Every finding on record at Western Hills Healthcare Residence

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 18 (Resident #63) residents reviewed for baseline care plans. The facility failed to develop a baseline care plan that included services that would be provided to Resident #63. This failure could place residents at risk of not having continuity of care to safeguard against adverse events that were most likely to occur right after admission.Findings include: Record review of Resident #63's electronic face sheet, dated 7.10.2026, revealed a [AGE] year-old female who was admitted to the facility on 07.10.2026. Resident #63 had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) (lung disease), Obstructive sleep apnea (sleep disorder), Tobacco Use, Seizures (uncontrolled activity in the brain), and Essential Hypertension (high blood pressure). Record review of Resident #63's physician orders, dated 07.10.2026, included Oxygen via nasal cannula at 3 LPM PRN as needed for shortness of breath, Furosemide, Gabapentin, Hydrocodone-Acetaminophen, Ropinirole and Trazadone. Record review of Resident #63's admission MDS, dated 07.10.2026, documented no BIMS score needed for this assessment. Record review of Resident #63's baseline care plan, dated 07.12.2026, revealed 3. Health Conditions/Special Treatments, Oxygen therapy not checked CPAP while a resident was not checked. During an observation on 07.20.2026 at 09:33 AM, revealed Resident #63 had an oxygen concentrator in her room and a CPAP machine in her room for her use. During an interview on 07.20.2026 at 11:55 AM, Resident #63 stated she used her CPAP when she slept at night. During an interview on 07.22.2026 at 08:50 AM, LVN A stated the use of Oxygen, and a CPAP should be on the baseline care plan. LVN A stated if these were not on the care plan a resident could potentially be at risk of not receiving the care they needed. LVN A stated the DON was responsible for the baseline care plans. LVN A stated she did not know why this failure occurred. During an interview on 07.22.2026 at 10:02 am the DON stated her expectations were the baseline care plan be completed and accurate withing 48 hours of the residents admission. The DON stated the baseline care plans were her responsibility and a resident who used oxygen and a CPAP machine should be on the baseline care plan. The DON stated she did not feel this had a negative effect on the residents due to having physician orders for oxygen and CPAP use. The DON stated she did not know why this failure occurred. Record review of the facility's policy titled: Care Plans-Baseline, dated revised March 2022, documented the following-Policy statementA baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation The baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident representative.Physician ordersDietary ordersTherapy servicesSocial services; andPASRR recommendation, if applicable. The baseline care plan is used until the staff can conduct comprehensive assessments and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.5. Provision of the summary to the resident and/or resident representative is documented in the medical record.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 18 residents (Resident #63) reviewed for accidents and hazards. The facility failed to ensure Resident #63's safe smoking assessment was completed on admission. This failure could place residents at risk of serious bodily harm, physical impairment.The findings include: Record review of Resident #63's electronic face sheet, dated 7.10.2026, revealed a [AGE] year-old female who was admitted to the facility on 07.10.2026. Resident #63 had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) (lung disease), Obstructive sleep apnea (sleep disorder), Tobacco Use, Seizures, (uncontrolled activity in the brain) Essential Hypertension (high blood pressure). Record review of Resident #63's physician orders, dated 07.10.2026, included Oxygen via nasal cannula at 3 LPM PRN as needed for shortness of breath, Furosemide, Gabapentin, Hydrocodone-Acetaminophen, Ropinirole and Trazadone. Record review of Resident #63's admission MDS, dated 07.10.2026, documented no BIMS score needed for this assessment. Record review on 07.20.2026 at 11:55 AM revealed no safe smoking assessment in the electronic medical record for Resident #63. During an observation on 07.21.2026 at 11:15 AM revealed Resident #63 in the designated smoking area smoking a cigarette. During an interview on 07.22.2026 at 08:23 AM with the RN Regional [NAME] President of Clinical Operations, he stated his expectations were the safe smoking assessments would be completed during admission by the nurse performing the admission. The RN Regional [NAME] President of Clinical Operations stated this failure could lead to a resident not being safe to smoke or need more supervision than other residents who smoked. The RN Regional [NAME] President of Clinical Operations stated this could lead to harm to the residents such as burns to the skin or clothing. The RN Regional [NAME] President of Clinical Operations stated he did not know who this failure occurred. During an interview on 07.22.2026 at 08:50 AM, LVN A stated the safe smoking assessment should be done on admission, quarterly and if there was a significant change of condition. LVN A stated not having the safe smoking assessment completed could lead to harm to the residents such as burns to clothing or skin. LVN A stated she did not know how this failure occurred or who was responsible for monitoring the completion of the safe smoking assessments. During an interview on 07.22.2026 at 10:02 AM, the DON stated her expectations were the safe smoking assessments were completed on admission by the admission nurse. The DON stated the safe smoking assessments helped determine if the resident required a smoking apron or increased supervision. The DON stated she was responsible for ensuring the assessments were completed. The DON stated she did not have a system to ensure the completion of the safe smoking assessments. The DON stated she did not know why this failure occurred. Record review of the facility's policy titled: Smoking Policy-Residents, dated revised August 2022, revealed:Policy statementThis facility has established and maintains safe resident smoking practices.Policy Interpretation and Implementation Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.Smoking in only permitted in designated resident smoking areas, which are located outside of the building.6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes:Current level of tobacco consumptionMethod of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.);Desire to quit smoking andAbility to smoke safely with or without supervision (per a completed safe smoke evaluation).

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for reach in coolers located in the kitchen reviewed for food and nutrition services. The facility's reach in cooler #1 and reach in cooler #3 were observed with fuzzy debris covering the door seals, and door jam facing. This failure could place residents at risk of contamination of food stored in coolers and possible foodborne illness.Findings include: Observation on 7/20/26 at 8:40 AM, during initial tour of the facility's kitchen revealed the reach in cooler #1 and reach in cooler #3 had fuzzy debris growing on door seals and mold growing on door jam facing where the doors closed. The food stored in the reach in coolers were sealed in containers and had not been contaminated. Interview on 7/20/26 at 9:15 AM, the Dietary Manager stated the kitchen cleaning schedule was posted on the Dietary Office wall and staff were to follow the schedule. The Dietary Manager stated the reach in coolers and all other equipment needed to be cleaned and sanitized inside and outside of equipment as needed or daily. The Dietary Manager stated mold growing in the reach in cooler door seals and door jams were unacceptable and would be addressed immediately. The Dietary Manager stated mold growth on the reach in coolers could be a risk for contamination. Interview on 7/22/26 at 2:30 PM, the DON stated the expectation of dietary staff was to clean and sanitize the kitchen and the kitchen equipment to avoid contamination and possible food borne illness. Mold should not be allowed to grow anywhere in dietary. Record review on 7/20/26 at 9:30 AM, of the cleaning schedule posted on the wall outside of the dietary office in the kitchen documented Cleaning schedule for reach in coolers to be cleaned inside and out was scheduled weekly. Record review of the facility's policy Sanitation 2001 Med-Pass, (Revised December 2008).Washing/Sanitizing Equipment, Surfaces, and Utensils: #2 All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.

Based on interview and record review, the facility failed to ensure the facility assessment development and inform of staffing decisions, inform of specific staffing needs, and plan to maximize recruitment and retention of direct care staff for 1 of 1 facility to care for its residents.1.The facility failed to outline in their Facility Assessment the informed staffing decisions to ensure that there were enough staff with the appropriate competencies and skill sets. 2.The facility failed to outline in their Facility Assessment the specific staff needs for each resident unit in the facility, specific staffing needs for each shift and adjust as necessary.3.The facility failed to develop and maintain a plan to maximize recruitment and retention of direct care staff. These failures placed residents at risk of not having corporate oversite and insufficient staff with appropriate competencies and skill sets necessary to care for their resident's needs based on changes to its resident population.Findings Included:Record Review of the facility's document titled Facility Assessment, dated 01/05/2026, reflected on the assessment no evidence of facility resources needed to provide competent resident support and care daily and during emergencies, staff training/education and competencies, staff assignment needs, or a plan to maximize recruitment and retention of direct care staff. Further review reflected the facility assessment tool was reviewed by QAPI on 01/23/2026 with no governing body member present.Record review of the document titled Resident Matrix, dated 06/29/2026, reflected the facility had a census of 59 residents. Further review of the Facility Matrix reflected 17 residents had fallen, 3 residents had pressure ulcers, 3 residents had infections, and 1 resident who utilized an enteral tube (a tube that enters the body from the skin on the abdomen and ends in the stomach for nutrition and medication administration).During an interview on 06/29/2026 at 4:13 p.m., the ADMN stated it was her expectation for the Facility Assessment to have all areas that were required filled out. She stated she was responsible for filling out the Facility Assessment and had piggybacked off the Facility Assessment from the previous Administrator. She stated she was unaware the Facility Assessment needed information about the staffing decisions including how it arrived at the staffing needs and how the facility planned to retain their staff. She stated the governing body was available to her for questions, but they were not at the QAPI meeting when the Facility Assessment was discussed. She stated the facility management was always discussing staffing needs to care for the residents during morning meetings and she would come up to the facility during off hours when needed to see how the staff were doing. She did not feel any negative impact had occurred to the residents who resided in the facility from the Facility Assessment not having those items completed. She stated the facility did not have a policy regarding the Facility Assessment.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 05/12/2025 between 10:45AM and 11:30 AM of the kitchen revealed: Dry Storage: 1. Cheerios type cereal out of the original container not labeled with a use by date. 2. Raisin bran type cereal out of the original container not labeled with a use by date. 3. [NAME] crispy type cereal out of the original container not labeled with a use by date. 4. Corn Flakes type cereal out of the original container not labeled with a use by date. Refrigerator: 1. 3 containers of strawberries were not labeled with a received or a use by date. 2. 1 container of blueberries was not labeled with a received or use by date. 3. 1 opened container of thickened sweet tea was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 4. 1 opened container of thickened tea was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 5. 1 opened container of thickened apple juice was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 6. 1 opened container of thickened cranberry was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. Freezer #1: 1. 8 packages of hot dog buns out of the original container not labeled with a food description or a use by date. 2. 4 bags of tater tots out of the original container not labeled with a food description or a use by date. Freezer #2: 1. 4 packages of chopped chicken out of the original container not labeled with a food description or a use by date. 2. 4 package of chicken pieces out of the original container not labeled with a food description or a use by date. The DM stated food items should have been labeled with a food item description, a receive date, open date, and a use by date. The DM stated all staff were responsible for labeling food. The DM stated she was responsible to monitor, and she monitored by looking thru the refrigerators and freezers weekly. The DM stated residents could have gotten sick if they had received food that was not labeled correctly. The DM stated what led to failure was staff had gotten into a rush and forgot to label food items. During an interview on 05/13/25 at 9:27 AM the Dietician stated her expectation was food should have been labeled with a food description and a receive date, open date and use by date. The Dietitian stated staff that either received food, removed food from the original package or was putting food items back into the refrigerator/freezer were responsible to ensure food items were labeled appropriately. The Dietitian stated the DM was responsible to monitor that food was being labeled correctly. The Dietitian stated she monitored on her monthly visits, by looking thru the kitchen. The Dietician stated that she would address with DM any concerns she found and staff would be in-serviced on the issues that needed to be addressed. The Dietician stated the effect on residents, for food not labeled, could have been a resident could have received a food the resident was allergic to, or could have received food that was past its use by date which could have led to a resident becoming ill. The Dietician stated she did not have an explanation to what led to failure of items not being labeled correctly. During an interview on 05/14/2025 at 2:30 PM the ADMN stated her expectation was that food should have been labeled with a description of the food item, received date, open date and use by date. The ADMN stated the kitchen staff that received food items, removed food items from original containers or opened a food item were responsible to ensure the food items were labeled correctly. The ADMN stated the DM was responsible to ensure food was labeled appropriately. The ADMN stated residents could have become ill from food that was past its use by date. The ADMN stated oversight by the DM led to the failure of food not being labeled correctly. Record review of the facility policy titled Food Storage, without a date, revealed: Food should be dated as it placed on the shelves .Date marking should include date opened, and use by. Review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 05/14/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 4 (Resident #1, Resident #3, Resident #14, and Resident #28) of 15 residents reviewed for unnecessary medications. The facility failed to ensure Resident #1's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #3's PRN Lorazepam was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #14's PRN Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #28's PRN Lorazepam was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, lung disease, and kidney failure. Review of Resident #1's Annual MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #1 had taken anti-anxiety medications during the last 7 days. Review of Resident #1's Comprehensive Care Plan review completed 04/21/2025, revealed: Focus: Resident uses anti-anxiety medications (lorazepam) r/t anxiety disorder. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Resident will show decreased episodes of s/s of anxiety. Interventions: Give anti-anxiety medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #1's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 2 hours as needed for anxiety 365 day stop date, order date 10/09/2024, and Lorazepam Oral Tablet 0.5 MG Give 2 tablet by mouth every 2 hours as needed for anxiety 365 day stop date, order date 10/09/2024. Review of Resident #1's April 2025 MAR revealed 10 doses of Lorazepam were administered. Review of Resident #1's May 2025 MAR up until 05/13/2025, revealed 3 doses of Lorazepam were administered. Review of Resident #1's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Review of Drugs.com for Lorazepam accessed on 05/14/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, and depression. Review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #3 had taken anti-anxiety medications during the last 7 days. Review of Resident #3's Comprehensive Care Plan review completed 04/10/2025, revealed: Focus: Resident uses anti-anxiety medications (lorazepam) r/t hospice. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: Give anti-anxiety medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #3's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 0.5 mg by mouth every 2 hours as needed for anxiety give 1-2 tablets, order date 04/07/2025. Review of Resident #3's April 2025 MAR revealed 3 doses of Lorazepam were administered. Review of Resident #3's May 2025 MAR up until 05/13/2025, revealed no evidence of Lorazepam being given for the entire month. Review of Resident #3's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Resident #14 Review of Resident #14's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, infection to lower leg, and kidney failure. Further review revealed no evidence of an insomnia diagnoses. Review of Resident #14's Admission MDS dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #14 had taken anti-anxiety medications during the last 7 days since entry. Review of Resident #14's Comprehensive Care Plan review completed 05/13/2025, revealed: Focus: Resident uses anti-anxiety medication Diazepam r/t anxiety disorder and sleep. Goal: Resident will show decreased episodes of s/s of anxiety. Interventions: .Give anti-anxiety medications ordered by physician (Diazepam). Monitor/document side effects and effectiveness . Review of Resident #14's electronic Physicians Orders revealed: Diazepam Oral Tablet 2 MG Give 1 tablet by mouth every 12 hours as needed for insomnia, order date 04/23/2025. Review of Resident #14's April 2025 MAR revealed Diazepam was administered daily since ordered. Review of Resident #14's May 2025 MAR up until 05/13/2025, revealed 9 doses of Diazepam were administered. Review of Resident #14's physician progress notes revealed no evidence of documented rationale to order PRN Diazepam for more than 14 days. Review of Drugs.com for Diazepam accessed on 05/14/2025 at https://www.drugs.com/diazepam.html revealed: Diazepam belongs to a class of medications called benzodiazepines. Diazepam is used in a to treat anxiety disorders, or alcohol withdrawal symptoms. Resident #28 Review of Resident #28's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: dementia, Parkinson's, and muscle weakness. Review of Resident #28's Quarterly MDS dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #28 had not taken any anti-anxiety medications during the last 7 days. Review of Resident #28's Comprehensive Care Plan review completed 03/25/2025, revealed no evidence of anxiety or resident taking antianxiety medications. Review of Resident #28's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 2 hours as needed for anxiety for 365 Days, order date 01/08/2025, and Lorazepam Oral Tablet 0.5 MG Give2tablet by mouth every 2 hours as needed for anxiety for 365 Days, order date 01/08/2025. Review of Resident #28's April 2025 MAR revealed no evidence of Lorazepam being given for the entire month. Review of Resident #28's May 2025 MAR revealed no evidence of Lorazepam being given for the entire month. Review of Resident #28's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. During an interview on 05/14/25 at 10:40 AM, the Administrator stated she was not aware that there had to be a documented rationale for the need to continue psychotropic PRN medications longer than 14 days. During an interview on 05/14/25 at 10:47 AM, the DON stated PRN psychotropics can only be for 14 days unless the resident was on hospice, and they can order them for a year. He stated there is no documented rationale for the continued need of the medication by the physician. He stated he was not aware the documentation was required. Review of facility policy titled; Psychotropic Medication Use dated July 2022 revealed in part: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. Review of facility policy titled; Abuse/Neglect, revised 10/04/22 revealed in part: The resident has the right to be free from abuse, misappropriation of resident property, and exploitation as defined in this subject. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms.

45732 Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #1, Resident #3, and Resident #28) of 15 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident are addressed and met 24 hours per day to ensure Resident #1, Resident #3, and Resident #28 received adequate end-of-life care. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day and to have a physician certification and recertification of the terminal illness for Resident #1, Resident #3, and Resident #28. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old female admitted to the facility on hospice services on 04/01/2023 with diagnoses to include: anxiety, lung disease, and kidney failure. Review of Resident #1's Annual MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section O: revealed Resident #1 was on hospice care. Review of Resident #1's Comprehensive Care Plan review completed 04/21/2025, revealed: Focus: Resident has an order for Do Not Resuscitate (DNR). Goal: Resident decision for DNR will be honored. Interventions: Resident receives services from hospice. Review of Resident #1's electronic Physicians Orders revealed: Admit to Hospice DX: Ends Stage Renal Failure (kidney failure), dated 04/01/2023. Review of Resident #1's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #1. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, and depression and admitted to hospice services on 03/04/2025. Review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Review of Section O revealed Resident #3 was on hospice care. Review of Resident #3's Comprehensive Care Plan review completed 04/10/2025, revealed: Focus: Resident has an order for Do Not Resuscitate (DNR). Goal: Resident decision for DNR will be honored. Interventions: Resident receives services from hospice. Review of Resident #3's electronic Physicians Orders revealed: Hospice to evaluate and admit if indicated, date 03/04/2025. Review of Resident #3's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #3. Resident #28 Review of Resident #28's electronic face sheet revealed an [AGE] year-old male admitted to the facility on hospice services on 11/04/2020 with diagnoses to include: dementia, Parkinson's, and muscle weakness. Review of Resident #28's Quarterly MDS dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Review of Section O revealed Resident #28 was on hospice care. Review of Resident #28's Comprehensive Care Plan review completed 03/25/2025, revealed: Focus: Resident has been placed on hospice services. Goal: Residents needs will be met, and comfort will be maintained. Interventions: Work cooperatively with hospice team to ensure residents spiritual, emotional, intellectual, physical, and social needs are met. Review of Resident #28's electronic Physicians Orders revealed: Admit to Hospice Services with diagnoses End Stage Parkinson's disease, date 11/04/2020. Review of Resident #28's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #28. During an interview on 05/13/25 at 02:51 PM, the DON stated there was no documentation of communication between hospice and the facility. He stated the facility staff, and the hospice staff communicate verbally. He stated the facility did not have hospice binders. He stated he was not aware that there had to be written documentation and that he was not aware of the required documents from hospice. During an interview on 05/14/25 at 10:40 AM, the Administrator stated the facility should have had hospice binders for each resident on hospice. She stated it should have included the certification of terminal illness and all communication regarding care provided by the hospice providers. She verified that there was no communication forms and no certifications of terminal illness and that she has reached out to the hospice company. She stated the negative effect of not having the binders would be poor communication regarding resident care. Review of facility policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

Based on interview and record review the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 15 residents (Resident #48) reviewed for antipsychotic medication consents. The facility failed to ensure Resident #48's HHSC Form 3713 for Risperdal (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability) was signed by Resident #48 or Resident #48's responsible party, prior to resident receiving the medication. This failure could affect residents who received antipsychotics by placing them at risk of not being informed of their treatment options , to make informed decisions regarding their care. Findings included: Record review of Resident #48's electronic face sheet dated 12/04/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: Alzheimer's disease (common cause of dementia characterized by a progressive decline in memory, thinking and behavior), dementia (group of symptoms affecting memory, thinking and social abilities), Major Depressive disorder and anxiety disorder. Record review of Resident #48's Significant change MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #48 had a BIMS score of 2 (meaning severe cognitive impairment); Section N-Medications: Resident #48 had received antipsychotic medications during the previous 7-day period. Record review of Resident #48's physician order dated 05/14/2025 revealed: Risperdal oral tablet .5mg (Risperidone) Give .5 prescriber tablet by mouth two times a day related to Dementia . with a start date of 05/09/2025. Record review of Resident #48's Medication Administration Record dated May 2025 revealed Resident #48 received Risperdal twice per day on 05/10/2025, 05/11/2025, 05/12/2025 and 05/13/2025. Record review of Resident #48's HHSC Form 3713 for Risperdal revealed no evidence of a signature by Resident #48 or their representative prior to 05/14/2025. During an interview on 05/13/25 at 3:06 PM the DON stated he did not have a signed HHSC form 3713 for Resident #48's Risperdal that was started on 05/09/2025. The DON stated he did get verbal consent from Resident #48's representative and had mailed the consent to Resident #48's representative. During an interview on 05/13/25 at 3:03 PM Resident #48's representative stated he had received a phone call, from the DON, and was notified Resident #48 was ordered new medications. Resident #48's representative stated he was not told Resident #48 was prescribed an antipsychotic and was not told the risks and benefits of the new antipsychotic. During an interview on 05/14/2025 at 1:45 PM the DON stated he had called Resident #48's Representative and told him there was a new order for Risperdal. The DON stated he did not tell Resident #48's Representative that Risperdal was an antipsychotic and did not tell him the risks and benefits of the medication. The DON stated he did not know you could not get a verbal consent for the HHSC Form 3713. The DON stated he thought he could have mailed the HHSC Form 3713. The DON stated after further reading his expectation was that the HHSC Form 3713 should have been signed prior to start of an antipsychotic medication. The DON stated the nurse that took the new medication order was responsible for ensuring the HHSC Form 3713 was signed prior to the antipsychotic medication being given. The DON stated he was responsible to monitor and that he monitored by running reports of new medications. The DON stated the effect on residents could have been residents were not aware of all the side effects of a new medication. The DON stated what led to the failure was oversight on his part, and he did not know a verbal consent would not be sufficient for an antipsychotic medication. During an interview on 05/14/2025 at 2:30 PM the ADMN stated her expectation was that residents and/or their representative should have been notified when given a new antipsychotic medication. The AMDN stated they should have been notified of what the new medication was, why it was being given, what the risk and benefits of the new medication were and should have signed an HHSC consent form prior to the antipsychotic being given. The ADMN stated the nurse who received the order was responsible to ensure the consent was signed prior to giving a new antipsychotic. The ADMN stated the DON was responsible to monitor that consent forms were completed prior to giving antipsychotics. The ADMN stated residents could have been affected because they may not have all information needed about new medications. The ADMN stated what led to the failure was oversight by DON. The ADMN stated the DON did not know that a verbal consent would not be sufficient for an antipsychotic and that the HHSC Form had to be signed prior to administration of medication. Record review of facility policy titled Antipsychotic Medication Use dated July 2022 revealed: Residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 05/14/2025 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed Under 26 TAC S554.1207, a resident receiving antipsychotic or neuroleptic medications must provide written consent. Written consent can also be given by a person authorized by law to consent on the resident's behalf. Consent for antipsychotic and neuroleptic medications must be documented on Texas Health and Human Services Commission (HHSC) Form 3713 . If the antipsychotic or neuroleptic medication is being prescribed to a resident for the first time, a NF must complete Form 3713 before the first dose is administered. Review of drugs.com accessed on 05/16/2025 at https://www.drugs.com, revealed Risperdal was a Drug class: Atypical antipsychotics. 45732

Based on interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 1 of 15 residents (Resident #6) reviewed for misappropriation and exploitation, in that: The facility failed to ensure that Resident #6 was not subject to financial misappropriation or exploitation from the BOM. The BOM accepted $3700 cash from Resident #6 on 11/18/2024 and failed to apply the money too Resident #6's account. The noncompliance was identified as Past Non-Compliance. The noncompliance began on 11/18/2024 and ended on 04/14/2025. The facility had corrected the non-compliance before the survey began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. Findings Included: Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: diabetes, infection, anxiety, and depression. Review of Resident #6's Annual MDS dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #6's receipts reflected on 11/18/24 the BOM received $3700 cash from Resident #6 for Room and board. Review of Facility Journal Entry Report for April 2025 ran on 05/14/2025 revealed Resident #6 had a bad debt total of $3780. During an interview on 05/14/2025 at 1:00 pm, the Administrator stated that she had observed to her what seemed like suspicious behavior from the BOM. She stated that the facility had several Medicaid pending residents for a longer time than expected. She stated she and the Corporate Revenue Cycle Director started an audit of Medicaid applications which were to be completed by the BOM. She discovered multiple Medicaid applications that the BOM had said had been completed were never started. She stated she then when looking through receipt booklets and she discovered that several cash payments had been accepted by the BOM. She stated there was a receipt for Resident #6 for $3700 that had not been applied to Resident #6's account or deposited into the facility bank account. She stated the BOM stated she was not aware that she could not take cash payments and that she bought money orders with the cash, and she must have lost the money orders. She stated the BOM denied stealing the cash. Administrator then stated she discovered that monthly account statements were not being sent out to residents which was why no residents or family members were aware of their accounts being delinquent. During an interview on 05/14/2025 at 1:00 pm, Resident #6 stated she was not aware of all of the details regarding the missing money and that her family takes care of all her financials. She stated that she had given the BOM #3700 cash on 11/18/2024. During an interview on 05/14/2025 at 1:10 pm, Resident #6's family member stated she was informed that the cash that Resident #6 had given to the BOM was never applied to Resident #6's account and that the facility made it right. She stated that she was not upset and that no harm was caused. She stated that she had received one monthly account statement since Resident #6's account debt had been cleared. Review of facility policy titled; Abuse/Neglect, revised 10/04/22 revealed in part: The resident has the right to be free from abuse, misappropriation of resident property, and exploitation as defined in this subject. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It was determined this failure placed the facility in Past Non-Compliance from 11/18/2024 to 04/14/2025. The facility took the following actions to correct the non-compliance: Review of Facility Investigation Report form 3613-A, dated 04/18/2025, revealed: Facility Investigation Findings: Confirmed. Provider Action Taken Post-Investigation: in conducting an audit of [Resident #6's] account it was confirmed that payment made in cash of $3700 on 11/18/2024and was not applied to Resident #6's account. Corporate Revenue Cycle Director conducted an audit of facility deposits and no matching $3700 was deposited into facility accounts. The BOM was terminated immediately for misappropriation of funds and Medicaid applications not being completed. Police Department is investigating report of alleged misappropriation of funds. Corporate Revenue Cycle Director is completing audit on all resident accounts at this time. In-service regarding abuse and neglect was completed by staff. Corporate Revenue Cycle Director adjusted [Resident #6's] account to reflect deposit of $3780. Review of facility in-service titled, Abuse, Neglect, and Misappropriation, dated 04/14/2025, revealed 19 signatures. During interviews on 05/14/2025 from 1:30-2:30 pm, 6 staff members stated they had been in-serviced and understood abuse and neglect and misappropriation of property. Review of Resident #6's account summary, dated 04/18/2025 revealed a credit of $3780 and no outstanding balance. Review of Employee Disciplinary Report, dated 04/14/2025, signed by the BOM, revealed termination of employment. Review of police report revealed on 04/11/2025 a report of possible fraud was received. During an interview on 05/14/2025 at 3:10 pm, The COO stated the misappropriation was corrected in the following ways: audits were performed, the family of Resident #6 was notified, Resident #6's account was credited, and the BOM was terminated. He stated actions put in place to prevent further failure were weekly financial reviews, and segregation of duties between the person receiving the monies and the person depositing the monies. He stated money will be taken by the medical records person and then given to the business office to deposit. He stated there currently was not a BOM for the facility, but a new person had been hired but had not started yet.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 2 (Residents #10, and Resident #34) of 6 residents reviewed for smoking safety. The facility failed to ensure Resident #10's lighter and cigarettes were not stored on their person. The facility failed to ensure Resident #34's lighter and cigarettes were not stored on their person. These failures could affect residents who smoke by putting them at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #10 Record review of Resident #10's electronic face sheet dated 12/08/2023 revealed resident was a [AGE] year-old male who was initially admitted on [DATE] with a recent readmitted [DATE]. Resident #10 was admitted with medical diagnoses of paraplegia, muscle wasting, non-insulin dependent diabetes, mood disorder, nicotine dependence, major depressive disorder, anxiety, intermittent explosive disorder, gout, high blood pressure, 3 pressure ulcers, blood clots, respiratory disease, dysfunctional bladder, and heartburn. Review of Resident #10's Annual MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Summary Score, a score of 15 out of 15 indicating intact cognition. For Section J Health Conditions, subsection J1300 Current Tobacco Use, 1. Yes was entered. Record review of Resident #10's Safe Smoking assessment dated [DATE] revealed: This Resident is safe to smoke unsupervised, at this time. Record review of Resident #10's Comprehensive Care Plan dated 11/21/24, reviewed/revised 02/07/25, revealed Focus: [Resident] is an active smoker at this time and requires no monitoring when smoking. Goal [Resident] will be able to state understanding of smoking rules of the facility through next review date. Interventions/Tasks [Resident] may have his smoking materials with him and keep at nurses' station or med room, [Resident] will have a safe smoking assessment completed at least quarterly. Record review of Resident #10's electronic medical records revealed Resident #10 signed a document titled Smoking Policy - Residents on 02/10/25. During an observation on 05/14/25 at 10:10 AM, Resident #10 wheeled himself outside to the designated smoking area. Resident #10 asked for a light. Resident #10 was informed he had to get a light from a staff member. Resident #10 went back inside the building then came out with a staff member. The staff member lit his cigarette with a disposable lighter. Resident #10 did not have signs of damage to his clothing or exposed skin related to cigarettes or a lighter. Record review of Resident #10's weekly skin assessments from 12/15/23 to current revealed no documentation of wounds related to cigarettes or a lighter. Resident #34 Record review of Resident #34's electronic face sheet dated 05/16/2023 revealed resident was a [AGE] year-old male initially admitted on [DATE] with medical diagnoses of Alzheimer's disease, anxiety, weakness, high blood pressure, dementia, major depressive disorder, heart failure, and a cardiac pacemaker (an implanted medical device that regulates heart rhythm). Review of Resident #34's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns, subsection C0500. BIMS Summary Score, Resident #34 had a BIMS score of 14 out of 15 indicating intact cognition. Record review of Resident #34's Safe Smoking assessment dated [DATE] revealed: This resident is safe to smoke unsupervised, at this time., All smoking materials will be kept at the nurses station, Care Plan up to date or updated, and The evaluation has been discussed with the resident. Record review of Resident #34's Comprehensive Care Plan last revised on 02/07/2025 revealed: Focus: [Resident] is an active smoker at this time and requires monitoring at smoke times. Goal [Resident] will be able to state understanding of smoking rules of the facility through the next review date. Interventions/Tasks [Resident] has signed and understands the smoking policy, [Resident] will have a safe smoking assessment completed quarterly., [Resident] prefers his cigarettes to be kept at the nurse's station or med room. Record review of Resident #34's electronic medical records revealed Resident #34 signed a document titled Smoking Policy - Residents on 02/07/25. During an observation and interview on 05/13/25 at 10:11 AM, Resident #34 wheeled himself out to the designated smoking area. No staff were present. Observed as Resident #34 pulled a cigarette and disposable lighter out of his shirt pocket and lit the cigarette. No staff member was present to supervise the resident. Resident #34 stated he kept his cigarettes and lighter in his room and was able to come out to the smoking area when he wants without supervision. At approximately 10:14 AM, observed Resident #10 wheel himself out to the smoking area. Resident #10 had a cigarette and lighter on his lap. Resident #10 stated he was also permitted to have his cigarettes and lighter in his room and smoke when he wants unsupervised. Resident #10 was not observed smoking at this time. During an observation on 05/13/25 at 10:48 AM, noted the facility Safe Smoking - Residents policy posted in the front lobby. During an observation and interview on 05/14/25 at 08:32 AM, Resident # 34 wheeled himself outside to the designated smoking area. Resident #34 pulled a pack of cigarettes and a disposable lighter out of the pocket on the upper left sleeve of his jacket. No staff was present to supervise Resident #34. Resident #34 lit the cigarette. Resident #34 stated he kept his cigarettes and lighter in the jacket pocket. During an observation on 05/14/25 at 10:15 AM, no supplemental oxygen was in Resident #34's room. During an observation and interview on 05/14/25 at 09:50 AM, Resident #34 had no signs of damage to his clothing or exposed skin related to a lighter or cigarettes. Resident #34 appeared to have no tremors when holding his cigarette. Resident #34 denied burning himself. Record Review of Resident #34's weekly skin assessments from 02/06/25 to current revealed no documentation of wounds related to cigarettes or a lighter. Record review of grievances for previous 6 months revealed no complaints related to smoking or residents having a lighter in their room. During an observation and interview on 05/14/25 at 08:58 AM, the DON stated the facility's policy was for smokers to have a safe smoking evaluation done upon admission. He explained residents were not permitted to have cigarettes or lighters in their room. The DON stated tobacco products and supplies must be locked in the medication rooms at each nurse' station. He stated his expectations were for staff to report to the DON or Administrator if a resident was found with cigarettes or lighter in their room. The DON stated the staff assigned to a smoker's hall, or staff that was available, would be responsible for supervising during scheduled smoking times. He stated the responsibility for monitoring for safe smoking practices was all staff members. He stated training on safe smoking practices included staff reviewing the information for each resident on the summary of resident tasks and the care plan. The DON denied knowledge of incidents in the facility related to smoking paraphernalia. Accompanied the DON to Resident # 10's room. The DON explained Resident #10 was approved to roll his own cigarettes in his room. He stated Resident #10 requested the supplies from the nurses. He rolled cigarettes in his room then returned the supplies to the nurse. Upon entering Resident #10's room, the resident was lying in bed listening to music. Resident #10 told the DON his supplies were in the 2nd drawer of his nightstand and gave permission for the DON to look. A clear plastic bag of tobacco and a cigarette pack were in the drawer. Resident #10 stated his lighter was in the 2nd right side drawer of the dresser. The DON located the lighter, and explained to the resident that he could ask for it at the nurses' station before he went outside to smoke and needed to return the lighter to the nurse when he came back in. Resident #10 did not have a roommate and was not on supplemental oxygen. Accompanied the DON to the locked unit to check smoking supplies. A long safety lighter was in a drawer at the nurse's station. Cigarettes and smokeless tobacco were stored in a clear plastic box in the locked medication room. During an interview on 05/14/25 at 09:16 AM, the Administrator stated residents were evaluated for safe smoking prior to approval to smoke ad lib. She stated cigarettes and lighters were kept at the nurse's station. Her expectations of staff if a resident was found with cigarettes and/or lighter was for staff to report to her or DON and remove the item(s) from the resident's possession. She stated she or the DON would talk with the resident, review the smoking policy with the resident and complete a safe smoking evaluation. The Administrator stated she had worked in the facility for 3 years and could not recall an incident related to a resident possessing a lighter. She stated staff was in-serviced on safe smoking procedures by herself and/or the DON. She stated she and the DON were responsible for training and monitoring for compliance. During an interview on 05/14/25 at 11:25 AM, LVN A, Treatment Nurse, stated she was responsible for weekly skin assessments. She stated she had not discovered a wound on a resident who smoked that appeared to be caused by a cigarette or lighter. LVN A stated potential consequences of having a lighter in a resident room may be if a roommate was on oxygen the lighter could be a fire danger. She stated the reason for the failure to keep residents from having lighters in their room was because family and visitors were unaware of the policy. She added, some residents go out on pass with family and could return with a lighter without staff knowing. During an interview on 05/14/25 at 11:43 AM, LVN B stated was not aware Resident # 10 had a lighter in his room. She stated the cause of the failure may be because Resident #10's family brought him groceries, cigarettes, and loose tobacco to roll his own cigarettes. She stated Resident #10 also ordered tobacco supplies online. LVN B stated potential consequences of residents keeping smoking supplies in their room may be a resident would smoke in the room, trigger the fire alarm, or set a fire. She explained training was provided via in-services and information on resident smoking assessments was available to staff in the electronic medical records. She stated the DON was responsible for monitoring for training compliance. LVN B stated she had not noticed burns on the clothing or skin of a resident who smoked. During an interview on 05/14/25 at 11:49 AM with the DON and VPCS, the VPCS stated facility expectations were for a smoking assessments to be completed on admission and routinely. He stated some residents were approved to smoke at will. The VPCS stated smoking items were kept by the nurses. The DON explained a re-assessment of smoking safety was done when the resident had a change in status. The DON stated the reason for the failure was visitors giving residents cigarettes and/or lighters. The DON stated the facility supplied safety lighters that are kept at each nurse's station. The VPCS stated when smoking supplies were found on a resident or in a resident's room, the resident was re-educated, and a safe smoking evaluation was done. He stated each resident that smoked signed the smoking policy during the admission process. The VPCS and the DON did not directly answer potential consequences of a resident having a lighter in their room. Record review of facility policy Smoking Policy - Residents Policy Interpretation and Implementation, Item 13. Resident may not keep cigarettes, e-cigarettes, or lighters (those items must be kept at the nursing station). Smokeless tobacco items can be kept by the resident as deemed appropriate. Care plans will specify if resident is utilizing cigarettes, e-cigarettes, or smokeless tobacco items. 45732

44728 Based on interview and record review, the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for Diabetic care. 1. The facility failed to ensure RN C notified the physician that Resident #38's blood glucose was over 250, 5 times during a 3-month review period. 2. The facility failed to ensure RN C administered Resident #3's Insulin Glargine 3 times during a 3-month review period and Resident #38's Insulin Glargine 2 times during a 3-month review period, per physician order. 3. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period, per physician order. 4. The facility failed to ensure LVN L notified the physician that Resident #38's blood glucose was over 250, 1 time during a 3-month review period. 5. The facility failed to ensure LVN L administered Resident #38's Insulin Glargine 7 times during a 3-month review period and Resident #11's Insulin Glargine 1 time during a 1-month review period, per physician order. 6. The facility failed to ensure LVN F administered Resident #3's Insulin Lispro 1 time during a 3-month review period, per physician order. 7. The facility failed to ensure LVN F notified physician that Resident #38 blood glucose was over 250 per physician order, 2 times during a 3-month review period and Resident #31's blood glucose was over 400 per physician order 2 times during a 1-month review period. 8. The facility failed to ensure that LVN F administered Resident #31's Insulin Novolin per physician order 1 time during a 1-month review period. 9. The facility failed to ensure LVN E notified physician that Resident #38 blood glucose was over 250 per physician order, 8 times during a 3-month review period. 10. The facility failed to ensure LVN E administered Resident #3's Insulin Lispro 2 times during a 3-month review period, per physician order. 11. The facility failed to ensure LVN B notified physician that Resident #38 blood glucose was over 250, 1 time during a 3-month review period. 12. The facility failed to ensure LVN B administered Resident #3's Insulin Lispro 1 time during a 3-month review period, per physician order. 13. The facility failed to ensure LVN B administered Resident #3's Insulin Glargine 1 time during a 3-month review period, per physician order. 14. The facility failed to ensure LVN B administered Resident #38's Insulin Glargine one time during a 3-month review period, per physician order. 15. The facility failed to ensure LVN E notified physician that Resident #38 blood glucose was over 250 per physician order, 8 times during a 3-month review period. 16. The facility failed to ensure RN A notified physician that Resident #38's blood glucose was over 250 per physician order, 7 times during a 3-month review period. 17. The facility failed to ensure RN A notified physician that Resident #38 blood glucose was over 250 per physician order, 7 times during a 3-month review period. 18. The facility failed to ensure RN A administered Resident #38's Insulin Glargine 14 times during a 3-month review period, per physician order. 19. The facility failed to ensure LVN K administered Resident #38's Insulin Glargine 4 times during a 3-month review period, per physician order. An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment; Section N-Medications Resident #3 received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; Resident #3 will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM, Resident #3 was in his wheelchair and talking with nurse while she checked his blood glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses of Diabetes Mellitus, high blood pressure; Section N-Medications Resident #11 received Insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: Resident #11 has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: Resident #11 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor(metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 units held at 4:30PM with no evidence of documentation of rationale for holding or who held medication. 4. 03/20/2024 Novolin R Solution 10 units held at 6:30AM with blood glucose of 323 documented by LVN N Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident # 31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); Section N-Medications Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021 Record review of Resident #31's physician reviewed on 03/22/2024 revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March 2024 MAR revealed no evidence that physician was notified when Resident #31's Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. 2. 03/09/2024 at 1630 (4:30 PM) blood glucose of 480 recorded by LVN F, physician not notified. 3. 03/14/2024 at 1630 (4:30 PM) blood glucose of 439 recorded by LVN F, physician not notified. Review of Resident #31's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 11:14 AM, Resident #31 was sitting at table in dining room watching television. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); Section N-Medications Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022 Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024 Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022 Offer substitutes for foods not eaten. Date Initiated: 11/28/2022. Record review of Resident #38's physician order reviewed on 03/20/2023 revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250. Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed no evidence that the physician was notified when insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN N. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A. 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. Record Review of Resident # 38's January 2024, February 2024 and March 2024 MARs revealed no evidence that physician was notified for the following blood glucose: 1. 01/11/2024 at 8:00 PM blood glucose of 282 recorded by LVN E. 2. 01/12/2024 at 8:00 PM blood glucose of 295 recorded by LVN P. 3. 01/15/2024 at 8:00 PM blood glucose of 285 recorded by LVN N. 4. 01/18/2024 at 9:00 AM blood glucose of 255 recoded by LVN O. 5. 01/19/2024 at 8:00 PM blood glucose of 322 recorded by Staff Q. 6. 01/21/2024 at 9:00 AM blood glucose of 409 recorded by LVN E 7. 01/24/2024 at 8:00 PM blood glucose of 428 recorded by LVN N. 8. 01/26/2024 at 8:00 PM blood glucose of 282 recorded by LVN P. 9. 01/27/2024 at 8:00 PM blood glucose of 260 recorded by RN A. 10. 01/28/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 11. 01/30/2024 at 8:00 PM blood glucose of 293 recorded by LVN E. 12. 01/31/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 13. 02/06/2024 at 8:00 PM blood glucose of 352 recorded by LVN E. 14. 02/07/2024 at 9:00 AM blood glucose of 283 recorded by LVN E. 15. 02/07/2024 at 8:00 PM blood glucose of 326 recorded by LVN O. 16. 02/12/2024 at 8:00 PM blood glucose of 362 recorded by LVN E. 17. 02/14/2024 at 8:00 PM blood glucose of 380 recorded by RN A. 18. 02/15/2024 at 8:00 PM blood glucose of 280 recorded by RN A. 19. 02/17/2024 at 8:00 PM blood glucose of 314 recorded by LVN O. 20. 02/18/2024 at 8:00 PM blood glucose of 266 recorded by LVN O. 21. 02/21/2024 at 8:00 PM blood glucose of 399 recorded by LVN O. 22. 02/22/2024 at 8:00 PM blood glucose of 344 recorded by LVN O. 23. 02/24/2024 at 8:00 PM blood glucose of 370 recorded by RN A. 24. 02/25/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 25. 02/27/2024 at 8:00 PM blood glucose of 336 recorded by LVN O. 26. 02/29/2024 at 8:00 PM blood glucose of 332 recorded by LVN E. 27. 03/02/2024 at 8:00 PM blood glucose of 350 recorded by RN C. 28. 03/03/2024 at 8:00 PM blood glucose of 384 recorded by RN C. 29. 03/04/2024 at 8:00 PM blood glucose of 375 recorded by RN C. 30. 03/05/2024 at 8:00 PM blood glucose of 287 recorded by LVN B. 31. 03/11/2024 at 9:00 AM blood glucose of 285 recorded by LVN L. 32. 03/13/2024 at 8:00 PM blood glucose of 309 recorded by RN C. 33. 03/14/2024 at 9:00 AM blood glucose of 284 recorded by LVN E. 34. 03/14/2024 at 8:00 PM blood glucose of 318 recorded by RN C. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his wife stated the Lantus should have been held if blood glucose was less than 120 would hold because he would bottom out (blood glucose would drop low). RN C stated Resident #38 refused offered snack when she held the insulin. RN C stated she used her nursing judgement about holding the insulin. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated she will text the doctor with updates but does not always. RN C stated the doctor would get mad if they contacted him with everything. RN C stated if the orders stated to contact doctor for blood glucoses over 250, then the doctor should have been contacted. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/21/2024 at 7:53 PM, Resident #38 stated he had snacks in his room, and a refrigerator. Resident #38 stated he will usually ask if he needs more snacks in the evenings before bed. During an observation and interview on 03/23/2024 at 10: 15 AM, Resident #38 was coming into the building from the outside smoking area. Resident #38 stated he had been out on smoke break and no concerns expressed. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held or that Resident #38 had any blood glucoses over 250. The MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in physician order. The DON stated her expectation would be for nurses to contact physician if physician order stated to contact physician for blood glucose being above 250. She stated nurses should document in chart when physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could cause adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect blood glucose reading hours after the insulin was held. Physician D stated Registered Nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician orders should have been followed. LVN L stated not giving insulin per order and not contacting physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact physician when insulin was held and would hold if resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long-acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that was ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted physician when holding insulin for Resident # 3 and #38. LVN F did not provide a reason for why she did not contact the doctor. During an attempted telephone follow-up interview on 03/22/2024 at 6:25 PM with the MD, the MD did not answer and a message to return call was left. The MD did not return the call. During an attempted telephone interview on 03/22/2024 at 6:38 PM with LVN K, LVN K did not answer and a message to return call was left, LVN K did not return call. During an attempted telephone interview on 03/22/2024 at 6:39 PM with RN A, RN A did not answer and message to return call was left, RN A did not return call. During an attempted telephone interview on 03/22/2024 at 6:41 PM with LVN B, LVN B did not answer and message to return call was left, LVN B did not return call. During a follow-up interview on 03/23/2024 at 3:07PM, the DON stated her expectation was if nurses used their nursing judgment they need to follow up with the physician and document in the resident's chart. The DON stated herself and the ADON were responsible for monitoring. The DON stated the effect on residents could have led to possible decline of residents. The DON stated what led to failure was that nursing staff in the past were allowed to use nursing judgement. The DON stated the nursing process they followed was the Texas Board of Nursing. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated his expectation was nurses could apply their nursing judgement, but needed to follow physician orders and notify physician with any change of condition that staff follow policy and notify physician in change of resident status. The ADMN stated the DON was responsible for monitoring. The ADMN stated staff not contacting the physician could have resulted in residents not getting care in a timely manner. The ADMN stated what led to failure was lack of follow up and oversight of management. Record review of facility policy titled Adverse Consequences and Medication Errors, dated February 2023, revealed, Examples of medications errors include: Omission - a drug is ordered but not administered Unauthorized drug- a drug is administered without a physician's order; Wrong dose (e.g. , Dilantin 12 mL ordered, [NAME]/in 2 mL given); Wrong route of administration (e.g. , ear drops given in eye ); Wrong dosage form (e .g., liquid ordered, capsule given); Wrong drug (e.g., vibramycin ordered, vancomycin given) According to the Texas Board of Nursing website, https://www.bon.texas.gov accessed on 03/22/2024 revealed A nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/practice_dept_, accessed on 03/22/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 03/22/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 2:45 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/22/2024 at 3:45 PM. Record review of Plan of Removal accepted on 03/23/2024 at 3:17 PM reflected the following: The facility failed to have nursing staff with appropriate competenci [TRUNCATED]

48883 Based on observation, interview, and record review, the facility failed to have a system in place to monitor that nursing staff were notifying the physician for 4 of 6 residents (Resident #3, Resident #11, Resident #31, Resident #38) when insulin was held and resident blood glucoses over 250 for 2 of 6 (Resident #38, Resident #31) residents reviewed for diabetic care. 1. The facility failed to notify the physician when Resident #3's Insulin Glargine and Insulin Lispro were held without a physician order 13 times during a 3-month review (January 2024, February 2024, March 2024). 2. The facility failed to notify the physician when Resident #11's Insulin Glargine and Novolin R Solution was held without a physician order 4 times during a 1-month review (March 2024). 3. The facility failed to notify the physician when Resident #31's Insulin Glargine and Novolin R Solution was held without a physician order 3 times during a 1-month review (March 2024). 4. The facility failed to notify the physician of Resident #31's blood glucoses that were greater than 400 3 times during a 1-month review (March 2024). 5. The facility failed to notify the physician of Resident #38's blood glucoses that were greater than 250 34 times during a 3-month review period (January 2024, February 2024, March 2024). 6. The facility failed to notify the physician when Resident #38's Insulin Glargine was held without a physician order 32 times during a 3-month review (January 2024, February 2024, March 2024). An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of delayed medical treatment and diabetic complications. Findings include: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses included: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed the resident had a BIMS score of 10 meaning moderate cognitive impairment and Section N-Medications received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; [Resident #3] will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician's order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Further review of physician's orders revealed no order for blood sugar checks or orders about notification to the physician. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM revealed Resident #3 was in his wheelchair and talking with the nurse while she checked his blood glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information, Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses reflected Diabetes Mellitus, high blood pressure; and Section N-Medications reflected Resident 131 received insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: [Resident #11] has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: [Resident #11] will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 [Resident #11] will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 [Resident #11] will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor (metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician's order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Further review of physician's orders revealed no order for blood sugar checks or orders about notification to the physician. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 units held at 4:30PM with no evidence of documentation of rationale for holding or who held the medication. 4. 03/20/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN N. Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses, Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); and Section N-Medications reflected Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021. Record review of Resident #31's physician's orders revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March 2024 MAR revealed Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. 2. 03/09/2024 at 1630 blood glucose of 480 recorded by LVN F, physician not notified. 3. 03/14/2024 at 1630 blood glucose of 439 recorded by LVN F, physician not notified. Review of Resident #31's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on the secure unit on 03/18/2024 at 11:14 AM revealed Resident #31 was sitting at table in dining room watching television and appeared to not be in distress. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); and Section N-Medications reflected Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022. Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024. Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022. Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (unhealthy pale appearance), Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing (abnormal breathing pattern), acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022. Offer substitutes for foods not eaten. Date Initiated: 11/28/2022 . Record review of Resident #38's physician's orders revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250. Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN N. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A . 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. Record Review of Resident #38's January 2024, February 2024 and March 2024 MARs the following blood glucose: 1. 01/11/2024 at 8:00 PM blood glucose of 282 recorded by LVN E. 2. 01/12/2024 at 8:00 PM blood glucose of 295 recorded by LVN P. 3. 01/15/2024 at 8:00 PM blood glucose of 285 recorded by LVN N. 4. 01/18/2024 at 9:00 AM blood glucose of 255 recoded by LVN O. 5. 01/19/2024 at 8:00 PM blood glucose of 322 recorded by Staff Q. 6. 01/21/2024 at 9:00 AM blood glucose of 409 recorded by LVN E 7. 01/24/2024 at 8:00 PM blood glucose of 428 recorded by LVN N. 8. 01/26/2024 at 8:00 PM blood glucose of 282 recorded by LVN P. 9. 01/27/2024 at 8:00 PM blood glucose of 260 recorded by RN A. 10. 01/28/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 11. 01/30/2024 at 8:00 PM blood glucose of 293 recorded by LVN E. 12. 01/31/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 13. 02/06/2024 at 8:00 PM blood glucose of 352 recorded by LVN E. 14. 02/07/2024 at 9:00 AM blood glucose of 283 recorded by LVN E. 15. 02/07/2024 at 8:00 PM blood glucose of 326 recorded by LVN O. 16. 02/12/2024 at 8:00 PM blood glucose of 362 recorded by LVN E. 17. 02/14/2024 at 8:00 PM blood glucose of 380 recorded by RN A. 18. 02/15/2024 at 8:00 PM blood glucose of 280 recorded by RN A. 19. 02/17/2024 at 8:00 PM blood glucose of 314 recorded by LVN O. 20. 02/18/2024 at 8:00 PM blood glucose of 266 recorded by LVN O. 21. 02/21/2024 at 8:00 PM blood glucose of 399 recorded by LVN O. 22. 02/22/2024 at 8:00 PM blood glucose of 344 recorded by LVN O. 23. 02/24/2024 at 8:00 PM blood glucose of 370 recorded by RN A. 24. 02/25/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 25. 02/27/2024 at 8:00 PM blood glucose of 336 recorded by LVN O. 26. 02/29/2024 at 8:00 PM blood glucose of 332 recorded by LVN E. 27. 03/02/2024 at 8:00 PM blood glucose of 350 recorded by RN C. 28. 03/03/2024 at 8:00 PM blood glucose of 384 recorded by RN C. 29. 03/04/2024 at 8:00 PM blood glucose of 375 recorded by RN C. 30. 03/05/2024 at 8:00 PM blood glucose of 287 recorded by LVN B. 31. 03/11/2024 at 9:00 AM blood glucose of 285 recorded by LVN L. 32. 03/13/2024 at 8:00 PM blood glucose of 309 recorded by RN C. 33. 03/14/2024 at 9:00 AM blood glucose of 284 recorded by LVN E. 34. 03/14/2024 at 8:00 PM blood glucose of 318 recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin or when blood glucose was above 250 per physician's order. During an interview on 03/19/24 05:02 PM, the DON stated that the blood sugars should have been documented in the resident's chart. The DON stated she did not know why blood sugars were not entered. She stated if documentation was not in the chart there was not another way to prove it had been completed. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his family member stated the Lantus should have been held if blood glucose was less than 120mg/dL because he would bottom out (blood glucose would drop low). RN C stated she used her nursing judgement about holding the insulin and had not contacted the physician to verify. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated if the orders stated to contact doctor for blood glucoses over 250mg/dL doctor should have been contacted. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held or that Resident #38 had any blood glucoses over 250. The MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in the physician's orders. The DON stated her expectation would be for nurses to contact the physician if the order stated to contact he physician for blood glucose being above 250. She stated nurses should document in the chart when the physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could have caused adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect the blood glucose reading hours after the insulin was held. Physician D stated the registered nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify the physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician's orders should have been followed. LVN L stated not giving insulin per orders and not contacting the physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact the physician when insulin was held, and would hold if the resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long- acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that were ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted the physician when held insulin for Residents #3 and #38. LVN F did not provide a response for not contacting the physician or why held the insulin. Attempted telephone follow up interview on 03/22/2024 at 6:25 PM with the MD. The MD did not answer and a message to return the call was left. The MD did not return the call. Attempted telephone interview on 03/22/2024 at 6:38 PM with LVN K. LVN K did not answer and a message to return the call was left. LVN K did not return the call. Attempted telephone interview on 03/22/2024 at 6:39 PM with RN A. RN A did not answer and a message to return the call was left. RN A did not return the call. Attempted telephone interview on 03/22/2024 at 6:41 PM with LVN B. LVN B did not answer and a message to return the call was left. LVN B did not return the call. During a follow-up interview on 03/23/2024 at 3:07PM, the DON stated her expectation was that nurses should have notified the physician with every change of condition and document their attempts. The DON stated herself and the ADON were responsible for monitoring, by talking with nurses and reviewing resident charts. The DON stated the effect on residents could have led to a possible decline. The DON stated what led to the failure was that nursing staff in the past were allowed to use nursing judgement. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated his expectation was that staff follow the policy and notify the physician of a change in the resident's status. The ADMN stated the DON was responsible to monitor. The ADMN stated staff not contacting the physician could have resulted in resident not getting care in a timely manner. The ADMN stated what led to failure was lack of follow up and oversight of management. Record review of facility policy titled, Nursing Policy and Procedure Manual 2003 date March 11, 2023 revealed, The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident' s clinical record . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician' s orders and the resident' s status and response to interventions. This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 2:45 PM. The Administrator was informed of the IJ. The Administrator was provided with the IJ template on 03/22/2024 at 3:45 PM. Record review of Plan of Removal accepted on 03/23/2024 at 3:17 PM reflected the following: The facility failed to have nursing staff with appropriate competencies and skills set to provide nursing and related services to assure resident safety. Nursing staff held residents' insulin for two residents (#3 and #38) without a physician's order nor notification to the physician when the insulin was held. This had the potential to affect 6 residents that are dependent on insulin at high risk for diabetic complications, serious illness, hospitalization , and/or death. The medical director, [Medical Director Name], MD, was notified of the immediate jeopardy on 03/22/2024 at 4:13 p.m. Clinical Compliance Nurse will: On 03/23/2024, provide re-education for facility director of nursing regarding notifying physician of change in resident condition, including notifying physician when holding resident's insulin, and documentation of the notification, in-service on Scope of practice decision making module, Nursing scope of practice as related to medication administration, med error policy, policy on nursing care of older adult with diabetes. Director of Nursing/Designee will: On 3/22/24, initiated re-education to all licensed nurses regarding notifying physician of change in resident condition, including notifying physician when holding resident's insulin, and documentation of the notification, resident change of condition, in-service on scope of practice decision making module, nursing scope of practice as related to medication administration, med error policy, policy on nursing care of older adult with diabetes. Expected completion date is 3/23/2024. Any staff member not receiving this education by 03/23/2024, will be educated prior to next scheduled shift. An employee roster and schedule will be used to validate education compliance. Have all licensed nurses show competency upon start of next shift via competency-based training via post-test and with continued audits and skills validation. Competency testing initiated on 3/22/24. Expected completion date is 3/23/2024. Any staff member not receiving this education by 03/23/2024 will be educated prior to next scheduled shift. An employee roster and schedule will be used to validate education compliance. Facility per diem nurses, new hires, and agency nurses will receive this re-education prior to reporting for duty. Physician was contacted for hold parameters for all six residents. Nurses will be in-serviced on asking for hold parameters for new insulin orders on 3/23/2024. If nurse is not available they will be educated before starting their next shift. 6 diabetic residents identified medication administration records were audited for failures related to following physician orders. Audit initiated on 3/22/24. Audit completed on 3/23/24. Negative findings will be reviewed with physician. Findings from the audit were reviewed with physician on 3/22/24 and 3/23/24. Monitoring insulin medication document records for accuracy of following physician orders initiated on 3/22/24. Monitoring will continue 3 X week for four weeks and then review findings with QAPI team. If the physician notification was required, we will ensure it is documented in resident medical record. Clinical Compliance Nurse will monitor POR weekly with DON beginn [TRUNCATED]

48883 Based on observation, interview, and record reviews, the facility failed to remain free of significant medication errors for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for medication administration. 1. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 6 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #38's Insulin Glargine 1 times during a 3-month review period (January 2024, February 2024, March 2024)., per physician order. 2. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period (January 2024, February 2024, March 2024). 3. The facility failed to ensure LVN L administered Resident #38's Insulin Glargine 7 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #11's Insulin Glargine 1 time during a 1-month review period (March 2024), per physician order. 4. The facility failed to ensure LVN F administered Resident #3's Insulin Lispro 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician order. 5. The facility failed to ensure LVN F administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician order. 6. The facility failed to ensure that LVN F administered Resident #31's Insulin Novolin per physician order 1 time during a 1-month review period (March 2024). 7. The facility failed to ensure LVN E administered Resident #3's Insulin Lispro 2 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 8. The facility failed to ensure LVN B administered Resident #3's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 9. The facility failed to ensure LVN B administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 10. The facility failed to ensure RN A administered Resident #38's Insulin Glargine 14 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 11. The facility failed to ensure LVN K administered Resident #38's Insulin Glargine 4 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 12. The facility failed to ensure LVN N administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 13. The facility failed to ensure LVN N administered Resident #11's Novolin Solution 1 time during a 1-month review period (March 2024) per physician's order. 14. The facility failed to ensure LVN O administered Resident #38 Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure placed residents that received insulin at risk illness, hospitalization s, and exacerbation of their disease processes. Findings included: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment.Section N-Medications Resident #3 received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; Resident #3 will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM, Resident #3 was in his wheelchair and talking with nurse while she checked his Blood Glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses of Diabetes Mellitus, high blood pressure; Section N-Medications Resident #11 received Insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: Resident #11 has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: Resident #11 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor(metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 unites held at 4:30PM with no evidence of documentation of rationale for holding or who held the medication. 4. 03/20/2024 Novolin Solution 10 units held at 0630 with blood glucose of 323 documented by LVN N. Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); Section N-Medications Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021 Record review of Resident #31's physician reviewed on 03/22/2024 revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March MAR dated revealed no evidence that physician was notified when Resident #31's Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. During an observation on 03/18/2024 at 11:14 AM, Resident #31 was sitting at table in dining room watching television. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11(moderate cognitive impairment); Section N-Medications Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022 Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024 Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022 Offer substitutes for foods not eaten. Date Initiated: 11/28/2022 Record review of Resident #38's physician order reviewed on 03/20/2023 revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250 Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed no evidence that the physician was notified when insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN C. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A. 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. During an interview on 03/21/2024 at 7:53 PM, Resident #38 stated he had snacks in his room, and a refrigerator. Resident #38 stated he will usually ask if he needs more snacks in the evenings before bed. During an observation and interview on 03/23/2024 at 10:15 AM, Resident #38 was coming into the building from the outside smoking area. Resident #38 stated he had been out on smoke break and no concerns expressed. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his family member stated the Lantus should have been held if blood glucose was less than 120mg/dL because he would bottom out (blood glucose would drop low). RN C stated she had not verified family's request and used her nursing judgement. RN C stated when Resident #38 refused the snack that she offered, so she held the insulin if the blood sugar was low. RN C stated she used her nursing judgement about holding the insulin. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated she would send the doctor a text with updates but does not always. RN C stated the doctor would get mad if they contacted him with everything. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held. MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in physician order. The DON stated her expectation would be for nurses to contact physician if physician order stated to contact physician for blood glucose being above 250. She stated nurses should document in chart when physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could have caused adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect blood glucose reading hours after the insulin was held. Physician D stated Nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician's orders should have been followed. LVN L stated not giving insulin per orders and not contacting the physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact the physician when insulin was held, and would hold if the resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long- acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that was ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted physician when holding insulin for Resident #3 and #38. LVN F did not provide a response for why she did not contact the doctor or held the insulin. During an attempted telephone follow-up interview on 03/22/2024 at 6:25 PM with the MD, MD did not answer and a message to return call was left. The MD did not return the call. During an attempted telephone interview on 03/22/2024 at 6:38 PM with LVN K, LVN K did not answer and a message to return call was left, LVN K did not return call. During an attempted telephone interview on 03/22/2024 at 6:39 PM with RN A, RN A did not answer and message to return call was left, RN A did not return call. During an attempted telephone interview on 03/22/2024 at 6:41 PM with LVN B, LVN B did not answer and message to return call was left, LVN B did not return call. During a follow-up interview on 03/23/2024 at 3:07PM, the DON stated her expectation was if nurses used their nursing judgment they needed to follow up with the physician and document in the resident's chart. The DON stated herself and the ADON were responsible for monitoring, by talking with nurses and reviewing resident charts The DON stated the effect on residents could have led to possible decline of residents. The DON stated what led to failure was that nursing staff in the past were allowed to use nursing judgement. The DON stated the nursing process they followed was the Texas Board of Nursing. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated his expectation was nurses were to follow physician orders. The ADMN stated the DON was responsible for monitoring. The ADMN stated staff not contacting the physician could have resulted in residents not getting care in a timely manner. The ADMN stated what led to failure was lack of follow up and oversight of management. Record review of facility policy titled Adverse Consequences and Medication Errors, dated February 2023, revealed, Examples of medications errors include: Omission - a drug is ordered but not administered Unauthorized drug- a drug is administered without a physician's order; Wrong dose (e.g. , Dilantin 12 mL ordered, [NAME]/in 2 mL given); Wrong route of administration (e.g. , ear drops given in eye ); Wrong dosage form (e .g., liquid ordered, capsule given); Wrong drug (e.g., vibramycin ordered, vancomycin given). A significant medication-related error is defined as: a. Requiring medication discontinuation or dose modification. (Consult the current list of medications that should not be abruptly discontinued.) b. Requiring hospitalization or extending a hospitalization . c. Resulting in disability. d. Requiring treatment with a prescription medication. e. Resulting in cognitive deterioration or impairment. f. Life threatening. g. Resulting in death. Review of drugs.com website, https://www.drugs.com accessed on 03/27/2024 revealed, Insulin glargine is a long-acting insulin used to treat type 1 and type 2 diabetes in certain patients to improve and maintain blood glucose levels. Insulin glargine is a man-made form of human insulin that is used once daily to provide a base level of insulin that keeps working for 24 hours or longer. Insulin Lispro is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. According to the Texas Board of Nursing website, https://www.bon.texas.gov accessed on 03/22/2024 revealed, A nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/practice_dept_, accessed on 03/22/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 03/22/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 2:45 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/22/2024 at 3:45 PM. Record review of Plan of Removal accepted on 03/23/2024 at 3:17 PM reflected the following: The Facility failed to ensure residents were free of significant medication errors when nursing staff held insulin without a physician's order. Nursing staff held insulin for two residents (#3 and #38) without a physician's order nor notification to the physician when the insulin was held. This had the potential to affect 6 residents that are dependent on insulin at risk of poor control of diabetes, and can result in excessively high blood sugars and death. The medical director, [Medical Director Name], MD, was notified of the immediate jeopardy on 03/22/2024 at 4:13 p.m. Clinical Compliance Nurse [Nurse Name] RN, BSN, clinical compliance nurse, will: On 03/23/2024, provide re-education for facility director of nursing regarding notifying physician of change in resident condition, including notifying physician when holding resident's insulin, and documentation of the notification, Inservice on scope of practice decision making module, Nursing scope of practice as related to medication administration, med error policy, policy on nursing care of older adult with diabetes. Pharmacy Consultant: Pharmacy consultant notified of medication errors and immediate jeopardy deficiencies and will schedule a follow up educational in-service to nursing staff within the next 30 days for further prevention. On 3/23/24, initiated video in-service education to all licensed nurses regarding medication error prevention and following physician orders. Expected completion date is 3/23/24. Any staff member not receiving this education by 03/23/2024, will be educated prior to next scheduled shift. An employee roster and schedule will be used to validate education compliance. Director of Nursing/Designee will: On 3/22/24, initiated re-education to all licensed nurses regarding notifying physician of change in resident condition, including notifying physician when holding resident's insulin, and documentation of the notification, resident change of condition, in-service on scope of practice decision making module, nursing scope of practice as related to medication administration, med error policy, policy on nursing care of older adult with diabetes. Expected completion date is 3/23/2024. Any staff member not receiving this education by 03/23/2024, will be educated prior to next scheduled shift. An employee roster and schedule will be used to validate education compliance. Have all licensed nurses show competency upon start of next shift via competency -based training via post-test and with continued audits and skills validation. [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly. The facility failed to ensure that food items were disposed of properly. The facility failed to ensure the freezer was free from loose food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 03/18/2024 between at 10:15 AM too 10:45 AM of the kitchen revealed: Refrigerator 1. 2 gallon jugs of sweet tea without an open or use by date 2. 29 individual containers of chocolate milk with an expiration date of 3/17/2024 3. 9 individual foam containers with lids without a label identifying the item and were not dated Dry Storage 1. 1 package of taco seasoning in a plastic bag with a zipper not labeled with an open date 2. 1 plastic container filled with opened graham cracker crumbs with an open date of 03/13/2023 3. 15 opened loaves of bread not in the original box, not labeled with an item description, an open date or used by date 4. 15 opened packages of hamburger buns not in the original box, not labeled with an item description, an open date or used by date. 5. 10 opened packages of hotdog buns not in the original box, not labeled with an item description, an open date or use by date. Small chest freezer 1. Chunks of loose frozen chicken in bottom of freezer and a piece chicken stuck to the rim of the top of the freezer. During an interview on 03/18/2023 at 11:00 AM, the DM stated food removed from the original package should have been labeled with a receive date, open date and use by date. The DM stated items in the original package should have an open date. The DM stated items should have been disposed of if they were past the expiration date. The DM stated the effect on residents could have made them ill. The DM stated what led to failure was that staff forgot to label items and overlooked the dates. The DM stated that there should not have been loose food in the freezer, that if someone had spilt something they would have needed to clean it up. During an interview on 03/20/24 at 10:33 AM, the Dietician stated food items out of original package should have been labeled with an open date, use by date and item description date. The Dietician stated the DM was responsible for monitoring the kitchen. The Dietician could not provide a reason for what led to failure and she stated that everything needed to be labeled. The Dietician stated the failures could have caused adverse effects to the residents. The Dietician stated the freezer should not have loose food; all food should be sealed in a container. The Dietician stated if someone had spilled food into the freezer they should have cleaned it up when spilled. During an interview on 03/23/24 at 3:52 PM, the ADMN stated his expectation was that food be stored appropriately per policy and food should have been discarded when past use by date. The ADMN stated the DM was responsible for monitoring. The ADMN stated the effect on residents could have caused possible illness. The ADMN stated what led to failure was oversight and staff failing to verify storage areas for dates. Record review of facility policy titled, Food Safety, dated 2012 revealed: Food is to be tightly wrapped or sealed and covered in clean container. Open food shall be labeled, dated and stored properly .Do not keep potentially hazardous food in refrigerator pas the labeled expiration date. Record review of facility policy titled Storage Refrigerators dated 2012 revealed: Storage refrigerator shall be kept clean and organized. Spills are to be wiped up immediately. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 03/23/2023 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #30, Resident #33, and Resident #38) of 6 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plan that included preventative pressure ulcer interventions for Resident #30. The facility failed to update care plan with current dental care needs for Resident # 33. The facility failed to develop care plan that included smoking care needs for Resident #38. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #30 Record review of Resident #30's face sheet dated 03/21/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 11/04/2020 and the following diagnoses: Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), contracture of right and left hands (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), and cognitive communication deficit. Record review of Resident #30's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior BIMS score of 1 (severe cognitive impairment); Section GG- Functional Abilities and Goals revealed helper does all of the effort for rolling left and right in bed, sit to lying, and chair to bed transfer; Section M- Skin Conditions revealed resident was at risk of developing pressure ulcers and had no pressure ulcers but used pressure reducing device for chair. Record review of Resident #30's care plan dated 10/16/2023 revealed: Resident #30 had an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility with Goal: will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Date initiated: 11/17/2020 Revision on: 06/25/2021 Target date: 10/05/2023 .Interventions/Tasks: requires skin inspection q (every) week. Observe for redness, open area, scratches, cuts, bruises and report changes to the Nurse .requires lifter sheet to turn and reposition .resident is totally dependent on staff for repositioning and turning in bed. Resident #30 had limited physician mobility r/t (related to) disease process Parkinson's Disease with Goal: will remain free of complications related to immobility, including .skin-breakdown .Interventions/Tasks: requires (2) staff participation for mobility Date initiated: 11/17/2020 Revision on 06/25/2021. PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN (as needed) Date Initiated: 11/17/2020. Record review of Resident #30's care plan dated 01/11/2024 revealed: Resident #30 had stage 3 pressure ulcer to his buttocks due to hx (history) of ulcers, immobility, and incontinence of bowel and bladder. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date .Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness Date Initiated: 12/28/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 12/28/2023. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 12/28/2023. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 12/28/2023. Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 12/28/2023. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 and the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness, and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment); Section L- Oral/Dental Status mouth or facial pain, discomfort or difficulty with chewing. Record review of Resident #33's care plan dated 3/7/2024 revealed Resident #33 had oral/dental health problems r/t recent tooth extractions; mouth pain Date Initiated: 8/10/2021 Revision on: 11/16/2022. During an observation and interview on 03/19/24 9:14 a.m., Resident #33 stated her teeth were removed when she was admitted on ,d+[DATE]. Resident #33 stated she had received dentures, but they did not fit and were sent back over the summer. Resident #33 showed her teeth, gums appeared to be healed, no irritation or bleeding. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); Section J- Health Conditions revealed resident used tobacco. Record review of Resident #38's care plan dated 02/13/2024 revealed no evidence of smoking monitoring or care. During an observation and interview on 03/23/2024, Resident #38 was coming in from outside. Resident #38 stated he had been out on smoke break, no concerns expressed. During an interview on 03/21/2024 at 9:56 a.m., RN H stated when a new wound was reported to her, she would assess wound and LVN M would update the care plan. She stated she had been working as the treatment nurse for the last 3 weeks and had attempted to update care plans when she discovered the care plans needed updating .She was able to update the care plans, but LVN M updated more since RN H performed the MDS assessments. During an interview on 03/22/2024 at 8:29 a.m., LVN M stated she performed the MDS assessments. She stated she does look in residents record to make sure Braden risk assessment had been performed so that she would know how much at risk a resident was for pressure ulcers prior to documenting on assessment. She stated if a resident had a risk for skin breakdown, it should have been care planned. She stated not having the risk for pressure ulcers on care plan could cause harm to resident such as pressure ulcer formation from staff not knowing that resident was at risk or interventions to perform. LVN M stated she and the DON monitored care plans. She stated when a care plan needed to be updated prior to MDS assessment, she or the treatment nurse could update. She does not know why pressure ulcer prevention was not mentioned on care plan prior to pressure ulcer formation. During a follow up interview on 03/23/2024 at 2:48 p.m., LVN M stated she was responsible for ensuring care plans were completed. She stated care plans should include anything related to resident care, active diagnosis, and medications. She stated when acute needs occur, the interdisciplinary team updates care plans. The effect of care plans not being accurate would have on residents could make them not receive care they want or treatment against their wishes. LVN M stated smoking status and code status should be incorporated in care plans. LNV M stated goals should be updated and resolved in care plans. She stated that she had overlooked Resident #38s smoking status. During an interview on 03/23/2024 at 3:07 p.m., the DON stated LVN M was responsible for comprehensive care plans. She stated her expectation was the resident's needs, medications, and active diagnosis be incorporated in the care plans. She stated smoking status and pressure ulcer prevention should be incorporated in care plans. She stated care plans not being updated with current needs could cause resident to not have quality of care they deserve. She felt the failures occurred due to lack of communication between staff members and MDS coordinator LVN M. She stated care plans are updated as new concerns arise and quarterly. She stated an interdisciplinary team included MDS coordinator, DON, Social Worker, Therapy, Dietary, and Activities review care plans. Record review of facility policy titled Care Plans revised on 10/04/2022 revealed: The facility will develop a Comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident=s medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment. Record review of facility policy titled Skin Integrity Management revised on 03/07/2007 revealed: Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure sores must be completed. The Director of Nurses or designee does this.

Based on interviews and record reviews the facility failed the ensure physician visits were conducted once every 30 days for 2 of 24 residents (Resident #3, Resident #20) and every 60 days for 4 of 24 residents (Resident #31, Resident #33, Resident #38, Resident #45) who were review for physician visits. The facility failed to have Resident #3 seen by physician at least once every 30 days for the first 90 days after admission since 10/03/2023. The facility failed to have Resident #20 seen by physician at least once every 30 days for the first 90 days after admission on 09/23/2023. Resident #20 was last seen on 11/09/2023. The facility failed to have Resident #31 seen by physician at least every 60 days after the first 90 days for the past year from 02/2023. Resident #31 was last seen 04/16/2023. The facility failed to have Resident #33 seen by physician at least every 60 days for the past year from 02/2023 and received one visit from facility physician on 11/07/2023. The facility failed to have of Resident #38's seen by a physician with a missed visit in 10/2023 and no physician visits after 11/21/2023. The facility failed to have Resident #45 seen by physician at least every 60 days after the first 90 days after admission on 03/13/2023. Resident #45 was last seen on 09/25/2023. This deficient practice could lead to a decline in health status or untreated conditions. Findings included: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on 10/03/2023. Resident #3's diagnoses include: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment. Record review of Resident #3 Physician Progress Notes revealed no time stamp when he was last seen by primary physician from last admission of 10/03/2023. Resident #20 Record review of Resident #20's facesheet revealed she was admitted to the facility on [DATE], with an initial admitted [DATE] with a diagnosis of lack of coordination Heart failure Pneumonia, Respiratory Failure and Urinary Tract Infections. Record review of Resident #20's MDS dated [DATE] revealed a BIMS of 09 (moderately impaired). Record review of Resident # 20's physician visits revealed she did not have an initial admission visit by a Physician and was not visited by a physician until 11/09/2023. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment). Record review of physician visit documentation revealed Resident #31 had missing physician visit between dates 4/16/2023 - 8/25/2023, & 9/25/2023 - 3/20/2024. The facility provided no evidence of physician visits for Resident #31 from 4/16/2023 to current date. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 and the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness, and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment). Record review of Resident #33's electronic charting and paper review revealed: since February of 2023 there was one visit on 11/07/2023 with a facility physician. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment). Record review of Resident #38's physician visits revealed a missed visit in 10/2023 and no physician visits after 11/21/2023. Resident #45 Record review of Resident #45's Facesheet dated 03/23/2024 revealed resident was a 72 yr-old female with an admitted [DATE] and a diagnosis of Dementia, Cognitive Communication deficit, and Hypertension. Record review of Resident #45 revealed resident was admitted on [DATE] and did not have an initial admission visit. The facility physicians last visit for Resident #45 was on 02/16/2024. The facility provided no evidence of resident's physician visits for 03/13/2023 through 09/25/2023. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated it was his expectation that all residents be seen by the Physician per facility policy. He stated it was the responsibility of the DON, MDS and ADMN to monitor physician visits. The negative effect for residents could be diagnoses being missed or possible medications needed. The ADMN stated in missed visits, it could have presented challenges to the resident and their plan of care. He stated the failure was due to the lack of follow up with physicians getting their documentation entered or submitted into the resident electronic records. During an interview on 03/23/24 at 4:26 PM, the DON stated the physician was to see the resident within the first 24-72 hours for a new admission with in-putting progress notes at least every 60 days. She stated Medical Records was to monitor physician visits. The DON stated all physician visits and progress notes should have been in the resident electronic charting, but the physicians were not great about turning them in to her and sometimes have to call the Medical Director and ask for them. She stated the negative impact to residents were the possibility of residents having issues that could be elevated or escalated before the physician can see them. The DON stated her expectations were for the physician to visit at least every 30 days and documenting in the resident medical records in a timely manner. Record review of facility policy Physician Services Guidelines with the revised date if 10/04/2022 revealed: Physician Visits: Medical care of each resident must be supervised by a physician. The physician must visit based on a frequency noted below and must review the resident's total program of care, including medications and treatments, at each visit and write, sign and date progress notes. Also, all orders must be signed and dated. 1. The initial comprehensive visit may not be performed by a PA, NP, or CNS. 2. Admission order may not be performed by a PA, NP or CNS. 3. Other required visits and orders may be performed and signed by PA, MP or CNS. Physician Orders: Monthly orders can be reviewed and signed on each scheduled visit. Oral/telephone order should be signed and dated by the position in a timely manner. Physician Progress Notes: The progress note should reflect the review of the resident's total program of care and should include the following items as applicable: 1. Change in diagnosis 2. Cognitive status 3. Change in weight 4. Progress and problems in meeting care plan goals 5. Measures taken to reach highest practical functional level (rehabilitative/restorative progress) 6. Status of specialized treatments and medical indications i.e., urinary catheter, tube feedings, decubitus care, etc.) Frequency: The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required and as indicated. Physician attendance at care plan meetings is not a prerequisite of participation. The physician my sign the care plan or add an ancillary order stating Care plan reviewed and approved.

44728 Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 4 of 13 residents (Resident #6, #33, #54) reviewed for abuse. The facility failed to conduct a thorough investigation and report findings from their investigation of pharmaceutical services and misappropriation of property within 5 working days regarding Resident #6. The facility failed to conduct a thorough investigation and report findings from their investigation of abuse within 5 working days regarding Resident #33. The facility failed to conduct a thorough investigation and report findings from their investigation of neglect within 5 working days regarding Resident #54. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Resident #6 Record Review of the resident #6's Face Sheet dated 03/19/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 06/18/2023 with the diagnoses of shortness of breath, heart failure, and chest pain. Review of Resident #6's MDS, dated [DATE], Section C revealed a BIMS score of 15 (cognitively intact). Review of Resident #6's Care Plan dated 03/07/2024 revealed: Focus: Resident #6 requires pain management r/t pain, date initiated 10/05/2023 and a revised on 10/05/2023. Goal: Resident #6 will not have an interruption in normal activities due to pain through the review date. Date initiated: 10/05/2023, Target date of 05/15/2024. Interventions: Administer analgesia (oxycodone-APAP, Tylenol) as per orders. Give 1/2 hours before treatments or care. Date initiated: 10/05/2023, Target date of 03/08/2024. Record review of an Incident report dated 02/27/2024 revealed an allegation of Pharmaceutical Services and Misappropriation of Property of Resident #6, At approximately 1:15 PM on 02/26/2024, the facility ADMN was notified by facility DON, that two facility nurses reported a drug diversion incident regarding a residents' medication. Review of an investigation file revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 with the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment). Record review of Resident #33's care plan dated 3/7/2024 revealed, Resident #33 has a behavior problem r/t delusion. Resident #33 has misconceptions and beliefs that staff are talking about her. She firmly believes that staff intentionally ignore her. Date Initiated: 11/30/2021. Goal: will have fewer episodes of misconceptions/beliefs by next review date. Date Initiated: 11/30/2021. Revision on: 11/16/2022, and a Target date: 05/19/2024 .Interventions/Tasks:.Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention, remove from situation, and take alternate location as needed, Date initiated: 11/30/2021. Record review of Incident report dated 02/13/2024 revealed an allegation of Abuse of Resident #33, At approximately 10:45 PM on 02/10/2024, the facility administrator was notified by LVN E that an agency nurse was speaking to a resident in a verbally inappropriate manner Review of investigation file revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #54 Record review of Resident #54's face sheet dated 03/21/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admitted [DATE] with the following diagnosis Pneumonia, muscle wasting, lack of coordination, Parkinson's Disease with a history of falling and cognitive communication deficit. Record review of Resident #54's Annual MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns BIMS score of 0 (severe cognitive impairment). Record review of Resident #54's Care Plan dated 02/26/2024 revealed; Focus: Resident #54 has had an actual fall with injury, minor injury, r/t poor balance, poor communication/comprehension 08/19/23, 08/20/23, 10/5/23, 10/16/23, 10/22/23, 10/23/23, 10/25/23, 10/29/23, and 10/30/23. 11/21/23, 11/23/23, 11/27/23, 12/25/23, 01/09/24, 1/28/24 (x2), 1/30/24 with fracture date initiated: 01/30/2024, Revision on 02/26/2024 with a cancel date of 02/26/2024. Goal: Resident #54 will resume usual activities with further incident through the review date. Interventions: For apparent acute injury, determined and address causative factors of the fall. Record review of Incident report dated 02/06/2024 revealed an allegation of Neglect of Resident #54 At approximately 7:45 PM on 02/05/2024, the facility ADMN was notified that a radiology report was received for Resident #54 which indicated a left femoral neck fracture. The resident had two falls on 02/02/2024 and 02/03/2024. Review of facility's investigations revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. During an interview on 03/19/2024 at 09:25 AM, the ADMN stated a thorough investigation included, witness interviews, resident medical information and performing in-services to staff involved. The ADMN stated he was waiting to turn in the form 3613-A self-report investigations to HHSC. The ADMN stated he should have immediately started the investigations when the incidents were reported to him. He stated he had 24 hours to report incidents to HHSC when there was no injury but if there was, he would have two hours after the incident happened. He stated he had investigated and found confirmation that the incidents did occur or not, with having 5 business days to complete and submit reports to HHSC. The ADMN stated the reason he had not completed those four intakes was because he had waited on documents from agencies to give him the completed documents needed for those intakes. He stated he himself as ADMN monitored the reports in making sure they were being completed for a timely submission. He stated the negative impact on residents would be different for each, as it depended on the allegation. He stated his expectations for self-reporting would have been to submit to HHSC with-in 5 business days as per facility policy and procedures. During an interview on 03/22/2024 at 8:57 AM, the DON stated the ADMN as well as herself investigated the previous facility self-reports together and depended on what the allegations were. She stated the self-reports should have been completed in a timely manner as it helps in preventing any further allegations with protecting the residents as well. She stated with investigating in a timely manner, it aided in correcting the problems that arise. The DON stated after the allegations were investigated, they should be followed up with in-services and trainings. She stated the facility self-reports were put into place to protect residents further from whatever the allegations may have been. She stated she believed the facility investigations should have been completed and turned into HHSC with 5 business days with all of the evidence for investigation gathered as well as the conclusion of the outcome. Record Review of facility policy Form 3613-A, SNF updated date of 03/23/2023 revealed: Purpose: The purpose to this form is to furnish a standardized format for long-term care (LTC) providers to document their self-reported incident investigation summary, analysis and finding(s) in accordance with regulatory requirements. Procedure: After making an oral via 800#, submit Form 3613-A, Provider Investigation Report, with statements and other relevant documentation, within the applicable regulatory time frame: Five working days for NF's Investigation Report Fax Cover Sheet should include: HHSC Intake ID No, Provider Type, Incident Category, Incident Date, Time and Location, Individual(s) or Resident(s) Involved in the Incident, Alleged Perpetrator(s), Witness(es), Description of the Allegation, Investigation Summary, Investigation Findings, Provider Action Post-Investigation and Signature Section. Record Review of facility Inservice Training Attendance Roster dated 03/19/2024 revealed: One-on-One Inservice Training topic: 3913-A Instructor: Facility RCO Employee attendance: ADMN Follow-Up Activities: Will CC Regional RCO on all reports. Record review of facility policy Abuse/Neglect dated 2003 with a revision date of 10/04/2022 revealed: The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility E. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC . .4. A report to the appropriate agency will include the following: e. the nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of resident or misappropriation of resident property. f. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form 8. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property by the companies employees as set forth in state law (including to the state survey and certification agency). 48883

48883 Based on interviews and record reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 3 (Resident #24, Resident #41, and Resident #49) of 4 residents reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #24, Resident #41 and Resident #49's medication regimen review which had pharmacy recommendations. The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Resident #24 Record review of Resident #24's face sheet dated 03/20/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 12/17/2018 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), repeated falls, and anxiety. Record review of Resident #24's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 00 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #24's physician orders reviewed on 03/23/2024 revealed Ativan Tablet 0.5mg (lorazepam) give 1 tablet by mouth every 8 hours as needed for anxiety start date 12/14/2022 with no end date. Record review of Resident #24's medication administration record January 2024 - March 2024 revealed: -Ativan Tablet 0.5mg given on 1/1/2024 at 6:50 p.m., -Ativan Tablet 0.5mg given on 3/5/2024 at 10:00 p.m., and -Ativan Tablet 0.5mg given on 3/10/2023 at 12:03 p.m. Record review of Resident #24's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #24's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendation dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Resident #41 Record review of Resident #41's face sheet dated 03/20/2024 revealed an [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 02/28/2023 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), major depressive disorder, anxiety disorder, insomnia, and type 2 diabetes mellitus. Record review of Resident #41's annual MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 3 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder; Section N- Medications Antipsychotics were received on a routine basis and physician documented GDR as clinically contraindicated. Record review of Resident #41's physician orders reviewed on 03/20/2024 revealed: Quetiapine fumarate 25mg tablet (Seroquel) give 1 tablet by mouth at bedtime related to insomnia start date 2/28/2023 with no end date. Trazodone tablet 100mg give 1 tablet by mouth at bedtime for depression start date 02/28/2023 with no end date. Lorazepam tablet 0.5mg (lorazepam) give 1 tablet by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Lorazepam tablet 0.5mg give 2 tablets by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Record review of Resident #41's medication administration record January 2024 - March 2024 revealed: Resident #41 received quetiapine fumarate 25mg 1 tablet every night at 9:00 p.m. and trazodone 100mg tablet every night at 9:00 p.m. Resident #41 received lorazepam 0.5mg 1 tablet on 2/29/2024 at 10:00 a.m. Record review of Resident #41's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 5/15/2023. Physician signature with rational Patient is on hospice documented but no indication of duration observed. Record review of Resident #41's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #41's pharmacy recommendations dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #41's pharmacy recommendations dated 02/23/2024 revealed that pharmacist recommended: Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Trazodone 100mg qhs since 223 consider 50mg qhs. Seroquel 25mg qhs since 223 consider d/c? If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Resident #49 Record review of Resident #49's face sheet dated 03/20/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 09/25/2023 and the following diagnoses: morbid obesity, vascular dementia (dementia caused by blood flow issues), adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood, altered mental status, and weakness. Record review of Resident #49's quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 6 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #49's physician orders reviewed on 03/20/2024 revealed: Lorazepam Tablet 1mg give 1 tablet by mouth every 8 hours as needed for anxiety start date 10/24/2023 with no end date. Record review of Resident #49's medication administration record January 2024 - March 2024 revealed: Lorazepam Tablet 1mg given on 1/1/2024 at 2:45 a.m. Lorazepam Tablet 1mg given on 1/4/2024 at 2:00 a.m. and 4:21 p.m. Lorazepam Tablet 1mg given on 1/5/2024 at 7:26 p.m. Lorazepam Tablet 1mg given on 1/6/2024 at 11:52 a.m. Lorazepam Tablet 1mg given on 1/7/2024 at 6:41 p.m. Lorazepam Tablet 1mg given on 1/8/2024 at 3:00 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 1/10/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 1/11/2024 at 11:23 p.m. Lorazepam Tablet 1mg given on 1/12/2024 at 8:57 a.m. Lorazepam Tablet 1mg given on 1/13/2024 at 9:07 a.m. Lorazepam Tablet 1mg given on 1/16/2024 at 12:00 a.m. Lorazepam Tablet 1mg given on 1/18/2024 at 12:45 a.m. and 10:45 p.m. Lorazepam Tablet 1mg given on 1/20/2024 at 6:31 a.m. Lorazepam Tablet 1mg given on 1/21/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 1/24/2024 at 9:32 a.m. Lorazepam Tablet 1mg given on 1/25/2024 at 7:49 a.m. Lorazepam Tablet 1mg given on 1/28/2024 at 4:00 a.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 1/29/2024 at 9:41 a.m. Lorazepam Tablet 1mg given on 1/30/2024 at 10:30 a.m. Lorazepam Tablet 1mg given on 2/1/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 2/2/2024 at 10:30 p.m. Lorazepam Tablet 1mg given on 2/3/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/5/2024 at 8:01 a.m. and 9:21 p.m. Lorazepam Tablet 1mg given on 2/6/2024 at 7:01 a.m. Lorazepam Tablet 1mg given on 2/9/2024 at 8:56 a.m. Lorazepam Tablet 1mg given on2/11/2024 at 11:00 a.m. Lorazepam Tablet 1mg given on 2/12/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/13/2024 at 9:21 a.m. Lorazepam Tablet 1mg given on 2/15/2024 at 7:10 a.m. Lorazepam Tablet 1mg given on 2/16/2024 at 4:21 p.m. Lorazepam Tablet 1mg given on 2/18/2024 at 4:32 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 2/19/2024 at 8:09 a.m. Lorazepam Tablet 1mg given on 2/21/2024 at 8:07 a.m. and 4:16 p.m. Lorazepam Tablet 1mg given on 2/22/2024 at 4:54 p.m. Lorazepam Tablet 1mg given on 2/24/2024 at 4:48 a.m. Lorazepam Tablet 1mg given on 2/25/2024 at 1:00 a.m. and 6:15 p.m. Lorazepam Tablet 1mg given on 2/26/2024 at 12:34 p.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 2/28/2024 at 1:37 a.m. and 7:08 p.m. Lorazepam Tablet 1mg given on 3/1/2024 at 4:11 p.m. Lorazepam Tablet 1mg given on 3/2/2024 at 8:42 a.m. and 11:20 p.m. Lorazepam Tablet 1mg given on3/3/2024 at 10:45 p.m. Lorazepam Tablet 1mg given on 3/4/2024 at 11:45 p.m. Lorazepam Tablet 1mg given on 3/8/2024 at 12:30 a.m. Lorazepam Tablet 1mg given on 3/9/2024 at 10:10 a.m. Lorazepam Tablet 1mg given on 3/10/2024 at 10:10 a.m. and 11:30 p.m. Lorazepam Tablet 1mg given on 3/12/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 3/16/2024 at 12:15 a.m. Lorazepam Tablet 1mg given on 3/17/2024 at 1:30 a.m. Lorazepam Tablet 1mg given on 3/19/2024 at 1:30 a.m. Record review of Resident #49's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Lorazepam since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #49's pharmacy recommendations dated 01/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 1mg PRN since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. During an interview on 03/19/2023 at 3:32 p.m., the DON stated she was responsible for ensuring pharmacy recommendations were completed. The DON stated when she received pharmacy recommendations, she faxed them to the physician's office and wrote pending down on recommendation form. The DON stated she did not follow up after she had faxed the recommendation to the physician. She did not state a negative outcome. She stated that she was unsure if facility policy had any timeframes on when she was expected to follow up with physician. Record review of facility policy titled Consultant Pharmacist Drug Regimen Review with no date reviewed on 03/19/2024 revealed: The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director of Nursing, the responsible physician, and the Medical Director, where appropriate .The Consultant Pharmacist provides the report to the responsible physician and the Director of Nursing within seven working days of review. The physician provides a written response to the report to the facility within (one month) after the report is sent. A copy of the report is kept by the facility until the physician's signed responses is returned. The physician response is provided to the Consultant Pharmacist for review and then filed by the facility. The facility maintains copies of signed reports on file for (at least one year).

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 3 of 3 residents (Residents #1, #2, and #6) reviewed for respiratory care. The facility failed to ensure that Residents #1, #2 and #6 oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen at risk of respiratory complications and/or possible respiratory infections. Findings included: Resident #1 Record Review of the resident #1's Face Sheet dated 03/23/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 02/18/2023. Resident #3 had a Diagnoses of COPD (Chronic obstructive pulmonary disease, a group of diseases that cause airflow blockage and breathing-related problem). Resident #1's MDS, dated [DATE], Section C revealed a BIMS score of 09 (moderately impaired). Section O revealed Resident #1 was on Oxygen therapy while a Resident, 7 number of days this therapy was administered for at least 15 minutes a day in the last 7 days. Resident #1's Care Plan dated 02/08/2024 revealed: Focus-Congestive Heart Failure, Goal-Will have clear lung sounds .within normal limits. Will verbalize less difficulty breathing (Dyspnea) and be more comfortable. Interventions- Oxygen therapy 2-4 L/min titrate to keep sats > 90 %as ordered. Resident #1's physician orders dated 03/13/2024 revealed: Oxygen @ 5L/min via NC q shift every shift and Change Oxygen and Nebulizer tubing and clean concentrator filter every 2 weeks on Sundays every night shift every 2 weeks on Sunday. During observations on 03/18/2024 at 10:42 AM, Resident #1 had Oxygen on via nasal cannula with undated oxygen tubing. During interview on 03/18/2023 at 10:42 AM, Resident #1 was unable to answer due to cognitive impairment when the tubing had been changed. Resident # 2 Record Review of the Resident #2's Face Sheet dated 03/19/2024, revealed she was a [AGE] year-old female, admitted to the facility on [DATE], with an initial admit on 09/17/2019. Resident #2 had a diagnosis of Acute Pulmonary Edema (the heart is not able to pump efficiently, blood can back up into the veins) and Respiratory Failure. Review of Resident #2's MDS, dated [DATE], Section C revealed a BIMS score of 08 (moderately impaired). Resident #2 was on Oxygen therapy while a Resident. During interview on 03/18/2023 at 10:42 AM, Resident #2 was unable to answer due to cognitive impairment when the tubing had been changed. Review of Resident #2's Care Plan dated 03/07/2024 revealed: Focus- Oxygen Therapy r/t respiratory illness with date Initiated: 11/20/2022. Goal-will have no s/sx of poor oxygen absorption. Interventions- . provide extension tubing or portable oxygen apparatus. Monitor for s/sx of respiratory distress. Resident #2 has, O2 via nasal prongs @ 2-5L/min to keep sats >90%. Review of Resident #2's physician orders dated 03/13/2024 revealed: Monitor oxygen saturation every shift. Apply PRN O2 AT 2-5L/MIN VIA N/C as per PRN order. During an observation on 03/18/2024 at 10:35 AM, Resident #2 had oxygen on via nasal cannula with undated oxygen tubing. Resident #6 Record Review of the resident #6's Face Sheet dated 03/19/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 06/18/2023. Resident #3 had a diagnosis of shortness of breath, and heart failure, and chest pain. Resident #6's MDS, dated [DATE], Section C revealed a BIMS score of 15 (cognitively intact). Resident #6's Care Plan dated 03/07/2024 revealed: Focus-altered cardiovascular status r/t HTN, heart failure. Goal- will be free from s/sx of complications of cardiac problems through the review date 05/15/2024. Interventions-Give oxygen as ordered by the physician. Focus- altered respiratory status r/t allergies, congestion, shortness of breath. Goal- Resident #6 will have no s/sx of poor oxygen absorption. Intervention- Monitor for s/sx of respiratory distress and Monitor/document/report abnormal breathing patterns. Resident #6's physician orders dated 03/07/2024 revealed: May use oxygen @2-3 l/m via nasal canula PRN to keep O2 sats > 90 % every 8 hours as needed. During observation on 03/19/2024 at 3:45 PM, Resident #6 had Oxygen on via nasal cannula with undated oxygen tubing. During an interview on 03/19/2024 at 11:21 AM, LVNG stated the Oxygen tubing had to be dated when changed out. She stated the nurses should change them out on the night shift on Sundays but would have depended on the physician order. LVNG stated if the tubing was not changed out it could cause the resident harm with a possible respiratory infection. She stated she did not know who monitored if the tubing was dated. She stated if the tubing was not dated, the nurse taking care of that resident would not have known exactly when it was changed. During an interview on 03/22/2024 at 8:36 AM, LVNM stated the facility policy for dating the oxygen tubing was that it should have been changed out at least every 7 days, but ultimately depended on the physician's order. She stated monitoring should had been the charge nurse for that resident in making sure all oxygen tubing was dated when changed. LVNM stated this could harm the residents that used oxygen causing them to have respiratory infections. She stated the failure occurred with the charge nurses, with her expectations being to date all oxygen tubing when changed out. During an interview on 03/22/2024 at 8:49 AM, the DON stated the oxygen tubing should have been changed out on the night shift every Sunday and dated when done so. She stated it should be dated as to know when it needed to be changed out. She stated it was the charge nurses who monitored the oxygen tubing, but ultimately it was her as the DON who should monitor. She stated the negative impact to residents could have been the growing of bacteria in the oxygen lines. She stated the failure occurred with the nurses, with her expectations were that staff follow the order of the physicians. Record review of facility policy Oxygen Administration dated 2003 with Revision date of 02/13/2007 revealed: Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 3. The resident will be free from infection. Procedure: . 11. Change device and tubing when needed. Oxygenation administration equipment will be changed weekly and PRN.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care for 2 (Resident #110 and Resident #258) of 6 residents reviewed for baseline care plans. The facility failed to complete Resident #110 and Resident #258's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Resident #110 Record review of Resident #110's face sheet dated 03/23/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 03/02/2024, with the following diagnoses: Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), iron deficiency anemia (insufficient iron), dementia, insomnia (inability to sleep), hypertension (high blood pressure), constipation, and difficulty in walking. Record review of Resident #110's entry MDS dated [DATE] revealed resident was admitted on [DATE] with no evidence of BIMS score. Record review of Resident #110's baseline care plan dated 03/18/2024 revealed care plan was completed on 03/18/2024 more than 48 hours after admission, he could not communicate easily with staff, he was able to understand staff, he wore glasses, he had DNR (do not resuscitate) code status, he had allergies to the following medications: iodine and povidone iodine, and his goals were to remain in facility. Resident #258 Record review of Resident # 258's face sheet dated 03/23/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 03/08/2024 and the following diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Parkinsonism (slow movement, rigidity and problems with walking), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). Record review of Resident #258's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 9 meaning moderate cognitive impairment. Record review of Resident #258's baseline care plan dated 03/19/2024 revealed care plan was completed on 03/19/2024 more than 48 hours after admission, he could communicate easily with staff, he was able to understand staff, he wore glasses and hearing aids, he was a full code meaning wanted resuscitation, he had allergies to the following medications: codeine, Lexapro, and Vasotec, and his goal was to return to community. During an interview on 03/23/2024 at 3:07 p.m., the DON stated she was responsible for completing baseline care plans. She stated baseline care plans needed to be completed within the first 24 hours after admission. She stated the failure occurred because of multiple nurses quitting that caused her to work as a direct care staff that lead to her being behind on her duties. The DON stated the effect of not completing baseline care plans timely could cause resident needs not being readily available to nursing staff. Record review of facility policy titled; Care Plans revised on 10/04/2022 revealed: The facility will develop a Base Line Care Plan within 48 hours of each resident's admission that includes but not limited to a short-term and long-term objective and timetables to meet resident's medical, nursing, and mental and psycho-social needs that are identified on admission care plan will be reviewed and approved by an R.N.

Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent pressure ulcers and did not develop avoidable pressure ulcers, and residents with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for five (Residents #4, #48, #50, #52, and #108) of 10 reviewed for pressure ulcers. A. Resident #108 was admitted to the facility on [DATE] with redness to his coccyx. The facility failed to conduct a thorough skin assessment or a Braden Scale for Resident #108 upon admission. The facility failed to identify and treat a pressure ulcer to his coccyx. On 01/18/2018, he was admitted to a local hospital with an unstageable pressure ulcer to his coccyx and a stage 1 to his left heel. On 1/23/18 he was readmitted to the facility under hospice care. B. The facility failed to prevent the development of a pressure ulcer from a knee immobilizer. Resident #52 returned to the facility on [DATE] with orders to wear a knee immobilizer. The facility did not perform a skin assessment upon his return to the facility. On 1/10/18 a blister to the back of the left ankle was identified. On 1/22/18 the immobilizer pressed against the wound to the left ankle, which was open with red, inflamed edges with patches of black eschar. C. The facility failed to prevent the development of an unstageable pressure ulcer to Resident #50's scapula. They did not provide a pressure reducing surface (overlay) for the geri chair. D. Resident #48 was admitted with DTIs to both heels. The facility failed to prevent the development of pressure ulcers to each buttocks. E. The facility failed to identify and treat an unstageable pressure sore between Resident #4's toes and prevent the development of a stage 2 pressure sore to her left inner perianal area. This failure resulted in an Immediate Jeopardy (IJ) identified on 1/25/18. The IJ was lowered on 1/26/18 to a severity level of actual harm that was not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could affect the 7 residents with pressure sores, placing them at risk for worsening pressure ulcers, new pressure ulcers, infections, potential life-threatening complications, and even death. Findings include: Resident #108 Record Review of Resident #108's Admission record dated 01/26/18 revealed he was an [AGE] year old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #108's Admission MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 9 indicating he had moderate cognitive impairment. MDS revealed he required extensive assistance of two persons for bed mobility. MDS revealed he was at risk for developing pressure ulcers but did not have one or more unhealed pressure ulcers at Stage 1 or higher. Review of Resident #108's care plan dated 01/11/18 revealed he has diabetes mellitus. Interventions include to check all of body for breaks in skin and treat promptly as ordered by doctor. He also had a care plan for potential/actual alteration in skin integrity related to fragile skin with an initiation date of 01/25/18 upon return from Hospital A. Goal included there would be no complications related to sheering of the buttocks and skin injury sheering of the buttocks and he would be free from injury to skin on the buttocks. Interventions included: follow facility protocols for treatment of [REDACTED]. Record Review of Resident #108's Admit/Readmit evaluation dated 01/10/18 revealed he had redness/shearing to coccyx and bruising to left antecubital along with scattered bruising to upper extremities from IV's. Observation on 01/15/18 at 2:19 P.M. and 4:41 P.M., revealed Resident #108 was lying in bed on his back. Resident had a scoop mattress on his bed. In an interview on 01/17/18 at 3:05 p.m., CNA C said Resident #108 currently had an open area to his coccyx Record Review of Resident #108's Progress notes dated 01/10/18 to 01/18/18 did not reveal any skin issues related to coccyx. Record Review of facility Progress Notes dated 01/18/18 at 8:40 a.m. revealed resident #108 had been yelling frequently since beginning of shift. Resident had eyes closed and not answering questions asked by the nurse. Resident was noted to be red to face and very warm to touch. Vital Signs at 7:25 a.m. 93% rate, Temperature 103.5, Pulse 147, Respirations 22, blood pressure 152/87, Fasting blood glucose 334. Foley Catheter patent and draining little amount of yellow cloudy urine to bedside drainage. Resident hollered out when touched. APAP suppository administered for increase temperature and pain at 7:45 a.m., LVN L spoke with son and nurse at Hospital A. DON notified of residents condition. Dispatch was notified of need to transport to Hospital A emergency room . Family and Hospital A emergency room notified. Hospital A EMT (Emergency Medical Technician) arrived at 8:30 a.m. Resident #108 was placed on monitor and vital signs continue to increase. Resident hollered out during transferring to gurney. Resident and techs left at 8:35 a.m. Signed LVN L Record Review of facility Progress notes dated 01/18/18 at 1:40 p.m., revealed Hospital A called and reported resident #108 would be admitted for urinary tract infection at that time. Signed LVN L Record Review of Hospital A's Care Activity assessment dated [DATE] at 5:31 p.m. revealed Resident #108 had an unstageable decubitus to his coccyx and a stage 1 to his left heel. Skin was noted to be dry and heel protectors were in place. Record Review of Hospital A's Care Activity assessment dated [DATE] at 10:30 p.m. revealed Resident #108 had an unstageable decubitus to coccyx. Record Review of Hospital A's Care Activity assessment dated [DATE] at 6:21 a.m., revealed he had an unstageable decubitus to his coccyx and a stage 1 decubitus to his left heel. Resident #108 had heel protectors in place. Record Review of Hospital A's Care Activity assessment dated [DATE] at 11:57 a.m. revealed Resident #108 had an unstageable decubitus to coccyx. Record Review of Hospital A's Care Activity assessment dated [DATE] at 7:00 p.m. revealed Resident #108 had an unstageable decubitus to coccyx and a stage 1 decubitus to left heel. Heel protectors were in place. In an interview on 01/26/18 at 1:50 p.m., RN A (Hospital A nurse) said Resident #108 was admitted on [DATE] to Hospital A. She said upon her admission assessment she found an unstageable decubitus to Resident #108's coccyx. She said the area on his coccyx had thin skin, dark purple underneath but without drainage. She said she was assigned to the resident on 01/23/18 when he was discharged back to the nursing facility. She said he had two open areas to his coccyx and it appeared necrotic. Review of Discharge Summary with admission back to the facility from Hospital A with readmission date of [DATE] and discharge date of [DATE] revealed Resident #108's discharge [DIAGNOSES REDACTED].The patient, in the emergency room , had a blood culture obtained as well as a wound culture. The patient upon examination was noted to have an abscess in the right antecubitual fossa that grew [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus aureus). The patient's blood culture also grew [MEDICAL CONDITION]. Review of Resident #108's Medication Discharge Summary report dated 01/25/18 from Hospital A revealed an order on 01/18/18 to apply Happy Hiney ointment topically twice a day to his coccyx. Review of Discharge Packet Summary from Hospital A dated 01/23/18 revealed to discharge resident to nursing facility with a Hospice Referral. Record Review of Resident #108's weekly skin assessment dated [DATE] (upon readmission from the hospital) revealed he had a .6cm x .6 cm dark scab to right antecubital; Coccyx 10.5cm x 5 cm dark purple with .5cm x .5 cm and a .7 x .5cm small open areas in the center, no drainage, barrier cream applied and foam. Back of left hand had a 10cm x 11cm purple bruising, monitor, left heel had 2cm [MEDICAL CONDITION] cm light purple area no open areas noted, skin prep applied. Resident had open area to scrotum measuring 1.5 cm x 1.6 cm, barrier cream applied. Resident readmitted from hospital with all these areas .Signed LVN G In an interview on 01/25/18 at 6:30 p.m., DON said LVN H was employed as the treatment nurse, failed to conduct a skin assessment or Braden scale for resident #108 upon initial admission on 01/10/18. DON said LVN H was no longer employed at this facility. Record Review of Resident #108's Braden Scale for Predicting Pressure Score Risk dated 01/26/18 revealed score of 8 indicating resident was at very high risk for skin breakdown. Signed by LVN G In an interview on 01/25/18 at 6:55 p.m., ADON said Resident #108 had a scoop mattress on his bed prior to his hospitalization on [DATE]. Upon his return (01/23/18) to the nursing facility he received a pressure relieving air mattress. In an interview on 01/26/18 at 2:55 p.m., LVN G said Resident #108 had excellent skin. She said he had two raised areas with scab on bilateral antecubital areas with bruising to left lower arm with swelling. She said he had no open areas to his bottom before his hospitalization on [DATE] (Note - On 01/17/18 CNA C had stated Resident #108 had an open area to his coccyx) In an interview and record review on 01/25/18 at 4:30 p.m., LVN G said Resident #108 had no skin issues prior to his admission to Hospital A on 01/18/18 but returned to the facility on [DATE] with redness to left heel and open areas to coccyx with skin discolored (dark purple/black) and peeling. Observation on 01/25/18 at 6:55 p.m. revealed Resident #108 to be lying on back in bed. There was a pressure relieving air mattress to the resident's bed that was provided by Hospice. Resident had large black discolored area (approximate size of a salad plate) to his entire bottom (buttock and coccyx) with multiple red open crater areas covered with black eschar. Skin was peeling off the area. There were multiple areas where skin had peeled away, leaving depressions with more black/brown underlying tissue. Resident #108 had a red area to left heel and heel protectors were on bilaterally. In an interview on 01/25/18 at 6:58 p.m., LVN G said barrier cream was the only treatment being used for open areas to Resident #108's buttock and coccyx area due to the open areas and the skin peeling off. Surveyor requested Resident #108's Nursing Progress notes dated 01/23/18 (upon return from Hospital A) to 01/26/18 but did not receive them. Resident #52 Record review of Resident #52's face sheet dated 6/2017 revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #52's Quarterly MDS (Minimum Data Set) dated 7/1/17 revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating he was cognitively intact. MDS revealed he was at risk for developing pressure ulcers but did not have one or more unhealed pressure ulcers at Stage 1 or higher. MDS revealed he did have one stage 2 healed pressure ulcer present on the prior assessment that had completely closed. Record review of the National Pressure Ulcer Advisory Panel website (www.npuap.org accessed 2/5/18) revealed stage 2 pressure ulcers are now called stage 2 pressure injuries. Stage 2 pressure ulcers/injuries are defined as: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . Record review of resident #52's care plan revised on 9/14/17 revealed he was a two person assist for bathing, toileting and transferring using a hoyer lift and turning in bed. Resident # 52 was to have a pressure relieving device in his wheelchair seat every shift, barrier cream to skin after incontinent episodes, weekly skin assessments, mobility monitoring, check resident every 2 hours, alternating air pressure mattress, report to physician skin status: appearance, color and impairment. Record review of Resident 52's care plan partially revised on 10/30/15, 11/10/16, 3/20/17 and 7/11/17 revealed: Focus: 'Resident 52 has potential for pressure ulcer development related to a history of ulcers and incontinence. Resident 52 has a history of stage 2 pressure ulcer to his coccyx related to incontinence, immobility, refused to lay down all night long to allow staff to provide incontinent care.' Goal: 1. Resident #52 will remain free of stage 2 to coccyx. Revised on 7/11/17. 2. The resident will be free of preventable breakdown through the next review date on 12/30/17. Interventions: 1. Alternating pressure relief mattress for pressure relief. Date initiated 11/10/16 7. Monitor and report to MD as needed for changes in skin status, appearance, color or impaired skin. Revised 10/30/15. 8. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Revised 10/30/15. Record review of Resident #52's Braden scale revealed: 9/29/17 a score of 17 and indicated he was at low risk for developing pressure ulcers. Signed LVN H 12/27/17 revealed a Braden Scale score of 16 and indicated he was at low risk for developing pressure ulcers. Signed LVN H Record review of Resident # 52's discharge orders from Hospital A dated 12/27/17 at 2:45pm revealed: 1. Follow up with your primary care provider or orthopedist next week. 2. Get prescription filled and take as directed. 3. Return to the Emergency Department for any acute changes. 4. Wear knee immobilizer as directed. Record Review of Resident #52's skin assessments revealed a skin assessment was not completed after return from the hospital until 1/3/18. Record Review of Resident #52's weekly skin assessments revealed the following: 12/20/17 - no skin issues as documented by LVN H 12/27/17- skin assessment not completed due to resident being out of the building. 1/3/18 -revealed no documentation of pressure ulcers as documented by LVN H. 1/10/18- skin assessment a '5.0 x 2.0' (no unit of measurement documented) blister to the back of the left ankle, no drainage noted, no sting applied and covered with a bandage as documented by LVN H. 1/17/18 - skin assessment revealed a [MEDICAL CONDITION]' (no unit of measurement documented) tear at the top of the crack (no further description given) no drainage noted, area cleansed with normal saline, applied hydrogel and collagen; right buttock with '[MEDICAL CONDITION]' open area to top of right buttock on scar tissue, cleansed with normal saline, applied hydrogel and collagen; left ankle with '5.5x3.5' open area to back of ankle with scant amount of bloody drainage, cleansed with normal saline, applied xeroform and a foam dressing as documented by LVN G. Observation on 1/17/18 at 9:30 a.m. revealed Resident #52's right leg had been previously amputated below the knee. The blister on Resident #52's posterior left lower leg had the skin on top of the blister skin was rolled up and the wound was open. This observation was directly after Resident #52 completed his shower. LVN G measured the blister to the left lower leg at 5.0x2.0, applied 'no sting' and a windowpane bandage to blister. Observation on 01/17/18 at 11:26 a.m. revealed Resident #52 lying in bed on his back with left leg immobilizer on. Left leg was elevated on one pillow with heel touching bed. LVN G removed left leg immobilizer and revealed resident to have indentions to left knee from left leg immobilizer being on. Wound to left posterior leg discolored with open area noted. No dressing on left posterior leg wound. Immobilizer touching open wound. Left heel discolored brown in color. Resident had an abrasion to top of left foot with redness noted but no drainage. Resident has a regular mattress on his bed. No specialty air mattress or pressure relieving mattress on bed. In an interview on 1/17/18 at 3:00 p.m., DON said, I know the wound care (LVN G) nurse was not certified and the plan was to get her into the next wound care certification class. In a phone interview on 1/17/18 at 4:30 p.m., Physician A reported he trusted the wound care nurse to apply her knowledge to each situation but said he should have been notified in a timely manner about any skin changes for resident #52. Record review of Resident #52's medication review report with a date range of 12/20/17 through 1/18/18 revealed these medications were used during wound care: 1/17/18 no sting wipes were ordered to be applied to the blister behind left ankle and cover with a bandage one time every day until resolved. 1/18/18- new ankle wound orders were for the wound to be cleansed with normal saline, apply xeroform gauze on the wound and cover with a bordered foam dressing change daily and as needed. Observation on 01/22/18 at 1:52 p.m. revealed resident #52 was lying on his back in bed on a regular mattress. Resident had left leg elevated on one pillow, no heel protector on, heel was resting on mattress. LVN G was to do a dressing change on the posterior left leg wound. Removing the leg immobilizer revealed there was no dressing on the wound for LVN G to remove. LVN G found a washcloth pushed between the immobilizer and the wound on the left leg. Upon evaluation of the posterior left leg wound, the wound was open, the edges of the wound were red and inflamed and patches of black eschar were present. There were two open areas to the buttocks that were dry and only one pink open area was visible. Observation on 01/25/18 at 4:11 p.m. revealed resident #52 lying in bed on his back on a regular mattress. Left leg elevated on one pillow with left leg immobilizer on. Resident had a dressing in place over the posterior left leg wound. A white washcloth was stuffed between the leg immobilizer and the wound dressing to the posterior left leg. Interview and observation on 01/25/18 at 5:13 p.m. revealed resident #52 lying in bed on his back on a regular mattress. LVN G removed bandage and said wound to posterior lower left leg was much worse today, the wound was more red around the edges and black with yellow and green near the center. LVN G said physician A had 'seen the wound yesterday and said if the wound worsened, he would possibly send him to wound care'. When she was asked if she had notified physician A about the wound changes, she said no. Resident #52's left posterior leg had increased redness and discoloration. The wound bed was yellow/green and black in color and was approximately the size of a dollar bill. Edges of the left lower leg wound had redness to edges of wound spreading away from the wound. Resident was asked by LVN G if he had pain in the left leg and he responded yes. In an interview on 01/25/18 at 4:30 p.m., LVN G said resident #52 was not considered a pressure ulcer, it was considered friction injury due to the left leg immobilizer. During Interviews on 1/16/17 at 11:10am, CNA A said, CNAs do not remove the resident's leg immobilizer. CNA L said, I remove it when he comes to the shower room and replace it after his shower. LVN G said, I unstrap the immobilizer when I do his dressing change to the left ankle and then reapply the immobilizer. Record review of physicians orders dated 1/26/18 of the follow up visit with Physician A revealed new orders for non-weight bearing for 1 month on left leg, collagen and hydrophil to wound, leave left leg brace off except during transfers. Resident #50 Review of Resident #50's clinical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; peripheral autonomic [MEDICAL CONDITION], protein calorie malnutrition, muscle weakness, major [MEDICAL CONDITIONS] with hallucinations, generalized anxiety disorder. Review of Resident #50's Annual MDS assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) was not done due to resident was rarely or never understood. MDS revealed she required extensive assistance of two staff to physically assist with bed mobility. MDS also revealed Resident #50 was at risk for developing pressure ulcers but did not have any unhealed pressure ulcers at that time and did not have any healed pressure ulcers present on the prior assessment. Review of Resident #50's quarterly MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) could not be conducted due to resident was rarely or never understood. MDS revealed she required extensive assistance of two staff to physically assist with bed mobility. MDS also revealed Resident #50 was at risk for developing pressure ulcers but currently had one stage 2 pressure ulcer with date of oldest Stage 2 pressure ulcer of 09/21/17 and one stage 3 pressure ulcer that was not present upon admission/entry or reentry. MDS revealed she had had no healed pressure ulcers. Review of Resident #50's quarterly MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) could not be conducted due to resident was rarely or never understood. MDS revealed resident required extensive assistance of two staff to physically assist with bed mobility. MDS revealed resident was at risk of developing pressure ulcers and did have one unhealed pressure ulcer at Stage 1 or higher. MDS revealed she had one Stage 3 pressure ulcer present that was not present upon admission/entry or reentry. Resident had a pressure relieving device to her chair and bed. She was not on a turning or positioning program. According to www.npuap.org (accessed 2/6/18) a Stage 3 pressure ulcer is Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Review of Resident #50's Care plan revised on 01/04/18 revealed She had an unstageable pressure ulcer on left upper back related to Braden score less than 19, friction, history of ulcers, immobility, incontinence and nutritional deficit. Interventions include: Assess for wound healing weekly and as needed, avoid positioning on pressure ulcer, monitor and report to MD as needed changes in changes in skin status, appearance, color, wound healing, signs/symptoms of infection, pressure relieving/reducing devices on bed/chair, reposition at least every 2 hours, more often as needed or requested Review of Resident #50's Braden scales revealed: 09/22/17 revealed a score of 13 indicating resident was at moderate risk for skin breakdown. Signed LVN H 11/24/17 revealed a score of 14 indicating a moderate risk for skin breakdown. Signed LVN H Review of Resident #50's skin assessments revealed: 09/21/17 revealed on 09/18/17 nurse was notified of abrasion on left upper back. 1.2cm x 1.1 cm in size. Collagen and foam dressing applied and nurse would continue to monitor. Signed LVN H 09/28/17 revealed abrasion to left upper back changed to Stage 2 pressure ulcer to be 0.9cm x 1.0 cm open area, slough present. Redness and irritation noted around pressure ulcer. Dressing carried out as ordered. Will continue to monitor. Signed LVN H 12/07/17 revealed a stage 3 pressure ulcer that measures 2.0 x 1.5 cm. Signed LVN H 12/28/17 revealed an unstageable ulcer to left scapula measuring 2.2 cm x 2.0 cm. Signed LVN H Review of Resident #50's most recent physician's orders [REDACTED]. On 10/04/17 an order for [REDACTED]. Record Review of Resident #50's Medication Review Report printed on 01/16/18 revealed: an order on 11/30/17 to cleanse stage 3 pressure ulcer to left upper back with [MEDICATION NAME] wound cleanser, apply silver-sept, cover with silver calcium alginate and foam dressing every day until resolved once a day. This order was discontinued on 12/01/17. On 12/13/17 an order was written to cleanse stage 3 to left upper back with normal saline, apply santyl ointment to slough tissue only, apply calcium alginate and cover with foam dressing every day until resolved one time a day. This order was discontinued on 12/18/17. On 12/19/17, an order to cleanse Stage 3 pressure ulcer to left upper back with [MEDICATION NAME] wound cleanser, apply silver-sept, cover with silver calcium alginate and foam dressing every day until resolved one time a day every Sunday and Saturday. On 12/22/17, an order to cleanse stage 3 to left upper back with Normal saline, apply santyl ointment to slough tissue only, apply calcium alginate and cover with foam dressing every day until resolved one time a day every Monday, Tuesday, Wednesday, Thursday and Friday. In an interview on 01/18/18 at 9:50 a.m., Guardian A said Guardianship Case manager visited Resident #50 on 12/07/17 and the Case manager's notes revealed no issues with skin breakdown (despite the facility identifying a stage 3 on that same day). She said the expectation was for nursing home staff to contact them with any changes in condition and/or for consent for medications and treatment. Observation on 01/22/18 at 2:16 p.m. revealed resident to have open area approximately 1.75cm x 2cm to left scapula. Red/purple discoloration noted to edges of wound. Center of wound had a yellowish/green covering visible. Observation on 01/23/18 at 1:00 p.m. revealed Resident #50 sitting in geri- chair positioned on her back without overlay in geri-chair. Observation and Interview on 01/23/18 at 1:20 p.m., ADON said the resident #50 was to have an overlay in the geri-chair when she was up in the chair. No overlay was observed on geri- chair. ADON obtained an overlay from Laundry department and placed it on resident's geri- chair. Observation on 01/25/18 at 6:35 p.m. revealed Resident #50 lying in bed positioned on right side. Bandage removed from wound to left scapula. Wound open, red with yellowish green noted to center of wound. Yellowish drainage noted to dressing. LVN G measured wound at 2.6cm x 1.4 cm. There was a pressure relieving air mattress noted to Resident #50's bed. In an interview on 01/23/18 at 1:00 p.m., Guardianship Case manager said the facility had not notified her of the wound to left scapula. In an interview on 01/23/18 at 1:15 p.m., Physician C at the facility to see resident #50. He examined the wound to her left scapula and ordered she be referred to Hospital C for wound care evaluation and treatment. He said the nurses know to call him if the wound worsened. Observation on 01/25/18 at 3:48 p.m. revealed resident #50 lying on her back in bed. Resident #48 Review of resident #48's admission record revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; pain in right hip, muscle wasting and atrophy, [MEDICAL CONDITION], anxiety disorder, idiopathic progressive [MEDICAL CONDITION], [MEDICAL CONDITIONS], major [MEDICAL CONDITION], hypertension and muscle weakness. Review of resident #48's Admission MDS (Minimum Data Set) dated 12/15/17 revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating she was cognitively intact. MDS revealed she required extensive assistance of two staff for bed mobility. MDS revealed she was at risk for developing pressure ulcers. MDS also revealed she had two unstageable pressure ulcers with suspected deep tissue injury of which both were present upon admission/entry. Review of resident #48's care plan dated 12/15/17 revealed she had actual skin impairment related to deep tissue injury (DTI) on bilateral heels upon admit. DTI to left heel 1.8 x 2.3 cm, DTI to right heel 4.2 x 6.0 cm. Interventions included to notify MD of changes in wound, observe wound healing, provide wound care /preventative skin care as ordered for resident #48, Skin checks weekly per facility protocol and document findings and turn and reposition frequently to decrease pressure. Care plan dated 01/23/18 revealed resident #48 had a [MEDICAL CONDITION] related to fall and wore a brace while out of bed. Interventions included to reposition as necessary to prevent skin breakdown. According to www.npuap.org (accessed 2/6/18) - a Deep Tissue Injury (DTI) is Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. - An Unstageable Pressure ulcer is defined as Obscured full-thickness skin and tissue loss, Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Record Review of Resident #48's Admit/Readmit evaluation dated 12/12/17 (completed 4 days after admission on 12/08/17) revealed she had a pressure wound to right heel that measured 4.2cm x 6.0 cm that was a suspected deep tissue injury. Left heel had a pressure wound measuring 1.8cm x 2.3 cm that was a suspected deep tissue injury. Also noted was scarring to right hip and left knee due to previous surgeries. Signed LVN H Record review of resident #48's physician's orders [REDACTED]. This should be done weekly. order with a start date of 12/15/17 to apply no sting to DTI on right heel until resolved one time a day. Review of Resident #48's Weekly Skin assessments revealed: 12/13/17 revealed deep tissue injuries noted upon admission to facility. No further skin issues noted. Right heel has 4.2cm x 6.0 cm deep tissue injury noted to right heel. No sting and heel protectors applied. Will continue to monitor. Left Heel has a 1.8cm x 2.3 cm deep tissue injury noted to left heel. No sting and heel protectors applied. Will continue to monitor. Signed LVN H 12/14/17 revealed no open areas observed and no redness noted at this time. Wears heel protectors and has an area to back of right heel that measured 4cm x 4cm, an area to left heel th (TRUNCATED)

Based on interview and record review the facility failed to provide adequate supervision and assistive devices to prevent accidents for one of four (Resident #1) reviewed for accidents and supervision. The facility failed to ensure that Resident #1's bed alarm was on. Resident #1 suffered a fall on 5/29/2014 resulting in a fractured left hip. This facility failure resulted in actual harm to Resident #1 and could affect the 23 residents identified by the facility as having bed alarms by placing them at risk for falls and or injuries. Findings Include: Review of Resident #1 ' s closed Record of admitted d 10/09/2012 revealed an admission date of [DATE]. Record of Admission revealed Resident #1 was [AGE] years old. Review of Resident #1 ' s Physician order [REDACTED]. These orders contained an order for [REDACTED]. Review of Resident #1 's Nurse ' s Notes written by LVN A dated 5/29/2014 revealed the following: 1505 (3:05 pm)- CNA alerted this nurse of Resident on floor in her room. Res. (Resident) lying on her (R) side near her bed, O2 N/C bridging her nose above her nares, S/T noted @ (L) elbow, faint reddish circular area 2 (L) hip. V/S P= 102, R= 22, B/P 94/49, O2 sat 86% on R/A. Res. replied " I hurt everywhere " when asked if she was hurt anywhere. Moves RLE voluntarily, moves LLE when asked, no misalignment noted, BUE move well. Assist x 3 to move res to bed using a blanket sling D/T skin integrity concerns, Res c/o hip pain when raised from floor. Summoned DON and ADON. CB x 2 in reach on bed where res lies. (there was no documentation as to whether the Resident ' s bed alarm was in place or sounding) 1550 (3:50pm)- Res transported via ambulance to local hospital. RP daughter notified. 1645 (4:45pm) -Received call from local hospital informing of Dx: FX (L) hip, N.O. total bed rest. Resident is to return to the N.H. via ambulance. 1910 (7:10pm)- Res. arrives @ N.H., Res rec ' d (received) pain meds @ hospital per ER. Review of Resident #1 ' s x- ray report dated 5/29/2014 revealed the following: Exam: Single View of the Pelvis History: fall with pelvic pain Findings/Impression: A single AP view of the pelvis was performed. A partially visualized intertrochanteric fracture of the left femur is seen with associated soft tissue swelling. Recommend dedicated views of the left hip to further evaluate this finding. Osteoarthritic changes are seen in both hips and in the partially visualized lumbar spine. The bones appear osteopenic. Exam is otherwise unremarkable. Review of Resident #1 ' s hospital Physician order [REDACTED]. 1. Total bed rest 2. Diagnosis- Fx (L) hip Review of Resident #1 ' s Fall Risk Evaluation dated 3/30/2014 revealed a total score of 19. Total score of 10 or above represents High Risk. Review of Resident #1 ' s ADL Care Plan undated revealed under special devices: bed alarm Review of Resident #1 ' s Treatment Sheet dated 5/1/2014- 5/31/2014 revealed the following: 03/30/2014 Bed Alarm to remind Resident to call for assist Q shift. Review of Resident #1 ' s Monthly Summary dated 5/13/2014 under Section P Restraints revealed bed alarm. Review of Resident #1 ' s significant change MDS dated [DATE] revealed a BIMS score of 3 (indicating severe cognitive impairment), inattention and disorganized thinking that was continuous, delusions, other behaviors not directed at others. Resident #1 required supervision set up only for bed mobility, limited assistance of 1 person physical assist for transfers, walking in room, walking in corridor, locomotion on unit and locomotion off unit. Resident #1 was noted to be unsteady 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. Resident #1 had no functional limitations to her range of motion and used a walker for mobility. Resident #1 had no physical restraints. Review of Resident #1 ' s Plan of Care revealed the following: Risk for falls/occasional supervision for transfers due to weakness and unsteadiness with original date of 10/11/2012. Noted under interventions (handwritten) 3/30/2014 Bed Alarm In an interview upon entrance on 6/13/2014 at 8:45 a.m., the DON said that she had been called to Resident #1 ' s room on 5/29/2014 after Resident #1 fell . She said that when she arrived to the resident ' s room, the resident was in bed grimacing a little. The DON said that the staff had assessed the resident on the floor after the fall and that the resident had not complained of any pain. She said that the resident was sent to the emergency room for evaluation and returned approximately 2 hours later with a fractured hip. The DON said that in the week prior to the fall, Resident #1 had been declining. She said that Resident #1 was sleeping more, refusing meals and medications, very confused and was having incontinent episodes. The DON said that Resident #1 did not have any restraints but did have a bed alarm. The DON said that when questioned, none of the staff could remember if the alarm was sounding or not when they went to the resident ' s room and discovered that she had fallen. The DON said " if I had to guess, I would guess that it (the bed alarm) wasn ' t sounding. " In an interview on 6/13/2014 at 9:45 a.m., CNA A said that she had worked the 6 am- 2pm shift on 200 hall on 5/29/2014. CNA A said that Resident #1 had wanted to get up really early that morning around 6:30 a.m. or so. She said that after breakfast, the hospice aide came in for Resident #1 ' s bath. CNA A said that the hospice aide had put Resident #1 to bed. CNA A said that Resident #1 did not get back up that day for lunch. CNA A said that she did not remember seeing or checking the bed alarm that day after the hospice aide had put Resident #1 to bed. CNA A said that she did rounds at 2:00 p.m. with CNA C and Resident #1 was still in bed asleep and the door to the resident ' s room was open. Interview on 6/13/2014 at 11:05 a.m., CNA B said that she had worked the 6 a.m.-2 p.m. shift with CNA A on 5/29/2014. She said that she and CNA A had done their last round between 1:45 p.m. and 2:00p.m. CNA B said that she was staying until 6:00 p.m. She said that she saw CNA A giving report to CNA C. CNA B said that she was busy doing showers and the next thing she knew, CNA C was calling the nurse because Resident #1 had fallen. CNA B said that she did not hear Resident #1 ' s bed alarm going off but she was busy with other residents and in and out of the shower room. CNA B said that when she was getting diapers, Resident #1 was still in bed and the door to her room was open. CNA B said " that ' s all I know. " Review of the hospice aide visit note dated 5/29/2014 revealed the hospice aide arrived to Resident #1 at 9:15 a.m. and exited at 10:30 a.m. Interview on 6/13/2014 at 12:30 p.m., the hospice Clinical Director said that the aide who had performed am care on Resident #1 on 5/29/2014 was unavailable for interview. The Clinical Director said that Resident #1 ' s nurse had seen Resident #1 that day also. Review of the hospice Nurse Visit Note dated 5/29/2014 revealed that the hospice RN arrived to Resident #1 at 1:45 p.m. and exited at 2:30 p.m. Interview on 6/13/2014 at 1:40 p.m., the hospice RN said that she had seen Resident #1 on 5/29/2014 between 1:45- 2:30 pm. The RN said that the resident was in bed asleep during her assessment. The hospice RN said that Resident #1 did have a bed alarm but that she did not know if the switch was turned on or not. Interview on 6/13/2014 at 1:10 p.m. CMA A said that she worked the 2- 10p.m. shift on 200 hall on 5/29/2014. She said that she was getting ready for her first medication pass when LVN A told her that Resident #1 had fallen. CMA A said that when she got to Resident #1 ' room, the resident was still on the floor. She said that the nurse was assessing her and the resident was not complaining of pain. She said that the nurse would ask Resident #1 if she could wiggle her toes or move her legs and the resident was able to do it. CMA A said that it wasn ' t until they lifted the resident with the blanket to put her to bed that the resident began to complain of pain. CMA A said that Resident #1 had a bed alarm but that she did not hear it going off when she entered Resident #1 ' s room. CMA A said that the bed alarm did not go off when they put the resident back into bed. Interview on 6/13/2014 at 1:50 p.m., LVN A said that she was the nurse for the 2- 10 shift on Hall 200 on 5/29/2014. LVN A said that the first time she saw Resident #1 that shift was when she was called to the resident ' s room and she was on the floor. LVN A said that she thought that she had been told that Resident #1 was on the floor by CNA B (it was later determined through review of the daily schedule dated 5/29/2014 , it would have had to have been CNA C who had alerted the nurse). LVN A said that when she got to Resident #1 ' s room, the resident was in the floor lying on her right side. LVN A said that Resident #1 was not complaining of pain and was actively attempting to get up off the floor. She said that she assessed her and checked for misalignment of lower extremities and there was none present. She said that she, CMA A and CNA C put a heavy bed spread under her and lifted her to the bed. She said that once they lifted her into the air, the Resident winced in pain and said it hurt " a little " . LVN A said that she decided to go ahead and put the resident in the bed so that she would be more comfortable instead of back on the hard floor. She said that she called for the DON and ADON to come to the room and then the ambulance to take the resident to the hospital to be evaluated. LVN A said that the bed alarm to Resident #1 ' s bed was not going off when she entered the resident ' s room. LVN A said that she saw the bed alarm on the side rail of the resident ' s bed and the light was not on (indicating that the alarm was not on). Attempted to contact CNA C on 6/13/2014 at 10:26 a.m. who no longer is employed at the facility. There was no answer and there was no ability to leave a message. Review of facility policy and procedure dated 06/02 titled Falls revealed the following: Policy: all residents will receive assessment and necessary treatment following any fall or injury by the appropriate health professional. Procedure: 1. Documentation will be completed according to the Incident or Accident reporting procedures. 2. All incidents involving a fall are reviewed to determine the circumstances surrounding the fall. 3. If appropriate, a referral for therapy screen will be requested. 4. The resident ' s health care plan will be reviewed and updated as appropriate. Interview on 6/13/2014 at 2:45 p.m., the DON said that the facility does not have a policy per say on bed alarms. She said that they just document that the residents have them on the treatment sheets every shift. The DON said that everyone is just supposed to check them. Review of list received from the DON on 6/13/2014 at 3:00pm revealed 23 residents had bed alarms.

Based on observations, interviews, and record reviews the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for one of nine residents (Resident #5) reviewed for aspiration risk. The facility failed to: a). Position Resident #5 while eating to remain in an upright position to avoid choking; b). React or reposition Resident #5 when he was choking, coughing and gurgling while being fed on [DATE]. Resident #5 was pronounced expired [DATE] at 10:55 p.m. The physician stated that the cause of death for Resident #5 was most likely aspiration. An Immediate Jeopardy was identified on [DATE] at 3:40 p.m. While the Immediate Jeopardy was removed [DATE] at 7:40 p.m. the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Nine residents could be placed at high risk for aspiration, pneumonia and death if the deficient practice continued. Findings include: Review of Resident #5's medical record revealed he was an [AGE] year old male originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5 ' s medical record " Physician order [REDACTED]. " Review of Resident #5 ' s medical record " Physician order [REDACTED]. Review of Resident #5's medical record "Consolidated physician's orders [REDACTED]. Review of Resident #5's MDS dated [DATE] page 12 revealed that Resident #5 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assistance while eating. Review of Resident #5 ' s " Diet Card " revealed a pureed diet with nectar thick liquids. Observation on [DATE] at 8:04 a.m. revealed that Resident #5 was being fed a pureed diet while sitting leaned back approximately sixty degrees in a Geri-chair, leaning to the right, by CNA #A (Certified Nurse Aide). Resident #5 began coughing, choking and gurgling when CNA #A stepped away from the table to obtain supplies. At this time there were four CNA's (CNA #B, #C, and CNA #D) and two LVN's (Licensed Vocational Nurse) (LVN #A and LVN #B) in the dining room, none of the staff attempted to reposition the resident when Resident #5 began coughing, choking and gurgling. Observation on [DATE] at 8:06 a.m. revealed that Resident #5 was being fed a pureed diet by CNA #A, Resident #5 began coughing, choking and gurgling again and staff did not intervene. LVN #A walked over to Resident #5 while he was coughing, choking and gurgling, stood beside Resident #5, but did not attempt to reposition. Interview on [DATE] at 8:15 a.m. CNA #A stated that the Geri-chair does not sit up any higher and that he did re-position Resident #5 once, and Resident #5 does this all the time (referring to choking, coughing, and gurgling). CNA #A stated that he does put his hand behind Resident #5 to assist him to sit up a little straighter. Surveyor was in the main dining room on [DATE] from 8:00 a.m. until after meal service was complete, and did not observe staff to reposition Resident #5. Interview on [DATE] at 8:22 a.m. LVN #B stated that the Geri-chair does not sit up any higher and that Resident #5 does lean to the right all the time. She stated that Resident #5 does cough and gurgle a lot and "we try to give him time to clear his throat between bites, this is the way Resident #5 signals to stop." She stated that CNA #A should have thickened Resident #5's liquids to a nectar thick consistency prior to serving Resident #5; she stated that Buttermilk and the orange juice are pre-thickened from the kitchen. She went on to state that Resident #5's choking, coughing, and gurgling does concern her and did not have an answer when asked why did staff appear to be unconcerned when Resident #5 began choking, coughing and gurgling, stating "I don't know." Interview on [DATE] at 8:30 a.m. with RN #A stated that she expects staff to intervene when a resident begins to cough, choke or gurgle while being fed. She stated that she expects staff to stop feeding the resident, to notify the nurse, to sit the resident straight up. She stated that she expects the nurse to intervene and assess the resident ' s lung sounds, check the oxygen saturation for the resident and to notify the resident ' s physician. Interview on [DATE] at 10:20 a.m. RN#A stated that " Aspiration Precautions " means for the head of the bed to be elevated, sit upright when eating or drinking, if the resident needs to be fed, for the resident to be fed slowly, to thicken liquids to reduce the chance of aspiration, not to use straws for the resident to get a drink, and to alternate between bites of food and sips of liquid. Interview on [DATE] at 10:25 a.m. ADON (Assistant Director of Nurses) stated that "Aspiration Precautions" means that staff monitor while eating or drinking, for staff to watch for signs or symptoms of aspiration. She went on to state that all nurses and CNA's are taught aspiration precautions while in school, that she discusses with staff when a resident is on aspiration precautions. She stated that she expects staff to intervene when a resident is choking, coughing or gurgling while being fed and to notify the residents physician. She stated the facility does not have a policy about positioning residents while feeding. Interview on [DATE] at 11:05 a.m. ADON stated that she had spoken to the Hospice RN, RN #B, and was told that RN #B had spoken with Resident #5 ' s power of attorney who did not think that a swallow study would benefit Resident #5 at this time and did not want Resident #5 to be sent from the facility for any outside of facility testing. Interview on [DATE] at 1:20 p.m. ADON stated that Resident #5 uses a Geri-chair if these orders were still in effect, the charge nurse would be responsible for seeing that these orders were being carried out properly, she stated that hospice had ordered for Resident #5 to use a Geri-chair on [DATE] and that Resident #5 had been using the Geri-chair since that time. Observation on [DATE] at 7:50 a.m. revealed Resident #5 ' s head was down, and his eyes were closed. CNA #F was observed putting pureed food into Resident #5's mouth even though he was not responding. It was noted that the food fell out of Resident #5's mouth. Observation on [DATE] at 11:20 a.m. revealed LVN #D and CNA #F provided wound care for Resident #5. It was noted at this time that Resident #5 had a wet cough and did not respond to staff. CNA #F stated Resident #5 usually opens his eyes, grunts, moans or sometimes says hello. Review of Resident #5's medical record "Nurse's Notes" dated [DATE] at 0720 (7:20 a.m.) revealed that the hospice RN had been to the facility to assess Resident #5 for elevated temperature of 102.4 degrees Fahrenheit and gurgling which [MEDICATION NAME] drops (for gurgling, to dry secretions) were ordered and given. At 0920 (9:20 a.m.) the Nurse's Notes revealed that the family was notified and at bedside, that Resident #5 was unresponsive. Review of the medical record revealed Resident #5 ' s condition continued to deteriorate until [DATE] at 10:55 p.m. when the hospice RN documented Resident #5 was deceased and notified family. Interview on [DATE] at 11:45 a.m. with RN #B, who is the Hospice RN for Resident #5, stated that she was off over the weekend; she was given report this morning ([DATE]) of Resident #5's death. She stated that from what she knows that it sounded like Resident #5 died from pneumonia or possible aspiration. Interview on [DATE] at 1:00 p.m. Physician #A, who is the primary care physician for Resident #5 and the Medical Director for Hospice, stated that the cause of death for Resident #5 was most likely aspiration. <http://www.dads.state.tx.us/quality matters/qcp/pneumonia/index.html> revealed "Aspiration pneumonia is caused by inhaling foreign material (usually food, liquids, vomit, or secretions from the mouth) into the lower airways ...Aspiration can present the following symptoms in individuals who are aging and have swallowing difficulties, and in those with neurological impairment: - A voice change (such as gurgling or hoarseness) after swallowing; - Severe coughing - Cyanosis associated with drinking, eating or regurgitation of stomach contents; - An elevated respiratory rate; - Fever; - Chills; - Pleuritic chest pain; and - Chest crackles <http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A 9/>, Part of the signs, symptoms and complications of Parkinson ' s disease is difficulty swallowing and one complication is Pneumonia from breathing in (aspiration). www.AuroraBayCare.com <http://www.AuroraBayCare.com> titled "Positioning During Eating" dated ,[DATE] revealed: "Ideal positioning during eating - Seated on a firm surface, such as a straight chair - Feet flat on the floor - Equal weight bearing on both buttocks (not tilted to one side) - Sitting up straight or slightly forward (Exception: someone with hip precautions should not bend forward greater than 90 degrees) - Head upright, in midline (middle of the body) with chin slightly tucked down - If an individual needs to be in bed or in a recliner, try to follow the above guidelines. Use towels or pillows to help with proper positioning ...." On [DATE] at 3:40 p.m. an Immediate Jeopardy was called, and the Administrator, ADON, and RN " A " were informed. The facility submitted an action plan as follows: Action Plan: FOR IMMEDIACY on [DATE] On this date there are 9 (nine) residents identified to be at risk for swallowing difficulties due to cough or choking easily. Resident #3 is on a NPO and has feeding tube. She just had a Swallow study done [DATE]. Resident #4 is on NPO diet. He has a feeding tube. The facility staff does not feed him. He had a Swallow study done ,[DATE]. Resident #27 is on a Dental Soft diet. On [DATE] Medical Director has given an order to monitor for signs and symptoms of choking. Resident #11 is on a Dental Soft diet. On [DATE] Medical Director has given an order to monitor for signs and symptoms of choking. Resident #22 is on a Dental Soft diet due to poor dental hygiene. She does have a recent increase of drooling and saliva. On [DATE] Medical Director has given an order to monitor for signs and symptoms of choking. Resident #25 is on a Pureed with low concentrated sweets. We have a Physicians Order to monitor for choking. Resident #2 is on a Regular diet, but does cough at times during meals. On [DATE] Medical Director has given an order to monitor for signs and symptoms of choking. Resident #26 has Pureed diet with nectar thickened liquids. On [DATE] Medical Director has given an order to monitor for signs and symptoms of choking. RN #A has assessed the above identified residents. There were no adverse effects of Aspiration. Staff was in-serviced on [DATE] on assessing and identifying resident with swallowing difficulties, signs and symptoms of Aspiration, and adverse effects of Aspiration and proper positioning while feeding. There are two residents, Resident #24 and Resident #29 that have the potential to be at risk due to positioning. Medical Director has given us an order to Therapy to evaluate positioning. The action plan was verified to have been completed through interviews with facility staff, review of inservice records, meal observations, and resident record reviews. The immediate jeopardy was removed on [DATE] at 7:40 p.m., but the facility remained out of compliance at a scope of isolated and severity of actual harm. Review of a list provided by the facility ADON on [DATE] identified nine resident were at risk for aspiration.

Based on interviews and record reviews the facility failed to implement policies and procedures that prohibit neglect of residents. The facility failed to ensure one of seven residents (#3) reviewed was provided the services necessary to avoid physical harm as evidenced by: a) failure to thoroughly assess and consult with Resident #3's primary physician in a timely manner after the resident complained of abdominal pain, had a distended bladder and a decrease in urinary output for two days after a catheter was placed. This failure resulted in Resident #3 being transported to hospital B for removal of his catheter and placement of a temporary suprapubic catheter. Resident #3 was then transported to hospital A and underwent surgery for [REDACTED]. An IJ was identified on 04/24/12. While the IJ was removed 04/24/12, the facility remained out of compliance at a pattern of actual harm because the facility had not yet monitored their plan for effectiveness. Any of the five residents with catheters (which inclulded Resident #3) in the facility could be affected by these deficient practices. Findings include: Record review of Resident #3's face sheet revealed he was an [AGE] year old male admitted to the facility 03/28/12. No diagnoses were listed. Review of Resident #3's "Discharge Summary" from hospital A dated 03/28/12 revealed discharge diagnoses of Hematochezia (the passage of blood in the feces. Source www.medlineplus.com), resolved, Duodenitis, Acute blood loss [MEDICAL CONDITIONS], Hypertension and History of [MEDICAL CONDITION]. In an interview on 04/24/12 at 1:07 p.m., LVN A said Resident #3 had not voided for eight hours after his catheter was removed at hospital A. She said she received an order to place a catheter in Resident #3, and that the catheter was placed without difficulty. LVN A said when she started to inflate the catheter bulb, Resident #3 hollered out and complained of pain, so instead of putting 30 cc's of fluid, she only put 10-15 cc in the bulb. She said Resident #3's family expressed concern about his lack of urinary output. Review of Resident #3's nurse's notes dated 03/28/12 at 8:00 p.m. written by LVN A revealed, "This 87 white male admitted from hospital A ...(hospital nurse's name) reported removing catheter at 10:20 this a.m. ....notified nurse (nurse's name) at hospital B clinic of resident current condition that his penis and scrotum is red/[MEDICAL CONDITION], hadn't voided since foley catheter discontinued this a.m. At 6:30 p.m., orders received per Physician D to reinsert foley catheter ...reinserted 16 Fr. French) foley catheter tolerated fair 15 cc bulb out of 30cc noted with 350cc immediate return of blood tinged urine immediate relief ... " Review of Resident #3's "Admission Nursing Evaluation" written by LVN A dated 03/28/12 revealed, "...Treatments/Procedures-foley catheter 16 Fr. (30cc bulb) tolerated 15 cc bulb..." Review of Resident #3's "Daily Skilled Nurse's Note" dated 03/29/12 revealed "...discharge around foley; urine color reddish-yellow, concentrated (day shift), dark amber (night shift) ..." Review of Resident #3's nurse's noted dated 03/29/12 at 5:15 a.m. written by LVN E revealed, "...resident continues with blood tinged urine to bed side drainage, bleeding around foley catheter from penis. Penis and scrotum continue to be red and swollen, voices "this hurts and [MEDICAL CONDITION] I pee" , output 200cc...will pass on to next shift to notify MD of problem ..." Review of Resident #3's "Daily Skilled Nurse's Note, side two" , written by LVN D, undated, revealed "...Ate 100% of both meals...Penis continues to be swollen, and bulging in some areas, bloody drainage noted at tip of penis...spoke with (physician's name) who stated to change MD to (physician's name) and culture penis discharge, after collecting culture-start Bactrim DS..." Review of Resident #3's "Daily Skilled Nurse's Note, side two" dated 03/29/12 written by LVN C, revealed "...resident continues with penis swollen and bulging in some areas and slightly red. Continues with bloody drainage top of penis minimal amount. Foley catheter patent and draining amber colored urine with sediment. [MEDICAL CONDITION] he urinates...fluids encouraged ..." In an interview on 04/24/12 at 2:47 p.m., LVN B said on 03/30/12 at the end of her shift, the CNA's reported Resident #3 had no urine output. She said she looked in Resident #3 ' s urinary collection bag and saw only 25-50 cc's of dark brown urine. She said she tried to wiggle Resident #3's catheter to get urine output without success. Review of Resident #3's nurse's notes written by LVN B dated 03/30/12 at 2:45 p.m. revealed, "...several attempts made to get foley catheter patent and draining with no success." In an interview on 04/23/12 at 3:50 p.m., the DON said Resident #3 could not urinate when he was admitted to the facility 03/28/12 at 4:00 p.m. She said a catheter was placed by LVN A with 15cc (cubic centimeters) of fluid placed into the bulb (the part of the catheter inside the bladder to hold the catheter in place). She said there was a 350 cc return of blood-tinged urine. She said Resident #3 had bulges in his penis while in the facility. The DON said Resident #3 had no urine output on 03/30/12, and LVN B tried to get the catheter patent without success. She said LVN C obtained an order to irrigate the catheter on 03/30/12 and instilled 60 cc sterile water into the catheter with a 100 cc return into the collection bag. The DON said Resident #3 complained of burning with urination, and fluids were encouraged. She aid Resident #3 had bloody drainage from his penis and that a culture was done with antibiotics started. The DON said that on 03/30/12 at 3:15 p.m., she assessed Resident #3 and his abdomen was distended and hard with decreased bowel sounds. The DON said an ambulance was called and Resident #3 was sent to hospital B. The DON said Resident #3 ' s family came to the facility the next week and discharged him. She said the family told the facility that someone had told them (the family) that the facility needed teaching on catheters. The surveyor asked the DON if in-services on catheters were held after the incident and she stated, "No". In an interview on 04/24/12 at 9:34 a.m., the DON said she knew there was something wrong with Resident #3's penis while he was in the facility. In an interview on 04/24/12 at 11:00 a.m., the DON was asked if Resident #3's catheter was ever removed by the facility or his physician notified when he had pain and decreased urinary output. She said, "No" . In an interview on 04/24/12 at 10:15 a.m., LVN C said Resident #3's penis was swollen and deformed with no urinary output. She said she called the emergency room at hospital B on 03/30/12 and received an order to irrigate the catheter with 60 cc of fluid. LVN C said another nurse had advanced Resident #3's catheter before she irrigated it, so she did not advance it. LVN C said she irrigated the catheter as ordered and got a 100cc return of fluid without resistance. She said Resident #3 had discomfort while she irrigated the catheter, complained of abdominal discomfort, and his abdomen was distended. She said Resident #3 wanted to go to the hospital. She said she called the emergency room at hospital B again, and Resident #3 was sent to hospital B. LVN C said she received a call from hospital B that night and was told Resident #3's "plumbing was all messed up" . She said on 03/30/12 the DON listened to Resident #3's bowel sounds, and was aware of his decreased urinary output. Review of Resident #3's nurse's notes written by LVN C dated 03/30/12 at 2:50 p.m. revealed "Called E.R. (emergency room ) back re: output 25cc from 6:00 a.m.-2:00 p.m. ....Received call back...advance catheter, check for obstructions. Flush with 60cc sterile H2O (water)/monitor. Foley catheter not kinked, catheter advanced by another nurse. Foley catheter flushed with 66cc sterile H20, resident tolerated well, voiced some discomfort, 100cc return...resident complained burning with urination; fluids encouraged...resident noted with foley catheter draining and patent, dark amber urine with sediment to bed side drainage. Minimal amount of bleeding draining to top of penis, penis continues swollen and bulging in some areas...3:15 p.m., "...Abdomen noted distended hard, complained of abdominal discomfort...called E.R....will monitor. "...3:30 p.m., "Resident requesting to go to hospital, family here and agreed... "4:00 p.m., Resident in route to (name of hospital) ..." ...8:00 p.m., "spoke with (nurse's name) at (hospital name), resident to be transferred ...plumbing all messed up..." Review of Resident #3's physician orders [REDACTED]." In an interview on 04/24/12 at 10:35 a.m., LVN D said she never advanced Resident #3's catheter. In an interview on 04/24/12 at 9:45 a.m., LVN D said Resident #3's penis "was misshapen" with a bulge on one side and two bulges on the other side. She said she obtained a physician's orders [REDACTED]. Review of Resident #3's nurse's notes written by LVN E, undated, revealed, "...at 01:25 resident complained of pain to penile/scrotum area. Continues to be swollen and red... " 03:30...could not obtain UA (urinalysis) due to resident not urinating enough in foley catheter. Fluids encouraged and accepted...06:00; Resident continues to have problems with urination. Output 100cc, no urine in tube. Unable to get UA at this time." Review of Resident #3's "Treatment Record" revealed the following: 03/28/12 Intake=800cc Output=350cc 03/29/12 Intake=1200cc Output=550cc 03/30/12 Intake=1000cc Output=125cc Review of Resident #3's "Plan of Care" dated 03/30/12 revealed, "Problems/Strengths-Risk for UTI (urinary tract infection) due to indwelling catheter-Goals-No signs of UTI: fever: cloudy, bloody, or discolored urine: scant output or odor...Interventions- Monitor indwelling catheter and change catheter or bag when needed; Monitor for sediment, cloudy odor, blood amount; Report problems with urine or fever promptly to MD; Encourage fluids; Monitor lab as ordered; Turn every two hours and monitor skin for redness; Good peri care..." In an interview on 04/24/12 at 12:55 p.m., CNA A said when she showered Resident #3 03/29/12, his catheter had a small amount of dark orange-brown colored urine in the collection bag. In an interview on 04/23/12 at 12:05 p.m., Resident #3's daughter said her father had a catheter before while in hospital A that was removed before he was discharged [DATE]. Resident #3's daughter said her father had a catheter placed at the facility after he had not voided for eight hours. She said the nurse (LVN A) who placed it got it in, but the balloon was in the urethra. Resident #3's daughter said Resident #3 was sent to hospital B where the catheter was removed, and a temporary suprapubic catheter was placed. She said Resident #3 had urethral trauma and was sent back to hospital A where he had an emergency permanent suprapubic catheter placed. Resident #3's daughter said the physician who performed the surgery at hospital A told her that Resident #3 may have to keep the suprapubic catheter due to his urethral trauma. In an interview on 04/23/12 at 4:50 p.m., the administrator said Resident #3's family came to the facility and discharged him 04/03/12. The Administrator said the family told her they had been told that what was wrong with Resident #3 was that his catheter had been placed incorrectly by the facility. In an interview on 04/23/12 at 5:00 p.m., the DON was asked if inservices were given to licensed staff after the administrator was told the facility incorrectly placed Resident #3's catheter. The DON said, "No." In an interview on 04/24/12 at 8:40 a.m., RN A at hospital B confirmed she took care of Resident #3 in the emergency room . The RN said she saw bright red blood and swelling of Resident #3's penis and called the physician in to remove the catheter. The RN said the physician came in and removed the catheter, and that there was more fluid in the bulb than called for. In an interview on 04/24/12 at 6:00 p.m., Physician A said she received Resident #3 at hospital B. She said she went and looked at his abdomen which had obvious palpable bladder distention that "looked like a mass". Physician A said she deflated Resident #3's catheter balloon and aspirated 60cc of clear fluid from a 30cc balloon. She said there was blood at the meatus of Resident #3's penis. She said she attempted to insert another catheter, but could not advance it, so she placed a temporary suprapubic catheter via his bladder with a large volume of urine returned. Physician A said Resident #3 was transferred to hospital A. Review of Resident #3's emergency room physician's Progress Notes written by Physician A from hospital B, revealed, "... Palp (palpable) bladder to umbilicus...Old foley removed-~60cc of fluid in a 30cc balloon and blood at meatus. Clotted blood in foley. Attempted to place new foley and got back gross blood. Suprapubic catheter (TLC triple lumen catheter) placed and 640cc urine aspirated .... "Clinical Impression" Acute [MEDICAL CONDITION] traumatic urethral injury." Review of Resident #3's "Emergency Physician Record" written by Physician A, from hospital B revealed, "Progress Notes", "Suprapubic catheter placement. Using sterile technique, 18 gauge needle placed in lower abdomen midline with return of fresh, non-bloody urine. TLC placed using sterile technique. TLC secured into place and 640cc urine aspirated from bladder with relief of discomfort (physician's signature)." In an interview on 04/26/12 at 9:05 a.m., Physician B said when he placed the suprapubic catheter in Resident #3, the urethra had partial disruption with "pretty bad damage. " Review of Resident #3's clinical record dictated by Physician B at Hospital A revealed, "History and Physical... Chief Complaint: Urethral rupture...he did have a catheter changed some days ago and has been having quite a bit of pain since then. He was seen in the emergency room tonight with no urine output. They did remove his Foley catheter. There was a 30cc balloon, which apparently had 60cc, and they were unable to pass another catheter and did place what appears to be a triple-lumen central line directly into the bladder. I did with a Uro-jet attempt to scope him here. At the mid bulbar urethra, the urethra was severely macerated with a very large false passage and visible fat. I was unable to find the true lumen of the urethra ..." Review of Resident #3's clinical record dictated by Physician B at hospital A revealed, "Operative Report...Procedure: 1. Cystoscopy. 2. Difficult Foley placement. 3. Suprapubic catheter placement ...At the mid-bulbar urethra, there was severe maceration and disruption of the urethra ...The suprapubic catheter was sutured into position..." Review of the facility's policy received 04/24/12 at 9:55 a.m. "Condition change, of the Resident" revealed, "...Purpose- To observe, record and report any condition change to the attending physician so proper treatment will be implemented ....Procedure- 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...observe for pain...if you are unable to reach the attending physician or the physician on call, call the facility medical director...General Resident Care Plan Documentation Guidelines- 1. Identify underlying problem causing the condition change ..." Review of the facility's policy received 04/24/12 at 9:34 a.m. "Catheter (indwelling), Insertion and Removal of (female and male), " "...Do not force water into balloon. If resistance is encountered or the resident complains of pain, deflate balloon, advance farther into the bladder and inflate ..." The DON provided a list of five residents having catheters 04/24/12. CMS 672 dated 04/23/12 revealed a census of 90.

Based on observation, interview and record review the facility failed to do an accurate and complete assessment and notify the physician one of seven sampled residents (Resident #3) developed lower abdominal pain and distention, a significant decrease in urinary output and penis deformity. The facility failed to: a) Ensure Resident #3's catheter was properly inserted and maintained; b) Assess Resident #3's catheter for patency in a timely manner; c) Assess Resident #3 for penile pain and drainage; d) Notify Resident #3's physician of penile pain/discharge/deformity and decreased urinary output. Resident #3 had abdominal pain and distention with decreased urinary output and penis deformity for two days after a catheter was placed. He was sent to the emergency room (hospital B) 03/30/12 where the physician discovered 60 cc fluid in the 30cc catheter bulb with urethral trauma. A temporary suprapubic catheter was placed and Resident #3 was transferred to hospital A and underwent surgery for [REDACTED]. An IJ was identified on 04/24/12. While the IJ was removed 04/24/12, the facility remained out of compliance at a pattern of actual harm because the facility had not yet monitored their plan for effectiveness. These failures could affect any of the five residents in the facility with catheters. This failure placed residents at risk for not receiving proper care and services due to staff not notifying their physician when there is a catheter-related complication. Findings include: Record review of Resident #3's face sheet revealed he was an [AGE] year old male admitted to the facility 03/28/12. No diagnoses were listed. Review of Resident #3's "Discharge Summary" from hospital A dated 03/28/12 revealed discharge diagnoses of Hematochezia (the passage of blood in the feces, www.medlineplus.comresolved, Duodenitis, Acute blood loss [MEDICAL CONDITIONS], Hypertension and History of [MEDICAL CONDITION]. In an interview on 04/24/12 at 1:07 p.m., LVN A said Resident #3 had not voided for eight hours after his catheter was removed at hospital A. She said she received an order to place a catheter in Resident #3, and that the catheter was placed without difficulty. LVN A said when she started to inflate the catheter bulb, Resident #3 hollered out and complained of pain, so instead of putting 30 cc's of fluid, she only put 10-15 cc in the bulb. She said Resident #3's family expressed concern about his lack of urinary output. Review of Resident #3's facility nurse's notes dated 03/28/12 at 8:00 p.m. written by LVN A revealed, "This 87 white male admitted at 4:00 p.m. ...(nurse's name) reported removing foley catheter at 10:20 this a.m. ....notified nurse (nurse's name) at hospital B clinic of resident current condition that his penis and scrotum is red/[MEDICAL CONDITION], hadn't voided since foley catheter discontinued this a.m. At 6:30 p.m., orders received per (physician's name) to reinsert foley catheter...skin assessment noted...scrotum is red/[MEDICAL CONDITION]. All fingers are swollen...medications...Diagnoses: [REDACTED]. New order reinserted 16 Fr. French) foley catheter tolerated fair 15 cc bulb out of 30cc noted with 350cc immediate return of blood tinged urine immediate relief..." Review of Resident #3's "Admission Nursing Evaluation" dated 03/28/12, written by LVN A revealed, "...Treatments/Procedures-foley catheter 16 Fr. (30cc bulb) tolerated 15 cc bulb ..." Review of Resident #3's nurse's noted dated 03/29/12 at 5:15 a.m. written by LVN E revealed, "...resident continues with blood tinged urine to bed side drainage, bleeding around foley catheter from penis. Penis and scrotum continue to be red and swollen, voices "this hurts and [MEDICAL CONDITION] I pee" , output 200cc...will pass on to next shift to notify MD of problem..." Review of Resident #3's "Daily Skilled Nurse's Note" dated 03/29/12 revealed "...discharge around foley; urine color reddish-yellow, concentrated (day shift), dark amber (night shift)..." In an interview on 04/24/12 at 12:55 p.m., CNA A said when she showered Resident #3 03/29/12, his catheter had a small amount of dark orange-brown colored urine in the collection bag. In an interview on 04/24/12 at 2:47 p.m., LVN B said on 03/30/12 at the end of her shift, the CNA's reported Resident #3had no urine output. She said she looked in Resident #3 ' s urinary collection bag and saw only 25-50 cc's of dark brown urine. She said she tried to wiggle Resident #3's catheter to get urine output without success. Review of Resident #3's nurse's notes written by LVN B dated 03/30/12 at 2:45 p.m. revealed, "...several attempts made to get foley catheter patent and draining with no success." In an interview on 04/23/12 at 3:50 p.m., the DON said Resident #3 could not urinate when he was admitted to the facility. She said a catheter was placed by LVN A with 15cc (cubic centimeters) of fluid placed into the bulb (the part of the catheter inside the bladder to hold the catheter in place). She said there was a 350 cc return of blood-tinged urine. She said Resident #3 had bulges in his penis while in the facility. The DON said Resident #3 had no urine output on 03/30/12, and LVN B tried to get the catheter patent without success. She said LVN C obtained an order to irrigate the catheter on 03/30/12 and instilled 60 cc sterile water into the catheter with a 100 cc return into the collection bag. The DON said Resident #3 complained of burning with urination, and fluids were encouraged. She aid Resident #3 had bloody drainage from his penis and that a culture was done with antibiotics started. The DON said that on 03/30/12 at 3:15 p.m., she assessed Resident #3 and his abdomen was distended and hard with decreased bowel sounds. The DON said an ambulance was called and Resident #3 was sent to hospital B. The DON said Resident #3's family came to the facility the next week and discharged him. She said the family told the facility that someone had told them (the family) that the facility needed teaching on catheters. The surveyor asked the DON if in-services on catheters were held after the incident and she stated, "No", that LVN C's documentation was good . In an interview on 04/24/12 at 9:34 a.m., the DON said she knew there was something wrong with Resident #3's penis while he was in the facility. In an interview on 04/24/12 at 11:00 a.m., the DON was asked if Resident #3's catheter was ever removed by the facility when he had pain and decreased urinary output. She said, "No" . In an interview on 04/24/12 at 10:15 a.m., LVN C said Resident #3's penis was swollen and deformed with no urinary output. She said she called the emergency room at hospital B on 03/30/12 and received an order to irrigate the catheter with 60 cc of fluid. LVN C said another nurse had advanced Resident #3's catheter before she irrigated it, so she did not advance it. LVN C said she irrigated the catheter as ordered and got a 100cc return of fluid without resistance. She said Resident #3 had discomfort while she irrigated the catheter, complained of abdominal discomfort, and his abdomen was distended. She said Resident #3 wanted to go to the hospital. She said she called the emergency room at hospital B again, and Resident #3 was sent to hospital B. LVN C said she received a call from hospital B that night and was told Resident #3's "plumbing was all messed up". She said on 03/30/12 the DON listened to Resident #3's bowel sounds, and was aware of his decreased urinary output. Review of Resident #3's "Daily Skilled Nurse's Note, side two" undated, written by LVN C revealed "...resident continues with penis swollen and bulging in some areas and slightly red. Continues with bloody drainage top of penis minimal amount. Foley catheter patent and draining amber colored urine with sediment. [MEDICAL CONDITION] he urinates...fluids encouraged ..." Review of Resident #3's nurse's notes written by LVN C dated 03/30/12 at 2:50 p.m. revealed "Called E.R. (emergency room ) back re: output 25cc from 6:00 a.m.-2:00 p.m. ....Received call back...advance catheter, check for obstructions. Flush with 60cc sterile H2O (water)/monitor. Foley catheter not kinked, catheter advanced by another nurse. Foley catheter flushed with 66cc sterile H20, resident tolerated well, voiced some discomfort, 100cc return...resident complained burning with urination; fluids encouraged...resident noted with foley catheter draining and patent, dark amber urine with sediment to bed side drainage. Minimal amount of bleeding draining to top of penis, penis continues swollen and bulging in some areas...3:15 p.m., "...Abdomen noted distended hard, complained of abdominal discomfort ...called E.R....will monitor. "...3:30 p.m., "Resident requesting to go to hospital, family here and agreed ..." 4:00 p.m., Resident in route to (name of hospital) ... "...8:00 p.m., "spoke with (nurse's name) at (hospital name), resident to be transferred...plumbing all messed up..." Review of Resident #3's physician orders [REDACTED]." In an interview on 04/24/12 at 10:35 a.m., LVN D said she never advanced Resident #3's catheter. In an interview on 04/24/12 at 9:45 a.m., LVN D said Resident #3's penis "was misshapen" with a bulge on one side and two bulges on the other side. She said she obtained a physician's orders [REDACTED]. The physician was not notified of Resident #3's penis being misshaped. Review of Resident #3's "Daily Skilled Nurse's Note, side two" , undated, written by LVN D revealed "...Ate 100% of both meals...Penis continues to be swollen, and bulging in some areas, bloody drainage noted at tip of penis...spoke with (physician's name) who stated to change MD to (physician's name) and culture penis discharge, after collecting culture-start Bactrim DS..." Review of Resident #3's nurse's notes by LVN E, undated, revealed, "...at 01:25 resident complained of pain to penile/scrotum area. Continues to be swollen and red ..." 03:30...could not obtain UA (urinalysis) due to resident not urinating enough in foley catheter. Fluids encouraged and accepted...06:00; Resident continues to have problems with urination. Output 100cc, no urine in tube. Unable to get UA at this time." Review of Resident #3's "Treatment Record" revealed the following: 03/28/12 Intake=800cc Output=350cc 03/29/12 Intake=1200cc Output=550cc 03/30/12 Intake=1000cc Output=125cc Review of Resident #3's "Plan of Care" dated 03/30/12 revealed, "Problems/Strengths-Risk for UTI (urinary tract infection) due to indwelling catheter-Goals-No signs of UTI: fever: cloudy, bloody, or discolored urine: scant output or odor...Interventions- Monitor indwelling catheter and change catheter or bag when needed; Monitor for sediment, cloudy odor, blood amount; Report problems with urine or fever promptly to MD; Encourage fluids; Monitor lab as ordered; Turn every two hours and monitor skin for redness; Good peri care..." In an interview on 04/23/12 at 12:05 p.m., Resident #3's daughter said her father had a catheter before while in hospital A that was removed before he was discharged [DATE]. Resident #3's daughter said her father had a catheter placed at the facility after he had not voided for eight hours. She said the nurse (LVN A) who placed it got it in, but the balloon was in the urethra. Resident #3's daughter said Resident #3 was sent to hospital B where the catheter was removed, and a temporary suprapubic catheter was placed. She said Resident #3 had urethral trauma and was sent back to hospital A where he had an emergency permanent suprapubic catheter placed. Resident #3's daughter said the physician who performed the surgery at hospital A told her that Resident #3 may have to keep the suprapubic catheter due to his urethral trauma. In an interview on 04/23/12 at 4:50 p.m., the administrator said hospital B told the family when that what was wrong with Resident #3 was that his catheter had been placed incorrectly by the facility. She said the family informed her when they discharged him 04/03/12. In an interview on 04/23/12 at 5:00 p.m., the DON was asked if inservices were given to licensed staff after the administrator was told the facility incorrectly placed Resident #3's catheter. The DON said, "No." In an interview on 04/24/12 at 8:40 a.m., RN A at hospital B confirmed she took care of Resident #3 in the emergency room . The RN said she saw bright red blood and swelling of Resident #3's penis and called the physician in to remove the catheter. The RN said the physician came in and removed the catheter, and that there was more fluid in the bulb than called for. In an interview on 04/24/12 at 6:00 p.m., Physician A said she received Resident #3 at hospital B. She said she went and looked at his abdomen which had obvious palpable bladder distention that "looked like a mass". Physician A said she deflated Resident #3's catheter balloon and aspirated 60cc of clear fluid from a 30cc balloon. She said there was blood at the meatus of Resident #3's penis. She said she attempted to insert another catheter, but could not advance it, so she placed a temporary suprapubic catheter via his bladder with a large volume of urine returned. Physician A said Resident #3 was transferred to hospital A. Review of Resident #3's emergency room physician's Progress Notes, written by Physician A from hospital B revealed, "... Palp (palpable) bladder to umbilicus...Old foley removed-~60cc of fluid in a 30cc balloon and blood at meatus. Clotted blood in foley. Attempted to place new foley and got back gross blood. Suprapubic catheter (TLC triple lumen catheter) placed and 640cc urine aspirated...." Clinical Impression "Acute [MEDICAL CONDITION] traumatic urethral injury." Review of Resident #3's "Emergency Physician Record" written by Physician A from hospital B, revealed, "Progress Notes", "Suprapubic catheter placement. Using sterile technique, 18 gauge needle placed in lower abdomen midline with return of fresh, non-bloody urine. TLC placed using sterile technique. TLC secured into place and 640cc urine aspirated from bladder with relief of discomfort (physician's signature)." In an interview on 04/26/12 at 9:05 a.m., Physician B said when he placed the suprapubic catheter in Resident #3, the urethra had partial disruption with "pretty bad damage." Review of Resident #3's clinical record at Hospital A, dictated by Physician B revealed, "History and Physical... Chief Complaint: Urethral rupture ..he did have a catheter changed some days ago and has been having quite a bit of pain since then. He was seen in the emergency room tonight with no urine output. They did remove his Foley catheter. There was a 30cc balloon, which apparently had 60cc, and they were unable to pass another catheter and did place what appears to be a triple-lumen central line directly into the bladder. I did with a Uro-jet attempt to scope him here. At the mid bulbar urethra, the urethra was severely macerated with a very large false passage and visible fat. I was unable to find the true lumen of the urethra..." Review of Resident #3's clinical record at hospital A dictated by Physician B revealed, "Operative Report...Procedure: 1. Cystoscopy. 2. Difficult Foley placement. 3. Suprapubic catheter placement...At the mid-bulbar urethra, there was severe maceration and disruption of the urethra...The suprapubic catheter was sutured into position..." Review of the facility's policy received 04/24/12 at 9:55 a.m. "Condition change, of the Resident" revealed, "...Purpose- To observe, record and report any condition change to the attending physician so proper treatment will be implemented....Procedure- 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...observe for pain...if you are unable to reach the attending physician or the physician on call, call the facility medical director...General Resident Care Plan Documentation Guidelines- 1. Identify underlying problem causing the condition change..." Review of the facility's policy received 04/24/12 at 9:34 a.m. "Catheter (indwelling), Insertion and Removal of (female and male), "...Do not force water into balloon. If resistance is encountered or the resident complains of pain, deflate balloon, advance farther into the bladder and inflate ..." The Administrator, DON and ADON were notified 04/24/12 at 1:10p.m. of Immediate Jeopardy related to catheters. The facility submitted an Action Plan to decrease the immediacy. The Action Plan was accepted 04/24/12 at 5:00 p.m. The Plan of Action stated, "Action Plan for Immediate Concern April 24, 2012. Director of Nurses (name) and ADON (name) have assessed each resident that have a foley catheter to ensure proper placement and ensure that they are patent. Each Licensed Nurse on duty for the day shift and the evening shift have been inserviced on the Foley Catheter Policy, how to insert a Foley catheter, removal of a foley catheter, and assessing and reporting change of condition to physician Licensed Nursing also inserviced on the notification of Physician upon identification of problems or adverse affects, or changes of condition immediately upon identification. Corporate RN is scheduled to educate all Licensed Nursing Staff on duty on 04/24/12 and will be checked off on demonstrating abilities and skills to insert and remove a foley catheter and adverse signs and symptoms of problematic conditions. As of 04/24/12 at 3:00p.m., no foley catheters will be started or removed by floor nurses until education is complete. As of 04/24/12 at 3:00 p.m., (the) Medical Director notified of Immediate Jeopardy status and the need to send all residents to the E.R. for catheter placement until education is complete with nursing staff. There are 5 total residents identified to have a catheter (this included Resident #3, whohad been discharged ). One resident is in the hospital non-related to catheter problems. (names listed). The plan of action was verified to have been completed as follows: As of 4:00 p.m. on 04/24/12 all of the 4 residents in the facility were assessed by DON and ADON and no residents were identified to have adverse affects with the catheters." Review of the facility's inservice records dated 04/24/12 revealed an inservice given entitled "Catheter (Indwelling), Insertion and removal of (Male and Female), presented by the DON to all licensed staff on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. In an interview on 04/25/12 at 8:20 a.m., the DON said inservices were being given to all licensed staff regarding assessing residents and notifying the physician of changes in condition. Interview on 04/25/12 at 9:00 a.m., the Corporate RN said she had inserviced the 10:00 p.m.-6:00a.m. shift that morning on catheter insertion and removal. On 04/24/12 at 5:00 p.m., the Administrator, DON and ADON were informed the Immediate Jeopardy was removed. The facility remained out of compliance at severity level Actual Harm, and a scope of pattern, because the facility had not yet monitored their plan for effectiveness. The DON provided a current list of four residents having catheters 04/24/12.

Based on interviews and record reviews the facility administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently for one of seven residents (#3) reviewed with changes of condition. The facility administrator failed to: a) supervise nursing staff to ensure residents were assessed and physicians were notified for residents with changes of condition (Resident #3). b) ensure implementation of facility policy and procedures regarding significant change of condition for Resident #3. c) Monitor and supervise the DON to ensure she carried out her responsibilities to direct nursing care to the facility residents including appropriate and adequate training of staff. d) Implement the facility's abuse and neglect policies. The administrator was made aware of Resident #3's catheter complications. e) Act when she became aware that licensed care staff training was needed for catheter placement. The DON failed to: a) Supervise nursing staff to ensure resident assessment for catheter placement were completed; to ensure prompt notification to physicians for residents with catheter complications and change of condition (Resident #3). b) Implement the facility's policies and procedures for notifying resident's primary physicians to ensure timely treatment of [REDACTED]. c) Failure to monitor Resident #3's condition daily to ensure significant resident condition changes were addressed. d) The DON did not supervise licensed nursing staff to ensure Resident #3's abdominal distention, decreased urinary output and abdominal pain were assessed, his primary physician notified and appropriate treatment implemented. Resident #3 had a catheter placed in the facility 03/28/12 and complained of abdominal pain, had abdominal distention and decreased urinary output for two days before he was sent to hospital B, where his catheter was found to have 60cc fluid in a 30cc bulb and Resident #3 had a urethral disruption. Resident #3 had a temporary suprapubic catheter placed at hospital B 03/30/12 and was transferred to hospital A 03/30/12 for placement of a permanent suprapubic catheter. An Immediate Jeopardy identified on 04/24/12 at 1:20 p.m. On 04/24/12 at 5:00 p.m., the Administrator, DON and ADON were informed the Immediate Jeopardy was removed. The facility remained out of compliance at severity level Actual Harm, and a scope of pattern, because the facility had not yet monitored their plan for effectiveness. There were a total of 5 residents with catheters (including Resident #3, who did not return after being admitted to the hsopital 03/30/12) who could be affected by this deficient practice. The residents could experience for catheter-related complications. Findings include: Record review of Resident #3's face sheet revealed he was an [AGE] year old male admitted to the facility 03/28/12. No diagnoses were listed. Review of Resident #3's "Discharge Summary" from hospital A dated 03/28/12 revealed discharge diagnoses of Hematochezia, resolved, Duodenitis, Acute blood loss [MEDICAL CONDITIONS], Hypertension and History of [MEDICAL CONDITION]. In an interview on 04/24/12 at 1:07 p.m., LVN A said on 03/28/12 Resident #3 had not voided for eight hours after his catheter was removed at hospital A. She said she received an order to place a catheter in Resident #3, and that the catheter was placed without difficulty. LVN A said when she started to inflate the catheter bulb, Resident #3 hollered out and complained of pain, so instead of putting 30 cc's of fluid, she only put 10-15 cc in the bulb. She said Resident #3's family expressed concern about his lack of urinary output. Review of Resident #3 nurse's notes on admitted d 03/28/12 at 8:00 p.m. written by LVN A revealed, "This 87 white male admitted at 4:00 p.m. from (hospital A) ...(Hospital A nurse's name) reported removing catheter at 10:20 this a.m. ....notified nurse (nurse's name) at hospital B's clinic of resident current condition that his penis and scrotum is red/[MEDICAL CONDITION], hadn't voided since foley catheter discontinued this a.m. At 6:30 p.m., orders received per Physician D to reinsert foley catheter ...reinserted 16 Fr. French) foley catheter tolerated fair 15 cc bulb out of 30cc noted with 350cc immediate return of blood tinged urine immediate relief..." Review of Resident #3's "Admission Nursing Evaluation" dated 03/28/12, untimed, written by LVN A revealed, "...Treatments/Procedures-foley catheter 16 Fr. (30cc bulb) tolerated 15 cc bulb..." Review of Resident #3's "Daily Skilled Nurse's Note" dated 03/29/12 revealed "...discharge around foley; urine color reddish-yellow, concentrated (day shift), dark amber (night shift)..." In an interview on 04/24/12 at 2:47 p.m., LVN B said on 03/30/12 at the end of her shift, the CNA ' s reported Resident #3had no urine output. She said she looked in Resident #3's urinary collection bag and saw only 25-50 cc's of dark brown urine. She said she tried to wiggle Resident #3's catheter to get urine output without success. Review of Resident #3's nurse's notes written by LVN B dated 03/30/12 at 2:45 p.m. revealed, "...several attempts made to get foley catheter patent and draining with no success." In an interview on 04/23/12 at 3:50 p.m., the DON said Resident #3 could not urinate when he was admitted to the facility. She said a catheter was placed by LVN A with 15cc (cubic centimeters) of fluid placed into the bulb (the part of the catheter inside the bladder to hold the catheter in place). She said there was a 350 cc return of blood-tinged urine. She said Resident #3 had bulges in his penis while in the facility. The DON said Resident #3 had no urine output on 03/30/12, and LVN B tried to get the catheter patent without success. She said LVN C obtained an order to irrigate the catheter on 03/30/12 and instilled 60 cc sterile water into the catheter with a 100 cc return into the collection bag. The DON said Resident #3 complained of burning with urination, and fluids were encouraged. She said Resident #3 had bloody drainage from his penis and that a culture was done with antibiotics started. The DON said that on 03/30/12 at 3:15 p.m., she assessed Resident #3 and his abdomen was distended and hard with decreased bowel sounds. The DON said an ambulance was called and Resident #3 was sent to hospital B. The DON said Resident #3's family came to the facility the next week and discharged him. She said the family told the facility that someone had told them (the family) that the facility needed teaching on catheters. The surveyor asked the DON if in-services on catheters were held after the incident and she stated, "No", that LVN C's documemtation was good. In an interview on 04/24/12 at 9:34 a.m., the DON said she knew there was something wrong with Resident #3's penis while he was at the facility. In an interview on 04/24/12 at 11:00 a.m., the DON was asked if Resident #3's catheter was ever removed by the facility when he had pain and decreased urinary output. She said, "No". In an interview on 04/24/12 at 10:15 a.m., LVN C said Resident #3's penis was swollen and deformed with no urinary output 03/30/12. She said she called the emergency room at hospital B on 03/30/12 and received an order to irrigate the catheter with 60 cc of fluid. LVN C said another nurse (LVN D) had advanced Resident #3's catheter before she irrigated it, so she did not advance it. LVN C said she irrigated the catheter as ordered and got a 100cc return of fluid without resistance. She said Resident #3 had discomfort while she irrigated the catheter, complained of abdominal discomfort, and his abdomen was distended. She said Resident #3 wanted to go to the hospital. She said she called the emergency room at hospital B again, and Resident #3 was sent to hospital B. LVN C said she received a call from hospital B that night and was told Resident #3's plumbing was all messed up". She said on 03/30/12 the DON listened to Resident #3's bowel sounds, and was aware of his decreased urinary output. Review of Resident #3's "Daily Skilled Nurse's Note, side two" dated 03/29/12, written by LVN C revealed "...resident continues with penis swollen and bulging in some areas and slightly red. Continues with bloody drainage top of penis minimal amount. Foley catheter patent and draining amber colored urine with sediment. [MEDICAL CONDITION] he urinates...fluids encouraged ..." In an interview on 04/24/12 at 9:45 a.m., LVN D said Resident #3's penis "was misshapen" with a bulge on one side and two bulges on the other side when she took care of him 03/29/12. She said she obtained a physician's orders [REDACTED]. In an interview on 04/24/12 at 12:55 p.m., CNA A said when she showered Resident #3 03/29/12; his catheter had a small amount of dark orange-brown colored urine in the collection bag. Review of Resident #3's "Daily Skilled Nurse's Note, side two", written by LVN D, undated, revealed "...Ate 100% of both meals...Penis continues to be swollen, and bulging in some areas, bloody drainage noted at tip of penis...spoke with (physician's name) who stated to change MD to (physician's name) and culture penis discharge, after collecting culture-start Bactrim DS..." Review of Resident #3's nurse's notes written by LVN C dated 03/30/12 at 2:50 p.m. revealed "Called E.R. (emergency room at hospital B) back re:output 25cc from 6:00 a.m.-2:00 p.m.....Received call back...advance catheter, check for obstructions. Flush with 60cc sterile H2O (water)/monitor. Foley catheter not kinked, catheter advanced by another nurse. Foley catheter flushed with 60cc sterile H20, resident tolerated well, voiced some discomfort, 100cc return...resident complained burning with urination; fluids encouraged...resident noted with foley catheter draining and patent, dark amber urine with sediment to bed side drainage. Minimal amount of bleeding draining to top of penis, penis continues swollen and bulging in some areas...3:15 p.m., "...Abdomen noted distended hard, complained of abdominal discomfort...called E.R....will monitor. "...3:30 p.m., "Resident requesting to go to hospital, family here and agreed..." 4:00 p.m., Resident in route to (name of hospital)..." ...8:00 p.m., "spoke with (nurse's name) at hospital B, resident to be transferred...plumbing all messed up..." Review of Resident #3's physician orders [REDACTED]." In an interview on 04/24/12 at 10:35 a.m., LVN D said she never advanced Resident #3's catheter. Review of Resident #3's nurse's notes written by LVN E, undated, revealed, "...at 01:25 resident complained of pain to penile/scrotum area. Continues to be swollen and red ..." 03:30...could not obtain UA (urinalysis) due to resident not urinating enough in foley catheter. Fluids encouraged and accepted...06:00; Resident continues to have problems with urination. Output 100cc, no urine in tube. Unable to get UA at this time." Review of Resident #3's nurse's noted dated 03/29/12 at 5:15 a.m. written by LVN E revealed, "...resident continues with blood tinged urine to bed side drainage, bleeding around foley catheter from penis. Penis and scrotum continue to be red and swollen, voices "this hurts and [MEDICAL CONDITION] I pee" , output 200cc...will pass on to next shift to notify MD of problem..." Review of Resident #3's "Treatment Record" revealed the following: 03/28/12 Intake=800cc Output=350cc 03/29/12 Intake=1200cc Output=550cc 03/30/12 Intake=1000cc Output=125cc In an interview on 04/23/12 at 12:05 p.m., Resident #3's daughter said her father had a catheter before while in hospital A that was removed before he was discharged [DATE]. Resident #3's daughter said her father had a catheter placed at the facility after he had not voided for eight hours. She said the nurse who placed it got it in, but the balloon was in the urethra. Resident #3's daughter said Resident #3 was sent to hospital B where the catheter was removed, and a temporary suprapubic catheter was placed. She said Resident #3 had urethral trauma and was sent back to hospital A where he had an emergency permanent suprapubic catheter placed. Resident #3's daughter said the physician who performed the surgery at hospital A told her that Resident #3 may have to keep the suprapubic catheter due to his urethral trauma. In an interview on 04/23/12 at 4:50 p.m., the administrator said Resident #3's family told when they came to the facility to discharge him 04/03/12 that what was wrong with Resident #3 was that his catheter had been placed incorrectly by the facility. In an interview on 04/23/12 at 5:00 p.m., the DON was asked if inservices were given to licensed staff after the administrator was told the facility incorrectly placed Resident #3's catheter. The DON said, "No." In an interview on 04/24/12 at 8:40 a.m., RN A at hospital B confirmed she took care of Resident #3 in the emergency room . The RN said she saw bright red blood and swelling of Resident #3's penis and called the physician in to remove the catheter. The RN said the physician came in and removed the catheter, and that there was more fluid in the bulb than called for. In an interview on 04/24/12 at 6:00 p.m., Physician A said she received Resident #3 at hospital B. She said she went and looked at his abdomen which had obvious palpable bladder distention that "looked like a mass" . Physician A said she deflated Resident #3's catheter balloon and aspirated 60cc of clear fluid from a 30cc balloon. She said there was blood at the meatus of Resident #3's penis. She said she attempted to insert another catheter, but could not advance it, so she placed a temporary suprapubic catheter via his bladder with a large volume of urine returned. Physician A said Resident #3 was transferred to hospital A. Review of Resident #3's emergency room physician's Progress Notes written by Physician A, from hospital B, dated 03/30/12 revealed, "... Palp (palpable) bladder to umbilicus...Old foley removed-~60cc of fluid in a 30cc balloon and blood at meatus. Clotted blood in foley. Attempted to place new foley and got back gross blood. Suprapubic catheter (TLC triple lumen catheter) placed and 640cc urine aspirated .... "Clinical Impression" Acute [MEDICAL CONDITION] traumatic urethral injury." Review of Resident #3's "Emergency Physician Record" from hospital B, written by Physician A revealed, "Progress Notes", "Suprapubic catheter placement. Using sterile technique, 18 gauge needle placed in lower abdomen midline with return of fresh, non-bloody urine. TLC placed using sterile technique. TLC secured into place and 640cc urine aspirated from bladder with relief of discomfort (physician's signature)." In an interview on 04/26/12 at 9:05 a.m., Physician B said when he placed the suprapubic catheter in Resident #3 at hospital A, the urethra had partial disruption with "pretty bad damage." Physician B said he had seen Resident #3 in 2009 for [MEDICAL CONDITIONS]. Review of Resident #3's clinical record at Hospital A dictated by Physician B, dated 03/31/12 revealed, "History and Physical...Chief Complaint:Urethral rupture...he did have a catheter changed some days ago and has been having quite a bit of pain since then. He was seen in the emergency room tonight with no urine output. They did remove his Foley catheter. There was a 30cc balloon, which apparently had 60cc, and they were unable to pass another catheter and did place what appears to be a triple-lumen central line directly into the bladder. I did with a Uro-jet attempt to scope him here. At the mid bulbar urethra, the urethra was severely macerated with a very large false passage and visible fat. I was unable to find the true lumen of the urethra..." Review of Resident #3's clinical record dictated by Physician B at hospital A, dated 03/31/12 revealed, "Operative Report ...Procedure: 1. Cystoscopy. 2. Difficult Foley placement. 3. Suprapubic catheter placement ...At the mid-bulbar urethra, there was severe maceration and disruption of the urethra ...The suprapubic catheter was sutured into position..." Review of the facility's policy received 04/24/12 at 9:55 a.m. "Condition change, of the Resident" revealed, "...Purpose- To observe, record and report any condition change to the attending physician so proper treatment will be implemented....Procedure- 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...observe for pain...if you are unable to reach the attending physician or the physician on call, call the facility medical director...General Resident Care Plan Documentation Guidelines- 1. Identify underlying problem causing the condition change..." Review of the facility's policy received 04/24/12 at 9:34 a.m. "Catheter (indwelling), Insertion and Removal of (female and male), "...Do not force water into balloon. If resistance is encountered or the resident complains of pain, deflate balloon, advance farther into the bladder and inflate..." The Administrator, DON and ADON were notified 04/24/12 at 1:20p.m. of Immediate Jeopardy related to catheters. The facility submitted an Action Plan to decrease the immediacy. The Action Plan was accepted 04/24/12 at 5:00 p.m. The Plan of Action stated, "Action Plan for Immediate Concern April 24, 2012. Director of Nurses (name) and ADON (name) have assessed each resident that have a foley catheter to ensure proper placement and ensure that they are patent. Each Licensed Nurse on duty for the day shift and the evening shift have been inserviced on the Foley Catheter Policy, how to insert a Foley catheter, removal of a foley catheter, and assessing and reporting change of condition to physician Licensed Nursing also inserviced on the notification of Physician upon identification of problems or adverse affects, or changes of condition immediately upon identification. Corporate RN is scheduled to educate all Licensed Nursing Staff on duty on 04/24/12 and will be checked off on demonstrating abilities and skills to insert and remove a foley catheter and adverse signs and symptoms of problematic conditions. As of 04/24/12 at 3:00p.m., no foley catheters will be started or removed by floor nurses until education is complete. As of 04/24/12 at 3:00 p.m., Medical Director notified of Immediate Jeopardy status and the need to send all residents to the E.R. for catheter placement until education is complete with nursing staff. There are 5 total residents identified to have a catheter. One resident is in the hospital non-related to catheter problems. (names listed). As of 4:00 p.m. on 04/24/12 all of the 4 residents in the facility were assessed by DON and ADON and no residents were identified to have adverse affects with the catheters. " Review of the facility's inservice records dated 04/24/12 revealed an inservice given entitled "Catheter (Indwelling), Insertion and removal of (Male and Female)", presented by the DON to all licensed staff on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. In an interview on 04/25/12 at 8:20 a.m., the DON said inservices were being given to all licensed staff regarding assessing residents and notifying the physician of changes in condition. Interview on 04/25/12 at 9:00 a.m., the Corporate RN said she had inserviced the 10:00 p.m.-6:00a.m. shift that morning on catheter insertion and removal. On 04/24/12 at 5:00 p.m., the Administrator, DON and ADON were informed the Immediate Jeopardy was removed. The facility remained out of compliance at severity level Actual Harm, and a scope of pattern, because the facility had not yet monitored their plan for effectiveness. The DON provided a current list of four residents having catheters 04/24/12.

Based on observation, interview, and record review, the facility failed to consult the primary physician of a change in condition for one of seven residents (Resident #3) reviewed with catheters. The facility failed to consult Resident #3's physician when the resident developed abdominal pain and distention, had a significant decrease in urinary output and penis deformity for two days after a catheter was placed. Resident #3 had abdominal pain and distention with decreased urinary output and penis deformity for two days after a catheter was placed. He was sent to the emergency room (hospital B) 03/30/12 where the physician discovered 60 cc fluid in the 30cc catheter bulb with urethral trauma. A temporary suprapubic catheter was placed and Resident #3 was transferred to hospital A and underwent surgery for [REDACTED]. An IJ was identified on 04/24/12. While the IJ was removed 04/24/12, the facility remained out of compliance at a pattern of actual harm because the facility had not yet monitored their plan for effectiveness. This failure could place 5 residents with catheters at risk for not receiving timely medical intervention for catheter-related problems. Findings included: Review of Resident #3's face sheet revealed he was an [AGE] year old male admitted to the facility under the services of Physician C 03/28/12. No diagnoses were listed. Review of Resident #3's "Discharge Summary" from hospital A dated 03/28/12 revealed discharge diagnoses of Hematochezia (the passage of fresh blood through the anus, usually in or with stools. www.medlineplus.com), resolved, Duodenitis, Acute blood loss [MEDICAL CONDITIONS], Hypertension and History of [MEDICAL CONDITION]. In an interview on 04/24/12 at 1:07 p.m., LVN A said Resident #3 had not voided for eight hours after his catheter was removed at hospital A. She said she received an order to place a catheter in Resident #3, and that the catheter was placed without difficulty. LVN A said when she started to inflate the catheter bulb, Resident #3 hollered out and complained of pain, so instead of putting 30 cc's of fluid, she only put 10-15 cc in the bulb. She said Resident #3's family expressed concern about his lack of urinary output. She did not contact Resident #3's physician about this. Review of Resident #3 nurse's notes on admitted d 03/28/12 at 8:00 p.m. written by LVN A revealed, "This 87 white male admitted at 4:00 p.m. from (hospital A) ...(Hospital A nurse's name) reported removing catheter at 10:20 this a.m. ....notified nurse (nurse's name) at hospital B's clinic of resident current condition that his penis and scrotum is red/[MEDICAL CONDITION], hadn't voided since foley catheter discontinued this a.m. At 6:30 p.m., orders received per Physician D to reinsert foley catheter ...reinserted 16 Fr. French) foley catheter tolerated fair 15 cc bulb out of 30cc noted with 350cc immediate return of blood tinged urine immediate relief..." Review of Resident #3's "Admission Nursing Evaluation" dated 03/28/12 written by LVN A revealed, "...Treatments/Procedures-foley catheter 16 Fr. (30cc bulb) tolerated 15 cc bulb ..." Review of Resident #3's "Daily Skilled Nurse's Note" dated 03/29/12 revealed "...discharge around foley; urine color reddish-yellow, concentrated (day shift), dark amber (night shift) ..." In an interview on 04/24/12 at 12:55 p.m., CNA A said when she showered Resident #3 03/29/12 his catheter had a small amount of dark orange-brown colored urine in the collection bag. In an interview on 04/24/12 at 2:47 p.m., LVN B said on 03/30/12 at the end of her shift, the CNA's reported Resident #3 had no urine output. She said she looked in Resident #3's urinary collection bag and saw only 25-50 cc's of dark brown urine. She said she tried to wiggle Resident #3's catheter to get urine output without success. Review of Resident #3's nurse's notes written by LVN B dated 03/30/12 at 2:45 p.m. revealed, "...several attempts made to get foley catheter patent and draining with no success." In an interview on 04/23/12 at 3:50 p.m., the DON said Resident #3 could not urinate when he was admitted to the facility. She said a catheter was placed by LVN A with 15cc (cubic centimeters) of fluid placed into the bulb (the part of the catheter inside the bladder to hold the catheter in place). She said there was a 350 cc return of blood-tinged urine. She said Resident #3 had bulges in his penis while in the facility. The DON said Resident #3 had no urine output on 03/30/12, and LVN B tried to get the catheter patent without success. She said LVN C obtained an order to irrigate the catheter on 03/30/12 and instilled 60 cc sterile water into the catheter with a 100 cc return into the collection bag. The DON said Resident #3 complained of burning with urination, and fluids were encouraged. She aid Resident #3 had bloody drainage from his penis and that a culture was done with antibiotics started. The DON said that on 03/30/12 at 3:15 p.m., she assessed Resident #3 and his abdomen was distended and hard with decreased bowel sounds. The DON said an ambulance was called and Resident #3 was sent to hospital B. The DON said Resident #3's family came to the facility the next week and discharged him. She said the family told the facility that someone had told them (the family) that the facility needed teaching on catheters. The surveyor asked the DON if the physician was notified or in-services on catheters were held after the incident and she stated, "No", that LVN C's documentation was good. In an interview on 04/24/12 at 9:34 a.m., the DON said she knew there was something wrong with Resident #3's penis while he was in the facility. In an interview on 04/24/12 at 11:00 a.m., the DON was asked if Resident #3's catheter was ever removed by the facility when he had pain and decreased urinary output. She said, "No" . In an interview on 04/24/12 at 10:15 a.m., LVN C said Resident #3's penis was swollen and deformed with no urinary output 03/30/12. She said she called the emergency room at hospital B on 03/30/12 and received a telephone order from Physician D order to irrigate the catheter with 60 cc of fluid. LVN C said another nurse had advanced Resident #3's catheter before she irrigated it, so she did not advance it. LVN C said she irrigated the catheter as ordered and got a 100cc return of fluid without resistance. She said Resident #3 had discomfort while she irrigated the catheter, complained of abdominal discomfort, and his abdomen was distended. She said Resident #3 wanted to go to the hospital. She said she called the emergency room at hospital B again, and Resident #3 was sent to hospital B. LVN C said she received a call from hospital B that night and was told Resident #3's "plumbing was all messed up" . She said on 03/30/12 the DON listened to Resident #3's bowel sounds, and was aware of his decreased urinary output. Review of Resident #3's "Daily Skilled Nurse's Note, side two" written by LVN C dated 03/29/12, revealed "...resident continues with penis swollen and bulging in some areas and slightly red. Continues with bloody drainage top of penis minimal amount. Foley catheter patent and draining amber colored urine with sediment. [MEDICAL CONDITION] he urinates ...fluids encouraged ..." . There was no documentation of the physician being notified. Review of Resident #3's nurse's notes written by LVN C dated 03/30/12 at 2:50 p.m. revealed "Called E.R. (emergency room at hospital B) back re: output 25cc from 6:00 a.m.-2:00 p.m. ....Received call back ...advance catheter, check for obstructions. Flush with 60cc sterile H2O (water)/monitor. Foley catheter not kinked, catheter advanced by another nurse. Foley catheter flushed with 60cc sterile H20, resident tolerated well, voiced some discomfort, 100cc return ...resident complained burning with urination; fluids encouraged ...resident noted with foley catheter draining and patent, dark amber urine with sediment to bed side drainage. Minimal amount of bleeding draining to top of penis, penis continues swollen and bulging in some areas...3:15 p.m., "...Abdomen noted distended hard, complained of abdominal discomfort...called E.R....will monitor. "...3:30 p.m., "Resident requesting to go to hospital, family here and agreed ..." 4:00 p.m., Resident in route to (name of hospital) ... "...8:00 p.m., "spoke with (nurse's name) at (hospital name), resident to be transferred...plumbing all messed up ..." Review of Resident #3's telephone order given by Physician D at hospital B clinic, dated 03/30/12 written by LVN C (no time) revealed, "Advance catheter, check for obstruction, flush with 60cc sterile H2O, monitor." In an interview on 04/24/12 at 9:45 a.m., LVN D said Resident #3's penis "was misshapen" with a bulge on one side and two bulges on the other side. She said she obtained a physician's orders [REDACTED]. The physician was not notified of Resident #3's penis being misshaped. In an interview on 04/24/12 at 10:35 a.m., LVN D said she never advanced Resident #3's catheter. Review of Resident #3's "Daily Skilled Nurse's Note, side two" written by LVN D, undated, revealed "...Ate 100% of both meals...Penis continues to be swollen, and bulging in some areas, bloody drainage noted at tip of penis ...spoke with (physician's name) who stated to change MD to (physician's name) and culture penis discharge, after collecting culture-start Bactrim DS..." Review of Resident #3's nurse's noted dated 03/29/12 at 5:15 a.m. written by LVN E revealed, "...resident continues with blood tinged urine to bed side drainage, bleeding around foley catheter from penis. Penis and scrotum continue to be red and swollen, voices "this hurts and [MEDICAL CONDITION] I pee" , output 200cc...will pass on to next shift to notify MD of problem ..." Review of Resident #3's nurse's notes written by LVN E, undated, revealed, "...at 01:25 resident complained of pain to penile/scrotum area. Continues to be swollen and red ..." ...03:30...could not obtain UA (urinalysis) due to resident not urinating enough in foley catheter. Fluids encouraged and accepted...06:00; Resident continues to have problems with urination. Output 100cc, no urine in tube. Unable to get UA at this time." Review of Resident #3's "Treatment Record" revealed the following: 03/28/12 Intake=800cc Output=350cc 03/29/12 Intake=1200cc Output=550cc 03/30/12 Intake=1000cc Output=125cc In an interview on 04/23/12 at 12:05 p.m., Resident #3's daughter said her father had a catheter before while in hospital A that was removed before he was discharged [DATE]. Resident #3's daughter said her father had a catheter placed at the facility after he had not voided for eight hours. She said the nurse who placed it got it in, but the balloon was in the urethra. Resident #3's daughter said Resident #3 was sent to hospital B where the catheter was removed, and a temporary suprapubic catheter was placed. She said Resident #3 had urethral trauma and was sent back to hospital A where he had an emergency permanent suprapubic catheter placed. Resident #3's daughter said the physician who performed the surgery at hospital A told her that Resident #3 may have to keep the suprapubic catheter due to his urethral trauma. In an interview on 04/23/12 at 4:50 p.m., the administrator said Resident #3's family came to the facility to discharge him 04/03/12 and said they were told what was wrong with Resident #3 was that his catheter had been placed incorrectly by the facility. In an interview on 04/23/12 at 5:00 p.m., the DON was asked if inservices were given to licensed staff after the administrator was told the facility incorrectly placed Resident #3's catheter. The DON said, "No". In an interview on 04/24/12 at 8:40 a.m., RN A at hospital B confirmed she took care of Resident #3 in the emergency room . The RN said she saw bright red blood and swelling of Resident #3's penis and called Physician A in to remove the catheter. The RN said the physician came in and removed the catheter, and that there was more fluid in the bulb than called for. In an interview on 04/24/12 at 6:00 p.m., Physician A said she received Resident #3 at hospital B. She said she went and looked at his abdomen which had obvious palpable bladder distention that "looked like a mass". Physician A said she deflated Resident #3's catheter balloon and aspirated 60cc of clear fluid from a 30cc balloon. She said there was blood at the meatus of Resident #3's penis. She said she attempted to insert another catheter, but could not advance it, so she placed a temporary suprapubic catheter via his bladder with a large volume of urine returned. Physician A said Resident #3 was transferred to hospital A. Review of Resident #3's emergency room physician's Progress Notes from hospital B written by Physician A, revealed, "... Palp (palpable) bladder to umbilicus ...Old foley removed-~60cc of fluid in a 30cc balloon and blood at meatus. Clotted blood in foley. Attempted to place new foley and got back gross blood. Suprapubic catheter (TLC triple lumen catheter) placed and 640cc urine aspirated .... "Clinical Impression", Acute [MEDICAL CONDITION] traumatic urethral injury." Review of Resident #3's "Emergency Physician Record" written by Physician A from hospital B, revealed, "Progress Notes", "Suprapubic catheter placement. Using sterile technique, 18 gauge needle placed in lower abdomen midline with return of fresh, non-bloody urine. TLC placed using sterile technique. TLC secured into place and 640cc urine aspirated from bladder with relief of discomfort (physician's signature)." In an interview on 04/26/12 at 9:05 a.m., Physician B said when he placed the suprapubic catheter in Resident #3, the urethra had partial disruption with "pretty bad damage." Review of Resident #3's clinical record dictated by Physician B at Hospital A revealed, "History and Physical... Chief Complaint: Urethral rupture...he did have a catheter changed some days ago and has been having quite a bit of pain since then. He was seen in the emergency room tonight with no urine output. They did remove his Foley catheter. There was a 30cc balloon, which apparently had 60cc, and they were unable to pass another catheter and did place what appears to be a triple-lumen central line directly into the bladder. I did with a Uro-jet attempt to scope him here. At the mid bulbar urethra, the urethra was severely macerated with a very large false passage and visible fat. I was unable to find the true lumen of the urethra ..." Review of Resident #3's clinical record dictated by Physician B at hospital A, revealed, "Operative Report...Procedure: 1. Cystoscopy. 2. Difficult Foley placement. 3. Suprapubic catheter placement ...At the mid-bulbar urethra, there was severe maceration and disruption of the urethra ...The suprapubic catheter was sutured into position ..." The Administrator, DON and ADON were notified 04/24/12 at 1:20p.m. of Immediate Jeopardy related to catheters. The facility submitted an Action Plan to decrease the immediacy. The Action Plan was accepted 04/24/12 at 5:00 p.m. The Plan of Action stated, "Action Plan for Immediate Concern April 24, 2012. Director of Nurses (name) and ADON (name) have assessed each resident that have a foley catheter to ensure proper placement and ensure that they are patent. Each Licensed Nurse on duty for the day shift and the evening shift have been inserviced on the Foley Catheter Policy, how to insert a Foley catheter, removal of a foley catheter, and assessing and reporting change of condition to physician Licensed Nursing also inserviced on the notification of Physician upon identification of problems or adverse affects, or changes of condition immediately upon identification. Corporate RN is scheduled to educate all Licensed Nursing Staff on duty on 04/24/12 and will be checked off on demonstrating abilities and skills to insert and remove a foley catheter and adverse signs and symptoms of problematic conditions. As of 04/24/12 at 3:00p.m., no foley catheters will be started or removed by floor nurses until education is complete. As of 04/24/12 at 3:00 p.m., Medical Director notified of Immediate Jeopardy status and the need to send all residents to the E.R. for catheter placement until education is complete with nursing staff. There are 5 total residents identified to have a catheter. One resident is in the hospital non-related to catheter problems. (names listed)." The plan of action was verified to have been completed as follows: As of 4:00 p.m. on 04/24/12 all of the 4 residents in the facility were assessed by DON and ADON and no residents were identified to have adverse affects with the catheters." Review of the facility's inservice records dated 04/24/12 revealed an inservice given entitled "Catheter (Indwelling), Insertion and removal of (Male and Female)", presented by the DON to all licensed staff on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. In an interview on 04/25/12 at 8:20 a.m., the DON said inservices were being given to all licensed staff regarding assessing residents and notifying the physician of changes in condition. Interview on 04/25/12 at 9:00 a.m., the Corporate RN said she had inserviced the 10:00 p.m.-6:00a.m. shift that morning on catheter insertion and removal. On 04/24/12 at 5:00 p.m., the Administrator, DON and ADON were informed the Immediate Jeopardy was removed. The facility remained out of compliance at severity level Actual Harm, and a scope of pattern, because the facility had not yet monitored their plan for effectiveness. The DON provided a current list of four residents having catheters 04/24/12.

Based on interviews and record reviews the facility failed to implement written policies and procedures that prohibit neglect of residents. The facility failed to ensure appropriate training and monitoring of catheter insertion and care to licensed staff, resulting in physical harm to one of seven residents (#3) reviewed for a change in condition as evidenced by: a) failure to thoroughly assess and consult with Resident #3's primary physician in a timely manner after the resident complained of abdominal pain, had a distended bladder, a significant decrease in urinary output and penis deformity for two days after a catheter was placed. This failure resulted in Resident #3 being transported to hospital B for removal of his catheter and placement of a temporary suprapubic catheter. Resident #3 was then transported to hospital A and underwent surgery for [REDACTED]. An IJ was identified on 04/24/12. While the IJ was removed 04/24/12, the facility remained out of compliance at a pattern of actual harm because the facility had not yet monitored their plan for effectiveness. Any of the five residents with catheters (which inclulded Resident #3) in the facility could be affected by these deficient practices. Findings include: Record review of Resident #3's face sheet revealed he was an [AGE] year old male admitted to the facility 03/28/12. No diagnoses were listed. Review of Resident #3's "Discharge Summary" from hospital A dated 03/28/12 revealed discharge diagnoses of Hematochezia (the passage of blood in the feces. Source www.medlineplus.com), resolved, Duodenitis, Acute blood loss [MEDICAL CONDITIONS], Hypertension and History of [MEDICAL CONDITION]. In an interview on 04/24/12 at 1:07 p.m., LVN A said Resident #3 had not voided for eight hours after his catheter was removed at hospital A. She said she received an order to place a catheter in Resident #3, and that the catheter was placed without difficulty. LVN A said when she started to inflate the catheter bulb, Resident #3 hollered out and complained of pain, so instead of putting 30 cc's of fluid, she only put 10-15 cc in the bulb. She said Resident #3's family expressed concern about his lack of urinary output. Review of Resident #3's nurse's notes dated 03/28/12 at 8:00 p.m. written by LVN A revealed, "This 87 white male admitted from hospital A ...(hospital nurse's name) reported removing catheter at 10:20 this a.m. ....notified nurse (nurse's name) at hospital B clinic of resident current condition that his penis and scrotum is red/[MEDICAL CONDITION], hadn't voided since foley catheter discontinued this a.m. At 6:30 p.m., orders received per Physician D to reinsert foley catheter ...reinserted 16 Fr. French) foley catheter tolerated fair 15 cc bulb out of 30cc noted with 350cc immediate return of blood tinged urine immediate relief ... " Review of Resident #3's "Admission Nursing Evaluation" written by LVN A dated 03/28/12 revealed, "...Treatments/Procedures-foley catheter 16 Fr. (30cc bulb) tolerated 15 cc bulb..." Review of Resident #3's "Daily Skilled Nurse's Note" dated 03/29/12 revealed "...discharge around foley; urine color reddish-yellow, concentrated (day shift), dark amber (night shift) ..." Review of Resident #3's nurse's noted dated 03/29/12 at 5:15 a.m. written by LVN E revealed, "...resident continues with blood tinged urine to bed side drainage, bleeding around foley catheter from penis. Penis and scrotum continue to be red and swollen, voices "this hurts and [MEDICAL CONDITION] I pee" , output 200cc...will pass on to next shift to notify MD of problem ..." Review of Resident #3's "Daily Skilled Nurse's Note, side two" , written by LVN D, undated, revealed "...Ate 100% of both meals...Penis continues to be swollen, and bulging in some areas, bloody drainage noted at tip of penis...spoke with (physician's name) who stated to change MD to (physician's name) and culture penis discharge, after collecting culture-start Bactrim DS..." Review of Resident #3's "Daily Skilled Nurse's Note, side two" dated 03/29/12 written by LVN C, revealed "...resident continues with penis swollen and bulging in some areas and slightly red. Continues with bloody drainage top of penis minimal amount. Foley catheter patent and draining amber colored urine with sediment. [MEDICAL CONDITION] he urinates...fluids encouraged ..." In an interview on 04/24/12 at 2:47 p.m., LVN B said on 03/30/12 at the end of her shift, the CNA's reported Resident #3 had no urine output. She said she looked in Resident #3 ' s urinary collection bag and saw only 25-50 cc's of dark brown urine. She said she tried to wiggle Resident #3's catheter to get urine output without success. Review of Resident #3's nurse's notes written by LVN B dated 03/30/12 at 2:45 p.m. revealed, "...several attempts made to get foley catheter patent and draining with no success." In an interview on 04/23/12 at 3:50 p.m., the DON said Resident #3 could not urinate when he was admitted to the facility 03/28/12 at 4:00 p.m. She said a catheter was placed by LVN A with 15cc (cubic centimeters) of fluid placed into the bulb (the part of the catheter inside the bladder to hold the catheter in place). She said there was a 350 cc return of blood-tinged urine. She said Resident #3 had bulges in his penis while in the facility. The DON said Resident #3 had no urine output on 03/30/12, and LVN B tried to get the catheter patent without success. She said LVN C obtained an order to irrigate the catheter on 03/30/12 and instilled 60 cc sterile water into the catheter with a 100 cc return into the collection bag. The DON said Resident #3 complained of burning with urination, and fluids were encouraged. She aid Resident #3 had bloody drainage from his penis and that a culture was done with antibiotics started. The DON said that on 03/30/12 at 3:15 p.m., she assessed Resident #3 and his abdomen was distended and hard with decreased bowel sounds. The DON said an ambulance was called and Resident #3 was sent to hospital B. The DON said Resident #3 ' s family came to the facility the next week and discharged him. She said the family told the facility that someone had told them (the family) that the facility needed teaching on catheters. The surveyor asked the DON if in-services on catheters were held after the incident and she stated, "No". In an interview on 04/24/12 at 9:34 a.m., the DON said she knew there was something wrong with Resident #3's penis while he was in the facility. In an interview on 04/24/12 at 11:00 a.m., the DON was asked if Resident #3's catheter was ever removed by the facility or his physician notified when he had pain and decreased urinary output. She said, "No", that LVN C's documentation was good . In an interview on 04/24/12 at 10:15 a.m., LVN C said Resident #3's penis was swollen and deformed with no urinary output. She said she called the emergency room at hospital B on 03/30/12 and received an order to irrigate the catheter with 60 cc of fluid. LVN C said another nurse had advanced Resident #3's catheter before she irrigated it, so she did not advance it. LVN C said she irrigated the catheter as ordered and got a 100cc return of fluid without resistance. She said Resident #3 had discomfort while she irrigated the catheter, complained of abdominal discomfort, and his abdomen was distended. She said Resident #3 wanted to go to the hospital. She said she called the emergency room at hospital B again, and Resident #3 was sent to hospital B. LVN C said she received a call from hospital B that night and was told Resident #3's "plumbing was all messed up" . She said on 03/30/12 the DON listened to Resident #3's bowel sounds, and was aware of his decreased urinary output. Review of Resident #3's nurse's notes written by LVN C dated 03/30/12 at 2:50 p.m. revealed "Called E.R. (emergency room ) back re: output 25cc from 6:00 a.m.-2:00 p.m. ....Received call back...advance catheter, check for obstructions. Flush with 60cc sterile H2O (water)/monitor. Foley catheter not kinked, catheter advanced by another nurse. Foley catheter flushed with 66cc sterile H20, resident tolerated well, voiced some discomfort, 100cc return...resident complained burning with urination; fluids encouraged...resident noted with foley catheter draining and patent, dark amber urine with sediment to bed side drainage. Minimal amount of bleeding draining to top of penis, penis continues swollen and bulging in some areas...3:15 p.m., "...Abdomen noted distended hard, complained of abdominal discomfort...called E.R....will monitor. "...3:30 p.m., "Resident requesting to go to hospital, family here and agreed... "4:00 p.m., Resident in route to (name of hospital) ..." ...8:00 p.m., "spoke with (nurse's name) at (hospital name), resident to be transferred ...plumbing all messed up..." Review of Resident #3's physician orders [REDACTED]." In an interview on 04/24/12 at 10:35 a.m., LVN D said she never advanced Resident #3's catheter. In an interview on 04/24/12 at 9:45 a.m., LVN D said Resident #3's penis "was misshapen" with a bulge on one side and two bulges on the other side. She said she obtained a physician's orders [REDACTED]. Review of Resident #3's nurse's notes written by LVN E, undated, revealed, "...at 01:25 resident complained of pain to penile/scrotum area. Continues to be swollen and red... " 03:30...could not obtain UA (urinalysis) due to resident not urinating enough in foley catheter. Fluids encouraged and accepted...06:00; Resident continues to have problems with urination. Output 100cc, no urine in tube. Unable to get UA at this time." Review of Resident #3's "Treatment Record" revealed the following: 03/28/12 Intake=800cc Output=350cc 03/29/12 Intake=1200cc Output=550cc 03/30/12 Intake=1000cc Output=125cc Review of Resident #3's "Plan of Care" dated 03/30/12 revealed, "Problems/Strengths-Risk for UTI (urinary tract infection) due to indwelling catheter-Goals-No signs of UTI: fever: cloudy, bloody, or discolored urine: scant output or odor...Interventions- Monitor indwelling catheter and change catheter or bag when needed; Monitor for sediment, cloudy odor, blood amount; Report problems with urine or fever promptly to MD; Encourage fluids; Monitor lab as ordered; Turn every two hours and monitor skin for redness; Good peri care..." In an interview on 04/24/12 at 12:55 p.m., CNA A said when she showered Resident #3 03/29/12, his catheter had a small amount of dark orange-brown colored urine in the collection bag. In an interview on 04/23/12 at 12:05 p.m., Resident #3's daughter said her father had a catheter before while in hospital A that was removed before he was discharged [DATE]. Resident #3's daughter said her father had a catheter placed at the facility after he had not voided for eight hours. She said the nurse (LVN A) who placed it got it in, but the balloon was in the urethra. Resident #3's daughter said Resident #3 was sent to hospital B where the catheter was removed, and a temporary suprapubic catheter was placed. She said Resident #3 had urethral trauma and was sent back to hospital A where he had an emergency permanent suprapubic catheter placed. Resident #3's daughter said the physician who performed the surgery at hospital A told her that Resident #3 may have to keep the suprapubic catheter due to his urethral trauma. In an interview on 04/23/12 at 4:50 p.m., the administrator said Resident #3's family came to the facility and discharged him 04/03/12. The Administrator said the family told her they had been told that what was wrong with Resident #3 was that his catheter had been placed incorrectly by the facility. In an interview on 04/23/12 at 5:00 p.m., the DON was asked if inservices were given to licensed staff after the administrator was told the facility incorrectly placed Resident #3's catheter. The DON said, "No." In an interview on 04/24/12 at 8:40 a.m., RN A at hospital B confirmed she took care of Resident #3 in the emergency room . The RN said she saw bright red blood and swelling of Resident #3's penis and called the physician in to remove the catheter. The RN said the physician came in and removed the catheter, and that there was more fluid in the bulb than called for. In an interview on 04/24/12 at 6:00 p.m., Physician A said she received Resident #3 at hospital B. She said she went and looked at his abdomen which had obvious palpable bladder distention that "looked like a mass". Physician A said she deflated Resident #3's catheter balloon and aspirated 60cc of clear fluid from a 30cc balloon. She said there was blood at the meatus of Resident #3's penis. She said she attempted to insert another catheter, but could not advance it, so she placed a temporary suprapubic catheter via his bladder with a large volume of urine returned. Physician A said Resident #3 was transferred to hospital A. Review of Resident #3's emergency room physician's Progress Notes written by Physician A from hospital B, revealed, "... Palp (palpable) bladder to umbilicus...Old foley removed-~60cc of fluid in a 30cc balloon and blood at meatus. Clotted blood in foley. Attempted to place new foley and got back gross blood. Suprapubic catheter (TLC triple lumen catheter) placed and 640cc urine aspirated .... "Clinical Impression" Acute [MEDICAL CONDITION] traumatic urethral injury." Review of Resident #3's "Emergency Physician Record" written by Physician A, from hospital B revealed, "Progress Notes", "Suprapubic catheter placement. Using sterile technique, 18 gauge needle placed in lower abdomen midline with return of fresh, non-bloody urine. TLC placed using sterile technique. TLC secured into place and 640cc urine aspirated from bladder with relief of discomfort (physician's signature)." In an interview on 04/26/12 at 9:05 a.m., Physician B said when he placed the suprapubic catheter in Resident #3, the urethra had partial disruption with "pretty bad damage. " Review of Resident #3's clinical record dictated by Physician B at Hospital A revealed, "History and Physical... Chief Complaint: Urethral rupture...he did have a catheter changed some days ago and has been having quite a bit of pain since then. He was seen in the emergency room tonight with no urine output. They did remove his Foley catheter. There was a 30cc balloon, which apparently had 60cc, and they were unable to pass another catheter and did place what appears to be a triple-lumen central line directly into the bladder. I did with a Uro-jet attempt to scope him here. At the mid bulbar urethra, the urethra was severely macerated with a very large false passage and visible fat. I was unable to find the true lumen of the urethra ..." Review of Resident #3's clinical record dictated by Physician B at hospital A revealed, "Operative Report...Procedure: 1. Cystoscopy. 2. Difficult Foley placement. 3. Suprapubic catheter placement ...At the mid-bulbar urethra, there was severe maceration and disruption of the urethra ...The suprapubic catheter was sutured into position..." Review of the facility's policy received 04/24/12 at 9:55 a.m. "Condition change, of the Resident" revealed, "...Purpose- To observe, record and report any condition change to the attending physician so proper treatment will be implemented ....Procedure- 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...observe for pain...if you are unable to reach the attending physician or the physician on call, call the facility medical director...General Resident Care Plan Documentation Guidelines- 1. Identify underlying problem causing the condition change ..." Review of the facility's policy received 04/24/12 at 9:34 a.m. "Catheter (indwelling), Insertion and Removal of (female and male), " "...Do not force water into balloon. If resistance is encountered or the resident complains of pain, deflate balloon, advance farther into the bladder and inflate ..." The DON provided a list of five residents having catheters 04/24/12.