Every finding on record at Vista Manor Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to coordinate and communicate effectively among the interdisciplinary team to ensure diabetic residents received continuity of care in accordance with professional standards of practice, the care plan, and resident choice to attain or maintain their highest practicable physical, mental and psychosocial wellbeing, (#1). This failure in care coordination resulted in a lack of proper blood glucose monitoring and treatment for 48 days, during which resident #1 developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. The resident required emergency 911 transfer to the hospital and admission to the Intensive Care Unit (ICU), for 3 days. This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes.On 3/17/26, resident #1 was found with severe hypoxia, cold, clammy skin, pallor, and a blood glucose finger stick reading high, that indicated it exceeded the device's measurement capabilities. Resident #1 had a diagnosis of type II diabetes but had not been ordered any finger stick glucose monitoring or medications for diabetes since her re-admission on [DATE]. She was transferred to the hospital via 911 and admitted to the Intensive Care Unit (ICU). She was admitted with sepsis (infection) and HHS with blood glucose level of 945 milligrams per deciliter (mg/dl).HHS is a life-threatening complication of diabetes, mainly type II diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment, or it could be fatal. HHS involves a lack of insulin, but the person usually produces enough insulin to prevent the production of ketones. In addition, there's usually an underlying condition, such as an infection, that's also contributing to the high blood sugar. If you manage diabetes well, your risk for developing HHS is low but certain conditions and situations can trigger HHS to develop in people who aren't managing diabetes well. Common triggers of HHS include infections like pneumonia, urinary tract infections (UTI), and sepsis. Other triggers include stopping diabetes medications and cardiovascular issues such as stroke, pulmonary embolism or heart attacks. The risks factors for HHS include diagnosis of type II diabetes, having poorly managed diabetes, being 65 or older, and having a history of infections, illness or a heart condition. If untreated HHS could lead to seizures, coma, organ failure, or death, (retrieved from my.clevelandclinic.org on 04/23/26). The facility failed to recognize resident #1 was not receiving diabetic care and failed to appropriately communicate within the interdisciplinary team (IDT) to ensure resident #1 received appropriate and timely diabetic care according to her goals and wishes. The lack of oversight by the IDT team led to resident #1 not having a diabetic treatment plan which placed her and all diabetic residents at risk for serious injury, impairment, or death. This failure resulted in Immediate Jeopardy which began on 1/28/26.Findings:Cross reference F552, F600, and F867Resident #1, an [AGE] year-old female, was initially admitted to the facility on [DATE] for respite care (temporary care to give caregivers a break) with hospice services and re-admitted on [DATE] from an acute care hospital for skilled nursing care without hospice services. Her admitting diagnoses included type II diabetes mellitus with hyperglycemia (elevated blood sugar levels), sacral pressure ulcer stage 3, chronic kidney disease, obesity, history of myocardial infarction (heart attack), atrial fibrillation, heart disease, and neuromuscular dysfunction of bladder (nerve damage that impairs bladder control).The Agency for Healthcare Administration (AHCA) Form 5000-3008 dated 1/28/26 documented resident #1 required a surrogate for decision making and listed the resident's husband as emergency contact but her cognitive status at transfer was alert, oriented, and able to follow instructions. Her primary diagnoses were UTI, and urinary retention with use of urinary catheter. The form directed the facility to review the Medication Administration Record (MAR) to review times when medications such as anticoagulants, antibiotics, and insulin were last administered.Resident #1's hospital records for admission date 01/24/26 listed uncontrolled type II diabetes mellitus with hyperglycemia as one of her active diagnoses and insulin Lispro 0-5 units subcutaneous (SQ) with meals and nightly was part of her medication list for diabetes management along with finger stick blood glucose monitoring. Her last blood glucose at the hospital on [DATE] was 239 mg/dl, which was flagged as abnormal.On 04/13/26 at 4:43 PM, Licensed Practical Nurse (LPN) A said she was familiar with resident #1 because she was a re-admit. She explained that when a resident was admitted from the hospital, they arrived with an admission packet which included the discharge medication list, AHCA form 3008, and the clinical documents. She explained resident #1's discharge medication list from the hospital did not look like what she was used to. She recalled that on 1/28/26 she had several admissions, so she was unable to look through all the documents that came in resident #1's admission packet. LPN A said she did not have time that night to look at any other documents that arrived with the resident, so she called the attending physician and reconciled the medications based on the medication list that was provided. As part of the admission process, LPN A said she did a blood glucose finger stick on resident #1 and the result was 273 mg/dl, which she acknowledged was abnormal. She said she documented the result but did not check to see if the resident had orders for diabetic medications and did not report the result to the attending physician because it was the end of her shift. LPN A said she figured the clinical team would discuss the resident's abnormal blood glucose during the morning clinical meeting.For reference, individuals with type II diabetes are recommended to keep fasting blood sugars between 80 mg/dl and 130 mg/dl and less than 180 mg/dl 2 hours after meals (medicalnewstoday.com, retrieved 4/28/26).On 4/13/26 at 2:49 PM, the Unit Manager (UM) for [NAME] 1 unit said she attended the morning clinical meeting on 1/29/26. She explained that during clinical meetings the 24-hour report was usually reviewed which included admissions/re-admissions, changes in condition, resident assessments, new physician orders, and progress notes. She could not recall if the team reviewed resident #1's clinical documents but they did review her orders to ensure they were in the system. She said if there had been any concerns with her orders, they would have called the attending physician to clarify. She said this was resident #1's second admission so the clinical team knew about her. The UM said resident #1 was transferred to another unit, [NAME] 2 unit on 1/29/26 and then she did not recall hearing about her during clinical meetings until she was transferred to the hospital on 3/17/26. She said LPN A should have reported the abnormal blood glucose result to the attending.On 4/13/26 at 3:13 PM, the UM for [NAME] 2 unit said she did not attend the morning clinical meeting on 1/29/26 as she was assisting with resident care. She explained she liked to work alongside the staff so sometimes she did not attend the meetings, but the Director of Nursing (DON) or other Unit Manager communicated with her after the meetings. She could not recall on which day resident #1 was transferred to her unit from [NAME] 1 unit but she believed it was on the weekend and not when it was documented, 1/29/26. She explained her expectation was for the nurses to review the clinical documents to ensure they didn't miss anything and if they had question, they should clarify with the physician, hospital, resident, or family. She said if there were no orders for diabetic management, the nurses should have made the attending physician aware. She said the clinical team did not discuss resident #1's diabetic management until after she was transferred to the hospital on 3/17/26. She recalled the DON held a meeting with LPN A to discuss how diabetic management orders were missed during admission. She said resident #1's family never had concerns related to her diabetes management and did not make any complaints. She added that resident #1 was being followed closely by several physicians.Review of resident #1's progress notes, revealed a note from the Advanced Practice Nurse Practitioner (APRN) on 1/29/26 which listed resident #1's diagnoses, medical history, current and past medications, labs, vital signs, and plan of care. It noted resident #1 was a type II diabetic, on Metformin, received respite care, and was followed by hospice. Last fingerstick blood glucose level on 1/28/26 at 11:34 PM was 273. The plan was to continue hypertension and diabetes management with a palliative focus. There were no new orders documented for diabetes management. A second progress note on 02/02/26 with date of service 1/30/26 from the attending physician noted: type II DM (diabetes mellitus) condition unstable as blood glucose readings remain persistently elevated (273 on 1/29 (done 1/28) and 240 on 1/19) most recent A1c ([DATE]) is 8.2%indicating poor glycemic control. Episodes of chronic kidney disease and advanced age are risk factors that increase the risk for diabetes-related complications. The plan was to monitor BG (blood glucose), A1c, renal function, and symptoms of hypo/hyperglycemia. The attending physician did not give any new orders for diabetes management.A1c is a test that measures average blood sugar levels over the past 2-3 months. For most adults with diabetes, an A1c of less than 7% is generally recommended, but individual targets may vary based on personal health conditions (healthline.com, retrieved 4/28/26).On 4/13/26 at 4:47 PM, in a telephone interview with the attending physician, it was revealed that he did not mean to say resident #1's diabetes was unstable but instead meant to say it was stable. He did not answer when asked if the rest of his note was also a mistake. The attending stated that he was aware resident #1 was diabetic and his treatment plan was appropriate based on her complex medical history. He said the recommendations to monitor BG (blood glucose), A1c, renal function, and symptoms of hypo/hyperglycemia were not orders. He expected staff to know the physical signs and symptoms of hypo/hyperglycemia and that they would report changes in condition. The attending stated that it was difficult to say if resident #1's increased blood glucose caused her to have sepsis or if the sepsis caused her blood glucose to rise but he acknowledged there was a possibility that her blood glucose could have been lower with proper blood glucose monitoring and medications, but it was hard to say. He agreed that a blood glucose level of over 900 mg/dl could cause severe injury.Review of resident #1's Order Summary Report dated 4/11/26 revealed there were no orders for diabetic treatment or monitoring from 1/28/26 to 3/17/26. The resident had a diet order for Consistent Carbohydrates Diabetic (CCD) diet that started on 1/28/26. There was a Comprehensive Metabolic Panel (CMP) ordered by the attending physician on 3/11/26.Results of resident's #1 CMP on 3/12/26 per the medical record, revealed her blood glucose level was 285 mg/dl.On 4/17/26 at 4:58 PM, a phone interview was conducted with the prior Dietician, who was a consultant for the facility. He was unable to access resident #1's record as he no longer worked with the facility but stated that when he evaluated residents, he looked at hospital records, physician orders, progress notes, and the AHCA 3000 form to create the dietary plan. He said if the resident was diabetic, he would recommend the CCD diet and monitor labs and blood sugar levels during follow ups to ensure the dietary plan was working. He explained that if the resident had no orders for diabetic medications or monitoring but had diagnosis of diabetes, he would clarify the plan with the DON.Review of resident #1's assessments revealed she had been evaluated by the dietician on 02/05/26. The note listed her diagnoses including type II diabetes and noted she had pressure sores to her sacrum. There were no diabetic medications listed or labs. The plan was for a CCD diet and to follow up with labs. There was no evidence resident #1's diabetes was being controlled or monitored via diet since there was no mention of her abnormal fingerstick blood glucose result on 1/28/26 or the diabetic plan based on review of her clinical documents from the hospital.Review of resident #1's progress notes from 3/12/26 to 3/17/26 revealed the Nurse Practitioner reviewed the blood glucose result from the CMP and there were no new orders for diabetic management from any of the multiple providers who assessed her from 1/28/26 to 3/17/26.Resident #1 had a care plan for diabetes management initiated on 1/19/26 and revised 2/10/26 by the Director of Minimum Data Set (MDS). The goal was for the resident to have no complications related to diabetes through next review date with target date 4/21/26. The interventions included:(Initiated 1/19/26)- diabetes medication as ordered by doctor, monitor for medication effectiveness, routine skin inspections, and notify provider of abnormal observations.(Initiated 2/10/26)- fasting blood sugars as ordered, monitoring for s/s (signs and symptoms) of hypo/hyperglycemia.On 4/14/26 at 4:29 PM, the Director of MDS acknowledged resident #1's diabetic care plan had been pulled from her previous admission on [DATE] which was created based on the diabetic plan she had at that time, which included medications and daily blood glucose monitoring. She said the care plan was created based on the resident's orders, diagnoses, assessments, and clinical history which was obtained from hospital records. She confirmed resident #1 did not have any orders for diabetes management but the care plan was standard for a diabetic resident. She explained that some care plans were created with the expectation that orders would be put in at some point based on their diagnosis and diabetes was one of them because most diabetic residents had orders for either medications, labs, and/or monitoring. The Director of MDS said she had a care plan meeting with resident #1's family on 2/10/26 but there were no concerns related to her diabetes management. She said she pulled resident orders every morning and updated the care plan as needed and if there were concerns, they would talk about it during morning clinical meetings. She was unable to explain why resident #1 had interventions initiated on 2/10/26 for obtaining fasting blood sugars as ordered and monitoring for s/s of hypo/hyperglycemia when there were no new orders.On 4/18/26 at 1:04 PM, resident #1's representative (son), stated he did not recall speaking about his mother's diabetic care plan during the care plan meeting on 2/10/26 with the Director of MDS. He explained he expected the facility to provide his mother with diabetic medications and monitoring like they had during her previous admission on [DATE]. He said he had concerns with her BG because he would visit the facility every day and would see staff giving her sugar on her meal trays even though she was supposed to be on a diabetic diet. He kept finding sugar packets all over the resident's room, so he posted signs in her room for staff to not give her regular sugar. On 4/15/26 at 2:17 PM, LPN B confirmed she was the assigned nurse for resident #1 on 3/17/26. She said it was her first time being assigned to resident #1 so she was not familiar with her. She recalled that at 5:30 PM when she noticed the resident was having difficulty breathing, she did a head-to-toe assessment including a BG. She said she was not aware resident #1 was diabetic but it was standard practice to test the person's glucose level during a change in condition. She said resident #1's BG read 'high on the machine which meant it was too high for the machine to read it. She called and reported the resident's condition to the on-call Nurse Practitioner (NP) including the high BG reading but there were no orders related to BG control just related to her low oxygen levels. She was instructed by the NP to provide oxygen and call back if s/s did not resolve. LPN B told the DON (unsure of date) that she had reported the BG results to the NP but did not document it. She confirmed she did not tell the resident's family about resident #1's BG levels being elevated, she said the resident was transferred due to low oxygen.Review of resident #1's hospital records for date 3/17/26, revealed the report from Emergency Medical Services (EMS) which showed their primary impression was diabetic hyperglycemia and secondary impression was shortness of breath. They arrived at the facility at 7:05 PM and did a BG at 7:29 PM which was noted to be high.On 4/13/26 at 5:24 PM, the DON stated resident #1 did not show any s/s of hyperglycemia so there was no indication for the clinical team to look at her diabetic management. She said LPN A entered the medications that were listed on the medication list from the hospital and there were no diabetic medications. She confirmed the clinical team reviewed resident #1's hospital records on 1/29/26, during clinical meeting and there were no orders for diabetes management. She acknowledged the LPN A should have reported the elevated BG reading on 1/28/26 to the attending physician.According to the Facility Assessment updated 8/2024, the facility is able to care for residents with metabolic disorders such as Diabetes. The facility is able to manage medical conditions by performing assessments, early identification of problems/deterioration, and management of certain conditions such as diabetes.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified and addressed a systemic process failure related to coordination, communication, and continuity of care for a resident requiring diabetes management. Following a resident's hospitalization for complications related to not receiving diabetic treatments for 48 days, the facility failed to immediately identify the factors that contributed to the resident's decline. Approximately three months later, after the survey team identified the incident, the QAPI committee initiated a Performance Improvement Plan (PIP) that lacked documentation and root cause.On 3/17/26, resident #1 was found with severe hypoxia, cold, clammy skin, pallor, and a blood glucose finger stick reading high, that indicated it exceeded the device's measurement capabilities. Resident #1 had a diagnosis of type II diabetes but had not been monitored or treated since her re-admission on [DATE]. She was transferred to the hospital via 911 and admitted to the Intensive Care Unit (ICU). She had a blood glucose level of 945 mg/dl, sepsis (infection) and HHS.HHS is a life-threatening complication of diabetes, mainly type II diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment, or it could be fatal. HHS involves a lack of insulin, but the person usually produces enough insulin to prevent the production of ketones. In addition, there's usually an underlying condition, such as an infection, that's also contributing to the high blood sugar. If you manage diabetes well, your risk for developing HHS is low but certain conditions and situations can trigger HHS to develop in people who aren't managing diabetes well. Common triggers of HHS include infections like pneumonia, urinary tract infections (UTI), and sepsis. Other triggers include stopping diabetes medications and cardiovascular issues such as stroke, pulmonary embolism or heart attacks. The risks factors for HHS include diagnosis of type II diabetes, having poorly managed diabetes, being 65 or older, and having a history of infections, illness or a heart condition. If untreated HHS could lead to seizures, coma, organ failure, or death, (retrieved from my.clevelandclinic.org on 04/23/26). Findings:Cross reference F552, F600 and F684 Review of the facility's Policy and Procedure titled, Quality Assurance and Performance Improvement (QAPI), revised 12/08/25 defined an adverse event as, an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof. High risk areas referred to care and service areas associated with significant risk to the health or safety of residents and errors in these care areas had the potential to cause adverse events resulting in pain, suffering, and/or death. Examples provided included administration of high-risk medications such as insulin. The policy detailed Performance Improvement (PI) identified areas of opportunity and underlying causes and provided approaches to correct systemic problems or barriers to improvement. QAPI was defined as taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality. The program's purpose was to prevent deviation from care processes to the extent possible, focus on indicators of outcomes of care, quality of life, and resident choice, and developing and implementing plans to correct and/or improve identified areas. On 4/09/25 at 9:17 AM, the Director of Nursing (DON) acknowledged an incident where resident #1 did not receive their diabetic medications or monitoring which led to her being hospitalized . The DON said when resident #1 was re-admitted to the facility from the hospital on 1/28/26, the hospital had taken her off the oral diabetic medications and put her on insulin, but the admitting nurse never entered the order so resident #1 went without diabetic care until she was transferred to the hospital on 3/17/26, around 48 days later. The DON stated the facility had not taken the incident to QAPI or created a PIP. She said the facility conducted audits of all diabetic residents in the facility after the resident returned on 3/20/26 but she was unable to provide documentation of the audits or of any review of the audit results by the QAPI committee to determine if the facility needed to take action. On 4/13/26 at 5:24 PM, the DON stated statement was that they did not receive a discharge medication list for resident #1 from the hospital on 1/28/26. She said the facility did not hold any QAPI meetings related to the incident after they realized her BG was elevated when she arrived at the hospital. The DON said that after the resident returned to the facility on 3/20/26 there were no new processes implemented. She said the medical director was made aware of the incident after the resident had been transferred to the hospital, but he did not call for an Ad Hoc or bring it to QAPI. The DON conveyed that issues were usually brought to the Interdisciplinary team (IDT) meeting, every morning, and they determined if the incident/issue was a reportable. She confirmed resident #1's incident was not discussed in IDT or QAPI until after the concerns were brought up during the recertification survey of 4/06/26 to 4/09/26, even after identifying the resident was sent to the hospital on 3/17/26 with hyperglycemia. Further review showed the facility failed to initiate a PIP to investigate the underlying causes of the breakdown in medication administration, physician order transcription, and/or medication reconciliation processes. There was no evidence of a structured root cause analysis, interdisciplinary involvement, measurable improvement goals, or ongoing monitoring for effectiveness. On 4/13/26 at 4:47 PM, in a telephone interview, the Medical Director confirmed there had been no Ad Hoc or QAPI meeting after he found out resident #1's BG was elevated and she was admitted to the ICU. He was unable to provide an explanation of why the incident had not been investigated or brought to QAPI but said resident #1 had been treated by multiple providers while she was at the facility and was unsure of what their recommendations were. The physician said resident #1 had been followed by hospice during her initial admission on [DATE] and they were managing her diabetic medications, but he was not aware the resident was no longer on hospice services when she returned on 1/28/26. He said resident #1 was transferred to the hospital because she had hypoxia and not because she was hyperglycemic. He said it was hard to determine if hyperglycemia could have been prevented by the facility, had she been on diabetic medications, because she had a urinary tract infection which could increase the BG level for diabetic residents.In people with diabetes, infections can trigger or worsen hyperglycemia, and uncontrolled high blood sugar can make infections more severe and harder to treat, (retrieved from pmc.ncbi.nlm.nih.gov on 4/30/26). In a joint interview with the Director of Nursing (DON), Nursing Home Administrator (NHA), and Medical Director (via phone) on 4/14/26 at 12:19 PM, the DON, NHA, and Medical Director confirmed there was no formal performance improvement project or review by QAPI after resident #1 was found on 3/17/26 with an unreadable (high) blood glucose level and she was hospitalized in the ICU with sepsis and HHS, until the concern was brought to the facility's attention during the previous recertification survey. The NHA explained the facility felt they did not need to investigate the incident of resident #1's rehospitalization and related hyperglycemia because they felt resident #1's elevated BG could not have been prevented, and she was transferred to the hospital due to hypoxia.

Based on observation, interview, and record review, the facility failed to coordinate, communicate, and document the change in diabetic treatment plan for a chronically ill resident who required a surrogate for decision making, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. Resident #1 and her representative were not informed of the risks associated with not receiving diabetic care and were not given the choice to make an informed decision on the treatment plan. The failure in care coordination resulted in lack of diabetes care and monitoring according to resident/family wishes for 48 days, during which the resident developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. The resident required emergency 911 transfer to the hospital and admission to the Intensive Care Unit (ICU), for 3 days.HHS is a life-threatening complication of diabetes, mainly type II diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment, or it could be fatal. HHS involves a lack of insulin, but the person usually produces enough insulin to prevent the production of ketones. In addition, there's usually an underlying condition, such as an infection, that's also contributing to the high blood sugar. If you manage diabetes well, your risk for developing HHS is low but certain conditions and situations can trigger HHS to develop in people who aren't managing diabetes well. Common triggers of HHS include infections like pneumonia, urinary tract infections (UTI), and sepsis. Other triggers include stopping diabetes medications and cardiovascular issues such as stroke, pulmonary embolism or heart attacks. The risks factors for HHS include diagnosis of type II diabetes, having poorly managed diabetes, being 65 or older, and having a history of infections, illness or a heart condition. If untreated HHS could lead to seizures, coma, organ failure, or death, (retrieved from my.clevelandclinic.org on 04/23/26). On 3/17/26, resident #1 was found with severe hypoxia, cold, clammy skin, pallor, and a blood glucose finger stick reading high, that indicated it exceeded the device's measurement capabilities. Resident #1 had diagnosis of type II diabetes but had not been monitored or treated since her re-admission on [DATE]. She was transferred to the hospital via 911 and admitted to the Intensive Care Unit (ICU). She had a blood glucose level of 945 milligrams per deciliter (mg/dl), sepsis (infection) and HHS.The facility failed to ensure resident #1 and her representative were informed, in a timely manner, of the diabetic treatment options available and associated risks so they could make an informed decision. The facility made a choice for the resident that was not in alignment with her or her representative's healthcare goals which placed her and other residents at risk for serious injury, impairment, or death. This failure resulted in immediate Jeopardy which began on 1/28/26.Findings:Cross reference F684, F600, and F867Record review revealed resident #1, an [AGE] year-old female, was initially admitted to the facility on [DATE] for respite care (temporary care to give caregivers a break) with hospice services and re-admitted on [DATE] from an acute care hospital for skilled nursing care without hospice services. Her admitting diagnoses included type II diabetes mellitus with hyperglycemia (elevated blood sugar levels), sacral pressure ulcer stage 3, chronic kidney disease, heart failure, obesity, history of myocardial infarction (heart attack), and neuromuscular dysfunction of bladder (nerve damage that impairs bladder control).The Agency for Healthcare Administration (AHCA) Form 5000-3008 dated 1/28/26 documented resident #1 required a surrogate for decision making and listed the resident's husband as emergency contact but her cognitive status at transfer was alert, oriented, and able to follow instructions. Her primary diagnoses were UTI, and urinary retention with use of urinary catheter. The form directed the facility to review the Medication Administration Record (MAR) to review times when medications such as anticoagulants, antibiotics, and insulin were last administered.Review of the Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date of 02/04/26 showed during the look back period, resident #1 scored 13 out 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. No behavior or rejection of care were noted. It was noted the resident and family were active participants in the assessment process.Resident #1's hospital records for admission date 01/24/26 listed uncontrolled type II diabetes mellitus with hyperglycemia as one of her active diagnoses. She was treated with insulin Lispro 0-5 units subcutaneous (SQ) with meals and nightly. Her BG was monitored daily with her last one on being 239 mg/dl on 1/27/26, which was flagged as abnormal.On 04/13/26 at 4:43 PM, Licensed Practical Nurse (LPN) A stated in an interview she worked the 3 PM to 11 PM shift on 1/28/26 and was the admitting nurse for resident #1. She mentioned resident #1 had been previously admitted to the facility so she was familiar with her. She described the admission process. Resident #1 arrived with discharge paperwork from the hospital, which included clinical documents, discharge medication list, and discharge instructions. She said she completed the admission assessment, which included a head-to-toe assessment, blood glucose fingerstick, and interview with resident and/or representative. She claimed that it was standard to check blood glucose on newly admitted residents even if they were not diabetic. LPN A confirmed resident #1's blood glucose reading was 273 mg/dl, which was abnormal (high). She reviewed the hospital discharge medication list, which did not include diabetic medications, and called the attending physician to reconcile the medications. She said she did not receive any orders for diabetic medications or monitoring and did not report the abnormal blood glucose reading to the attending physician. She explained, it was the end of her shift when she spoke with the attending physician and was sure the resident would be discussed during morning clinical meeting. LPN A acknowledged she did not report the results of the fingerstick to resident #1 or her representative and did not ask how she managed her diabetes.On 4/13/26 at 2:49 PM, the Unit Manager (UM) for [NAME] 1 unit said she was part of the morning clinical meetings which included the Director of Nursing (DON), UM for [NAME] 2, and the Director of MDS. She explained that during clinical meetings the team discussed the previous night's admissions for each unit and clinical issues related to resident care. She said the team reviewed the medication orders entered by the admitting nurse and compared them to what was found in the clinical documents which included the 3008 form, discharge medication list, History and Physical (H&P), and Medication Administration Record (MAR). She said if there were discrepancies with the medications ordered they would call the attending to clarify. She recalled resident #1 was initially admitted on [DATE] for respite care and her blood glucose was managed with two oral antidiabetic medications by the same attending physician. She acknowledged the team reviewed resident #1's discharge documents and medications ordered but did not discuss her diabetes treatment plan. The UM said she was unsure how it was missed. On 4/13/26 at 3:13 PM, the UM for [NAME] 2 said resident #1 was transferred to her unit on 1/29/26 and remained there until she was transferred to the hospital on 3/17/26. She said she did not always attend the clinical meetings because she liked to stay involved in resident care along with her staff, but she would be briefed by the DON after the meeting. She recalled she did not attend the meeting on 1/29/26 and did not recall being informed that resident #1 did not have a diabetic treatment plan. She said as the UM, she reviewed admissions/re-admissions clinical documents and would audit charts sometimes. She did not recall reviewing resident #1's medical record or speaking with the resident or representative regarding her diabetic treatment plan.On 4/13/26 at 4:47 PM, resident #1's attending physician confirmed he was also the facility's medical director. He stated he was familiar with resident #1 because he had been her attending since initial admission on [DATE]. He said the admission nurse called him on 1/28/26 (unsure of time) to reconcile resident #1's medications but there was a discrepancy with the paperwork the hospital sent and was unable to get clarification from them. He said he was aware resident #1 was a diabetic that had been previously treated with oral antidiabetic medications and was unsure why she was no longer taking them. He was aware she was treated with insulin at the hospital but decided not to continue that treatment plan. The attending physician explained resident #1 was a hospice resident with complex diagnoses so it was beneficial for her to stay hyperglycemic (elevated blood glucose) instead of hypoglycemic (low blood glucose) to prevent further complications. He was reminded that resident #1 was not receiving hospice services during her 1/28/26 admission and he said he was not aware. He confirmed he did not give orders for diabetic medications or monitoring, but staff knew to report if the resident showed physical signs and symptoms of hypo/hyperglycemia. In a later interview on 4/14/26 at 12:19 PM, the attending said via phone that he had a conversation with resident #1's representatives, her son and husband, (unable to provide date or time) about her diabetic treatment plan and they agreed with his plan. He said the representative wanted the resident to be treated with a palliative approach which he said meant they did not want her to be poked or prodded unnecessarily but the representative was not asked for clarification of what this meant. He was unable to provide documentation of the conversation but acknowledged it should have been documented.A palliative approach is holistic, compassionate care aimed at improving quality of life and relieving suffering for people living with serious or life-threatening illnesses, staring early in the course of illness rather than only at end of life. A palliate approach to care engages in advance care planning to support health care wishes, provides information, education, and community support. Conversations with the person or family are important to ensure wishes are followed and the person receives the care they want and need. (interiorhealth.ca, Palliative Approach to Care, retrieved 4/27/26).Resident #1's baseline care plan, started by LPN A on 1/28/26, documented she was on diabetic medications, and the goal was for resident to adhere to the prescribed individualized treatment plan for management of diabetes. The interventions included obtaining fingerstick blood glucose monitoring, diabetic medications, and monitoring for medication side effects. Resident #1 did not have physician's orders for blood glucose monitoring, medications, or a treatment plan. On 4/14/26 at 4:29 PM, the MDS Director confirmed she had worked at the facility for almost a year and had been a nurse for over 30 years. She explained the baseline care plan was generally started by the admission nurse and then she would complete it after the morning clinical meeting. She attended the clinical meeting on 1/29/26 but did not recall discussing resident #1's diabetic treatment plan. She said resident #1 was a re-admission on [DATE] so she pulled forward the care plan from the previous admission and continued the diabetic plan she had. She stated she was not aware resident #1 had no orders for diabetes management and did not discuss this with the clinical team or the attending physician. The MDS Director said a care plan meeting was held with the resident and representatives on 2/10/26. She explained they reviewed resident #1's medications and treatment plan and the representatives had no questions or concerns. She said the resident's representatives wanted a palliative approach to her care, which she agreed was not in the care plan so there was no clear explanation for what the resident or representative's wishes were.Review of the care conference record dated 2/10/26, revealed resident #1, her representatives, MDS Director, and Social Service Director (SSD) attended at the meeting. In the comment section it was noted the plan of care was reviewed and other areas such as medications, care, treatments, and therapies were discussed. There was no documentation to show the representatives were aware of resident #1's diabetic treatment plan.In a phone interview with one of resident #1's representatives, her husband, on 4/13/26 at 12:30 PM, he said she had been a diabetic for many years and had been managed with oral diabetic medications but during her 1/24/26 hospital admission, the hospital discontinued the oral medications and put her on insulin because of hyperglycemia and uncontrolled diabetes. He said he was not aware resident #1's blood glucose was not being monitored or that she was not receiving insulin. He said he did not have any conversations with the attending physician about changing the treatment plan for diabetes and confirmed she was not receiving hospice services during her 1/28/26 admission.On 4/13/26 at 4:40 PM, resident #1's other representative, her son, said via phone interview that he was not aware the facility was not providing his mother with diabetic medications or daily fingerstick blood glucose monitoring until she was transferred to the hospital on 3/17/26. He said the facility called a meeting after the incident and their explanation for her not receiving diabetic care was that orders were transferred improperly into their system. He said they told him and his father that they were not aware of her not getting diabetic medicine or care until a nurse from the hospital called and made them aware she had not been receiving diabetic medication. He said the facility did not tell him the diabetic treatment plan had been changed, and he did not have any conversations with the attending physician. In a later phone interview on 4/18/26 at 12:16 PM, he said the facility did not tell him that his mother's blood sugar was high on 3/17/26, instead they told him she was being transferred due to low oxygen levels. He said he felt angry and upset when he learned the facility had not been giving her diabetic medications or care and said he never expected that. He said he absolutely expected the facility to provide diabetes care including medication and he would expect if facility or attending wanted to discontinue the diabetic treatments they would speak with him and discuss because he would not have agreed to that. On 4/13/26 at 5:24 PM, a meeting was held with the clinical team which included the DON, UMs for both units, Director of MDS, [NAME] Nurse Consultant (RNS), Regional [NAME] President of Clinical Services, and the attending physician (via phone). The DON stated she spoke with one of resident #1's representatives and he told her that he did not want his mother poked and prodded which she believed meant he did not want her to receive daily fingerstick for blood glucose checks or insulin injections, but she acknowledged she did not ask him to explain what he meant.Review of the Facility Assessment updated 8/2024, revealed they provided person centered care and encouraged staff to incorporate the resident in the care planning process, record and discuss treatment and care preferences, and offer/assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advance care planning.

Based on observation, interview, and record review, the facility's Interdisciplinary Team (IDT) failed to protect the resident's right to be free from neglect by failing to identify the need for a diabetic treatment plan for a type II diabetic resident with a history of uncontrolled diabetes, chronic kidney disease, and recurrent urinary tract infections which placed her at a high risk for decline, (#1). This affected 1 out of 8 diabetic residents whose treatment plans were reviewed, out of 43 residents in the facility with a diagnosis of diabetes. This failure resulted in a lack of proper blood glucose monitoring and treatment for 48 days, during which resident #1 developed sepsis and Hyperosmolar Hyperglycemic State (HHS), a life-threatening condition that could lead to organ failure, coma or death. The resident required emergency 911 transfer to the hospital and admission to the Intensive Care Unit (ICU), for 3 days.On 3/17/26, resident #1 was found with severe hypoxia, cold, clammy skin, pallor, and a blood glucose finger stick reading high, that indicated it exceeded the device's measurement capabilities. Resident #1 had diagnosis of type II diabetes but had not been monitored or treated since her re-admission on [DATE]. She was transferred to the hospital via 911 and admitted to the Intensive Care Unit (ICU) with blood glucose level of 945 milligrams per deciliter (mg/dl), sepsis (infection) and HHS.HHS is a life-threatening complication of diabetes, mainly type II diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment, or it could be fatal. HHS involves a lack of insulin, but the person usually produces enough insulin to prevent the production of ketones. In addition, there's usually an underlying condition, such as an infection, that's also contributing to the high blood sugar. If you manage diabetes well, your risk for developing HHS is low but certain conditions and situations can trigger HHS to develop in people who aren't managing diabetes well. Common triggers of HHS include infections like pneumonia, urinary tract infections (UTI), and sepsis. Other triggers include stopping diabetes medications and cardiovascular issues such as stroke, pulmonary embolism or heart attacks. The risks factors for HHS include diagnosis of type II diabetes, having poorly managed diabetes, being 65 or older, and having a history of infections, illness or a heart condition. If untreated HHS could lead to seizures, coma, organ failure, or death, (retrieved from my.clevelandclinic.org on 04/23/26). The facility neglected to recognize resident #1 was not receiving diabetic care and failed to appropriately communicate within the interdisciplinary team (IDT) to ensure resident #1 received appropriate and timely diabetic care according to her goals and wishes. The lack of oversight by the IDT team led to resident #1 not having a diabetic treatment plan which placed her and all 42 diabetic residents at risk for serious injury, impairment, or death. This failure resulted in Immediate Jeopardy which began on 1/28/26.Findings:Cross reference F552, F684, and F867Resident #1, an [AGE] year-old female, was initially admitted to the facility on [DATE] for respite care (temporary care to give caregivers a break) with hospice services and re-admitted on [DATE] from an acute care hospital for skilled nursing care without hospice services. Her admitting diagnoses included Type II diabetes mellitus with hyperglycemia (elevated blood sugar levels), sacral pressure ulcer stage 3, chronic kidney disease, obesity, history of myocardial infarction (heart attack), atrial fibrillation, heart disease, and neuromuscular dysfunction of bladder (nerve damage that impairs bladder control).Review of resident #1's medical record revealed that during her 1/19/26 to 1/24/26 short term respite admission, she was on hospice and her diabetes was managed with two oral diabetic medications, daily blood glucose monitoring, and periodic lab tests. Her average daily fingerstick BG results averaged between 120 mg/dl to 240 mg/dl, while on medications, (average normal BG: 80-130 mg/dl before meals and less than 180 mg/dl 1-2 hours after meals). Review of progress notes revealed the medical team closely monitored her blood glucose levels and were focused on preventing hypoglycemia (low blood glucose levels). There was no evidence resident #1 had any episodes of hypoglycemia during the respite admission.Hypoglycemia, or low blood sugar, occurs when blood glucose levels fall below normal, typically below 70 mg/dl. It is particularly prevalent in individuals with diabetes, especially those on insulin or certain medications. However, not taking diabetes medication for fear of low blood sugars could lead to uncontrolled diabetes, (retrieved from mayoclinic.org on 4/28/26).The medical record revealed resident #1 was discharged home on 1/24/26 but was admitted to the hospital a few hours later with complaints of chest pain.Resident #1's hospital records for admission date 01/24/26 noted resident presented with generalized weakness and urinary tract infection. Uncontrolled type II diabetes mellitus with hyperglycemia was listed as one of her active diagnoses and she was treated with insulin Lispro 0-5 units subcutaneous (SQ) sliding scale with meals and nightly. Blood glucose monitoring four times per day was also ordered. Her last blood glucose at the hospital on [DATE] was 239 mg/dl, which was flagged as abnormal.The Agency for Healthcare Administration (AHCA) Form 5000-3008 dated 1/28/26 revealed resident #1's primary diagnoses were generalized weakness, UTI, and urinary retention with use of urinary catheter. The form directed the facility to review the Medication Administration Record (MAR) for review of times when medications such as anticoagulants, antibiotics, and insulin were last administered.According to resident #1's medical record her blood glucose fingerstick reading on 1/28/26 was 273 mg/dl, which was abnormal. Her blood glucose was not monitored after 1/29/26 to 3/17/26 when she was transferred to the hospital.Review of resident #1's progress notes on 1/28/26 revealed the abnormal blood glucose reading had not been reported to the attending physician immediately. There were no new orders. Review of resident #1's Order Summary Report dated 4/11/26 revealed there were no orders for diabetic treatment or monitoring from 1/28/26 to 3/17/26. The resident had diet order for Consistent Carbohydrates Diabetic (CCD) diet that started on 1/28/26. A Comprehensive Metabolic Panel (CMP) was ordered by the attending physician on 3/11/26 and the on-call provider on 3/17/26.In an interview on 4/13/26 at 4:43 PM, Licensed Practical Nurse (LPN) A said she reviewed resident #1's medication list and Agency for Healthcare Administration (AHCA) form 3008 on 1/28/26 but did not see orders for diabetic medications or monitoring. She reconciled the medications with the attending physician but neglected to make him aware the resident's blood glucose reading was abnormal. She indicated there were no orders for diabetic medications or monitoring. LPN A's rationale was that the clinical team would discuss the resident's diabetic care during the morning clinical meetings. Resident #1's abnormal blood glucose level was neglected by staff during the 3 PM to 11 PM shift and there was no documentation to show it was addressed during the 11 PM to 7 AM shift.On 4/13/26 at 2:49 PM, the Unit Manager (UM) for [NAME] 1 unit confirmed she had attended the morning clinical meeting on 1/29/26. She said the team did not discuss resident #1's diabetes or abnormal blood glucose reading. She agreed LPN A should have reported the abnormal blood glucose result to the attending right away and should have reviewed the clinical notes.On 4/13/26 at 3:13 PM, the UM for [NAME] 2 unit confirmed resident #2 was transferred to her unit sometime after 1/29/26. She said she did not attend morning clinical meeting on 1/29/26 because she was assisting with resident care, which she did often. She was not aware resident #1's diabetes was not being managed and said neither the resident nor the family complained of anything. She said she did not understand how LPN A missed the diabetic orders on admission or how they were missed when resident #1 was transferred to her unit. She agreed the attending physician should have been made aware by staff that the resident was diabetic and had no diabetic orders. The UM for [NAME] 2 said, I would not like to say that it was neglect, but it was a lack of care.In a telephone interview with resident #1's representative, her son, on 4/18/26 at 1:04 PM, he said he was concerned with resident #1's blood glucose because he would see staff providing her regular sugar packets on her meal tray. He complained to the staff and put up a sign in her room to alert staff not to give her sugar.Resident #1's progress notes were reviewed from 1/28/26 to 3/17/26 and revealed several providers had mentioned the need for diabetes monitoring including the attending physician and Advanced Practice Registered Nurse (APRN) but there were no new orders or documentation to show recommendations were discussed amongst the Interdisciplinary team (IDT) to ensure resident #1 was provided the care she needed and as per her wishes.The following were some of the progress notes:1/29/26 APRN initial progress note: BG 273 mg/dl on 1/28/26 and recommended to continue management of hypertension and diabetes.02/02/26 attending physician note: type II DM condition unstable as blood glucose readings remain persistently elevated (273 on 1/29 and 240 on 1/19) most recent A1c ([DATE]) is 8.1% indicating poor glycemic control. Monitor BG, A1c, renal function, and symptoms of hypo/hyperglycemia.On 4/15/26 at 5:21 PM, in a telephone interview, the APRN who evaluated resident #1 on 1/29/26 confirmed she had cared for resident #1 under the supervision of the attending physician since her initial admission on [DATE]. She said she could not access the resident's medical record to provide clarification on her notes. She asserted resident #1 was on hospice but was informed she was not during the 1/28/26 admission. She said diabetic care depended on what the resident's wishes were so she would not order labs or treat a diabetic resident who was on hospice and wished not to be poked or prodded. Her progress note dated 1/29/26 was reviewed and there was no documentation to show the resident or representatives declined diabetes care.On 4/13/26 at 4:47 PM, in a telephone interview with the attending physician, who was also the Medical Director, provided several versions of why resident #1 did not have diabetes care. He stated the hospital had neglected to send the appropriate medication list and instead sent a Medication Administration Record (MAR), which he did not consider to be a discharge medication list. He attempted to contact the hospital but was unsuccessful. He asserted the hospital should not have taken her off the oral diabetic medication she was taking during her initial admission on [DATE]. He said he preferred for the resident not to take medication due to her medical complexity and hospice status. He explained, resident #1 had a complex medical history and he wanted to prevent her from being hypoglycemic, which was contradictory to what he noted on his progress note on 2/2/26. He was reminded that his progress note mentioned resident #1's diabetes was unstable and she had poor glycemic control based on her blood glucose reading on 1/28/26. He contended that although he recommended blood glucose monitoring, he did not order it because he spoke with the family and they did not want her to be poked and prodded. He acknowledged there was no documentation to show he spoke with the family and that they agreed with his treatment plan. He agreed that a blood glucose level of over 900 mg/dl could cause severe injury.On 4/13/26 at 5:24 PM, the Director of Nursing (DON) confirmed that on 1/28/26 there might have been confusion on whether the discharge medication list for resident #1 had been provided by the hospital but she agreed that there was a list of medications, which the nurse reconciled with the attending. She said during the morning clinical meeting the team did not call the attending to clarify orders even though it was part of their process. She believed the facility did not neglect resident #1 because she did not exhibit symptoms of hyperglycemia prior to 3/17/26 and she was transferred to the hospital due to low oxygen levels. She said the facility became aware of resident #1's elevated blood glucose from the hospital after she had been transferred. However, the DON acknowledged that the discharge nurse on 3/17/26 had told her that the resident's BG was high when she performed a fingerstick at approximately 5:30 AM prior to EMS being called. Also, a CMP had been ordered by the on-call provider at 6:30 AM, which showed the resident's BG was 899 mg/dl. The DON said the results were reviewed by the APRN after resident #1 had been transferred to the hospital. She sustained that resident #1's elevated BG could not have been prevented and therefore it was not neglect.On 4/14/26 at 12:19 PM, a meeting was held with the clinical team (DON, ADON, Director of MDS, and UMs for both units), Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC), Senior [NAME] President (VP) of Operations, and Attending Physician/Medical Director (via phone). The DON stated that resident #1 had a medication list from the hospital which the admission nurse reconciled with the attending. She said insulin was not listed on the medication list. The Regional VP of Operations confirmed the AHCA 3008 form noted the MAR was attached for review of medication times which included insulin; however, it was not best practice to use the MAR to reconcile medications because it could have been inaccurate. She confirmed the APRN was aware resident #1's BG was 273 on admission, however there was no documentation to show any actions were taken by the APRN or that she communicated with the IDT. The Attending/Medical Director said he could not recall if he was made aware of the BG reading but said the whole IDT was aware resident #1 was diabetic. He agreed that resident #1's poor glycemic control was not ideal but due to her comorbidities and to prevent further kidney injury, he preferred to not put her on diabetic medications. He said her family preferred a palliative approach, but he was unable to provide documentation that this was discussed with the family.The NHA stated the team had a discussion related to the incident and given the fact that resident #1 had not been transferred to the hospital due to low oxygen not hyperglycemia, they did not feel the facility neglected resident #1's diabetes care. She said she became aware resident #1's BG was elevated when the hospital called her to say the resident's son did not want the resident to return to the facility. She said she called the resident's son for a meeting at the facility to discuss his concerns, but he never told them he had an issue during the meeting and was fine with his mother returning to the facility. She said they did not discuss why the resident was not receiving diabetic care during the meeting.Review of resident #1's medical record revealed she was re-admitted to the facility on [DATE] under the same attending physician with orders for insulin before meals, at bedtime, and on a sliding scale as well as daily BG monitoring.In a telephone interview with resident #1's son on 04/13/26, 4/16/26 and 4/18/26, he maintained the facility told him they had made a mistake when they transcribed the orders from the hospital and his mother did not receive diabetic medications. He said the doctors that treated her at the facility were the only ones responsible for her care. He expressed feeling angry and upset when he learned the facility had not provided his mother diabetic care which ultimately contributed to her decline and hospitalization.The Centers for Medicare and Medicaid Services defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish or emotional distress, (retrieved on 5/01/26 from www.eCFR.gov).

Based on observation, interview, and record review, the facility failed to prevent an avoidable fall with fracture for 1 of 3 residents reviewed for falls, of a total sample of 8 residents, (#1). Findings:Record review revealed resident #1 was an [AGE] year-old female, admitted to the facility on 1/19/26 for hospice respite care and discharged [DATE]. On 1/28/26, resident #1 was admitted to the facility for long term care. On 3/17/26 resident #1 was admitted to the hospital's Intensive Care Unit with diagnoses of critically high blood sugar, sepsis, pneumonia and a heart attack. On 3/20/26, resident #1 was readmitted to the facility for long term care. The 5 Day Medicare Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident's cognition was intact. Review of the Activities of Daily Living (ADL) section of the assessment indicated the resident had no impairment of her arms or legs and needed set-up and clean-up assistance for eating and oral hygiene. The assessment showed the resident required assistance of one staff person for bed mobility and had a urinary catheter and was incontinent of bowel. The Discharge Rehab Functional Assessment for the End of Medicare Stay dated 4/3/16 indicated resident #1 needed set-up and clean-up assistance for eating and oral hygiene and was dependent for toileting and bathing. The resident required the assistance of one staff person for bed mobility and dressing of the upper and lower body. Review of the resident's medical record revealed a care plan for falls related to decreased mobility, weakness, cardiac conditions, nerve pain, and spinal stenosis. A nursing care plan for ADL self-care performance was initiated 1/19/26 and revised 4/6/26. The interventions noted the resident required meal tray set up and the resident could feed self after set-up. Dressing, hygiene, oral care and bed mobility required the assistance of one staff. On 4/17/26 at 3:20 PM, the Director of Rehabilitation stated he was familiar with resident #1 as she had physical therapy from 1/28/26 to 3/16/26. He reported the resident's functionality was a maximum assist (1 person) for bed mobility, turning and repositioning. Her lower body had minimal movement. He stated she was dependent for lower body ADLs and maximum assist for upper body. He stated that transfers required a mechanical lift requiring two staff to assist. Review of nursing progress notes dated 4/11/26 at 10:12 PM, by Licensed Practical Nurse (LPN) C noted the resident had a fall. The note read, S/P (status post) fall. New orders for pain management, X-Rays for right shoulder and arm. TX (treatment) order for right shin skin tear. 3cm (centimeter) by 3cm.< (less than) 0.1. V/S (vital signs) B/P (blood pressure) 126/78 P (pulse) 78 R (respirations) 22 T (temperature) 97.6 02 (oxygen) sat (saturation) 97%. Blood glucose 151. Spoke with husband R/T (related to) new TX orders. Son came to facility to see her. Hospice arrived at 8:30(PM) and wrote new orders. Included x-rays, labs including U/A (urinalysis). Resident and staff stated the head did not hit anything. NEURO (neurological) check completed and no concerns noted. Review of physician orders on 4/11/26 showed an order for right forearm and right shoulder x-ray and pain medication every six hours as needed. Review of the right shoulder and right forearm radiology report dated 4/12/26 at 2:09 PM for the right shoulder revealed, No clearly displaced fracture by AP (Anteroposterior) view. The right forearm showed no fracture. An AP projection means the x-ray beam passes from the front of the patient to the back, (retrieved from www.NIH.gov on 4/27/26). Review of the rehabilitation post fall note dated 4/14/26 at 6:54 AM, revealed resident #1 on 4/11/26 at 8:15 PM, was rolled out of bed during care. The notes included, Education to staff per nursing to roll patient towards staff member during care. Review of the nursing post fall note on 4/12/26 at 3:10 AM, revealed resident #1 had a Numeric Pain Rating Scale (NPRS) of 2 out of 10 and two staff members to assist for repositioning was added to the care plan. The Numeric Pain Rating Scale (NPRS) is a validated, self-reported measure in which 0 indicates no pain and 10 indicates the worst pain, (retrieved from www.AHRQ.gov on 4/27/26). Review of the nursing post fall note dated 4/13/26 at 3:40 PM, indicated resident #1 had a pain level of 6/10 and the resident received pain medication. On 4/15/26 at 12:45 PM, resident #1 was observed sitting upright in her bed with the head of the bed elevated. The quarter-length side rails at the head of the bed were in the up position. The bed was in a high position. Her upper body was slightly leaning towards the right side of the bed. Her left hand was on her right forearm. The resident said she had pain all over. She stated, I was pushed and rolled out of bed to the floor, on Saturday when I was getting a bath. She revealed she was in pain most of the time since the fall and sometimes received pain medication. Review of the orders on the day of the fall, 4/11/26 showed the resident was ordered Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) 1 tablet by mouth every 6 hours, as needed for pain by the hospice provider. On 4/13/26 an order for Oxycodone HCl Oral Tablet 5 mg by mouth every 2 hours as needed for severe breakthrough pain, call if 3 doses in 24 hours. On 4/14/26 an order for Dexamethasone (steroid) 4 mg oral was obtained for right shoulder pain for 5 days. Review of the medication administration record (MAR) from 4/11/26 through 4/15/26 indicated resident #1 received pain medication as needed on 4/12/26 at 3:34 PM, 4/13/26 at 12:42 AM and 6:45 AM. The resident received scheduled pain medications on 4/13/26 at 6:00 PM and 4/14/26 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Break through medication was given on 4/15/26 at 3:29 PM. Review of nursing progress note for 4/15/26 at 7:07 PM, by the Director of Nursing (DON), read, This writer was notified by CNA (Certified Nursing Assistant) A that assistance was needed in resident's room. Upon entering the resident's room, she was alert and looking towards the door. This writer observed the resident had tremors to her left arm. When asked how she was feeling, the resident stated not good in a low voice. As the interview with the resident continued, the resident was only able to answer yes and no questions. The resident was unable to follow commands such as to smile, raise arms, and squeeze hands. This writer notified assigned nurses to bring vital sign equipment to room, as well as glucometer to check her glucose level. The nurse stated that her dinner glucose test was in the 200 range. When checked by the additional nurse in room, the resident's glucose level had risen to 381. The MD (Medical Doctor) was present in the facility and came to assess resident. Resident's baseline was reported to MD and showed resident with a change in condition. Temp was 98.5, B/P was unable to be obtained due to tremors to left arm as resident was guarding her right arm due to discomfort from previous fall. O2 in place via NC (nasal canula). Another nurse assigned to the resident entered the room to report that 911 had been called. EMS (Emergency Medical Services) arrived a few minutes later and transported the resident to (name of hospital) ER (Emergency Room) for further eval (evaluation). Assessment of resident shortly after lunch by this writer showed vital signs of B/P 156/58, Pulse 72, Resp 17, Temp 98.7, O2 sats 98% on O2 via NC. Glucose level was 121 at lunch. Resident was alert and oriented and could hold a conversation and answer questions appropriately. Lung sounds were clear, resident able to perform hand grips, abdomen was soft with no distention or c/o (complaints of) tenderness. Bowel sounds present and normoactive. Resident has a foley catheter that was draining straw colored urine without sediment. Skin was warm and dry to touch. Resident was able to state that she was on a diabetic diet and used pink sweetener packets. Resident was observed drinking from water cup at bedside and able to grip cup without difficulty. Resident was at baseline during this prior assessment but had a noted decline during this episode resulting in transfer to ER. A review of the acute care hospital records dated 4/15/26 noted that upon arrival to the Emergency Department (ED), resident #1's chief complaint was altered mental status and fever. A right shoulder x-ray was completed due to the resident's complaint of pain and a recent fall. The x-ray result revealed an Acute comminuted impacted fracture of the right humerus head and surgical neck. A comminuted impacted fracture of the humeral head and surgical neck is a severe, multi-fragmentary break (comminuted) in which the upper ball-shaped part of the shoulder (humeral head) is forced into the shaft (impacted) at the neck, usually shattering into 3 or 4 pieces, (retrieved on 4/27/26 from NIH.gov). On 4/16/26 at 4:50 PM, in a telephone interview with hospice Registered Nurse (RN) K, he stated he was aware the resident had a fall on the previous Saturday. He said he was aware the resident was in the hospital with a shoulder fracture. The nurse explained the resident was not a candidate for surgery and the family was placing her with hospice. He further stated the family only wanted to treat her shoulder fracture medically. On 4/16/26 at 7:00 PM, CNA A stated she had been with the facility for the entire six months she had been a CNA. She explained she was completing peri-care on resident #1 and standing on the resident's left side of the bed and the resident was lying on her left side. She stated while she was still on the left side of the bed, when she completed cleaning the resident's back side, she told the resident to roll over to the right side. She described that the resident rolled to her right side and moved her right leg over and then slid off the right side of the bed. CNA A stated she had her hand on the resident's lower hip and upper leg while she attempted to move around the foot of the bed to the right side, to prevent the resident from falling but the resident's legs fell off the bed, followed by her right hip and right shoulder. CNA A noted the resident was on her right side when she landed on the floor. She reported the resident did not hit her head. The CNA explained she called out for help and stayed with the resident. She recalled two nurses came to the resident's room and assessed the resident, who complained of right knee pain and had a skin tear to the right shin. CNA A explained that once the nurse completed the assessment, they used a mechanical lift to get the resident back in bed. She recalled at that time the resident complained of whole right-sided pain. CNA A stated she met with the DON and Assistant DON after the fall who educated her on bed mobility for residents. She said she was told, I should always roll the resident towards the side I am on. On 4/17/26 at 3:55 PM, LPN C explained she responded to the resident's room when she heard CNA A calling for help. She recalled the resident was lying on the floor parallel to her bed on her right side. She stated, I was shocked because the resident doesn't move. She remembered she assessed her neurological function, and she was ok and didn't hit her head. The nurse explained they rolled her onto her back and LPN C assessed her range of motion. She was able to move all of her extremities. She stated they obtained a mechanical lift and put her back in bed with the assistance of two staff. LPN C stated CNA A reported she went to roll the resident, the resident's leg went over the bed and she slid off. LPN C notified the on-call physician and family, then completed an incident report while on-shift. On 4/17/26 at 1:45 PM, the DON explained she had completed the fall investigation and met with the Interdisciplinary Team on Monday 4/13/26. She stated she was notified at the time of the occurrence by LPN C who reported the resident had slid off the bed during peri-care. She explained LPN C had assessed resident #1, notified hospice and her family, and immediately put a two staff assist care plan in for resident #1's bed mobility. The DON recalled LPN C completed a post fall huddle, which included the circumstances of the fall, medications prior to the fall, and interventions needed post fall. She indicated she obtained a statement from CNA A and provided education to her. The DON confirmed her expectation was for CNAs to roll residents towards them instead of away. Review of the One-on-One Inservice Record provided to CNA A on 4/13/26 included, Safe resident turning. Pull, don't push, and always roll residents toward you, not away. On 4/17/26 at 2:00 PM, the ADON explained the orientation for CNAs required a skills demonstration for bed mobility. She stated CNAs must demonstrate the proper procedure for bed mobility and the CNA will keep demonstrating until the proper procedure is acceptable. She stated that CNA A had passed the skills demonstration for bed mobility at orientation. She did not explain why CNA A did not follow the protocol when turning resident #1 in bed. Review of the facility's Orientation Competency, Bed Mobility - Turning and Positioning Competency Validation, under the section of Side Lying Position, the first step validated the resident was to be rolled towards the caregiver. On 4/17/26 at 5:00 PM, CNA D explained when she had a resident that required the assist of one staff for turning in bed, I always roll the resident towards me, so the resident doesn't roll out of bed. On 4/17/26 at 5:04 PM, CNA E stated when she completed bed baths, she rolled the resident towards herself, or else they could fall out of the bed. She stated if she needed to change sides, she would keep the resident on their back until she was on the other side and then roll the resident to her. On 4/17/26 at 5:12 PM, CNA F explained when she performed peri-care or bathing, she always rolled the resident to the side she was on, so they don't roll out of bed. She stated, I will not roll a resident until I am on the side the resident is rolling to. On 4/17/26 at 5:15 PM, the Unit Manager (UM) explained the bed should be in low position and the resident should be rolled to the side the CNA is on, or else the resident could roll out of bed and get hurt. She stated, My priority is resident safety, and the expectation is the team follow safety processes to keep the residents safe. On 4/18/26 at 12:16 PM, in a telephone interview with resident #1's husband, he stated he was at the facility until 5:00 PM on the evening his wife fell. He stated he had just gotten home when the facility called to tell him she had fallen. He stated the facility had taken an X-ray done and it looked, okay. He explained when his wife went to the hospital, she complained of shoulder pain, and they took another X-ray which showed a fracture. He stated she had never had a fracture of the shoulder before. He said the strength in her upper body had gone down recently so she couldn't roll herself in bed. On 4/18/26 at 1:04 PM, in a telephone interview with resident #1's son, he stated his mother had never had a previous fall at the facility and had not had any falls in several years because she was bedridden. He explained she had never had a previous right shoulder fracture and could use that hand and arm to feed herself before the fall. The son further stated she could not fall out of bed herself because she could barely move her legs. He recalled his mother told him when the staff were changing her, the small staff pushed her, and she went over the side when her legs went over. He said she hit her hip and shoulder but not her head. The son recalled she told him, The staff pushed her too far. He stated she was sent to the hospital because she had a urinary tract infection and was unresponsive. While she was there, she again complained of right shoulder pain, so they did an X-ray that showed a fracture. He stated she didn't have any old injury to her shoulder. Resident #1's son conveyed his mother was no longer able to eat by herself because she was right-handed and couldn't use that arm. He explained she was able to feed herself and do simple things with her right arm before the fall. He stated now he had to be with her to feed her three times a day because he did not trust the facility to feed her. He stated he visited his mother every day before the fall and usually had pain levels between two and three from sitting and lying in bed for long periods. The son said after the fall, his mother's pain levels were between nine and ten and she required narcotic medications for pain. He stated she was in extreme pain after the fall and noted she was not a candidate for surgery because of her age and condition. On 4/18/26 at 2:25 PM, CNA G said she worked the 7 AM to 3 PM shift and had cared for resident #1 on almost every shift as she was on her usual assignment. She explained prior to the resident's fall, the resident was able to eat independently and brush her own teeth. She said she would help cut her meat into smaller pieces, but the resident always fed herself. She noted the resident would brush her own teeth. CNA G stated, after the fall she was 'weak handed' and needed help to eat and to brush her teeth. On 4/18/26 at 2:30 PM, CNA A stated her usual assignment included resident #1 on the 3 PM to 11 PM shift. She explained prior to resident #1 s fall, the resident was able to use both arms and hands to eat. She stated after the fall, she became weak in her arms and hands and needed help eating and drinking. On 4/18/26 at 2:35 PM, LPN H said she was very familiar with resident #1. She noted prior to resident #1's fall, the resident took her medications and drank from a cup without assistance. The nurse said after the fall, she had to put the resident's medication in her mouth and had to hold the water cup, for her. On 4/18/26 at 12:15 PM, in a joint interview, the Nursing Home Administrator (NHA) and DON discussed the residents' fall on 4/11/26. The DON stated that CNA A yelled out to a nurse for help when the resident fell out of bed. The nurse arrived and assessed the resident then completed the incident report while on shift. The DON stated hospice arrived about 45 minutes later and also assessed the resident. Hospice ordered an x-ray of right shoulder and right forearm, labs, and pain medication. The x-ray results were received on 4/12/26 and revealed no fracture. On 4/15/26, 4 days after the fall, the resident had a change in condition, was only able to answer yes and no questions and her responses were delayed. The DON indicated the facility called 911 for transport to the hospital emergency department and the resident was admitted to the hospital for sepsis. They said on 4/16/26, the facility received the ED report which noted the resident had complained about shoulder pain and an x-ray was taken which showed an acute shoulder fracture. The NHA stated on 4/16/26, she was notified that resident #1 had a fracture and they contacted the facility's contracted mobile x-ray company for a re-read of the x-ray taken on 4/11/26. She said the report came back showing an old shoulder fracture. The NHA stated they contacted the Risk Manager (RM) at the hospital and told her there were conflicting x-ray results and asked if their x-ray department could re-read their x-ray and the RM agreed. The NHA said they received a call from the RM on 4/17/26 who said the x-ray re-read showed a chronic fracture. The NHA requested a copy of the re-read results, but the hospital RM told them she could not provide the information requested because the hospital wanted to do a CT (computerized tomography) Scan to age the fracture. The NHA said the hospital could not do a CT scan as the resident had been discharged from the hospital. The RM told them they would not be able to provide the re-read and were leaving the reading as an acute fracture.

Based on observation, interview and record review, the facility failed to ensure a physician's order was obtained prior to the administration of oxygen therapy for 1 of 1 resident reviewed for oxygen (O2) therapy out of a total sample of 40 residents, (#89).Findings: Resident #89 was admitted to the facility on [DATE] with diagnoses of respiratory failure with hypoxia, chronic obstructive pulmonary disease, congestive heart failure, and dependence on supplemental oxygen. On 4/06/26 at 8:47 AM, the resident was observed in bed with a nasal cannula that delivered oxygen (O2) at 2.5 liters per minute (L) . He commented that he just got back from the hospital the previous night. He said he was there for shortness of breath, swollen legs and pneumonia. A review of resident #89's medical record revealed there was no physician's order for oxygen. The Minimum Data Set from 3/18/26 indicated he was cognitively intact, dependent on staff for moderate assistance, and used continuous oxygen. A care plan for resident #89 dated 2/26/26 indicated he used O2 for pneumonia and respiratory failure, and instructed staff to monitor him for difficulty breathing. On 4/8/26 at 9:15 AM, Licensed Practical Nurse (LPN) A explained when they get a hospital admission, the nurses help each other put orders into the system, or the unit managers assist. She said having an order in the medical record would ensure a resident received the correct liter of oxygen. On 4/07/26 at 9:48 AM, the Registered Nurse (RN) Unit Manager (UM) of [NAME] 1 said audits are completed on oxygen orders often to ensure they are accurate. On 4/08/26 at 9:37 AM, resident #89 was observed using 3 L of O2. He was measuring his oxygen saturation using a finger oxygen sensor meter. His blood oxygen level was at 96%. He explained he checked it often to be certain it stayed above 90%, because he depended on oxygen to breathe comfortably. On 4/08/26 at 9:43 AM, the UM of [NAME] 1 was unable to find an order in the computer for resident #89 for oxygen. She confirmed the resident was on oxygen and had no order. On 4/08/26 at 10:42 AM, The Director of Nursing confirmed that if a resident is on O2, it should be documented in the order set and the care plan. She said they performed chart audits in their morning meetings so no orders from the hospital were missed, especially after an admission. On 4/09/26 at 10:21 AM, The Administrator stated if a resident is on oxygen, it should be reflected in an order. She also remarked they have a mock survey process; the leaders each have a group of residents, and they check their oxygen concentrators. She added they will now verify that the orders are in the computer as well. A review of the facility's Oxygen Administration Policy dated 1/26/26 instructed staff to verify the provider order prior to administration of O2. It affirmed that oxygen was supposed to be delivered at a flow rate prescribed by a physician.

Based on observation and interview, the facility failed to promote a dignified existence related to standing over a resident while assisting with eating for 1 of 1 resident reviewed for dignity, out of a total sample of 40 residents, (#9).Findings: Resident #9 was admitted to the facility on [DATE] with diagnoses including dysphagia, hemiplegia and hemiparesis, need for assistance with personal care, and major depressive disorder. Review of the Quarterly Minimum Data Set assessment with assessment reference date of 3/26/26 revealed resident #9 had a Brief Interview for Mental Status (BIMS) score of 06/15 which indicated she had severe cognitive impairment. The assessment indicated she had impairments to her upper and lower extremities on both sides and was dependent on staff for eating. During meal observation on 4/06/26 at 12:34 PM, resident #9 was in bed with the head of the bed elevated. Her meal tray was located on her overbed table positioned on the left side of the bed. Certified Nursing Assistant (CNA) B was observed as she stood on resident #9's left side, scooped meal with a spoon and assisted resident #9 with her meal. On 4/08/26 at 10:46 AM, CNA B approached surveyor and identified herself as the staff member who assisted resident #9 with her meal on 4/06/26. She acknowledged she stood over the resident beside the bed while she assisted her. CNA B explained she knew she was not supposed to stand over the resident and should have been seated beside her. On 4/08/26 at 12:13 PM, the Director of Nursing (DON) stated she was aware a staff member was observed standing over resident #9 as she assisted her with eating. The DON clarified her expectation was for staff to sit at eye level when assisting with meals to ensure each resident's dignity was respected. Review of the facility's policy and procedure for Administration - Resident Rights revised 11/11/25 indicated each resident would have the right to be treated courteously, fairly and with the fullest measure of dignity.

Based on interview and record review, the facility failed to ensure coordination of Level I Preadmission Screening and Resident Review (PASRR) findings with the resident assessment process to identify, communicate, and incorporate a diagnosis of Post-Traumatic Stress Disorder (PTSD) into the resident's assessment documentation for 1 of 1 resident reviewed for PASRR, resident #4, from a total sample of 40 residents.Review of resident #4's medical record revealed the initial PASRR dated 11/24, did not identify a diagnosis of Post-Traumatic Stress Disorder (PTSD).Review of resident #4's record further revealed an updated PASRR completed on 4/07/2026, documented as PASRR UPDATED.pdf, which identified a diagnosis of PTSD and required update to the resident's assessment documentation.The record also showed an annual Minimum Data Set (MDS) assessment dated [DATE] that included a diagnosis of Post-Traumatic Stress Disorder (PTSD). The PASRR was not updated to reflect this diagnosis until April 2026.The record included a psychiatric evaluation dated 2/20/25 which identified PTSD as part of the resident's mental health diagnoses.On 4/8/2026 at 10:13 AM, the Social Services Director stated the PTSD diagnosis identified on the updated PASRR was not recognized or acted upon prior to review of the facility matrix in April 2026. The Social Services Director stated the diagnosis was present in the record since July when the MDS coordinator added it to the diagnosis section of the MDS. She said to her knowledge the new diagnosis was not discussed or identified by any of the Interdisciplinary Team (IDT) except the MDS Coordinator.On 4/8/2026 at 12:14 PM, the MDS Coordinator stated she entered new diagnoses into the Minimum Data Set assessment and that diagnoses were reviewed and discussed in morning interdisciplinary meetings, with updates made to the medical record as needed. The MDS Coordinator did not explain why the PTSD diagnosis for resident #4 was not identified or addressed through the established review process. On 4/8/2026 at 10:35 AM, the Director of Nursing (DON) stated the PTSD diagnosis documented on the PASRR was not reflected in the resident's assessment documentation and was not incorporated into the interdisciplinary process when initially identified. The DON stated the PASRR findings were not acted upon until later review and confirmed the issue was identified during matrix review in April 2026 while preparing for survey. The DON acknowledged this was an oversight.Review of the facility's policy and procedure titled Social Services - Trauma Informed Care, effective 4/1/2022 and revised 3/12/2026, read, expectations for identification and response to trauma-related needs.

Based on interview and record review, the facility failed to develop and/or revise a comprehensive, person-centered care plan to address a diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 1 resident reviewed for care planning of a total sample of 40 residents, (#4).Resident #4 was admitted to the facility on [DATE] from an acute care hospital.A psychiatric evaluation dated 2/20/25 identified PTSD as part of the resident's mental health diagnoses. Behavioral health progress notes dated 3/28/25, 7/14/25, 7/31/25, 8/21/25, 9/17/25, 9/23/25, 10/1/25, 10/14/25, and 10/28/25 documented a diagnosis of Post-Traumatic Stress Disorder (PTSD). A comprehensive Minimum Data Set (MDS) assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE] identified PTSD in Section I (Active Diagnoses).Review of resident #4's care plans revealed no care plan for trauma until 4/08/26.On 4/8/26 at 10:13 AM, the Social Services Director stated the PTSD diagnosis was present in the record but was not addressed in care planning prior to identification of the diagnosis on 4/06/26. The Social Services Director acknowledged the care plan omission was not identified until that time. On 4/8/26 at 12:14 PM, the MDS Coordinator stated diagnoses were entered into the MDS, reviewed in interdisciplinary meetings, and was unable to explain why the PTSD diagnosis was not incorporated into the resident's care plan. On 4/8/26 at 10:35 AM, the Director of Nursing stated the PTSD diagnosis was not incorporated into the interdisciplinary care planning process and was not reflected in the resident's care plan prior to April 2026. She acknowledged this was an oversight.Review of the facility's policy titled Care Planning and Interdisciplinary Team Process, effective 4/1/22 and revised 3/12/26, indicated requirements for development and revision of individualized care plans based on resident assessments and changes in condition.

Based on observation, interview, and record review, the facility failed to ensure waste was properly contained in a covered dumpster and the garbage storage area was maintained in a sanitary condition to prevent pests. This had the potential to affect all 118/118 residents residing at the facility. Findings: On 5/15/25 at approximately 9:30 AM, during the inspection of the garbage disposal area with the Dietary Services Manager, there were white and black package wrapping materials and other debris littered on the ground around the dumpster. In addition, both the dumpster lids were left open. The Dietary Services Manager confirmed the dietary department was responsible to keep the area around the dumpster clean of debris but was unsure who was responsible to ensure the lids on the dumpster were kept closed. She stated it was important to keep this area clean and the lids closed to keep wildlife and/or pests from the dumpster which could bring germs and disease into the facility. On 5/15/25 at 1:05 PM, the Dietary Services Manager and the Regional Manager along with the Environmental Services Manager conveyed it was the dietary department's responsibility to keep the area around the dumpster clean and to ensure the dumpster lids were closed. He stated he and the Floor Technician emptied trash into the dumpster that morning at approximately 8:00 AM and did not close the dumpster lid, when they were finished. He confirmed he should have closed the dumpster lid after use to keep out pests. Review of the facility policy entitled, Dispose of Garbage and Refuse, dated August 2018, indicated the Dietary Services Manager was to coordinate with the Director of Maintenance to ensure the area surrounding the exterior dumpster was maintained in a manner free of rubbish or debris and that appropriate lids were provided for all containers.

The facility failed to ensure food was prepared and served to residents at appropriate temperatures, failed to ensure staff performed appropriate hand hygiene during food handling, including with glove use during the preparation of food and handling of clean dishware. These failures had the potential to affect the 113/118 residents who ate food by mouth at the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] with the diagnoses that included Diabetes Mellitus, type II; disorder of bone density and structure, depression, hypertension and deficiency of B-vitamins. On the quarterly Minimum Data Set (MDS) dated [DATE], her Brief Interview for Mental Status (BIMS) score was determined to be 8/15, which indicated moderate cognitive impairment. On 5/15/25 at 10:20 AM, resident #1 stated the food was sometimes cold when the residents received it. She explained she was tired of being served cold eggs, so she asked to not receive eggs any longer. On 5/15/25 at 9:20 AM, during the initial kitchen tour, the temperature logs for all meals served on the previous days, 5/11/25 and 5/12/25 were not completed. Therefore staff could not know that food items on those days were prepared and served at appropriate temperatures. The cooks who worked those days was not present during the visit. In addition, the temperature log for that day's lunch, 5/15/25 was pre-filled at 9:20 AM, before their meal preparation and cooking was completed, and several hours before the start of the lunch service. AM [NAME] D stated she sometimes filled out the temperature logs prior to the meal if she thought she might run behind schedule later. She added that her food temperatures were always over 200 degrees Fahrenheit (F) but when she recorded the temperatures on the log early, she recorded them lower and that she left both the original temperature log and the revised one in the temperature log binder. The binder was reviewed with no evidence documented that verified the cook's explanation, which was acknowledged by the Dietary Services Manager. The Dietary Services Manager confirmed the pre-filling of the temperature log seemed to be a regular occurrence and added it was important staff took temperatures immediately prior to the meal service, and recorded them promptly to ensure food safety and palatability for residents. On 5/15/25 at 12:37 PM, a lunch meal test tray was conducted with the Dietary Services Manager and the Regional Manager. The temperature of the macaroni and cheese with ham was 148 degrees Fahrenheit (F) and the temperature of the seasoned greens were 123 degrees F. Both the Dietary Services Manager and the Regional Manager acknowledged for food to be more palatable for residents, the macaroni and cheese with ham and the seasoned greens should be hotter. The lunch plates were in an insulated base and had an insulated lid, but there was no hot plate warmer under the plates in the cart, to keep the food warm. The Regional Manager and Dietary Services Manager said they were not aware the facility did not utilize plate warmers for meal delivery. The Dietary Services Manager and the Regional Manager acknowledged that although some trays in this cart were served to residents soon after arrival, other trays in the larger cart, which had arrived to the unit earlier than that cart, were not yet passed out to residents, making for a longer hold time before service to residents. The Regional Manager conveyed the use of hotplate warmers would help keep the food at a more palatable temperature. The facility's policy entitled Food: Preparation, dated February 2023, indicated the cooks would prepare all food items in a fashion that permitted rapid heating to appropriate minimum temperatures. A Service Line Checklist detailed temperatures for all hot and cold foods were to be taken prior to their service and recorded on the form. 2. On 5/15/25 at 9:00 AM, during the initial kitchen tour, it was noted that the handwashing sink was out of soap. Dietary Aide B stated he washed his hands in the same hand sink that morning, and acknowledged there had not been soap at the sink so he washed his hands with water only. He acknowledged washing with only water did not sanitize his hands which was important to not spread germs to residents dining at the facility. Dishwasher C conveyed the soap in the hand sink area ran out earlier in the day. He explained he didn't do anything to replenish the soap because he thought the housekeeping staff would do it at some point. AM [NAME] D confirmed she was also aware there was no soap in the dispenser that morning and washed her hands using another sink. The Dietary Services Manager informed Dietary Aide B and Dishwasher C it was important to replenish the hand soap because staff needed to always use soap when they washed their hands. A short time later at 9:35 AM, Dietary Aide B was observed wearing gloves while bagging up cookies. Dietary Aide B then removed his gloves and threw them in a garbage can. He then began removing clean meal plates from the dish washing racks without sanitizing his hands. Dietary Aide B acknowledged he didn't wash or sanitize his hands after removing the gloves, and before handling clean dishes. He stated, I must have forgot; my bad. He conveyed it was important to wash his hands after removing gloves to prevent any cross contamination. On 5/15/25 at 11:45 AM, the Dietary Manager stated she had not given any in-services to dietary staff on handwashing as she had only been working at the facility a short time. On 5/15/23 at 3:30 PM, the Assistant Director of Nursing (ADON)/ Infection Control Preventionist, stated it was important staff washed their hands with soap to get germs and bacteria off them and prevent spread of germs to others. She added it was important that staff washed their hands after removing gloves because germs and/or food particles could get on hands and then onto whatever staff handled next. The ADON confirmed staff were educated on gloves, hand washing and infection prevention, and were expected to use soap to wash their hands after removing gloves. The facility policy entitled Warewashing, dated February 2023, indicated the dining services staff would be knowledgeable in the proper technique for handling sanitized dishware.

The facility failed to reasonably accommodate the needs and preferences of a resident by providing only crackers for snacks on a routine basis, even after the resident requested a more substantial alternative. This affected one of two sampled residents, of a total sample of 113 residents who ate food at the facility, (#2). Findings: Resident #2 was a [AGE] year-old man admitted on [DATE] with diagnoses of anemia, depression, anxiety, chronic pain, gastro-esophageal reflux disease and chronic kidney disease, stage two. Review of the admission Minimum Data Set (MDS) dated [DATE], resident #2 had intact cognitive abilities. On 5/15/25 at 10:32 AM, resident #2 stated he had requested an evening snack every night so far at the facility and received some form of cracker; saltines, graham crackers, or goldfish. He said only once was he provided with anything more substantive, a peanut butter and jelly sandwich. He relayed that once when he asked for something more, a staff member gave him their own personal cookie because there was nothing besides crackers. Resident #2 stated he had spoken with the Dietary Manager who told him the department brought snacks to the units but he explained nursing staff would tell him that they only had crackers available. Resident #2 added he expressed to the staff he would like a variety such as ice cream, popsicles, cookies, sandwiches, pudding or cookies because he was hungry and needed something more than crackers to tide him overnight. On 5/15/25 at 11:45 AM, the Dietary Manager stated the policy and procedure for snacks at the facility was to provide only saltine crackers, graham crackers, or Goldfish crackers for snacks. She explained if they were out of Goldfish crackers, she would provide oatmeal creme pies. She added she only provided sandwiches for residents' snacks if nurses requested them but didn't stock them regularly because they were often wasted. The Dietary Manager added, the procedure was that a nurse would come to the kitchen in the afternoon around 2:30-3:30 PM, and request peanut butter and jelly sandwiches for evening snacks for their unit. The Dietary staff would then prepare the sandwiches and deliver them to the requested unit. She said staff acknowledged she had spoken with resident #2 twice this week regarding his desire for a more substantial snack; once about not getting large portions for meals, as ordered, and the other instance the resident made them aware he wanted something more than the crackers that were available in the evenings. The Dietary Manager acknowledged she had a diet requisition for resident #2 to receive 'large portions' and provided paper documentation of such. She was unsure about whether Dietary staff had missed providing him with large portions during his meals, but said she planned for him to receive 'double portions' to make the intent of the order more clear to staff working in the kitchen. The Dietary Manager confirmed she had not thought about offering resident #2 a more substantial evening snack, per his requests. At that time the facility's Regional Manager joined the conversation and stated the current contract with the facility allowed for only the resident snacks currently being provided (the crackers). He acknowledged providing a greater variety of snacks would provide for the residents' requests and needs. The facility policy 011 entitled Snacks, dated October 2022 indicated bedtime snacks would be provided for all residents as identified in the individual plans of care. The policy also indicated the dietary department would collaborate with the residents, nursing, and management team to identify necessary beverage and snack items to be provided to each resident. It added, the dietary department would assemble and deliver to each unit both individually planned and bulk snack items to be offered at bedtime by nursing.

Based on interview, and record review, the facility failed to promote freedom from an accident hazard, the provision of hot coffee without verifying a safe temperature and/or ensuring the use of appropriate cups, for 3 of 5 residents reviewed for accidents, (#1, #4, and #5); and failed to prevent a burn injury for 1 of 3 residents reviewed for skin injuries, (#1), out of a total sample of 5 residents. The facility's failure to identify the untested temperature of hot coffee as a hazard which posed a risk for burns for residents with cognitive and/or physical impairments resulted in actual harm for resident #1 and placed all residents who received untested hot coffee at risk. Resident #1, a physically and cognitively impaired resident, received hot coffee in a Styrofoam cup and accidentally spilled the liquid on his leg. He suffered blisters and full-thickness skin loss, characteristics of second and third-degree burns, that placed him at risk for infection, a disfiguring scar, and decreased mobility. The resident required ongoing weekly assessments by a wound care specialist and daily dressing changes. Findings: 1. Review of the medical record revealed resident #1, an [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included stroke with left side weakness and paralysis, left elbow contracture (shortening of the muscle that causes a stiff joint), arthritis of both knees, generalized muscle weakness, and a history of falling. Resident #1 was discharged to a nearby Skilled Nursing Facility (SNF) on 10/31/24 at his family's request. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 9/25/24 revealed resident #1 had adequate hearing, used clear speech with distinct and intelligible words, was able to express his ideas and wants, and had clear comprehension of verbal communication. The resident had impaired vision and did not wear glasses. The document revealed resident #1 did not exhibit any hallucinations, disorganized thinking, or an altered level of consciousness during the look back period. He did not display any behavioral symptoms or reject evaluation or care that was necessary to achieve his goals for health and well-being. Resident #1 had functional limitation in range of motion of his arm and leg on one side and he used a wheelchair for mobility. The resident required set-up or clean-up assistance for eating and partial assistance for mobility and walking short distances. The MDS assessment revealed resident #1 had no pressure ulcers, wounds or skin problems, and he had pressure relieving devices for his bed and chair. Review of the medical record revealed resident #1 had a care plan for activities of daily living self-care performance deficit, initiated on 8/27/19. The interventions indicated he required the supervision of one staff after routine tray set up for eating and needed assistance with opening containers, cutting large items and opening and applying condiments. A care plan for the potential for impairment to skin integrity was initiated on 10/03/24. The document revealed resident #1 had blisters on the side and back of his left upper thigh. The interventions instructed nursing staff to monitor and document the location, size and treatment of the skin injury; report any abnormalities, signs of infection, or failure to heal to the physician; and re-direct behavior that could cause open wounds. Review of Weekly Skin Checks from July to September 2024 revealed resident #1 had no skin issues. The Weekly Skin Observation form dated 10/02/24 showed the resident had multiple blisters on the side and back of his left upper thigh. The document indicated the injuries included red open areas from popped blisters. Review of the Wound Care Specialist Advanced Practice Registered Nurse (APRN) Progress Note dated 10/02/24 revealed the provider saw resident #1 for initial evaluation of a left thigh wound with the context described as trauma, blister. The document indicated Wound #1 on the left posterior thigh was a full thickness trauma wound that measured 12.04 centimeters (cm) x 3.7 cm x 0.1 cm and had a scant amount of clear drainage. Wound #2 on the left lateral thigh was a partial thickness trauma wound that measured 1.9 cm x 2.5 cm x no measurable depth. The Wound Care Specialist APRN Progress Note revealed the provider next saw resident #1 on 10/16/24 for follow-up of his left thigh wound. Wound #1 was increased in size and measured 19.29 cm x 7.67 cm x 0.1 cm and had a moderate amount of clear drainage and 51 to 75% slough or soft, dead tissue. Wound #2 measured 1.7 cm x 2.5 cm x 0 cm and had 76 to 100% of eschar or hardened, dead tissue. Review of the Wound Care Specialist APRN Progress Note dated 10/23/24 revealed Wound #1 measured 15.31 cm x 5.61 cm x 0.1 cm and had moderate drainage. Wound #2 measured 1.01 cm x 2.33 cm x 0.1 cm. Both wounds were determined to be full thickness skin loss at that visit. A Progress Note dated 10/30/24 revealed Wound #1 measured 15 cm x 5.0 cm x 0.1 cm and had a moderate amount of clear drainage. Wound #2 measured 1.0 cm x 2.1 cm x 0 cm and was covered with eschar. On 11/01/24 at 2:19 PM, in a telephone interview, resident #1's sister stated on 10/02/24, Registered Nurse (RN) B called to inform her she received change of shift report from the Director of Nursing (DON) regarding a skin issue on her brother's leg. The resident's sister stated RN B explained when she evaluated the area, there were two blisters on the left side of his thigh, but when she fully removed his pants, she discovered there was a large wound that extended from under his buttock down the back of his thigh. The resident's sister recalled she was told the area measured about eight inches and went down to the white meat. She stated she visited her brother a few days later and he informed her the injury was from spilling hot coffee on himself. She stated she was told the coffee was made on the unit at the nurses' station and provided in a Styrofoam cup. The resident's sister explained her brother had a stroke and as a result, his fingers were crooked. She stated he used a special spoon to eat and needed a cup with a handle as he had to place his fingers through the handle to hold it properly. Resident #1's sister stated the facility suggested her brother's injury was caused by his wheelchair. She expressed disbelief and explained her brother had propelled himself throughout the facility in his wheelchair for years and never had any skin issues. On 11/04/24 at 9:55 AM, the [NAME] 2 Unit Manager (UM) stated she learned about resident #1's wound in the daily clinical meeting on 10/02/24 when the DON informed the interdisciplinary team that he had a shearing-type wound on his leg. The UM explained she did not evaluate the skin concern that day, but one to two days later, Licensed Practical Nurse (LPN) A asked her to observe the area while she did resident #1's wound care and changed the dressing. The UM recalled the resident had two areas on the side of his thigh that appeared to be popped, draining blisters. She stated LPN A then showed her another wound on the back of resident #1's thigh that was between six and eight inches long and seeping fluid. The UM explained she was shocked, as the DON never mentioned the large wound on the back of his thigh, only that he had shearing on the side. The UM stated the areas did not have the appearance of typical shearing wounds. When asked about the cause of the wounds, the UM stated RN B informed her resident #1 said his coffee spilled. Shearing occurs when forces parallel to the skin stretch and distort internal tissue while there is downward pressure, leading to decreased blood flow and tissue death. Shearing forces contribute to pressure injuries (retrieved from www.merckmanuals.com/professional/dermatologic-disorders/pressure-injury/pressureinjuries#Etiology_v8381516 on 11/18/24). Burn wounds from heat sources such as scalding liquids raise the temperature of the skin and cause tissue death. The classification of burns depends on the depth and severity of penetration of the skin's surface. Second-degree or partial thickness burns involve the first two layers of skin. The burn site may be deep red and/or have blisters and a glossy appearance from leaking fluid, with possible loss of some skin. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. The burn site may appear white, (retrieved from www.hopkinsmedicine.org/health/conditions-and-diseases/burns on 11/18/24). Third degree burns can occur in two seconds with liquids of 148 degrees and in one second with liquids of 155 degrees (retrieved from the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities on 11/18/24). On 11/04/24 at 10:08 AM, in a telephone interview, RN B recalled on the morning of 10/02/24, she received change of shift report from the DON, who told her resident #1 had blisters on his leg. She stated the DON asked her if she was aware of the skin injury. RN B explained she toileted resident #1 the day before and was certain his skin was intact with no blisters, abrasions, shearing, or any other skin issue on his legs. She stated the Wound Care Specialist APRN was in the facility that morning conducting weekly wound rounds, and she assessed resident #1's leg. RN B explained later that shift, she checked the resident's electronic medical record and discovered there was no documentation about the wound. She stated she completed a note regarding the change in condition and notified the Primary Care APRN and the resident's emergency contact, his sister. She then decided to check the resident's skin so she could complete an accurate Skin Observation note and was surprised to discover the areas were worse than described by the DON. She stated when she saw the extent of the wound on the back of resident #1's thigh, she asked the Primary Care APRN who was onsite, to assess the resident's wounds. On 11/04/24 at 10:31 AM, the Primary Care APRN confirmed she was in the facility on 10/02/24 and RN B asked her to assess resident #1. She stated his lateral thigh had a few popped blisters, but she did not remember seeing the wound on the back of the thigh. The Primary Care APRN recalled the Wound Nurse or the Wound Care Specialist APRN had already seen the resident earlier that day. She explained she later learned the injury was a burn from hot coffee. Review of the Primary Care APRN's Acute Care Progress Note dated 10/16/24 revealed resident #1's chief complaint was follow-up regarding a wound on his left posterior thigh. The document indicated the resident had a full thickness injury on the back of his left thigh, which according to the unit manager [name of UM], is a burn from coffee. On 11/04/24 at 11:44 AM, in a telephone interview, LPN A recalled she was assigned to care for resident #1 on the day following the discovery of his skin injury. She confirmed he had no prior skin issues. LPN A explained she was the night shift nurse and although the dressing change was scheduled for the day shift, she did it as the dressing was soiled from a large amount of dark-colored wound drainage. She recalled showing the wound to the UM who appeared shocked when she saw it as she thought it was just shearing. LPN A said, I asked him what happened, and he said he spilled coffee. LPN A stated the coffee cart from the kitchen arrived on the unit between 7:30 AM and 8:00 AM, but one of the other night nurses had a personal coffee maker that was used on the unit. On 11/04/24 at 12:43 PM, in a telephone interview, Certified Nursing Assistant (CNA) C confirmed he was regularly assigned to care for resident #1 on the night shift. He stated on the morning of 10/02/24, he was in the bathroom with the resident and noted he had skin sloughing on the back of his thigh. CNA C stated he immediately notified the assigned nurse, the DON. He acknowledged there was a coffee maker on the unit, but he did not know if someone provided resident #1 with hot coffee that day. On 11/04/24 at 1:29 PM, in a telephone interview, LPN D confirmed she provided a coffee maker and flavored creamers for use on the unit during the overnight shift. She explained there were residents who got up early, between 5:30 AM and 6:00 AM, and she normally brewed a pot of coffee at about 5:00 AM to accommodate them. She stated sometimes she even had to make two pots if they were all drinking it. LPN D said, It became almost a full-time job. She acknowledged neither she nor other staff checked the temperature of the coffee before they provided it to residents. She stated resident #1 usually got up at 6:30 AM and she routinely made his coffee early and left it in his room, to ensure it was ready for him. LPN D recalled on the morning of 10/02/24, at about 5:30 AM, she stood at her medication cart and heard the DON yell for help from resident #1's room. She stated CNA C ran into the room and she followed behind, but the DON looked out and said she didn't need her. LPN D explained she thought resident #1 fell as he often got up in the morning by himself, without calling for help. LPN D stated when she later asked CNA C what happened in resident #1's room, he acted like he did not know what she was talking about. LPN D verified resident #1 eventually told her he was burned that morning when he spilled hot coffee on himself. On 11/05/24 at 1:46 PM, in a telephone interview, CNA E stated about a day or two after the incident, she heard resident #1 was burned by hot coffee. She validated staff brewed coffee in the unit's pantry in the early morning. CNA E confirmed she observed LPN D distributing coffee to residents on many occasions. She verified LPN D usually made resident #1's coffee and left it on a table in his room. CNA E explained soon after this incident occurred, someone removed the coffee pot and staff were instructed not to give the residents hot liquids anymore. On 11/05/24 at 1:07 PM, in a telephone interview, the Wound Care Specialist APRN confirmed on 10/02/24, the DON approached her in the hallway and asked her to see resident #1 as he had a large blister on the back of his thigh. She stated she determined the wound was caused by trauma and surmised it could have been caused by constant rubbing on the seat of his wheelchair. The Wound Care Specialist APRN was informed resident #1 reported the wounds were the result of a hot coffee spill. She said, I am not 100% sure it was not a burn. It is a possibility that it is a burn injury and full thickness would be a third-degree burn. She expressed doubts that the resident would have tried to drink coffee that was hot enough to scald his leg. She added that she usually saw dietary staff arrive on the unit with coffee at about 7:30 AM while she was rounding. The Wound Care Specialist APRN was told residents on the unit received coffee prepared by staff at about 5:30 AM and safe temperatures were not verified before serving the hot liquid. She acknowledged she did not have access to that information at the time she assessed resident #1's wounds. On 11/04/24 at 4:15 PM, resident #1 confirmed an incident occurred before he was discharged from the facility to his current SNF. He pointed to his left thigh and said, I got burned with the coffee. Resident #1 explained he got coffee every morning from LPN D. He said, She makes it for me special, every morning. She knows how I like it. She's the best one. The resident recalled on that morning, he got out of bed by himself and sat in his wheelchair. He demonstrated how he reached across his body with his right hand and grasped the white Styrofoam cup. He brought his arm back towards his chest and showed how the cup of coffee tipped and spilled down the left side of his thigh and under his left leg. Resident #1 stated he then went to the bathroom to remove his clothes, and the DON found him there. He confirmed CNA C entered the room soon afterward. On 11/05/24 at 4:11 PM, the UM at resident #1's current SNF stated he completed the admission assessment on 10/31/24. Joint review of the document revealed the resident was admitted with a burn wound to the rear left thigh. The UM recalled he received the information from the resident and his family. He verified resident #1 clearly stated the etiology of the wound and although his speech was sometimes soft and a little slow, he was able to communicate well, make his needs known, and easily participate in conversation. The UM showed the resident's current Brief Interview for Mental Status (BIMS) Evaluation tool which had a score of 8/15, indicating moderate cognitive impairment. The UM explained he was also the facility's Wound Care Nurse and once informed the wound was a burn, he realized the orders from the previous facility were more appropriate for a pressure-type wound, not a burn, so he obtained new physician orders. 2. Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, difficulty walking, and seizures. The MDS Quarterly assessment with ARD of 8/22/24 revealed resident #4 had a BIMS score of 15/15 which indicated he was cognitively intact. The resident used a walker for mobility. Resident #4 had a care plan for physical mobility deficits related to a stroke with right sided weakness, initiated on 3/05/24. The interventions indicated the resident was able to ambulate with a rolling walker. A care plan for risk for falls related to stroke with right sided weakness, seizures, and a history of falling was initiated on 3/07/24. The interventions instructed staff to anticipate and meet the resident's needs and reorient him regarding safety reminders. On 11/05/24 at 10:31 AM, resident #4 confirmed he was one of the residents who received coffee early in the mornings before the kitchen was open. He explained LPN D was a great nurse as she made coffee for the residents who were up early. Resident #4 stated his routine was to go to the nurses' station and LPN D would pour the hot coffee into his cup. He pointed to a personal stainless steel insulated cup that was in a cup holder attached to his walker. Resident #4 explained LPN D even bought cup holders for some residents so they would not have to carry the hot coffee. The resident shared that LPN D no longer provided hot coffee since the incident that involved a resident #1 who was burned when he spilled hot coffee on himself. Resident #4 said, He hardly had use of his hands. He has a really rough time holding things sometimes. He was in his room when it happened. He told me about it the next day. 3. Review of the medical record revealed resident #5, a [AGE] year-old male, was readmitted to the facility on [DATE] with diagnoses including stroke with left side weakness and paralysis, repeated falls, generalized muscle weakness, chronic pain, and left foot drop. The MDS Quarterly assessment with ARD of 8/09/24 revealed resident #5 had a BIMS score of 12 which indicated moderate cognitive impairment. He required set-up assistance for eating and supervision or touching assistance for mobility. Resident #5 had limitation in functional range of motion of one leg and used a wheelchair. Resident #5 had a care plan for activities of daily living self-care performance deficit related to left side paralysis following a stroke, impaired mobility and balance, and a history of falling, revised on 2/21/24. The interventions included set-up assistance of one staff member before eating. A care plan for risk for falls, revised on 5/29/24, revealed resident #5 had gait and balance problems, left side weakness, poor trunk control, and poor safety awareness. The goals included minimizing the risks of incidents and injury. The interventions instructed nursing staff to anticipate and meet his needs and therapy staff were to evaluate for wheelchair modifications as indicated. On 11/05/24 at 10:25 AM, resident #5 verified he was one of the residents who received early morning cups of coffee from LPN D. He explained he was a retired roofer, and for many years he woke up at about 4:30 AM to go to work. The resident stated he still could not sleep later than that. Resident #5 described the cup as white Styrofoam with a lid. When asked about the temperature of the coffee, he said, I've got to let it sit to cool it off a little before I can drink it. On 11/04/24 at 12:02 PM, the Dietary Manager stated the facility's process to ensure safety and prevent burns was to check the temperatures of all food and beverages in the kitchen before the items were served to residents. He explained after temperatures were checked, coffee and hot water for tea were poured into containers for service. He confirmed hot coffee and tea should be served in diner-type plastic cups with a handle and covered with a plastic lid. The Dietary Manager stated the facility's maximum allowed temperature for hot liquids was 145 degrees Fahrenheit. He verified kitchen staff arrived at 6:00 AM so it should not be possible for residents to get coffee earlier. According to the National Coffee Association the optimal temperature for brewing coffee is approximately 200 degrees Fahrenheit and the preferred serving temperature is between 140 and 155 degrees Fahrenheit (retrieved from www.ncausa.org on 11/18/24). Review of the facility's policy and procedure for Hot Liquids, updated on 7/29/24, revealed residents would receive hot liquids at a palatable temperature that would not burn the skin if spilled. The guidelines indicated coffee would be brewed at the recommended temperature and leave the kitchen at a temperature between 140 and 158 degrees. The policy revealed coffee served to residents outside of mealtimes should be checked to ensure the temperature was not above 145 degrees and it should never be served in Styrofoam cups.

Based on interview, and record review, the facility failed to implement its abuse and neglect prohibition policy and procedures related to conducting a thorough investigation of an injury of unknown origin to rule out neglect, to determine if reporting was necessary, and to ensure the safety of 1 of 3 residents reviewed for skin injuries, out of a total sample of 5 residents, (#1). Findings: On 11/01/24 at 2:19 PM, and 11/08/24 at 3:06 PM, in telephone interviews, resident #1's sister stated on 10/02/24, she received notification from the facility that her brother had an extensive skin injury on the back of his thigh. She explained she was not able to visit until about nine days later, and when she spoke with her brother, he told her he accidentally spilled hot coffee on his leg. The resident's sister stated the hot liquid was provided in a Styrofoam cup instead of a cup with a handle which he needed due to his contracted fingers. She recalled she spoke to the Minimum Data Set Coordinator by telephone on 10/17/24 regarding her brother's care plans. The resident's sister said, She kept saying wound and I said, Y'all keep saying it's a wound. It's a burn. Resident #1's sister stated Registered Nurse (RN) B, and the [NAME] 2 Unit Manager (UM) spoke to her about the wounds and plan of care, but no member of the facility management team ever reached out to her regarding an investigation into how the wound occurred. On 11/04/24 at 11:25 AM, the Administrator confirmed she was the facility's Risk Manager and was made aware of resident #1's skin injury in the daily interdisciplinary team (IDT) meeting. She stated she was told the resident was tall and scooted himself down in his wheelchair, and the provider validated the wound was caused by friction. The Administrator explained the Director of Nursing (DON) would be more knowledgeable of the details of the investigation. On 11/04/24 at 12:00 PM, the facility's DON explained she had first-hand knowledge of an incident that involved resident #1 as she was his assigned nurse when injuries were discovered on his left thigh. She stated on 10/02/24 at approximately 5:30 AM, Certified Nursing Assistant (CNA) C called her to resident #1's bathroom. She recalled he had a small blister on his left lateral thigh and a ruptured blister about 12 centimeters long on the back of his thigh. The DON stated the resident informed her he thought it was a scratch from his chair. She explained she examined the chair and noted the cushion was missing and there was a bar with rivets, but no liquid or wound drainage on the seat of the wheelchair. She stated neither the resident's pants nor his bed was wet or soiled. The DON stated the Wound Care Specialist Advanced Practice Registered Nurse (APRN) was in the building that day and she thought the skin injury could have been caused by friction. The DON stated about nine days later, the Administrator called her and asked if she was aware that resident #1's wound was possibly a burn, according to his sister. She stated she again asked resident #1 what caused the wounds, and he denied spilling hot coffee. The DON was unable to explain how the resident could have developed such a significant wound without any visible blood, drainage or moisture in the wheelchair or on his pants. She said, I don't know. I investigated to make sure there was no neglect or abuse. The DON acknowledged although she was directly involved as the assigned nurse at the time the skin injury was discovered, she also conducted the incident investigation. She explained the Administrator, who was the facility's Risk Manager, was also involved in the investigation. The DON stated she obtained statements from the resident, the Dietary Manager, and CNA C. However, she was only able to provide a written statement by the Dietary Manager and her own, a response to the Administrator's communication regarding the allegation of a burn injury. The DON acknowledged although resident #1 was alert and oriented, she did not have a written statement that recorded the details of his interview. She confirmed she did not obtain any written statements from the resident's sister, staff who worked on the unit during that shift or those who cared for the resident during the previous shift. The DON said, Sometimes staff write statements, but if I am already in [the electronic incident report], I just type it in. The DON pointed to a personal coffee maker in her office and explained she sometimes provided coffee for staff but not for residents, and she did not give resident #1 coffee that morning. She stated she was aware Licensed Practical Nurse (LPN) D also had personal coffee maker on the unit, but the Administrator made her take it home. On 11/04/24 at 9:55 AM, the [NAME] 2 UM stated she learned about resident #1's skin injury in the daily IDT meeting on 10/02/24 when the DON reported he had a shearing wound. She stated when she saw the wound a few days later, she was shocked as she only knew about blisters on the lateral thigh. She recalled the large wound on the back of the thigh did not have the appearance of typical shearing. The UM stated RN B said resident #1 reported the wound occurred when he spilled his coffee. She stated to her knowledge, the facility had not initiated an investigation, and she was neither interviewed nor asked to give a statement. On 11/04/24 at 10:08 AM, in a telephone interview, RN B recalled when she toileted resident #1 the day before the wounds were noted, his skin was intact. She stated she was not involved in an incident investigation regarding resident #1 and was never asked to provide a statement. On 11/04/24 at 10:58 AM, the facility's Wound Nurse confirmed on the morning resident #1's wounds were discovered she was rounding with the Wound Care Specialist APRN who determined the injuries were trauma blisters. The Wound Nurse said, To be honest, I do not think we even asked him how it happened. She stated in the following days she heard staff discussing that the injury was a burn. On 11/04/24 at 11:44 AM, in a telephone interview, LPN A stated she asked resident #1 about his thigh wounds and he told her he spilled hot coffee on his leg. LPN A explained one of the night nurses brought in a coffee maker and residents were able to get hot coffee before the cart came from the kitchen at breakfast time. She stated she was never interviewed or asked to give a statement as part of an incident investigation. On 11/04/24 at 12:43 PM, in a telephone interview, CNA C stated on the morning of 10/02/24 he got resident #1 out of bed and took him to the bathroom where he noticed injuries on his thigh. He stated the resident had been in bed all night, and to his knowledge, had not received any hot liquids. CNA C stated he immediately alerted the DON. He acknowledged there was a coffee maker on the unit and confirmed the following day he heard staff discussing the resident being burned by hot coffee. On 11/04/24 at 1:29 PM, in a telephone interview, LPN D acknowledged she brought in a coffee maker and provided residents, including resident #1, with coffee on the overnight shift. LPN D recalled she was off for two or three days and when she returned, her coffee maker and bag of flavored creamer were not in the usual cabinet at the nurses' station. She said she asked where they were, but nobody would say anything. LPN D explained she unlocked the DON's office, found her coffee maker there, retrieved it, and threw it away. She said, I wasn't about to let them pin anything on me. LPN D stated on 10/02/24 at about 5:30 AM, the DON yelled for help from resident #1's room and CNA C ran to assist her. She was informed that sequence of events differed from the facility's incident report. LPN D stated she never heard about an incident investigation. She verified resident #1 told her he received hot coffee that morning and it burned him. She stated nobody ever asked her to provide either a verbal or written statement about the coffee maker, a coffee spill, or resident #1's burn. On 11/04/24 at 4:15 PM, resident #1 confirmed an incident occurred before he was discharged from the facility. He pointed to his left thigh and said, I got burned with the coffee. Resident #1 explained he got coffee every morning from LPN D. The resident recalled that morning, he got out of bed by himself and sat in his wheelchair. He demonstrated how he reached across his body with his right hand and grasped the white Styrofoam cup. He brought his arm back towards his chest and showed how the cup of coffee tipped and spilled down the left side of his thigh and under his left leg. Resident #1 was informed CNA C stated he assisted him from bed to the bathroom that morning. The resident emphasized he took himself to the bathroom where the DON found him first and then CNA C came in afterwards. Resident #1 confirmed neither the DON nor the Administrator interviewed him about his burn. On 11/05/24 at 5:20 AM, in a telephone interview, CNA C was informed his previous statement conflicted with resident #1's statement regarding the occurrences on 10/02/24. CNA C stated he could not recall the true turn of events of that night. He revised his previous statement to indicate he was not sure whether he got resident #1 out of bed, or if he found him in the bathroom, or if the DON called him to the resident's room. CNA C did not remember if he provided a written statement and stated he was never interviewed as a witness for an investigation. On 11/05/24 at 11:40 AM, the Administrator stated the facility's incident investigation process was the nurse would trigger an incident report which was reviewed and investigated by the DON. The Administrator explained her role as Risk Manager was to review the incident report and/or investigation before it was closed and ask any questions that she felt were not answered. The Administrator stated she often completed the review process in conjunction with the DON who provided necessary clinical input. She reviewed the incident report regarding resident #1's injuries and stated it was entered on 10/02/24 at 5:30 AM, by the DON who was the resident's assigned nurse. The Administrator stated the DON's investigation showed resident #1's injuries resulted from friction in the wheelchair. Review of the skin assessment attached to the incident report revealed the document was not completed and closed until 11/04/24 at 9:49 AM, after State Survey Agency (SSA) staff entered the facility. The Administrator was informed that interviews with resident #1 and multiple staff members revealed significantly conflicting information that did not support the facility's findings and conclusion. She stated no staff informed her the resident's injury was a burn and she would have expected them to provide her with that information. She acknowledged the incident investigation did not include documentation of attempted or actual interviews with nursing staff or the resident. The Administrator recalled on around 10/11/24, she was notified resident #1's sister alleged her brother's leg was burned by hot coffee. She stated it might have been close to that time that she discovered LPN D used a coffee maker on the unit, and she immediately instructed staff to remove the appliance. The Administrator acknowledged thorough investigations were not completed at the time of the incident or after the resident's sister made an allegation regarding a burn injury. She confirmed the DON remained adamant that her statement was accurate, but since the investigation was not completed timely, there were discrepancies that may never be resolved. The Administrator explained she did not report the incident as it did not meet the criteria based on the knowledge she had at that time. She verified current investigative findings supported that reporting was required. On 11/05/24 at approximately 11:55 AM, the Regional Clinical Specialist stated her role was to support the facility's DON when necessary. She validated since the DON was involved in resident #1's incident as a witness, she should not have led the investigation. The Regional Clinical Specialist stated the DON never reached out to her for assistance with the investigation and she was not aware of a hot coffee burn allegation until the Administrator notified her after SSA staff entered the facility on 11/04/24. She confirmed she reviewed the initial investigation and said, The paperwork I have does not indicate that all those people were interviewed as I do not have written statements. She explained she conducted preliminary interviews with staff, and they informed her resident #1 was alert and oriented, able to make himself understood, and had situational awareness. She verified that information supported the resident's ability to provide a reliable statement regarding his injuries. The Regional Clinical Specialist stated when the resident's sister made the allegation regarding a burn injury, the facility should have initiated a second investigation and considered reporting at that time. Review of the facility's policy and procedures for Resident Accident and Incidents, dated 4/01/22, revealed the facility would report, document, and investigate all incidents that involved residents. The document defined an incident as an occurrence that was not consistent with routine care of a resident and might be an accident or a situation that could cause an accident. The document indicated an electronic incident report should be completed by the nurse and necessary reports filed according to regulations. The policy indicated statements should be obtained at the time of the incident and should include additional facts and potential contributing factors. Review of the facility's policy and procedures for Abuse, dated 4/01/22, revealed an injury should be classified as an injury of unknown origin if the source of the injury was not observed or could not be explained by the resident, and the injury was suspicious because of its extent or location. The policy indicated any reports of abuse, neglect, or injuries of unknown origin should be promptly and thoroughly investigated and a root cause analysis would be completed. The document revealed the Administrator and his/her designee would investigate incidents with the assistance of appropriate personnel and obtain statements from involved staff, the resident, and the roommate if possible. During the investigation, the Administrator would keep the resident or the representative informed of the progress of the investigation, investigative findings, and corrective action. The policy revealed serious bodily injuries should be reported immediately, not later than two hours after an allegation was made, to the SSA and Adult Protective Services. If there was no serious bodily injury, reporting should be initiated within 24 hours. The policy indicated a follow-up report with the results of the facility's investigation should be submitted within five days of the immediate report.

Based on observation, interview and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 2 of 2 residents reviewed for respiratory care from a total sample of 35 residents, (#100, #366). Findings: 1. Review of the medical record revealed resident #100 was admitted to the facility on [DATE] from the hospital. His diagnosis included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, type 2 diabetes, unspecified dementia, need for assistance with personal hygiene care, and dependent on supplemental oxygen. Resident #100's Admission Minimum Data Set (MDS) with an assessment reference date of 4/12/24 revealed the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he had severely impaired cognitive skills for daily decision making. The MDS assessment noted the resident received oxygen therapy and required moderate assistance from staff for transfers, personal hygiene care, dressing, bathing, and toileting hygiene. The MDS noted the resident did not exhibit behavior symptoms or rejection of care that was necessary to achieve the resident's goals for health and well-being. Review of resident #100's medical record revealed a care plan was initiated on 4/17/24 and revised on 4/26/24 which indicated the resident was oxygen dependent for COPD. The interventions included setting the oxygen via nasal cannula (NC) as ordered. Resident #100's physician order showed an active order for oxygen at 2 liters per minute (LPM) via NC continuously every shift for supplemental oxygen. Oxygen can be given to COPD patients but only in controlled amounts .Hypercapnia respiratory failure is when there is too much carbon dioxide in your blood, and near normal or not enough oxygen in your blood, and it can be fatal. It commonly occurs in people with COPD who are given too much or uncontrolled amounts of oxygen. Retrieved on 5/17/24 from drugs.com. On 5/13/24 at 1:30 PM, resident #100 was observed lying in bed with oxygen administered through a nasal cannula. The oxygen concentrator's liter flow rate was set between 4.5 and 5 LPM. He stated he did not adjust the oxygen concentrator. On 5/13/24 at 2:52 PM, Registered Nurse (RN) A reviewed resident #100's oxygen order and stated the current order specified the resident was to receive 2 LPM of oxygen continuously via NC. She observed the resident's oxygen concentrator setting and acknowledged it was set between 4.5 and 5 LPM which was incorrect. She confirmed the flow rate should have been set to 2 liters as prescribed. RN A stated it was the nurse's responsibility to set the resident's oxygen flow rate as prescribed and to routinely monitor the oxygen settings every shift to ensure the flow rates align with the physician's order. She reiterated it was important to have the oxygen set at the correct flow rate and not have it set at a higher rate than prescribed to prevent the resident from becoming more oxygen dependent. She also stated it was imperative residents diagnosed with COPD should not be administered oxygen at a higher flow rate than prescribed because it can cause the resident's Carbon Dioxide (CO2) to increase and suppress their respirations. On 5/15/24 at 1:44 PM, Director of Nursing (DON) acknowledged it was the nurse's responsibility to check the oxygen (O2) concentrator every shift to ensure the flow rate matched the physician order. She stated it was imperative the resident receive the prescribed oxygen to prevent respiratory complications from occurring. She also stated if a resident diagnosed with COPD was administered oxygen at a higher rate than prescribed, it could increase the resident's CO2 and interfere with the O2 and CO2 exchange. 2. Review of the medical record revealed resident #366 was admitted to the facility on [DATE] from the hospital. His diagnosis included rhabdomyolysis, cerebral infarction, type 2 diabetes, cirrhosis of liver, muscle wasting and atrophy, need for assistance with personal care, and heart failure. Resident #366's Admission Minimum Data Set (MDS) with an assessment reference date of 5/3/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he did not have any cognitive impairment. The MDS assessment noted the resident received oxygen therapy and required maximal assistance from staff for transfers, bathing, and dressing. The MDS also noted the resident did not exhibit behavior symptoms or rejection of care that was necessary to achieve the resident's goals for health and well-being. Review of resident #366's medical record revealed a care plan was initiated on 5/9/24 which indicated the resident had congestive heart failure with interventions that included setting the oxygen per physician orders. Resident #366's physician order showed an active order for oxygen at 3 LPM via NC continuously every shift for supplemental oxygen. Oxygen is a medication that requires a prescription from a healthcare provider .If you take in more oxygen that your body needs, it can slow your breathing and heart rate to dangerous levels. Too much oxygen can lead to oxygen toxicity or oxygen poisoning. Retrieved on 5/17/24 from my.clevelandclinic.org. On 5/13/24 at 1:45 PM, resident #366 was observed lying in bed with oxygen administered through a nasal cannula. The oxygen concentrator's liter flow rate was set between 4.5 and 5 LPM. He stated he did not adjust the oxygen concentrator. On 5/13/24 at 2:52 PM, RN A reviewed resident #366's oxygen order and stated the current order specified the resident was to receive oxygen 3 LPM continuously via NC. She observed the resident's oxygen concentrator setting and acknowledged it was set between 4.5 and 5 LPM which was incorrect. She confirmed the oxygen flow rate should have been set to 3 liters as prescribed. RN stated it was the nurse's responsibility to set the resident's oxygen flow rate as prescribed and to routinely monitor the oxygen settings every shift to ensure the flow rates align with the physician's order. She reiterated it was important to have the oxygen set at the correct flow rate and not have it set at a higher rate than prescribed to prevent the resident from becoming more oxygen dependent. She also stated it was imperative residents diagnosed with COPD should not be administered oxygen at a higher flow rate than prescribed because it can cause the resident's CO2 to increase and suppress their respirations. On 5/15/24 at 1:44 PM, Director of Nursing (DON) acknowledged it was the nurse's responsibility to check the oxygen concentrator every shift to ensure the rate matches the physician order. She stated it was imperative the resident receive the prescribed oxygen to prevent respiratory complications from occurring. The facility's oxygen policy read, The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there are physician's orders for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, and interview, the facility failed to ensure staff donned facial hair restraints correctly and failed to ensure dishware was allowed to air dry before storing. Findings: On 5/16/24 at 11:45 AM, the facility's lunch tray line was observed. The Dietary Aide at the end of the line had his facial hair restraint below his bottom lip and his mustache was exposed. He received plates of food from the cook and placed them on a tray while he conversed with his co-workers. When asked why his hair restraint did not cover his mustache, he replied, I forgot. Neither the cook, who was directly across from the Dietary Aide or the Area Manager explained why they had not instructed the Aide to correctly don the facial hair restraint. During kitchen inspection on 5/16/24 at 2:24 PM, the facility's cookware and serveware were observed. A metal storage rack, with various sizes of pans and cookware was noted next to the three compartment sink. There were 5 large hotel pans, 6 inches deep, that were stacked on top of each other. The pans were noted to be wet (wet nesting). The facility's Food Service Director said the pans should have been allowed to air dry before they were stored.

Based on interview, and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 35 residents, (#17). Findings: Resident #17 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included end-stage renal disease, cardiac pacemaker, depression, and oxygen dependence. The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #17 had a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated moderate cognitive impairment. She presented with a depressed mood, no behaviors, and dependent for mobility and personal care. Resident #17 was received dialysis and pain management services. On 05/13/24 at 11:53 AM, resident #17 was observed in her room sitting up in bed. She stated she had moved to Florida to live with her family but when she got sick, they could no longer care for her. She complained that some of her belongings were missing, and she reported it to the nurse and aide. She was aware the grievance officer was the Social Service Director (SSD), and that she could report her issues to a staff member who would complete the grievance form on her behalf. Resident #17 stated she had reported other issues to staff in the past and Social Services followed up with her. Review of resident grievances from 10/23/23 through 5/1/24 showed several grievances for resident #17 regarding care, customer service, and call lights. There were no grievances about missing items. On 05/15/24 at 9:32 AM, resident #17 stated she had lost a watch and a black jacket with her initials, that her sister gave her. She stated that when she reported the missing items to multiple staff members, they told her they would look for the items, but a grievance was not filed. Resident #17 looked tearful when she said, there is no point telling them anything because they don't care. Review of the resident's medical record revealed an inventory of personal effects sheet signed by staff member and the resident on 9/27/22. There was evidence of the resident having a watch, blouses/shirts, dresses, shoes, dentures, and a cell phone with charger. There was a note indicating a suitcase with winter clothes and 3 other dresses. On 05/16/24 at 9:43 AM, Certified Nursing Assistant (CNA) B stated she had worked at the facility for over [AGE] years. CNA B said she was aware of the lost jacket but was not aware of the missing watch. She had searched the laundry room and resident #17's room for the jacket but did not find it. CNA B did not fill out a grievance form to report the missing jacket. CNA B stated that grievances were generally completed when residents had care complaints such as abuse or neglect but not for missing items. When a resident reports a lost item, we look for it. She was aware who the grievance officer was and had been educated on how to file a grievance. She further explained that a grievance form could be completed by either the resident or the staff member taking the report. The form was then given to the grievance officer, who would complete an investigation. On 05/16/24 at 9:49 AM, laundry staff stated when the unit lets them know resident clothes or personal items were missing, they looked for it in the dirty laundry. They explained they reported back to the unit if the item was not found, and the unit was responsible for filing a grievance with the SSD. On 05/16/24 at 9:51 AM, Registered Nurse (RN) C stated she had seen resident #17 wearing a black jacket but did not know it was missing. She was not aware of the lost watch but stated she would search the resident's room. RN C said if she knew resident #17 had missing items, she would have looked for them and filled out a grievance form. She explained a grievance can be completed by the resident, family member, or staff member on behalf of the resident. The completed form was then given to the grievance officer, the SSD who would initiate an investigation. RN C noted all staff members were responsible for filling out grievance forms. On 05/16/24 at 12:21 PM, an interview with the Unit Manager (UM) revealed she was not aware resident #17 had missing items. She stated that when a resident reported a lost item to a staff member, that staff member was responsible for filling out a grievance form. The UM explained there were blank grievance forms in her office, and once completed, they were given to the grievance officer, SSD. The grievance officer was responsible for communicating with the resident and completing the investigations. On 05/16/24 at 1:31 PM, an interview with the Social Service Director (SSD), who was also the Grievance Officer, revealed she had been employed at the facility for over 3 years and was very familiar with resident #17. She visited resident #17's room at least twice per week to talk. During their visits, resident #17 would talk to her about how she was feeling and any issues she might have had. She said the resident had reported some care issues for which the SSD filed grievances and completed investigations. The SSD stated she was not aware of any missing items for resident #17 and had she known, she would have filed a grievance. She explained at admission, residents and their family were educated on the grievance process and how to file a grievance. Education was provided to staff upon hire. The SSD indicated grievance forms were kept in the UM offices on both units and all staff members were responsible for completing them. A grievance should be filed for any resident issue. She noted the staff member would then turn in the completed form to SSD and an investigation would be opened. She reported grievances were to be filed immediately per facility policy and she would communicate with the resident or resident representative either verbally or in writing of the investigation results. She said residents completed an inventory sheet on admission, and they were encouraged to report any new items brought to the facility. If the item was on the inventory sheet and was not found, then we would replace it. On 05/16/24 at 2:37 PM, the Director of Nursing stated that a grievance form should be filled out for any resident issue or complaint including missing items. It is the responsibility of all staff members to complete the grievance form and give it to the SSD, grievance officer. All residents and family members are educated on completing a grievance. The DON explained the grievance process was important because it showed what the facility did to resolve a resident's complaint. On 05/16/24 at 03:57 PM the facility's Administrator stated that when a resident reported a missing item, staff were instructed to own the investigation for 10 minutes and look for the item before completing a grievance form. If the item was not found within 10 minutes, the staff were instructed to complete a grievance form. She said she had not heard about resident #17's missing items. She added it was important for staff to follow the grievance policy because they want to do what is right for the resident by finding their lost item or replace it if possible. Review of the facility's Grievance Program Policy and Procedure dated 4/1/22 and revised 6/6/23 revealed that a grievance was a concern that could not be resolved to the satisfaction of the person making the objection at the bedside and or immediately. Immediately was defined as within four or less hours. The process for filing a grievance was to document it, route to the grievance officer, discuss with appropriate individuals, investigate accordingly, and report to state or local law enforcement as needed. When a grievance was received by a staff member, they would notify their supervisor and complete the grievance or forward the completed report to the Grievance Officer. Furthermore, concerns related to alleged abuse, neglect, exploitation, or misappropriation of funds or belongings would be handled according to the state and federal guidelines.

Based on observation, interview, and record review, the facility failed to ensure a resident who was prescribed anti psychotic medications had appropriate diagnosis for its use for 1 of 5 residents reviewed for Unnecessary Medications, of a total sample of 35 residents, (#36). Finding: Review of the medical record revealed resident #36, an [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital. The resident had diagnoses that included Parkinson's Disease and Paranoid Schizophrenia. The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) 2/25/24 showed the resident scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was severely cognitively impaired. She had no indicators of psychosis (hallucinations/delusions) or behavioral symptoms. The assessment noted she was dependent on staff to complete Activities of Daily Living (ADL), and she had active diagnoses of Parkinson's Disease and Schizophrenia. The resident did not require the use of restraints or alarms, and she received high risk anti-psychotic medications with a noted indication during the look-back period. The Preadmission Screening and Resident Review (PASRR) (AHCA MedServ Form 004, Part A, March 2017) form completed by the hospital on 11/17/21 documented the resident did not have a Mental Illness (MI) or Suspected Mental Illness (SMI). The Comprehensive Care Plan included focus for Parkinson's Disease, behaviors related to Parkinson's Disease, cognitive impairment, Dementia, adverse effects of psychotropic and Parkinson's medications, and read, The resident uses psychotropic medications related to Parkinson's psychosis, paranoid schizophrenia Date initiated: 8/22/23 Revision on: 11/29/23. The Order Summary Report noted active physician's medication orders for Nuplazid (anti-psychotic) 34 milligrams for diagnoses of Neuroleptic Induced Parkinsonism, Other Hallucinations, and Paranoid Schizophrenia. On 5/15/24 at 11:59 AM, the [NAME] 1 Unit Manager explained, once a month she participated in meetings that included Psychiatric providers and Director of Nursing (DON). She said residents' care plans were discussed, and they reviewed medication changes and orders. She stated, we go over all the diagnoses to make sure they are still active. On 5/16/24 at 11:48 AM, the Lead MDS Coordinator explained that SOC (Standards of Care) meetings were conducted with nurse managers, the Advanced Practice Registered Nurse (APRN), and Medical Director where residents' psychiatric plans of care were discussed, appropriate diagnoses, and medications were determined. She said MDS coding was expected to adhere to the instructions of the Resident Assessment Instrument (RAI) manual. She said she was aware the Centers for Medicare and Medicaid (CMS) focused on misuse of Schizophrenia diagnoses for anti-psychotic medications, and the effort was a focus in their meetings. She explained, the process for determination of active diagnoses was by review of the psychiatric provider's progress notes where it included anti-psychotic medication use indications. She checked resident #36's medical record and said there was a diagnosis of Schizophrenia entered by the DON on 8/21/23 with an effective date of 11/23/21. She stated, we code what it specifically says by the psych (psychiatric) provider; if the physician has not said Schizophrenia, we do not use it, we go by what is in the notes. She checked the record and said the diagnosis for the resident's anti-psychotic medication use was Parkinson's Induced Psychosis and stated, that's not Schizophrenia. Review of the Psychiatric progress notes completed by the Physician Assistant, Certified (PA-C) from 8/24/23 to 3/29/24 included diagnoses of Recurrent Major Depressive Disorder, Delusional Disorders, and Psychosis due to Parkinson's Disease. All notes read, Nuplazid 34 mg 1 capsule by mouth once a day for parkinsonian induced psychosis. In an interview on 5/16/24 at 1:09 PM, the DON recalled she had entered a Schizophrenia diagnosis for resident #36 after she became aware the resident had increased visual and auditory hallucinations. The DON said the Psychiatric APRN later assessed the resident and determined the hallucinations were attributed to the diagnosis of Parkinson's Disease with Psychosis. She said she was aware that CMS focused on misuse of Schizophrenia diagnoses. The DON explained that the medical record was incorrect and said, I should have inactivated it. Review of the CMS RAI version 3.0 Manual read, . Steps for Assessment 1. Medical record sources for physician diagnoses include the most recent history and physical . , progress notes, and other resources as available. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to limited range of motion and contracture care, for 1 of 3 residents reviewed for limited range of motion and positioning (#25), out of a total sample of 35 residents. Findings: Resident #25 was admitted to the facility on [DATE] and readmitted from the hospital on 02/28/24 with diagnoses that included hemiplegia/hemiparesis following cerebral infarction, altered mental status, diabetes type II, contracture of left hand, vascular dementia, epilepsy, schizophrenia, and psychotic disorder. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed resident #25 was unable to complete the Brief Interview for Mental Status (BIMS) but was severely cognitively impaired for daily decision making. She presented with no moods, no behaviors, dependent for personal care and mobility, left upper and lower extremity impaired mobility, and no refusal of care. On 05/13/24 at 12:22 PM, resident #25 was lying in bed with knees bent to one side and eyes open. Her left arm was bent at the elbow onto her chest with left hand closed. She was unable to answer questions clearly but seemed to understand some words. She did not respond when asked to open her left hand or if she wore any devices on that hand. There was no brace, splint, or palm guard observed on her left hand or in the room. On 05/14/24 at 10:26 AM, the resident was observed lying in bed with no palm guard on her left hand. On 05/15/24 at 1:21 PM, Registered Nurse (RN) A stated she had been working at the facility for a few months and had not seen resident #25 with a splint or palm guard. RN A indicated resident #25 used to receive Occupational Therapy (OT) for the left hand but services had stopped a few months ago when the resident started hospice services. She said the facility did not have a Restorative Nursing Program (RNP) but some residents had orders for hand splints and the Certified Nursing Assistant (CNA) would assist with applying them. She added the resident did not normally refuse care. Review of the order summary report dated 05/16/24 revealed resident #25 had orders for OT to evaluate and treat resident #25 after hospital re-admission to facility on 02/28/24. Review of resident #25's comprehensive care plan revealed there was no care plan addressing limited range of motion, positioning, or palm guard use and/or refusal. On 05/15/24 at 3:16 PM, the Therapy Director stated resident #25 used to be on OT case load prior to being admitted to the hospital on 02/23/24. She noted the resident was readmitted on [DATE] and a new OT evaluation was ordered by the physician. The Director explained Resident #25 was evaluated on 03/03/24 for OT services and was to receive services related to her left-hand contracture daily. She recalled she was discharged from OT on 03/19/24 because she refused to wear the palm guard, was not making improvement, and there were recommendations for hospice evaluation by the physician. The Therapy Director explained the facility did not have RNP but instead had Functional Maintenance Program (FMP). The FMP was used by therapists to educate the direct care staff on how to prevent worsening contractures and skin breakdown. She further indicated staff were educated on palm guard use, but she failed to enter an order. The Director acknowledged she failed to communicate with the Minimum Data Set (MDS) coordinator, who was responsible for developing care plans. She stated she attended care plan meetings and provided therapy recommendations for all residents who received or were being discharged from therapy. Review of OT notes for resident #25 revealed an evaluation for services starting on 03/03/24 through 05/01/24. Treatment diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and contracture of left hand. The treatment plan included manual therapy techniques and prosthetic training 15 minutes per day. OT goals included safely wearing a hand roll, a palmar guard or even a carrot on left hand for up to 30 minutes. Assessment notes revealed resident #25 had a palm guard and roll for her left hand but refused to wear it. A progress note dated 03/15/24 showed resident exceeded the goal of wearing palm guard for one hour and maximum improvement was yet to be attained. An OT discharge summary from 03/21/24 showed maximum potential was achieved, and resident referred for FMP. The prognosis, with consistent staff follow-through, would allow the resident to maintain current level of functioning. The FMP plan was to facilitate resident maintaining current level of performance and to prevent decline, development of and instruction in the following FMP had been completed with the Inter Disciplinary Team (IDT): bed mobility, Range of Motion (ROM) (Passive) and splint or brace care. Review of the resident's medical record revealed a progress note from the Physiatrist on 03/18/24 that indicated the resident was observed wearing palm guard in the left hand and tolerates it when on. On 05/16/24 at 10:28 AM, CNA D stated she used to see the resident with a palm guard but had not seen her with it for a few months. CNA D indicated that when OT was discontinued, therapist came to educate them about resident having the palm guard. She further indicated it would be beneficial for resident #25 to have the palm guard because it would prevent her nails from digging in her palms that could cause skin breakdown. On 05/16/24 at 09:58 AM, RN C stated the resident received OT when she returned from the hospital, but it had ended a few months ago. She indicated that nothing was being done for resident #25's left hand to prevent worsening of contractures. She noted the resident used to wear a palm guard, but she had not seen it for a while. She explained she was unfamiliar with FMP but remembered a therapist came to educate staff on the use of the palm guard. She further explained that it was important to wear a palm guard for a resident with contractures because it would prevent skin breakdown as well as worsening contractures. On 05/16/24 at 12:21 PM, Unit Manager (UM) for [NAME] 2 unit, stated resident #25 received OT for a few weeks when she returned from the hospital, and she was used a palm guard. I am unsure of why OT ended. She said after a resident was discharged from therapy, an order was usually entered by the Therapy Director for use of a palm guard and FMP. The therapy director would come to the unit and educate the staff on how to apply the palm guard and there would be a care plan created by the MDS coordinator addressing the palm guard. She indicated that resident #25 was unable to verbalize her needs and she had refused care in the past.

Based on observation, interview, and record review, the facility failed to maintain comfortable temperature in 1 of 2 shower rooms, ([NAME] I) and failed to provide a safe and homelike environment in 1 of 13 rooms in the 300-hall, (room [ROOM NUMBER]). Findings: 1. On 1/31/23 at 11:00 AM, resident #3 stated the shower room was cold and he had informed the Certified Nursing Assistants (CNAs) but nothing was done about it. On 2/01/23 at 11:57 AM, resident #3 said he took a shower today and the shower room was too cold. On 1/31/23 at 12:04 PM, resident #9 explained the shower room could be warmer. He stated he had mentioned the cold temperature in the shower room to the CNAs, but they did nothing to address it. On 1/31/23 at 12:29 PM, resident #26 stated she preferred to get showers but the shower room was too cold. On 02/01/23 at 8:50 AM, Licensed Practical Nurse (LPN) D asked resident #70 if she was taking a shower today. Resident #70 responded as long as it is warm in there, she would take the shower. LPN D said, They always complain that shower room is cold. She explained she had overheard CNAs talk amongst themselves about residents' complaints of the cold shower room. She did not recall if anyone had reported this issue to maintenance. On 2/01/23 at approximately 2:00 PM, the shower rooms were observed with CNA L. CNA L stated she felt the difference in temperature from the [NAME] II shower room to the [NAME] I and mentioned it would feel cold for a resident after she stopped the running water. The temperature in [NAME] 1 shower room registered 74.6 degrees ( ) Fahrenheit (F). On 2/02/23 at 10:50 AM, the Maintenance Director stated they had complaints with shower room temperatures. The Maintenance Director explained the temperature was set at 70 F and the thermostat was controlled at the nurse's station. He indicated the thermostat for [NAME] II was moved to the Unit Manager's (UM) office. He reported he did not know residents had refused showers because of the cold shower room. On 2/02/23 at 11:03 AM, during tour of the shower room in [NAME] I, the Maintenance Director checked the temperature and stated it was 68 F. He said, It is too cold; 68 is too cold. He noted the thermostat was set at 69 F. The Maintenance Director raised the thermostat to 72 F and said it would take a few hours for the shower room to warm up. He checked the temperature in the [NAME] II's shower room which showed 70 F. He stated this was the correct temperature but the [NAME] 1 shower temperature was too cold. 2. On 1/31/23 at 9:19 AM, the right corner of the bedside table in room [ROOM NUMBER]-B was in disrepair. The top panel was broken on the right side, missing approximately 4 inches long by 2 inches wide. Splints were visible on the bedside table while resident #89 sat in front of the table with her personal papers lying on it. Resident #89 mentioned she had told someone about the condition of her table but did not get a replacement. On 2/02/23 at 10:29 AM, the broken bedside table was still in use in room [ROOM NUMBER]. Photographic evidence was obtained of the broken table on 2/01/23. On 2/02/23 at 10:35 AM, CNA K stated she always had the same assignment in the 300-hall. She stated if she found anything broken in a resident's room she completed a Repair Requisition form located by the nurses' station. She indicated someone from maintenance came every day and checked the completed requisition forms. She stated when she provided care to her residents, she ensured everything was working in their rooms. She indicated if a bedside table was broken, she looked for another one, wiped it down and replaced it. Later at 11:18 AM, CNA K shared she had worked the day before and today in room [ROOM NUMBER]. She explained she brought the meals during her shift which included breakfast and lunch and placed the tray on the bedside table. She indicated she often looked at the condition of bedside table when delivering the trays and she remembered pushing the bedside table to the wall this morning. She indicated she had not noticed the broken table in room [ROOM NUMBER]. CNA K added the resident could have scratched or hurt herself with the broken table. On 2/02/23 at 10:40 AM, the Maintenance Assistant stated they learned about needed repairs or replacement of equipment when staff completed a Repair Requisition form or entered a request in their maintenance electronic system. She indicated they collected the requisition forms every day. Review of submitted requisition forms in January 2023 revealed no requests or issues for room [ROOM NUMBER]. On 2/02/23 at 10:50 AM, the Maintenance Director stated when he inspected resident's rooms, he looked for the integrity of the entire room, paying attention to things that may have been overlooked by staff. He explained he expected the direct care staff to notice a non-working bedside table because they touch the table at least three times a day. On 2/02/23 at 11:10 AM, the Maintenance Director validated the broken bedside table in room [ROOM NUMBER]-B. The Maintenance Director stated this was a new table which probably got stuck and bent by the bed frame and no one reported it. He indicated anyone who delivered a meal tray every day should have noticed, reported and removed it from service right away. Review of the facility policy and procedure titled, Maintenance dated 11/30/14, read, The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. The procedure revealed daily rounds of the building by the Director to ensure the plant was free of hazards and in proper physical condition.

Based on observation, interview and record review, the facility failed to supervise a physically and cognitively impaired vulnerable resident while he was left outside in the facility courtyard in the sun and extreme heat for 1 of 7 residents reviewed for supervision of a total sample of 13 residents, (#1). The resident remained in the courtyard for one and half hours and suffered heat exhaustion, dehydration, life threatening [CONDITION(S)] and hospitalization . On 8/01/22 at approximately 11:30 AM, resident #1 was assisted to the outdoor courtyard by the Physical Therapy (PT) student. Neither the PT student nor the therapist observed any staff in or near the courtyard and did not inform resident #1's nurse or Certified Nursing Assistant (CNA) that the resident was in the courtyard. Approximately an hour and a half later, the therapy student saw resident #1 still in the courtyard in the sun and brought him inside to his room. A few minutes later, the resident's CNA found him drooling with his head slumped down and unresponsive. At 1:21 PM, the resident's nurse was notified and 911 was called. Emergency personnel arrived and noted the resident with hot, dry skin, unable to communicate, dehydrated and hypotensive. He was transported to the emergency room and fluids were given intravenously until his blood pressure and mental status improved. The resident was hospitalized and treated for [CONDITION(S)] and heat exhaustion and discharged 2 days later to another long term care facility. The facility's failure to provide supervision for this cognitively and physically impaired resident while he was left outside in extreme hot conditions for one and half hours resulted in resident #1's change in condition and subsequent hospitalization . This failure placed all residents who go to the outdoor courtyard when the weather is excessively hot at risk for heat exhaustion/heat stroke, serious injury/impairment/death. This failure resulted in Immediate Jeopardy which started on 8/01/22 and was removed on 8/13/22. Findings: Cross Reference to F609 Resident #1 was admitted to the facility on [DATE] with diagnoses that included weakness and paralysis to left side due to stroke, [CONDITION(S)], [CONDITION(S)], diabetes mellitus, chronic lung disease, and history of falls. [CONDITION(S)] is a brain disorder often following a stroke or head injury that affects the way a person understands both written and spoken language as well as the way they speak or can write (retrieved on 8/15/22 from Mayoclinic.org). Review of the Florida Agency for Healthcare Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/20/22, revealed resident #1's primary diagnosis was cervical stenosis of the spinal canal and a secondary diagnosis of falls. The form showed the resident required a surrogate for decision making, was not ambulatory and required assistance of 2 staff for transfers. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 8/15 which indicated moderate cognitive impairment. The assessment noted the resident required extensive assistance from one person for bed mobility, transfers and locomotion on the unit. Review of the functional abilities section showed resident #1 needed substantial assistance from staff for half the effort to wheel 50 feet using his wheelchair upon admission. The Admission/Readmission Data Collection with effective date of 7/19/22 revealed resident #1 was alert and oriented to person and place, but not time. The document showed resident #1 had memory problems, used a wheelchair and had general weakness. Resident #1's care plans for communication problem related to cardiovascular accident with [CONDITION(S)] and impaired cognitive function/dementia or impaired thought processes noted he had word finding difficulties in high demand situations and cognitive impairment initiated on 7/30/22. Interventions included staff to anticipate and meet resident's needs, ask yes/no questions if appropriate, use simple, brief consistent words/cues, present just one thought or idea at a time, use task segmentation to support short term memory deficits, cue, reorient and supervise the resident as needed. Review of the medical record revealed resident #1 had physician orders dated 7/20/22 for Occupational Therapy (OT), PT and Speech Therapy five times a week for four weeks to improve verbal expression, speech fluency and enhance cognitive skills including temporal orientation. The physician orders showed his prognosis and rehabilitation potential was fair. The resident's physician orders for medications dated 7/19/22 included [MEDICATION(S)], a blood thinner for [CONDITION(S)] disease, Buproprion HCl 24-hour Extended Release tablet for depression and [MEDICATION(S)] 20 milligrams. [MEDICATION(S)] is a medication used to treat high blood pressure. People who take [MEDICATION(S)] are warned to call a doctor if they have excessive sweating because they can have low blood pressure. They are also warned to avoid becoming dehydrated or overheated in exercise or hot weather because the medication can decrease sweating and make them more prone to heat stroke (retrieved on 8/11/22 from www.drugs.com). Review of the Speech Therapy Discharge Summary with dates of service 7/20/22 to 7/29/22 revealed resident #1 had a goal to improve working memory skills to 70 percent accuracy. His baseline working memory was assessed at 50 percent on 7/20/22 and was assessed at discharge on 7/29/22 with no change at 50 percent. A therapy progress note indicated progression as slow but steady towards the established goals and resident needed mild to moderate cues to recall safety precautions. A nursing progress note dated 8/01/22 at 12:50 PM, recorded as a late entry by the Assistant Director of Nursing (ADON) revealed she was informed that CNA found resident #1 drooling and unresponsive when he returned from therapy. The ADON documented she assessed the resident and asked the CNA to ask the therapist who returned him to his room what his condition was. The ADON then documented Emergency Medical Services (EMS) was initiated, and vital signs were taken. She noted when EMS arrived a few minutes later to transport resident #1 to the hospital, he was alert and answering some questions appropriately. In a telephone call on 8/10/22 at 12:36 PM, resident #1's wife stated she visited her husband at the facility almost every other day and took him outside to the courtyard at times. She reported she did not usually see any staff in the courtyard. She explained her husband had difficulty with his speech and was often hard to understand. She indicated he would not be able to identify if he was too hot or overheated, nor would he be able to alert someone that he was hot and needed something to drink. Resident #1's wife recalled on 8/01/22 at approximately 2:00 PM, she came to the facility, but her husband was not in his room. She stated a CNA told her they had rushed him to the hospital. She said she was surprised as she checked her phone and no one from the facility had called to tell her what had happened. She stated she received a call from EMS personnel while she was in his room and he told her, I need to let you know what happened. She said EMS personnel explained to her that facility staff had left her husband outside for over an hour and he was dehydrated when they arrived to the facility and his blood pressure crashed. She stated she asked the nurse what happened and was told only that her husband was slumped over and unresponsive when he came back from physical therapy (PT). Resident #1's wife said she then informed the nurse that EMS personnel told her he had been left outside and was dehydrated. She stated the nurse argued with her and conveyed her husband was allowed to go outside. She recounted the nurse never mentioned her husband ever being outside. She stated her son wanted to know what time resident #1 had his therapy, but the nurse would not answer him. She noted EMS gave her husband fluids through an intravenous line and were able to get his blood pressure back up once he was in the hospital. She explained the hospital was going to return him back to the facility a few days later but she told them, You can't send him back to the facility that tried to kill him. In a telephone call on 8/11/22 at 1:53 PM, the PT student stated she worked under supervision of staff, PT B from June until August 5th, 2022. She recalled she worked with resident #1 during his short stay at the facility on therapeutic exercises for his left sided weakness and upper body range of motion. She recalled on 8/01/22, the resident had an uneventful 30-minute physical therapy session with her after he had completed a 30-minute OT session with OT D. She said after therapy, she assisted resident #1 outside to the courtyard as per his request. She remembered there were several smokers sitting outside, but she did not see any staff there at the time. She said she did not inform any staff that the resident was outside as she had never told that she needed to. She stated it was normal to let residents outside after therapy sessions but she did not recall ever telling any staff that they were outside. The therapy student remembered after she took resident #1 outside, she worked with at least two other residents for half hour each, totaling 1 hour then went for lunch a few minutes before PT B left for his lunch. She explained about 10 minutes into her 30-minute lunch break, she realized she had forgotten something in her car and walked out through the courtyard where the resident sat on the concrete area near the herb garden. She said she did not see any staff outside in the courtyard when she headed towards the front of the building to her car. She reported she finished her lunch in her car and at the end of her 30-minute break she walked back through the courtyard and saw resident #1 still sitting in the sun in the same spot he was before. She recalled he looked sweaty, and his head was slightly reddened, and commented, You must be hot. She remembered the resident asked her to take him back inside. The therapy student stated when she wheeled resident #1's wheelchair back inside the gym, OT D was there, and he assisted her to put the wheelchair footrests back on as the resident could not hold his feet up off the ground and his shoe had come off. She said she passed PT B on his way back from lunch, and saw CNA A near the nurse's station when she wheeled resident #1 back to his room. Review of the historical weather data revealed on 8/01/22 at 12:00 PM the temperature was 90 degrees Fahrenheit (F), sunny, with a humidity level of 83%. There was no wind at that time of day. The heat index or feels like temperature was 115.8 F. Heat indices of 105 degrees F or above are classified as dangerous and can likely lead to heat exhaustion and heat stroke. (retrieved on 8/11/22 from the National Weather Service at www.NWS.com). In interviews on 8/11/22 at 12:45 PM and 2:58 PM, Occupational Therapist (OT) D recalled resident #1 had cognitive and speech difficulties and often needed instructions repeated several times. OT D stated resident #1 would not remember to ask for help when needed. He said on 8/1/22, he worked for a half hour with resident #1 at approximately 10:30 AM then handed him off to the physical therapy student. He stated he sat down to work at his computer and saw several of the regular smokers sitting under the covered patio but did not observe a staff member outside supervising the residents. He recalled the PT student brought the resident back inside the therapy gym and remembered the resident looked tired, not as alert as he was earlier, and the student took him back to his room. He said a little later, a CNA came to inquire what happened to resident #1 and PT B and the student went to the resident's room. OT D stated he often took residents outside to the courtyard after therapy and felt it was not the therapists' responsibility to monitor the residents outside. He noted the smart thing was to have a staff member outside to supervise the residents. OT D explained that while he worked he tried, . not to look out into the courtyard because they will ask me to do things for them. In interviews on 5/10/22 at 2:04 PM and 5/11/22 at 3:04 PM, agency CNA A stated she was assigned to resident #1 frequently during his time at the facility. She recalled on 8/01/22 she was at the nutrition room after lunch was delivered when she saw the therapy student bring resident #1 in his wheelchair towards his room. She thought he looked tired, and when she greeted him as they went past, the resident did not respond which was unusual for him. CNA A stated a few minutes later, she went to his room to set up his lunch tray and the resident's head was down, his face was pale, he was drooling and unresponsive. She remembered he felt clammy, but his skin felt hot. She said she ran to get the nurse, and when the nurse felt the resident's skin, she said it was hot and directed her to get cold, wet washcloths to put on his neck. She recalled the nurse then directed her to go to therapy to find out what happened. She recounted the therapy student and PT B followed her back to resident #1's room and told her the resident had been outside before he was brought back to his room. CNA A recalled emergency personnel arrived at the facility a short time later and took him to the hospital. In interviews on 8/10/22 at 2:31 PM and 8/12/22 at 2:19 PM, Physical Therapist (PT) B stated resident #1 usually came to therapy at 10:30 AM for half hour each of OT and PT. PT B recalled resident #1 asked to go outside frequently after therapy. He stated neither he nor the therapy student checked the temperature outside before they took the resident outside. He said he did not observe a staff member outside in the courtyard when resident #1 was assisted outside, nor did he notify resident #1's nurse or CNA that he was going to the courtyard after therapy. He stated once therapy was completed and a resident went outside or left the gym, he felt the therapy staff were no longer responsible for the resident. He recalled he learned about heat stroke in orientation but was not aware of a policy to warn residents of the heat or to limit the time residents spent outside if the heat index was high. He was not aware of a thermometer outside in the courtyard and neither he nor his student warned resident #1 to limit his time in the heat. PT B recounted he went to lunch around 12:30 PM and confirmed he did not check on resident #1 to see if he wanted to come in before he left the facility for lunch. PT B recalled a short time after he came back from lunch, a CNA came to the gym and asked about resident #1. He noted he and the therapy student returned with the CNA to resident #1's room and saw nursing staff had placed wet towel on his neck and cooling packs under his armpits to cool him. He stated resident #1 was breathing, but unable to stay awake and respond appropriately at that time. Review of the therapy timecard for PT B revealed he clocked out for lunch at 12:36 PM on 8/01/22 and clocked back in at 1:06 PM. On 8/12/22 at 2:50 PM, the Rehab Director stated therapy staff were not responsible to monitor residents outside but explained there were staff outside intermittently. She said they did not get any warnings of extreme temperatures outside or to limit or prevent residents from going outside if the temperatures were extreme. She explained there was no specific person that monitored the residents once they went outside after therapy. She said if the resident was incapable either physically or cognitively of getting themselves back inside then therapy would assume the responsibility to bring them back in. In a telephone interview on 8/11/22 at 4:36 PM, agency Licensed Practical Nurse (LPN) E recalled it was her second shift at the facility on 8/01/22. She recalled resident #1 went to therapy sometime after she gave him his morning medications, but she was unable to give an exact time. She stated therapy did not notify her that they were taking the resident to the gym nor did anyone notify her that he was taken outside to the courtyard after his therapy session. She explained sometime after lunch, CNA A notified her that resident #1 was unresponsive and not himself. She stated she went to the room to assess him and rubbed his chest very hard and received no response from him. She recalled resident #1 had a wet washcloth on his neck, and therapy staff showed up a short time later but did not tell staff how long resident #1 had been outside. She stated EMS personnel arrived a few minutes later and transported the resident to the hospital. On 8/10/22 at 4:42 PM, the ADON stated she was notified by a panicked looking CNA A that resident #1 was unresponsive. She said when she put her hand on his shirt and did not see him respond in any way she ran back towards the nurse's station to get help. She described the resident as unresponsive with his eyes open and drooling from his mouth. She stated she sent the CNA to therapy to find out what happened, notified the assigned LPN E, and the Advanced Practice Registered Nurse (APRN) who was on the unit then called 911. She explained she stayed at the nurse's station while other staff obtained his vital signs and EMS personnel arrived. She said a short time later resident #1's wife arrived on the unit after EMS had left. On 8/11/22 at 4:00 PM, APRN F explained the elderly population was more at risk for dehydration and heat related problems as they generally could not regulate their body temperature efficiently and they had less sensation to their skin. She added that medications could also affect how they responded to heat and that residents were not able to compensate when they were overheated. APRN F recalled on the afternoon of 8/01/22 she was in the building when she was informed of resident #1's change in condition but she did not examine him as EMS personnel had just arrived. She stated that because of the extreme heat and because elderly residents were more at risk, she would not recommend them to be outside without supervision or for extended periods of time. She continued that she could not confidently say resident #1 would be able to recognize he was overheated or know to come inside by himself. Review of the county EMS, Patient Care Record dated 8/01/22 revealed they received a 911 call from the facility at 1:21 PM and arrived at the facility 3 minutes later at 1:24 PM. The EMS narrative indicated they responded to the facility for a complaint of a resident with generalized weakness and once on scene, the nursing staff related the resident was left outside in a wheelchair for an unknown amount of time. The narrative also showed nursing staff reported the resident was hot, dry and unable to respond appropriately when found. EMS noted resident #1's skin was hot, dry and pink, he was confused and unable to respond until after fluids were given. The primary assessment was heat exhaustion and secondary assessment was noted as [CONDITION(S)]. At 1:35 PM, approximately 9 minutes after they arrived in resident #1's room, his blood pressure was 63/37 and just after they departed the facility at 1:39 PM, his blood pressure was 65/41. The report noted an intravenous catheter was inserted into the resident's arm, 800 milliliters of fluids was administered and the resident was placed in a head down position for transport to the hospital to facilitate oxygen perfusion to the brain. Review of the hospital emergency room record showed resident #1 was hypotensive upon arrival with blood pressure reading of 87/60 which improved with administration of fluids. The nurse's physical assessment documented on 8/02/22 showed resident #1's skin as skinburn/redness over his scalp, chest, shoulders and arms. His neurological assessment showed he had chronically impaired orientation, confused, forgetful and impulsive with rambling, garbled speech. Review of the facility's nursing staff assignment sheet provided by the facility for 8/01/22, revealed Activity Assistant C was not on the schedule to work. There was no staff assigned to supervise residents who smoked for neither the first nor second shift on 8/01/22. Review of the facility's CNA assignment sheets for 8/01/22 for the first and second shifts on both units of the facility revealed no tasks assigned for CNAs to monitor the smoking area or outside courtyard. On 8/10/22 at 3:18 PM, Activity Assistant C stated he was not sure if he worked at the facility on 8/01/22. He stated he did not keep a record of what days he worked but said if he was here that day, it would show on his timecard. He was shown a picture of resident #1 and stated the resident was not on the unit he usually worked and did not recognize him. He explained he knew the regular smokers and resident #1 was not someone he recognized. He said when he sat outside with the smokers he was there primarily to keep the smokers safe and added the residents often did not realize how hot it was and did not know to go inside to cool off. On 8/10/22 at approximately 3:30 PM, the Director of Nursing (DON) was asked to provide the payroll time sheet for Activity Assistant C. Approximately 40 minutes later the DON returned with Activity Assistant C's time sheet. The DON then presented a timecard change form filled out by hand that noted Activity Assistant C's timecard changed to show he worked on 8/01/22. The DON also presented a signed witness statement from Activity Assistant C that stated he had supervised the shaded smoke porch area on 8/01/22 from 6:45 AM to 3:30 PM. The typed document indicated he witnessed resident #1 coming outside to the smoking porch and then headed back into the therapy department for lunch. The DON explained she had texted Activity Assistant C on Monday 8/01/22 to work due to a call out. She was unable to provide the texts from that day showing her message to Activity Assistant C. Review of the Payroll Company time sheet for Activity Assistant C for payroll period of 8/03/22 revealed he had clocked in and out on 7/29/22, 7/30/22, 7/31/22, 8/02/22 and 8/03/22. There was no indication he clocked in on 8/01/22. Review of the Time Clock Adjustment form completed by hand for punch date of 8/01/22, reason for corrections showed forgot to punch in and out. The document indicated the time adjustment was submitted after payroll had closed. The form was initialed by the DON and signed by human resources staff. The date prepared was left blank as well as the dated posted sections of the form. On 8/11/22 at 10:19 AM, the DON stated they did not get a statement from the assigned nurse or the therapy student for what occurred on 8/01/22. She stated in her investigation she identified resident #1 was outside for approximately 20-30 minutes. She stated she had the statement from Activity Assistant C but was unable to answer why he did not remember the resident nor if he worked that day. The DON did not telephone the Activity Assistant and stated it was his day off and she would call him later. Review of the staff assignment sheet for 8/11/22 provided by the facility at the start of the survey on 8/10/22 revealed activity assistant C was scheduled to work on 8/11/22 and 8/12/22, but he was not at the facility during his scheduled shifts nor available for interview at that time. On 8/12/22 at 3:11 PM, the Administrator stated the facility did not have a policy regarding inclement or hot weather and residents going outdoors, only a policy for hurricanes or major storms. She stated there was no staff designated to monitor the weather or alert residents of extreme hot weather or other hazardous weather conditions. Review of the Facility Assessment Tool with most recent assessment date of 12/08/21 revealed services and care offered based on resident's needs included types of care the resident population required and that is provided to identify and reflect on the resources needed to provide this type of care listed under Identify hazards and risks for residents. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 8/01/22 a clinical review of resident's record was initiated by the Director of Clinical services. *As of 8/12/2022 education was provided to current licensed nurses, nursing assistants, department managers, contracted employees to include agency staff, dietary, housekeeping and therapy by the Executive Director, Director of Clinical Services, and the Regional Nurse related to Heat Related Illness, and fluid intake/acceptance refusal binder. Staff will not be allowed to work prior to being educated on the above mentioned. As of 8/13/22 105/119 staff including 100% of nurses and CNAs had received education. * On 8/12/22 a quality review was performed by the Director of Clinical Services to ensure Registered Nurse (RN) assessment was completed for residents who frequented outside to evaluate for any signs/symptoms of heat exhaustion, heat stroke or dehydration. Thirty four out of 34 residents, who frequently went to the outdoor area were evaluated by an RN with documentation in the medical record. None of the 34 residents presented with any signs/symptoms of heat exhaustion, heat stroke or dehydration. *On 8/12/22 the DON and Executive Director were educated by the Regional Nurse regarding the components of F689 and to ensure a system is in place to provide supervision for all residents who go outside during hot weather conditions. * On 8/12/22 a fluid intake/acceptance/refusal binder was implemented by the DON for residents who were outside in the smoking patio/courtyard. *On 8/13/22 wall thermometers were installed at exit doors near the entrance of the courtyard, including a hydrometer for measuring relative humidity, and wall clock to monitor time residents were outside. Heat-Related Illness information posters were placed at various locations throughout the center. A spot cooler was put in place in the designated smoking area. *On 8/13/22 a designated monitor was assigned to ensure resident supervision of smoke porch/courtyard daily from 6:45 AM - 9:00 PM, when the courtyard will be closed. When monitors not present on the smoke porch/courtyard, residents must be supervised by the staff member that brought the resident out. A process was put in place for monitor's break times where the Monitor called to the facility and relief staff were sent to the smoke porch/courtyard for supervision. *On 8/13/22 an ADHOC Quality Improvement Performance Committee meeting was held to review the results of facility wide quality reviews completed. The Medical Director agreed and approved the committee recommendations. Review of in-service and drill attendance sheets and reconciliation with staff rosters validated education was completed according to the facility's plan. Interviews conducted on 8/13/22 from 3:30 PM to 5:42 PM with 6 CNAs, 3 LPNs, 1 OT, Housekeeping staff, 3 Business Office staff, Activity Director, 1 Laundry aide and 1 Cook noted they were able to verbalize knowledge and understanding of the education provided. The sample was expanded to include 6 additional residents, (#2, #3, #4, #5, #16, #17) at risk for heat related problems and supervision outside as well as 2 additional residents at risk for neglect, (#10, #11). Observations, interviews and record reviews revealed residents had appropriate care plans, orders and supervision.

Based on interview and record review, the facility failed to ensure that residents were free from neglect as they failed to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 2 sampled residents with Advance Directives for full code on hospice services of a total sample of 5 residents receiving hospice services, (#1). On [DATE] at 8:30 PM, resident #1 on hospice services with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered Nurse (RN) A received orders from the physician to transfer the resident to the hospital and to check for hospice services. RN A did not to transfer the resident to the hospital but requested a visit from the hospice nurse. The hospice nurse arrived at 11:30 PM and pronounced resident #1's death 30 minutes after arrival. The facility's failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . While resident #1's respirations became more difficult, there was likelihood she suffered severe anxiety and distress. The Immediate Jeopardy was removed on [DATE] after validation of the implementation of the facility's IJ removal plan. Findings: Cross Reference to F678 and F726 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with respiratory distress and readmitted to the facility on [DATE]. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change reassessment Minimum Data Set (MDS) with an assessment reference date of [DATE] documented she was cognitively intact, required oxygen therapy and non-invasive mechanical ventilator assistance ([CONDITION(S)]) Continuous Positive Airway Pressure. Review of the resident's care plan for Full Code read, Resident has no advance directives and wishes to have CPR performed in the event of [CONDITION(S)]. The goal noted that resident's advanced directive would be followed. Review of the hospice Certification for the first 90-day period dated [DATE], documented justification for admission to hospice services with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:45 PM, RN A stated he was the nurse assigned to resident #1 on [DATE] on the 3 PM to 11 PM shift. He explained the resident was having difficulty breathing and he called the physician. He said the physician gave orders to send the resident to the hospital and to check if the resident was receiving hospice services. I reviewed the medical record, and she was a full code and on hospice, so I called hospice and requested to have a nurse come out to the facility. RN A recalled he was worried about the resident because she was agitated and not relaxed so he asked LPN D from another nursing unit to assess the resident. He remembered LPN D told him he should send the resident to the hospital but because she was on hospice, he needed to wait for the nurse to arrive. RN A stated he was aware that a resident could be full code while on hospice services. He verbalized any resident with full code orders should be provided life support measures such as CPR. He did not have an explanation as to why he did not send the resident to the hospital after the physician gave the order. RN A said he thought the hospice nurse would evaluate the resident and discuss with the hospice medical director and provide direction. On [DATE] at 3:54 PM, LPN B stated she was assigned to resident #1 on [DATE] on the 11 PM to 7 AM shift. She said RN A had reported that resident #1 was having respiratory difficulty and the hospice nurse was on her way to the facility. She said she had reviewed resident #1's medical record and verified she was a full code. LPN B recalled she checked on resident #1 and she had labored breathing. She said the resident was anxious, constantly took off her oxygen and she placed it back on. She added the resident was not speaking and her eyes were closed. LPN B stated the hospice nurse arrived at the facility at approximately 11:15 PM and I started doing my medication pass. She recalled at 12:00 AM, midnight, the hospice nurse informed her the resident had stopped breathing and she had already called the hospice physician and pronounced the death. LPN B explained that when the hospice nurse said she had done everything she thought the nurse had performed CPR. I never asked her if she had initiated CPR, I just assumed. LPN B said she was under the assumption the hospice nurse initiated CPR as required for a resident who was full code. It was my mistake; I was aware the resident was a full code, and I should have initiated CPR and called 911. She acknowledged she incorrectly documented a progress note noting the hospice nurse initiated CPR, called a code and notified Emergency Medical Services (EMS). LPN B said she saw the hospice nurse on the telephone and assumed she was calling EMS and the hospice physician. Review of a progress note dated [DATE] at 1:06 AM completed by LPN B noted, Upon arrival to the start of the shift at 11 PM, this nurse conducted rounds on resident #1. Resident was breathing with oxygen on at 4 liters. Approximately 15 minutes after the start of the shift, the hospice nurse arrived at the facility. While the hospice nurse was conducting an assessment with resident #1 she passed away. The hospice nurse pronounced the resident and notified the family. Another progress note by LPN B dated [DATE] at 1:47 AM read, the hospice nurse was at the resident's bedside and full code verified. The hospice nurse initiated full code, CPR continued, EMS notified, the hospice physician notified and he instructed the nurse to stop the CPR. The hospice nurse called the time of death at 12:01 AM. On [DATE] at 10:29 AM, during a telephone interview, resident #1's attending physician confirmed he had received a call from the facility. He said RN A updated him on resident #1's condition. The physician stated he initially thought the resident was a do not resuscitate (DNR) with hospice services. He said he gave an order to send the resident to the hospital and if the resident was on hospice to check with them on how to proceed. The physician stated, A nurse functions under the direction of a physician and follows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:29 AM, a phone interview was conducted with the hospice provider's Compliance Officer. She stated resident #1 was on hospice services and she had signed the consent form which indicated she had no advanced directive, so it defaults to a full code. She stated the hospice staff do not perform CPR on any resident receiving hospice services. She explained that on [DATE], the hospice nurse arrived at the facility at 11:30 PM and had spoken with LPN B. The hospice nurse assessed resident #1 and requested a breathing treatment. The breathing treatment was given and shortly after the resident stopped breathing. The hospice nurse then called the hospice triage nurse for direction as the resident was a full code. The hospice nurse then notified LPN B the resident had stopped breathing. On [DATE] at 12:09 PM, during a telephone interview, the hospice nurse stated she had arrived at the facility on [DATE] at 11:30 PM. She said she spoke with LPN B who communicated that resident #1 was not doing well. She noted she proceeded to see the resident along with LPN B and was aware the resident was a full code. She explained she had informed LPN B twice that as a hospice nurse she did not perform CPR on hospice residents. She recalled resident #1 stopped breathing, she pronounced the resident's death and then informed LPN B. LPN B did not initiate CPR for resident #1 and she did not call 911. On [DATE] at 10:42 AM, the Director of Nursing (DON) stated that all licensed nurses' function under the direction of a physician. She explained when a physician gives an order, the nurse was to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to the hospital and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that LPN B was aware of resident #1's code status and she should have initiated CPR when she was informed by the hospice nurse that the resident stopped breathing. Review of the facility's Advanced Directives Policy and Procedure, revision date [DATE], read, . The center will honor all properly executed advanced directives that have been provided by the resident and/or resident representative Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure, revision date [DATE], read, Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [CONDITION(S)] unless such resident has a valid Do Not Resuscitate (DNR) order. Procedure: 1. In the event of a [CONDITION(S)] immediately call for assistance 2. Two licensed nurses to verify: resident identity and current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In the absence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policy and Procedure, revision date [DATE], read, . Neglect is the failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Failure to take precautionary measures to protect the health and safety of the resident Review of the immediate corrective measures implemented by the facility revealed the following, which were reviewed by the surveyors: *On [DATE] LPN B was suspended and had submitted her resignation as of [DATE]. *On [DATE] the hospice nurse was removed from the schedule. *On [DATE] a quality review of the five current residents receiving hospice services was completed by the DON and Social Service Director (SSD) to ensure Do Not Resuscitate Orders (DNRO) were accurate, Advanced Directives were in place and care plans reflect resident wishes and physician orders. No issues were identified. *On [DATE] to [DATE] a facility wide review of current resident's code status was performed by the Regional Director of Nursing (RDCS) and SSD. Current Advanced Directives list obtained from medical records reviewed. No issues were identified. *On [DATE] 100% of the facility's licensed nurses' CPR certification were reviewed and verified to be current. *On [DATE] a Performance Improvement Plan was developed and initiated based on Root Cause Analysis (RCA) as determined by the Quality Assurance Performance Improvement (QAPI) committee. RCA identified as miscommunication between hospice nurse and the facility nurse: hospice nurse did not alert staff when resident #1 became unresponsive; facility once alerted of resident passing did not initiate CPR. RN A did not send the resident to the hospital after obtaining an order from the physician. *On [DATE] RN A received individualized training with the DON regarding assessment and change in condition and when appropriate to send resident to the hospital in efforts to prevent further occurrence. Individualized scenarios presented to validate competence. RN verbalized understanding. *Hospice nurses will be educated on facility Advanced Directives policy and procedures, Nurse Practice Act, facility policy for notification of family for resident change in condition prior to delivering resident care at the facility. *Licensed staff education initiated to include policy and procedures for CPR, Advanced Directives, Nurse Practice Act, Hospice Services, Notification of Family of Change in Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Education accompanied by post tests and participation in Code Blue drills to validate understanding and competency. All licensed nurses obtained a passing score. *All Staff education was completed to include Abuse and Neglect Policy and Procedure, Resident Rights Policy and Procedure and CPR Policy and Procedure. Certified letters were sent to those staff members that were not able to attend the education in person. Staff will be required to complete in-servicing with competency prior to working next shift. *All newly hired licensed nursing staff will receive education upon hire to include CPR Policy and Procedure, Advanced Directives Policy and Procedure, Nurse Practice Act, Hospice Services, Notification of Families of Change of Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE] an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to review recommendations made from the RCA. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Clinical Services, Regional Director of Clinical Services (RDCS) MDS Coordinator, Case Manager, Unit Manager, Human Resource Coordinator, Business Development Coordinator and Director of Rehabilitation Services. The Ad Hoc QAPI Committee approved the recommendations. Monthly QAPI meetings will be held to review the current plan. *All facility deaths will be reviewed by the RDCS weekly times two months to ensure policy and procedures are being followed or until QAPI determines substantial compliance. *The DCS/designee will continue quality reviews weekly times four weeks, then monthly times two months for resident Advanced Directives to ensure policies and procedures are being followed. *Code blue drills will continue with licensed nurses weekly on each shift for two months or until QAPI committee determines substantial compliance has been achieved. Staff interviews were conducted with 19 facility staff including 3 agency licensed nurses, 1 agency Certified Nursing Assistant, 3 facility licensed nurses, 5 facility CNAs, 2 dietary staff, 1 maintenance staff member, 1 therapy staff, 1 Personal Care Attendant and 2 housekeeping staff between [DATE]-[DATE]. Interviews revealed the facility had provided education on Abuse/Neglect, Resident Rights, CPR, Advanced Directives, Hospice Services, Notification of Family of Change of Condition, following physician orders, and the Nurse Practice Act.

Based on interview and record review, the facility failed to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 2 sampled residents on hospice services with orders for full code of a total sample of 5 residents receiving hospice services, (#1). On [DATE] at 8:30 PM, resident #1 on hospice services with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered Nurse (RN) A received orders from the physician to transfer the resident to the hospital and to check with hospice services. RN A did not to transfer the resident to the hospital but requested a visit from the hospice nurse. The hospice nurse arrived at 11:30 PM, and pronounced resident #1's death 30 minutes after arrival. The facility's failure to provide CPR resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE] when the immediate actions the facility implemented were verified. Findings: Cross Reference to F600 and F726 Resident #1, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized on [DATE] with respiratory distress and readmitted to the facility on [DATE]. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change reassessment Minimum Data Set with an assessment reference date of [DATE] documented she was cognitively intact, required oxygen therapy and non-invasive mechanical ventilator assistance ([CONDITION(S)]) Continuous Positive Airway Pressure. Review of the resident's care plan for Full Code read, Resident has no advanced directives and wishes to have CPR performed in the event of [CONDITION(S)]. The goal noted that resident's advanced directive would be followed. Review of the hospice Certification for the first 90-day period dated [DATE], documented justification for admission to hospice services with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:45 PM, RN A stated he was the nurse assigned to resident #1 on [DATE] on the 3 PM to 11 PM shift. He explained the resident was having difficulty breathing and he called the physician. He said the physician gave orders to send the resident to the hospital and to check if the resident was receiving hospice services. I reviewed the medical record and she was a full code and on hospice, so I called hospice and requested to have a nurse come out to the facility. RN A recalled he was worried about the resident because she was agitated and not relaxed, so he asked a nurse from another nursing unit, Licensed Practical Nurse (LPN) D to assess the resident. He remembered LPN D told him he should send the resident to the hospital but because she was on hospice he needed to wait for the nurse to arrive. RN A stated he was aware that a resident could be full code while on hospice services. He verbalized any resident with full code orders should be provided life support measures such as CPR. He did not have an explanation as to why he did not send the resident to the hospital after the physician gave the order. RN A said he thought the hospice nurse would evaluate the resident and discuss with the hospice medical director and provide direction. On [DATE] at 3:54 PM, LPN B stated she was assigned to resident #1 on [DATE] on the 11 PM to 7 AM shift. She said RN A had reported that resident #1 was having respiratory difficulty and the hospice nurse was on her way to the facility. She said she had reviewed resident #1's medical record and verified she was a full code. LPN B recalled she checked on resident #1 and she had labored breathing. She said the resident was anxious, constantly took off her oxygen and she placed it back on. She added the resident was not speaking and her eyes were closed. LPN B stated the hospice nurse arrived at the facility at approximately 11:15 PM and I started doing my medication pass. She recalled at 12:00 AM, midnight, the hospice nurse informed her the resident had stopped breathing and she had already called the hospice physician and pronounced the death. LPN B explained that when the hospice nurse said she had done everything, she thought the nurse had performed CPR. I never asked her if she had initiated CPR, I just assumed. LPN B said she was under the assumption the hospice nurse initiated CPR as required for a resident with orders for full code. It was my mistake, I was aware the resident was a full code and I should have initiated CPR and called 911. She acknowledged she incorrectly documented a progress note noting the hospice nurse initiated CPR, called a code and notified Emergency Medical Services (EMS). LPN B said she saw the hospice nurse on the telephone and assumed she was calling EMS and the hospice physician. Review of a progress note dated [DATE] at 1:06 AM, completed by LPN B noted, Upon arrival to the start of the shift at 11 PM, this nurse conducted rounds on resident #1. Resident was breathing with oxygen on at 4 liters. Approximately 15 minutes after the start of the shift, the hospice nurse arrived at the facility. While the hospice nurse was conducting an assessment with resident #1 she passed away. The hospice nurse pronounced the resident and notified the family. Another progress note by LPN B dated [DATE] at 1:47 AM read, the hospice nurse was at the resident's bedside and full code verified. The hospice nurse initiated full code, CPR continued, EMS notified, the hospice physician notified and he instructed the nurse to stop CPR. The hospice nurse called the time of death at 12:01 AM. On [DATE] at 10:29 AM, during a telephone interview, resident #1's attending physician confirmed he had received a call from the facility. He said RN A updated him on resident #1's condition. The physician stated he initially thought the resident was a Do Not Resuscitate (DNR) with hospice services. He said he gave an order to send the resident to the hospital and if the resident was on hospice to check with them on how to proceed. The physician stated, A nurse functions under the direction of a physician and follows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:29 AM, a phone interview was conducted with the hospice provider's Compliance Officer. She stated resident #1 was on hospice services and she had signed the consent form which indicated she had no advanced directive so it defaults to a full code. She stated the hospice staff do not perform CPR on any resident receiving hospice services. She explained that on [DATE], the hospice nurse arrived at the facility at 11:30 PM and had spoken with LPN B. The hospice nurse assessed resident #1 and requested a breathing treatment. The breathing treatment was given and shortly after the resident stopped breathing. The hospice nurse then called the hospice triage nurse for direction as the resident was a full code. The hospice nurse then notified LPN B the resident had stopped breathing. On [DATE] at 12:09 PM, during a telephone interview, the hospice nurse stated she had arrived at the facility on [DATE] at 11:30 PM. She said she spoke with LPN B who communicated that resident #1 was not doing well. She said she proceeded to see the resident along with LPN B and was aware the resident was a full code. She explained she had informed LPN B twice that as a hospice nurse she did not perform CPR on hospice residents. She recalled resident #1 stopped breathing, she pronounced the resident's death and then informed LPN B. LPN B did not initiate CPR for resident #1 and she did not call 911. On [DATE] at 10:42 AM, the Director of Nursing said that all resident with full code orders regardless of hospice status were to be provided CPR. She added that LPN B was aware of resident #1's code status and should have initiated CPR when she was informed by the hospice nurse that the resident stopped breathing. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure, revised on [DATE], read, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [CONDITION(S)] unless such resident has a valid Do Not Resuscitate (DNR) order. Procedure: 1. In the event of a [CONDITION(S)] immediately call for assistance 2. Two licensed nurses to verify: resident identity and current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In the absence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the surveyors: *On [DATE] LPN B was suspended and had submitted her resignation as of [DATE]. *On [DATE] the hospice nurse was removed from the schedule. *On [DATE] a quality review of the five current residents receiving hospice services was completed by the DON and Social Service Director (SSD) to ensure Do Not Resuscitate Orders (DNRO) were accurate, Advanced Directives were in place and care plans reflect resident wishes and physician orders. No issues were identified. *On [DATE] to [DATE] a facility wide review of current resident's code status was performed by the Regional Director of Nursing (RDCS) and SSD. Current Advanced Directives list obtained from medical records reviewed. No issues were identified. *On [DATE] 100% of the facility's licensed nurses' CPR certification were reviewed and verified to be current. *On [DATE] a Performance Improvement Plan was developed and initiated based on Root Cause Analysis (RCA) as determined by the Quality Assurance Performance Improvement (QAPI) committee. RCA identified as miscommunication between hospice nurse and the facility nurse: hospice nurse did not alert staff when resident #1 became unresponsive; facility once alerted of resident passing did not initiate CPR. RN A did not send the resident to the hospital after obtaining an order from the physician. *On [DATE] RN A received individualized training with the DON regarding assessment and change in condition and when appropriate to send resident to the hospital in efforts to prevent further occurrence. Individualized scenarios presented to validate competence. RN verbalized understanding. *Hospice nurses will be educated on facility Advanced Directives policy and procedures, Nurse Practice Act, facility policy for notification of family for resident change in condition prior to delivering resident care at the facility. *Licensed staff education initiated to include policy and procedures for CPR, Advanced Directives, Nurse Practice Act, Hospice Services, Notification of Family of Change in Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Education accompanied by post tests and participation in Code Blue drills to validate understanding and competency. All licensed nurses obtained a passing score. *All Staff education was completed to include Abuse and Neglect Policy and Procedure, Resident Rights Policy and Procedure and CPR Policy and Procedure. Certified letters were sent to those staff members that were not able to attend the education in person. Staff will be required to complete in-servicing with competency prior to working next shift. *All newly hired licensed nursing staff will receive education upon hire to include CPR Policy and Procedure, Advanced Directives Policy and Procedure, Nurse Practice Act, Hospice Services, Notification of Families of Change of Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE] an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to review recommendations made from the RCA. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Clinical Services, Regional Director of Clinical Services (RDCS) MDS Coordinator, Case Manager, Unit Manager, Human Resource Coordinator, Business Development Coordinator and Director of Rehabilitation Services. The Ad Hoc QAPI Committee approved the recommendations. Monthly QAPI meetings will be held to review the current plan. *All facility deaths will be reviewed by the RDCS weekly times two months to ensure policy and procedures are being followed or until QAPI determines substantial compliance. *The DCS/designee will continue quality reviews weekly times four weeks, then monthly times two months for resident Advanced Directives to ensure policies and procedures are being followed. *Code blue drills will continue with licensed nurses weekly on each shift for two months or until QAPI committee determines substantial compliance has been achieved. Staff interviews were conducted with 19 facility staff including 3 agency licensed nurses, 1 agency Certified Nursing Assistant, 3 facility licensed nurses, 5 facility CNAs, 2 dietary staff, 1 maintenance staff member, 1 therapy staff, 1 Personal Care Attendant and 2 housekeeping staff between [DATE]-[DATE]. Interviews revealed the facility had provided education on Abuse/Neglect, Resident Rights, CPR, Advanced Directives, Hospice Services, Notification of Family of Change of Condition, following physician orders, and the Nurse Practice Act.

Based on interview and record review, the facility failed to ensure nursing staff had appropriate competencies and skills sets to care for a resident with symptoms of respiratory distress who required hospitalization and basic life support and Cardiopulmonary Resuscitation (CPR) for 1 of 2 sampled residents of a total sample of 5 residents receiving hospice services, (#1). This failure contributed to resident #1 not being transferred to the hospital as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:30 PM, resident #1, on hospice services with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Registered Nurse (RN) A received orders from the physician to transfer the resident to the hospital and to check with hospice services. RN A did not to transfer the resident to the hospital but requested a visit from the hospice nurse. The hospice nurse arrived at 11:30 PM, and pronounced resident #1's death 30 minutes after arrival. The facility's failure to ensure nursing staff had the appropriate competencies and skill sets to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on [DATE] after validation of the implementation of the facility's immediate actions. Findings: Cross Reference to F600 and F678 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized [DATE] with respiratory distress and readmitted to the facility on [DATE]. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change reassessment Minimum Data Set with an assessment reference date of [DATE] documented she was cognitively intact, required oxygen therapy and non-invasive mechanical ventilator assistance ([CONDITION(S)]) Continuous Positive Airway Pressure. Review of the resident's care plan for Full Code read, Resident has no advanced directives and wishes to have CPR performed in the event of [CONDITION(S)]. The goal noted that resident's advanced directive would be followed. Review of the hospice Certification for the first 90-day period dated [DATE], documented justification for admission to hospice services with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:45 PM, RN A stated he was the nurse assigned to resident #1 on [DATE] on the 3 PM to 11 PM shift. He explained the resident was having difficulty breathing and he called the physician. He said the physician gave orders to send the resident to the hospital and to check if the resident was receiving hospice services. I reviewed the medical record, and she was a full code and on hospice, so I called hospice and requested to have a nurse come out to the facility. RN A recalled he was worried about the resident as she was agitated and not relaxed so he asked Licensed Practical Nurse (LPN) D from another nursing unit to assess the resident. He remembered LPN D told him he should send the resident to the hospital but because she was on hospice, he needed to wait for the nurse to arrive. RN A stated he was aware that a resident could be full code while on hospice services. He verbalized any resident with full code orders should be provided life support measures such as CPR. He did not have an explanation as to why he did not send the resident to the hospital after the physician gave the order. RN A said he thought the hospice nurse would evaluate the resident and discuss with the hospice medical director and provide direction. RN A said he had recently received inservice on Do Not Resuscitate (DNR), CPR, Resident Rights, Change of Condition but he could not recall any education regarding hospice services. He explained on [DATE] he had followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what he would do if the same situation arose, he stated, if the same situation happened today, I would do the same thing. On [DATE] at 3:54 PM, LPN B stated she was assigned to resident #1 on [DATE] on the 11 PM to 7 AM shift. She said RN A had reported that resident #1 was having respiratory difficulty and the hospice nurse was on her way to the facility. She said she had reviewed resident #1's medical record and verified she was a full code. LPN B recalled she checked on resident #1 and she had labored breathing. She said the resident constantly took off her oxygen and she placed it back on. She added the resident was not speaking and her eyes were closed. LPN B stated the hospice nurse arrived at the facility at approximately 11:15 PM and, I started doing my medication pass. She recalled a short while later at 12:00 AM, midnight, the hospice nurse informed her the resident had stopped breathing and she had already called the hospice physician and pronounced the death. LPN B explained that when the hospice nurse said she had done everything, she thought the nurse had performed CPR. I never asked her if she had initiated CPR, I just assumed. LPN B said she was under the assumption the hospice nurse initiated CPR as required for a resident who was full code. It was my mistake, I was aware the resident was a full code, and I should have initiated CPR and called 911. LPN B acknowledged she incorrectly documented a progress note that indicated the hospice nurse initiated CPR, and notified Emergency Medical Services (EMS). LPN B said she saw the hospice nurse on the telephone and assumed she was calling EMS and the hospice physician. Review of a progress note dated [DATE] at 1:06 AM completed by LPN B noted, Upon arrival to the start of the shift at 11 PM, this nurse conducted rounds on resident #1. Resident was breathing with oxygen on at 4 liters. Approximately 15 minutes after the start of the shift, the hospice nurse arrived at the facility. While the hospice nurse was conducting an assessment with resident #1 she passed away. The hospice nurse pronounced the resident and notified the family. Another progress note by LPN B dated [DATE] at 1:47 AM read, the hospice nurse was at the resident's bedside and full code verified. The note incorrectly documented the hospice nurse initiated full code, CPR continued, EMS notified, the hospice physician notified and he instructed the nurse to stop the CPR. The hospice nurse called the time of death at 12:01 AM. On [DATE] at 10:29 AM, during a telephone interview, resident #1's attending physician confirmed he had received a call from the facility. He said RN A updated him on resident #1's condition. He said he gave an order to send the resident to the hospital and if the resident was on hospice to check with them on how to proceed. The physician stated, A nurse functions under the direction of a physician and follows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:29 AM, a phone interview was conducted with the hospice provider's Compliance Officer. She stated the hospice staff do not perform CPR on any resident receiving hospice services. She explained that on [DATE], the hospice nurse arrived at the facility at 11:30 PM and had spoken with LPN B. The hospice nurse assessed resident #1 and requested a breathing treatment. The breathing treatment was given and shortly after, the resident stopped breathing. The hospice nurse then called the hospice triage nurse for direction as the resident was a full code. The hospice nurse then notified LPN B the resident had stopped breathing. On [DATE] at 12:09 PM, during a telephone interview, the hospice nurse stated she had arrived at the facility on [DATE] at 11:30 PM. She said she spoke with LPN B who communicated that resident #1 was not doing well. She noted she proceeded to see the resident along with LPN B and was aware the resident was a full code. She explained she had informed LPN B twice that as a hospice nurse she did not perform CPR on hospice residents. She recalled resident #1 stopped breathing and she immediately informed LPN B. LPN B did not initiate CPR for resident #1 and she did not call 911. When asked why she herself did not call 911, she said that she informed LPN B the resident stopped breathing. On [DATE] at 10:42 AM, the Director of Nursing (DON) stated that all licensed nurses functioned under the direction of a physician. She explained when a physician gives an order, the nurse was to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to the hospital and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that LPN B was aware of resident #1's code status and she should have initiated CPR when she was informed by the hospice nurse that the resident stopped breathing. She said LPN B assumed wrongly that the hospice nurse had initiated CPR, she should not have done that. The DON acknowledged that education about hospice not performing CPR was not included in their facility training. She added that if LPN B was aware the hospice nurse do not initiate CPR, she would have called 911 and initiated CPR. The DON stated that staff did training on facility's electronic learning system and in person training. She was not able to provide any documentation of evaluations completed by the facility to show nurses were competent to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's personnel file revealed RN A's hire date was [DATE]. Review of his orientation dated [DATE] documented he had received mandatory education on Resident Rights, Abuse and Neglect, Advanced Directives and Do Not Resuscitate Orders (DNRO), Hospice and End of Life, Respiratory Care, Change of Condition, and Transfers and Discharges. RN A's electronic facility education noted completion of education on [DATE] Advance Directives, CPR, Resident Rights, Abuse/Neglect, Hospice Services, Notification of Families of Change of Condition, Nurse Practice Act and participation in mock code drills on [DATE]. RN A had completed Basic Life Support (BLS) CPR and Automated External Defibrillator training by the American Heart Association on [DATE]. The facility was unable to provide any documentation to show competency was evaluated. Review of the facility' personnel file revealed LPN B's hire date was [DATE]. Review of the facility's educational transcript showed she completed training more than 2 years ago. Education on Abuse and Neglect was done on [DATE], Advanced Directive on [DATE], CPR refresher on [DATE], and Resident Rights on [DATE]. The facility was unable to provide any documentation of retraining in the past 2 years. Review of the Facility Assessment revealed the facility staff were competent to provide care and services to ensure individual resident's needs are met through competency training on a variety of diseases, conditions and cognitive disabilities. Special treatments and conditions include residents requiring hospice services. Staff education/training and competencies are based on job description and are completed upon orientation, at least annually and as needed through on-line learning and classroom sessions. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the surveyors: *On [DATE] LPN B was suspended and had submitted her resignation as of [DATE]. *On [DATE] the hospice nurse was removed from the schedule. *On [DATE] a quality review of the five current residents receiving hospice services was completed by the DON and Social Service Director (SSD) to ensure Do Not Resuscitate Orders (DNRO) were accurate, Advanced Directives were in place and care plans reflect resident wishes and physician orders. No issues were identified. *On [DATE] to [DATE] a facility wide review of current resident's code status was performed by the Regional Director of Nursing (RDCS) and SSD. Current Advanced Directives list obtained from medical records reviewed. No issues were identified. *On [DATE] 100% of the facility's licensed nurses' CPR certification were reviewed and verified to be current. *On [DATE] a Performance Improvement Plan was developed and initiated based on Root Cause Analysis (RCA) as determined by the Quality Assurance Performance Improvement (QAPI) committee. RCA identified as miscommunication between hospice nurse and the facility nurse: hospice nurse did not alert staff when resident #1 became unresponsive; facility once alerted of resident passing did not initiate CPR. RN A did not send the resident to the hospital after obtaining an order from the physician. *On [DATE] RN A received individualized training with the DON regarding assessment and change in condition and when appropriate to send resident to the hospital in efforts to prevent further occurrence. Individualized scenarios presented to validate competence. RN verbalized understanding. *Hospice nurses will be educated on facility Advanced Directives policy and procedures, Nurse Practice Act, facility policy for notification of family for resident change in condition prior to delivering resident care at the facility. *Licensed staff education initiated to include policy and procedures for CPR, Advanced Directives, Nurse Practice Act, Hospice Services, Notification of Family of Change in Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Education accompanied by post tests and participation in Code Blue drills to validate understanding and competency. All licensed nurses obtained a passing score. *All Staff education was completed to include Abuse and Neglect Policy and Procedure, Resident Rights Policy and Procedure and CPR Policy and Procedure. Certified letters were sent to those staff members that were not able to attend the education in person. Staff will be required to complete in-servicing with competency prior to working next shift. *All newly hired licensed nursing staff will receive education upon hire to include CPR Policy and Procedure, Advanced Directives Policy and Procedure, Nurse Practice Act, Hospice Services, Notification of Families of Change of Condition, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE] an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to review recommendations made from the RCA. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Clinical Services, Regional Director of Clinical Services (RDCS) MDS Coordinator, Case Manager, Unit Manager, Human Resource Coordinator, Business Development Coordinator and Director of Rehabilitation Services. The Ad Hoc QAPI Committee approved the recommendations. Monthly QAPI meetings will be held to review the current plan. *All facility deaths will be reviewed by the RDCS weekly times two months to ensure policy and procedures are being followed or until QAPI determines substantial compliance. *The DCS/designee will continue quality reviews weekly times four weeks, then monthly times two months for resident Advanced Directives to ensure policies and procedures are being followed. *Code blue drills will continue with licensed nurses weekly on each shift for two months or until QAPI committee determines substantial compliance has been achieved. Staff interviews were conducted with 19 facility staff including 3 agency licensed nurses, 1 agency Certified Nursing Assistant, 3 facility licensed nurses, 5 facility CNAs, 2 dietary staff, 1 maintenance staff member, 1 therapy staff, 1 Personal Care Attendant and 2 housekeeping staff between [DATE]-[DATE]. Interviews revealed the facility had provided education on Abuse/Neglect, Resident Rights, CPR, Advanced Directives, Hospice Services, Notification of Family of Change of Condition, following physician orders, and the Nurse Practice Act.

Based on observation, interview and record review the facility failed to initiate an investigation for injury of unknown origin after a [DIAGNOSES REDACTED].#71). Findings: Resident #71 was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with new [DIAGNOSES REDACTED]. Her prior [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] (pre-hospitalization ) indicated resident #71 had a Brief Interview for Mental Status (BIMS) of 11 that indicated moderate cognitive impairment. She was assessed to require supervision for bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident #71 was not steady but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfers (transfer between bed, chair or wheelchair). She required 1 person assist with toilet use and required set up or supervision for all other activities. Review of a nursing progress note dated 1/29/21 at 11:32 PM, read, Patient was leaning heavily to one side in wheelchair and verbally not making sense. Two CNAs (Certified Nursing Assistant) brought to my attention that she gets up and goes around the building. I assessed the patient while in bed and patient could not answer questions correctly. Another nurse confirmed that this was not her normal and that I should send her out for further evaluation. I obtained vital signs which were within normal range. I contacted the right persons and family. Daughter stated she would not be able to go visit her in the hospital but wanted to be updated on her status .Emergency unit arrived and they assessed patient who they stated the patient was answering back correctly and vital signs were stable for them .transported patient to .medical system (hospital). Review of the hospital Emergency Department (ED) record dated 1/29/21 read, presents to .ED with c/o (complaints of) left knee pain and swelling x 1 day. Patient is poor historian and d/t (due to) dementia her cognition kind of waxes and wanes .Patient denies falling/trauma to the left lower extremity .CT (computed tomography)of left knee with acute mildly comminuted fracture through intercondylar eminence and medial tibial plateau .received .IV (intravenous) [MEDICATION NAME] (narcotic pain medication) .knee immobilizer. The hospital record revealed that resident #71 was admitted on [DATE] and the history and physical read, Assessment and Plan: Pleasant 86 yo (year old) F (female) who presents with the following, acute comminuted fracture, intercondylar eminence and medial tibial plateau, acute microcytic [MEDICAL CONDITION], UTI (urinary tract infection) and elevated D-Dimer (indicates may be blot clot). Plan .keep immobilizer, .PT/OT (physical and occupational therapy) with instructions for no weight bearing on left leg . Review of the facility nursing progress note dated 1/30/21 at 9:31 AM read, Pt (patient) was sent to hospital at approx. 2230 (11:30 PM) last night. Daughter called the facility trying to find out why she was sent and if she was being admitted . This writer spoke with . ED, pt is being admitted for UTI, [MEDICAL CONDITION], elevated D-Dimer and left knee fracture. Daughter notified. A review of the facility abuse and incident logs did not show that an investigation for injury of unknown origin had been initiated until brought to the Executive Directors/Abuse Coordinator attention by surveyor on 3/19/21, 7 weeks after the facility became aware of resident's left knee fracture. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policies and Procedures with revision date of 11/28/17 read, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment .The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish disciplinary policy, which results in the fair and timely treatment of [REDACTED].Neglect .Failure to take precautionary measures to protect the health and safety of the resident .Training .Employee Obligation .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect .including injuries of unknown source .Is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours .Preliminary Investigation .An incident report shall be filed by the individual in charge who received the report .Investigation: The abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of alleged abuse .Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse .including injuries of unknown source .to a resident, is obligated to report such information immediately .Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely .a full investigation in order to obtain a clear picture of what actually happened . On 3/15/21 at 11:15 AM, resident #71 was observed lying in bed. She was oriented to person and place and was complaining of pain. She pressed the call light and the Activities Director (AD) came into the room and said she thought the resident's nurse had given her something earlier for pain and she would let the nurse know the resident was still in pain. On 3/15/21 at 11:40 AM, Licensed Practical Nurse (LPN) B said he had given resident #71 [MEDICATION NAME] approximately 30 minutes ago and that he had just checked on her and she was still in pain. He said he planned to call the physician if the medication was still not effective after 60 minutes. Resident #71 was ordered Tylenol pre-hospitalization and [MEDICATION NAME] was initiated after she returned to the facility post hospitalization . [MEDICATION NAME] is an oral medication that is used to help relieve ongoing moderate to moderately severe pain. [MEDICATION NAME] is similar to opioid (narcotic) [MEDICATION NAME]. It works in the brain to change how your body feels and responds to pain. (www.rxlist.com) Review of the resident's Medication Administration Records (MAR) from January 2021 to present date 3/19/21 noted that prior to hospitalization , 1/29/21 the resident had not required any pain medication. Upon return from the hospital on [DATE] she had been given [MEDICATION NAME] 7 times. On 3/19/21 at 10 AM, the Regional Registered Nurse (RN) stated, It was the perfect storm and we missed doing an abuse investigation for resident #71 regarding hospitalization and new fracture of left knee. She said the MDS coordinator reviewed the medical record when the resident returned to the facility from the hospital, spoke to staff and no one reported a fall. She added their normal process regarding resident with an injury of unknown origin was to initiate an investigation right away and complete an immediate report to the Agency for Healthcare Administration. She acknowledged this was not done. On 3/19/21 at 10:30 AM, the MDS coordinator said after the resident returned to the facility post hospitalization , she received therapy for pain/swelling of the left knee and decreased mobility. Prior to her going out to the ER (emergency room ) on 1/29/21, the nursing staff thought she had a stroke as she did not have any pain. It surprised us when we found out she was having pain in the ER. The MDS coordinator said she spoke with the floor nurse who sent her out to hospital on [DATE] and found out that by the time the EMTs (Emergency Medical Technician) arrived at the facility, the resident was making more sense talking to them. The MDS coordinator said they discussed resident #71 at the morning meeting on 2/5/21 after she came back from the hospital (2/3/21) and could not remember the name of the staff person who reviewed her hospital record. They said she had a fracture to her left knee. We reviewed her chart and questioned if she fell and she had not. The MDS coordinator verified resident #71 had a new fracture. The MDS coordinator said there was no discussion at the meeting regarding initiating an allegation for an injury of unknown origin. She said she assumed an investigation was already done by the Director of Clinical Services (DCS). The MDS Coordinator verified no one asked her to interview the staff on the resident's unit. She said she asked the staff if resident #71 had any falls so that she could complete the significant change MDS assessment dated [DATE]. She verbalized the MDS assessment was initiated as the resident had a new fracture and she needed to complete the assessment which addressed falls. She noted she spoke to staff on 2/5/21 but did not document the names of the nurse or Certified Nursing Assistant (CNA) who were on duty as she was not conducting an investigation. She did not recall if the DCS was present at the morning meeting along with the Case Manager and other managers. The MDS Coordinator validated resident #71 had a significant change in her condition as a result of the new fracture. She said the resident had declined functionally in her Activities of Daily Living (ADL). She acknowledged prior to hospitalization , the resident was able to transfer herself from the bed to the wheelchair with stand by assistance of staff. Post hospitalization she required staff to provide weight bearing assistance. If resident #71 had a fall she would not be able to get up on her own. She said she assumed the DCS did an investigation as this was a fracture of unknown origin which should always be investigated. She then stated, next time I may have to prod people to do their job. Review of the significant change in status MDS assessment dated [DATE] (post-hospitalization ), indicated the resident's BIMS was now 10 indicating moderate cognitive impairment. She previously required supervision only but now required 1 person extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #71 was now totally dependent with bathing, was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfers (transfer between bed and chair or wheelchair). On 3/19/21 at 11:24 AM, the Case Manager (CM) said she was present at the morning meeting on 2/5/21. She could not recall if they signed in for the meetings at that time or who the DCS was. She remembered she attended the morning meeting on 2/4/21 and was led to believe the resident's fracture was of an indeterminate age and was not acute. She said an acute fracture or injury of unknown origin would be investigated by the Administrator and DCS. She said if she knew the resident had an acute fracture, she would have reported to the DCS and an investigation would have been initiated by her. The CM said she knew resident #71 well as she saw her daily during room rounds. She noted the resident was alert with confusion and may not have remembered if she had fallen. If she had fallen, she would not have been able to get back up. The resident was able to get around independently with her wheelchair prehospitalization . The CM acknowledged that if the investigation was done timely, it would have been more accurate as some of the staff that worked in January 2021 no longer worked at the facility. On 3/19/21 at 12 PM, resident #71 self-propelled in wheelchair in her room. She was talkative and pleasant. She said she was in the hospital due to her knee. She could not recall how her left knee was fractured and added she had to wear an elastic type brace when she came back to the facility. She could not remember if she had any falls. On 3/19/21 at 12:08 PM, a telephone interview was conducted with resident #71's daughter. She said that she and her sister had questions about their mother's fractured knee. The daughter went on to say their mother had dementia and could not tell them what happened. She noted the first week after the fracture, the facility said they did not know anything about it. The facility just said she was complaining of her knee hurting and had a UTI. The daughter said her mother did not try to get out of her chair on her own and had concerns she may have fallen. She added the facility had a lot of staff turnover and used agency staff. She said if the staff were rough, her mother would not report it because she felt, the less said the better. On 3/19/21 at 12:58 PM, LPN A acknowledged she was the nurse who spoke with resident #71's daughter by phone the morning of 1/30/21. She noted the resident had been transferred to the hospital the night before. She said the daughter called her on 1/30/21 because she could not get answers from the hospital. She stated she called the hospital and was informed the resident was admitted to the hospital with [REDACTED]. LPN A said she informed the resident's daughter and the Unit Manager (UM) of the fracture. LPN A then said, if she had known that it was an acute fracture she would have tried to figure out what happened. She would have spoken to the staff to see if the resident fell and would have documented the acute fracture in the medical record. LPN A verified the resident was able to get herself in/out of bed and was independently mobile in her wheelchair prior to hospitalization . When she came back from the hospital, she was put on the observation unit for 2 weeks and had new order of [MEDICATION NAME] for pain. She had to stay in her room for 2 weeks due to [MEDICAL CONDITION] Disease 2019 quarantine procedures for new or re-admissions. On 3/19/21 at 1:26 PM, the UM said she started working at the facility on 1/25/21. She did not remember attending the morning meeting the week of 2/4/21 when the resident returned from the hospital. She did not remember any conversations regarding resident #71 having an acute fracture. She said the resident had increased pain due to the fracture and received [MEDICATION NAME] for pain. On 3/19/21 at 1:36 PM, the Physical Therapist (PT) said resident #71 received therapy from 2/4/21 to 2/24/21 due to fractured left knee. He said the resident returned from the hospital with left knee brace. She was guarded due to the pain and would not straighten her leg. He noted the resident was non weight bearing (NWB) when she returned from the hospital and was still presently NWB with the left leg. He noted she had poor cognition and it was challenging to do therapy as she needed frequent repeat instructions. He verbalized the resident could not get out of bed when she returned to the facility. We were doing the initial therapy with her in the bed for the first week. Prior to hospitalization , she could get out of bed by herself, bear weight both legs, get herself into the wheelchair, scoot, pivot with right leg into the chair. She could take herself to the bathroom and wheel self around the building. He said he completed the physical therapy evaluation when she returned from the hospital on [DATE]. She was total care with everything at that time. He said he could not get her out of bed for therapy due to pain and treatments were done in bed for positioning and range of motion. He noted therapy got her out of bed 6 days after she returned, on 2/10/21 with maximum assistance and NWB to left leg. He said she was discharged from therapy services on 2/24/21 because of her insurance. He added that transfers were still difficult for her. On 3/19/21 at 2:20 PM, Certified Nursing Assistant (CNA) F said that prior to hospitalization , the resident could get herself into the wheelchair from bed, go the bathroom on her own, and bathe herself while sitting on the toilet. She stated she needed help with dressing and could wheel self around the building. When she got back from the hospital, she was on the observation unit for 2 weeks. CNA F said that when the resident returned to her usual unit she could not turn in bed and now needed 2 staff to help her with everything. She said that since the resident is NWB to left lower leg, it takes 2 staff to bathe/turn her in bed, get her into the wheelchair and assist her onto the toilet. She can wheel herself in the wheelchair but all other ADLs except for eating require 2 staff. On 3/19/21 at 3:11 PM, an interview was conducted with the Executive Director (ED) and DCS. The ED said they had clinical meetings at about 9:00 AM which consisted of nurse leadership. After this meeting, morning meetings were held consisting of the entire leadership team. The ED said they would have discussed resident #71 at both meetings as the resident had returned from the hospital. He said the DCS was not at the clinical meeting on 2/4/21. The DCS said she was not aware that resident #71 had [DIAGNOSES REDACTED]. The DCS stated no one looked at resident #71's hospital record until this morning and they were not aware she had an acute fracture. They thought something was wrong with her knee. The DCS said their usual practice was to review the hospital record at the clinical meeting, and they should have reviewed resident #71 when she came back to the facility. The DCS said they should not have assumed it was an old injury. They noted that since an investigation of the fracture had not occurred when it was discovered 7 weeks ago, it was unlikely the facility would be able to obtain a clear picture of what actually happened. They acknowledged the facility utilized agency staff and had turn over in their management staff. Some of the staff involved in the care of resident #71 no longer worked at the facility and were not available for interview during the survey. On 3/19/21 at 3:46 PM, the attending physician said he was not aware resident #71 had an acute fracture and that he would need to review the records. He acknowledged the facility staff should have investigated the acute fracture/injury of unknown origin and reviewed the hospital records upon her return to the facility. Although the facility indicated they were not aware of resident #71 having new [DIAGNOSES REDACTED]. The resident's plan of care initiated on 2/21/21 for pain medication included [DIAGNOSES REDACTED]. Plan of care revised on 2/4/21 for potential for pain included [DIAGNOSES REDACTED]. The following care plans reviewed by the facility on 3/3/21 for ADL self-care performance deficit, alteration in musculoskeletal status, potential for pressure injury and functional bladder incontinence also included [DIAGNOSES REDACTED]. Review of the Facility Assessment Tool, dated, 8/18/17, revealed the facility was competent to provide care and services for residents with [DIAGNOSES REDACTED].

Based on interview and record review, administration neglected to use its resources effectively to provide medically necessary Bilevel positive airway pressure ([MEDICAL CONDITION]) treatment for [REDACTED].#1). The administration's failure to provide the necessary respiratory equipment ([MEDICAL CONDITION]) led to exacerbation of resident #1's acute [MEDICAL CONDITION] and subsequent loss of consciousness, need for cardiopulmonary resuscitation (CPR), intubation and return to the hospital's intensive care unit after 16 hours in the facility. While the resident was without the necessary [MEDICAL CONDITION] treatment during the night, there was high likelihood the resident could have suffered permanent brain damage (anoxia) and/or death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed prior to exit on [DATE] and the scope and severity was lowered to D-no actual harm with potential for more than minimal harm. Findings: Cross Reference to F600 and F695 Resident #1 was admitted to the facility on [DATE] at 9 PM after admission to the hospital for acute [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. The hospital's Patient Health Care Summary Discharge Plan reflected that the physician ordered continuous oxygen at 3 liters per minute during the day and [MEDICAL CONDITION] during the night. According to [NAME] Hopkins Medicine, [MEDICAL CONDITION] (Bilevel positive airway pressure) is a type of ventilator (breathing machine) that helps patients with medical problems that have difficulty breathing. The [MEDICAL CONDITION] delivers positive air pressure into the lungs on inspiration and expiration. [MEDICAL CONDITION] is used for Chronic obstructive [MEDICAL CONDITION] disorder, obstructive sleep apnea, obesity, pneumonia, asthma, and neurological diseases. A review of the Facility Assessment noted that no resident will be admitted to the facility until an evaluation is completed and staff are prepared to accept the admission. Respiratory treatments that the facility was able to provide included oxygen therapy, suctioning, [MEDICAL CONDITION] care, and respiratory [MEDICAL CONDITION]. On [DATE] at 2:20 PM, registered nurse (RN) A confirmed that she was resident #1's admitting nurse. She stated that the resident arrived at the facility without a [MEDICAL CONDITION] machine. RN A confirmed that she was aware the resident had orders and needed a [MEDICAL CONDITION] but she neglected to follow the admitting orders and secure a [MEDICAL CONDITION] machine for resident #1. On [DATE] at 2:47 PM, certified nursing assistant (CNA) B stated that she was assigned to resident #1 on [DATE] on the 3 PM to 11 PM shift. She said that the resident's daughter and niece were in attendance at admission. CNA B recalled that the niece told RN A that the resident needed a [MEDICAL CONDITION] machine at night and was concerned that she did not have one. On [DATE] at 11:55 AM, LPN D stated that she was the nurse that found resident #1 unresponsive on [DATE]. She stated that she was passing by the resident's room and noted the resident in her wheel chair with her head tilted back. LPN D said, She was still breathing but not responding. We could not get a blood pressure and then called a code. Emergency Medical Services arrived and they started CPR (cardiopulmonary resuscitation). They intubated the resident and transferred her to the hospital. On [DATE] at 3:26 PM, resident #1's attending physician was contacted by telephone. He stated that the resident's respiratory status was unstable. She had just been in the hospital for acute [MEDICAL CONDITION] requiring ventilator support in the Intensive Care Unit. He said he was not informed that the resident did not have the [MEDICAL CONDITION] machine when she was admitted . He added that he was with resident #1 the morning after she was admitted on [DATE] when she became unresponsive. He said she had been getting drowsier and drowsier over time and developed carbon [MEDICATION NAME] cyanosis because she was without the [MEDICAL CONDITION] machine during the night. He stated that the [MEDICAL CONDITION] was medically necessary and the facility should have had it when she arrived. The attending physician said, If the facility was not able to get the [MEDICAL CONDITION] for the resident's use then they should not have admitted the resident to the facility. On [DATE] at 1:40 PM, the Business Development Coordinator (BDC) indicated she was responsible for new admissions and stated she went to see the resident in the hospital prior to her admission to the nursing home. The BDC indicated she was aware that the resident required a [MEDICAL CONDITION] machine. She stated that she assumed that the resident would come to the nursing home with the [MEDICAL CONDITION] machine but she did not have a [MEDICAL CONDITION] machine when she arrived on [DATE] at 9:00 PM. The BDC said, On the evening of [DATE], I was made aware that (resident #1) was admitted to the facility without the [MEDICAL CONDITION] and I texted the Administrator to notify her that she did not have the [MEDICAL CONDITION] machine. On [DATE] at 1:45 PM, the Administrator confirmed that she was notified on [DATE], Friday night, by the BDC by text that resident #1 did not have her [MEDICAL CONDITION] machine. The Administrator stated that she was responsible for obtaining the [MEDICAL CONDITION] machine on [DATE]. She stated that the facility had a contract with a respiratory company that provided respiratory therapy services including [MEDICAL CONDITION] machines. She said, We call the company with the physician orders [REDACTED]. There is a ,[DATE]-hour delivery time and the facility must call the company before 7 PM for the [MEDICAL CONDITION] to be delivered on the same day. All calls after 7 PM will be delivered the following day. She said she was going to order the [MEDICAL CONDITION] but she never ordered it. The Administrator could not explain why the [MEDICAL CONDITION] machine was not ordered for the resident when she arrived at the facility despite a contracted respiratory services company at their service. On [DATE] at 1:20 PM, the director of nursing (DON) stated that he was not aware that resident #1 was admitted to the facility on [DATE] without a [MEDICAL CONDITION] machine per physician orders. It was not until Monday, [DATE], that he was notified about the [MEDICAL CONDITION] and that she coded requiring CPR, and readmission to the hospital. The DON said, The nurse never notified me. He confirmed that he was not notified by the Administrator that the resident did not have [MEDICAL CONDITION] when she was admitted to the facility. On [DATE] at 5:50 PM, an interview was conducted by phone with the facility's Medical Director. He stated that he was aware that resident #1 had coded at the facility because he was caring for her in the intensive care unit (ICU). He said there was a miss communication between the hospital and the facility regarding who was to obtain the [MEDICAL CONDITION] machine for resident #1, and As a result of (resident #1) not having the [MEDICAL CONDITION] at night, she developed carbon [MEDICATION NAME] cyanosis and sustained a respiratory arrest requiring her to be readmitted to the hospital, intubated and placed in the ICU. Review of the facility's corrective measures to remove Immediate Jeopardy revealed the following: Resident #1 no longer resided at the facility. The interdisciplinary team (IDT) reviewed all residents admitted since [DATE], who currently resided in the facility to ensure that durable medical equipment (DME), medications and treatments as ordered by physician were implemented. All other residents admitted during this time frame and were discharged were being audited to identify any issues. On [DATE], a 4-point plan was initiated related to coordination of care, admission orders [REDACTED]. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] with all department heads to review the process for ensuring that all new admissions received goods and services as ordered by physician. The facility will implement a process to ensure that all residents admitted to the facility have required DME in place or readily accessible at the time of admission. The medical director will be involved in the admission process decision to develop a plan for patients who are sent by the hospital without ordered equipment and supplies as ordered. On [DATE], the regional director of clinical services (RDCS) provided education to the clinical nursing administration team regarding a process to review all admission records. On [DATE], education for all licensed nurses regarding the admission process, following physician orders, medication reconciliation and obtaining DME was initiated. Fifty-seven percent of the nurses were educated, and certified letters were sent out on [DATE] to those staff members that were unable to be reached. Staff will be required to complete in-service with post-test to validate understanding prior to working. The business development liaisons were provided in-service by the Administrator on the admission process and acquiring DME prior to or at the time of admission. On [DATE], the RDCS provided education to the Administrator regarding the role of the Administrator in the admission process. The Administrator will be required to review each admission prior to arrival with the admissions department and/or liaisons to ensure necessary equipment is ordered timely with each admission. The survey team conducted observations and there were no current residents at the facility with [MEDICAL CONDITION] equipment. Interviews, reviews of audits, training plans, in-service post-testing, and letters sent to licensed nurses verified training regarding the admission process and obtaining physician ordered DME at the time of admission.

Based on record review and interview, the facility neglected to provide necessary respiratory equipment and services for a newly admitted resident for 1 of 1 sampled resident, (#1). On [DATE] at 9:00 PM, resident #1 was admitted to the facility from an acute care setting with admission orders [REDACTED]. The nurse failed to obtain the [MEDICAL CONDITION] machine as per physician orders [REDACTED].#1 would be without the [MEDICAL CONDITION] machine and necessary respiratory ventilation. These failures resulted in exacerbation of the resident's acute [MEDICAL CONDITION], loss of consciousness, need for cardiopulmonary resuscitation (CPR), intubation, return to the hospital after only 16 hours in the facility, and admission to the intensive care unit (ICU) for 3 days. While the resident was without the needed [MEDICAL CONDITION] treatment during the night, there was high likelihood the resident could have suffered permanent brain damage (anoxia) and/or death. The facility's neglect to provide the required [MEDICAL CONDITION] machine for respiratory care resulted in substandard quality of care at the Immediate Jeopardy level, starting on [DATE]. The Immediate Jeopardy was removed prior to exit on [DATE] and the scope and severity was lowered to D-no actual harm with potential for more than minimal harm. Findings: Cross reference F695, F835 A review of the medical record revealed that resident #1 was admitted to the hospital on [DATE] due to shortness of breath and leg swelling. Her [DIAGNOSES REDACTED]. The resident was intubated and became ventilator dependent. The resident improved, taken off the ventilator and discharged to the nursing home on [DATE]. The hospital discharge orders dated [DATE] noted that the resident required [MEDICAL CONDITION] at night and oxygen during the day. The nursing home neglected to order a [MEDICAL CONDITION] machine prior to the resident's arrival. The resident was without the necessary [MEDICAL CONDITION] machine during the night. The next morning, on [DATE] the resident went into respiratory distress and 911 was called. The resident was intubated and transferred to the hospital and diagnosed with [REDACTED]. The resident endured 3 days in the intensive care unit and was then discharged to another long term care facility. According to [NAME] Hopkins Medicine, [MEDICAL CONDITION] (Bilevel positive airway pressure) is a type of ventilator (breathing machine) that helps patients with medical problems that have difficulty breathing. The [MEDICAL CONDITION] delivers positive air pressure into the lungs on inspiration and expiration. [MEDICAL CONDITION] is used for Chronic obstructive [MEDICAL CONDITION] disorder, obstructive sleep apnea, obesity, pneumonia, asthma, and neurological diseases. On [DATE] at 1:40 PM, the Business Development Coordinator (BDC) indicated she was responsible for new admissions and stated saw the resident in the hospital prior to nursing home admission. The BDC indicated she was aware that the resident required a [MEDICAL CONDITION] machine. She stated that she assumed the resident would come to the nursing home with the [MEDICAL CONDITION] machine. She stated that the resident did not have a [MEDICAL CONDITION] machine when she arrived on [DATE] at 9:00 PM. On [DATE] at 3:26 PM, resident #1's attending physician stated that the resident used the [MEDICAL CONDITION] at night in the hospital. He said that the facility should have made arrangements to ensure the [MEDICAL CONDITION] was at the facility before the resident arrived. The physician was not aware that the facility did not provide the [MEDICAL CONDITION] machine for resident #1. The physician confirmed that the facility staff did not call him to review the resident's admitting orders. On [DATE] at 2:47 PM, certified nursing assistant (CNA) B stated that she was assigned to resident #1 on [DATE] on the 3 PM to 11 PM shift. She said that the resident's daughter and niece were in attendance at admission. CNA B recalled that the niece told RN A that the resident needed a [MEDICAL CONDITION] machine at night and was concerned that she did not have one. On [DATE] at 2:20 PM, RN A confirmed that she was resident #1's admitting nurse. She stated that the resident arrived at the facility without a [MEDICAL CONDITION] machine. RN A stated that she was aware that the resident had orders for [MEDICAL CONDITION] machine to be used at night. RN A could not recall if she called the attending physician to confirm resident #1's admission orders [REDACTED]. RN A confirmed that she was aware the resident had orders and needed a [MEDICAL CONDITION] but she neglected to follow the admitting orders and secure a [MEDICAL CONDITION] machine for resident #1. RN A stated that after the resident was admitted without the [MEDICAL CONDITION], she spoke to the hospital case manager. She said the case manger told her that the resident could remain at the nursing home as long as the resident was sitting up and had oxygen. The RN A did not identify who the case manager was or what her qualification were. RN A confirmed that she took advice from an unknown non-medical person, about the respiratory care needs of resident #1, instead of a physician. She stated, I know better next time. On [DATE] at 5:00 PM, the administrator and regional nurse consultant stated that RN A should have followed the orders for the [MEDICAL CONDITION]. They stated the nurse should have contacted the attending physician instead of taking direction from the hospital case manager. On [DATE] at 1:18 PM, the administrator and director of nursing (DON) revealed that the facility was aware of resident #1's respiratory care needs and the need for a [MEDICAL CONDITION] machine prior to the resident arriving at the nursing home. They confirmed that the resident had orders for a [MEDICAL CONDITION]. The administrator stated that she was notified on the evening of [DATE] that the resident arrived at the facility and did not have the [MEDICAL CONDITION]. She stated that she was responsible for obtaining the [MEDICAL CONDITION] machine prior to the resident's admission but thought it be okay if she ordered the machine the next day from the respiratory company. The administrator did not inquire if the physician was contacted regarding the resident being without the [MEDICAL CONDITION] at night. The DON stated he received a call from staff on [DATE] that a 'code' had been called for resident #1 and that she was transferred to the hospital. The administrator did not consider this event as a potential adverse incident and therefore the incident was never investigated. Administration had not determined that this incident was a culmination of neglectful acts and lack of necessary equipment that led to the resident's respiratory decline. The facility was aware that the resident came to the facility without a [MEDICAL CONDITION] and could have interceded to ensure necessary respiratory equipment was available for resident #1 but neglected to do so. Review of the facility's corrective measures to remove Immediate Jeopardy revealed the following: Resident #1 no longer resided at the facility. The interdisciplinary team (IDT) reviewed all residents admitted since [DATE], who currently resided in the facility to ensure that durable medical equipment (DME), medications and treatments as ordered by physician were implemented. All other residents admitted during this time frame and were discharged were being audited to identify any issues. On [DATE], a 4-point plan was initiated related to coordination of care, admission orders [REDACTED]. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] with all department heads to review the process for ensuring that all new admissions received goods and services as ordered by physician. The facility will implement a process to ensure that all residents admitted to the facility have required DME in place or readily accessible at the time of admission. The medical director will be involved in the admission process decision to develop a plan for patients who are sent by the hospital without ordered equipment and supplies as ordered. On [DATE], the regional director of clinical services (RDCS) provided education to the clinical nursing administration team regarding a process to review all admission records. On [DATE], education for all licensed nurses regarding the admission process, following physician orders, medication reconciliation and obtaining DME was initiated. Fifty-seven percent of the nurses were educated, and certified letters were sent out on [DATE] to those staff members that were unable to be reached. Staff will be required to complete in-service with post-test to validate understanding prior to working. The business development liaisons were provided in-service by the Administrator on the admission process and acquiring DME prior to or at the time of admission. On [DATE], the RDCS provided education to the Administrator regarding the role of the Administrator in the admission process. The Administrator will be required to review each admission prior to arrival with the admissions department and/or liaisons to ensure necessary equipment is ordered timely with each admission. The survey team conducted observations on [DATE] and there were no current residents at the facility with [MEDICAL CONDITION] equipment. Interviews, reviews of audits, training plans, in-service post-testing, and letters sent to licensed nurses verified training regarding the admission process and obtaining physician ordered DME at the time of admission.

Based on interview and record review, the facility failed to follow physician orders for respiratory care and services, failed to obtain physician ordered Bilevel positive airway pressure ([MEDICAL CONDITION]) equipment, failed to notify the physician of respiratory equipment not being available for resident use for a newly admitted resident at risk for acute [MEDICAL CONDITION] for 1 of 1 sampled resident, (#1). These failures contributed to the exacerbation of the resident's acute [MEDICAL CONDITION], loss of consciousness, need for cardiopulmonary resuscitation (CPR), intubation, return to the hospital after 16 hours in the facility and admission to the intensive care unit (ICU) for 3 days. While the resident was without the needed [MEDICAL CONDITION] treatment during the night, there was high likelihood the resident could have suffered permanent brain damage (anoxia) and/or death. On [DATE] at 9:00 PM, resident #1 was admitted to the facility from an acute care setting with admission orders [REDACTED]. Upon admission, resident #1's niece immediately notified the admitting nurse that resident #1 did not have the [MEDICAL CONDITION] machine that she needed to use at night. The nurse failed to obtain the [MEDICAL CONDITION] machine per physician order and failed to notify the attending physician that resident #1 would be without the [MEDICAL CONDITION] machine and required respiratory ventilation during the night. The facility's failure to follow physician orders for respiratory care and services, failure to obtain physician ordered respiratory equipment, and failure to notify the physician of inability to acquire physician ordered [MEDICAL CONDITION] equipment for respiratory care and services resulted in Substandard Quality of Care at the Immediate Jeopardy level, starting on [DATE]. The Immediate Jeopardy was removed prior to exit on [DATE] and the scope and severity was lowered to D-no actual harm with potential for more than minimal harm. The Immediate Jeopardy was removed prior to exit on [DATE]. Findings: Cross Reference to F600 and F835 Resident #1 was admitted to the facility on [DATE] at 9 PM after admission to the hospital for acute [MEDICAL CONDITION]. She was admitted to the facility for respiratory care and services and rehabilitation services. Her [DIAGNOSES REDACTED]. Review of the hospital report revealed she was admitted to the hospital on [DATE] from home with shortness of breath and leg swelling. While in the emergency room she was treated with diuretics (used to remove excess fluid from the body) and [MEDICAL CONDITION] ventilation. She was found to have poor responsiveness, poor respiratory effort and respiratory distress prompting a Code Blue (respiratory arrest). She was then intubated and placed on ventilator support and transferred to the intensive care unit (ICU). Review of the hospital Patient Health Care Summary Discharge Plan documented physician orders for oxygen during the day and [MEDICAL CONDITION] during the night. According to [NAME] Hopkins Medicine, [MEDICAL CONDITION] (Bilevel positive airway pressure) is a type of ventilator (breathing machine) that helps patients with medical problems that have difficulty breathing. The [MEDICAL CONDITION] delivers positive air pressure into the lungs on inspiration and expiration. [MEDICAL CONDITION] is used for Chronic obstructive [MEDICAL CONDITION] disorder, obstructive sleep apnea, obesity, pneumonia, asthma, and neurological diseases. The 3008 Patient Transfer Form, dated [DATE] and completed by the hospital (considered physician orders) documented under the Treatment Devices section that the resident was to have a nebulizer, continuous oxygen at 3 liters (L) via nasal cannula (NC), and [MEDICAL CONDITION]. Review of the facility's Admission/Readmission Data Collection form completed by Registered Nurse (RN) A on [DATE], documented that resident #1 was assessed to be short of breath when lying flat and on exertion, on continuous oxygen at 2 L NC and was to have [MEDICAL CONDITION]. The handwritten nurses note completed by RN A on [DATE], documented, the patient needs to be on [MEDICAL CONDITION]. A review of resident #1's Baseline Care Plan completed on the day of her admission, [DATE] documented she was to receive services and has orders for oxygen and [MEDICAL CONDITION]. The goal for treatments in the facility included to have no respiratory complications. Review of the Facility Assessment Tool dated [DATE], revealed the facility had determined that they were able to accept and provide care and services to residents with [MEDICAL CONDITIONS], pneumonia, asthma, [MEDICAL CONDITIONS] through a contracted respiratory therapy company. The facility had an assessment process in which admission staff conducted on-site visit prior to the resident's admission to determine if they could meet the resident's needs while at the facility. The Director of Nursing was responsible to ensure that specialized equipment was in the facility to meet the resident's medical needs. The facility assessment documented that no resident will be admitted to the facility until an evaluation is completed and the staff are prepared to accept the admission. Respiratory Treatments included oxygen therapy, suctioning, [MEDICAL CONDITION] care, and respiratory [MEDICAL CONDITION]. On [DATE] at 2:47 PM, Certified Nursing Assistant (CNA) B stated that she was assigned to provide care to resident #1 on day of admission, [DATE] on the 3 PM-11 PM shift and on [DATE] on the 7 AM-3 PM shift. She revealed that resident #1 was admitted to the facility on [DATE] at 9 PM with her niece and daughter. She stated the resident was a nice lady, very obese, required extensive assistance of 1 staff member for activities of daily living (ADL), she was wearing oxygen, and she was incontinent of bowel and bladder. On [DATE], I heard the niece tell (RN A) that (resident #1) needed a [MEDICAL CONDITION] machine at night. On [DATE], the next morning I provided ADL care to (resident #1). She was sitting in her bed with her head up to have her breakfast. I heard (LPN D) say that (resident #1) did not have her [MEDICAL CONDITION] machine and that she needed to order one. She was up in her wheelchair around lunch time when I saw all the staff in the room with her. She was not responding. She was not even in the facility for 24 hours and she had to be sent back to the hospital. On [DATE] at 2:20 PM, RN A revealed that she was the admitting nurse for resident #1 on [DATE] during the 3 PM-11 PM shift. The resident arrived at the facility at approximately 9:00 PM and did not have a [MEDICAL CONDITION] machine at the time of her admission. The resident's niece was the one that informed me that she needed to have the [MEDICAL CONDITION] during the night and that the facility was supposed to obtain the [MEDICAL CONDITION] machine. The niece then called the hospital. Later in the evening RN A said she received a call from the hospital Case Manager (name and title unknown). The hospital Case Manager told RN A that the resident could stay at the facility and that the facility was responsible to obtain the [MEDICAL CONDITION] machine for the resident. RN A then asked the case manager, Should I send the resident back to the hospital because she did not have the [MEDICAL CONDITION] for the night? RN A said the Case Manager stated that the resident did not need to go back to the hospital as long as she was sitting upright, and she was wearing her oxygen. RN A said, I know (resident #1) was supposed to have a [MEDICAL CONDITION] machine when she was admitted to the facility and the [MEDICAL CONDITION] was to be used at night. I don't remember if I called the physician to confirm (resident #1's) orders. RN A could not remember if she informed the physician that the resident did not have the necessary [MEDICAL CONDITION] machine. She stated that when a resident was admitted to the facility, the admitting nurse was responsible to review the hospital's discharge physician orders and call the attending physician to confirm the orders. On [DATE] at 10 AM, RN A stated that she did not know if the facility had ordered the [MEDICAL CONDITION] machine for resident #1. I know that the facility is responsible for obtaining the [MEDICAL CONDITION] machine and the respiratory therapist comes to the facility to set up the [MEDICAL CONDITION] machine. On [DATE], the hospital Case Manager told me that the hospital does not supply the [MEDICAL CONDITION] machines for the resident. RN A stated that as a nurse she was responsible for reviewing the physician orders and then to verify the orders with the attending physician. RN A confirmed that she had not verified resident #1 orders with the physician. RN A stated that on [DATE], no one had informed her that a resident was being admitted with orders for a [MEDICAL CONDITION] machine. RN A stated that she knew what a [MEDICAL CONDITION] was used for and that it was important for a resident's respiratory status and ability to breathe effectively. RN A could not explain why she took direction and orders from an unknown hospital Case Manager and failed to call the physician when she became aware that resident #1's [MEDICAL CONDITION] machine was not available? RN A said, I know now that I should have called the physician and sent (resident #1) back to the hospital on [DATE] because she did not have the [MEDICAL CONDITION] machine that was ordered by her physician. Review of the nursing progress note dated [DATE] at 12:30 PM, completed by Licensed Practical Nurse (LPN) D, reflected that she noticed resident #1's head was tilted back while her tray was in front of her. She tried to wake the resident and when she would not respond, she called a code because they were unable to obtain her blood pressure. The attending physician was in the facility at the time and gave an order to call 911. A nurse's note dated [DATE] at 5:10 PM, identified as a late entry, was completed by RN [NAME] and documented at around noon she heard a cry for assistance from resident #1's room. Resident #1's blood pressure was 80, her pulse was not palpable, and she was slow to respond to a sternal rub. Her physician was at bedside. The Emergency Medical Service (EMS) was present and she was transferred to the hospital. On [DATE] at 11:55 AM, LPN D stated that she was the nurse that found resident #1 unresponsive on [DATE]. She stated that she was passing by the resident's room and noted the resident in her wheel chair with her head tilted back. She was still breathing but not responding. We could not get a blood pressure and then called a code. A family member arrived at this time and stated, She was supposed to have a [MEDICAL CONDITION]. On [DATE] at 2:30 PM, RN [NAME] stated that on [DATE] she was the facility supervisor and she responded to a code for resident #1. When she arrived in resident #1's room, the resident was in bed and was barely responding to sternal rub. Her color was off, and she was barely holding on. Emergency Medical Services arrived and they started Cardiopulmonary resuscitation (CPR). They intubated the resident and transferred her to the hospital. On [DATE] at 3:26 PM, resident #1's attending physician was contacted by telephone. He stated that the resident had multiple respiratory [DIAGNOSES REDACTED]. She had just been in the hospital for acute [MEDICAL CONDITION] requiring ventilator support in the Intensive Care Unit. He said there was a problem with the facility nurses not calling him to reconcile hospital orders on admission. The physician stated that he was not notified of resident #1's admission orders [REDACTED]. He added that he was with resident #1 on [DATE] when she became unresponsive. She had been getting drowsier and drowsier over time and developed carbon [MEDICATION NAME] cyanosis because she was without [MEDICAL CONDITION] machine during the night. According to WebMD, carbon [MEDICATION NAME] cyanosis (hypercapnia) is a buildup of carbon [MEDICATION NAME] in the blood stream. It affects people who have [MEDICAL CONDITIONS]. Inflamed airways and damaged lungs make it harder for a person to breathe in the needed oxygen and breathe out the carbon [MEDICATION NAME] the body wants to get rid of. Too much carbon [MEDICATION NAME] in the blood is caused by hypoventilation (reduced amount of air enters the lungs). The physician stated that resident #1 needed to be on [MEDICAL CONDITION] during the night and the facility should have had [MEDICAL CONDITION] for the resident. The physician stated, If the facility was not able get the [MEDICAL CONDITION] for the resident's use then they should not have admitted the resident to the facility. The nurse should have never taken orders from the hospital case manager. The nurse should only be following the physician orders. On [DATE] at 5 PM, an interview with the Administrator and Regional Nurse Consultant revealed that a nurse cannot take direction or an order from a case manager. The Director of Nursing (DON) confirmed that a nurse can only take an order from a physician or advanced registered nurse practitioner (ARNP), and said, The nurse should have never taken direction or an order from the hospital case manager or social worker. If there is a written physician order for [REDACTED]. To my knowledge this did not happen on [DATE]. On [DATE] at 1:40 PM, the Administrator stated that the facility has a contract with a respiratory company and they provided [MEDICAL CONDITION] machines and respiratory therapy services. The Administrator stated, We call the company with the physician order and the respiratory therapist comes to the facility to set up the [MEDICAL CONDITION] machine. There is a ,[DATE]-hour delivery time and the facility must call the company before 7 PM for the [MEDICAL CONDITION] to be delivered on the same day. All calls after 7 PM will be delivered on the following day. Review of the Therapy Services Agreement provided by the Administrator revealed that the respiratory company had provided services to the facility since [DATE]. On [DATE] at 1:45 PM, the Business Development Coordinator (BDC) stated that she was responsible for all resident admissions to the facility. She stated that several days before resident #1's admission to the facility, she went to the hospital to evaluate resident #1. At that time, she saw a [MEDICAL CONDITION] machine in the resident's room and was told by the hospital case manager that resident #1 had her own personal [MEDICAL CONDITION] machine. The BDC then spoke to the nurse (name unknown) caring for resident #1 who stated that she would be admitted to the facility with a [MEDICAL CONDITION] machine. The BDC said, On the evening of (resident #1's) admission to the facility, [DATE], I was made aware that (resident #1) did not have [MEDICAL CONDITION] machine. I texted the Administrator at that time to notify her that the resident did not have the [MEDICAL CONDITION] machine. On [DATE] at 1:45 PM, the Administrator confirmed that she was notified on [DATE], Friday night, by the BDC by text that resident #1 did not have a [MEDICAL CONDITION] machine. The Administrator stated that she was responsible for obtaining the [MEDICAL CONDITION] machine. She stated that she was going to order the [MEDICAL CONDITION] the next day, on Saturday, as she was informed by facility staff that the resident would be okay without the [MEDICAL CONDITION] during the night. The Administrator stated that she never ordered the [MEDICAL CONDITION], The resident was sent to the hospital, so I did not need to order it. The Administrator could not explain why she did not attempt to obtain a [MEDICAL CONDITION] machine that evening for resident #1. On [DATE] at 6:10 PM, an interview was conducted by phone with resident #1's sister. She stated that her sister had been in the hospital for just over a week for breathing problems. She was intubated and placed on a ventilator in the intensive care unit (ICU). The [MEDICAL CONDITION] machine was a new treatment and she did not use it at home. While she was in the hospital, she was on oxygen during the day, and at night she was using the [MEDICAL CONDITION]. Resident #1's sister said, On [DATE], I went to the facility and I could not go into her room because she was unconscious, and everyone was working on her. She never had the [MEDICAL CONDITION] while she was in the facility. The facility should have gotten the [MEDICAL CONDITION] for her to use when she was admitted . On [DATE] at 5:50 PM, an interview was conducted by phone with the facility's Medical Director. He stated that he was aware that resident #1 had coded at the facility because he was caring for her in the ICU. He said there was a miss communication between the hospital and the facility regarding who was to obtain the [MEDICAL CONDITION] machine for resident #1. As a result, the resident did not get the [MEDICAL CONDITION] at night. By the morning, she developed carbon [MEDICATION NAME] cyanosis and sustained a respiratory arrest, requiring her to be readmitted to the hospital, intubated and placed in the ICU. On [DATE] at 1:20 PM, the DON stated that he was not aware that resident #1 was admitted to the facility on [DATE] without a [MEDICAL CONDITION] machine per physician orders. It was not until Monday, [DATE], that he was notified about the [MEDICAL CONDITION] and that she coded requiring CPR, and readmission to the hospital. The DON said, The nurse never notified me. Review of the facility's corrective measures to remove Immediate Jeopardy revealed the following: Resident #1 no longer resided at the facility. The interdisciplinary team (IDT) reviewed all residents admitted since [DATE], who currently resided in the facility to ensure that durable medical equipment (DME), medications and treatments as ordered by physician were implemented. All other residents admitted during this time frame and were discharged were being audited to identify any issues. On [DATE], a 4-point plan was initiated related to coordination of care, admission orders [REDACTED]. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] with all department heads to review the process for ensuring that all new admissions received goods and services as ordered by physician. The facility will implement a process to ensure that all residents admitted to the facility have required DME in place or readily accessible at the time of admission. The medical director will be involved in the admission process decision to develop a plan for patients who are sent by the hospital without ordered equipment and supplies as ordered. On [DATE], the regional director of clinical services (RDCS) provided education to the clinical nursing administration team regarding a process to review all admission records. On [DATE], education for all licensed nurses regarding the admission process, following physician orders, medication reconciliation and obtaining DME was initiated. Fifty-seven percent of the nurses were educated, and certified letters were sent out on [DATE] to those staff members that were unable to be reached. Staff will be required to complete in-service with post-test to validate understanding prior to working. The business development liaisons were provided in-service by the Administrator on the admission process and acquiring DME prior to or at the time of admission. On [DATE], the RDCS provided education to the Administrator regarding the role of the Administrator in the admission process. The Administrator will be required to review each admission prior to arrival with the admissions department and/or liaisons to ensure necessary equipment is ordered timely with each admission. The survey team conducted observations on [DATE] and there were no current residents at the facility with [MEDICAL CONDITION] equipment. Interviews, reviews of audits, training plans, in-service post-testing, and letters sent to licensed nurses verified training regarding the admission process and obtaining physician ordered DME at the time of admission.