placed to the on-call physician, and orders had been received to administer 15 units of [MEDICATION NAME] and to recheck the blood sugar in a couple of hours. The progress note indicated R61 had also expressed concern about the high blood sugar readings and would not eat until the blood sugar registered at a reasonable level. The note indicated the resident was alert but making nonsensical statements and unable to find the right words for what she was wanted to say. According to this progress note, R61's blood sugar had been rechecked at 9:30 a.m., and had registered as 546 mg/dl and that a call had been placed to the on-call physician, and orders received to administer another 10 units of [MEDICATION NAME] "STAT (immediately)" and recheck sugars every hour times two and call back. A nursing progress note entry written by licensed practical nurse (LPN)-A dated [DATE] at 4:06 p.m., indicated R61 had a blood sugar reading of 74, the physician had been notified, and orders had been received to provide a glass of juice and to monitor blood sugars every hour until the resident's blood sugars were normal several times, and to call the physician with updated readings. At 4:19 p.m. on [DATE], LPN-A had documented a progress note identifying that R61 would take 1.5 ounces of juice before wanting to rest, family (F) members at bedside, that the resident was able to speak in full sentences clearly and opened her eyes when spoken to. The note indicated R61 recognized F-G upon arrival to the resident's room. At 4:45 p.m. on [DATE], LPN-A documented in the progress notes that R61's blood sugar had been checked and measured 111. That progress note also indicated the physician had been notified with an update, and had directed LPN-A to hold the resident's p.m. (evening) dose of [MEDICATION NAME] that day, and to call the physician with any concerns. A nursing progress note entry written by registered nurse (RN)-E dated [DATE], at 4:51 a.m. included: "Res. (resident) was resting well at 1225 (12:25 a.m.) when this writer entered her room. A blood sugar check was done at that time which read HI. Res. was aroused easily and cooperative with procedure. She did verbalize usual aches and back pain. At that time she was given an [MEDICATION NAME] (pain medication) 5 mg tab. After approx. (approximately). 15 min (minutes). res. was observed to be resting quietly with head of bed elevated and snoring loudly. Call light was in place and no further complaints or requests were noted. T (temperature)-97.0. While doing 4 AM (4:00 a.m.) rounds, res. was found slumped slightly in her bed, color very pale, unresponsive, cool, clammy to touch, and unresponsive. No B/P (blood pressure), No resp (respirations), No pulse. (MD (medical doctor)-A) on call for (MD-B), -gave order to declare death and release body to the funeral home at 4:25 AM. (F-A) was called and gave clearance to allow funeral home to come. (F-A) stated the family had anticipated this call and would not be coming to facility until later this morning to pick up (R61's) belongings." RN-E, who had worked the night shift on [DATE], was interviewed on [DATE] at 3:00 p.m.. When asked by the surveyor what protocol she would follow if a resident had a "HI" blood sugar reading, RN-E stated she would usually call the doctor. However, RN-E stated she'd been informed by the evening nurse from [DATE], that R61 had been having "HI" blood sugar readings on the evening shift so she'd thought she didn't needed to call the doctor because he had previously been aware of the resident's high readings. RN-E added, "I probably should have called the doctor." MD-A (the facility's medical director) was interviewed on [DATE], at 12:00 p.m. about R61's status on ,[DATE] and [DATE]. MD-A stated he would expect a nurse to call the physician, or on call physician, if a resident had a blood sugar reading of "HI" in order to determine what adjustments might be needed for medications (referring to insulin), or to determine whether the resident needed immediate services from the emergency department. R61's care plan dated [DATE], identified a problem of diabetes mellitus II including approaches to administer insulin as ordered, monitoring blood sugar four times daily per physician orders, observe for signs and symptoms of [MEDICAL CONDITION] (high blood sugar), [DIAGNOSES REDACTED] (low blood sugar level), report any blood sugar readings out of acceptable range ,[DATE]. The facility's Physicians' Standing Orders dated [DATE], were reviewed and included: "28. For signs/symptoms of hyperglycemic reaction, initiate following protocol: b. If BS (blood sugar) > (greater) than 500, call M.D. (medical doctor)." The facility's policy, Diabetes Mellitus, Guidelines for (NURSING CARE OF RESIDENT WITH) undated, read, "PURPOSE 4. Recognize, treat or prevent complications commonly associated with diabetes. GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: Blood sugar level. GENERAL DOCUMENTATION GUIDELINES 8. Notification of physician of change in condition." The immediate jeopardy that began on [DATE] at 12:25 a.m., was removed on [DATE], at 3:00 p.m. after the facility had implemented a corrective action plan which included, immediate education of all nursing staff responsible for taking blood glucose testing to follow the current policy and physician orders/physician standing orders for reporting blood glucose levels greater than 400 mg/dl. This was confirmed by interviews conducted with licensed and unlicensed nursing staff on [DATE].

Based on interview and document review, the facility failed to ensure changes in clinical status, including significantly elevated blood sugar levels, were clinically monitored and promptly reported to the physician for 1 of 5 residents reviewed with diabetes (R61); and failed to initiate cardiopulmonary [MEDICAL CONDITION] resuscitation (CPR) for 1 of 5 residents (R61) who had a physician's orders [REDACTED]. The lack of clinical monitoring and failure to initiate CPR resulted in an immediate jeopardy situation. This resulted in harm for R61 who did not receive monitoring and care for an elevated blood sugar, and who did not receive CPR when her heart stopped. These two deficient practices resulted in an Immediate Jeopardy (IJ). The IJ was identified on [DATE], and began on [DATE] at 12:25 a.m.. The administrator and the director of nursing were notified of the IJ on [DATE], at 6:47 p.m. The immediate jeopardy was removed on [DATE], at 3:00 p.m., but non-compliance remained at the lower scope and severity of a G (actual harm that is not immediate jeopardy.) Findings include: R61's record was reviewed and according to the admission face sheet, R61 had been admitted to the facility on [DATE]. A hospital discharge summary dated [DATE], indicated R61 had been hospitalized prior to admission to the nursing home with an infection and had required a peripherally inserted central catheter (PICC) for infusion of [MEDICATION NAME] (ancef) (an antibiotic medication) until [DATE]. In addition, the hospital discharge summary indicated the resident was to maintain blood glucose levels (a test that measures the amount of a type of sugar in your blood) with goal of ,[DATE] mg (milligrams)/dl (deciliter) due to advanced age, a HgbA1c (hemoglobin A1c, test used as a standard tool to determine the blood sugar control for patients with diabetes over a three month period), and indicated on [DATE] R61's HgbA1c measured 9.5 percent (%) (reflecting an indication of not having good control of blood sugar readings) with the goal for the HgbA1c of 8% due to advanced age. The discharge summary also indicated the resident had been taking [MEDICATION NAME] N (intermediate-acting insulin with a slower onset of action and a longer duration of activity, up to 24 hours) twice daily prior to admission to the hospital and that while hospitalized , R61 had experienced an episode of [DIAGNOSES REDACTED] (low blood sugar) and that her insulin dose would likely require adjustment. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE]; indicated R61 had a BIMS (Brief Interview for Mental Status) score of 13, indicating R61 was cognitively intact. A review of R61's Medication Administration Record [REDACTED]"HI." The manufacturer's guidance for the Assure Platinum, glucose meter the facility utilized was reviewed and indicated that a reading of "HI" indicated the blood glucose reading was at or above 600 mg/dl. The manufacturer directions also indicated the blood glucose should be retested with a new test strip when there was a "HI" reading, and that the health care professional should be contacted. Although the progress notes indicated R61's physician had been contacted for readings over 400 mg/dl, and had given orders for additional insulin coverage and monitoring, the notes indicated the physician had not been notified of the "HI" reading identified on [DATE] at 12:25 a.m. A nursing progress note entry written by registered nurse (RN)-C dated [DATE] at 9:42 a.m., indicated R61's blood sugar reading had registered as "HI" at 7:00 a.m. that morning and that the physician had been notified and had ordered 5 units of [MEDICATION NAME] (short acting insulin) to be administered, and then to recheck the resident's blood sugar at 8:00 a.m. The progress note indicated the reading had been "HI" again at 8:00 a.m., another call had been placed to the on-call physician, and orders had been received to administer 15 units of [MEDICATION NAME] and to recheck the blood sugar in a couple of hours. The progress note indicated R61 had also expressed concern about the high blood sugar readings and would not eat until the blood sugar registered at a reasonable level. The note indicated the resident was alert but making nonsensical statements and unable to find the right words for what she was wanted to say. According to this progress note, R61's blood sugar had been rechecked at 9:30 a.m., and had registered as 546 mg/dl and that a call had been placed to the on-call physician. The on call physician ordered another 10 units of [MEDICATION NAME] "STAT (immediately)" and recheck sugars every hour times two and call back. At 10:36 a.m. on [DATE], RN-C's progress note indicated R61 had a blood sugar reading of 423 mg/dl, and that R61 had told the nursing assistant that she thought her family should be there, "just in case something happens." The note described R61 as "continues to be lethargic, lying with eyes closed, will open and attempt to answer questions, but falls asleep in mid-sentence." At 10:43 a.m. RN-C had documented that she'd attempted to reach R61's family (F)-E member and F-F, and that R61 was resting quietly in bed. At 11:44 a.m. RN-C had documented that F-F had been updated on R61's blood sugar from 11:30 a.m. which had measured 282 mg/dl and had updated F-F on R61's confusion/lethargy. The note indicated RN-C was going to wait one hour to reassess and administer sliding scale and scheduled [MEDICATION NAME] per physician. At 2:47 p.m. on [DATE], RN-C had documented a progress note that identified R61's blood sugar reading at 12:30 p.m. as having been 208 mg/dl, and that 9 units of [MEDICATION NAME] had been administered. The note indicated R61 had attempted to eat lunch, however a nursing assistant had reported R61 wouldn't eat, but did drink 120 cc (cubic centimeters) of chocolate milk. The note described R61 as comfortable and less lethargic, and that per physician RN-C would continue to recheck blood sugar every hour to ensure that R61's level did not drop too low. A nursing progress note entry written by licensed practical nurse (LPN)-A dated [DATE] at 3:47 p.m. indicated R61's blood sugar had been taken at 2:30 p.m. and had registered as 97 mg/dl. The LPN's entry indicated the RN (did not identify which nurse) had spoken to the physician, and had been told to give R61 a drink, and to recheck the blood sugar again at 3:30 p.m. and call physician with results. The progress note indicated R61's blood sugar had been rechecked at 3:30 p.m. and had registered as 57 mg/dl so the resident had been given 5.5 ounces of a protein drink. In addition, a call had been placed to the physician and orders had been received to administer one tube of Glucose 15 (a concentrated sugar mixture) STAT (immediately) and to recheck the blood sugar at 3:50 p.m. The LPN's note indicated R61 had consumed the tube of Glucose 15, and that her family had been at her bedside and had been kept updated. A nursing progress note entry written by licensed practical nurse (LPN)-A dated [DATE] at 4:06 p.m., indicated R61 had a blood sugar reading of 74, the physician had been notified, and orders had been received to provide a glass of juice and to monitor blood sugars every hour until the resident's blood sugars were normal several times, and to call the physician with updated readings. At 4:19 p.m. on [DATE], LPN-A had documented a progress note identifying that R61 would take 1.5 ounces of juice before wanting to rest, family (F) members at bedside, that the resident was able to speak in full sentences clearly and opened her eyes when spoken to. The note indicated R61 recognized F-G upon arrival to the resident's room. At 4:45 p.m. on [DATE], LPN-A documented in the progress notes that R61's blood sugar had been checked and measured 111. The progress note also indicated the physician had been notified with an update, and had directed LPN-A to hold the resident's p.m. (evening) dose of [MEDICATION NAME] that day, and to call the physician with any concerns. A nursing progress note entry written by registered nurse (RN)-E dated [DATE], at 4:51 a.m. read, "Res. (resident) was resting well at 1225 (12:25 a.m.) when this writer entered her room. A blood sugar check was done at that time which read HI. Res. was aroused easily and cooperative with procedure. She did verbalize usual aches and back pain. At that time she was given an [MEDICATION NAME] (pain medication) 5 mg tab. After approx. (approximately). 15 min (minutes). res. was observed to be resting quietly with head of bed elevated and snoring loudly. Call light was in place and no further complaints or requests were noted. T (temperature)-97.0. While doing 4 AM (4:00 a.m.) rounds, res. was found slumped slightly in her bed, color very pale, unresponsive, cool, clammy to touch, and unresponsive. No B/P (blood pressure), No resp (respirations), No pulse. (MD (medical doctor)-A) on call for (MD-B), -gave order to declare death and release body to the funeral home at 4:25 AM. (F-A) was called and gave clearance to allow funeral home to come. (F-A) stated the family had anticipated this call and would not be coming to facility until later this morning to pick up (R61's) belongings." In addition, during review of R61's record it was revealed the resident had a physician's orders [REDACTED]. RN-E, who had worked the night shift on [DATE], was interviewed on [DATE] at 3:00 p.m.. When asked by the surveyor what protocol she would follow if a resident had a "HI" blood sugar reading, RN-E stated she would usually call the doctor. However, RN-E stated she'd been informed by the evening nurse who worked the evening shift on [DATE], that R61 had been having "HI" blood sugar readings on the evening shift so she'd thought she didn't needed to call the doctor because the doctor had previously been aware of the resident's high readings. RN-E then added, "I probably should have called the doctor." During an interview with LPN-A on [DATE] at 4:30 p.m., LPN-A stated that when she'd reported off to RN-E at the end of her evening shift, she had informed RN-E of R61's blood sugars and that the last one had registered on the high side, but stated she couldn't remember now what that blood sugar had been. LPN-A stated RN-E had stated she would watch R61 and would take another blood sugar around 11:00 p.m. or 12:00 a.m. MD-A (the facility's medical director) was interviewed on [DATE], at 12:00 p.m. about R61's status on ,[DATE] and [DATE]. MD-A stated he would expect a nurse to call the physician, or on call physician, if a resident had a blood sugar reading of "HI" in order to determine what adjustments might be needed for medications (referring to insulin), or to determine whether the resident needed immediate services from the emergency department. R61's care plan dated [DATE], identified a problem of diabetes mellitus II including approaches to administer insulin as ordered, monitoring blood sugar four times daily per physician orders, observe for signs and symptoms of [MEDICAL CONDITION] (high blood sugar), [DIAGNOSES REDACTED] (low blood sugar level), report any blood sugar readings out of acceptable range ,[DATE]. The care plan also included, "(R61 name) (Full code) ..." The facility's Physicians' Standing Orders dated [DATE], were reviewed and included: "28. For signs/symptoms of hyperglycemic reaction, initiate following protocol: b. If BS (blood sugar) > (greater) than 500, call M.D. (medical doctor)." The facility's policy, Diabetes Mellitus, Guidelines for (NURSING CARE OF RESIDENT WITH) undated, read, "PURPOSE 4. Recognize, treat or prevent complications commonly associated with diabetes. GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: Blood sugar level. GENERAL DOCUMENTATION GUIDELINES 8. Notification of physician of change in condition." Interviews specific to CPR: During interview on [DATE], at 11:55 a.m., director of nursing (DON) stated the facility utilized the Physicians' Orders for Life Sustaining Treatment (POLST) for documenting advance directive wishes of residents. Use of the POLST is a national approach to end-of-life planning based on conversations between patients, loved ones, and medical providers. The POLST [MEDICATION NAME] is designed to ensure that seriously ill patients can choose the treatments they want to ensure their wishes are honored by medical providers. The DON stated the POLST was supposed to be filled out on every resident at the time of admission. She stated when residents are admitted from the hospital, and if a POLST has already been filled out, the facility would use the POLST to determine the resident's code status. However, the DON verified there had been no POLST documented for R61. During interview with the facility's administrator at 12:45 p.m. on [DATE], when asked how she expected staff to proceed for a resident who was a full code, the administrator stated she would expect staff to involve the resident's family as each case is individual. The administrator was interviewed again on [DATE] at 2:15 p.m.. The administrator stated RN-E had called her first when RN-E had found R61 to be without pulse or respirations. The administrator stated RN-E had told her R61 was a full code and had asked what to do. The administrator stated, "I told her to call the family and ask what they wanted." The administrator stated she had called the nurse back and was told the family "was good with it" because they had been at the facility during the day and had said their goodbyes. The administrator stated she did not know when RN-E had called the resident's doctor. Administrator verified that although the family had been at the facility during the day on [DATE], there had been no discussion about the resident's code status being modified. During interview on [DATE], at 2:30 p.m., social service designee (SSD)-Z stated F-E had stated to her on [DATE], R61 "is giving up, in so much pain with this abscess, it has been so much for (R61) including the trip to have the PICC replaced was hard on R61." The SSD-Z also stated, "(F-E) had stated (R61) was comfortable" and "let's keep it that way." However, the SSD-Z confirmed she had not discussed R61's code status, or comfort cares with F-E. During the interview with RN-E on [DATE], at 3:00 p.m., RN- E stated she had called the doctor first when she'd found R61 unresponsive at 4:00 a.m. on [DATE]. However, she had not been able to get through and the operator had said she'd have the doctor call back. RN-E stated,"In the meantime, I called the administrator and told her (R61) had passed away and was a full code." RN-E stated, "The administrator told me to call (R61's) family, and the family agreed not to do CPR. The doctor did not call me back within a half an hour so I called doctor again. I called the doctor then to verify (R61's) death." When asked what she was supposed to do if someone was a full code and found with no pulse and no respirations, RN-E stated, "Generally I would start CPR, but (R61) was well gone when I got in the room. It was obvious (R61) was gone already." SSD-Z was interviewed again on [DATE], at 11:00 a.m. When asked about the facility's practice for assessing advanced directives for each resident, SSD-Z said advance directives are supposed to be reviewed with each resident at the time of admission, and that staff were supposed to abide by the orders on hospital discharge summary for code stats when admitted . SSD-Z stated when residents were admitted , the staff inform the resident of the POLST and give them an option to fill it out if they want, or ask them if they want to use a copy of one already in place from a previous provider upon admission to their facility. SSD-Z said they only redo a POLST if a resident wants changes and then they would have the PA (physician assistant) or NP (nurse practitioner) go over it with the resident. The SSD-Z stated if there was no PA or NP available, she would go over it with the resident and the NP or PA would sign off the form when next at the facility for rounds. The SSD-Z stated R61 had declined to fill out a POLST on admission, and that R61 had wanted to go by what was on the hospital discharge orders. The SSD-Z verified she had not documented her conversation with R61 regarding the resident's preference for advance directives. During the interview with MD-A at 12:00 p.m. on [DATE], MD-A was asked about R61's full code status and how he would have expected the staff to proceed. MD-A stated generally with a full code the resident should be provided CPR. However, MD-A added, in cases where rigidity has set in, if they're not going to conduct CPR, detailed policies should indicate when a resident should not be coded. MD-A also stated he would expect a resident with change in condition, or declining health status, to be re-assessed and to have their code status re-addressed. During interview on [DATE], at 1:20 p.m., the DON stated when a resident had a declining status she would expect staff to notify the doctor, to notify her, to do an assessment and evaluate the situation, and to notify family. The DON said if someone had a declining status and was a full code, she would expect the resident's code status to be re-assessed if possible. The facility policy, CONDITION CHANGE, OF THE RESIDENT (OBSERVING, RECORDING AND REPORTING) undated, included: "PROCEDURE 5. Monitor resident's condition frequently until stable." The facility policy, EMERGENCY CARE, GENERAL GUIDELINES FOR undated, included: "PROCEDURE 7. If a resident expires, initiate CPR unless ordered otherwise. Call paramedics. Call the attending physician and resident's family or responsible party, as appropriate." The facility policy, CARDIOPULMONARY RESUSCITATION (CPR) undated, included: "GENERAL RESIDENT RIGHTS GUIDELINES- Explain advance directive rights to resident on admission; include the resident's family and representatives. Have the physician explain the following to the resident and the resident's representative to assist in making advanced directive decisions: a. CPR and reason for procedure to the resident. B. Benefits of the procedure to the resident. C. Adverse affects, risks, and /or complications of the procedure to the resident." The facility's policy did not identify any instructions for when initiation of CPR, for a resident who had requested to be a full code, would not be appropriate based on the clinical signs and symptoms present at the time the resident was found without a pulse or respirations. The facility policy, ADVANCE DIRECTIVES dated [DATE], read, "PROCEDURE: All residents are asked upon admission if they have completed a health directive or a power of attorney for healthcare or any other document which expresses their views or choices on healthcare issues. Information regarding healthcare directives is included in their admission packet. The resident or resident's representatives' signature is obtained on the admission form verifying they received the information upon admission on advance directives. Directives are placed on face sheet and scanned onto the computer. Once an advance directive is completed, it will be reviewed quarterly and with significant changes with care plan conferences by the IDT (interdisciplinary team), resident and resident's representative. The Power of Attorney for Healthcare or physician's orders [REDACTED]. The physician or nurse practitioner will discuss the options with the resident or resident's representative and will sign and complete the POLST form. The Power of Attorney for Healthcare form can be completed with the resident by Social Services Designee if able to do so and notarized/witnessed accordingly." The facility policy, NOTIFICATION OF RIGHTS and SERVICES dated [DATE], read, "A facility must immediately inform resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in s 483.12(a)." The IJ that began on [DATE], was removed on [DATE], at 3:00 p.m. when the facility implemented a corrective action plan which included, immediate education of all nursing staff to initiate and provide CPR for residents who had made a choice to have CPR initiated if found with signs and symptoms of death, and the facility's development of a policy that reflected the resident's choice to be a full code status. In addition, the facility had initiated immediate education of all nursing staff to follow their current policy, and standing orders, for reporting blood glucose levels greater than 500 mg/dl. The implementation of these interventions were confirmed by interviews conducted with licensed and unlicensed nursing staff on [DATE], and review of the facility's revised policies.

Based on observation, interview, and document review, the facility failed to comprehensively assess and treat acute moderate to severe pain following a fall which resulted in severe head and neck pain for 1 of 1 resident (R42) reviewed for pain. This resulted in harm to R42. Findings include: R42 had moderate to severe pain of the head and neck following a fall incident on 11/24/2012 at 7:49 p.m. which was not relieved with Tylenol (a pain medication recommended for mild to moderate pain) for three days before an order for [REDACTED]. R42 was admitted to the facility 11/10/10 and had [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] indicated the resident had a BIMS (Brief Interview for Mental Status) of 10 (moderately impaired), occasional moderate pain that did not limit function, and no past history of falls. According to an incident report dated 11/24/12, R42 experienced a fall from a standing position to the floor landing on face on 11/24/12 at 7:49 p.m. The incident report described the R42 to have a bruise and open cut on forehead and also a bruise on the nasal bridge of the nose. Also R42 complained of moderate pain located in head/neck area. The physician was contacted on 11/24/12 at 10:02 p.m. and no orders received. R42 was observed on 11/26/12 at 3:29 p.m. and noted to have a large hematoma on forehead that was the diameter of baseball. Also a bruise was observed across the bridge of the nose and extended under both eyes. R42 was holding head with her hands and heard moaning and saying that her head hurt. R42 was sitting with head and neck bent forward while seated in a straight back wheelchair. Again at 5:15 p.m. on 11/26/12, R42 was observed with head and neck bent forward while sitting in a straight back wheelchair at the dining room table and a pillow placed behind her neck. During an interview on 11/27/12 at 5:45 p.m. licensed practical nurse (LPN)-B stated R42 had fallen a few days prior and had a " massive " headache. LPN-B was asked if an x-ray had been taken and said that none had been done. During an interview on 11/27/12 at 7:40 p.m. nursing assistant (NA)-B stated she was concerned because R42 was sitting with head and neck bent forward and lying in bed in this same position. NA-B stated this was a new position for R42 since the fall as she had not done it before the fall incident. During an interview on 11/28/12 at 8:30 a.m. LPN-A stated R42 was able to hold neck/head in an upright position before the fall (fall occurred on 11/24/12) and since the fall R42 had kept her head and neck in a forward bent position. The nursing notes were reviewed from 11/24/12 through 11/27/12. The notes indicated staff was aware R42 had experienced ongoing head and neck pain, but lacked documentation that interventions were provided to minimize the pain or that the nurse practitioner (NP) was aware of the continuing pain for an additional three days after the fall. On 11/24/12 at 11:00 p.m. the nurse document R42 was lying in bed and complained of severe head pain and neck pain. The nurse practitioner (NP) was notified and instructed staff to continue to monitor the resident and update her with any changes. Ice was applied. On 11/25/12 at 2:49 p.m. the resident complained of head and neck pain. The resident indicated it was hard to straighten head. Neurological checks were done and within normal limits. On 11/26/12 at 2:49 p.m. the nurse documented R42 complained of neck pain with activities of daily living and with movement while in the wheelchair. The documentation indicated R42 stated, "I need a neck brace." On 11/27/12 three nursing notes indicated the resident had complained of head and neck pain, was moaning out with pain, and that R42 required assist of two staff to walk to the bathroom. The note indicated R42 ' s head leaned down and tilted to the right side. When asked to lift head up, R42 stated could not due to pain. Resident required being fed by staff due to position of head. Resident progress notes dated 11/27/12 at 4:34 p.m. indicated the resident was seen by the NP "d/t (due to) increased pain and soreness in neck and head from recent fall" and a medication change (NP ordered [MEDICATION NAME]-[MEDICATION NAME] one tab four times per day for pain due to trauma) and occupational therapy orders was completed. On 11/27/12 at 9:18 p.m. nursing documentation indicated the resident requested to lie down at 3:30 p.m. and did not want to get up for supper due to pain in head and neck. R42 did get up at 6:00 p.m. and was observed to hold head in hands the entire time at the dinner table and complaining of pain in neck and head. After dinner R42 went back to bed and had difficulty with bedtime cares due to resident holding head and not wanting any cares done due to pain. [MEDICATION NAME] (pain medication) given at 8:00 p.m. and the medication was effective. On 11/28/12 at 5:12 a.m. the nursing notes indicated "Resident resting when checked on periodically throughout the night, but when attempted to move (R42 ) to change position and give (R42 ) a drink of water (R42 ) was clearly still in a lot of pain, not wanting to be touched, calling out 'Oh it hurts too much. " During review of the pain regimen for R42 following the fall which resulting in moderate to severe neck and head pain on 11/24/12 at 7:49 p.m. it was noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Again received Tylenol 325 mg 2 tabs PRN for head and neck pain on 11/27/2012 at 5:10 a.m. and no results documented. On 11/27/12 (three days after the fall and no relief from moderate to severe pain) an order for [REDACTED]. The consultant pharmacist was interviewed on 11/28/12 at 11:10 a.m. and indicated the facility had an emergency drug kit (e-kit) that contained [MEDICATION NAME] 5/500 mg. The consultant pharmacist reviewed the content of the emergency drug kit and noted that the e-kit did contain the [MEDICATION NAME] and stated that with a one-time order from the NP the staff could have obtained the pain medication from the e-kit. The NP was interviewed on 11/28/12 at 12:30 P.M. and stated she would have given staff a one-time order for the e-kit [MEDICATION NAME] if the staff had contacted her about not having the correct dose of [MEDICATION NAME] available so the resident could have received pain relief sooner. The care plan provided 11/28/12 had a problem dated 11/27/12 that stated, " Has a history of complaints of right ankle bone pain. Recent fall on 11/24/12 with complaints of pain to head and neck. " The care listed 2 interventions/approached specific to head and neck pain. Interventions included: 1. dated 11/27/12 " Administer medications: [MEDICATION NAME]. Evaluate/record/report effectiveness and any adverse side effects. " 2. dated 11/27/12 " PT to eval and treat for neck pain. " No further care plan was found related to pain or management of hematoma and pain in head and neck. The physical therapy assessment done the same day it was ordered by the physician on 11/27/12 was reviewed. The initial assessment indicated that prior to the fall the resident was able to transfer and walk with contact guard assistance due to unsteadiness during transfer. The assessment indicated that R42 ' s current level was moderate assistance requiring 50% physical assistance. The assessment noted the " patient completes all functional transfers and ambulation with head held in severe flexion." During an interview on 11/28/12 at 11:25 a.m. the physical therapy aid stated R42 was seen by the therapist the day before and the physical therapy notes of 11/27/12 indicated R42 was in severe pain. During an interview with the physical therapist (PT) on 11/28/12 at 11:55 a.m. the PT indicated she felt R42 had a contusion and stiff neck muscles from the fall that were causing the pain and that it may take up to 4 weeks to get the pain and stiffness resolved. The director of nursing was interviewed on 11/29/12 at 12:50 p.m. indicated R42 did not have a comprehensive pain assessment and monitoring pain medication for effectiveness following her fall.