Every finding on record at White Oak Post Acute Care

Based on observation, interviews, and record review the facility failed to ensure residents were free of medication errors for 1 (#R7) of 2 residents observed during medication pass. The facility failed to ensure Resident #R7 received his Hyperkalemia medication as ordered by the physician. Findings: Review of the facility's undated policy titled, Medications-Administering revealed the following, in part:Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3.) Medications must be administered in accordance with the orders, including any required time frame. 7.) The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of Resident #R7's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Chronic Kidney Disease, Stage 3 and Hyperkalemia. Review of Resident #R7's current Physician's Orders revealed the following, in part: Start Date: 07/14/2026 - Lokelma Oral Packet 10 GM-Give 1 packet by mouth two times a day related to Chronic Kidney Disease, Stage 3 - Scheduled at 8:00 a.m. and 8:00 p.m. On 08/19/2026 at 08:30 a.m., an observation was made of Resident #R7's 08:00 a.m. medication administration performed with S3LPN. S3LPN was observed to administer one Lokelma 5 GM packet to Resident #R7. On 08/19/2026 at 11:50 a.m., an interview was conducted with S3LPN. S3LPN confirmed she administered one packet of Lokelma 5 GM to Resident #R7. She reviewed and confirmed Resident #R7's Physician's Order was for Lokelma 10 GM and she had administered one 5 GM packet. S3LPN confirmed Resident #R7 should have received 10 GM of Lokelma.On 08/19/2026 at 12:00 p.m., an interview was conducted with S1DON. S1DON reviewed and confirmed Resident #R7 should receive 1 packet of 10 GM Lokelma.On 08/19/2026 at 2:29 p.m., an interview was conducted with S2NP. S2NP stated he was made aware resident #R7 had received 5 GM of Lokelma instead of the ordered 10 GM. S2NP stated Resident #R7's potassium levels had been reviewed and had remained within normal limits. S2NP stated Resident #R7's ordered dosage was Lokelma 10 GM and he would receive Lokelma 10 GM going forward.

Based on observations, record review and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure temperatures were documented for the medication refrigerator in 1 of 1 (Med Room A) medication storage rooms observed. Findings: On 06/01/2026 at 9:15 a.m., an observation was made of Med Room A with S3ADON. Review of the form titled Nursing Refrigerator Checklist dated May 2026, for the refrigerator located in Med Room A revealed no documentation of temperatures for 05/23/2026, 05/24/2026, and 05/29/2026 - 05/31/2026. On 06/01/2026 at 9:20 a.m., an interview was conducted with S3ADON. She reviewed the form titled Nursing Refrigerator Checklist dated May 2026 and confirmed there were no temperatures documented for 05/23/2026, 05/24/2026, and 05/29/2026 - 05/31/2026. She stated night shift nurses were responsible for documenting the medication refrigerator temperatures each night. On 06/03/2026 at 11:48 a.m., an interview was conducted with S2DON. She reviewed the form titled Nursing Refrigerator Checklist dated May 2026 for the refrigerator located in Med Room A and confirmed there were no temperatures documented for 05/23/2026, 05/24/2026, and 05/29/2026 - 05/31/2026. S2DON confirmed the temperatures of the medication refrigerator should have been documented daily by the night shift nurses, and were not.

Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 2 (#57 and #58) of 34 residents reviewed during the initial pool. Findings: Review of the facility's undated policy titled Call Lights: Accessibility and Timely Response revealed the following, in part:Policy:The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside. to allow residents to call for assistance.Policy Explanation and Compliance Guidelines:4. Staff will ensure the call light is within reach of resident. Resident #57Review of Resident #57's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Generalized Muscle Weakness, Greenstick Fracture of Shaft of Humerus Right Arm with Routine Healing, and Other Abnormalities of Gait and Mobility. Review of Resident #57's Quarterly MDS with an ARD of 04/23/2026, revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed Resident #57 had a functional limitation affecting one side of her upper and lower extremity, was always incontinent of bowel and dependent on staff assistance for toileting hygiene. Review of Resident #57's current Care Plan revealed the resident had a history of Greenstick Fracture to Right Arm. Interventions included to ensure the resident's call light is within reach. An observation was made on 06/01/2026 at 8:56 a.m. of Resident #57 in her room. She was lying in bed and her call light was observed inside the resident's laundry basket out of reach. An interview was conducted at this time and Resident #57 stated she was not sure where her call light was and it had been missing for a while. She stated she used her call light when she needed help from staff. She confirmed she could not reach her call light. An observation and interview was conducted on 06/01/2026 at 9:05 a.m. with S6CNA. S6CNA stated Resident #57 used her call light to call staff for assistance and it should be kept in reach. S6CNA observed and confirmed Resident #57's call light was inside her laundry basket and out of the resident's reach. Resident #58Review of Resident #58's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Morbid Obesity Due To Excess Calories, Chronic Combined Systolic and Diastolic Congestive Heart Failure, Generalized Muscle Weakness, and Acquired Absence of Right Leg Below Knee. Review of Resident #58's Quarterly MDS with an ARD of 05/22/2026, revealed a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed Resident #58 was always incontinent of bowel and bladder and was dependent on staff assistance for toileting hygiene. Review of Resident #58's current Care Plan revealed the resident was at risk for falls. Interventions included to ensure the resident's call light is within reach. An observation was made on 06/01/2026 at 10:05 a.m. of Resident #58 in her room. She was lying in bed and her call light was observed hanging below the side rail. An interview was conducted at this time and Resident #58 stated she used her call light when she needed staff assistance. She confirmed her call light was out of reach. An observation and interview was conducted on 06/01/2026 at 10:07 a.m. with S8CNA. S8CNA stated Resident #58 used her call light when she needed staff assistance. S8CNA observed and confirmed Resident #58's call light was out of reach. S8CNA confirmed Resident #58's call light should be kept in reach. An observation was made on 06/02/2026 at 8:20 a.m. of Resident #58 in her room. She was lying in bed and her call light was observed hanging below the side rail near the floor. An interview was conducted at this time and Resident #58 stated she was not able to reach her call light. An observation and interview was conducted on 06/02/2026 at 8:23 a.m. with S10LPN. S10LPN stated Resident #58 used her call light to communicate to staff when she needed to be changed and if she needed assistance. S10LPN observed and confirmed Resident #58's call light was out of reach and should be kept in reach. An interview was conducted on 06/02/2026 at 2:35 p.m. with S2DON. S2DON was made aware of the above findings. S2DON confirmed if a resident can use their call light, then their call lights should be kept in reach.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1 (#57) of 25 residents reviewed in the final sample. The facility failed to ensure Resident #57's urinary catheter securement device was in place at all times.Findings: Review of the facility's undated policy titled Physician Services/Physician Orders revealed the following, in part:Policy Interpretation and Implementation:3. Staff will follow and implement all physician orders in accordance with plan of care. Resident #57Review of Resident #57's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Neuromuscular Dysfunction of Bladder and Other Disorders of Urinary System. Review of Resident #57's Quarterly MDS with an ARD of 04/23/2026, revealed the resident had an indwelling catheter. Review of Resident #57's current Physician Orders revealed the following, in part:Start date: 01/06/2026-Urinary Catheter: Change Suprapubic Catheter securement device every day shift starting on the 6th and ending on the 6th every month related to Neuromuscular Dysfunction of Bladder. Review of Resident #57's current Care Plan revealed the resident was had an Indwelling Suprapubic Catheter, Neurogenic Bladder, and risk for infection. An observation was made on 06/01/2026 at 9:15 a.m. of S6CNA and S7CNA performing ADL care for Resident #57. Resident #57's suprapubic catheter tubing was observed stretched out in the resident's abdominal fold with no securement device. An observation was made on 06/02/2026 at 7:45 a.m. of S9WC performing catheter care for Resident #57. Resident #57's suprapubic catheter tubing was observed stretched out in the resident's abdominal fold with no securement device. An interview was conducted on 06/02/2026 at 8:10 a.m. with S9WC. She confirmed Resident #57's suprapubic catheter tubing did not have a securement device and should have. She stated the purpose of catheter securement device was to prevent the catheter from being pulled on or pulled out. An interview was conducted on 06/02/2026 at 8:17 a.m. with S10LPN. She verified she was the nurse assigned to Resident #57 on 06/01/2026 and 06/02/2026. She was made of aware of the observations on 06/01/2026 and 06/02/2026 of no securement device to Resident #57's suprapubic catheter. She stated Resident #57's catheter should have been secured at all times to prevent it from being pulled on or out. An interview was conducted on 06/02/2026 at 12:55 p.m. with S6CNA. She confirmed on 06/01/2026, Resident #57's catheter had no securement device. She stated Resident #57's catheter should have been secured so it does not get pulled on or out. An interview was conducted on 06/02/2026 at 2:35 p.m. with S2DON. She stated Resident #57's suprapubic catheter should be secured to prevent the catheter from being pulled on or out. She confirmed physician orders for Resident #57's catheter should have been followed.

Based on observations, interviews, and record review, the facility failed to ensure a resident received proper treatment and care to maintain good foot health by failing to maintain proper toenail length for 1 (#34) of 3 residents observed for foot care.Findings: Review of the facility's policy titled, Nail Care revealed the following, in part:Policy: The purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Policy Explanation and Compliance Guidelines:1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.3. Principles of nail care:c. if a resident has a toe infection, Diabetes Mellitus or Peripheral Vascular Disease, toenail trimming should be performed by a physician or practitioner. Review of Resident #34's Clinical Record revealed an admission date of 11/28/2025 and diagnoses, which included Type 2 Diabetes Mellitus, Chronic Venous Hypertension with Ulcer and Inflammation of Left Lower Extremity, Chronic Venous Insufficiency, and Morbid Obesity. Review of Resident #34's Quarterly MDS with an ARD of 03/06/2026 revealed a BIMS of 15, which indicated intact cognition. Further review revealed supervision or touching assistance with personal hygiene. Review of Resident #34's current Physician orders revealed daily treatment to a Left Lower Leg Vascular Wound. Review of Resident #34's current Care Plan revealed no documentation pertaining to foot care. Review of Resident #34's Clinical Record revealed no documentation he had been seen by a Podiatrist. An observation was made of Resident #34 on 06/01/2026 at 8:55 a.m. Resident #34's bilateral toenails were thick and long, extending past the tips of his toes. An interview was conducted with Resident #34 at that time. Resident #34 stated nobody had offered to trim his toenails but he needed them cut. Resident #34 stated his toenails were too long. An observation was made of Resident #34 on 06/02/2026 at 9:40 a.m. Resident #34's bilateral toenails were thick and long, extending past the tips of his toes. An interview was conducted with S16CNA on 06/02/2026 at 9:43 a.m. She stated wound care nurses were responsible for all residents' toenail care. She stated there was also a Podiatrist who came to the facility and trimmed toenails. She confirmed Resident #34's toenails were too long and needed to be trimmed. She stated she previously reported to S5LPN Resident #34's toenails needed to be trimmed. An interview was conducted with S5LPN on 06/02/2026 at 9:46 a.m. She stated she was responsible to assess residents' fingernails and toenails to see if they needed to be trimmed. She stated if the resident was Diabetic, she reported to the social worker to have the Podiatrist trim the resident's toenails. She stated she had not identified Resident #34's toenails being too long and needing to be trimmed or reported the need for a podiatrist appointment for Resident #34. An observation was made of Resident #34's toenails with S5LPN on 06/02/2026 at 9:50 a.m. S5LPN confirmed Resident #34's toenails were too long, extended past the tips of the toes, and needed to be trimmed. During the observation, Resident #34's wife was at his bedside. Resident #34's wife stated, his toenails need to be trimmed bad. An interview was conducted with S14WC on 06/02/2026 at 10:32 a.m. She stated she was responsible for trimming Diabetic residents' toenails. She stated she performed wound care on Resident #34's left leg vascular wound daily and noticed his toenails were too long and needed to be trimmed. She explained Resident #34's toenails were very thick and required specialty clippers, which the facility did not currently have. She confirmed Resident #34 was at risk for foot complications. She stated S15SW managed residents' on the Podiatrist's list. She stated she was unsure if Resident #34 was on the Podiatrist's list. An interview was conducted with S15SW on 06/02/2026 at 11:22 a.m. She stated the resident, nurses, or CNAs notified her if any resident needed to be seen by podiatry. She stated she then placed the residents on the Podiatrist's list to be seen at the next visit. She stated the Podiatrist held clinic in the facility one to two times per month. She stated Resident #34 was placed on the podiatry list on 05/29/2026, 06/01/2026, or 06/02/2026. She stated the podiatrist held clinic in the facility on 05/29/2026 so Resident #34 had to be added after that or he would have been seen on 05/29/2026, and he was not. A follow-up interview was conducted with S15SWon 06/03/2026 at 10:34 a.m. She confirmed Resident #34 had not seen the podiatrist since admission to the facility. An interview was conducted with S2DON on 06/02/2026 at 12:30 p.m. She stated the nurses were responsible for assessing fingernails and toenails. She stated if the resident's toenails were thickened or yellow, the Podiatrist would trim them. She stated the Podiatrist held clinic in the facility monthly, and there was a list of residents who needed to be seen. She stated S15SW held the running list of residents needing to be seen by the podiatrist. She was made aware of the condition of Resident #34's toenails. She stated Resident #34's toenails should not have gone that long without trimming.

Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure tube feeding formula was administered as prescribed for 1 (#77) of 3 residents reviewed for tube feedings.Review of the Clinical Record for Resident #77 revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status.Review of the current Physician Orders for Resident #77 revealed, in part, the following:Enteral: continuous feed: Isosource 1.5 at 70 milliliters an hour.An observation was made on 06/01/2026 at 8:55 a.m. of Resident #77. Observed Resident #77's feeding tube attached to a feeding pump which read an error of Notice pump inactive.An observation was made on 06/01/2026 at 10:46 a.m. of Resident #77. Observed Resident #77's feeding tube attached to a feeding pump which read an error of Notice pump inactive.An observation was made on 06/01/2026 at 11:38 a.m. of Resident #77. Observed Resident #77's feeding tube attached to a feeding pump which read an error of Notice pump inactive.An interview was conducted on 06/01/2026 at 11:39 a.m. with S11LPN. She stated the feeding pump was currently not infusing. She stated the resident had tube feedings ordered continuous and stated it's probably been paused since around 5:00 a.m., and I didn't look at it when I came on shift. She confirmed the tube feeding should not have been paused for that period of time.An interview was conducted on 06/03/2026 at 3:00 p.m. S2DON. She confirmed tube feedings should be administered at the ordered rate.

Based on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to properly label respiratory care equipment for 1 (#74) of 2 residents investigated for respiratory care.Findings: Review of the facility's undated policy titled, Oxygen Administration revealed the following in part:Oxygen Administration Safety & Guidelines18. Tubing, cannulas, and masks should be dated and replaced weekly unless otherwise ordered. Review of Resident #74's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease without Heart Failure, and Cough. Review of the Resident #74's Quarterly MDS with ARD of 03/24/2026 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #74's Physician's Orders revealed the following in part: Start: 06/02/2025 - Check Oxygen saturation every shift related to Shortness Of Breath; if saturation lower than 90% notify NP/MD and place on 2 Liters oxygen per nasal cannula. On 06/01/2026 at 8:45 a.m., an observation was made of Resident #74 sitting up in bed. While in the resident's room, an observation was made of resident's portable oxygen canister with tubing attached. Oxygen tubing was not labeled with the date. On 06/01/2026 at 9:10 a.m., an observation and interview was conducted with S5LPN. S5LPN observed and confirmed the tubing connected to Resident #74's portable oxygen canister was not labeled with the change date and should have been. On 06/02/2026 at 3:53 p.m., an interview was conducted with S2DON. S2DON confirmed oxygen tubing should be changed weekly and should be labeled with the change date.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a Pressure Ulcer received care based on the comprehensive assessment and professional standards of practice to promote healing by failing to ensure the air mattress was properly functioning for 1 (#21) of 2 residents reviewed with pressure ulcers.Findings: Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Stage 4 Sacral Pressure Ulcer and Spastic Quadriplegic Cerebral Palsy. Review of Resident #21's Quarterly MDS with an ARD of 04/08/2026 revealed she had a BIMS of 12, which indicated moderate cognitive impairment. Further review revealed Resident #21 was dependent on staff for turning and repositioning. Review of Resident #21's current Physician Orders revealed pressure reducing mattress to bed. Review of Resident #21's current Care Plan revealed the following, in part:Problem: Stage 4 Pressure Ulcer to Sacrum.Interventions: Pressure relieving air mattress to bed. On 06/03/2026 at 9:58 a.m., an observation was made of Resident #21. She was lying in bed turned toward her left side with the use of a wedge. Resident #21's air mattress pump was off and the power cord was unplugged from the wall and lying on the floor under the bed. Resident #21 stated she was uncomfortable. On 06/03/2026 at 10:00 a.m., S12CNA was notified Resident #21 stated she was uncomfortable. S12CNA entered Resident #21's room. On 06/03/2026 at 10:03 a.m., an observation was made of Resident #21. She was lying in bed turned toward her right side with the use of a wedge. On 06/03/2026 at 11:30 a.m., an observation was made of Resident #21. She was lying in bed turned toward her right side with the use of a wedge. Resident #21's air mattress pump was off and the power cord was unplugged from the wall and lying on the floor under the bed. On 06/03/2026 at 12:14 p.m., an observation was made of Resident #21. She was lying in bed on her back with the positioning wedge to the left of her. Resident #21's air mattress pump was off and the power cord was unplugged from the wall and lying on the floor under the bed. Resident #21's air mattress was deflated. An interview was conducted with Resident #21 at that time. She stated she had placed herself on the bedpan, was uncomfortable, and needed assistance getting off the bedpan. On 06/03/2026 at 12:17 p.m., surveyor notified S5LPN and S12CNA of Resident #21 stating she was uncomfortable, was on a bedpan, and needed assistance getting off the bedpan. On 06/03/2026 at 12:18 p.m., an observation was made of S12CNA repositioning Resident #21. S12CNA turned Resident #21 toward her left side with the use of a wedge. Resident #21's air mattress was deflated. Resident #21 was not on a bedpan. On 06/03/2026 at 12:30 p.m., an interview was conducted with Resident #21. She stated her mattress was uncomfortable and it felt like she was lying on the bedframe. On 06/03/2026 at 12:42 p.m., an observation was made of Resident #21 with S14WC and S12CNA present. S14WC and S12CNA both confirmed Resident #21's air mattress pump was off and not plugged in. S14WC confirmed Resident #21's air mattress was deflated. On 06/03/2026 at 12:48 p.m., an interview was conducted with S5LPN. She stated Resident #21's air mattress should have been monitored during rounds to ensure it was on and functioning properly. She confirmed Resident #21's air mattress should have been plugged in, on, and functioning properly at all times. On 06/03/2026 at 12:50 p.m., an interview was conducted with S12CNA. She stated she and the nurse were responsible to ensure Resident #21's air mattress was on and functioning properly. She stated she had not identified the air mattress pump was off or the mattress was not inflated when she provided care for Resident #21. She confirmed Resident #21's air mattress pump should have been on and functioning properly. On 06/03/2026 at 1:21 p.m., an interview was conducted with S14WC. She confirmed Resident #21 had an air mattress related to her Sacral Pressure Ulcer, decreased mobility, and risk for Pressure Ulcers. She confirmed Resident #21's air mattress should always be on and functioning properly. She stated the CNAs and nurses should have checked Resident #21's air mattress and pump during each round to ensure the pump was on and the mattress was properly inflated. She stated the air mattress being deflated with Resident #21 in the bed could potentially lead to worsening of her pressure ulcer and/or additional skin breakdown. On 06/03/2026 at 1:40 p.m., an interview was conducted with S13CN. She confirmed Resident #21's air mattress pump should have been on, functioning properly, and the mattress should have been inflated at all times while Resident #21 was lying in bed. On 06/03/2026 at 2:23 p.m., an interview was conducted with S2DON. She stated air mattresses and air mattress pumps should be checked for proper functioning during the staffs' every two hour rounds.

Based on observations, interviews, and record review, the facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality by nursing staff failing to observe and ensure a resident consumed medications for 2 (#34 and #59) of 32 residents reviewed in the initial pool. Findings: Resident #34 Review of Resident #34's Clinical Record revealed an admission date of 11/28/2025 and diagnoses, which included Type 2 Diabetes Mellitus, Chronic Venous Hypertension, Hypertensive Heart Disease, Heart Failure, Gastroesophageal Reflux Disease, Major Depressive Disorder, Constipation, Polyosteoarthritis, Chronic Back Pain, and Morbid Obesity. Review of Resident #34's Quarterly MDS with an ARD of 03/06/2026 revealed he had a BIMS of 15, which indicated intact cognition. Review of Resident #34's current Physician Orders revealed the following: Lasix 40mg by mouth daily, Losartan Potassium 50mg by mouth daily, Metoprolol Succinate Extended Release 25mg by mouth daily, Multivitamin tablet by mouth daily, Pantoprazole Sodium Delayed Release 25mg by mouth daily in the morning, Sennosides 8.6mg give 2 tablets by mouth daily, Glipizide 5mg by mouth twice daily, and Wellbutrin 150mg by mouth twice daily. Further review revealed Resident #34 was ordered to receive Methocarbamol 750 mg and Acetaminophen Extra Strength 500mg two tablet by mouth every eight hours as needed for pain. Resident #34 did not have an order for medication self-administration or to leave medications at the bedside. Review of Resident #34's MAR dated 06/01/2026 revealed a check mark with initials, which indicated the following medications were administered at 8:00 a.m.: Lasix 40mg, Losartan Potassium 50mg, Metoprolol Succinate Extended Release 25mg, Multivitamin tablet, Pantoprazole Sodium Delayed Release 25mg, Sennosides 8.6mg 2 tablets, Glipizide 5mg, and Wellbutrin 150mg. An observation and interview was conducted of/with Resident #34 on 06/01/2026 at 8:55 a.m. Resident #34 was seated in his wheelchair in his room next to his bedside table. There were two clear medication cups containing medications on Resident #34's bedside table. One medication cup contained two round, white, tablets Resident #34 identified as Extra Strength Tylenol. Resident #34 stated the nurse brought him the Tylenol last night and he never took them. The second medication cup contained the following: one large round white tablet, one small round green tablet, one oval red gel capsule, one oval orange tablet, two small round orange tablets, one small round white tablet, one small oval white tablet, one medium oval white tablet, and one oval yellow tablet. Resident #34 identified the second medication cup as his morning medications. He stated the nurse delivered them to his room around 8:00 a.m. There were also two loose tablets, one oval white tablet and one round gray tablet, resting directly on the bedside table. Resident #34 identified the two loose tablets on the table as his wife's medication from last night. Resident #34 stated his wife did not take her evening medications yesterday. An observation was made of Resident #34's room with S5LPN on 06/01/2026 at 9:47 a.m. The medication cup Resident #34 identified as his morning medications was not present. S5LPN confirmed there was one medication cup containing two round white tablets and there were two tablets, one oval white tablet and one round gray tablet, resting directly on the bedside table. S5LPN stated Resident #34's medications should never have been left at the bedside. S5LPN stated the nurses should always observe the resident take medications to ensure they were consumed as ordered. An interview was conducted with Resident #34 on 06/01/2026 at 10:00 a.m. He stated he took his morning medications this morning after surveyor exited his room. He stated the nurse brought them to his room around 8:00 a.m. this morning. He stated the nurse always left his medications at his bedside and he took them when he wanted. An interview was conducted with S13CN on 06/02/2026 at 12:39 p.m. She stated medications should not have been left at the bedside unless the resident had an order to leave them at the bedside. She stated the nurses should observe the resident consume all of their medications prior to exiting the room. Resident #59 Review of Resident #59's Clinical Record revealed an admission date of 12/16/2025 and diagnoses, which included Hypertensive Heart Disease with Heart Failure and Acute or Chronic Diastolic Congestive Heart Failure. Review of Resident #59's Quarterly MDS with an ARD of 04/23/2026 revealed a BIMS of 14, which indicated intact cognition. Review of Resident #59's current Physician Orders revealed the following, in part: Lasix Tablet 40 mg Give 1 tablet by mouth one time a day at 8:00 a.m. Review of Resident #59's MAR dated 06/01/2026 revealed the following, in part: Lasix 40 mg by mouth at 8:00 a.m. with a check mark and initials indicating S4LPN administered Resident #59's Lasix at 8:00 a.m. An observation was made of Resident #59 on 06/01/2026 at 9:25 a.m. He had a white tablet in a medication cup on his bedside table. An interview was conducted with Resident #59 at that time. He stated he had taken his morning medication and did not realize there was a tablet left in the medication cup. An observation was made of Resident #59 with S4LPN on 06/01/2026 at 9:45 a.m. S4LPN confirmed Resident #59 had a white tablet in a medication cup on his bedside table. S4LPN identified the white tablet in the medication cup as Resident #59's 8:00 a.m. Lasix. An interview was conducted with S4LPN on 06/01/2026 at 9:45 a.m. She confirmed she had administered Resident #59's 8:00 a.m. medications. She further confirmed nurses were responsible for ensuring residents took all of their medication and she had not. An interview was conducted with S2DON on 06/02/2026 at 3:53 p.m. S2DON stated nurses were responsible for ensuring residents consumed all of their medications before leaving their room. She further confirmed medications should never be left at the bedside.

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene, proper glove usage, and utilized proper Personal Protective Equipment (PPE) while providing care for 2 (#57 and #77) of 7 sampled residents who were on Enhanced Barrier Precautions (EBP).Findings: Review of the facility's policy dated 03/2024, titled, Enhanced Barrier Precautions revealed the following, in part:Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.2. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices such as urinary catheters, feeding tubes.4. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing briefs, device care or use, wound care. Resident #57Review of the Clinical Record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder and Other Disorders of Urinary System. Review of Resident #57's current Physician Orders revealed the resident had orders for Suprapubic Catheter care and Enhanced Barrier Precautions. An observation was made on 06/01/2026 at 8:56 a.m. of a sign on Resident #57's door which read Enhanced Barrier Precautions Wear gloves and a gown for the following high contact resident care activities: Dressing, Transferring, Providing hygiene, Changing linens, Changing briefs, device care or use: urinary catheter. An observation was made on 06/01/2026 at 9:15 a.m. of S6CNA and S7CNA performing ADL care for Resident #57. Without performing hand hygiene, S6CNA donned gloves, emptied Resident #57's urinary catheter bag into a container and flushed it down the toilet. S6CNA removed the soiled gloves and without performing hand hygiene donned new gloves. Without performing hand hygiene, S7CNA donned gloves, unfastened Resident #57's brief and assisted the resident to turn on her left side. S6CNA cleaned the resident with perineal wipes and removed the brief. Without changing gloves or performing hand hygiene, S6CNA applied a clean brief, assisted S7CNA to turn the resident, change the resident's clothing, and transferred the resident to the wheelchair. Without changing gloves or performing hand hygiene, S6CNA brushed the resident's hair and removed the resident's bed linens. S6CNA and S7CNA removed their gloves and exited Resident #57's room without performing hand hygiene. S6CNA and S7CNA did not don a gown while performing high contact care to Resident #57. An interview was conducted on 06/01/2026 at 9:24 a.m. with S7CNA. S7CNA stated she was not aware Resident #57 was on EBP. S7CNA confirmed Resident #57 had a catheter and she should have donned a gown prior to providing care. S7CNA confirmed she should have performed hand hygiene before and after resident care. An interview was conducted on 06/01/2026 at 9:25 a.m. with S6CNA. S6CNA stated she was not aware Resident #57 was on EBP. S6CNA stated the EBP sign and PPE on Resident #57's room door was used for her former roommate. S6CNA stated Resident #57 had a catheter and she should have donned a gown prior to providing care for Resident #57. S6CNA confirmed she did not change her gloves during care or perform hand hygiene before care, when going from dirty to clean, and after removing her gloves and should have. Resident #77 Review of the Clinical Record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status. Review of Resident #77's current Physician Orders revealed the resident had orders for PEG tube care and feeding and Enhanced Barrier Precautions.An observation was made on 06/01/2026 at 11:38 a.m. of a sign on Resident #77's door which read Enhanced Barrier Precautions Wear gloves and a gown for the following high contact resident care activities: device care or use: feeding tube. Observed S11LPN enter Resident #77's room with gloves donned and provide direct care to Resident #77's PEG tube. S11LPN never donned a gown.An interview was conducted on 06/01/2026 at 11:39 a.m. with S11LPN. She confirmed she should have donned a gown prior to providing direct care to Resident #77's PEG tube. An interview was conducted on 06/02/2026 at 2:35 p.m. with S2DON. She verified Resident #77 had a PEG tube and was on Enhanced Barrier Precautions. She verified Resident #57 had a suprapubic catheter and was on Enhanced Barrier Precautions. She stated staff should don a gown and gloves when providing high contact care for Resident #57 and Resident #77, and for any residents on Enhanced Barrier Precautions. She confirmed staff should perform hand hygiene before and after providing care to a resident, and before and after glove use/changes. She confirmed staff should change their gloves and perform hand hygiene after performing perineal care and when going from dirty to clean areas.

Based on observations, interviews, and record reviews, the facility failed to ensure an effective system was in place for staff to identify unsafe smokers and implement interventions including supervision to prevent accident hazards for 2 (#1, #5) of 3 residents reviewed for unsafe smoking. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 04/15/2026 when he was observed smoking in another resident's room while oxygen was in use. Resident #1 was a moderately cognitively impaired resident who was deemed an unsafe smoker upon admission to the facility on [DATE]. After 04/15/2026, not all staff were educated. On 05/03/2026, Resident #1 was noted smoking cigarettes in his room with smoking paraphernalia in his possession. Interviews revealed multiple staff members were unaware Resident #1 was assessed as an unsafe smoker. An observation of Resident #5, an assessed unsafe smoker, on 05/04/2026 revealed the resident had smoking paraphernalia in her possession. The facility failed to ensure staff were aware of which residents were deemed unsafe smokers and implemented designated interventions to prevent accident hazards. This failed system placed all residents in the facility at a likelihood to sustain serious injury, harm, impairment, or death. S1ADM and S5CN were notified of the immediate jeopardy situation on 05/04/2026 at 7:20 p.m. The Immediate Jeopardy was removed on 05/05/2026 at 6:05 p.m., as confirmed by onsite verification through observations, record reviews, and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 109 residents residing in the facility. Findings: Review of facility's undated policy titled, Smoking Policy revealed the following, in part:The facility provides a safe and healthy environment for residents, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents.2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision.3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas, smoking in room.the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurse's station or other specified location. If the resident is non-compliant with this, the resident may be asked for permission to conduct routine room/belonging checks to ensure the safety of the affected resident, other residents, staff, and visitors. These safety interventions will be care planned.4. Residents will not be allowed to smoke in areas or in a manner that creates significant safety hazard for the resident, other residents, staff or visitors.5. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in accordance with his/her care plan.6. Smoking is not allowed in residents' rooms.10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Review of the facility's undated Smoke Monitor/Smoke Aid Job Summary revealed the following, in part:Responsible for the care of the residents in a designated smoke area of the facility. Knowledgeable of residents who are considered unsafe smokers.Responsibilities2. Responsible for obtaining an updated list of all residents who are unsafe smokers including recommended interventions. Resident #1Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Parkinson's Disease. Review of Resident #1's Quarterly MDS with an ARD of 04/22/2026 revealed a BIMS of 12, which indicated he was moderately cognitively impaired. Further review revealed he was independent with ADL's. Review of Resident #1's admission Smoking Evaluation dated 01/16/2026 revealed he was deemed an unsafe smoker. Further review revealed the following in part:Has the resident demonstrated he only smokes in designated areas in or around the facility? No. Requires constant supervision by staff for safety during smoking. Review of Resident #1's current Physician's Orders revealed the following, in part:Resident deemed unsafe smoker-supervision required while smoking. Every 30 minute safety checks. Start date 05/04/2026. Review of Resident #1's current Care Plan revealed a problem was initiated on 02/16/2026 stating the resident was deemed an unsafe smoker who required supervision while smoking. On 04/15/2026, Resident #1 was found smoking in another resident's room who had oxygen in use. At that time Resident #1 was removed from the room and escorted outside. The facility initiated hourly checks and to intervene as necessary to protect the rights and safety of others. On 05/03/2026, Resident #1 was smoking in his room. The facility confiscated the cigarettes and instructed Resident #1 on smoking risks and hazards. The facility also implemented daily room checks for smoking paraphernalia and increased safety rounds to every 30 minutes. Review of Resident #1's Nurse's Note revealed S13LPN documented on 04/15/2026 a 3:30 p.m., Resident #1 was found smoking in another resident's room that had oxygen in use. Resident #1 was escorted out of the building and made aware there was no smoking ever allowed in the facility. Resident #1 was informed to always go outside and smoke. S12RN documented on 05/03/2026 at 9:52 a.m., Resident #1 was smoking in his room. Resident #1 confirmed he was smoking and aware he was not supposed to. Cigarettes were confiscated. Resident stated another resident lit the cigarette, but didn't know who. Review of Resident #1's electronic Task Flowsheet dated 04/16/2026 through 05/04/2026 revealed hourly safety checks had been documented as completed by CNA staff. On 05/05/2026 at 9:52 a.m., an interview was conducted with S13LPN. She stated Resident #1 was an unsafe smoker. She stated there was a list of safe and unsafe smokers at the nurse's station for staff to reference. She stated unsafe smokers were not supposed to have cigarettes or lighters in their possession. She stated some of the residents would ask other residents for cigarettes. She stated, on 04/15/2026, Resident #1 was caught smoking in another resident's room by S14LPN. She stated she was assigned to Resident #1 that shift, and after she was notified, she told Resident #1 smoking was only allowed on the smoking patio and he shook his head like he understood. She stated Resident #1 was oriented to self and situation but was also confused. She stated after this incident, safety checks were initiated every hour for the resident. S13LPN stated it was both hers and Resident #1's assigned CNA's responsibility to ensure they were completing hourly rounding for Resident #1 to make sure he was safe and not smoking. On 05/05/2026 at 10:35 a.m., an interview was conducted with S14LPN. She stated, on 04/15/2026, she saw Resident #1 standing in another resident's room with a lit cigarette. She stated Resident #1 had a lit cigarette in his hand, and he was standing behind the other resident, who had oxygen in place via nasal cannula. She stated the other resident's oxygen concentrator was beside him. She stated that resident had a back door to his room, which led to the outdoor patio. She stated she walked Resident #1 out the back door, had him extinguish his cigarette, and then walked him around to his assigned nurse, S13LPN. She stated she was unaware if Resident #1 was a safe or unsafe smoker as she had never been assigned to care for him. She stated unsafe smokers were not allowed to have cigarettes and lighters in their possession. She stated it was dangerous for Resident #1 to be next to the other resident with a lit cigarette since that resident was wearing oxygen. She stated after the incident, she notified S1ADM of what happened. She stated there was a list of the residents who were safe and unsafe smokers at the nurse's station for staff to reference. On 05/04/2026 at 12:02 p.m., an interview was conducted with S10HK. She stated, on 05/03/2026, she walked past Resident #1's room, and the whole room was smoky and smelled like cigarette smoke. She stated she reported it to S12RN. She stated this morning, she was notified Resident #1's toilet was clogged up. She stated there were towels and cigarette butts in the toilet. On 05/04/2026 at 3:32 p.m., an interview was conducted with S12RN. She stated on 05/03/2026 she was notified Resident #1 was smoking in his room. She stated when she entered Resident #1's room, it smelled like cigarette smoke. She stated Resident #1 admitted to smoking in his room. She stated she told Resident #1 he had to smoke on the smoking patio. She stated Resident #1 told her he did not have a lighter and said another resident lit it for him. She stated he would not tell her which resident lit the cigarette for him. She stated she searched his room for smoking paraphernalia and there was one pack of cigarettes in his pocket, and another pack in his nightstand, which was almost empty. She stated she took Resident #1's cigarettes to the Smoke Monitor, and the Smoke Monitor put his name on it and put them in the lock box. She stated she notified S1ADM and S2DON of the incident. She stated she was unaware if Resident #1 was a safe or unsafe smoker. She stated if a resident was a safe smoker, they could possess their lighters and cigarettes. She stated an unsafe smoker required supervision while smoking and was not supposed to be in possession of smoking paraphernalia. She stated this incident was the first time she was aware Resident #1 had smoked inside the facility. On 05/04/2026 at 11:36 a.m., an interview was conducted with S3CNA. He stated he was assigned to Resident #1 today and was familiar with Resident #1. He stated this morning, Resident #1's toilet was flooded with cigarette butts when he came in for his shift. He stated he received in report this morning, Resident #1 was smoking in his room over the weekend. He stated the Smoking Monitors had a list of all residents who were safe and unsafe smokers outside. He stated Resident #1 was a safe smoker, so he did not require supervision while smoking. He stated all unsafe smokers required supervision. He stated safe smokers could go outside and smoke at any time of the day without supervision, including Resident #1. He stated Resident #1 could have gotten cigarettes from another resident. On 05/04/2026 at 11:50 a.m., an interview and observation was conducted with Resident #1. He stated he had cigarettes in his room but lost them and had not been able to find them. He could not recall when he lost them. He denied having a lighter. When asked other questions related to smoking, Resident #1 declined to respond. On 05/04/2026 at 11:18 a.m., an interview was conducted with S8SM. She stated she was a Smoke Monitor. She stated it was her responsibility to oversee the safety of smoking residents on the smoking patio. She stated every morning when she arrived for her shift, she received a list which notified her which residents were safe and unsafe smokers. She stated she reviewed the list daily and it was kept in the locked box with the unsafe smoker's cigarettes. She stated Resident #1 was a safe smoker and smoked fine by himself. She stated Resident #1 smoked on the patio several times a day. She stated she gave Resident #1 cigarettes when he came outside to smoke. She stated unsafe smokers were supposed to be supervised and were not supposed to have access to smoking paraphernalia. She stated safe smokers were able to keep cigarettes and lighters in their possession. She stated this was the facility's smoking process in which she received training upon hire in March 2026. She stated she had not received any additional training since hire. At that time, an observation was made of the lock box in S8SM's possession. There was a carton of cigarettes with Resident #1's name on them observed inside of the box. A copy of the facility's smoking list was observed in the box and an observation of it was made with S8SM. The smoking list revealed Resident #1's name and beside his name read Resident deemed unsafe smoker-supervision required while smoking with a revision date of 02/17/2026. S8SM stated she did not know Resident #1 was an unsafe smoker and his status must have changed recently and no one told her. On 05/05/2026 at 8:40 a.m., an interview was conducted with S9SM. He stated he was a Smoke Monitor. He stated he had been working at the facility since November 2025 and received training on the facility's smoking process upon hire. He stated he had not received any additional training since hire. He stated it was his responsibility to carry out the interventions for unsafe smokers. He stated he knew which residents were safe and unsafe smokers by looking at the smokers list, which was printed out each morning and given to him. He stated he looked at the list each day. He stated all unsafe smokers were not allowed to have cigarettes or lighters in their possession, and required supervision while smoking. He stated Resident #1 was a safe smoker when he was admitted to the facility. He stated Resident #1 was found in another resident's room smoking last month and was deemed unsafe after that. He stated Resident #1 used to smoke all throughout the day, but over the last few weeks, had been only smoking in the afternoon. On 05/04/2026 at 2:29 p.m., an interview was conducted with S18CNA. She stated she was familiar with Resident #1. She stated Resident #1 was an unsafe smoker and required supervision while smoking. She stated Resident #1's cigarettes were required to stay locked up with the Smoke Monitors. She stated about a month ago, a cigarette was found in Resident #1's room and was taken. She stated he did not have a lighter but he was asking for one. She stated if Resident #1 acquired cigarettes, it would be from another resident. On 05/04/2026 at 2:37 p.m., an interview was conducted with S16LPN. She stated she was assigned to Resident #1 today and had been assigned to him a few times in the past two weeks. She stated she was unsure if Resident #1 smoked or not. She stated the safe smokers could keep smoking paraphernalia on them. She stated she was told in report today that Resident #1 was just placed on 30 minutes checks due to him smoking in his room on 05/03/2026. She stated she was not sure if Resident #1 was on any supervision checks prior to today. She stated yesterday, 05/03/2026, he was not. She stated, prior to today, staff were supposed to round on Resident #1 every 2 hours. On 05/04/2026 at 3:15 p.m., an interview was conducted with S11CNA. She stated Resident #1 went outside to smoke all of the time. She stated Resident #1 was a safe smoker. She stated the Smoking Monitor had a list outside with all the safe and unsafe smokers. She stated it was the responsibility of the Smoking Monitor to implement interventions for unsafe smokers. Review of the In-Service provided by the facility related to Accident and Hazard Prevention dated 04/15/2026 revealed the following, in part:-Smoking Monitoring-watch residents smoke-Report burn holes in clothes/wheelchairsFurther review revealed of the 20 staff members who signed the in-service, S8SM, S9SM, S3CNA, S11CNA, S16LPN, and S12RN were not included. There was no documented evidence provided to reveal staff education after the incident on 05/03/2026. 05/05/2026 at 9:03 a.m., an interview was conducted with S6MDS. She stated when a resident who smoked was admitted to the facility, if they were oriented, then either S6MDS or S7MDS would complete a smoking assessment. She stated a smoking assessment was completed on each resident who smoked. She stated once the assessment was completed, the resident's smoking status would be entered into their care plan and would be added to the facility's smoking list. On 05/05/2026 at 3:45 p.m., an interview was conducted with S7MDS. She stated there was a meeting each morning in which the Interdisciplinary Team talked about any resident incidents which had taken place and developed interventions for that incident. She stated she was notified when Resident #1 was found smoking in another resident's room on 04/15/2026. She stated the intervention put into place for Resident #1 after was the initiation of hourly safety checks. She stated when Resident #1 was found smoking in his room on 05/03/2026, the immediate intervention put into place was the resident's cigarettes were taken by the nurse. On 05/04/2026 at 4:22 p.m., an interview was conducted with S2DON. S2DON stated she was the interim DON at the facility and started on 04/16/2026. She stated Resident #1 was an unsafe smoker but able to have cigarettes in his possession. She stated Resident #1 required supervision while smoking. She stated safe smokers could have both cigarettes and lighters but unsafe smokers usually had to have smoking paraphernalia locked up. She stated she was unaware Resident #1 had smoked inside the facility prior to 05/03/2026. On 05/04/2026 at 6:06 p.m., a follow up interview was conducted with S2DON. She stated Resident #1 had smoked inside the building prior to 05/03/2026. She confirmed Resident #1 was an unsafe smoker and was not supposed to have any smoking paraphernalia. She stated the intervention put into place for Resident #1 after he was found smoking yesterday was the initiation of safety checks every 30 minutes, which started today on 05/04/2026. She stated Resident #1 was more than likely getting cigarettes from other residents. She stated the facility had spoken with cognitive unsafe smokers about giving not giving out cigarettes, but was not sure when that was. On 05/05/2026 at 10:08 a.m., an interview was conducted with S19CNAS. She stated she was responsible for overseeing the Smoke Monitors. She stated the Smoke Monitors were educated on the smoking process and who were safe and unsafe smokers upon hire. She stated the Smoker Monitors were provided daily with list of the safe and unsafe smokers. She stated the Smoke Monitors should know which residents were safe and unsafe by looking at the list each morning when they received it. On 05/05/2026 at 2:20 p.m., an interview was conducted with S1ADM. She stated when a resident was admitted to the facility, the MDS nurse completed the resident's smoking assessment, then the MDS nurse put the resident on the safe or unsafe smoker list, and entered their smoking status into their care plan. She stated smoking aids had an orientation upon hire which included showing them the smoker's box which contained the unsafe smoker's cigarettes and when and how to obtain the smoker's list, which included safe and unsafe smokers. She stated everyone should have known Resident #1 was an unsafe smoker. She stated the Smoke Monitors were supposed to know which residents were safe and unsafe smokers because a new, updated list was printed out each morning and given to them at the start of their shift. She stated the Smoke Monitors should check the smoking list every morning to ensure they knew which residents were safe smokers and which residents were unsafe smokers. She stated these lists were also at the nurse's station so she didn't know how staff could not have known Resident #1 was an unsafe smoker. She stated every staff member should have known Resident #1 was an unsafe smoker because the facility had a list of unsafe smokers at the nurse's station. She stated she was aware Resident #1 was found smoking in another resident's room, who was actively receiving oxygen. She confirmed it was dangerous for Resident #1 to have a lit cigarette near a resident who was receiving oxygen. She stated after that incident, Resident #1 was placed on hourly safety checks. She stated unsafe smokers were supposed to be supervised while smoking and were not supposed to have smoking paraphernalia in their possession. She stated she was made aware on 05/04/2026 that Resident #1 smoked in his room over the weekend. She stated the unsafe smoking residents would find a way to acquire smoking paraphernalia and there was nothing she could do to prevent it. Resident #5Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Epilepsy, Nicotine Dependence, Lack of Coordination, and Abnormalities of Mobility. Review of Resident #5's smoking assessment dated [DATE] revealed she was an unsafe smoker. Review of Resident #5's current Care Plan revealed the following, in part:Problem: Resident is an unsafe smokerInterventions: Resident requires a smoking apron while smoking, and clothes pins/ tips; Resident requires supervision while smoking; the resident's smoking supplies are stored by staff. Review of facility's smoker's list with interventions as of 05/04/2026 revealed the following: Resident #5 deemed unsafe smoker-required smoke apron, clothes pin to hold cigarette, and supervision while smoking. On 05/04/2026 at 6:00 p.m., an observation was made of Resident #5. Resident #5 was sitting in her wheelchair in the entryway of the dining room. She was observed holding two whole, unlit brown colored cigarettes. She reported she was going out to the smoking patio. She did not state where she got the cigarettes from or if she should have them. On 05/04/2026 at 11:18 a.m., an interview was conducted with S8SM. She stated unsafe smokers were supposed to be supervised and were not supposed to have access to smoking paraphernalia. On 05/05/2026 at 8:40 a.m., an interview was conducted with S9SM. He stated all unsafe smokers were not allowed to have cigarettes or lighters in their possession, and required supervision while smoking. On 05/04/2026 at 7:20 p.m., an interview was conducted with S1ADM and S5CN. They confirmed unsafe smokers should not be in possession of any smoking paraphernalia. Removal PlanThe facility failed to ensure an effective system was implemented to ensure staff could identify, supervise, and implement interventions for Resident #1 and Resident #5 who had been assessed as unsafe smokers. Resident #1 was searched as well as his room and cigarette was removed at the time of incident and education was provided. Resident monitoring was increased from every 30 minute monitoring to 1:1 to ensure safety on 05/04/2026. Resident #5's cigarette butts were removed and her room searched as well. Resident #5 was placed 1:1 while out of bed to ensure safety. All smoking residents are potentially affected by this deficient practice.-Staff will be in-serviced by S2DON/S1ADM/Designee on safe and unsafe smokers and how to obtain that information, what practices exhibited by the resident are indications of unsafe smoking practices, and to notify nursing immediately with any identified concerns beginning on 05/04/2026 and no staff will be allowed to work until in-servicing has been received. Staff will be in-serviced on above at time of hire and twice annually.-The smoking assistants have been re-in serviced on 05/05/2026 on safe and unsafe smokers. Updated lists provided as needed with any changes in resident status. A binder will be set up with resident face sheets with photos to ensure resident identity. This binder will be kept with the smoking attendant. This will be completed on 05/05/2026. S2DON/Designee will monitor smoking assistants 5 days/week for 8 weeks beginning on 05/05/2026 to ensure smoking protocols are followed.-Smoking hours have been extended from 7:00 a.m.-7:00 p.m. to 7:00 a.m.-10:00 p.m. at night beginning on 05/04/2026 with a smoking attendant in place during those hours.-Daily room searches implemented on 05/04/2026 for all unsafe smokers and will continue as part of plan of care for residents who have been deemed unsafe.-The facility will provide house cigarettes (facility provided cigarettes) as needed for safe and unsafe smoking residents beginning on 05/04/2026. The cigarettes will be provided on the smoke patio with a smoke attendant present. Resident Council meeting will be held on 05/05/2026 to ensure residents are knowledgeable of the implementation of house cigarettes. S17RADM will provide education to cognitively intact residents to ensure no cigarettes/lighters are given to unsafe smokers.-List of smoking residents added to department head QA rounds for additional daily oversight on 05/05/2026. S5CN educated department head staff on daily checks of unsafe smoking rooms to ensure no smoking paraphernalia in rooms on 05/05/2026. Education included checking for presence of smoking paraphernalia including but not limited to lighters, matches, cigarettes/cigars, ashes, or evidence of smoking. If items are found, they are to be removed immediately, notify the floor nurse as well as department head nursing team. Additional interventions will be implemented as needed to maintain resident safety.S2DON/Designee will monitor 8 residents/week for 8 weeks then randomly to ensure safe smoking practices maintained and compliance with smoking policy beginning on 05/05/2026. S2DON/Designee will interview 8 random employees weekly for 8 weeks to ensure knowledge of safe smoking practices beginning on 05/05/2026. Audit reports will be submitted to S1ADM and QAPI committee for review and new interventions will be implemented as needed.The facility will ascertain substantial compliance by 05/05/2026.

Based on observation, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place for staff to identify unsafe smokers and implement safety interventions for 2 (#1 and #5) of 3 residents assessed as unsafe smokers. Findings: Cross Reference F689Review of facility's undated policy titled, Smoking Policy revealed the following, in part:The facility provides a safe and healthy environment for residents, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents.2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision.3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas, smoking in room.the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurse's station or other specified location. If the resident is non-compliant with this, the resident may be asked for permission to conduct routine room/belonging checks to ensure the safety of the affected resident, other residents, staff, and visitors. These safety interventions will be care planned.4. Residents will not be allowed to smoke in areas or in a manner that creates significant safety hazard for the resident, other residents, staff or visitors.5. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in accordance with his/her care plan.6. Smoking is not allowed in residents' rooms.10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Review of the facility's undated Smoke Monitor/Smoke Aid Job Summary revealed the following, in part:Responsible for the care of the residents in a designated smoke area of the facility. Is knowledgeable of residents who are considered unsafe smokers.Responsibilities2. Responsible for obtaining an updated list of all residents who are unsafe smokers including recommended interventions. Review of the facility's undated policy, titled, Administrator revealed the following, in part: Job summary: The Administrator directs and coordinates all activities of the nursing home, in carrying out its objective of providing the best possible care for each resident, in striving to recreate a sense of security.for the residents. Qualifications: 5.) Willingness to accept responsibility for activities of the nursing home. Responsibilities: 1.) Efficient functioning and coordination of all departments. 5.) Adopts and enforces rules and regulations for the health care and safety of recipient, patients and others and the protection of their personal property and civil rights. Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Parkinson's Disease. Review of Resident #1's Quarterly MDS with an ARD of 04/22/2026 revealed a BIMS of 12, which indicated he was moderately cognitively impaired. Further review revealed he was independent with ADL's. Review of Resident #1's admission Smoking Evaluation dated 01/16/2026 revealed he was deemed an unsafe smoker. Further review revealed the following, in part:Has the resident demonstrated he only smokes in designated areas in or around the facility? No. Requires constant supervision by staff for safety during smoking. Review of Resident #1's current Physician's Orders revealed the following, in part:Resident deemed unsafe smoker-supervision required while smoking. Review of Resident #1's current Care Plan revealed a problem was initiated on 02/16/2026 stating the resident was deemed an unsafe smoker who required supervision while smoking. On 04/15/2026, Resident #1 was found smoking in another resident's room who had oxygen in use. At that time Resident #1 removed from room and escorted outside. The facility initiated hourly checks and to intervene as necessary to protect the rights and safety of others. On 05/03/2026, Resident #1 was smoking in his room. The facility confiscated the cigarettes and instructed Resident #1 on smoking risks and hazards. The facility also implemented daily room checks for smoking paraphernalia and increased safety rounds to every 30 minutes. On 05/04/2026 at 11:36 a.m., an interview was conducted with S3CNA. He stated the Smoking Monitors had a list of all residents who were safe and unsafe smokers outside. He stated Resident #1 was a safe smoker, so he did not require supervision while smoking. He stated all unsafe smokers required supervision. He stated safe smokers could go outside and smoke at any time of the day without supervision, including Resident #1. He stated Resident #1 could have gotten cigarettes from another resident. On 05/04/2026 at 3:15 p.m., an interview was conducted with S11CNA. She stated Resident #1 went outside to smoke all of the time. She stated Resident #1 was a safe smoker. She stated the Smoking Monitor had a list outside with all the safe and unsafe smokers. On 05/04/2026 at 11:18 a.m., an interview was conducted with S8SM. She stated she was a Smoke Monitor. She stated it was her responsibility to oversee the safety of smoking residents on the smoking patio. She stated every morning when she arrived for her shift, she received a list which notified her which residents were safe and unsafe smokers. She stated she reviewed the list daily. She stated Resident #1 was a safe smoker and he smoked fine by himself. She stated this was the facility's smoking process in which she received training upon hire in March 2026. She stated she had not received any additional training since hire. A copy of the facility's smoking list was observed with S8SM. The smoking list revealed Resident #1's name and beside his name read Resident deemed unsafe smoker-supervision required while smoking with a revision date of 02/17/2026. S8SM stated she did not know Resident #1 was an unsafe smoker and his status must have changed recently and no one told her. On 05/05/2026 at 8:40 a.m., an interview was conducted with S9SM. He stated he was a Smoke Monitor. He stated he had been working at the facility since November 2025 and received training on the facility's smoking process upon hire. He stated he had not received any additional training since hire. He stated he knew which residents were safe and unsafe smokers by looking at the smokers list, which was printed out each morning and given to him. He stated he looked at the list each day. He stated all unsafe smokers were not allowed to have cigarettes or lighters in their possession, and required supervision while smoking. He stated Resident #1 was a safe smoker when he was admitted to the facility. He stated Resident #1 was found in another resident's room smoking last month and was deemed unsafe after that. He stated Resident #1 used to smoke all throughout the day, but over the last few weeks, had been only smoking in the afternoon. Review of the In-Service Sign-In sheet provided by the facility related to Accident and Hazard Prevention dated 04/15/2026 revealed the following, in part:-Smoking Monitoring-watch residents smoke-Report burn holes in clothes/wheelchairsFurther review revealed of the 20 staff members who signed the in-service, S8SM, S9SM, S3CNA, S11CNA, S16LPN, and S12RN were not included. On 05/05/2026 at 10:08 a.m., an interview was conducted with S19CNAS. She stated she was responsible for overseeing the Smoke Monitors. She stated the Smoke Monitors were educated on the smoking process and who were safe and unsafe smokers upon hire. She stated the Smoker Monitors were provided with a list of the safe and unsafe smokers daily. She stated the Smoke Monitors should know which residents were safe and unsafe by looking at the list each morning when they received it. On 05/04/2026 at 4:22 p.m., an interview was conducted with S2DON. She stated she began as the interim DON for the facility on 04/16/2026 She stated Resident #1 was an unsafe smoker but able to have cigarettes in his possession. She stated Resident #1 required supervision while smoking. She stated safe smokers could have both cigarettes and lighters but unsafe smokers usually had to have smoking paraphernalia locked up. She stated she was unaware Resident #1 had smoked inside the facility prior to 05/03/2026. On 05/04/2026 at 6:06 p.m., a follow up interview was conducted with S2DON. She confirmed Resident #1 was an unsafe smoker and was not supposed to have any smoking paraphernalia. She stated the intervention put into place for Resident #1 after he was found smoking yesterday was the initiation of safety checks every 30 minutes, which started today on 05/04/2026. She stated Resident #1 was more than likely getting cigarettes from other residents. On 05/05/2026 at 2:20 p.m., an interview was conducted with S1ADM. She stated when a resident was admitted to the facility, the MDS nurse completed the resident's smoking assessment, then the MDS nurse put the resident on the safe or unsafe smoker list, and entered their smoking status into their care plan. She stated smoking aids had an orientation upon hire which included showing them the smoker's box which contained the unsafe smoker's cigarettes and when and how to obtain the smoker's list, which included safe and unsafe smokers. She stated everyone should have known Resident #1 was an unsafe smoker. She stated the Smoke Monitors were supposed to know which residents were safe and unsafe smokers because a new, updated list was printed out each morning and given to them at the start of their shift. She stated the Smoke Monitors should check the smoking list every morning to ensure they knew which residents were safe smokers and which residents were unsafe smokers. She stated these lists were also at the nurse's station so she didn't know how staff could not have known Resident #1 was an unsafe smoker. She stated every staff member should have known Resident #1 was an unsafe smoker because the list was available to them at the nurse's station. She stated she was aware Resident #1 was found smoking in another resident's room, who was actively receiving oxygen. She stated after that incident, Resident #1 was placed on hourly safety checks. She stated unsafe smokers were supposed to be supervised while smoking and were not supposed to have smoking paraphernalia in their possession. She stated she was made aware on 05/04/2026 that Resident #1 smoked in his room over the weekend. She stated the unsafe smoking residents would find a way to acquire smoking paraphernalia and there was nothing she could do to prevent it. Resident #5Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Epilepsy, Nicotine Dependence, Lack of Coordination, and Abnormalities of Mobility.Review of Resident #5's current Care Plan revealed the following, in part:Problem: Resident is an unsafe smoker (dated 04/09/2026)Interventions: Resident requires a smoking apron while smoking, and clothes pins/ tips; Resident requires supervision while smoking; the resident's smoking supplies are stored by staff. Review of facility's Smoker's list with interventions as of 05/04/2026 revealed the following: Resident #5 deemed unsafe smoker-required smoke apron, clothes pin to hold cigarette, and supervision while smoking. An interview was conducted on 05/04/2026 at 8:40 a.m. with S8SM. S8SM stated Resident #5 was an unsafe smoker, and required assisted to light her cigarettes and wore a smoking apron. An observation was conducted on 05/04/2026 at 4:30 p.m. of Resident #5. Resident #5 was observed sitting in her wheelchair at the entryway of the dining room holding two whole unlit brown cigarettes. An interview was conducted on 05/04/2026 at 7:20 p.m. with S1ADM. S1ADM confirmed the process for the facility was any smoker deemed unsafe should not have possession of their cigarettes or lighter, and she expected staff to implement interventions for the unsafe smoker per their plan of care and smokers assessment.

Based on observations and interviews, the facility failed to provide drinks consistent with resident preferences for 1 (#R7) of 1 resident observed for drinking preferences. The facility failed to provide Resident #R7 coffee when he requested it. Findings: Review of Resident #R7's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #R7's Quarterly MDS with an ARD of 02/20/2026 revealed a BIMS of 8, which indicated he was moderately cognitively impaired. On 05/05/2026 at 12:25 p.m., an observation was made of Resident #R7 self-propelling himself out of his room in his wheelchair, holding a drinking tumbler. He waved his drinking tumbler in the air. When asked if he wanted coffee, he shook his head yes. At that time, S4LPN was observed down the hall. S4LPN was notified Resident #R7 wanted coffee. S4LPN shook her head and stated no. On 05/05/2026 at 12:28 p.m., an observation and interview was conducted with S15OT walking toward Resident #R7. S15OT told Resident #R7 he could not have coffee because it was not coffee time. She stated Resident #R7 could only have coffee at the coffee times posted. She stated Resident #R7 did not ask for water, and he only wanted coffee all day. She further stated he could not have coffee all day because then he would be going to the restroom all day. S15OT was observed telling Resident #R7 that it was currently 12:30 p.m. and at 1:30 p.m. the residents were having a party and he could get coffee then. On 05/06/2026 at 8:09 a.m., an interview was conducted with S4LPN. She verified she was assigned to Resident #R7 on 05/05/2026. She stated when residents wanted coffee, there was a coffee station at the front of the facility with coffee times posted. She stated Resident #R7 was aware of when the coffee times were. She confirmed she told Resident #R7 he could not have coffee yesterday. She stated most of the time, Resident #R7 took two sips of coffee then would throw it on the ground. She confirmed residents should be able to have coffee whenever they wanted. On 05/06/2026 at 9:30 a.m., an observation was made of the coffee sign posted by the coffee station. The coffee sign revealed the following:Come enjoy a hot fresh cup of coffee daily Monday through Sunday7:00 a.m. to 8:00 a.m.10:00 a.m. to 10:30 a.m. On 05/06/2026 at 11:22 a.m., an interview was conducted with S2DON. She stated there was a coffee shop the residents could get coffee at during the coffee hours. She stated after those hours, residents could tell their CNA or nurse, and that staff member could go get the resident coffee from the kitchen. She stated residents should be able to have coffee whenever they wanted.

Based on interviews and record reviews, the facility failed to ensure the physician was immediately notified when there was a significant change in the resident's skin condition for 1 (#3) of 3 sampled residents with pressure ulcers. This deficient practice resulted in an actual physical harm for Resident #3 when S3CNA observed and reported to S4LPN three dime size blisters on the resident's sacrum on 02/14/2026, and S4LPN failed to notify the physician. The physician was notified on 02/18/2026 when the wound was noted as a stage 3 pressure ulcer by S6TxNurse. On 02/18/2026, Resident # 3 was diagnosed with a stage 3 pressure ulcer measuring length 8.1 centimeters (cm) x width 9.2 cm x depth 0.1 cm. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Review of the facility's policy titled Skin Program, Pressure Ulcers & Other Wounds revealed the following in part: Risk Assessment & Routine Care for All Residents: Nursing Assistants will check all residents' skin during each episode of care, bathing, etc. Reddened areas will be reported to the licensed nurse. Care of Residents with Wounds (Pressure & Non-Pressure Related):If a resident does develop a reddened area or wound, the licensed nurse will implement the following interventions: Notify resident, family, and physician of reddened area or wound; the notification of the physician will be done during normal physician office hours unless a treatment order is needed. Review of Resident #3's medical record revealed an admission date of 05/06/2024, and diagnoses which included, in part: Pressure Ulcer of Sacral Region, Unspecified Stage, with an onset date of 02/18/2026. Review of Resident #3's Significant Change Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 01/22/2026, revealed the resident was always incontinent of bowel and bladder, dependent for bed mobility, and had no unhealed pressure ulcers. Review of the Resident #3's medical record did not reveal documentation of a skin assessment completed on 02/14/2026. Review of Resident #3's Skin Check dated 02/18/2026 revealed the following in part:Skin Issues - New Issue; Location - Sacrum; Pressure ulcer / Injury; New wound; Stage 3 Pressure ulcer / injury: Full thickness skin loss; in-house acquired; new onset; no signs of infection; no wound pain; staged by in-house nursing; length 8.1 cm, width 9.2 cm, depth 0.1 cm; area 74.52. Review of the nurse's notes dated 02/18/2026 at 3:55 p.m. by S6TxNurse revealed Resident #3 noted with a stage 3 pressure injury to his sacrum. Discovered while doing his body audit. S2NP notified. Responsible Party also notified. New orders in place. Wound Care nurse practitioner (NP) will follow up with the patient on 2/19. Review of the wound care visit report dated 02/19/2026 and signed by S2NP revealed the following in part: Wound #1 Sacral is an acute Stage 3 Pressure Injury Pressure Ulcer. Initial wound encounter measurements are 8.1 cm length x 9.2 cm width x 0.1 cm depth, with an area of 74.52 square (sq) cm. Adipose is exposed. Three open areas in close proximity measured together as 1 wound. Site - sacral. Percent of Slough: 50. Percent of granulation: 40. Treatment Order: Cleanse wound with wound cleanser (pat dry), apply Santyl, apply barrier, and apply a clean dry dressing. On 03/16/2026 at 2:18 p.m., an interview was conducted with S6TxNurse. She said she found Resident #3's sacrum wound on 02/18/2026 during his weekly body audit. S6TxNurse stated when she found the pressure ulcer on 02/18/2026 it was a stage 3. S6TxNurse stated when she called Resident #3's daughter to inform her of the wound on 02/18/2026, his daughter told her Resident #3 had blisters on his buttocks over the weekend. On 03/17/2026 at 11:10 a.m., an interview was held with S3CNA. S3CNA confirmed she worked the day shift on 02/14/2026. S3CNA said she found three dime size fluid filled blisters on Resident #3's buttocks on 02/14/2026. S3CNA said she reported it to the nurse. She said the facility provided a training after this incident related to notifying the nurse immediately when there is a change in the resident's skin and documenting it in the jot book. On 03/17/2026 at 4:06 p.m., an interview was held with S4LPN. She said on 02/14/2026 it was reported to her Resident #3 had a skin condition on his buttocks. S4LPN said the skin was reddened and open, but she did not remember the size. She stated she put skin prep on the area. S4LPN confirmed she did not notify the doctor or Resident #3's responsible party. S4LPN said she did not remember if she documented the findings. S4LPN said she received a written discipline for the incident and had the skin policy reviewed with her. S4LPN said she should have notified the doctor or NP, put orders in the computer, documented her assessment, and notified the Director of Nurses (DON), treatment nurse, and family. On 03/18/2026 at 8:03 a.m., an interview was held with S1CorpRN. S1CorpRN explained when a new wound was found the nurse who finds the wound should contact the physician or NP promptly. S1CorpRN said S4LPN did not report her findings to Resident #3's physician or NP or anyone else. S1CorpRN explained since the incident the CNAs had been educated on recognizing skin issues with prompt notification to the nurse with any concerns, and documentation in the jot book. S1CorpRN said the nurses had been trained on assessing, documenting, and promptly notifying the doctor and family of new or changed wounds. S1CorpRN said S4LPN had a 1:1 training regarding this incident. S1CorpRN said she was reading all nurses notes seven days a week. She said the CNAs have a jot book at the nurse's station where they document resident concerns. S1CorpRN explained when something is written in the jot book, it is copied and brought to the morning meetings to be followed up on. She said huddle meetings are held with the CNAs, and the CNA supervisor brings those concerns to the department heads. S1CorpRN said the staff have been trained to communicate during these meetings if they see something that is not normal for a resident. S1CorpRN explained they have not had any additional in-house acquired wounds since 02/18/2026. Throughout the survey from 03/16/2026 to 03/18/2026, observations, record reviews, and staff interviews revealed staff received training on the facility's skin program, pressure ulcers, and other wounds policy. Interviews revealed CNAs were knowledgeable of reporting changes in skin condition immediately to their nurse and documenting the information in the jot book. Interviews revealed nurses were knowledgeable of assessing wounds, documenting wounds, and notifying the physician or NP and responsible party of the findings immediately. The facility had implemented the following actions to correct the deficient practice:02/20/2026 - 02/26/2026: Weekly body audits for facility completed with no additional findings.02/21/2026 - 1:1 education with S4LPN.02/23/2026 (started) - 2/26/26 (completed) - CNA and nursing education regarding prompt identification and notification of any wounds identified, turn and reposition every 2 hours, floating of heels. New staff will receive training prior to starting in their position.02/23/2026 (started and completed) - department head rounds with specific details of needed skin care routines for residents (float, turn, heel boots, specialty mattresses, etc.).02/23/2026 (started) - Use of CNA jot book and copies of information to be given to department head nurses daily. Daily monitoring of nurse's notes by regional nurse. Daily CNA huddles to discuss any changes in residents' condition (skin concerns, decreased appetite, increased activities of daily living assistance needed, etc.); if any concerns voiced, CNA supervisor reports concerns to DON immediately; documentation and notifications checked to ensure physician (MD) or nurse practitioner (NP) has been notified and orders received as needed. If proper documentation / notifications have not been completed, notifications would happen at that time and re-education / disciplinary action would occur as needed. This will be an ongoing process. 03/03/2026 - Weekly high risk meeting with discussion of all pressure wounds and treatments. This will be an ongoing process. 03/12/2026 (hired) addition of QA nurse on evening shift 5 days/week to provide for increased facility monitoring. A portion of her job duties will include ensuring timely rounds of residents, ensuring residents on appropriate turn schedules, heels floated, etc. Facility was in compliance on 02/26/2026. The facility will be conducting on going monitoring for a total of 8 weeks.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care for 2 (#5 & R1) of 4 residents reviewed for infection control.Review of the facility's titled Enhanced Barrier Precautions dated January 2025 revealed the following, in part: It is the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: (i.e. Wounds and / or indwelling medical devices (e.g. urinary catheters) even if the resident is not known to be infected or colonized with a MDRO. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care: urinary catheters, and wound care: any skin opening requiring a dressing. Resident #5Review of Resident #5's medical record revealed an admission date of 01/08/2026 with the diagnosis of pressure ulcer of left buttock stage 3. Review of Resident #5's physician's orders dated 01/08/2026 revealed Enhanced Barrier Precautions related to pressure injury. Resident #R1 Review of Resident #R1's medical record revealed an admission date of 11/14/2025 with diagnoses which included, in part: Non-Pressure Chronic Ulcer of the Left Calf, limited to breakdown of skin, Non-Pressure Chronic Ulcer of Unspecified Part of Left Lower Leg, with fat layer exposed, Non-Pressure Chronic Ulcer of Other Part of Left Foot, with muscle involvement without evidence of necrosis, Pressure Ulcer of Left Ankle Stage 3, and Pressure Ulcer of Left Heel Unstageable. Review of Resident R1's care plan dated 11/16/2025 revealed he had an indwelling catheter. On 03/17/2026 at 8:35 a.m., an observation was made of S10TxNurse providing wound care for Resident #5. S10TxNurse wore gloves but no gown while providing wound care. An observation of the resident's door did not reveal signage of EBP. On 03/17/2026 at 10:31 a.m. an observation was made of S7CNA emptying Resident #R1's indwelling catheter. S7CNA was wearing gloves, but no gown. On 03/17/2026 at 10:35 a.m., an interview was held with S7CNA. S7CNA confirmed she had not put on a gown to empty Resident #R1's urinary catheter. An observation of the resident R1's door revealed EBP signage. On 03/17/2026 at 12:29 p.m., an interview was held with S8LPN. S8LPN verified Resident #R1 had wounds and a urinary catheter. On 03/17/2026 at 1:40 p.m., upon entering Resident #5's room, S7CNA was observed changing the resident's brief. S7CNA was wearing gloves, but no gown. S7CNA verified she was not wearing a gown and stated she just forgot. An observation of the sign above Resident #5's bed revealed Enhanced Barrier Precautions. On 03/17/2026 at 3:45 p.m., an interview was held with S10TxNurse. She confirmed she did not have a gown on during Resident #5's wound care. She said she only wore gowns with big wounds or infections. She said Resident #5's wound was not big or infected. On 03/18/2026 at 11:16 a.m., an interview was held with S9DON and S12Adm. S9DON stated all residents with infections, peg tubes, wounds, colostomies, ostomies, urinary catheters, tube feedings, and pressure ulcers should be on enhanced barrier precautions. S9DON stated the process for communication of which residents were on EBP would be to place a sign on the exterior of the resident's door. S9DON confirmed staff should wear a gown and gloves when emptying a urinary catheter or providing wound care.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly labeled, dated, and sealed. This had the potential to affect 92 residents who were served from the kitchen.Findings:On 12/01/2025 at 8:28 a.m., an initial tour of the kitchen was conducted with S5DM. The observations were made of the following items available for consumption:Main kitchen area:1 clear bag of Grits (1/2 bag) opened, undated, and not sealed.2 clear bags of cornbread mix opened and undated.5 clear bags of seasoning mixes opened and undated.1 box of powdered sugar opened, undated, and not sealed.Walk-In Cooler: 1 Large, plastic bag of cheddar cheese opened and undated.1 Large, plastic bag of parmesan cheese opened and undated.1 tray of liquid-filled drinking cups (10 cups) undated and unlabeled.8 bowls of fruit cocktail undated, and unlabeled. On 12/01/2025 at 8:45 a.m., an interview was conducted with S5DM. He confirmed the above items were not dated and should have been. He confirmed the liquid-filled drinking cups and bowls of fruit cocktail were not labeled and should have been. He confirmed the grits and powdered sugar were not sealed and should have been.On 12/02/2025 at 3:45 p.m., an interview was conducted with S1ADM. She was made aware of the aforementioned findings in the kitchen. She confirmed all food and drink items should be sealed, dated, and labeled.

Based on interviews and record reviews, the facility failed to ensure a resident's MDS Assessment accurately reflected their status for 5 (#4, #7, #13, #21, and #43) of 19 residents in the sample. The facility failed to ensure: 1. Resident #7 was coded correctly for antipsychotics; 2. Resident #43 was coded correctly for insulin; 3. Resident #13 was coded correctly for their Level II PASRR status; and 4. Resident #4 and #21 were coded correctly for restraint status. This deficient practice had the potential to affect a current census of 92 residents. 1. Review of Resident #7's Clinical Record revealed an admission date of 02/20/2024 with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Schizophrenia, Delusional Disorders, and Unspecified Dementia. Review of Resident #7's Quarterly MDS with an Assessment Reference Date (ARD) of 10/02/2025 revealed, in part, the following: Section N. Medications N0415. High-Risk Drug Classes: Use and Indication A. Antipsychotic: Yes Review of Resident #7's Physician Orders dated September 2025 to current revealed no antipsychotic medication was ordered for this resident. On 12/03/2025 at 10:36 a.m., an interview was conducted with S8MDS. He reviewed Resident #7's September 2025 through October 2025 physician orders and confirmed Resident #7 had not received an antipsychotic medication. He reviewed Resident #7's Quarterly MDS with ARD of 10/03/2025. He confirmed Section N0415 was coded as Resident #7 taking an antipsychotic, which was coded inaccurately. He confirmed Resident #7 had not taken an antipsychotic medication therefore Section N0415 of the MDS was coded inaccurately. On 12/03/2025 at 12:50 p.m., an interview was conducted with S3DON. She confirmed Resident #7 had not received an antipsychotic medication therefore Section N0415 of the MDS was coded inaccurately. She confirmed all residents' MDS should be accurately coded for the medications they received. 2. Review of Resident #43's Clinical Record revealed an admission date of 08/06/2025 with diagnoses which included Diabetes. Review of Resident #43's Quarterly MDS with an ARD of 11/03/2025 revealed in part, the following: Section N. Medications N0350. Insulin A. Insulin injections. Record the numbers of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days: 1. Review of Resident #43's Physician Orders dated October 2025 to current revealed no insulin injection was ordered. Review of Resident #43's Medication Administration Record (MAR) dated October 2025 to current revealed no administration of insulin injections. On 12/03/2025 at 9:45 a.m., an interview was conducted with S8MDS. He reviewed Resident #43's Quarterly MDS with an ARD of 11/03/2025 and confirmed the resident was coded for insulin. S8MDS reviewed Resident #43's medical record and confirmed the resident had not received insulin. S8MDS confirmed Resident #43 was inaccurately coded for receiving an insulin injection and should not have been. On 12/03/2025 at 10:17 a.m., an interview was conducted with S3DON. She stated she reviewed Resident #43's Quarterly MDS and medical record. S3DON confirmed the MDS coding for insulin was inaccurate. 3. Review of Resident #13's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed, in part, active diagnoses of Schizophrenia and Depression. Review of Resident #13's Annual MDS with an ARD of 06/18/2025, revealed, in part, the following: Section A - Identification InformationA1500. PASRR - Is the resident currently considered by the state's Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 0. No. Section I - Active Diagnoses: I5800. Depression (other than bipolar) – Yes; and I6000. Schizophrenia – Yes. Review of Resident #13's current PASRR Level II Evaluation Summary and Determination Notice, dated 10/20/2025, revealed, in part, the following: Approved for admission by Level II Authority for a temporary period effective 10/20/2025 through 10/20/2026 due to qualifying diagnoses of Paranoid Schizophrenia and Depression. Review of Resident #13's current Care Plan, as of 12/01/2025 at 12:45 p.m., revealed, in part, the following problem identified by the facility: Level II PASRR. On 12/03/2025 at 11:50 a.m., an interview was conducted with S9MDS. S9MDS confirmed a resident's MDS should be accurately coded to reflect their Level II PASRR and Resident #13's was not. On 12/03/2025 at 2:00 p.m., an interview was conducted with S3DON. S3DON confirmed she expected a resident's MDS to accurately reflect their Level II PASRR status and Resident #13's did not. 4. Resident #4Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Obesity and Congestive Heart Failure. Further review revealed she was currently receiving treatment for multiple wounds. Review of Resident #4's Annual MDS with an ARD of 10/23/2025 revealed, in part, she was assessed to have a BIMs of 15 which indicated she was cognitively intact. Further review revealed, in part, the following:Section GG – Functional StatusGG0115. Functional Limitation in Range of Motion. Upper Extremities: No impairment. Lower Extremities: Impairment on both sides. GG0130. Self Care. Eating, Oral Hygiene, Toileting, Shower/Bath, Dressing Upper Body: Independent. Dressing Lower Body, Footwear: Dependent on staff.GG0170. Mobility. Repositioning, Roll Side to Side, Sit to Lying: Independent. Transfers: Dependent on staff. Section M - Skin ConditionsM0150. Risk of Pressure Ulcers/Injuries: Yes. M1030. Number of Venous and Arterial Ulcers: 1. Section P - Restraints and Alarms - Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. P0100A - Restraints used in bed: A. Bed Rail: 2 - Used daily. Review of Resident #4's Physician Orders, dated 04/01/2025 through 12/02/2025, revealed, in part, the following: An order written on 04/08/2025 and discontinued on 08/04/2025 for Grab bar x2 to assist with bed mobility; An order written on 11/05/2024 and discontinued on 05/28/2025 for Requires Hoyer lift with 2 person assist for transfer; and An order written on 08/04/2025 for Grab bar x1 to assist with sliding board transfer. Review of Resident #4's current Care Plan, as of 12/01/2025, revealed, in part, the following problem identified by the facility: Requires assistance with transfers. Review of Resident #4's Restraint Reduction - Safety Device Assessment, dated 08/16/2025, revealed, in part, the following: 3. Device type: Grab bars x2. 4. When used: While in bed. 5. Can the device be easily removed by the resident: Yes. 6. Does the device limit the resident's normal freedom of movement in any way: No.7. Does the device limit the resident's normal access to their body in any way: No. 8. Restraint or safety device: Safety Device. 9. Cognitive Status: Alert/Oriented. 10. Short-term memory: No impairment. 11. Mobility: Independently in wheelchair. 12. Elimination: Incontinent. 15. Weight bearing status: Non-weight bearing. 2. Does resident use grab bars: Yes. 3. Uses grab bar for mobility: Yes. 3. Specific medical symptom which requires device: Debility and wounds. 7. Is this the least restrictive intervention possible: Yes. On 12/02/2025 at 1:50 p.m., an interview was conducted with Resident #4. She confirmed she utilized the grab bar(s) to aide with repositioning in the bed and to assist with using the slide board to transfer in/out of bed. She confirmed the grab bars did not restrict her movement or prevent her from getting in/out of bed but actually improved her ability to do so. Resident #21Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, Epilepsy; History of Cerebral Infarction; Abnormal Posture; and Spastic Quadriplegic Cerebral Palsy. Further review revealed she was currently receiving treatment for a sacral wound. Review of Resident #21's Quarterly MDS with an ARD of 10/22/2025 revealed, in part, she was assessed to have a BIMs of 12 which indicated she was moderately cognitively intact. Further review revealed, in part, the following: Section GG – Functional StatusGG0115. Functional Limitation in Range of Motion. Upper and Lower Extremities: Impairment on both sides. GG0130. Self Care. Eating, Oral Hygiene, Toileting, Shower/Bath, Dressing and Footwear: Dependent on staff.GG0170. Mobility. Repositioning, Roll Side to Side, Sit to Lying, Transfers: Dependent on staff. Section P - Restraints and Alarms - Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. P0100A - Restraints used in bed: A. Bed Rail: 2 - Used daily. Review of Resident #21's Physician's Orders, dated 03/01/2025 through 12/02/2025, revealed, in part, the following: An order written on 11/05/2024 for Requires Hoyer lift & 2 person assist with transfer; An order written on 04/08/2025 and discontinued on 08/04/2025 for Grab bar x2 to assist with bed mobility; and An order written on 08/16/2025 for Grab bar x2 to assist with bed mobility, transfers, safety. Review of Resident #21's current Care Plan, as of 12/01/2025, revealed, in part, the following:Problem: At Risk for Falls. Interventions: Grab bar x2 to assist with bed mobility. Problem: Stage 4 Sacral Pressure Ulcer.Interventions: Grab bar x2 on bed for repositioning.Problem: Requires assistance with transfers. Interventions: Grab bar x2 for bed mobility and repositioning. Problem: Impaired Mobility - Requires staff assistance to complete ADLs. Interventions: Grab bar x2 for bed mobility and repositioning; Hoyer lift for all transfers. Review of Resident #21's Restraint Reduction - Safety Device Assessment, dated 08/05/2025, revealed, in part, the following: 3. Device type: Grab bar x2. 4. When used: While in bed. 5. Can the device be easily removed by the resident: Yes. 6. Does the device limit the resident's normal freedom of movement in any way: No.7. Does the device limit the resident's normal access to their body in any way: No. 8. Restraint or safety device: Safety Device. 9. Cognitive Status: Alert/Oriented. 10. Short-term memory: No impairment. 11. Mobility: Bed mobility with assistance. 12. Elimination: Incontinent. 15. Weight bearing status: Non-weight bearing. 2. Does resident use grab bars: Yes. 3. Uses grab bar for mobility: Yes. 3. Specific medical symptom which requires device: History of Stroke. 7. Is this the least restrictive intervention possible: Yes. On 12/03/2025 at 11:28 a.m., an interview was conducted with S10CNA. S10CNA confirmed she was familiar with Resident #4 and #21. S10CNA confirmed Resident #4 and #21 had grab bars to increase their mobility and assist with safety. S10CNA confirmed the grab bars did not restrict their movement or ability to access their own bodies. S10CNA confirmed Resident #4 actually utilized the grab bars when using her slide board to transfer in and out of bed, as well as to aid in repositioning while in bed. S10CNA confirmed Resident #21 was not physically capable of getting out of bed independently and required a Hoyer lift for transfers. S10CNA confirmed Resident #21 utilized her grab bars for repositioning herself in bed and when receiving incontinence care from staff. On 12/03/2025 at 11:30 a.m., an interview was conducted with S11CNA. S11CNA confirmed she was familiar with Resident #4 and #21. S11CNA confirmed Resident #4 and #21 had grab bars to increase their mobility and assist with safety. S11CNA confirmed the grab bars did not restrict their movement or ability to access their own bodies. S11CNA confirmed Resident #4 actually utilized the grab bars when using her slide board to transfer in and out of bed, as well as to aid in repositioning while in bed. S11CNA confirmed Resident #21 was not physically capable of getting out of bed independently and required a Hoyer lift for transfers. S11CNA confirmed Resident #21 utilized her grab bars for repositioning herself in bed and when receiving incontinence care from staff. On 12/03/2025 at 10:51 a.m., an interview was conducted with S13NP. S13NP confirmed he was familiar with Resident #4 and #21, as well as their orders. S13NP confirmed he had written orders for Resident #4 and #21 to utilize bed rails/grab bars to increase their mobility and assist with safety. S13NP confirmed Resident #4 and #21 did not have restraints in use. On 12/03/2025 at 11:50 a.m., an interview was conducted with S9MDS. S9MDS reviewed the MDS Resident Assessment Instrument's instructions for coding Section P regarding side rails as a restraint. S9MDS confirmed the instructions indicated side rails/grab bars would only be considered a restraint if they restricted a resident's freedom of movement or access to their own body. S9MDS confirmed Resident #4 and #21 utilized side rails/grab bars to increase their mobility and assist with safety and did not restrict their movement or prevent access to their own body. S9MDS confirmed Resident #4 and #21 did not have restraints in use and their MDS was coded incorrectly. On 12/03/2025 at 11:55 a.m., an interview was conducted with S8MDS. S8MDS confirmed Resident #4 utilized the grab bars when using her slide board to transfer in/out of bed, as well as to aid in repositioning while in bed. S8MDS confirmed Resident #21 was not physically capable of getting in/out of bed independently, required a Hoyer lift for transfers and two person staff assist for all ADLs. S8MDS confirmed Resident #21 utilized her grab bars for repositioning in bed and/or while receiving incontinence care from staff. S8MDS confirmed Resident #4 and #21's side rails/grab bars did not restrict their movement or prevent them from accessing their own body and should not have been coded as a restraint. On 12/03/2025 at 2:00 p.m., an interview was conducted with S3DON. S3DON confirmed she expected a resident's MDS to accurately reflect whether or not they had restraints in use and Resident #4 and #21's did not.

Based on observations, interviews, and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 (#10, #79, and #95) of 19 sampled residents. The facility failed to ensure:1. Medication administration was accurately documented on the MAR for Residents #10 and #95; and2. Colostomy changes were documented for Resident #79.1. Review of the facility's undated policy titled, Medication-Documentation of Administration revealed the following, in part: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). Resident #10 Review of Resident #10's Clinical Record revealed an admission date of 02/05/2025 and diagnoses, which included Hypertensive Heart Disease and Peripheral Vascular Disease. Review of Resident #10's Quarterly MDS with an ARD of 11/12/2025 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #10's current Physician Orders revealed the following, in part: Lasix oral tablet 40 mg by mouth twice daily at 5:00 a.m. and 12:00 p.m. Review of Resident #10's MAR dated 12/01/2025 revealed the following, in part: Lasix 40 mg by mouth at 12:00 p.m. with a check mark and initials indicating S7LPN administered Resident #10's Lasix at 12:00 p.m. On 12/01/2025 at 3:55 p.m., an observation was made of Resident #10. She had a white tablet in a medication cup on her bedside table. An interview was conducted with Resident #10 at that time. She identified the white pill as her Lasix. She stated she was not going to take her Lasix. On 12/01/2025 at 4:00 p.m., an observation was made of Resident #10 with S7LPN. S7LPN confirmed Resident #10 had a white tablet in a medication cup on her bedside table. S7LPN identified the white tablet in the medication cup as Resident #10's 12:00 p.m. Lasix. On 12/01/2025 at 4:02 p.m., an interview was conducted with S7LPN. She confirmed she left Resident #10's 12:00 p.m. Lasix at Resident #10's bedside and did not observe her consume the medication. She confirmed she documented the Lasix as being administered when the resident did not consume the medication, which was inaccurate. On 12/02/2025 at 2:33 p.m., an interview was conducted with S3DON. She confirmed nurses should witness the resident consume their medications. She confirmed medication administration documentation was not accurate and should have been. Resident #95 Review of Resident #95's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Neoplasm Related Pain. Review of Resident #95's current Physician Orders revealed the following, in part: Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 4 hours as needed for Pain related to Neoplasm Related Pain. Start date: 10/30/2025 Review of Resident #95's MAR dated 11/01/2025-11/30/2025 revealed administration of Oxycodone HCL oral tablet 5 mg was documented as the following, in part: 11/01/2025: no administrations documented 11/02/2025: administered 3 times 11/03/2025-11/07/2025: administered 1 time daily 11/08/2025-11/09/2025: no administrations documented 11/10/2025-11/11/2025: administered 1 time daily 11/12/2025: no administrations documented 11/13/2025: administered 1 time 11/14/2025: no administrations documented 11/15/2025-11/17/2025: administered 1 time daily 11/18/2025: administered 2 times 11/19/2025-11/22/2025: administered 1 time daily 11/23/2025-11/24/2025: administered 2 times daily 11/25/2025-11/26/2025: administered 1 time daily 11/27/2025: administered 2 times 11/28/2025: administered 1 time 11/29/2025: administered 3 times 11/30/2025: administered 1 time Review of Resident #95's Narcotic Log dated 10/30/2025, revealed administration of Oxycodone HCL oral tablet 5 mg was documented as the following, in part: 11/01/2025 at 8:00 a.m., amount given 1, amount left 89. 11/02/2025 at 11:22 p.m., amount given 1, amount left 88 11/03/2025 at 5:43 a.m., amount given 1, amount left 87 11/03/2025 at 10:00 a.m., amount given 1, amount left 86 11/03/2025 at 2:00 p.m., amount given 1, amount left 85 11/03/2025 at 6:00 p.m., amount given 1, amount left 84 11/04/2025 at 9:45 a.m., amount given 1, amount left 83 11/04/2025 at 6:00 p.m., amount given 1, amount left 82 11/05/2025 at 8:57 a.m., amount given 1, amount left 81 11/05/2025 at 8:00 p.m., amount given 1, amount left 80 11/06/2025 at 5:00 a.m., amount given 1, amount left 79 11/06/2025 at 8:57 a.m., amount given 1, amount left 78 11/06/2025 at 7:00 p.m., amount given 1, amount left 77 11/07/2025 at 9:12 a.m., amount given 1, amount left 76 11/07/2025 at 6:00 p.m., amount given 1, amount left 75 11/08/2025 at 9:00 a.m., amount given 1, amount left 74 11/08/2025 at 4:00 p.m., amount given 1, amount left 73 11/09/2025 at 12:00 a.m., amount given 1, amount left 72 11/09/2025 at 9:00 a.m., amount given 1, amount left 71 11/09/2025 at 1:00 p.m., amount given 1, amount left 70 11/10/2025 at 1:15 a.m., amount given 1, amount left 69 11/10/2025 at 8:00 a.m., amount given 1, amount left 68 11/10/2025 at 6:00 p.m., amount given 1, amount left 67 11/11/2025 at 9:10 a.m., amount given 1, amount left 66 11/11/2025 at 6:00 p.m., amount given 1, amount left 65 11/12/2025 at 8:00 a.m., amount given 1, amount left 64 11/12/2025 at 12:00 p.m., amount given 1, amount left 63 11/12/2025 at 6:00 p.m., amount given 1, amount left 62 11/13/2025 at 8:18 a.m., amount given 1, amount left 61 11/13/2025 at 6:00 p.m., amount given 1, amount left 60 11/14/2025 at 1:00 a.m., amount given 1, amount left 59 11/14/2025 at 9:02 a.m., amount given 1, amount left 58 11/15/2025 at 9:02 a.m., amount given 1, amount left 57 11/16/2025 at 4:00 a.m., amount given 1, amount left 56 11/16/2025 at 8:00 p.m., amount given 1, amount left 55 11/17/2025 at 2:15 a.m., amount given 1, amount left 54 11/17/2025 at 6:00 a.m., amount given 1, amount left 53 11/17/2025 at 10:00 a.m., amount given 1, amount left 52 11/18/2025 at 7:29 a.m., amount given 1, amount left 51 11/19/2025 at 8:32 a.m., amount given 1, amount left 50 11/21/2025 at 8:02 a.m., amount given 1, amount left 49 11/22/2025 at 2:00 a.m., amount given 1, amount left 48 11/22/2025 at 10:00 p.m., amount given 1, amount left 47 11/22/2025 at no time documented, amount given 1, amount left 46 11/22/2025 at 4:00 p.m., amount given 1, amount left 45 11/23/2025 at 3:00 a.m., amount given 1, amount left 44 11/23/2025 at 7:00 a.m., amount given 1, amount left 43 11/23/2025 at 5:00 p.m., amount given 1, amount left 42 11/24/2025 at 4:33 a.m., amount given 1, amount left 41 11/24/2025 at 10:05 a.m., amount given 1, amount left 40 11/24/2025 at 6:00 p.m., amount given 1, amount left 39 11/25/2025 at 3:00 a.m., amount given 1, amount left 38 11/25/2025 at 6:00 p.m., amount given 1, amount left 37 11/26/2025 at 3:00 a.m., amount given 1, amount left 36 11/26/2025 at 8:55 a.m., amount given 1, amount left 35 11/26/2025 at 1:00 p.m., amount given 1, amount left 34 11/27/2025 at 12:00 a.m., amount given 1, amount left 33 11/27/2025 at 4:00 a.m., amount given 1, amount left 32 11/27/2025 at 8:30 a.m., amount given 1, amount left 31 11/27/2025 at 12:30 p.m., amount given 1, amount left 30 On 12/03/2025 2:10 p.m., an interview was conducted with S3DON. She stated all narcotic medications administered should be accurately documented on the resident's MAR and the narcotic log. She reviewed Resident #95's MAR, dated 11/01/2025-11/30/2025, and narcotic log for Oxycodone HCL oral tablet 5 mg and confirmed the administration was not documented accurately on the MAR and should have been. 2. Resident #79 Review of Resident #79's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Colostomy. Review of Resident #79's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/2025, revealed a BIMS of 15, which indicated intact cognition. Review of Resident #79's current physician orders revealed the following, in part: Order date: 11/28/2025. Change colostomy bag every 72 hours and as needed. SPACE Further review of Resident #79's current Physician Orders revealed no orders to change his colostomy prior to 11/28/2025. Review of Resident #79's current MAR revealed no documentation indicating his colostomy had been changed since admission on [DATE]. Review of Resident #79's Nurses' Notes, dated from, 11/17/2025 to 12/02/2024, revealed no documentation indicating Resident #79's colostomy had been changed. On 12/01/2025 at 11:30 a.m., an interview was conducted with Resident #79. He stated he had concerns with the night shift not changing his colostomy bag. On 12/03/2025 at 1:10 p.m., an interview was conducted with S4ADON. She reviewed Resident #79's clinical record and confirmed there was no documentation indicating his colostomy had been changed. On 12/03/2025 at 11:12 a.m., an interview was conducted with S3DON. She stated she reviewed Resident #79's clinical record and could not find documentation indicating staff had changed his colostomy bag. She confirmed colostomy bag changes for Resident #79 were not documented and should have been.

Based on record reviews and interview, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate PASRR Level II determinations and recommendations into a resident's transitions of care for 1 (#98) of 4 (#3, #13, #66, and #98) residents reviewed for PASRR.Findings: Review of the facility's undated policy titled Resident Assessment-Coordination with PASRR Program revealed the following, in part: Policy Explanation and Compliance Guidelines:7. Recommendations, such as any specialized services, from a PASRR Level II Determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of Resident #98's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Unspecified Psychosis. Review of Resident #98's Form 142 revealed he was approved for admission by Level II authority for a temporary period of 01/09/2025 - 01/08/2026. Review of Resident #98's PASRR Level II Evaluation Summary and Determination Notice dated 01/09/2025 revealed the Level II authority had approved 365 days of nursing facility placement with the following to occur during his stay: 1. Assertive Community Treatment2. Substance Use Disorder Assessment by a Licensed Addictions Counselor3. Substance Use Disorder outpatient treatment a. Individual counseling by a Licensed Addictions Counselor b. Group counseling by a Licensed Addictions Counselor UHC to assist with any needed referrals. Review of Resident #98's clinical record revealed none of the PASRR Level II recommendations listed above had been implemented or had attempted to be implemented. On 12/02/2025 at 1:30 p.m., an interview was conducted with S1ADM. She stated she reviewed Resident #98's medical record and confirmed none of his PASRR level II recommendations had been implemented.

Based on observations, interviews, and record review, the facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality by nursing staff failing to observe and ensure a resident consumed medication for 1 (#10) of 7 residents reviewed for medication administration.Findings: Review of Resident #10's Clinical Record revealed an admission date of 02/05/2025 and diagnoses, which included Hypertensive Heart Disease and Peripheral Vascular Disease. Review of Resident #10's Quarterly MDS with an ARD of 11/12/2025 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #10's current Physician Orders revealed the following, in part: Lasix oral tablet 40 mg by mouth twice daily at 5:00 a.m. and 12:00 p.m. Review of Resident #10's MAR dated 12/01/2025 revealed the following, in part:Lasix 40 mg by mouth at 12:00 p.m. with a check mark and initials indicating S7LPN administered Resident #10's Lasix at 12:00 p.m. An observation was made of Resident #10 on 12/01/2025 at 3:55 p.m. She had a white tablet in a medication cup on her bedside table. An interview was conducted with Resident #10 at that time. She stated she woke up from a nap and the tablet was on her bedside table. She identified the white pill as her Lasix. She stated she did not take her Lasix if it was after 1:00 p.m. because she would urinate all night. She stated, since she woke up after 1:00 p.m., she decided not to take her Lasix. An observation was made of Resident #10 with S7LPN on 12/01/2025 at 4:00 p.m. S7LPN confirmed Resident #10 had a white tablet in a medication cup on her bedside table. S7LPN identified the white tablet in the medication cup as Resident #10's 12:00 p.m. Lasix. An interview was conducted with S7LPN on 12/01/2025 at 4:02 p.m. She confirmed she left Resident #10's Lasix at her bedside this afternoon. She confirmed she should have observed Resident #10 consume her Lasix to ensure it was taken. An interview was conducted with S3DON on 12/02/2025 at 2:33 p.m. She confirmed nurses should witness the resident consume their medications. She confirmed medications should never be left at the bedside.

Based on observations, interviews and record review the facility failed to provide adequate supervision for 1 (#5) of 3 (#5, #6, and #7) residents reviewed for wandering. The facility failed to ensure staff appropriately supervised Resident #5 who was assessed to be a wanderer, unsafe smoker, and a high fall risk. This deficient practice resulted in an immediate jeopardy situation on the weekend of 02/15/2025 through 02/16/2025, when Resident #5, a severely cognitively impaired resident identified as a wanderer, unsafe smoker and high fall risk, entered the smoking patio while no staff were present to provide supervision. Resident #5 self-propel himself in his wheelchair through the gate of the smokers' patio onto the sidewalk along the resident patio exterior doors. When Resident #5 attempted to enter back through the gate into the smoking patio, he was unable to maneuver his wheelchair over the uneven concrete. He stood up from his wheelchair and fell on to the concrete walkway. Random Resident #R3 observed Resident #5 fall and was unable to locate the smoking attendant on the smoking patio. Random Resident #R3 went inside the facility and notified S14WC of Resident #5 being on the ground. This failure to provide adequate supervision for Resident #5 created a likelihood of serious injury for Resident #5 when he fell outside on the concrete. S1ADM was notified of the Immediate Jeopardy on 02/26/2025 at 2:15 p.m. This deficient practice continued at a potential for more than minimal harm for the 5 residents residing in the facility identified as moderate to high risk for wandering and elopement. Findings: Review of the facility's undated, Routine Resident Checks policy revealed the following, in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Review of the facility's job description for the Smoke Monitor Attendant, dated 09/20/2024, revealed the following, in part: Responsibilities: 4. Responsible for monitoring all residents in the smoking area, monitoring the area, and intervening as needed for any resident safety issues. 6. Other assistance and assist all residents when needed. Review of facility's Staff Orientation Packet, revealed the following, in part: The smoking monitor attendant is on duty from 7 a.m. to 7 p.m., seven days per week . Further review revealed the Staff Orientation Packet was signed by S10CNA on 01/16/2025 and S13CNA on 12/03/2024, which indicated they received the training on the aforementioned dates. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following; History of Cerebral Infarction, Hemiplegia and Hemiparesis, History of Falling, and Cognitive Communication Deficit. Review of Resident #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/06/2024 revealed Resident #5 was assessed by the facility to have a BIMS (Brief Interview Mental Status) of 3, indicating the resident was severely cognitively impaired. Further review revealed he self-propelled himself independently in his manual wheelchair. Review of Resident #5's Elopement Risk Evaluation, dated 02/13/2025, revealed the following, in part: 6. Does the resident wander? Yes. 8. Does the resident wander aimlessly or non-goal directed (i.e. confused, moves without purpose, may enter others' rooms and explore others' belongings)? Yes. Review of Resident #5's Fall Risk Assessments, dated 01/01/2024 through 02/24/2025, all indicated Resident #5 was identified by the facility to be a high fall risk. A review of Resident #5's Physician Orders, dated February 2025, revealed the following, in part: 11/17/2024 - Wanderguard monitoring; check placement and function of wanderguard bracelet every shift. 12/18/2024 - Unsafe smoker; smoker/monitor resident every shift. 02/13/2025 - Every 30 minute checks due to falls and census checks related to elopement risk. Review of Resident #5's Care Plan, dated 01/01/2025 through 02/24/2025, revealed the following, in part: Problem: Resident #5 is at risk for elopement Interventions: 02/13/2025 - Monitor Resident #5 every 30 minutes and keep wander guard in place. Problem: The resident has had an actual fall with no injury. Interventions: 01/16/2025 - Resident #5 had an unwitnessed fall, fall mat at bedside when resident in bed; 01/19/2025 - Resident #5 had an unwitnessed fall, concave mattress for bed edge definition; 01/23/2025 - Resident #5 had a witnessed fall, helmet cap in place while up in wheelchair; 02/04/2025 - Resident #5 had a witnessed fall, keep resident in high traffic areas; 02/08/2025 - Resident #5 had an unwitnessed fall, activity vest applied while up in wheelchair; and 02/13/2025 - Monitor every 30 minutes Review of Resident #5's CNA Task Log, dated 02/01/2025 through 02/26/2025, revealed the following, in part: Task: Census Checks every 30 minutes related to falls and elopement risk. Further review revealed no documented evidence to indicate Resident #5's 30 minute checks were performed as ordered during the timeframe reviewed. On 02/25/2025 at 4:40 p.m., an interview was conducted with Random Resident #R2, a cognitively intact resident. He confirmed he resided in Room C where his bed was located near the outside wall with a window overlooking the outside patio of the facility. He confirmed during the weekend of 02/15/2025 through 02/16/2025, while in his room, he heard someone shouting for help. He stated when he looked out of his bedroom window, he saw Resident #5 lying on the ground on the patio near his exterior door. He confirmed he went to the ward clerk desk and notified the nurse but could not recall her name. He confirmed after he reported the incident, he went outside to the smoking patio and there was no smoking aide present but there were residents out there smoking. On 02/25/2025 at 4:47 p.m., an interview was conducted with Random Resident #R3, a cognitively intact resident. He confirmed he recalled Resident #5 falling during the weekend of 2/15/2025 through 02/16/2025. He stated he went out to the smoking patio after lunch and confirmed a smoking aide was not present. He confirmed he saw Resident #5 self-propel himself out of the dining room door onto the smoking patio then continued through the patio gate onto the concrete walkway that ran alongside the rear of the building. He confirmed he watched Resident #5 self-propel himself to the end of the concrete walkway where he turned himself around and came back towards the smoking patio. He stated when Resident #5 attempted to self-propel himself back toward the gate of the smoking patio, his wheelchair got stuck on the uneven concrete. He stated after Resident #5 got stuck, he stood up and fell down to the concrete sidewalk. He confirmed no staff were present on the patio at the time Resident #5 fell so he went back inside the facility to the ward clerk desk to look for someone to assist Resident #5. On 02/24/2025 at 11:30 a.m., an interview was conducted with S13CNA. She confirmed she worked as the smoking aide during the weekend of 02/15/2025 through 02/16/2025. She confirmed she did not sit out on the smoking patio during her shift that weekend. She confirmed she sat at the ward clerk's desk or the main dining room throughout her entire shift unless an unsafe smoker came to her requesting to smoke. She confirmed she was aware Resident #5 was an unsafe smoker. She was unaware Resident #5 was a wanderer. She confirmed she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025 while she was assigned as the smoking aide. On 02/25/2025 at 4:50 p.m., an observation of the smoking patio located to the rear of the facility was conducted. To the right of the smoking patio revealed a gate with a concrete sidewalk which extended from the gate to the sidewalk of the exterior patio doors for Hall B. It is noted the concrete sidewalk was not flushed together and was slightly elevated on the gate side of the sidewalk. On 02/25/2025 at 9:57 a.m., an interview was conducted with S9LPN. She confirmed Resident #5 self-propelled himself throughout the facility all day in his wheelchair. She confirmed he was assessed by the facility to be a wanderer and required a Wanderguard at all times. She confirmed Resident #5 had frequent falls because he could not remember to ask for staff assistance before attempting to stand or transfer himself. She confirmed Resident #5 was assessed to be an unsafe smoker and required supervision when he was outside smoking. She confirmed Resident #5 required increased supervision from staff due to all of the above and staff were aware to keep an eye on him. She confirmed every day a staff member was assigned to serve as the smoking aide and they were responsible for being outside on the patio to provide supervision and assistance for residents from 7:00 a.m. to 7:00 p.m. On 02/24/2025 at 11:32 a.m., an interview was conducted with S10CNA. She confirmed on the weekend of 02/15/2025 through 02/16/2025, she worked an extra shift as the smoking aide and remained on the smoking patio throughout her entire shift from 7:00 a.m. to 7:00 p.m. She confirmed Resident #5 was a very busy resident who moved himself around the facility all day long and required frequent monitoring every 30 minutes. She confirmed she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025. On 02/24/2025 at 1:40 p.m., an interview was conducted with S12CNA. She confirmed there was a staff member assigned to be the smoking aide from 7:00 a.m. to 7:00 p.m. every day. She confirmed the smoking aide was responsible for remaining outside on the smoking patio throughout their shift to provide supervision to any residents who were outside. She confirmed she worked the weekend of 02/15/2025 through 02/16/2025 as Resident #5's CNA. She confirmed Resident #5 was a very busy resident who moved himself around the facility all day long and frequently fell because he could not remember to ask for staff assistance before attempting to stand or transfer himself. She stated on the weekend of 02/15/2025 through 02/16/2025, she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025. On 02/24/2025 at 4:07 p.m., an interview was conducted with S14WC. She confirmed she worked during the weekend of 02/15/2025 through 02/16/2025. She confirmed during that weekend, after lunch a resident came to her desk in the lobby and reported Resident #5 had fallen outside. She confirmed she could not recall if this occurred on 02/15/2025 or 02/16/2025 but confirmed it was one of those days. She stated S15CNA was at the ward clerk desk when Resident #5's fall was reported. On 02/25/2025 at 4:59 p.m. an interview was conducted with S15CNA. She confirmed she worked during the weekend of 02/15/2025 through 02/16/2025 and was not assigned to Resident #5. She stated she was at the ward clerk desk when Random Resident #R3 reported Resident #5 fell and was on the ground outside the patio area. She stated she reported the fall to S16RN and they went outside together. She stated once they arrived outside, Resident #5 was noted in a sitting position on the ground outside of the gated smoking patio. She confirmed there should be an assigned smoking aide present on the patio every day from 7:00 a.m. to 7:00 p.m. but she could not recall if they were present when Resident #5 fell . On 02/25/2025 at 9:25 a.m., an interview was conducted with S16RN. She confirmed she was the day shift charge nurse during the weekend of 02/15/2025 through 02/16/2025. She stated she initially did not recall Resident #5 having an unwitnessed fall during that weekend. She then confirmed Resident #5 did have an unwitnessed fall during that weekend. She confirmed she did not recall who reported the fall to her or who assisted her, but confirmed the fall occurred after lunch around 1:00 p.m. She stated when she arrived outside Random Resident #R2 was near Resident #5. She confirmed Resident #5 was sitting on his bottom on the concrete walkway on the outside of the gated smoking patio. She stated she did not recall if there was a smoking aide on the smoking patio when the fall occurred or if anyone was assigned as the smoking aide that day. She confirmed there was a weekend recently when there was not an assigned smoking aide but could not be sure if it was the weekend of Resident #5's fall. On 02/25/2025 at 12:15 p.m., an interview was conducted with S17WC. She stated she was responsible for the smoking aide schedule. She stated there was a smoking aide assigned for every weekend in January 2025 and February 2025. She stated if the smoking aide did not show up on their assigned day, administration would pull the restorative aide or someone else until they called a worker in to supervise residents on the smoking patio. She further stated the assigned smoking aide should be present on the smoking patio from 7:00 a.m. to 7:00 p.m. She confirmed if the smoking aide was seated at her desk, residents would be able to enter the dining room and exit to the smoking patio without being seen. On 02/25/2025 at 12:28 p.m., an interview was conducted with S8ADON. She stated the smoking aide was assigned daily from 7:00 a.m. to 7:00 p.m. and was expected to be present on the smoking patio during their entire shift to provide supervision for residents outside. She stated the smoking aide should request another staff to relieve them prior to leaving the smoking patio for any breaks so the area was never left unattended. She confirmed if the smoking aide was seated at S17WC's desk, residents would be able to enter the dining room and exit to the smoking patio without being seen. On 02/25/2025 at 1:50 p.m., an interview was conducted with S1DON. He stated the smoking aide was assigned daily from 7:00 a.m. to 7:00 p.m. and was expected to be present on the smoking patio during their entire shift to provide supervision for residents outside. He stated the smoking aide should request another staff to relieve them prior to leaving the smoking patio for any breaks so the area was never left unattended. He confirmed new employees received the smoking policy and the policy/procedure was reviewed during orientation. He stated all CNA's were aware of the rules for the smoking aide, which was to remain on the patio at all times from 7:00 a.m. to 7:00 p.m. He confirmed the smoking patio should have supervision for all residents from 7:00 a.m. to 7:00 p.m. daily. He confirmed Resident #5 would not be safe outside without supervision and was care planned for high traffic areas, which included the smoking patio due to the presence of constant supervision in that area. The Immediate Jeopardy was removed on 02/27/2025 at 2:55 p.m., after it was determined through observation, interview, and record review; the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. The facility failed to ensure Resident who is at risk for falls and wandering, received adequate supervision on 02/15/2025 and 02/26/2025. All residents who are cognitively impaired, wander, and are at risk for falls are potentially affected by this deficient practice. 2. The outside patio fence gate is to remain closed. Starting on 02/27/2025, Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form on 5 random days/week for 8 weeks then randomly to ensure adequate supervision provided to residents. Disciplinary action up to termination will take place if this occurs again. All staff will be in serviced beginning on 02/26/2025 by Administrator/DON/Designee on providing supervision to resident while out on smoke patio, the smoke monitor will remain outside and must be relieved by other staff to leave that area. All staff members will be required to complete the training prior to working their shift. In-service will be completed 02/27/2025, no employee will be allowed to begin their shift until the training, has been received. 3. Starting on 02/27/2025, Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form on 5 random days/week for 8 weeks then randomly to ensure adequate supervision provided to residents. Audit reports will be submitted to the Administrator and QAPI committee for review and new interventions implemented as needed. The facility asserts the likelihood for serious harm to any Resident no longer exists as of 02/27/2025.

Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. An effective system was in place to ensure licensed nurses and nurse aids were competent in the skill sets required to meet resident needs for 10 of 10 (S4CNA, S9WCN, S11CNA, S24CNA, S27CNA, S38CNA, S40CNA, S43LPN, S47CNA, and S48CNA) personnel files reviewed for documentation of skills competency. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the Immediate Jeopardy on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 75 residents requiring assistive devices and/or supervision with transfers. Cross Reference: F-689. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, and Primary Generalized Osteoarthritis. Review of Resident #54's MDS with an ARD of 07/26/2024 revealed, in part, a BIMS summary score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed she was dependent on staff for transfers. Review of Resident #54's Physical Therapy Note dated 07/25/2024 revealed, in part, she required a Hoyer lift for transfers. Review of Resident #54's current Care Plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices required for transfers. Review of Resident #54's Resident Summary on 09/18/2024 in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She stated, at the time of the transfer, she required a Hoyer lift with the assistance of two staff members for transfers. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the emergency room . An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She confirmed, at the time of the incident, she was unaware how to identify a resident's transfer status. She stated Resident #54 was cognitively intact so she asked the resident how much assistance she needed to be transferred from the bed to the wheelchair. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. An interview was conducted with S4CNA on 09/18/2024 at 3:40 p.m. She stated upon hire she was made aware verbally of what each resident required in only the resident section she was working in. She stated she was not trained on how to determine the amount of assistance and/or supervision a resident needed for transfers. She stated she made her own assessment of the resident or asked the resident how much assistance they needed for transfers. She stated she had not been observed by anyone to ensure she was competent in performing tasks. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. An interview was conducted with S35RD on 09/18/2024 at 12:12 p.m. She stated Resident #54 has required a Hoyer lift for transfers since 07/25/2024. An interview was conducted with S11CNA on 09/18/2024 at 9:09 a.m. She stated if she did not know the transfer status of a resident she would ask another staff or the resident. An interview was conducted with S37TP on 09/18/2024 at 9:18 a.m. She stated she was unaware of how to determine the transfer status of a resident. She stated if she was unsure of a resident's transfer status, she would ask another CNA or the resident. An interview was conducted with S38CNA on 09/18/2024 at 9:47 a.m. She stated there was not a particular place to look to identify a resident's transfer status. She stated when a new resident came into the facility, therapy evaluated them and verbally notified the CNAs how much assistance was needed. She confirmed the only way to know a resident's transfer status was by verbal communication. An interview was conducted with S39CNA on 09/18/2024 at 9:57 a.m. She stated she worked with residents every day and was familiar with each resident's capability. She stated she would transfer each resident based on that resident's capability. An interview was conducted with S27CNA on 09/18/2024 at 10:20 a.m. She stated verbal communication was how she knew how much assistance and supervision each resident required for transfers. She stated if she was unsure how much assistance or supervision the resident required for transfers, she would ask another CNA, the CNA supervisor, or the resident. She stated if a resident's transfer status changed, she was not sure she would be aware. An interview was conducted with S40CNA on 09/18/2024 at 1:15 p.m. She stated she determined how much assistance and supervision each resident required based on her own assessment. She stated there was nowhere for her to go and look to see what therapy determined was the safest for resident transfers. She reviewed Resident #54's ADL charting and Resident Summary and confirmed there was nowhere in the chart indicating the amount of supervision and/or assistance Resident #54 required for transfers. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS reviewed Resident #54's Therapy Note dated 07/25/2024 and confirmed that was the date Resident #54 was determined to require a Hoyer lift for transfers. S29MDS stated the direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how, and were not trained, to update, anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed by therapy to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. An interview was conducted with S3ADN on 09/19/2024 at 9:50 a.m. She stated competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by herself and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. She stated prior to yesterday afternoon, the amount of staff required and how to transfer a resident was not listed in the residents' clinical record, including the Resident Summary, for the CNAs to see. She stated prior to yesterday afternoon, the only process the facility had in place for a resident's transfer status was by word of mouth. She stated it was not acceptable for a CNA to assess a resident for their transfer status. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff or protective gear. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking outside of his room with smoking paraphernalia unsupervised. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. The Immediate Jeopardy continued when interviews with CNAs and Nursing Staff revealed they did not know their role in identifying, assessing and implementing safe smoking interventions for residents who smoked. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 26 residents identified by the facility as being a smoker. Findings: 2. Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the at the nurses station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's Clinical Record revealed he was admitted to facility on 06/14/2024 with diagnoses which included: Tobacco use, and nicotine dependence. Review of Resident #87's Safe Smoking Evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed Resident #87 was deemed an unsafe smoker. Review of Physician's Orders dated 06/26/2024 revealed: Resident is deemed as an unsafe smoker. Review of Resident #87's current Care Plan revealed the following, in part: Problem: Onset date of 09/01/2024, Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Further review revealed Resident #87 did not have a care plan for smoking prior to 09/01/2024. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without protective gear. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with S29MDS at 4:11 p.m. She confirmed she was responsible for performing smoking assessments. She confirmed Resident #87 was an unsafe smoker due to limited motion with his hands, and should not have possession of cigarettes and lighters. She confirmed floor nurses and floor CNAs were responsible to notify her if they observed residents smoking in undesignated areas and/or without their smoking interventions. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. She reported being unaware which residents were safe or unsafe smokers, until provided a list on 09/17/2024 per administration staff. She confirmed she bought Resident #87 three packs of cigarettes and placed them in his top television dresser drawer in the past without knowing he was an unsafe smoker. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. She stated since she was employed she was not provided with a safe or unsafe smokers list until the evening of 09/17/2024, and she would depend on staff to tell her which were safe or unsafe smokers. She stated prior to 09/17/2024 she was unaware of who was a safe or unsafe smoker or the interventions required. She reported the facility provided a lock box for resident's cigarettes on the evening of 09/17/2024. She stated prior to 09/17/2024 she did not have a lock box and each resident held their own cigarettes. An interview was conducted with S32LPN on 09/19/2024 at 12:05 p.m. She confirmed knowing Resident #87 was smoking in undesignated areas in July. She confirmed she did not report this incident to administration as she thought they read her nurse's notes. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. He confirmed the facility's process for a newly admitted resident was to review their History and Physical, assess the resident and if they were a smoker, and if so MDS would perform a smoking evaluation. He confirmed the MDS nurses were responsible to update the computer system which staff could review to identify any safe or unsafe smokers. He reported MDS was also responsible for verbally communicating any changed smoking interventions with the staff during the 2:00 p.m. staff meeting. He confirmed residents should only smoke in the designated smoking area, unsafe smokers should not possess cigarettes or lighters, and unsafe smokers should only smoke during constant supervision. Resident #75 Review of Resident #75's Clinical Record revealed an admitted [DATE]. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Safe Smoking Evaluation on 09/17/2024 revealed no documented evidence a smoking evaluation was completed. Review of Resident #75's Physician Orders, dated 06/26/2024 through 09/17/2024, regarding his smoking status was attempted on 09/17/2024 with no documented evidence available for review. Review of Resident #75's current Care Plan, as of 09/17/2024, regarding his smoking status was attempted with no documented evidence available for review. Review of Resident #75's Nurses Notes revealed staff were aware the resident smoked on the following dates: 07/01/2024 at 11:31 a.m. by S43LPN; 07/01/2024 at 7:15 p.m. by S43LPN; 08/16/2024 at 3:57 p.m. by S33LPN; 08/20/2024 at 3:55 a.m. by S42LPN; and 08/22/2024 at 5:48 a.m. by S42LPN. An observation and interview was conducted with Resident #75 on 09/17/2024 at 9:25 a.m. Resident #75 was seated in his wheelchair smoking a cigarette on the patio outside of his room and confirmed this was where he typically smoked. Resident #75 confirmed he was a smoker and had been since he admitted to the facility in June of 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted nor had any members of the staff observed him smoking. A pack of cigarettes and a lighter was present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware he was only supposed to smoke in a designated smoking area. An interview was conducted with S29MDS on 09/18/2024 at 9:45 a.m. S29MDS stated upon a resident's admission to the facility, it was the responsibility of the floor nurse to alert the MDS team if a resident was a smoker so they could be assessed for smoking safety. S29MDS confirmed the MDS team was responsible for performing resident smoking assessments to determine safe or unsafe smoker. S29MDS confirmed the MDS team was responsible for using the smoking assessment results to update a resident's care plan with smoking interventions to ensure resident safety. S29MDS confirmed the MDS team was responsible for updating the facility's list of smoking residents, which also identified if they were safe or unsafe. S29MDS stated the list of smoking residents was kept at all nurses stations and all staff were expected to use it and assist with ensuring interventions were implemented. S29MDS stated if a resident was not on the list as a smoker but staff saw them smoking, the staff member should alert MDS to perform a smoking assessment. S29MDS confirmed all residents who smoke should be identified immediately and assessed as either a safe or unsafe smoker with necessary interventions identified and implemented. S29MDS confirmed Resident #75 was admitted to the facility on [DATE]. S29MDS confirmed the MDS team was not aware Resident #75 was a smoker. S29MDS confirmed Resident #75 was not assessed to determine if he was a safe or unsafe smoker and if he required any interventions for smoking safety. An interview was conducted with S33LPN on 09/18/2024 at 10:45 a.m. S33LPN confirmed she was aware Resident #75 was a smoker and could not say if he was on the smoking list or not. S33LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S33LPN confirmed Resident #75 was allowed to keep his cigarettes and lighter on him at all times. S33LPN confirmed she never made the MDS nurses or anyone else aware Resident #75 was a smoker and was not aware she should. An interview was conducted with S27CNA on 09/19/2024 at 8:51 a.m. S27CNA stated if she saw a change in a resident's smoking status, she would check the list to see if they were safe or unsafe but was unaware she should alert anyone to their change in smoking status. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not provide any training to new hires regarding the facility's smoking procedure, identifying safe smokers, designated smoking areas or implementing safe smoking interventions. S40CNA confirmed floor CNAs did not have anything to do with the smoking process or alerting anyone of a newly admitted resident being a smoker. An interview was conducted with S43LPN on 09/19/2024 at 9:10 a.m. S43LPN confirmed she had been aware Resident #75 was a smoker since he admitted to the facility in June 2024. S43LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S43LPN confirmed Resident #75 had been allowed to keep his cigarettes and lighter on him at all times. S43LPN confirmed Resident #75 was not on the smokers list and she assumed he was left off by mistake. S43LPN confirmed she never made the MDS nurses or anyone else aware Resident #75 was a smoker and was not aware she should. S43LPN stated she was under the impression residents were assessed for smoking status during admission and if they were a smoker they would be added to a list for MDS to assess for safety then the facility's overall list would be updated afterwards. S43LPN confirmed she was never trained or made aware of anything she should be doing or responsible for in regards to identifying or implementing interventions for smoking residents. S43LPN confirmed the patio outside of a resident's room was not considered a designated smoking area. S43LPN confirmed she had never intervened to have them smoke in the designated area. S43LPN confirmed she was not aware direct care staff were responsible for intervening when residents smoked in undesignated areas or when they were not following smoking safety protocol. S43LPN confirmed she was not aware direct care staff were responsible for confiscating smoking paraphernalia from residents who were not supposed to have it in their possession. S43LPN confirmed she was not aware direct care staff were responsible for monitoring residents while outside, even if smoking, and were responsible for holding smoking paraphernalia at the nurses station then handing it out at smoking times. S43LPN confirmed she was not aware floor nurses were responsible for identifying a resident as a safe or an unsafe smoker and were responsible for notifying anyone of a resident's smoking status. S43LPN confirmed she was unaware floor nurses should alert anyone to a resident's smoking status. S43LPN confirmed she could not recall receiving any specific training on the smoking policy or her responsibilities in regards to residents who smoke. S43LPN stated she the facility had a smoking attendant so anything smoking related was their responsibility. An interview was conducted with S34LPN on 09/19/2024 at 9:15 a.m. S34LPN confirmed she was unaware she should know if a resident was a safe or unsafe smoker and did not know where to find that information. S34LPN confirmed she was unaware she should notify anyone of a resident's change in smoking status. An interview was conducted with S16CON on 09/19/2024 at 1:04 p.m. S16CON confirmed the MDS team was responsible for performing safe smoking assessments then updating the resident's plan of care, and updating administrative staff during the daily 2pm staff meeting. S16CON reported the MDS team would verbally alert direct care staff of any changes in interventions. S16CON confirmed direct care staff should access care tasks in the computer charting system to review information on which residents are safe or an unsafe smokers and what interventions should be implemented for each resident. S16CON confirmed the smoking policy and resident specific smoking interventions should be monitored and implemented by all members of staff to ensure resident safety. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed if a resident was found to be a smoker but had not been identified previously, she would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. S16CON confirmed she would expect floor staff to inform residents not to smoke on their patios and to make their supervisor or someone in administration aware if a resident remained noncompliant with this policy. An interview was conducted with S1ADM on 09/19/2024 at 6:00 p.m. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing their admission paperwork should also interview the resident or their family member to confirm if they were a smoker. S1ADM stated once a resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed if a resident was found to be a smoker but had not been identified previously, he would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or unsafe smoker. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not considered a designated smoking area and staff should not have allowed residents to smoke there. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork received prior to admission. S1ADM confirmed Resident #75's smoking status should have also been verified with him upon admission. S1ADM confirmed if floor staff later identified Resident #75 to be a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments were completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed floor staff should not have been allowing Resident #75 to smoke unsupervised on his patio. Resident #49 Review of the clinical record revealed Resident #49 was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's Safe Smoking Evaluation, dated 6/14/2024, revealed resident was noncompliant in following smoking policies and all smoking materials must be kept a the nurses station. Review of Resident #49's current Physicians Order revealed, in part, the following: 09/16/2024 - Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's Care Plan revealed, in part, the following: Problem: 8/29/2024 - Resident wishes to smoke and is designated an Impaired Smoker. This smoker requires observation or constant supervision. Has a history of smoking in his room. Further review revealed Resident #87 did not have a care plan for smoking prior to 08/29/2024. An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. 3. Review of the facility's Competency Skills Check Offs was attempted for the following employees with no documented evidence produced for review: S4CNA; S9RN; S11CNA; S24CNA; S27CNA; S38CNA; S40CNA; S43LPN; S47CNA; and S48CNA. An interview was conducted with S9RN on 09/19/2024 at 8:54 a.m. S9RN confirmed she began working at the facility 2 months ago. S9RN confirmed the facility did not require her to perform competency skills check offs prior to being allowed to provide care to residents independently. An interview was conducted with S27CNA on 09/19/2024 at 9:09 a.m. S27CNA confirmed she was responsible for training newly hired CNAs. S27CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S27CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S43LPN on 09/19/2024 at 9:10 a.m. S43LPN stated she began working at the facility 6 months ago. S43LPN confirmed the facility did not require her to perform competency skills check offs prior to being allowed to provide direct resident care independently. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she would only teach the new hire the things she was doing in her normal day with her current resident assignment; there was no checklist of things to cover. S40CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S40CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S3ADN on 09/19/2024 at 10:07 a.m. S3ADN confirmed she, S8CNS, and S2DON were responsible for ensuring direct care staff were competent to perform their jobs. S3ADN stated CNAs, upon hire and annually, performed a competency skills check offs with either herself or S2DON. S3ADN confirmed she did not have any documentation of staff competency skills check offs. S3ADN confirmed new hire and annual competency skills check offs were given to the human resources department to be kept in employee files. An interview was conducted with S31HR on 09/19/2024 at 9:07 a.m. S31HR confirmed she was responsible for maintaining personnel files. S31HR confirmed she was never given any new hire or annual competency skills check offs to be put in employee files. S31HR reviewed the requested personnel files and confirmed the files did not contain any competency skills check offs in them. An interview was conducted with S2DON on 09/19/2024 at 9:01 a.m. S2DON stated training for direct care CNA's and LPN's consisted of 3 days of shadowing a preceptor o [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure licensed nurses and nurse aids were trained and competent to update, implement, and identify a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; 2. Ensure licensed nurses and nurse aids were trained and competent to implement and identify safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. Ensure licensed nurses and nurse aids were competent in the skills sets required to meet resident needs for 10 of 10 (S4CNA, S9RN, S11CNA, S24SA, S27CNA, S38CNA, S40CNA, S43LPN, S47CNA, and S48CNA) personnel files reviewed for competency skills check offs. Cross Reference: F689 and F726. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the Immediate Jeopardy on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 75 residents requiring assistive devices and/or supervision with transfers. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will documents resident transferring and lifting needs in the care plan. 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Review of S4CNA's personnel file revealed a hire date of 12/23/2023. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs were completed. Review of S11CNA's personnel file revealed a hire date of 03/06/2024. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Review of S27CNA's personnel file revealed a hire date of 12/28/2020. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Review of S38CNA's personnel file revealed a hire date of 10/03/2023. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, Major Depressive Disorder, and Primary Generalized Osteoarthritis. Further review revealed the resident was dependent on staff and required a Hoyer lift for transfers. Review of Resident #54's current Care Plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices required for transfers. Review of Resident #54's Resident Summary in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the emergency room . An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She confirmed, at the time of the incident, she was unaware how to identify a resident's transfer status. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS confirmed Resident #54 was determined to require a Hoyer lift for transfers on 07/25/2024. S29MDS stated direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary to show a resident's transfer status until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how, and were not trained, to update anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. She stated MDS should have updated the residents' Resident Summary for the CNA staff to determine a residents transfer needs. An interview was conducted with S3ADN on 09/19/24 at 9:50 a.m. She stated competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by herself and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. She stated prior to yesterday afternoon, the amount of staff required and how to transfer a resident was not listed in the residents' clinical record for the CNAs to see. She stated prior to yesterday afternoon, the only process the facility had in place for a resident's transfer status was by word of mouth. She stated it was not acceptable for a CNA to assess a resident for their transfer status. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff or protective gear. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking outside of his room with smoking paraphernalia unsupervised. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. The Immediate Jeopardy continued when interviews with CNAs and Nursing Staff revealed they did not know their role in identifying, assessing and implementing safe smoking interventions for residents who smoked. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 26 smoking residents requiring assessment, supervision or interventions for smoking safety. Findings: 2. Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the at the nurses station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's Clinical Record revealed he was admitted to facility on 06/14/2024 with diagnoses which included: Tobacco use, and nicotine dependence. Review of Resident #87's Safe Smoking Evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed Resident #87 was deemed an unsafe smoker. Review of Resident #87's Physician Order, dated 06/26/2024, revealed resident deemed an unsafe smoker. Review of Resident #87's current Care Plan revealed the following, in part: Problem: Onset date of 09/01/2024 Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Further review revealed Resident #87 did not have a care plan for smoking prior to 09/01/2024. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without a smoking apron. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with S29MDS on 09/17/2024 at 4:11 p.m. S29MDS confirmed she was responsible for performing the facility's safe smoking assessments. S29MDS confirmed Resident #87 was an unsafe smoker due to limited use of both hands, and should not be in possession of cigarettes or lights. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. S25AD confirmed she was not made aware which residents were safe or unsafe smokers. S25AD confirmed she had purchased Resident #87's cigarettes in the past then given them to him to keep in his possession. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. S24SA confirmed she was responsible for supervising resident smoking in the facility's designated smoking area. She confirmed she was not made aware which residents were safe or unsafe smokers. She confirmed she was not made aware of what interventions the facility's unsafe smokers required. She confirmed she was not provided with a lock box to store resident's smoking paraphernalia and was not aware she should. She confirmed all smoking residents were allowed to hold their own smoking paraphernalia at all times. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. He confirmed the facility's process for a newly admitted resident was to review their hospitalization paperwork and to assess the resident in person. S1ADM confirmed if a resident was a smoker, MDS should perform a safe smoking assessment. He confirmed MDS nurses were responsible to update the computer system to allow floor staff to identify safe or unsafe smokers and the interventions they required. S1ADM confirmed MDS was also responsible for verbally communicating any changes in interventions to the facility's staff during the daily 2pm staff meeting. He confirmed residents were only allowed to smoke in the designated smoking area. He confirmed unsafe smokers should not have smoking paraphernalia in their possession and should only smoke with constant staff supervision. S1ADM confirmed the facility's policies and procedures were not implemented to provide supervision and prevent accidents for resident's that smoke. Resident #75 Review of Resident #75's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Safe Smoking Evaluation on 09/17/2024 revealed no documented evidence a smoking evaluation was completed. Review of Resident #75's Physician Orders, dated 06/26/2024 through 09/17/2024, regarding his smoking status was attempted on 09/17/2024 with no documented evidence available for review. Review of Resident #75's current Care Plan, as of 09/17/2024, regarding his smoking status was attempted with no documented evidence available for review. An observation and interview was conducted with Resident #75 on 09/17/2024 at 9:25 a.m. Resident #75 was seated in his wheelchair smoking a cigarette on the patio outside of his room and confirmed this was where he typically smoked. Resident #75 confirmed he was a smoker and had been since he admitted to the facility in June of 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted nor had any members of the staff observed him smoking. A pack of cigarettes and a lighter was present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware he was only supposed to smoke in a designated smoking area. An interview was conducted with S29MDS on 09/18/2024 at 9:45 a.m. S29MDS stated upon a resident's admission to the facility, it was the responsibility of the floor nurse to alert the MDS team if a resident was a smoker so they could be assessed for smoking safety. S29MDS confirmed the MDS team was responsible for performing resident smoking assessments to determine safe or an unsafe smoker. S29MDS confirmed the MDS team was responsible for using their smoking assessment results to update a resident's care plan with smoking interventions to ensure resident safety. S29MDS confirmed the MDS team was responsible for updating the facility's list of smoking residents, which also identified if they were safe or unsafe. S29MDS stated the list of smoking residents was kept at all nurses stations and all staff were expected to use it and assist with ensuring interventions were implemented. S29MDS stated if a resident was not on the list as a smoker but staff saw them smoking, the staff member should alert MDS to perform a smoking assessment. S29MDS confirmed all residents who smoke should be identified immediately and assessed as either a safe or non-safe smoker with necessary interventions identified and implemented. S29MDS confirmed Resident #75 was admitted to the facility on [DATE]. S29MDS confirmed the MDS team was not aware Resident #75 was a smoker. S29MDS confirmed Resident #75 was never assessed to determine if he was a safe or an unsafe smoker and if he required any interventions for smoking safety. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not provide any training to new hires regarding the facility's smoking procedure, identifying safe smokers, designated smoking areas or implementing safe smoking interventions. S40CNA confirmed floor CNAs did not have anything to do with the smoking process or alerting anyone of a newly admitted resident being a smoker. An interview was conducted with S16CON on 09/19/2024 at 1:04 p.m. S16CON confirmed the MDS team was responsible for performing safe smoking assessments then updating the resident's plan of care, and updating administrative staff during the daily 2pm staff meeting. S16CON reported the MDS team would verbally alert direct care staff of any changes in interventions. S16CON confirmed direct care staff should access care tasks in the computer charting system to review information on which residents are safe or an unsafe smokers and what interventions should be implemented for each resident. S16CON confirmed the smoking policy and resident specific smoking interventions should be monitored and implemented by all members of staff to ensure resident safety. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed if a resident was found to be a smoker but had not been identified previously, she would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. S16CON confirmed she would expect floor staff to inform residents not to smoke on their patios and to make their supervisor or someone in administration aware if a resident remained noncompliant with this policy. An interview was conducted with S1ADM on 09/19/2024 at 6:00 p.m. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing their admission paperwork should also interview the resident or their family member to confirm if they are a smoker. S1ADM stated once a resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed if a resident was found to be a smoker but had not been identified previously, he would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or an unsafe smoker. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not considered a designated smoking area and staff should not have been allowing residents to smoke there. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork received prior to admission and since Resident #75 was cognitive, his smoking status should have also been verified with him upon admission. S1ADM confirmed if floor staff later identified Resident #75 to be a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments were completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed floor staff should not have been allowing Resident #75 to smoke unsupervised on his patio. S1ADM confirmed the facility's policies and procedures were not followed and implemented as they should if a resident identified by staff to be a smoker was not assessed for smoking safety and was being allowed to knowingly smoke unsupervised in an undesignated smoking area. Resident #49 Review of Resident #49's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's Safe Smoking Evaluation, dated 6/14/2024, revealed resident was noncompliant in following smoking policies and all smoking materials must be kept a the nurses station. Review of Resident #49's current Physicians Order revealed, in part, the following: 09/16/2024 - Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's Care Plan revealed, in part, the following: Problem: 8/29/2024 - Resident wishes to smoke and is designated an Impaired Smoker. Interventions: This smoker requires observation or constant supervision. Has a history of smoking in his room. Further review revealed Resident #87 did not have a care plan for smoking prior to 08/29/2024. An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. An interview was conducted with S16CON on 09/19/2024 at 11:15 a.m. S16CON confirmed a resident assessed to be an unsafe smoker should not have cigarettes and lighter in their possession. S16CON confirmed the facility's policies and procedures had not been followed and implemented as they should if Resident #49 possessed a cigarette and lighter when not under staff supervision. 3. Review of Annual and/or New Hire Competency Skills Check Offs was attempted for the following employees with no documented evidence produced for review: S4CNA; S9RN; S11CNA; S24SA; S27CNA; S38CNA; S40CNA; S43LPN; S47CNA; and S48CNA. An interview was conducted with S27CNA on 09/19/2024 at 9:09 a.m. S27CNA confirmed she worked at the facility for 9 years. S27CNA confirmed she was responsible for training newly hired CNAs. S27CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S27CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she worked at the facility for over [AGE] years. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S40CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S3ADN on 09/19/2024 at 10:07 a.m. S3ADN confirmed she, S8CNS, and S2DON were responsible for ensuring direct care staff were trained and competent to perform their jobs. S3ADN stated CNAs, upon hire and annually, performed a competency skills check offs with either herself or S2DON. S3ADN confirmed she did not have any documentation of staff competency skills check offs. S3ADN confirmed new hire and annual competency skills check offs were given to the human resources department to be kept in employee files. An interview was conducted with S31HR on 09/19/2024 at 9:07 a.m. S31HR confirmed she was responsible for maintaining personnel files. S31HR confirmed she was never given any new hire or annual competency skills check offs to be put in employee files. S31HR reviewed the requested personnel files and confirmed the files did not contain any competency skills check offs in them. An interview was conducted with S2DON on 09/19/2024 at 9:01 a.m. S2DON stated training for direct care CNA's and LPN's consisted of 3 days of shadowing a preceptor on their assigned floor. S2DON stated after shadowing was complete, new hire competency was determined by their preceptor by asking the preceptor if they felt the new employee was ready to work independently. S2DON confirmed she was unaware if the facility conducted or documented new hire and annual competency skills check offs for their direct care staff. An interview was conducted with S41COO on 09/19/2024 at 9:55 a.m. S41COO confirmed competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by S3ADN and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. S41COO confirmed the facility's policies and procedures had not been implemented as they should if direct care nurses and CNAs were allowed to provide direct care to residents without first demonstrating their competency through competency checks and skills checkoffs. 44965 46981 47546 48333

Based on observations, interviews and record reviews, the facility failed to ensure residents remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The facility failed to ensure: 1. An effective system was in place for nursing staff to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place for staff to implement safe smoking interventions for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the immediate jeopardy situation on 09/18/2024 at 5:00 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any resident requiring assistive devices and/or supervision with transfers. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, Major Depressive Disorder, and Primary Generalized Osteoarthritis. Review of Resident #54's MDS with an ARD of 07/26/2024 revealed, in part, a BIMS summary score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed she was dependent on staff for transfers. Review of Resident #54's Physical Therapy Note dated 07/25/2024 revealed, in part, she required a Hoyer lift for transfers. Review of Resident #54's current Physician Orders dated September 2024 revealed no documentation indicating how much assistance, supervision, and/or assistive devices the resident required for transfers. Review of Resident #54's current Care Plan revealed the following, in part: Problem: At risk for falls Fall on 08/28/2024 Interventions: 08/28/2024 at 3:46 p.m., Resident sent to the emergency room for evaluation and treatment. Further review of Resident #54's care plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices the resident required for transfers. Review of Resident #54's Resident Summary in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. Review of Resident #54's Nurse's Note dated 08/28/2024 at 10:57 p.m. by S34LPN revealed the following, in part: At 3:45 p.m., Resident was found on the floor bleeding from head; it was a witnessed fall. S4CNA said she was helping her out of the bed when the resident forcefully tried to get out on her own. Emergency Medical Services was called. Resident was transferred to a local hospital. Review of Resident #54's Incident Report dated 08/28/2024 at 3:46 p.m. revealed the following, in part: Incident type: Fall with head injury Associate involved: S4CNA Report prepared by: S34LPN Narrative of incident and description of injuries: S4CNA said she was helping the resident out of the bed when the resident forcefully tried to get out on her own. Resident noted with skin laceration above left eyebrow. Heavy bleeding from site noted with no complaints of pain or dizziness. On-call Nurse Practitioner notified and gave ok for emergency room transfer. Injury to head quarter size bleeding. Review of Resident #54's Hospital Records dated 08/28/2024 revealed the following, in part: HPI Assessment: Patient presented to the Emergency Department after a fall. Patient reports that she tripped and fell while being transferred to the bed with the help of the nurse. She states that she hit her head and has had a bad headache since. Progress Note: Left Frontal Scalp Contusion closed with tissue adhesive by the attending physician. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She stated, at the time of the transfer, she required a Hoyer lift with the assistance of two staff members for transfers. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the emergency room . An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She stated at that time, she was working as needed with the facility. She stated she became full time with the facility on 09/01/2024. She stated on that particular evening, she was unaware how to identify a resident's transfer status. She stated Resident #54 was cognitively intact so she asked the resident how much assistance she needed to be transferred from the bed to the wheelchair. She stated Resident #54 stated she and S4CNA could do it together. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. She stated, as a result of the fall, Resident #54 had a laceration above her left eye. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated S4CNA notified her that S4CNA was assisting Resident #54 with a transfer from the bed to the wheelchair when Resident #54 landed on the floor. She stated Resident #54 had a laceration above one of her eyes and was sent to the ER. She explained, 08/28/2024 was her first day working in the facility. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. She stated S4CNA was unaware of Resident #54's transfer status. An interview was conducted with S35RD on 09/18/2024 at 12:12 p.m. She stated the therapists determined the safest way to transfer each resident. She stated after the therapists completed their assessment, they communicated it with nursing verbally. She stated Resident #54 has required a Hoyer lift for transfers since 07/25/2024. She stated Resident #54's need for a Hoyer lift with transfers was verbally communicated with nursing. An interview was conducted with S36LPN on 09/18/2024 at 1:00 p.m. She stated the CNAs should be able to see each residents' transfer status in the ADL charting. She reviewed Resident #54's transfer status in the ADL documentation and confirmed there was not a transfer status listed for Resident #54. She demonstrated where the transfer lift status would be selected and confirmed it read choose one, which indicated it had not been selected. She confirmed Resident #54's transfer status was not in the care plan. She confirmed the left side of the screen, which read Resident Summary did not include Resident #54's transfer status. An interview was conducted with S10LPN on 09/18/2024 at 1:24 p.m. She stated if she was unsure how Resident #54 should be transferred, she would check the resident's Physician Orders. She reviewed Resident #54's current Physician Orders and confirmed there was no order for a Hoyer lift and/or transfer status. She reviewed Resident #54's Resident Summary, and confirmed it did not reveal how much assistance or supervision Resident #54 required for transfers or that she required a Hoyer lift. She confirmed she was unable to locate any documentation in Resident #54's Clinical Record to determine how much assistance and/or supervision Resident #54 required with transfers. An interview was conducted with S11CNA on 09/18/2024 at 9:09 a.m. She stated if she did not know the transfer status of a resident she would ask another staff or the resident. An interview was conducted with S37TP on 09/18/2024 at 9:18 a.m. She stated she was unaware of how to determine the transfer status of a resident. She stated if she was unsure of a resident's transfer status, she would ask another CNA or the resident. An interview was conducted with S38CNA on 09/18/2024 at 9:47 a.m. She stated there was not a particular place to look to identify a resident's transfer status. She stated when a new resident came into the facility, therapy evaluated them and verbally notified the CNAs how much assistance was needed. She confirmed the only way to know a resident's transfer status was by verbal communication. An interview was conducted with S39CNA on 09/18/2024 at 9:57 a.m. She stated she worked with residents every day and was familiar with each resident's capability. She stated she would transfer each resident based on that resident's capability. An interview was conducted with S27CNA on 09/18/2024 at 10:20 a.m. She stated verbal communication was how she knew how much assistance and supervision each resident required for transfers. She stated if she was unsure how much assistance or supervision the resident required for transfers, she would ask another CNA, the CNA supervisor, or the resident. She stated if a resident's transfer status changed, she was not sure she would be aware. An interview was conducted with S40CNA on 09/18/2024 at 1:15 p.m. She stated she determined how much assistance and supervision each resident required based on her own assessment. She stated there was nowhere for her to go and look to see what therapy determined was the safest for resident transfers. She reviewed Resident #54's ADL charting and Resident Summary and confirmed there was nowhere in the chart indicating the amount of supervision and/or assistance Resident #54 required for transfers. An interview was conducted with S36LPN on 09/18/2024 at 1:50 p.m. She stated she was unaware of how to update a Resident Summary in the resident's clinical record. She stated she did not know how to update anything in the record to be visualized by the CNAs. An interview was conducted with S29MDS on 09/18/2024 at 1:52 p.m. She stated she was unaware of how to update a Resident Summary in the resident's clinical record. She stated she did not know how to update anything in the record to be visible for the CNAs. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS reviewed Resident #54's Therapy Note dated 07/25/2024 and confirmed that was the date Resident #54 was determined to require a Hoyer lift for transfers. S29MDS stated the direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how to update anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed by therapy to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. She stated MDS should have updated the residents' Resident Summary for the CNA staff to determine a residents transfer needs. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking unsupervised outside of his room with smoking paraphernalia. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any resident requiring assessment, supervision or interventions for smoking safety. Findings: Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the resident at the nurse's station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included: Quadriplegia C5-C7 incomplete, Tobacco use, Hereditary and Idiopathic Neuropathy, Progressive Spinal Muscle Atrophy, Central Cord Syndrome at C7 level of Cervical Spinal Cord Sequela, nicotine dependence. Review of Resident #87's Admission MDS with an ARD of 06/20/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Further review revealed functional limitations in range of motion to bilateral sides, current tobacco use, and that resident was dependent on staff for eating, oral hygiene, and toileting, dressing and personal hygiene. Review of Resident #87's safe smoking evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed: Range of motion with limitations, weak grasp with difficulty holding smoking material, impaired ability to see adequate light, smoking materials used by the resident cigarettes, resident is unable to independently and safely light smoking materials. Resident was deemed an unsafe smoker. Review of Physician's Orders dated 06/26/2024 revealed: Resident is deemed as an unsafe smoker. Review of Resident #87's Nurse's Note dated 07/27/2024 at 9:04 a.m. revealed the resident was informed by staff that smoking on the patio was not allowed and Resident #87 was informed of the designated area by the dining room with a smoker's aid. Signed by: S32LPN Review of Resident #87's current Care Plan revealed the following, in part: Problem: 09/01/2024-Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Interventions: Provide resident with the following while smoking: observation, constant supervision, protective gear. An observation was conducted of Resident #87 on 09/17/2024 at 9:00 a.m. Resident #87 was smoking unsupervised on the patio outside of his room without protective gear. He had in his possession a pack of cigarettes and a yellow lighter. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without a protective gear. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with Resident #87 on 09/17/2024 at 11:14 a.m. Resident #87 reported he smoked about a half pack of cigarettes a day, usually on his outdoor patio. He reported he can light his cigarette, but it takes two hands. An interview was conducted with S29MDS on 09/17/2024 at 4:11 p.m. S29MDS reported she was responsible for performing smoking assessments. She confirmed Resident #87 was an unsafe smoker due to limited motion with his hands, and should not have possession of cigarettes and lighters. She confirmed she was unaware Resident #87 was smoking unsupervised without protective gear in undesignated areas. An interview was conducted with S33LPN on 09/17/2024 at 3:59 p.m. S33LPN confirmed Resident #87 was an unsafe smoker. She confirmed she was unaware he was smoking unsupervised without protective gear in undesignated areas. An interview was conducted with S8CNS on 09/17/2024 at 4:26 p.m. S8CNS reported she was unaware Resident #87 was smoking unsupervised without protective gear in an undesignated area. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. S25AD reported she was unaware which residents were safe or unsafe smokers, until she was provided a list on 09/17/2024 by administration staff. She confirmed she bought Resident #87 three packs of cigarettes and placed them in his top television dresser drawer in the past. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. S24SA reported she was employed by the facility on 09/09/2024. She stated she was not provided with a safe or unsafe smokers list until the evening of 09/17/2024. She stated prior to 0917/2024 she was unaware of who was a safe or unsafe smoker or the interventions required. She reported the facility provided a lock box for resident's cigarettes on the evening of 09/17/2024. She stated prior to 09/17/2024 she did not have a lock box and each resident held their own cigarettes. An interview was conducted with S32LPN on 09/19/2024 at 12:05 p.m. S32LPN confirmed knowing Resident #87 was smoking in undesignated areas in July. She confirmed she did not report this incident to administration. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. S2DON, S16CON, and S1ADM were present for the interview. S1ADM confirmed residents should only be smoking in the designated smoking area. S16CON confirmed unsafe smokers should not possess cigarettes or lighters and should only smoke during constant supervision. Resident #75 Review of Resident #75's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Cerebral Infarction; Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side; Generalized Muscle Weakness; and Lack of Coordination. Further review of the clinical record revealed no documentation of Resident #75 being a smoker or a safe smoking evaluation being completed. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed the resident required assistance from staff for eating, oral hygiene, toileting, showering/bathing and dressing. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Care Plan and Physician's Orders, dated 06/26/2024 through 09/17/2024, revealed no documentation of the resident's smoking status and needs. Review of Resident #75's Nurses Notes, dated 06/26/2024 through 09/17/2024, revealed staff were aware the resident smoked on the following dates: 07/01/2024 at 11:31 a.m. by S43LPN; 07/01/2024 at 7:15 p.m. by S43LPN; 08/16/2024 at 3:57 p.m. by S33LPN; 08/20/2024 at 3:55 a.m. by S42LPN; and 08/22/2024 at 5:48 a.m. by S42LPN. An observation and interview was conducted on 09/17/2024 at 9:25 a.m. with Resident #75. Resident #75 was observed seated in his wheelchair smoking a cigarette on the patio outside of his room. He confirmed this was where he typically smoked. A pack of cigarettes and a lighter were present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware of a designated smoking area. Resident #75 confirmed he was a smoker and had been since he was admitted to the facility in June 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted . An observation was conducted on 09/18/2024 at 9:25 a.m. of Resident #75 seated in his wheelchair inside of his room with a pack of cigarettes and a lighter in the cup holder. An interview was conducted on 09/19/2024 at 9:10 a.m. with S43LPN. S43LPN confirmed knowing Resident #75 was a smoker since he was admitted to the facility in June 2024. S43LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S43LPN confirmed the patio outside of a resident's room was not considered a designated smoking area. S43LPN confirmed Resident #75 was allowed to keep his cigarettes and lighter on him at all times. S43LPN confirmed Resident #75 was not on the smokers list but she assumed he was left off by mistake. S43LPN confirmed floor nurses were not responsible for identifying a resident as a safe or unsafe smoker. S43LPN stated floor nurses and floor CNAs did not monitor residents while outside or hold their cigarettes or lighters. S43LPN confirmed she never made the MDS nurses aware Resident #75 was a smoker because they should be given that information by the admission team upon admit. S43LPN confirmed she was unaware floor nurses should alert anyone to a resident's smoking status. An interview was conducted on 09/18/2024 at 9:45 a.m. with S29MDS. S29MDS confirmed Resident # 75 was not identified as a smoker since admission to the facility. S29MDS confirmed Resident #75 had never been assessed to determine if he was a safe or unsafe smoker. S29MDS confirmed the MDS team had not been made aware Resident #75 was a smoker and required a safe smoking assessment. S29MDS stated when a resident was admitted to the facility, it was the responsibility of the floor nurse to alert the MDS team if a safe smoking evaluation was needed. S29MDS confirmed all residents who smoke should be identified immediately then assessed as either a safe or unsafe smoker with necessary interventions identified. S29MDS stated once a resident was identified as a smoker and determined safe or unsafe, they were added to the facility's smoker list and the list was updated for staff to reference. An interview was conducted on 09/19/2024 at 1:04 p.m. with S16CON. S16CON confirmed MDS was responsible for performing safe smoking assessments then updating the resident's plan of care. S16CON confirmed direct care staff should access care task in the computer for information on which residents are safe and unsafe smokers. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. An interview was conducted on 09/19/2024 at 6:00 p.m. with S1ADM. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing the admission should also ask cognitive and verbal residents or their family member if they are a smoker. S1ADM stated once an admitting resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or unsafe smoker. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork not resident interview. S1ADM confirmed Resident #75 was cognitive and verbal and should have been interviewed regarding his smoking status during the admission process and he was not. S1ADM confirmed if floor staff observed Resident #75 as a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments had been completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not a designated smoking area and staff should not have allowed residents, including Resident #75, to smoke there. Resident #49 Review of the clinical record revealed Resident #49 was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's most recent MDS, with an ARD 08/29/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed the resident used a manual wheelchair and required set up and clean up assistance with eating, partial to moderate assistance with toileting and bathing, and supervision or touching assistance with transfers. Review of Resident #49's Safe Smoking Evaluation dated 06/14/2024 revealed the resident was noncompliant in following smoking policies and all smoking materials must be kept at the nurse's station. Review of Resident #49's Physicians order dated 09/16/2024 revealed the following in part: Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's current Care Plan revealed the following: Problem: 08/29/2024 Resident wishes to smoke and is designated an Impaired Smoker. This smoker requires: observation or constant supervision history of smoking in room. Interventions: Resident will smoke safely at designated areas at scheduled times through next review, Provide resident with the following while smoking : Observation, Resident oriented to smoking procedure and areas, Resident will ask for smoking materials at main nurse's station An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An interview was conducted with S12LPN on 09/19/2024 at 4:50 p.m. S12LPN stated Resident #49 was an unsafe smoker and should not keep his own smoking materials. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. An interview was conducted with S16CON on 09/19/2024 at 11:15a.m. S16CON confirmed Resident #49 had cigarettes and a lighter in his possession. She confirmed Resident #49 was an unsafe smoker and should not have the above in his possession. 44965 47546 48333

Based on observations, interviews, and record review the facility failed to provide the necessary treatment and services, consistent with professional standards, to promote healing and prevent the development of new pressure ulcers by failing to ensure a resident's heels were floated as ordered for 1(#2) of 3 (#2, #R1 and #R4) residents reviewed for facility acquired pressure ulcers. This deficient practice resulted in an actual harm for Resident #2, a paraplegic with no sensation to the lower extremities, on 07/16/2024 at 8:58 a.m. when the resident was observed lying in bed with his feet resting directly on the foot board and heels not floated off the surface of the mattress. Further observations were made at 10:39 a.m., 11:51 a.m., and 1:00 p.m. when S6TN confirmed there were new areas of discoloration on both the resident's right and left heel. On 07/17/2023 at 7:25 a.m., Resident #2 was assessed by S7NP and was found to have a Deep Tissue Injury (DTI) to the left heel measuring 3.5 cm x 6.0 cm x 0 cm. Findings: Review of the undated facility policy titled Skin Program, Pressure Ulcers and Other Wounds revealed the following, in part: Risk Assessment and Routine Care for All Residents 1. All residents will be assessed for risk of impaired skin integrity at admission 3. Risk factors identified will be evaluated for possible reduction or elimination and preventative interventions implemented accordingly. Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE]. Further review revealed Resident #2 had diagnoses which included Unspecified Injury at Unspecified Level of Thoracic Spinal Cord and Osteomyelitis of Vertebra Cervicothoracic Region. Review of Resident #2's Admission MDS with an ARD of 06/19/2024 revealed a BIMS of 15 which indicated intact cognition. Further review revealed Resident #2 was dependent on rolling left and right and was assessed by the facility as being at risk for developing pressure ulcers. Review of Resident #2's Braden Scale Risk Assessment - For Predicting Pressure Sore Risk dated 06/13/2024 revealed the following, in part: Sensory Perception - Slightly Limited Mobility - Very Limited Braden Risk Total Score - 16 Braden Risk Level - The resident is at risk for the development of pressure ulcers Review of Resident #2's Current Physician's Orders revealed an order dated 07/08/2024 to float heels while in bed. Review of Resident #2's current Care Plan revealed the following, in part: Problem: At risk for skin impairment 06/19/2024 Moisture Associated Skin Damage Interventions: Float Heels Review of Resident #2's Physical Therapy Evaluation and Plan of Treatment dated 06/13/2024 revealed the following, in part: Current Referral - .patient underwent T3-T6 decompressive laminectomy with posterior fusion and washout .post operatively was found to have complete T4 sensory and motor level paralysis. Sensation / Sensory Processing - Impaired (loss of sensory T4 distally) Sharp / Dull = Impaired Touch / Pressure = Impaired Review of Resident #2's Nurse's Notes revealed the following, in part: 07/11/2024 at 7:10 p.m., Skin assessment complete. No new skin issues noted. On 07/16/2024 at 8:58 a.m., an observation was made of Resident #2 lying in bed with his feet resting directly on the foot board. Resident #2's heels were not floated off the mattress. On 07/16/2024 at 10:39 a.m., an observation was made of Resident #2 lying in bed with his feet resting directly on the foot board. Resident #2's heels were not floated off the mattress. On 07/16/2024 at 11:51 p.m., an observation was made of Resident #2 with S8CNA. Resident #2 was lying in bed with his feet resting directly on the foot board. Resident #2's heels were not floated off the mattress. S8CNA removed Resident #2's sock and his right heel was observed to have a large round discolored area. On 07/16/2024 at 1:00 p.m., an observation was made of Resident #2 with S6TN. Resident #2 was lying in bed with his feet resting directly on the footboard. Resident #2's heels were not floated off the mattress and he was not wearing heel boots. S6TN confirmed Resident #2's feet were resting directly on the foot board. Resident #2's heel boots were observed in his wheelchair. S6TN removed Resident #2's socks to find a large circular discolored area to Resident #2's right heel and a linear appearing discoloration to Resident #2's left heel. S6TN stated the last time she performed wound care for Resident #2 was on 07/12/2024 and the areas of discoloration were not present on the heels. S6TN confirmed no one reported the discolored areas to Resident #2's heels. On 07/17/2024 at 7:25 a.m., an observation was made of Resident #2 with S6TN and S7NP. Resident #2's feet were observed to be directly on the foot board. Resident #2's heels were not floated off the mattress and he was not wearing heel boots. S6TN confirmed Resident #2's feet were resting directly on the foot board. S6TN instructed Resident #2 to pull himself up in bed. Resident #2 attempted to pull himself up in bed with a trapeze bar and the sides of the mattress, but was unable to independently pull himself up to get his feet off the footboard. S7NP assessed both the left and right heel. She stated the right heel had a blister on it and the left heel had a DTI. S7NP measured the left foot heel discoloration. S7NP stated the left heel discoloration was a DTI which was caused by pressure. S7NP stated the DTI could have been caused by Resident #2's feet touching the bed and not wearing the heel protectors. On 07/17/2024 at 10:50 a.m., an interview was conducted with S2ADON. S2ADON stated Resident #2 cannot move his lower body at all. S2ADON stated Resident #2 would require someone to pull him over. On 07/17/2024 at 2:03 p.m., an interview was conducted with S16LPN. S16LPN stated Resident #2 required significant assistance with repositioning. S16LPN stated Resident #2 could pull himself a little to the side but needed his leg moved to turn to his side. S16LPN stated Resident #2 gets help turning to his side he can do the rest. S16LPN confirmed she cared for the resident on 07/14/2024 and stated she did not notice discoloration to his heels. On 07/17/2024 at 4:07 p.m., an interview was conducted with Resident #2. Resident #2 confirmed he could not feel his feet and did not know when they were resting directly on the footboard. Resident #2 confirmed he never refused his heel boots or requested them to be removed. Resident #2 stated does not know if the heel boots are on or not due to his lack of sensation. On 07/18/2024 at 9:07 a.m., an interview was conducted with S6TN. S6TN stated due to Resident #2's immobility of his lower body he would be at risk for pressure ulcers. S6TN stated she does not know if Resident #2 can feel his feet. S6TN stated Resident #2 can use the trapeze to pull himself up and confirmed the resident could not pull himself up enough to get his feet off of the footboard. S6TN confirmed Resident #2 required assistance with repositioning. S6TN stated if the CNAs had placed the heel protectors on Resident #2's feet the left heel DTI could have been prevented. On 07/18/2024 at 2:58 p.m., an interview was conducted with S4LPN. S4LPN confirmed she cared for Resident #2 on 07/16/2024. S4LPN stated CNAs were responsible for placing heel boots and floating heels. S4LPN stated if a resident had heel boots provided, the heel boots would be used to float the resident's heels. S4LPN stated she did not notice if Resident #2's heels were floated or in heel boots on 07/16/2024. On 07/18/2024 at 3:10 p.m., an interview was conducted with S8CNA. S8CNA confirmed she worked with Resident #2 on 07/16/2024. S8CNA stated Resident #2's feet should have been floated and confirmed the resident's heel boots were not on his feet on 07/16/2024. S8CNA stated CNAs and nurses assigned to the resident were responsible for floating the heels and putting the heel boots on. S8CNA confirmed Resident #2 was not wearing his heel boots when she arrived for her shift at 6:00 a.m. On 07/18/2024 at 3:37 p.m., an interview was conducted with S1DON. S1DON was made aware of the aforementioned findings. S1DON confirmed Resident #2's feet should not have been on the footboard of the bed. S1DON stated she expected for a resident who was ordered to have heels floated to have the heels floated at all times while in bed.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure all admission orders were obtained, clarified, and entered into the resident's electronic medical record. The facility failed to ensure Resident #1 had physician orders for PEG and nephrostomy site care. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2023. On 05/12/2024, Resident #1 was transferred to the local emergency room for an elevated temperature and altered mental status. Resident #1's hospital diagnoses included Sepsis, Nephrostomy associated Urinary Tract Infection (UTI), and Infected PEG tube. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/05/2024 at 5:17 p.m. The Immediate Jeopardy was removed on 06/06/2024 at 8:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the residents who were admitted or readmitted to the facility. Findings: Cross Reference F684 On 06/04/2024 at 12:30 p.m., an interview was conducted with S2DON. She stated she was unaware who was responsible for PEG and nephrostomy dressing changes or where it was charted. On 06/05/2024 at 11:00 a.m., an interview was conducted with S16UM. She stated for residents who had PEG tubes and nephrostomy tubes, there would be an order which read, Monitor site q shift. She stated nurses should monitor those sites for redness, swelling, tenderness, and drainage. She stated floor nurses were responsible for changing dressings to PEG tube and nephrostomy tube sites. She stated all residents who had PEG tubes had a split gauze dressing to the site. She stated nurses should change PEG tube dressings daily and as needed. She stated orders for nephrostomy dressing changes would come from the doctor. She stated it was the floor nurses responsibility to change the nephrostomy dressing as ordered. She stated every morning herself, S14WC, S15ADON and S2DON met together for a morning meeting and discussed all newly admitted residents and reviewed their orders to ensure they were appropriate. On 06/05/2024 at 11:22 a.m., an interview was conducted with S15ADON. She stated she was responsible for putting the admission orders in for Resident #1 and ensuring they were correct. She stated she did not receive orders to change the dressing for Resident #1's nephrostomy tube upon admission. She confirmed she should have called the doctor to obtain orders for the nephrostomy tube dressing changes and did not. She stated she did not enter orders to monitor the sites for Resident #1's PEG tube and nephrostomy tube and should have. On 06/05/2024 at 2:38 p.m., an interview was conducted with S2DON. She stated S15ADON or S16UM were responsible for putting in orders for newly admitted residents. She stated any resident who had an indwelling device, such as a PEG tube or nephrostomy tube needed to have orders to monitor the site and orders for dressing changes. She reviewed Resident #1's physician orders and confirmed the resident did not have orders to monitor the sites or change the dressings for the PEG tube and nephrostomy tube sites. She confirmed when an order was not obtained or entered into the residents electronic medical record, it did not populate in the MAR or TAR for the nurses to complete. She confirmed there was no documentation Resident #1's PEG site and nephrostomy site had been monitored and dressing changes performed. She stated Resident #1's nephrostomy site and PEG site should have been monitored and any concerns reported to the Nurse Practitioner. She confirmed Resident #1 should have had dressing changes completed to the PEG and nephrostomy tube sites.

Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained and clarified for 2 (#1 and #3) of 5 (#1, #2, #3, #5, and #6) residents reviewed for indwelling devices. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2024. On 05/12/2024, Resident #1 was transferred to the local emergency room for an elevated temperature and altered mental status. Resident #1's hospital diagnoses included Sepsis, Nephrostomy associated Urinary Tract Infection (UTI), and Infected PEG tube. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/05/2024 at 5:17 p.m. The Immediate Jeopardy was removed on 06/06/2024 at 8:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the residents who were admitted or readmitted to the facility. Findings: Review of the facility's Standing Orders revised on 07/07/2023 included: Peg Care: Clean daily with soap and water. Notify NP/MD if any purulent drainage. Review of the facility's undated policy titled Admission Orders revealed the following, in part: Policy Explanation and Compliance Guidelines: 1. The written orders should include at a minimum: c. Routine care orders 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. Review of the facility's undated policy titled Nephrostomy and Cystostomy Tube Care and Maintenance revealed the following, in part: Policy Explanation and Compliance Guidelines: 2. The care and maintenance of nephrostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions. Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Quadriplegia and Traumatic Brain Injury. Review of Resident #1's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes, all dated May 2024, revealed no documentation of PEG tube site care, nephrostomy tube site care, or that monitoring had been completed. Review of Resident #1's Hospital Medical Records, dated 05/12/2024, revealed the following, in part: -Temperature 101.2 -Medical Decision Making Diagnoses: Sepsis, Severe Sepsis, Septic Shock, Nephrostomy associated UTI, infected PEG tube, and Pneumonia. -Patient had a bandage over the left nephrostomy tube that appeared old and crusted. There was also purulent discharge around the PEG site. -Physical Exam: Abdominal: Peg tube in left upper abdomen. There is some purulent type drainage from this. Genitourinary: There is a nephrostomy tube in the left flank. This is covered with a bandage that appears to be quite old. It was crusted and peeling from the skin. There was purulent drainage on the bandage that was dried. Review of Resident #1's Hospital Medical Records dated 05/14/2024 revealed the following, in part: Wound cultures from PEG site growing staph and gram negative rods. Continue Cefepime and Vancomycin. Urinary Tract Infection associated with nephrostomy catheter-urinalysis consistent with UTI. On 06/04/2024 at 8:47 a.m., an interview was conducted with the Case Manager of the local emergency department. She stated Resident #1, a nonverbal resident, was transferred from the facility to the hospital in early May 2024. She stated Resident #1 presented to the hospital with purulent drainage around her PEG tube site and a dressing over the nephrostomy tube site that was old and crusted. On 06/04/2024 at 12:30 p.m., an interview was conducted with S2DON. She stated she was unaware who was responsible for PEG and nephrostomy dressing changes or where it was charted. On 06/04/2024 at 2:02 p.m., an interview was conducted with S6LPN, who provided care to Resident #1 in May 2024. She verified Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated floor nurses were responsible for changing PEG site dressings and the wound care nurse was responsible for changing nephrostomy site dressings. She verified there was no order for Resident #1 to have PEG site monitoring or care. She stated if she provided care to Resident #1's PEG site she would have documented it in the nurse's notes. She stated she was unaware if Resident #1 had nephrostomy site care orders since wound care was responsible. She confirmed she did not change Resident #1's nephrostomy site dressing while she was admitted in May and stated if she would have, she would have documented it in the nurse's notes. On 06/05/2024 at 9:23 a.m., an interview was conducted with S14WC. She stated floor nurses were responsible for changing the dressings on PEG tubes and nephrostomy tubes. She stated all residents had to have a split gauze over the site if they had a PEG tube. She stated the facility had a standing order for PEG tube site care the nurses could enter in the resident's electronic medical record. She stated after the standing order was entered by the nurse, the dressing change would populate on the MAR for the nurses to complete. She stated she was not sure how often nephrostomy tube site dressings were changed because she was not responsible for nephrostomy tube sites. She confirmed she did not change Resident #1's PEG tube or nephrostomy tube dressings while the resident was admitted in May. On 06/06/2024 at 9:53 a.m., an interview was conducted with S5LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated she did not know who was responsible for completing nephrostomy site dressing changes. She stated the floor nurses completed PEG site dressing changes. She confirmed she did not change the dressing to Resident #1's nephrostomy site while she was admitted in May. She stated if she completed site care it would have been documented in the residents MAR. She stated S15ADON or S16UM were responsible for entering orders for newly admitted residents. She verified orders should have been entered on admit for PEG and nephrostomy site care. She confirmed when no orders were entered, the floor nurses should have called and obtained an order to care for Resident #1's PEG site and nephrostomy tube site. On 06/06/2024 at 10:38 a.m., an interview was conducted with S11LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated wound care nurses were responsible for PEG tube and nephrostomy tube dressing changes. She confirmed she did not change Resident #1's PEG tube or nephrostomy tube dressings while she was admitted in May. She stated if site care was performed, it would have been documented in the residents MAR or TAR. She confirmed all residents with PEG tubes and nephrostomy tubes should have orders to monitor the site and change the dressings. On 06/06/2024 at 1:42 p.m., an interview was conducted with S13LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated she never completed a full skin assessment on Resident #1 since she worked overnight. She stated floor nurses were responsible for PEG tube and nephrostomy tube dressing changes. She confirmed she did not change Resident #1's PEG tube and nephrostomy tube dressings while she was admitted in May. She stated dressing changes were documented in the resident's MAR. She stated for any indwelling device, there should be an order to monitor the site and change the dressing. She stated if a resident did not have an order for site care or monitoring, the floor nurse should call the doctor and obtain an order because care would need to be provided to the site(s). On 06/05/2024 at 11:00 a.m., an interview was conducted with S16UM. She stated for residents who had PEG tubes and nephrostomy tubes, there would be an order which read, Monitor site q (every) shift. She stated nurses should monitor those sites for redness, swelling, tenderness, and drainage. She stated floor nurses were responsible for changing dressings to PEG tube and nephrostomy tube sites. She stated all residents who had PEG tubes had a split gauze dressing to the site. She stated nurses should change PEG tube dressings daily and as needed. She stated orders for nephrostomy dressing changes would come from the doctor. She stated it was the floor nurses responsibility to change the nephrostomy dressing as ordered. On 06/05/2024 at 11:22 a.m., an interview was conducted with S15ADON. She stated the floor nurse was responsible for site care and dressing changes to all indwelling devices, including PEG and nephrostomy tubes. She stated wound care nurses were responsible for wounds only. She stated she was responsible for putting the admission orders in for Resident #1. She stated she did not receive orders to change the dressing for Resident #1's nephrostomy tube upon admission. She confirmed she should have called the doctor to obtain orders for the nephrostomy tube dressing changes and did not. She stated she did not enter orders to monitor the sites for Resident #1's PEG tube and nephrostomy tube and should have. On 06/05/2024 at 2:38 p.m., an interview was conducted with S2DON. She stated S15ADON or S16UM were responsible for putting in orders for newly admitted residents. She stated any resident who had an indwelling device, such as a PEG tube or nephrostomy tube needed to have orders to monitor the site and orders for dressing changes. She stated it was the floor nurses responsibility to change PEG tube and nephrostomy tube dressings. She reviewed Resident #1's physician orders and confirmed the resident did not have orders to monitor the sites or change the dressings for the PEG tube and nephrostomy tube sites. She confirmed when an order was not obtained or entered into the residents electronic medical record, it did not populate in the MAR or TAR for the nurses to complete. She confirmed there was no documentation Resident #1's PEG site and nephrostomy site had been monitored and dressing changes performed. She stated Resident #1's nephrostomy site and PEG site should have been monitored and any concerns reported to the Nurse Practitioner. She confirmed Resident #1 should have had dressing changes completed to the PEG and nephrostomy tube sites. Resident #3 Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Paraplegia and Neuromuscular Dysfunction of Bladder. Review of Resident #3's Quarterly MDS with an ARD of 05/02/2024 revealed the resident had a BIMS of 12, which indicated he was moderately cognitively impaired. Review of Resident #3's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes, all dated February 2024, revealed no documentation of PEG tube site care, nephrostomy tube site care, or that monitoring had been completed. Review of Resident #3's Nurses Notes, dated February 2024, revealed no documentation nephrostomy tube site care or monitoring had been completed. Further review revealed on 02/18/2024 at 9:05 a.m., S12LPN wrote Resident #3's nephrostomy tube was out. The resident stated it had been in for 2 1/2 weeks but had not been connected to a drainage bag and was not in use. He denied being in pain and the on call Nurse Practitioner was notified. On 06/05/2024 at 10:10 a.m., an interview was conducted with Resident #3. Resident #3 was fully oriented and able to carry on an appropriate conversation. He stated he had a nephrostomy tube that got pulled out accidentally a few months ago. He stated the nephrostomy tube had been inserted for a few weeks when it came out. He stated the wound care nurse changed the dressing to the nephrostomy site a few times when she was completing his wound care dressing changes because the dressing was crusty and nasty. He stated the nurses did not know they were responsible for changing his nephrostomy tube dressing. He stated the nurses who took care of him did not look at the dressing at all while he had the nephrostomy tube. He stated the nurses thought the wound care nurse was changing the dressing, but if he did not have pressure ulcers, it would have never gotten changed. On 06/05/2024 at 10:50 a.m., an interview was conducted with S14WC. She stated Resident #3 had a nephrostomy tube a few months ago. She stated it was the floor nurses responsibility to change the nephrostomy tube dressings. She stated she remembered changing Resident #3's nephrostomy tube dressing a few times while she was changing his pressure ulcer dressings. She stated she could not recall if there was drainage on the dressing when she changed it. She stated when she did change Resident #3's nephrostomy dressing, she verbally notified the nurse. On 06/05/2024 at 11:30 a.m., an interview was conducted with S6LPN. She stated Resident #3 was completely oriented. She stated Resident #3 had a nephrostomy tube but she did not know when it was taken out. She stated she never changed Resident #3's nephrostomy tube dressing. She stated if she needed to change a dressing she would know because there would be an order for the nurse to change the dressing in the resident's chart. She stated there were no orders to change Resident #3's nephrostomy dressing. On 06/06/2024 at 9:43 a.m., an interview was conducted with S5LPN. She stated Resident #3 was completely oriented. She stated he had a nephrostomy tube but it had been out for a few months. She stated she never changed Resident #3's nephrostomy tube dressing while he had the nephrostomy tube in place. She stated she was unsure who changed the nephrostomy tube dressings. On 06/10/2024 at 3:10 p.m., an interview was conducted with S2DON. She reviewed Resident #3's physician orders from February 2024. She confirmed Resident #3 had a nephrostomy tube during February 2024 and there were no orders to monitor the nephrostomy site or provide dressing changes to it. She verified without a Physician's order, it would not populate on the MAR/TAR for the nurses to change the dressing. She confirmed there was no documentation wound care was performed to Resident #3's nephrostomy tube site while the tube was in place.

Based on record review and interviews, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#7) of 2 (#7 and #8) residents reviewed with wander guards. This deficient practice resulted in an immediate jeopardy situation for Resident #7, a severely cognitively impaired resident with exit seeking behaviors, on the morning of 05/20/2024. At approximately 9:05 a.m., a Good Samaritan alerted the facility that Resident #7 was in a parking lot. After being alerted to Resident #7's elopement from the facility, staff located the resident in a parking lot, 1.1 miles away from the facility, across a high trafficked four-lane divided highway next to the interstate. The facility implemented corrective actions which were completed by 05/28/2024, prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses of Other Neurological Conditions, Aphasia, Cerebral Vascular Accident, Alcohol Use Unspecified with Withdrawal and Encephalopathy. Review of the Admit 5 day Assessment MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/27/2024, revealed Resident #7 had a BIMS (Brief Interview for Mental Status) of 4 which indicated severe cognitive impairment. Further review revealed Resident #7 wore a wander guard daily. Review of the Elopement Risk assessment dated [DATE] revealed Resident #7 had an Elopement Risk Score of 11. A score of 9 or greater indicated the resident was at risk for elopement. Resident #7 had intermittent confusion and wandered around the facility. Resident #7 required assistance with ambulation. A wander guard was placed for safety. Review of the current Care Plan for Resident #7 revealed the following: Start Date: 02/06/2024- Resident is at risk for elopement. Updated: 05/01/2024- Resident noted removing wander guard. Wander guard replaced. Updated: 05/20/2024- Resident was observed walking in the parking lot at a fast food chain with a bag of clothes. Intervention: 04/22/2024- Q1 hour checks 05/1/2024- Electric monitoring device attached to resident's wheelchair due to him removing off of person 05/20/2024- Resident assisted back to the facility by staff, kept in high traffic areas and relocated to a facility with a secure unit. Review of the Nurse's Notes for Resident #7 revealed the following: 04/22/2024 at 7:59 p.m.- Nurse found Resident #7 in room with window open. Resident #7 had wheelchair folded up and was trying to shove wheelchair through window. Nurse asked resident what he was doing and Resident #7 stated, I am leaving. Situation was reported to NP and DON. Resident #7 was moved closer to nurse's station and hourly checks were implemented. Signed by S16UM. 04/23/2024 at 12:10 p.m.- Resident #7 requires redirection when attempting to wander off unit. Signed by S19LPN. 05/01/2024 at 2:27 p.m.- Resident #7 was noted removing wander guard from leg. Staff aware and replaced wander guard. Signed by S20MDS. 05/20/2024 at 9:45 a.m.- Visitor came into the facility and spoke with S17UC. He asked if the facility had a resident by the name of Resident #7. Visitor stated there was a man at a fast food chain who identified himself as Resident #7. DON and three other nursing staff left in private vehicles. Upon arrival, Resident #7 was observed walking in the parking lot with a bag of clothes and a plastic shower rod (as if it were a cane). Resident #7 was brought back to the facility. Wander guard was not on Resident #7. Resident #7 was placed in a high traffic area near the main nurse's station. Resident #7 was transferred to sister facility. Signed by S2DON. 05/20/2024 at 12:03 p.m.- Resident #7 keeps repeating, I want to get out of here. Signed by S16UM. Review of a written statement from S18LPN revealed the following: On 05/20/2024, I made rounds on residents. Resident #7 at 7:00 a.m. was in room and in bed. At 8:00 a.m. I saw Resident #7 ambulating down the hall and I assumed he was going to the dining room for breakfast. Review of a written statement from S17UC revealed the following: On 05/20/2024, around 8:45 a.m. Resident #7 came to the Nurse's Station to leave. I redirected him down the hall. I observed him going down the hall. Review of the facility's Incident Reports revealed Resident #7 was found off of the facility's premises on 05/20/2024 at 9:05 a.m. by a Good Samaritan. On 06/06/2024 at 5:45 p.m., an interview was conducted with S17UC. She stated Resident #7 frequently stated he wanted to leave the facility. She stated Resident #7 kept taking his wander guard off so facility staff placed it on his wheelchair. She stated on the morning of 05/20/2024, Resident #7 attempted to get out of the front door while sitting in his wheelchair. She stated the alarm went off and the doors locked so the resident could not get out of the building. She stated Resident #7 went to her and told her he wanted to leave. She stated she walked Resident #7 back to his room which was the last time she saw him. On 06/06/2024 at 5:48 p.m., an interview was conducted with S16UM. She stated Resident #7 frequently made comments he wanted to leave the facility. She stated Resident #7's wander guard was placed on his wheelchair because he kept taking it off of his ankles. She stated on the morning of 05/20/2024 around 8:30 a.m. a Good Samaritan entered the facility and notified them Resident #7 was off premises at a nearby fast food chain's parking lot. On 06/06/2024 at 2:20 p.m., an interview was conducted with S2DON. She confirmed Resident #7 eloped from the facility on 05/20/2024. She confirmed Resident #7 left the facility grounds and was found by a Good Samaritan over a mile away from the facility after being gone for an undetermined amount of time. She confirmed the Good Samaritan came to the facility to let them know the location of their resident. On 06/06/2024 at 6:45 p.m., an interview was conducted with S1ADM. He stated staff relied on the wander guard to prevent elopement. He confirmed Resident #7 left the building and the facility's premises without being noticed or without staff realizing. He confirmed there had not been enough supervision present to prevent Resident #7's elopement and should have been. The facility had implemented the following actions to correct the deficient practice: 1.) 05/20/2024-Resident was returned to the facility safely. Head-to-toe assessment was performed, resident without injury. 2.) 05/20/2024- Resident was placed in high traffic area by unit clerk in line of site and was later transferred to another facility with a secure unit. 3.) 05/21/2024- All residents with wander guards were assessed to ensure wander guards were in place and functioning properly. Staff was in-serviced on hourly census checks for residents at risk for elopements. 4.) 05/21/2024- Nursing staff to perform hourly census checks for residents with wander guards. DON/Designee to perform weekly checks for wander guard functionality, elopements are discussed weekly in high-risk meeting. The elopement binders are reviewed weekly. Throughout the survey from 06/04/2024 to 06/10/2024, staff were observed making frequent rounds. Observations were made of the front door alarming and staff responding appropriately. Interviews with random staff revealed staff had received training on elopement and the importance to ensure all residents with wander guards had them on and were checked hourly.

Based on observation, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans for 2 (#41 and #51) of 3 (#41, #51, and #135) residents reviewed for hospitalization s. The facility failed to ensure: 1. Nursing staff appropriately assessed and intervened when Resident #41 exhibited signs of a Urinary Tract Infection; 2. Resident #51 was assessed after altered mental status was identified and before administering narcotics and other mind altering medications; and 3. Nursing staff identified Resident #51 was treated for [REDACTED]. This deficient practice resulted in an Actual Harm for Resident #41 on 3/13/2019 when the resident's responsible party informed S18LPN that the resident's urine looked horrible, had a foul smell, and requested a urinalysis. S18LPN documented that the resident's urine was dark in color and odorous with sediment noted in the catheter bag. An initial urinalysis was collected on 3/14/2019 and was repeated on 3/17/2019. Resident #41's urine was noted as yellow, cloudy, and odorous on 03/16/2019. On 3/17/2019 through 3/18/2019, the resident continued to exhibit abnormal urine assessments, changes in mental status and abnormal vital signs. On 3/17/2019, when the nursing staff received the resident's urinalysis results, they did not notify the Nurse Practitioner of the abnormal results or of the changes in the resident's condition. On 3/18/2019 at 8:40 p.m., the resident's family requested that the resident be transferred to the hospital. The resident was admitted into the hospital and diagnosed with [REDACTED]. This deficient practice resulted in an actual harm for Resident #51, on 04/27/2019 when S20LPN identified a decline in Resident #51's level of consciousness and proceeded to administer scheduled [MEDICATION NAME] ER 60 mg, [MEDICATION NAME] 300 mg, Duloxetine 60 mg, and [MEDICATION NAME] 10 mg at 8:00 a.m. to the resident. She later administered as needed [MEDICATION NAME]/APAP 10-325 mg at 12:00 p.m. S20LPN failed to monitor and reassess Resident #51's level of consciousness throughout the day and at 4:30 p.m., S20LPN attempted to administer medications again and identified Resident #51 to be lethargic, unable to swallow medication, and unable to respond. Resident #51 was transferred to a local emergency department and treated for [REDACTED]. Findings: Resident #41 Review of the Nursing Home Standing Orders revealed the following: *Foley Care: Daily catheter care. Change monthly and as needed. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set with an Assessment Reference Date of 03/07/2019 revealed Resident #41 had a Brief Interview of Mental Status score of 99, which indicated the resident was unable to complete the interview. Further review of the Minimum Data Set revealed he had an indwelling catheter. Review of the Care Plan revealed a risk for infection was noted related to indwelling catheter use. Interventions included the following: vital signs as ordered, obtain labs as ordered, notify the resident's physician of any abnormal findings and document, and notify the resident's physician with any signs and symptoms of infection. Review of the physician's orders [REDACTED]. *03/03/2019: Insert 16 French Foley catheter due to [MEDICAL CONDITION] *03/15/2019: Culture and sensitivity of urine STAT *No orders were noted for hospital transfer on 03/18/2019 Review of the Medication Administration Record dated 03/01/2019 through 03/31/2019 revealed that catheter care was not documented from 03/03/2019 through 03/18/2019. Review of the Skilled Daily Nurses Notes revealed a 16 French Foley catheter was inserted at 1:00 p.m. on 03/03/2019 due to [MEDICAL CONDITION]. Review of the Skilled Daily Nurses Notes, dated 03/03/2019 through 03/18/2019, revealed bowel and bladder assessments were not checked or noted on the following shifts: *03/03/2019: night shift *03/05/2019: evening and night shifts *03/06/2019: night shift *03/07/2019: night shift *03/08/2019: night shift *03/09/2019: evening shift *03/10/2019: evening shift *03/13/2019: night shift *03/14/2019: night shift *03/16/2019: evening shift *03/17/2019: evening shift Review of the Skilled Daily Nurses Notes revealed Resident #41's urine was documented as clear and yellow without an odor from 03/03/2019 through 03/10/2019. His urine color, consistency, and odor were not documented on 03/11/2019 or 03/12/2019. On 03/13/2019, Resident #41's urine was documented to be dark in color, odorous, and had the presence of sediment. Review of the Skilled Daily Nurses Note, dated 03/13/2019, revealed S18LPN noted the following: Daughter wants urinalysis and culture and sensitivity done on this resident. Stated the urine looks horrible and there's a foul smell - This is true. S6NP notified and okayed order. Review of the Nurse's Note, dated 03/15/2019, revealed the following: Resident representative at nursing station inquired about urinalysis results. Results given to her by 6-2 nurse. Explained to responsible party that resident has not been put on antibiotics pending culture and sensitivity. Responsible party verbalized understanding. Call placed to S6NP and call back received in response. S6NP stated do a STAT culture and sensitivity of the urine. Call placed to the resident's responsible party. Review of the Skilled Daily Nurses Note, dated 03/16/2019, revealed Resident #41 was disoriented, his urine was yellow, cloudy, and odorous, and his vital signs were marked as abnormal on the day shift with elevated heart rate and blood pressure. S31LPN noted the following at 11:30 a.m.: Lab called facility and requested urine specimen be drawn again. Urine aspirated from catheter tubing via aseptic technique and placed in sterile specimen cup. Specimen refrigerated, awaiting courier for transport to lab. Review of the Skilled Daily Nurses Note, dated 03/17/2019, revealed the resident was disoriented, his vital signs were marked as abnormal on the day shift with elevated heart rate and blood pressure, and his urine was dark yellow, cloudy, and odorous. S31LPN noted the following at 12:15 p.m.: Urinalysis resulted received. Urine culture not indicated. Called lab to confirm based on the presence of moderate bacteria. Representative stated urinalysis did not meet all criteria for culture and sensitivity. The resident's responsible party was notified and verbalized understanding. S31LPN noted the following at 4:45 p.m.: Resident lethargic and difficult to arouse. Respirations even and unlabored. Responds to painful stimuli and repositioning, but slow to respond to verbal commands. Blood pressure 102/83. Heart rate 158. Medications administered with much encouragement. Will continue to monitor. Review of the Skilled Daily Nurses Note, dated 03/18/2019, revealed Resident #41 was disoriented and had dark yellow, cloudy, and odorous urine. S18LPN noted the following at 8:40 p.m.: Approached by this resident's sister. She said, I don't like the way he's looking and he's not responding like he usually (does) - I want him send out to the hospital. She said S6NP was supposed to look at him today. She asked me (S18LPN) if he saw her brother. I (S18LPN ) told her that there were no new orders for the resident, but that doesn't mean S6NP didn't see him. She said, well I want him send out tonight. I (S18LPN) okayed her request. S18LPN noted the following at 9:00 p.m.: Resident transferred to the hospital for altered mental status. Review of the Urinalysis, dated 03/14/2019, revealed the following abnormal results: *Clarity: Turbid (Reference Range: Clear) *PH: 9 (Reference Range: 5-8) *Protein: 100 (Reference Range: Negative) *Hemoglobin: Moderate (Reference Range: Negative) *Leukocyte Esterase: Large (Reference Range: Negative) *White Blood Cells: >100 (Reference Range: None, 0-5) *Blood: 50-100 (Reference Range: None Seen, 0-1, 1-5) *Bacteria: Large (Reference Range: None Seen) *Mucus: Present (Reference Range: None) *Urine Culture Indicated: No Review of the Urinalysis, dated 03/17/2019, was noted as reviewed by S31LPN at 12:15 p.m. on 03/17/2019 and revealed the following abnormal results: *Clarity: Turbid (Reference Range: Clear) *Hemoglobin: Moderate (Reference Range: Negative) *White Blood Cells: >100 (Reference Range: None, 0-5) *Blood: 50-100 (Reference Range: None Seen, 0-1, 1-5) *Mucus: Present (Reference Range: None) *[MEDICATION NAME]: 5 (Reference Range: Negative) *Urobilinogen: 2 (Reference Range: Negative) *Protein: 100 (Reference Range: Negative) *Leukocyte Esterase: Moderate (Reference Range: Negative) *Bacteria: Moderate (Reference Range: None Seen) *Urine Culture Indicated: No Review of the hospital records from Resident #41's hospitalization , dated 03/18/2019 through 04/02/2019, noted he presented to the emergency department after developing altered level of consciousness. Staff in the emergency department noted foul-smelling purulent urine and his Foley catheter was changed. Evaluation revealed the following impression:[MEDICAL CONDITION] due to urinary tract infection. Urine cultures were noted as positive for [DIAGNOSES REDACTED] pneuoniae and E. coli. Blood cultures were noted as positive for staphylococcus aureus. Resident #41 was discharged back to the facility on [DATE] on intravenous [MEDICATION NAME]. Review of the physician's orders [REDACTED]. An interview was conducted with Resident #41's responsible party at 12:31 p.m. on 05/22/2019. She stated she reported to S18LPN that the resident's urine smelled and he had sediment in his catheter bag. She stated S18LPN told her that everyone had sediment in their urine and that was normal. She stated her brother was lethargic and she thought he may have had an infection. She stated it was several days before they said they would do the urinalysis after she first reported the smell and sediment to the nurse. She stated facility staff was going to do a urinalysis, but she requested to have him sent out instead. She stated she told facility staff to call the ambulance. She stated the hospital told her that the resident's catheter was clogged and the infection had spread to his blood by the time he got to the hospital. An interview was conducted with S33CNA at 10:12 a.m. on 05/23/2019. She stated Resident #41 had a catheter and was incontinent of bowels. She stated CNAs cleaned the resident's catheter during bed baths with soap and water and emptied the catheter every shift; however, nurses did catheter care. An interview was conducted with S15LPN at 10:19 a.m. on 05/23/2019. She stated Resident #41 had a catheter. She stated his catheter was changed on the 15th day of every month and catheter care was done daily by the CNAs. She stated the CNAs performed catheter care while bathing the resident. She was not able to recall why Resident #41 went to the hospital on [DATE]. An interview was S13LPN at 1:48 p.m. on 05/23/2019. She stated Resident #41 was admitted from the hospital with Bacteremia and received [MEDICATION NAME]. She stated catheter care was done by the nurse and should be documented on the medication administration record every shift. She stated CNAs drained the catheter bag every shift. An interview was conducted with S18LPN at 3:37 p.m. on 05/23/2019. She stated Resident #41 had never shown any signs of a urinary tract infection. She stated the resident's responsible party finds things all the time with the resident and wanted him to have a urinalysis done and be transferred out to the hospital. She stated Resident #41 was on [MEDICATION NAME], but it was not due to a UTI. She stated she was not sure why he was on antibiotics. She stated she was supposed to document catheter care every shift, but did not always document it. She stated it was not always on the medication administration record and she was not sure why. An interview was conducted with S35CNA at 3:43 p.m. on 05/23/2019. She stated she emptied the resident's catheter every shift, but she never cleaned his catheter area or performed catheter care. She stated the nurses performed catheter care. An interview was conducted with S21LPN at 2:48 p.m. on 05/24/2019. She stated she received Resident #41's urinalysis results on 03/15/2019. She stated she called S6NP to inform him of the results and inform him that a culture and sensitivity was not indicated. She stated she received an order to perform culture and sensitivity STAT. An interview was conducted with S5ADON at 3:12 p.m. on 05/24/2019. He verified a STAT order for a culture and sensitivity was written on 03/15/2019. He was not able to locate any results from this lab order. He stated the facility contacted the lab on 05/24/2019 and was informed the culture and sensitivity was cancelled. He stated he was not sure why the order was cancelled. He stated someone should have followed up on this. An interview was conducted with S21LPN in the presence of S3CN at 3:23 p.m. on 05/24/2019. S21LPN stated the culture and sensitivity ordered on [DATE] was cancelled by the lab. She stated the lab came to the facility to obtain the lab, but the order was not present when they arrived. She stated the lab left because the order was not ready. She stated the lab called to follow-up on the lab and requested it be redrawn on 03/16/2019. An interview was conducted with S3CN at 3:35 p.m. on 05/24/2019. He confirmed the facility received results from the resident's urinalysis at 12:15 p.m. on 03/17/2019. He verified the nurse documented the resident was lethargic and difficult to arouse at 4:45 p.m. on 03/18/2019. He confirmed the facility was not able to locate any documentation that the nurse practitioner was notified of the lab results or the resident's condition on 03/17/2019 or 03/18/2019. He confirmed the resident was transferred to the hospital at 9:00 p.m. on 03/18/2019. He stated he would have expected the nurse to notify the nurse practitioner or physician of the resident's dark urine with sediment and odor, lethargy, and lab results. S21LPN entered the room during the interview with S3CN at 3:43 p.m. on 05/24/2019. She stated she was not able to pull any urine out of the resident's indwelling urinary catheter for the culture and sensitivity ordered on [DATE]. She stated she could not pull any urine for the collection because he had a scant amount of urine output. She stated S18LPN was able to draw some urine and sent it to the lab, but the lab was cancelled. She stated, per S18LPN, the lab called back on 03/16/2019 and requested the urine be collected again, so she collected the urine. An interview was conducted with S3CN at 5:28 p.m. on 05/24/2019. He reviewed Resident #41's Medication Administration Record and verified catheter care was not documented for (MONTH) or (MONTH) of 2019. Resident #51 Review of the facility's Administering Pain Medications policy revealed, in part: General Guidelines 6. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief. Documentation: Document the following in the resident's medical record: 1. Results of the pain assessment 2. Medication 3. Dose 4. Route of Administration 5. Results of the medications (adverse or desired) Review of the clinical record revealed Resident #51 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 03/12/2019 revealed Resident #51 had a BIMS of 10, which indicated he was moderately cognitively intact. Review of Resident #51's (MONTH) 2019 Physicians Orders revealed, in part: [MEDICATION NAME] Tab 10 mg, 1 tablet by mouth three times a day Duloxetine Cap 60 mg, 1 capsule by mouth two times a day [MEDICATION NAME] Cap 300 mg, 1 capsule by mouth three times a day [MEDICATION NAME] Tab 60 mg ER, 1 tablet by mouth two times a day [MEDICATION NAME] Tab 1 mg, 1 tablet by mouth at bedtime as needed [MEDICATION NAME]/APAP Tab 10-325 mg, 1 tablet by mouth every six hours as needed [MEDICATION NAME] HCL Tab 25 mg, 1 tablet by mouth two times a day as needed Review of the Telephone physician's orders [REDACTED]. 04/27/2019 at 6:10 a.m., call on if level of consciousness does not improve. S29LPN 04/27/2019 at 4:55 p.m., transfer resident to hospital for evaluation of lethargy and unresponsiveness. S20LPN Review of Resident #51's (MONTH) 2019 MAR revealed, in part: On 04/27/2019, the MAR was initialed at the below times, which indicated the medication was given. [MEDICATION NAME] Tab 10 mg, 8:00 a.m. and 2:00 p.m. Duloxetine Cap 60 mg, 8:00 a.m. [MEDICATION NAME] Cap 300 mg, 8:00 a.m. and 12:00 p.m. [MEDICATION NAME] Tab 60 mg ER, 8:00 a.m. Review of the Controlled Drug Receipt/Record/Disposition Form revealed, in part: [MEDICATION NAME]/APAP tab 10-325 mg was signed out on 04/27/2019 at 5:30 a.m. by S29LPN and at 12:00 p.m. by S20LPN, which indicated the medication was given at those times. Further review of the (MONTH) 2019 MAR revealed there was no documented follow up pain assessment noted on the date of 04/27/2019 for [MEDICATION NAME]/APAP or [MEDICATION NAME]. Review of Resident #51's Nurse's Notes revealed, in part: 04/27/2019 at 6:15 a.m., upon morning rounds entered resident's room. Noticed resident was not responding as usual. Signed by S29LPN 04/27/2019 at 8:00 a.m., observed resident in bed with eyes closed. Responds to verbal stimuli. Confusion noted, incomplete thoughts noted. Continue to monitor resident, if condition worsens, send to emergency department. Signed by S20LPN 04/27/2019 at 4:30 p.m., resident lying in bed with eyes closed. Only opens eyes when name called. Vital signs 90/54, 90, 18, 96.4 degrees Fahrenheit. Unable to take afternoon medication due to drowsiness. Send to emergency room for evaluation. Signed by S20LPN Further review of the resident's Nurses Notes dated 04/27/2019 revealed no documentation regarding the resident's level of consciousness when the [MEDICATION NAME] APAP 10-325 mg was administered to the resident at 12:00 p.m. by S20LPN. Review of the Hospital Documentation for Resident #51 revealed, in part: Date of Admission: 04/27/2019 at 6:14 p.m. Chief Complaint: Per the nursing home, Resident #51 appeared drowsy, confused, and less verbal this morning. However, by the afternoon, the patient was too somnolent to take his medications, and he was transferred to the emergency department. At the time of my exam, patient had a respiratory rate of 5. Reviewing home medications indicated he was on [MEDICATION NAME] 10 mg every 6 hours as needed, [MEDICATION NAME] ER 60 mg every 12 hours, and [MEDICATION NAME] 1 mg nightly. [MEDICATION NAME] 0.4 mg was given as bedside with significant improvement in respiratory rate and mentation. 1 hour later, patient's respiratory rate again significantly depressed and he was again given [MEDICATION NAME] with improvement. Assessment/Plan: admitted to ICU for [REDACTED]. Problem List: Unintentional Overdose Neurological: [MEDICAL CONDITION], likely due to opioid overdose [MEDICAL CONDITION]. [MEDICATION NAME] ggt given, long-acting narcotics on board. Respiratory: Acute [MEDICAL CONDITION], respiratory rate 5, improved to 20 after [MEDICATION NAME]. Right Lower Lobe Infiltrate: Aspiration in setting of opioid overdose Assessment and Plan: 2. Acute [MEDICAL CONDITION], felt to be secondary to opioids given. 3. [MEDICAL CONDITION], suspect in combination with opiate induced as well as [MEDICAL CONDITION] Further review of the Hospital Documentation for Resident #51 revealed: 04/28/2019: Subjective: Resident #51 was on a considerable opioid prescription-chronic pain-and was responsive to [MEDICATION NAME] in the emergency department intermittently ultimately requiring a drip. Impression/Plan: Neurological: -acute opioid toxicity with decrease in clearance of routine regimen -holding medications, using [MEDICATION NAME] ggt to correct respiratory depression -weaning off [MEDICATION NAME] to off with resolution of lethargy Pulmonary: -acute hypercapnic [MEDICAL CONDITION] suspected-status corrected quickly with [MEDICATION NAME]. Review of the hospital physician's orders [REDACTED]. Review of the hospital Discharge Orders revealed: Reason for Consult: Presented with altered mental status from accidental overdose [MEDICAL CONDITION]. Review of the facility's Progress Note dated 05/07/2019 revealed in part: Hospital Course: He was medically stable for discharge on 05/02/2019. He was only needing PRN [MEDICATION NAME] during the days preceding discharge, so his [MEDICATION NAME] discontinued. He was counseled on the potentiation of opiates and benzos and [MEDICATION NAME] was discontinued. Patient's [MEDICAL CONDITION], chronic pain, and anxiety are stable on admit. Review of Resident #51's Care Plan revealed there were no updated problems, goals, or new interventions put into place once the resident was returned from the hospital on [DATE]. An interview was conducted with Resident #51 on 05/22/2019 at 9:35 a.m. The resident was observed to be alert and oriented to person, place, and time throughout the interview. He reported he had been admitted to the hospital about a month ago for loss of consciousness. He denied knowing the cause for the admission or the treatment he received. An interview was conducted with S27CNA on 05/22/19 at 10:37 a.m. She reported Resident #51 was having increased episodes of confusion prior to going to the hospital, but since he returned he had been alert and active during the day. An interview was conducted with S26CNA on 05/23/2019 at 8:56 a.m. She stated she was working with Resident #51 during the morning shift on 04/27/2019. She reported Resident #51 was normally alert and able to verbally communicate. She reported the resident was usually easy to wake up and would respond if his name was called. She stated she went to check on Resident #51 around breakfast time and noticed he was in a daze, blinking slowly, and would not respond to her. She reported she informed S20LPN of the residents altered state. She denied being instructed to increase monitoring for Resident #51. She reported the resident continued to be verbally non-responsive throughout her shift and she checked on him during her shift to see if he was breathing. She denied communicating about the residents decline with the nurse. On 05/23/2019 at 9:35 a.m., S16LPN was observed administering morning medications to Resident #51. S16LPN entered the room and stated here are your morning medications. She then proceeded to administer all morning medications to the resident by handing him a cup with all his pills. Once the resident swallowed his medications S16LPN walked out of the room. S16LPN was not observed assessing Resident #51 prior to medication administration. Upon interview immediately following medication pass, S16LPN stated she forgot to give Resident #51 the [MEDICATION NAME]/APAP, but she would go ahead and give it to him since he was going to ask her anyway. She reported Resident #51 was sent out on 04/27/2019 for a bladder infection or maybe pneumonia. She reported the resident was on PRN pain mediation and stated a follow up should be done 30 minutes to an hour after the medication was administered to assess the effectiveness. She reported the staff were not required to reassess the resident for a scheduled narcotic. A telephone interview was conducted with S20LPN on 05/23/2019 at 11:21 a.m. She confirmed she worked on 04/27/2019 from 6:00 a.m. to 6:00 p.m. She reported the first time she assessed Resident #51 that day was during morning medication pass. She reported at that time Resident #51 was confused and not at his baseline. She stated he was able to speak to her, but was harder to arouse. She confirmed she administered all his morning medications including [MEDICATION NAME], Duloxetine, [MEDICATION NAME], and [MEDICATION NAME] ER. She did not recall administering [MEDICATION NAME]/APAP to Resident #51 that day. She reported she later spoke with the on-call nurse practitioner to report the results of Resident #51's urinalysis. She reported she received a new order for an antibiotic and was told by the Nurse Practitioner to hold off on sending the resident to the emergency room for evaluation for a couple of days because he normally acted like this when he had a UTI. She stated communications and directives received from the Nurse Practitioner should be documented in the nurse's notes. She reported when she went to administer the afternoon medications she noticed Resident #51 was unresponsive and only able to open his eyes. She reported at that time she was concerned he would not be able to take his antibiotic, and she called the nurse practitioner. She stated the resident was sent to the emergency room via ambulance for evaluation and treatment. An interview was conducted with S3CN on 05/23/2019 at 11:59 a.m. He reported the nurses did not have to reassess a resident after administering a scheduled narcotic. He reported if a resident had an altered mental status he would expect the nurse to assess the resident thoroughly and increase monitoring for any changes. He confirmed the nurse should have done a thorough assessment of Resident #51 prior to administering scheduled [MEDICATION NAME], Duloxetine, [MEDICATION NAME], and [MEDICATION NAME]/APAP PRN. He reported the nurses should not have just assumed it was a UTI and administered narcotics without assessing the resident. He stated that since S20LPN identified a change in Resident #51 she should have followed through with the assessment. An interview was conducted with S13LPN and S14LPN on 05/24/2019 at 10:41 a.m. S14LPN reported when a resident returned to the facility from the hospital it was the resident's nurse or the utility nurse's responsibility to review the entire discharge packet and communicate the information to the staff. S13LPN confirmed the above statement. Both S13LPN and S14 LPN confirmed the staff should be made aware of a resident having to be administered [MEDICATION NAME] in the hospital due to an over dose. Neither S13LPN nor S14 LPN were aware Resident #51 had been treated for [REDACTED]. An interview was conducted with S3CN on 05/24/2019 at 10:59 a.m. He reported the process for receiving the discharge information when a resident returned was for the admission coordinator to send a copy to the DON, ADON, Administrator, and utility nurses. He reported the utility nurse would then review the paperwork and communicate the information throughout the facility. S3CN confirmed the facility should have known Resident #51 was treated for [REDACTED]. An interview was conducted with S7MDS on 05/24/2019 at 11:05 a.m. She confirmed she was responsible for updating the care plan for Resident #51. She denied being made aware Resident #51 was treated for [REDACTED]. She confirmed it should have been communicated in order for preventative measures to be put into place. She confirmed Resident #51's care plan was not revised to reflect the opioid over dose once he returned from the hospital. An interview was conducted with S21LPN on 05/24/2019 at 11:18 a.m. She confirmed she reviewed the discharge information for Resident #51 on 05/02/2019 upon reentry to the facility. She stated she reviewed the entire packet and communicated the orders and pertinent information to the staff. She reviewed the discharge packet for Resident #51 and confirmed she had not noticed the resident had been treated for [REDACTED]. She reported everyone gets that in the emergency room . She confirmed she was unaware Resident #51 was treated for [REDACTED].

Based on record reviews, interviews, and observations, the facility failed to ensure each resident's environment remained as free of accident hazards as possible for 1 (#3) 0f 5 (#1, #2, #3, #4, #5) sampled residents. This deficient practice resulted in an Actual Harm for Resident #3 on 03/18/2019 at 7:11 a.m. when the resident was found on the floor next to her bed. The resident had been positioned on an inflated low air loss mattress where due to the thickness of the mattress, the mattress was higher than the side rail on the bed. Resident #3 was diagnosed with [REDACTED]. The facility implemented corrective actions prior to the State Agency's investigation on 03/27/2019; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record revealed Resident #3 was an [AGE] year old female with an admission date of [DATE]. Her [DIAGNOSES REDACTED]. A review of the current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2019 revealed the following: Resident #3 was sometimes understood with a limited ability to make concrete requests and she usually understood but missed some of the part or intent of the message. She was able to comprehend most of the conversation. Resident #3 required limited assistance for upper body; and extensive assistance for lower body with ADL's. Review of the current care plan revealed Resident #3 was care planned for risk of injury related to impaired mobility and poor trunk control. Approaches included: total assist with transfers using a lift X2 persons, fall matt placed X1 placed on side of the bed, therapy screen, low bed, in service staff on low bed, assist rail X1 while in bed for enhanced mobility and bed edge definition, bed positioned against wall, call light within reach, and notify MD and RP of falls. A review of the Incident Log dated 01/01/2019-03/25/2019 revealed on 03/18/2019 Resident #3 was found on the floor with right arm pain and her arm was turned outward. Review of the EMT note dated 03/18/2019 at 11:00 a.m. revealed the following: an unwitnessed fall from bed with deformity to right arm; Resident #3 had a history of [REDACTED]. Review of an x-ray results dated 03/18/2019 revealed a comminuted and displaced distal humerus fracture to the right arm. A review of Resident #3's Physician's Progress note dated 03/25/2019 revealed a follow up visit from a recent emergency room visit for a fractured humerus. Overview stated Resident #3 was found on the floor and could have possibly been a result of a [MEDICAL CONDITION] secondary to her history of [MEDICAL CONDITIONS] spastic [MEDICAL CONDITION]. On 03/25/2019 at 5:15 p.m. Resident #3 was observed lying in bed with the HOB elevated at 35 degrees, feeding herself her dinner meal with her left hand. Her right arm was in a sling, fall mat in place, and the call light was in reach. On 03/27/2019 at 10:30 a.m. an interview was conducted with S11LPN. She reported on 03/18/2019, a CNA called her into the room because Resident #3 had fallen out of bed. She said Resident #3 was on the floor, between the bed and the wall, and was grimacing from pain to her right arm. She stated the bed side rails were up and the bed was not all the way against the wall. She said she called EMT, doctor, and family and Resident #3 was sent to the emergency room . She said Resident #3 returned to the facility the same day. She said interventions were implemented after the 03/18/2019 fall, and Resident #3 had not had any issues since that time. S11LPN said interventions were on the care plan and the care plan was in the chart. Review of the facility's investigation and root cause analysis revealed it was determined the resident most likely had an episode of possible [MEDICAL CONDITION] activity or the resident was not positioned directly in the center of the bed. Not being positioned in the center of the bed could have led to the resident falling out of the bed due to her involuntary movements. This was further caused by her side rail not being high enough to cover the mattress on the bed as well as her potentially being close to the edge of the bed with positioning. On 03/27/2019 at 10:40 a.m. an interview was conducted with S16CNA. She said she attended a recent in-service regarding resident bed positioning and bed safety. She said residents were to be placed in the middle of the bed and put the bed in the lowest position. She said she was to make sure the call light and phone were in residents reach and to check the fall matt. On 03/27/2019 from 1:30 p.m. - 2:30 p.m. observations were made of 22 low air loss beds and mattresses located in the facility. All mattresses were lower than the bed rails and all mattresses fit properly within the bed frame. There were no issues noted with the beds or the mattresses. Facility tour was completed with S6CNA. On 03/27/2019 at 2:58 p.m. an observation was made of Resident #3's room. The bed was low to the ground with a specialty mattress and a thick fall mat was noted. The bed was touching the wall, along the long side, with Resident #3's right side being closest to the wall. Her call light and phone were within reach. On 03/27/2019 at 3:00 p.m. an interview was conducted with Resident #3. She was nonverbal but could make her answers known with head motions and facial expressions. Resident #3 nodded her head up and down for yes, and she shook her head side to side for no. Surveyor asked if the staff came when she used the call light for assistance. She indicated a yes answer. Resident #3 was asked if a she remembered falling last week. She indicated a yes answer. Resident #3 was asked if she slipped out of the side of the bed when she fell . She indicted a yes answer. On 03/27/2019 at 3:55 p.m. an interview was conducted with S1ADM. He stated all air mattresses were inspected after Resident #3's fall and had passed maintenance inspections. On 03/27/2019 at 4:45 p.m. an interview was conducted with S12Maint. He reported after the 03/18/2019 fall of Resident #3, his team evaluated all air mattresses in the building to ensure the rail to the bed was higher than the mattress. He said they used a measuring tape to ensure there was at a minimum of 4 inches between the mattress and the top of the rail. S12Maint stated his team did weekly inspections of the specialty air beds and reported to S1ADM any negative findings. On 03/27/2019 at 5:10 p.m. an interview was conducted with S14CNA. She said she attended a recent in-service regarding resident positioning and bed safety. She said residents were to be in the middle of the mattress, check the level of the head of the bed, and place the bed in the lowest position. She said they were to make sure the call light and phone were in residents reach and to check the fall matt if it was ordered. On 03/27/2019 at 5:15 p.m. an interview was conducted with S15CNA. She said she attended a recent in-service regarding resident bed positioning and bed safety. She said residents were to be in the middle of the bed and place the bed in the lowest position. She said they were to make sure the call light and phone were in residents reach and to check the fall matt if it was ordered. On 03/27/2019 at 5:32 p.m. an interview was conducted with S13LPN. She said she attended a recent in-service regarding resident bed positioning and bed safety. She said she was to ensure residents were in the middle of the bed and the bed in the lowest position. She said she was to make sure the call light and phone were in residents reach and to check to see if the fall matt was in place. On 03/27/2019 at 5:50 p.m. an interview was conducted with S2DON. The DON confirmed after Resident #3's fall, it was determined the low air loss mattress had been inflated and the mattress was higher than side rail due to the thickness of mattress. She reported she in-serviced all staff in the facility immediately after the fall, followed by all staff later that day. S1DON said she had a monitoring tool in effect to ensure the safety of all resident's from falling out of their bed. The facility implemented the following actions to correct the deficient practice: 1. A review of follow up notes by the facility dated 03/27/2019 revealed five residents were interviewed by Administrative Staff and stated they did not have any concerns regarding being transferred to bed and/or being positioned in bed. They all stated they felt safe when they received this care. 2. A review of the facility's in-service trainings revealed two staff trainings held on 03/18/2019. The first was regarding positioning of residents in bed and the use of side rails with summary content: When placing residents in bed it is your responsibility to position resident correctly in the middle of the bed. If the resident has a side rail it must be up at all times while resident is in bed. Related to safety, always make sure call light and phone are within reach. The second was regarding low bed controls with summary content: Low bed operation and controller. Lock out key prevents elevation from lowest position once locked. Unlock, green light on, to operate all controls. Lock out (gold/orange lights). Fall mat to be on floor at all times when bed in lowest position. Bed to be in lowest position at any time unattended in room. Monitor electrical cards to prevent damage when bed lowered (keep under main frame). 3. A review of QA Minutes Meeting Sign in Sheet dated 03/21/2019 revealed comment: Current P[NAME] in place with monitoring tools in place are effective. Will continue to monitor and make changes as needed. 4. A review of the High Risk Management Committee Meeting Minutes dated 03/21/2019 revealed Attendees reviewed residents at risk for fall, including Resident #3. 5. Completed monitoring on 03/19/2019, 03/20/2019, 03/22/2019, 03/25/2019, and 03/27/2019 for resident positioning and CNA education needs.

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by failing to: 1. Ensure there was adequate supervision and monitoring for 1 (#2) of 10 (#2, #3, #5, #R8, #R16, #R17, #R18, #R19, #R20,#R21) residents who were assessed by the facility to require a wander guard; This failed practice had the potential to affect all 135 residents who currently reside in the facility. On 1/2/2019, an Immediate Jeopardy occurred for Resident #2, a cognitively impaired resident, who eloped from the facility unnoticed by staff. The resident was located 0.5 miles away from the facility at a local restaurant by an unidentified person who contacted the local police. The distance between the facility and the restaurant consisted of heavy traffic due to the close proximity of a major interstate and the commercial nature of the area. The police then transferred the resident to a nearby hospital at 5:19 p.m. where the staff there found the nursing home facility's telephone number on the resident's wander guard. On 1/2/2019 at 7:04 p.m., the resident was discharged from the local hospital and was returned to the nursing home facility. The Immediate Jeopardy continued due to all staff not being knowledgeable of their responsibilities when the alarm sounded on the exterior doors. The facility was notified of the Immediate Jeopardy on 1/30/19 at 2:09 p.m. The Immediate Jeopardy was removed on 1/30/19 at 4:37 p.m. when the provider presented an acceptable plan of removal. Through interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. 1. Resident #2 was located by S2ADM to reinsure that his wander guard was in place. Resident #2 was placed on 1:1 until all three shifts could be in-serviced, beginning on 1/30/19 at 3:50 p.m. Staff on the next two shifts will be in-serviced before the start of their shifts beginning on 1/30/19 at 10:00 p.m. 2. All other residents with wander guards were at risk and were checked by S2ADM or designee. 3. All current staff in the building were in-serviced on the wander-guard procedure and responding to alarms on 1/30/19 at 3:50 p.m. In-services will be conducted on all shifts to get all staff starting on 1/30/19 at 10:00 p.m. 4. Elopement risk assessments were done on all residents in the building on 1/3/19. Residents at risk for elopement are identified by staff through care plan updates, elopement binders available at the nurse's station and visual sight of wander guards. Binders were checked and updated 1/3/19. All residents, including elopements, will be monitored every two hours by staff. 5. Maintenance director or designee will check wander guard doors weekly for function beginning 1/30/19. S2ADM or designee will set off door three times per week for the next four weeks to ensure proper response by staff and staff retention of proper responses. S2ADM will personally run elopement drills for the next three months. 6. Maintenance director or designee will document weekly checks on monitoring tool for the next for weeks. Door tests by S2ADM will be documented on QA tool. Staff who do not respond appropriately will receive progressive disciplinary action leading up to termination, if needed. Results of these monitors will be addressed in QA/QI system through IDT meetings to determine success of plan or need for change of plan or continuation of plan. The next meeting will occur on 2/15/19. 7. Plan of correction tracking to continue through 2/25/19. Findings: 1. Cross reference findings to F689 Review of the facility's Wandering, Unsafe Resident policy revealed the following, in part: Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. Any resident at risk for elopement may require a monitoring devise such as a bracelet. 4. Staff will respond immediately should the resident activate the alarm by going near or out of the door. Staff will check outside and round the door to determine if resident is outside of the facility. If yes, this will be reported immediately to the supervisor. 5. All incidents such as the above will be reported to administration. 6. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 7. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the administrator and the DON, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads); d. Provide search teams with resident identification information; and e. Initiate and extensive search of the surrounding area. 8. When the resident returns to the facility, the DON or charge nurse shall: a. Examine the resident for injuries; b. Contact the attending physician and report findings and condition of the resident; c. Notify the resident's legal representative; d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of the facility's Elopements policy revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse of DON. 2. If any employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct anther staff member to inform the charge nurse or DON that a resident has left the premises. 3. When a departing individual returns to the facility, the DON or charge nurse shall: a. Examine the resident for injuries; b. Notify the attending physician; c. Notify the resident's legal representative of the incident; d. Complete and file report of incident/accident; and e. Document the event in the resident's medical record.

Based on observations, interviews, and record reviews, the facility failed to ensure there was adequate supervision and monitoring for 1 (#2) of 10 (#2, #3, #5, #R8, #R16, #R17, #R18, #R19, #R20,#R21) residents who were care planned as requiring a wander guard and being an elopement risk. On 1/2/2019, an Immediate Jeopardy occurred for Resident #2, a cognitively impaired resident, who eloped from the facility unnoticed by staff. The resident was located 0.5 miles away from the facility at a local restaurant by an unidentified person who contacted the local police. The distance between the facility and the restaurant consisted of heavy traffic due to the close proximity of a major interstate and the commercial nature of the area. The police then transferred the resident to a nearby hospital at 5:19 p.m. where the staff there found the nursing home facility's telephone number on the resident's wander guard. On 1/2/2019 at 7:04 p.m., the resident was discharged from the local hospital and was returned to the nursing home facility. The Immediate Jeopardy continued due to all staff not being knowledgeable of their responsibilities when the alarm sounded on the exterior doors. The facility was notified of the Immediate Jeopardy on 1/30/19 at 2:09 p.m. The Immediate Jeopardy was removed on 1/30/19 at 4:37 p.m. when the provider presented an acceptable plan of removal. Through interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. 1. Resident #2 was located by S2ADM to reinsure that his wander guard was in place. Resident #2 was placed on 1:1 until all three shifts could be in-serviced, beginning on 1/30/19 at 3:50 p.m. Staff on the next two shifts will be in-serviced before the start of their shifts beginning on 1/30/19 at 10:00 p.m. 2. All other residents with wander guards were at risk and were checked by S2ADM or designee. 3. All current staff in the building were in-serviced on the wander-guard procedure and responding to alarms on 1/30/19 at 3:50 p.m. In-services will be conducted on all shifts to get all staff starting on 1/30/19 at 10:00 p.m. 4. Elopement risk assessments were done on all residents in the building on 1/3/19. Residents at risk for elopement are identified by staff through care plan updates, elopement binders available at the nurse's station and visual sight of wander guards. Binders were checked and updated 1/3/19. All residents, including elopements, will be monitored every two hours by staff. 5. Maintenance director or designee will check wander guard doors weekly for function beginning 1/30/19. S2ADM or designee will set off door three times per week for the next four weeks to ensure proper response by staff and staff retention of proper responses. S2ADM will personally run elopement drills for the next three months. 6. Maintenance director or designee will document weekly checks on monitoring tool for the next for weeks. Door tests by S2ADM will be documented on QA tool. Staff who do not respond appropriately will receive progressive disciplinary action leading up to termination, if needed. Results of these monitors will be addressed in QA/QI system through IDT meetings to determine success of plan or need for change of plan or continuation of plan. The next meeting will occur on 2/15/19. 7. Plan of correction tracking to continue through 2/25/19. The deficient practice continued at a potential for more than minimal harm for the 10 other residents in the facility with wander guards. Findings: Review of the facility's Wandering, Unsafe Resident policy revealed the following, in part: Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. Any resident at risk for elopement may require a monitoring devise such as a bracelet. 4. Staff will respond immediately should the resident activate the alarm by going near or out of the door. Staff will check outside and round the door to determine if resident is outside of the facility. If yes, this will be reported immediately to the supervisor. 5. All incidents such as the above will be reported to administration. 6. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 7. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the administrator and the DON, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads); d. Provide search teams with resident identification information; and e. Initiate and extensive search of the surrounding area. 8. When the resident returns to the facility, the DON or charge nurse shall: a. Examine the resident for injuries; b. Contact the attending physician and report findings and condition of the resident; c. Notify the resident's legal representative; d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of the facility's Elopements policy revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse of DON. 2. If any employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct anther staff member to inform the charge nurse or DON that a resident has left the premises. 3. When a departing individual returns to the facility, the DON or charge nurse shall: a. Examine the resident for injuries; b. Notify the attending physician; c. Notify the resident's legal representative of the incident; d. Complete and file report of incident/accident; and e. Document the event in the resident's medical record. A review of Resident #2's clinical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the most recent 30 Day MDS with an ARD of 12/9/18 revealed Resident #2 had a BIMS score of 7, indicating severe cognitive impairment. The MDS also revealed Resident #2 required limited assistance for locomotion on and off the unit. A review of the Resident #2's care plan revealed the following: Problem Onset: 10/29/18, I am at risk for elopement. I have a wander guard in place. 1/3/19: I eloped from the facility Goals and Target Date: I will have no attempts at elopement through the next review, 3/20/19. A review of the facility's Risk Assessment for Elopement Form revealed the following: 10/9/18: Score of 8 11/13/18: Score of 9 1/3/19: Score of 20 A score of 10 is considered an elopement risk per the form. A review of the Facility's Report revealed Resident #2 left the building without anyone knowing on 1/2/19. A review of an email provided by the facility revealed: On 1/2/19 at approximately 4:00-4:15 p.m., I was standing in the hall talking with maintenance. The wander guard alarm was sounding. The floor nurse stated will someone please turn that off. I walked over to disarm it. There was nobody immediately outside of the door. At approximately 4:30, it was brought to my attention that we were searching for a resident. I joined the search until he was located. I remembered the alarm situation and brought it to the attention of the administrator at approximately 6:00 p.m. Earlier in the day, I had to disarm it due to the door being held open too long by a resident that takes increased time to exit and enter the doorway. She does not have a wander guard. Signed S33PTD An interview was conducted with Resident #2 on 1/29/19 at 11:29 a.m. The resident was alert, awake and resting in bed. When asked how long he had been at the facility, he was unable to answer. When asked if he remembered leaving the facility on 1/2/19, he stated no. An interview was conducted with S20CNA on 1/29/19 at 11:34 a.m. When asked what the process would be if there was a concern a resident had eloped, she reported she was unsure because she had just started a couple weeks ago and she could go ask someone. An interview was conducted with S4ADON on 1/29/19 at 11:54 a.m. She reported she had last seen Resident #2 around 3:00 p.m. to 3:30 p.m. in the day area on Hall A on 1/2/19. The interview was continued at 2:03 p.m. with S4ADON. She confirmed there was a lot of traffic coming in and out the door on Hall A and the alarm would frequently go off. She stated Resident #2 was pleasantly confused and this was the reason for the wander guard being placed. An interview was conducted with S3DON on 1/29/19 at 12:05 p.m. She reported she was notified Resident #2 eloped at 5:00 p.m. on 1/2/19. When asked what happened, she replied the alarm went off on Hall A and a therapist turned it off. When asked how long it was before staff identified Resident #2 as missing, she replied she did not know. When asked if Resident #2 was an elopement risk, she reported Resident #2's family wanted the wander guard placed due to being concerned Resident #2 would try and leave the facility. She further explained Resident #2 was confused and could move positions very quickly. An interview was conducted with S34PT on 1/29/19 at 12:34 p.m. She confirmed working on 1/2/19 when Resident #2 eloped. She reported Resident #2 enjoyed going outside and had tried to get out of the door on Hall A in the past. She reported someone had turned the alarm off and had not realized Resident #2 had left the facility. She explained Resident #2 must have walked out the door when someone had had it opened. She explained the alarm would go off if the door was open too long and Resident #2 could have walked out then. An interview was conducted with S33PTD on 1/29/19 at 1:02 p.m. He verified working on 1/2/19 when Resident #2 eloped. He reported he was talking to maintenance and a nurse told him to turn the alarm off. He stated he did not even realize the alarm was going off until the nurse pointed it out. He stated he silenced the alarm. He reported the alarm on Hall A goes off multiple times a day and has to be turned off. He reported he turned it off on 1/2/19 around 4:15 pm. An interview was conducted with S17MDS on 1/29/19 at 1:16 p.m. She reported Resident #2 was deemed an elopement risk on 10/29/18, when the care plan was implemented. She verified a wander guard was placed on Resident #2 on that date. An interview was conducted with S27CNA on 1/29/19 at 1:42 p.m. She reported he wandered a lot and had tried to get out of the side door on hall C before. An interview was conducted S14LPN on 1/29/19 at 2:15 p.m. She reported she was passing medications down the hall, when she came out of a room and heard the alarm on 1/2/19. She reported she told the therapist the alarm was going off and he turned the alarm off. She stated the alarm was turned off about 4:00 p.m. She reported realizing Resident #2 was missing when dinner trays were being passed. She reported the trays were passed that day between 4:30 p.m. and 5:00 p.m. She reported Resident #2 was not cognitive enough to have entered the number code to get out the door. She reported he must have walked out when someone had the door open. An interview was conducted with S19CNA on 1/29/19 at 2:30 p.m. She reported working the day Resident #2 eloped. She reported last seeing Resident #2 sitting in a brown chair near the entrance door on Hall A at 3:30 p.m. on 1/2/19. She reported she noticed Resident #2 was missing when the hall carts were being passed for dinner. An interview was conducted with S8LPN on 1/30/19 at 9:05 a.m. When asked what the proper response was when an alarm was going off, she replied she would go to the alarm to see why it was going off, walk out the door and look around, and then if there were no resident, she would turn the alarm off. When asked if that was all she would do, she responded yes. There was no mention of checking to make sure all resident were accounted for. An interview was conducted with S3DON on 1/30/19 at 10:40 a.m. She then explained there was a button at the nurse's station on Hall A that could be pressed to unlock the door. She reported if someone were trying to come into or out of the building through the door on Hall A, they would ring a bell and someone at the nurse's station could unlock the door. When asked if the nurse's station was in the line of sight of the door, she replied no. She verified if a staff member was at the nurse's station, they would have to get up and walk towards the door and around the therapy room to be able to see who wanted to go in or out. She explained the staff were supposed to make sure all residents were accounted for if they needed to turn the alarm off and could not find a cause of why it was going off. She reported she was unable to say if all staff had been educated about the elopement and proper protocol when turning the alarms off. On 2/1/19 at 4:00 p.m., the Regional Director was unable to provide verification that all staff who had worked since the elopement on 1/2/19 had been trained.

Based on record reviews, interviews, and observations, the facility failed to ensure a resident remained free of accident hazards for 1 (#20) of 40 residents assessed for accidents in Stage 1 of the Recertification survey. The facility failed to ensure that adequate supervision was provided when Resident #20 was transferred from the bed to a Geri Chair by one staff member. The facility had a total of 34 residents that required 2 person assistance during transfers identified by the facility. On 6/10/16 at approximately 5:30 a.m., an actual harm occurred when Resident #20, assessed by the facility as 2 person transfer, was transferred by 1 staff member from the bed to a Geri Chair. Resident #20's left ankle was caught in the Geri Chair during the transfer and this resulted in an acute fracture with no mild angulation involving the distal tibia. Findings: Review of the [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set for Resident #20 with an ARD (Assessment reference Date) of 4/1/16 revealed the resident had a BIMS (Brief interview for Mental Status) of 3 which indicated the resident was severely impaired for cognition. Further review revealed the resident required extensive assistance and two person physical assistance for transfers. Review of the care plan for Resident #20 revealed the following: Potential for Injury- At risk for falls, resident requires extensive assistance with all mobility needs, uses Geri chair for mobility. Interventions included- Transfer with two person assist. Update- 6/10/16- Left Ankle Fracture with transfer of resident from bed to Geri chair. Ortho appointment made to follow-up for supportive care, Hospice notified, CNA in-serviced. Review of the fall investigation's worksheet completed by S11LPN for Resident #20 on 6/10/16 revealed the following: Time Incident Occurred- 5:30 a.m. Brief Description: Hospice aid came to me and asked if I could assess the ankle of the resident, hospice aid informed me S9CNA was lifting and transferred the resident from the bed to the chair. Hospice aid asked S9CNA if she needed help, S9CNA denied help as hospice aid stood behind the Geri Chair. Hospice aid noticed the resident's ankle did not look normal and that the resident's foot got caught in the Geri chair during the transfer. I did my assessment and called the Doctor/Nurse Practitioner to get an x-ray order, Resident showed no signs of pain or distress. The ankle did appear swollen, therefore I called the doctor to get order. Hospice aid stated she had a break in this area before and believes it never healed correctly, I informed the oncoming nurse (S4LPN) of the matter of me ordering the x-ray and to notify the family if a positive result was to come back from the report. I also showed the oncoming nurse S4LPN the resident's ankle and she informed me that she would finish out the process, I was gone when the x-ray arrived. - S11LPN resident sustained [REDACTED]. Physician was notified. Recommendations, interventions- Please use medical lift or 2 person assist to transfer to prevent injury during transfer of resident. Ortho appointment made following x-ray positive for acute left ankle fracture per Nurse Practitioner, (Family accompanied to appointment) Hospice notified, no new orders. Review of the statement taken from the hospice CNA for the incident involving Resident #20 on 6/10/16 revealed the following: 6/10/16- Friday Morning, Hospice CNA and S9CNA was in the room with Resident #20 and asked S9CNA to help get resident up. She came in and assisted with myself. I asked if she needed help in getting her up and she said no she had it. We were in there together but I stepped back behind the wheelchair, she got her (Resident #20) out of bed by herself she did not use a lift. She used her arms and body, she was very easy getting the resident up. That is all I know when I get the nurse S11LPN and reported it. - Hospice CNA Review of the statement taken from S9CNA on 6/12/16 for the incident involving Resident #20 on 6/10/16 revealed the following: On the morning of June 10th Friday about 5:30 a.m., the hospice CNA for Resident #20 asked for me to help her to her Geri chair. I manually transported to her chair and as I transported her, her foot got caught. In a way she was resisting me to transport her. After I got her in the chair, the hospice aide noticed the bone in her ankle was poking out. The resident did not scream or show signs of pain. The hospice aid called the nurse in to look at it better. That was it. - S9CNA Review of the Radiology report for Resident #20 on 6/10/16 revealed the resident had an acute fracture with no mild angulation involving the distal tibia. An interview was held with S8CNA on 6/22/16 at 11:35 a.m. She stated she had been in-serviced recently regarding transfers with Resident #20. She stated they were to always transfer with two people. She stated there was an incident recently with Resident #20 where she was transferred by staff without 2 people and they fractured her ankle. Review of an in-service held with S9CNA revealed on 6/12/16 the CNA was instructed that before transferring a resident, the aide must know the care planned transfer status/ADL status of the resident. If the resident required more than one aide to transfer or equipment, such as a Hoyer, aide must follow established guidelines. Further review of the in-service revealed no documentation CNA was being monitored by staff to ensure CNA was competent to safely transfer residents. An observation was made of Resident #20 on 6/22/16 at 1:30 p.m. The resident was observed lying in bed and asleep. The resident had an ace bandage wrap to the left foot. The resident's family member was present during the observation. An interview was held with Resident #20's family member at that time. She confirmed the resident had a fracture to her left ankle. She stated the resident appeared to show increased signs of pain since the incident with her ankle. An interview was held with S4LPN on 6/23/16 at 10:30 am. She stated she was present the morning the resident was found to have a fracture to the ankle. She stated she was told by the night shift nurse that he was notified immediately by S9CNA and the hospice CNA. She said she was told S9CNA was transferring the resident by herself and that's when the fracture happened. She stated when she observed the residents ankle, there was some obvious swelling noted. She stated an X-ray was ordered and confirmed it was broken. An interview was held with S1DON, on 6/23/16 at 12:30 p.m. She stated she was not made aware of the incident with Resident #20 until Sunday evening. She confirmed Resident #20 was not transferred with two people for this incident. She stated S9CNA declined help and just transferred by herself and Resident #20's ankle got twisted during the transfer. She stated an x-ray was ordered that same say and confirmed the resident had a fracture. She stated S12RNS was monitoring S9CNA at night to ensure transfers were being done correctly but she could not show documentation S9CNA was monitored to ensure the in-service she received was effective. An interview was held with S12RNS on 6/24/16 at 10:00 a.m. She stated she supervised all halls on the night shift for the facility. She stated she was made aware of the incident with Resident #20 when she was instructed by S2ADON to in-service S9CNA on how to correctly transfer a resident. She stated the incident happened in the morning on 6/10/16. She stated she in-serviced S9CNA on 6/12/16 during their night shift. She confirmed Resident #20 was a 2 person assist for transfers and instructed S9CNA that 2 people were always to be used to transfer the resident. She stated she did not do anything else with S9CNA after the in-service. She stated she had only observed S9CNA transfer residents before the incident. She said she could not confirm S9CNA had been monitored after the incident by anyone else to ensure she was competent with transferring residents.

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use resources effectively and efficiently to maintain the highest practicable physical well being for for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents reviewed for receiving wound care. The facility failed to: 1. Ensure the physician promptly assessed a resident with a history of venous stasis ulcers when notified on 12/10/12 that the resident had a new skin tear. Upon notification on 12/10/12, the physician stated he would assess the resident on 12/10/12, however he did not assess the resident until 12/13/12. (#2) 2. Ensure the Registered Nurse assessed and measured the venous ulcer weekly after the resident's physician assessed the resident to have a venous stasis ulcer instead of a skin tear on 12/13/12. (#2) 3. Promptly notify the resident's physician when the condition of the venous stasis ulcer worsened on 1/23/13. (#2) 4. Failed to ensure the Registered Nurse notify the Director of Nurses (DON) promptly when the condition of the venous stasis ulcer deteriorated on 1/23/13 and the nurse experienced problems notifying the resident's physician of the deteriorating of the venous stasis ulcer. 5. Ensure a system was in place to communicate to different members of the nursing staff, DON and Physician when the status of the venous ulcer showed a decline in healing. Resident #2 was admitted to the facility on [DATE] with Stage II Decubitus Ulcers to his left lower extremity that healed on 8/31/12. Resident #2 was placed in Immediate Jeopardy on 12/13/12 when a [DIAGNOSES REDACTED]. After the [DIAGNOSES REDACTED]. From 12/9/12 to 2/4/13, there were four documented assessments of the venous stasis ulcer to the resident's left lower extremity. There was no other documented evidence provided by the facility showing where assessments that included meassurements were consistently done or notification to the Physician of the condition of the venous stasis ulcer to the resident's left lower extremity. The Immediate Jeopardy was lowered to a level three pattern when Resident #2 was admitted to a local hospital on [DATE] with exposed muscle and bone to his left lower extremity. The deficient practice remains at a level two with a potential for more than minimal harm for the other six residents with venous ulcers/pressure ulcers. Findings: Review of the facility's Change in a Resident's Condition or Status Policy revealed in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of the facility's Weekly Skin Assessment Record Policy revealed the following: Policy: Every resident regardless of score on the Pressure Ulcer Risk Assessment will be monitored for pressure ulcer prevention. All residents will have an entire body check completed on admission or re-admission and on a weekly basis by a Licensed Professional to ensure all potential and actual skin problems are identified, evaluated, and referred for treatment. Review of the record revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. An observation was not done of the resident throughout the survey because he remained hospitalized in a local hospital. Review of the resident's care plans revealed an Impaired Skin Integrity dated 8/16/12. Review of the care plan revealed in part: Problem, Need, Strength, Potential: Resident has disruption of skin surface, not related to pressure. Wound type: Skin tear to right calf, Stage II to left calf Goal: The resident's disruption of skin surface will remain free from infection and show evidence of healing by 11/16/12. Approach: Complete weekly skin assessment -Report changes in skin status to physician -Complete Braden Scale Risk Assessment quarterly and PRN and Skin Risk Analysis the 1st time the Braden Scale less than 18. -Wound care as ordered, see current treatment record and physician's orders [REDACTED]. -Monitor for pain and medicate PRN (as needed) per physician's orders [REDACTED]. -Educate resident/responsible party about skin condition and treatment -8/16/12- Tx (Treatment) as ordered -8/31/12- Tx changed to unna 3 times a week for protection, skin integrity on right and left lower extremities. Review of the resident's plan of care revealed Stasis Ulcer care plan dated 12/13/12. Review of the care plan revealed in part: Problem, Need, Strength, Potential Concern: Resident has stasis ulcer or open lesion caused by poor circulation. Location: Chronic venous stasis ulcers to legs. 2/4/13- Left calf venous stasis ulcer Related to: [MEDICAL CONDITION], Normal progression of disease with an unavoidable, predictable decline expected. Goal: Resident's stasis ulcer (s) will exhibit signs of healing evidenced by decrease in size, improved appearance, absence of drainage, and be free from signs and symptoms of infection by: no date given. Target Date: 3/13/13 Approach: -Report changes in skin status (i.e. s/s infection, non healing, new areas) to physician -Discuss non-compliance issues with resident/responsible party -Educate resident/responsible party about pressure ulcer etiology, primary risk factors, treatment, prevention -Monitor effectiveness of/response to treatment (s) as ordered-see physician's orders [REDACTED]. -8/31/12- Unna boots 3 xs weekly -Notify nurse immediately of any new areas of skin breakdown, redness, blisters, and bruises, discoloration noted during bathing or daily care -Provide pressure relieving or reduction device- Specialty mattress -Low Air Loss (LAL) 2/5/13- Wound Clinic Evaluation. Review of a physician progress notes [REDACTED]. C.C. (Chief Complaint) - Nurse called me and requested to evaluate legs regarding chronic venous stasis [MEDICAL CONDITION], circled + (positive) discharge. A/P (Assessment/Plan)- 1. Chronic venous stasis ulcers/legs 2. Multiple chronic pressure sores 3. Afib/ DM2 (Diabetes Mellitus) 4. Obesity/Diabetic [MEDICAL CONDITION] -Unfortunately bad outcome as pt. is completely immobile/bed bound. -Needs legs elevating, OOB (out of bed), -Guarded progress Review of a physician progress notes [REDACTED]. F/U DM2/Chronic Venous Stasis [MEDICAL CONDITION] C.C. (Chief Complaint) - Again discusses with pt. in length about need of frequent position change, physical activity, BIL (bilateral) legs elevated. A/P (Assessment/Plan)- 1. [MEDICAL CONDITION] bladder 2. DM/HTN (Hypertension) 3. Multiple chronic pressure sores 4. Chronic venous stasis [MEDICAL CONDITION] -Legs elevation daily -Physical activity daily -Reviewed meds -Guarded prognosis Review of a skin assessment performed by S4RN dated 8/2/12 at 8:30 p.m. revealed the resident was admitted with multiple scabbed areas to bilateral lower extremities, excoriations to his right and left posterior calf, a pink Stage II to right posterior calf measuring 2 cm (centimeter) (L- (Length)) x 0.4 (D)Depth)) cm and a pink Stage II to left posterior calf measuring 2 cm (L) x 0.2 cm (D). Review of the admission orders [REDACTED] Clean excoriations to posterior bilateral calves with normal saline and cover with 4 x 4. Stage II right and left calves, clean with normal saline, thin layer of [MEDICATION NAME] gel, cover with gauze. Review of the Clinical Wound Team Communication Form dated 8/3/12 revealed the area to the right calf had skin intact. Review of new orders for skin care included: -Clean left posterior calf Stage II Decubitus with wc (wound cleanser), apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. -Clean right calf skin tear with wc, apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. Review of a Dietary Communication Form dated 8/6/12 revealed orders for Zinc 220 mg, by mouth every day and Vitamin C 500mg by mouth twice a day. The indication for both was wound healing. Review of Wound Treatment Evaluation Records revealed treatment to the bilateral lower extremities was discontinued on 8/31/12 because the wounds had healed. Review of a Nursing Communication Form dated 8/31/12 revealed nurse comments that stated wounds to bilateral lower extremities were resolved but continued with stasis [MEDICAL CONDITION]. The form read unna boots per resident were requested. Review of the form revealed orders to discontinue treatment to bilateral lower extremities and apply unna boots that day (8/31/12) and change every Monday, Wednesday, and Friday. In an interview on 2/13/13 at 10:35 a.m., S6Wound Care Nurse stated the resident had a skin tear to his right calf instead of a Stage II Decubitus. She stated both ulcers healed on 8/31/12. She stated after 8/31/12, the resident was ordered unna boots per his request. She stated the treatment of [REDACTED]. She stated the night RNs were responsible for the application of the unna boots. Review of Weekly Skin Assessment Record Revealed the following by S9LPN: 11/1/12- Unna boots to lower bilateral extremities. 11/8/12- Unna boots to lower bilateral extremities. 11/15/12- Unna boots to lower bilateral extremities. 11/22/12 - 11/29/12- Unna boots to lower bilateral extremities. Stasis ulcers to bilateral legs. 12/6/12- Resident has unna boots applied to bilateral legs. 12/13/12- Resident has unna boots applied to bilateral legs. 12/20/12- Resident has unna boots applied to bilateral legs. No other skin issues. 12/27/12- Resident has unna boots applied to bilateral legs. 1/3/12- Resident has unna boots applied to bilateral legs, redness to sacral area, and skin missing from finger tips due to resident biting nails and skin also. 1/10/13- Unna boots applied to bilateral legs. Resident has skin missing to fingertips. Resident stated he bites his nails. 1/17/13- Resident has unna boots applied to bilateral legs. 1/24/13- Resident had unna boots applied to bilateral legs. 1/31/12- Resident has unna boots applied to bilateral legs. Review of the Medication Record from November 2012 - January 2013 revealed an order for [REDACTED]. A. Put initial in appropriate box when medication given B. Circle initials when medication refused C. State reason for refusal on nurse's notes Review of the Medication Records (MR) revealed the following documentation for the unna boot application: November 2012 11/2/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/5/12- Initialed by S3RN 11/7/12- Initialed by S3RN 11/9/12- Initialed by S7RN 11/12/12- Initialed by S3RN 11/14/12- Initialed by S3RN 11/16/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/19/12- Initialed by S3RN 11/21/12- Initialed by S3RN 11/23/12- Initialed by S7RN 11/26/12- Initialed by S3RN 11/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/30/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/2/12- Initialed by S7RN 12/4/12- "Refused" . Review of the of the Nurse's Medication Notes on the back of the informed read the resident requested the unna boot to be changed the next day. 12/5/12- Initialed by S3RN 12/7/12- Initialed by S7RN 12/9/12- Initialed by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/9/12 by read S3RN noticed a skin tear 2 cm x 1 cm with one reddened area around the wound. The document read S3RN informed the resident of the change. There was no time noted. 12/10/12- Circled initials by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/10/12 at 5:00 a.m. read S3RN sent a text message to S4Physician about the change in the state of the resident's left leg. The document read S4Physician texted her back saying that he would exam the resident that day. 12/12/12- Initialed by S3RN 12/14/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/16/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation that indicated what circled "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/17/12- Initialed by S3RN 12/19/12- Initialed by S3RN 12/21/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what circled "R" meant. Review of the facility's Punch Origin revealed S7RN was the night RN. 12/22/12- Initialed by S7RN 12/24/12- Initialed by S3RN 12/26/12- Initialed by S7RN 12/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/31/12- Initialed by S3RN 1/2/13- Initialed by S3RN 1/5/13- Initialed by S7RN 1/7/13- Initialed by S3RN 1/9/13- Initialed by S3RN 1/11/13- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 1/14/13- Initialed by S3RN 1/16/13- Initialed by S3RN 1/18/13- Initialed by S8RN 1/21/13- Initialed by S3RN 1/23/13- Initialed by S3RN- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented the resident had an excoriated area to the left lateral aspect of the leg measuring 2 cm x 3 cm. 1/24/13- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented she was unable to reach S4Physician but had left a message for him to evaluate the resident's leg. 1/25/13- Initialed by S8RN 1/28/13- Initialed by S3RN 1/31/13- S3RN's initials circled. Review of the Nurse's Medication Notes on the back the Medication Record timed for 10-6 revealed S3RN documented she removed the resident's unna boot to find the resident's wound approximately 2 cm x 4 cm x ? cm. The document read the wound bed was pink, no drainage, with the skin around the wound red. The document read she cleansed the wound with wc, applied ABD (abdominal pad) and gauze to the left lateral aspect of the lower leg for the MD to assess. 2/1/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 12 a.m. by S3RN read the resident's unna boot was changed. The documentation read S3RN sent a text message to S4Physician requesting that he evaluate the resident's leg. S3RN documented S4Physician texted back an order to refer the resident to a local outpatient wound clinic. 2/4/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 2:00 p.m. by S2DON revealed she reviewed the resident's left leg with an assessment per nurse notes. S2DON documented the resident's right calf skin was intact with pink shiny patches. She documented the wound nurse applied a wet to moist dressing per the physician's orders [REDACTED]. In an interview on 2/13/13 at 11:45 a.m., S2DON stated the "R" and the circled "R" on the Medication Record indicated the resident had refused a treatment and or medication. She stated the nurse's were supposed to document what treatment or medication the resident refused on the back of the Medication Record or in the nurse's notes. Review of the Nurse's Notes revealed the following: 11/2/12- No assessment of the resident's bilateral lower extremities. 11/5/12- No assessment of the resident's bilateral lower extremities. 11/7/12- No assessment of the resident's bilateral lower extremities. 11/9/12- No assessment of the resident's bilateral lower extremities. 11/12/12- No assessment of the resident's bilateral lower extremities. 11/14/12- No assessment of the resident's bilateral lower extremities. 11/16/12- No assessment of the resident's bilateral lower extremities. 11/19/12- No assessment of the resident's bilateral lower extremities. 11/21/12- No assessment of the resident's bilateral lower extremities. 11/23/12- No assessment of the resident's bilateral lower extremities. 11/26/12- No assessment of the resident's bilateral lower extremities. 11/28/12- No assessment of the resident's bilateral lower extremities. 11/30/12- No assessment of the resident's bilateral lower extremities. 12/2/12- No assessment of the resident's bilateral lower extremities. 12/4/12- entry by at 10:40 by S3RN- Resident in bed asleep. Woke him to change his unna boots. Resident requested if they could be done next day because he was sleepy. Will try to change next day. 12/5/12- No assessment of the resident's bilateral lower extremities. 12/7/12- No assessment of the resident's bilateral lower extremities. 12/8/12- entry by S7RN (no time indicated)-Unna boots reapplied after cleaning wounds on both extremities. Pt (patient) needs to have doctor evaluate wounds. 12/12/12- No assessment of the resident's bilateral lower extremities. 12/14/12- No assessment of the resident's bilateral lower extremities. 12/16/12- No assessment of the resident ' s bilateral lower extremities. 12/17/12- No assessment of the resident's bilateral lower extremities. 12/19/12- No assessment of the resident's bilateral lower extremities. 12/21/12- No documentation why the resident refused unna boot application nor an assessment of the resident's bilateral lower extremities. 12/22/12- No assessment of the resident's bilateral lower extremities. 12/24/12- No assessment of the resident's bilateral lower extremities. 12/26/12- No assessment of the resident's bilateral lower extremities. 12/28/12- No assessment of the resident's bilateral lower extremities. 12/31/12- No assessment of the resident's bilateral lower extremities. 1/2/13- No assessment of the resident's bilateral lower extremities. 1/5/13- No assessment of the resident's bilateral lower extremities. 1/7/13- No assessment of the resident's bilateral lower extremities. 1/9/13- No assessment of the resident's bilateral lower extremities. 1/11/13- No assessment of the resident's bilateral lower extremities. 1/14/13- No assessment of the resident's bilateral lower extremities. 1/16/13- No assessment of the resident's bilateral lower extremities. 1/18/13- No assessment of the resident's bilateral lower extremities. 1/21/13- No assessment of the resident's bilateral lower extremities. 1/25/13- No assessment of the resident 's bilateral lower extremities. 1/28/13- No assessment of the resident's bilateral lower extremities. 2/4/13- entry by S3RN at 11 p.m.- Changed wound dressing on resident's left and right lower legs. Wound bed is pink and wet. Cleaned the wound with wc, covered with ABD and gauze. The resident stated he will be going to wound clinic next day. No c/o pain. 2/4/13- entry by 2DON at 1:30 p.m.- Summoned to resident room by wound care nurse. Wife present at bedside. Assessed left calf and noted what appeared to be a stasis wound measuring approximately 2 cm wide x 5 cm long x 0.5 cm depth. Wound bed pink and granulated tissue noted. Minimal serous drainage noted. No complaint of pain. Resident stated he was aware of wound and is going to wound clinic for eval (evaluation) on the next morning. Wife upset that wound had progressed without husband informing her of wound care clinic eval. Wife stated husband had lost a toe on left foot due to poor circulation and diabetes. Further eval of wound revealed no odor or redness to surrounding tissue. Contacted S4Physician and confirmed order for wound clinic eval on 2/5/13 and ok to apply wet to moist dressing until eval the next day. Dressing applied per wound care nurse. Wife given info (information) on wound care clinic eval (evaluation) and possible LTAC (Long Term Acute Care) placement as previously needed if wound does not respond to clinic treatment. Wife/resident voiced no other concerns. 2/5/13- entry by S2DON at 1:00 p.m. - Call received from out pt. wound clinic. Staff unable to assess wound due to being unable to transfer resident onto table. Will send to a local hospital emergency room for eval/tx ( treatment) per their MD (medical doctor). Wife present. 2/5/13- entry by S13LPN at 6:50 p.m. - Spoke with resident's wife. Informed me that resident is at local hospital emergency room and will be admitted . Transported there from his wound care appointment due to resident constantly sliding out of wheelchair. A telephone interview was conducted with the resident's wife on 2/18/13 at 9:35 a.m. She stated she was upset the registered nurse changed the resident's dressings in the middle of the night because the wound care nurse could not. She stated she was at the facility on 2/4/13, when her husband informed her of his wound care clinic appointment. She stated he had not informed her of the condition of his left leg either. She stated she asked the wound care nurse to remove the dressings to both of his legs. She stated when the dressing was removed to his left leg, " the flesh looked as if it was torn apart and the muscles, tendons, and bone were clearly exposed. It looked like a dog had chewed on it. " She stated she was so upset that his leg was in such bad shape. She stated S2 DON looked at the leg as well. She stated S2DON agreed the leg needed treatment but "down played the severity of the wound." She stated on 2/5/12, the resident went to his scheduled wound care clinic appointment. She stated he kept scooting down in the wheelchair and the doctor was unable to assess him. She stated the doctor ordered the resident to report to a local emergency room for treatment where he was admitted . She stated Resident #2 had been admitted to a local Long Term Acute Care (LTAC) on 2/11/13 to receive intravenous antibiotics for 25 days. She stated they were hopeful Resident #2 would need reconstructive surgery instead of an amputation. Review of a local hospital's ED (Emergency Department) Chart Review dated 2/5/13 at 13:51 (1:51 p.m.) revealed the resident's chief complaint was wound check. Review of the musculoskeletal listed under the Physical Exam by the physician revealed the resident's left lower left had an extensive posterior venous stasis ulcer with exposed bone and muscle. Review of the local hospital's History and Physical dated 2/5/13 revealed in part: Physical Examination: Skin: There is a left posterior wound with a 6-inch ulceration exposing the bone. Both lower extremities are hairless and shiny and cold to touch. Distal pulses are palpable in the posterior pedis distribution. Impression and Plan: This is a man who presents with a large left lower extremity ulcer with a history of chronic diabetes, [MEDICAL CONDITIONS]. 1. Large left lower extremity wound/ulceration [MEDICAL CONDITION]-substantiated by [MEDICAL CONDITION] leukocytosis and high likelihood of underlying osteo[DIAGNOSES REDACTED] as suggested by bone exposure. I suspect the mechanism for his wound formation is chronic pressure induced ischemic from immobilization with superimposed microvascular disease and chronic diabetes mellitus. Review of a vascular consultation at a local hospital dated 2/6/13 revealed in part: Impression: This is a [AGE] year old male with a history of diabetes and significant deconditioning. His ulcers appeared to be decubitus in nature with a likely venous stasis. Recommendations: At this point, we have no vascular options for the patient besides amputation. I have discussed with the patient and the patient ' s family possible plastic surgery evaluation for possible muscle flap or skin flap management of his wound. Otherwise an amputation may be the best option given his overall deconditioning. Review of the local hospital's Discharge Summary dated 2/11/13 revealed in part: Discharge Diagnosis: [REDACTED]. During the course of Resident #2 ' s hospital stay he was treated intravenously with [MEDICATION NAME] and [MEDICATION NAME]. A Peripherally Inserted Central Catheter (PICC line) was placed on 2/11/13 and the resident was transferred to a local LTAC center on 2/11/13. An interview was conducted with S10CNA on 2/13/13 at 1:28 p.m. She stated she rarely cared for the resident when he was admitted to the facility. She stated she was familiar with him because she assisted his assigned aide with transferring and repositioning him in bed. She stated he favored S11CNA a lot. An interview was conducted with S11CNA on 2/13/13 at 1:30 p.m. She stated she had an excellent rapport with the client and his family, that she would be called to assist with him even if she wasn't assigned to him. She stated she assisted him with bed baths, incontinent care, and supervision/set-up with meals. She stated he rarely refused every 2 hour repositioning, turning in bed, elevation of his legs or sitting up in his wheelchair. She stated when he refused it was due to occasion right side pain. She stated she never saw his legs because his legs were always wrapped in unna boots. An interview was conducted with S12LPN on 2/13/13 at 1:39 p.m. She stated she was the assigned nurse to care for the resident on the 6 a.m. - 10 p.m. shift. She stated Resident #2 was a diabetic that was non-compliant with eating, repositioning/turning in bed, and getting out of bed. She stated he would not eat the facility food but would eat the junk food his wife bought for him. She stated he had diabetic [MEDICAL CONDITION] and experienced problems with touch in his fingers and lower legs. She stated he favored S11CNA and would cooperate with her by getting out of bed into his chair and turning/repositioning in bed. She stated she had not assessed the resident's legs because of the unna boots. She stated the night RNs cared for his legs and the unna boots. She stated she became aware of issues with the resident's legs when S3RN requested that she follow-up with the resident's doctor for wound clinic orders. She stated she spoke with S4Physician and confirmed orders for a local wound clinic. A telephone interview was conducted on 2/13/13 at 2:26 p.m. with S3RN. She stated she was the 10 p.m.-6 a.m. RN Supervisor every Sunday -Thursday. She stated while on duty, she changed the resident's unna boots. She stated the resident was non-complaint with positioning and turning and sometimes changing of the unna boot. She stated after she removed the resident's boots on 12/9/12, she cleansed the legs with wound cleaner to remove the dead skin. She stated she noticed a skin tear on the resident's left posterior leg. She stated she attempted to notify the doctor, but had no success. She stated on 12/10/12, another nurse informed her to text the doctor and she did so. She stated he did text back to inform her that he would see the resident on the same day. She stated when she returned to work on the night of 12/13/12, she discovered the doctor had seen the resident on 12/13/12 instead on 12/10/12 as stated. She stated no new skin orders were written and she continued to use wound cleaner to cleanse the wound and continued application of the unna boots. She stated the wound remained open and without change until the end of January. She stated the wound worsened by becoming larger. She stated she attempted to notify the MD twice at the end of January but was unable to reach him. She stated she continued to use the wound cleanser to clean the resident's legs and re-wrapped the resident's legs with the unna boots. She stated about a week later, she returned to work and the wound had become even larger. She stated she spoke with the MD on the morning of 2/1/13 concerning the deterioration of the wound. She stated he ordered a referral to a local wound clinic. She stated when she last assessed the wound, she never saw exposed muscle nor bone. She stated she notified the oncoming nurse a few times of the deterioration of the wound and thought they would have followed up with the resident's doctor. She stated she never reported his treatment refusals, because he would always consent to the treatment the next night she worked. She stated she notified the DON about the wound when she received an order to transfer the resident to the local wound clinic. She stated she never notified the DON of the deterioration of the wound nor the inability to reach the resident's physician when she was unable to reach him. She stated she did not chart an assessment of the resident's leg wound each time she changed the unna boot, but she should have. A telephone interview was conducted with S4Physician on 2/14/13 at 10:00 a.m. He stated he initially started treatment on the patient in August 2012. He stated the resident had Diabetes and severe [MEDICAL CONDITION] to his lower extremities from the Diabetes. He stated the resident had a history of [REDACTED]. He stated the resident was noncompliant with getting out of the bed and walking. He stated he spoke with the resident and his wife several times regarding his immobility, but the client remained non-compliant. He stated he tried to relieve the [MEDICAL CONDITION] by elevating the resident's legs, medication, and compression stockings. He stated he received a call from one of the nurses back in the beginning of December 2012, requesting that he examine the resident's legs. He stated on 12/13/12, he assessed the resident and found that his legs were oozing form [MEDICAL CONDITION]. He stated at that time, he felt the only treatment was to continue the unna boots, elevate the resident's legs and to get the resident out of the bed. He stated at the end of January 2013, he received another phone call from a nurse stating the resident's legs were getting worse. He stated he gave the nurse an order to refer the resident to a local wound clinic. He stated he received a second phone call in February 2013 regarding dressing changes for the resident's wound. He stated he gave orders for wet to dry dressings for the resident's leg. He stated he was notified by the facility after the resident was admitted to the hospital after he was unable to be seen at the local wound clinic. He stated he had never been notified by the facility that the resident had been refusing unna boot treatments. He stated he was unaware the resident had exposed muscle and bone to his left leg when admitted to the hospital. An interview was conducted on 2/14/13 at 11:45 a.m. with S2 DON. She stated the resident admitted f

Based on record reviews, and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6, #7) residents receiving wound care for venous stasis ulcers . The facility failed to: 1. Ensure the Registered Nurse assessed and measured the venous ulcer weekly after the resident's physician assessed the resident to have a venous stasis ulcer instead of a skin tear on 12/13/12. (#2) 2. Promptly notify the resident's physician when the condition of the venous stasis ulcer worsened on 1/23/13. (#2) 3. Ensure the Registered Nurse notify the Director of Nurses (DON) promptly when the condition of the venous stasis ulcer deteriorated on 1/23/13 and the nurse experienced problems notifying the resident's physician of the deterioration of the venous stasis ulcer. 4. Ensure a system was in place to communicate to different members of the nursing staff, DON and Physician when the status of the venous ulcer showed a decline in healing. Resident #2 was admitted to the facility on [DATE] with Stage II Decubitus Ulcers to his left lower extremity that healed on 8/31/12. Resident #2 was placed in Immediate Jeopardy on 12/13/12 when a [DIAGNOSES REDACTED]. After the [DIAGNOSES REDACTED]. From 12/9/12 to 2/4/13, there were four documented assessments of the venous stasis ulcer to the resident's left lower extremity. There was no other documented evidence provided by the facility showing where assessments that included meassurements were consistently done or notification to the Physician of the condition of the venous stasis ulcer to the resident's left lower extremity. The Immediate Jeopardy was lowered to a level three pattern when Resident #2 was admitted to a local hospital on [DATE] with exposed muscle and bone to his left lower extremity. The deficient practice remains at a level two with a potential for more than minimal harm for the other six residents with venous ulcers/pressure ulcers. Findings: Review of the facility's Change in a Resident's Condition or Status Policy revealed in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of the facility's Weekly Skin Assessment Record Policy revealed the following: Policy: Every resident regardless of score on the Pressure Ulcer Risk Assessment will be monitored for pressure ulcer prevention. All residents will have an entire body check completed on admission or re-admission and on a weekly basis by a Licensed Professional to ensure all potential and actual skin problems are identified, evaluated, and referred for treatment. Review of the record revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. An observation was not done of the resident throughout the survey because he remained hospitalized in a local hospital. Review of the resident's care plans revealed an Impaired Skin Integrity dated 8/16/12. Review of the care plan revealed in part: Problem, Need, Strength, Potential: Resident has disruption of skin surface, not related to pressure. Wound type: Skin tear to right calf, Stage II to left calf Goal: The resident's disruption of skin surface will remain free from infection and show evidence of healing by 11/16/12. Approach: Complete weekly skin assessment -Report changes in skin status to physician -Complete Braden Scale Risk Assessment quarterly and PRN and Skin Risk Analysis the 1st time the Braden Scale less than 18. -Wound care as ordered, see current treatment record and physician's orders [REDACTED]. -Monitor for pain and medicate PRN (as needed) per physician's orders [REDACTED]. -Educate resident/responsible party about skin condition and treatment -8/16/12- Tx (Treatment) as ordered -8/31/12- Tx changed to unna 3 times a week for protection, skin integrity on right and left lower extremities. Review of the resident's plan of care revealed Stasis Ulcer care plan dated 12/13/12. Review of the care plan revealed in part: Problem, Need, Strength, Potential Concern: Resident has stasis ulcer or open lesion caused by poor circulation. Location: Chronic venous stasis ulcers to legs. 2/4/13- Left calf venous stasis ulcer Related to: [MEDICAL CONDITION], Normal progression of disease with an unavoidable, predictable decline expected. Goal: Resident's stasis ulcer (s) will exhibit signs of healing evidenced by decrease in size, improved appearance, absence of drainage, and be free from signs and symptoms of infection by: no date given. Target Date: 3/13/13 Approach: -Report changes in skin status (i.e. s/s infection, non healing, new areas) to physician -Discuss non-compliance issues with resident/responsible party -Educate resident/responsible party about pressure ulcer etiology, primary risk factors, treatment, prevention -Monitor effectiveness of/response to treatment (s) as ordered-see physician's orders [REDACTED]. -8/31/12- Unna boots 3 xs weekly -Notify nurse immediately of any new areas of skin breakdown, redness, blisters, and bruises, discoloration noted during bathing or daily care -Provide pressure relieving or reduction device- Specialty mattress -Low Air Loss (LAL) 2/5/13- Wound Clinic Evaluation. Review of a physician progress notes [REDACTED]. C.C. (Chief Complaint) - Nurse called me and requested to evaluate legs regarding chronic venous stasis [MEDICAL CONDITION], circled + (positive) discharge. A/P (Assessment/Plan)- 1. Chronic venous stasis ulcers/legs 2. Multiple chronic pressure sores 3. Afib/ DM2 (Diabetes Mellitus) 4. Obesity/Diabetic [MEDICAL CONDITION] -Unfortunately bad outcome as pt. is completely immobile/bed bound. -Needs legs elevating, OOB (out of bed), -Guarded progress Review of a physician progress notes [REDACTED]. F/U DM2/Chronic Venous Stasis [MEDICAL CONDITION] C.C. (Chief Complaint) - Again discusses with pt. in length about need of frequent position change, physical activity, BIL (bilateral) legs elevated. A/P (Assessment/Plan)- 1. [MEDICAL CONDITION] bladder 2. DM/HTN (Hypertension) 3. Multiple chronic pressure sores 4. Chronic venous stasis [MEDICAL CONDITION] -Legs elevation daily -Physical activity daily -Reviewed meds -Guarded prognosis Review of a skin assessment performed by S4RN dated 8/2/12 at 8:30 p.m. revealed the resident was admitted with multiple scabbed areas to bilateral lower extremities, excoriations to his right and left posterior calf, a pink Stage II to right posterior calf measuring 2 cm (centimeter) (L- (Length)) x 0.4 (D)Depth)) cm and a pink Stage II to left posterior calf measuring 2 cm (L) x 0.2 cm (D). Review of the admission orders [REDACTED] Clean excoriations to posterior bilateral calves with normal saline and cover with 4 x 4. Stage II right and left calves, clean with normal saline, thin layer of [MEDICATION NAME] gel, cover with gauze. Review of the Clinical Wound Team Communication Form dated 8/3/12 revealed the area to the right calf had skin intact. Review of new orders for skin care included: -Clean left posterior calf Stage II Decubitus with wc (wound cleanser), apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. -Clean right calf skin tear with wc, apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. Review of a Dietary Communication Form dated 8/6/12 revealed orders for Zinc 220 mg, by mouth every day and Vitamin C 500mg by mouth twice a day. The indication for both was wound healing. Review of Wound Treatment Evaluation Records revealed treatment to the bilateral lower extremities was discontinued on 8/31/12 because the wounds had healed. Review of a Nursing Communication Form dated 8/31/12 revealed nurse comments that stated wounds to bilateral lower extremities were resolved but continued with stasis [MEDICAL CONDITION]. The form read unna boots per resident were requested. Review of the form revealed orders to discontinue treatment to bilateral lower extremities and apply unna boots that day (8/31/12) and change every Monday, Wednesday, and Friday. In an interview on 2/13/13 at 10:35 a.m., S6Wound Care Nurse stated the resident had a skin tear to his right calf instead of a Stage II Decubitus. She stated both ulcers healed on 8/31/12. She stated after 8/31/12, the resident was ordered unna boots per his request. She stated the treatment of [REDACTED]. She stated the night RNs were responsible for the application of the unna boots. Review of Weekly Skin Assessment Record Revealed the following by S9LPN: 11/1/12- Unna boots to lower bilateral extremities. 11/8/12- Unna boots to lower bilateral extremities. 11/15/12- Unna boots to lower bilateral extremities. 11/22/12 - 11/29/12- Unna boots to lower bilateral extremities. Stasis ulcers to bilateral legs. 12/6/12- Resident has unna boots applied to bilateral legs. 12/13/12- Resident has unna boots applied to bilateral legs. 12/20/12- Resident has unna boots applied to bilateral legs. No other skin issues. 12/27/12- Resident has unna boots applied to bilateral legs. 1/3/12- Resident has unna boots applied to bilateral legs, redness to sacral area, and skin missing from finger tips due to resident biting nails and skin also. 1/10/13- Unna boots applied to bilateral legs. Resident has skin missing to fingertips. Resident stated he bites his nails. 1/17/13- Resident has unna boots applied to bilateral legs. 1/24/13- Resident had unna boots applied to bilateral legs. 1/31/12- Resident has unna boots applied to bilateral legs. Review of the Medication Record from November 2012 - January 2013 revealed an order for [REDACTED]. A. Put initial in appropriate box when medication given B. Circle initials when medication refused C. State reason for refusal on nurse's notes Review of the Medication Records (MR) revealed the following documentation for the unna boot application: November 2012 11/2/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/5/12- Initialed by S3RN 11/7/12- Initialed by S3RN 11/9/12- Initialed by S7RN 11/12/12- Initialed by S3RN 11/14/12- Initialed by S3RN 11/16/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility s Punch Origin revealed S8RN was the night RN. 11/19/12- Initialed by S3RN 11/21/12- Initialed by S3RN 11/23/12- Initialed by S7RN 11/26/12- Initialed by S3RN 11/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/30/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/2/12- Initialed by S7RN 12/4/12- "Refused" . Review of the of the Nurse's Medication Notes on the back of the informed read the resident requested the unna boot to be changed the next day. 12/5/12- Initialed by S3RN 12/7/12- Initialed by S7RN 12/9/12- Initialed by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/9/12 by S3RN read noticed a skin tear 2 cm x 1 cm with one reddened area around the wound. The document read S3RN informed the resident of the change. There was no time noted. 12/10/12- Circled initials by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/10/12 at 5:00 a.m. read S3RN sent a text message to S4Physician about the change in the state of the resident's left leg. The document read S4Physician texted her back saying that he would exam the resident that day. 12/12/12- Initialed by S3RN 12/14/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/16/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation that indicated what circled "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/17/12- Initialed by S3RN 12/19/12- Initialed by S3RN 12/21/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what circled "R" meant. Review of the facility's Punch Origin revealed S7RN was the night RN. 12/22/12- Initialed by S7RN 12/24/12- Initialed by S3RN 12/26/12- Initialed by S7RN 12/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/31/12- Initialed by S3RN 1/2/13- Initialed by S3RN 1/5/13- Initialed by S7RN 1/7/13- Initialed by S3RN 1/9/13- Initialed by S3RN 1/11/13- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 1/14/13- Initialed by S3RN 1/16/13- Initialed by S3RN 1/18/13- Initialed by S8RN 1/21/13- Initialed by S3RN 1/23/13- Initialed by S3RN- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented the resident had an excoriated area to the left lateral aspect of the leg measuring 2 cm x 3 cm. 1/24/13- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented she was unable to reach S4Physician but had left a message for him to evaluate the resident's leg. 1/25/13- Initialed by S8RN 1/28/13- Initialed by S3RN 1/31/13- S3RN's initials circled. Review of the Nurse's Medication Notes on the back the Medication Record timed for 10-6 revealed S3RN documented she removed the resident's unna boot to find the resident's wound approximately 2 cm x 4 cm x ? cm. The document read the wound bed was pink, no drainage, with the skin around the wound red. The document read she cleansed the wound with wc, applied ABD (abdominal pad) and gauze to the left lateral aspect of the lower leg for the MD to assess. 2/1/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 12 a.m. by S3RN read the resident's unna boot was changed. The documentation read S3RN sent a text message to S4Physician requesting that he evaluate the resident's leg. S3RN documented S4Physician texted back an order to refer the resident to a local outpatient wound clinic. 2/4/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 2:00 p.m. by S2DON revealed she reviewed the resident's left leg with an assessment per nurse notes. S2DON documented the resident's right calf skin was intact with pink shiny patches. She documented the wound nurse applied a wet to moist dressing per the physician's orders [REDACTED]. In an interview on 2/13/13 at 11:45 a.m., S2DON stated the "R" and the circled "R " on the Medication Record indicated the resident had refused a treatment and or medication. She stated the nurse's were supposed to document what treatment or medication the resident refused on the back of the Medication Record or in the nurse's notes. Review of the Nurse's Notes revealed the following: 11/2/12- No assessment of the resident's bilateral lower extremities. 11/5/12- No assessment of the resident's bilateral lower extremities. 11/7/12- No assessment of the resident's bilateral lower extremities. 11/9/12- No assessment of the resident's bilateral lower extremities. 11/12/12- No assessment of the resident's bilateral lower extremities. 11/14/12- No assessment of the resident's bilateral lower extremities. 11/16/12- No assessment of the resident's bilateral lower extremities. 11/19/12- No assessment of the resident's bilateral lower extremities. 11/21/12- No assessment of the resident's bilateral lower extremities. 11/23/12- No assessment of the resident's bilateral lower extremities. 11/26/12- No assessment of the resident's bilateral lower extremities. 11/28/12- No assessment of the resident's bilateral lower extremities. 11/30/12- No assessment of the resident's bilateral lower extremities. 12/2/12- No assessment of the resident's bilateral lower extremities. 12/4/12- entry by at 10:40 by S3RN- Resident in bed asleep. Woke him to change his unna boots. Resident requested if they could be done next day because he was sleepy. Will try to change next day. 12/5/12- No assessment of the resident's bilateral lower extremities. 12/7/12- No assessment of the resident's bilateral lower extremities. 12/12/12- No assessment of the resident's bilateral lower extremities. 12/14/12- No assessment of the resident's bilateral lower extremities. 12/16/12- No assessment of the resident ' s bilateral lower extremities. 12/17/12- No assessment of the resident's bilateral lower extremities. 12/19/12- No assessment of the resident's bilateral lower extremities. 12/21/12- No documentation why the resident refused unna boot application nor an assessment of the resident's bilateral lower extremities. 12/22/12- No assessment of the resident's bilateral lower extremities. 12/24/12- No assessment of the resident's bilateral lower extremities. 12/26/12- No assessment of the resident's bilateral lower extremities. 12/28/12- No assessment of the resident's bilateral lower extremities. 12/31/12- No assessment of the resident's bilateral lower extremities. 1/2/13- No assessment of the resident's bilateral lower extremities. 1/5/13- No assessment of the resident's bilateral lower extremities. 1/7/13- No assessment of the resident's bilateral lower extremities. 1/9/13- No assessment of the resident's bilateral lower extremities. 1/11/13- No assessment of the resident's bilateral lower extremities. 1/14/13- No assessment of the resident's bilateral lower extremities. 1/16/13- No assessment of the resident's bilateral lower extremities. 1/18/13- No assessment of the resident's bilateral lower extremities. 1/21/13- No assessment of the resident's bilateral lower extremities. 1/25/13- No assessment of the resident 's bilateral lower extremities. 1/28/13- No assessment of the resident's bilateral lower extremities. 2/4/13- entry by S3RN at 11 p.m.- Changed wound dressing on resident's left and right lower legs. Wound bed is pink and wet. Cleaned the wound with wc, covered with ABD and gauze. The resident stated he will be going to wound clinic next day. No c/o pain. 2/4/13- entry by S2DON at 1:30 p.m.- Summoned to resident room by wound care nurse. Wife present at bedside. Assessed left calf and noted what appeared to be a stasis wound measuring approximately 2 cm wide x 5 cm long x 0.5 cm depth. Wound bed pink and granulated tissue noted. Minimal serous drainage noted. No complaint of pain. Resident stated he was aware of wound and is going to wound clinic for eval (evaluation) on the next morning. Wife upset that wound had progressed without husband informing her of wound care clinic eval. Wife stated husband had lost a toe on left foot due to poor circulation and diabetes. Further eval of wound revealed no odor or redness to surrounding tissue. Contacted S4Physician and confirmed order for wound clinic eval on 2/5/13 and ok to apply wet to moist dressing until eval the next day. Dressing applied per wound care nurse. Wife given info (information) on wound care clinic eval (evaluation) and possible LTAC (Long Term Acute Care) placement as previously needed if wound does not respond to clinic treatment. Wife/resident voiced no other concerns. 2/5/13- entry by S2DON at 1:00 p.m. - Call received from out pt. wound clinic. Staff unable to assess wound due to being unable to transfer resident onto table. Will send to a local hospital emergency room for eval/tx ( treatment) per their MD (medical doctor). Wife present. 2/5/13- entry by S13LPN at 6:50 p.m. - Spoke with resident's wife. Informed me that resident is at local hospital emergency room and will be admitted . Transported there from his wound care appointment due to resident constantly sliding out of wheelchair. A telephone interview was conducted with the resident's wife on 2/18/13 at 9:35 a.m. She stated she was upset the registered nurse changed the resident's dressings in the middle of the night because the wound care nurse could not. She stated she was at the facility on 2/4/13, when her husband informed her of his wound care clinic appointment. She stated he had not informed her of the condition of his left leg either. She stated she asked the wound care nurse to remove the dressings to both of his legs. She stated when the dressing was removed to his left leg, " the flesh looked as if it was torn apart and the muscles, tendons, and bone were clearly exposed. It looked like a dog had chewed on it. " She stated she was so upset that his leg was in such bad shape. She stated S2 DON looked at the leg as well. She stated S2DON agreed the leg needed treatment but "down played the severity of the wound." She stated on 2/5/12, the resident went to his scheduled wound care clinic appointment. She stated he kept scooting down in the wheelchair and the doctor was unable to assess him. She stated the doctor ordered the resident to report to a local emergency room for treatment where he was admitted . She stated Resident #2 had been admitted to a local Long Term Acute Care (LTAC) on 2/11/13 to receive intravenous antibiotics for 25 days. She stated they were hopeful Resident #2 would need reconstructive surgery instead of an amputation. Review of a local hospital's ED (Emergency Department) Chart Review dated 2/5/13 at 13:51 (1:51 p.m.) revealed the resident's chief complaint was wound check. Review of the musculoskeletal listed under the Physical Exam by the physician revealed the resident's left lower left had an extensive posterior venous stasis ulcer with exposed bone and muscle. Review of the local hospital's History and Physical dated 2/5/13 revealed in part: Physical Examination: Skin: There is a left posterior wound with a 6-inch ulceration exposing the bone. Both lower extremities are hairless and shiny and cold to touch. Distal pulses are palpable in the posterior pedis distribution. Impression and Plan: This is a man who presents with a large left lower extremity ulcer with a history of chronic diabetes, [MEDICAL CONDITIONS]. 1. Large left lower extremity wound/ulceration [MEDICAL CONDITION]-substantiated by [MEDICAL CONDITION] leukocytosis and high likelihood of underlying osteo[DIAGNOSES REDACTED] as suggested by bone exposure. I suspect the mechanism for his wound formation is chronic pressure induced ischemic from immobilization with superimposed microvascular disease and chronic diabetes mellitus. Review of a vascular consultation at a local hospital dated 2/6/13 revealed in part: Impression: This is a [AGE] year old male with a history of diabetes and significant deconditioning. His ulcers appeared to be decubitus in nature with a likely venous stasis. Recommendations: At this point, we have no vascular options for the patient besides amputation. I have discussed with the patient and the patient ' s family possible plastic surgery evaluation for possible muscle flap or skin flap management of his wound. Otherwise an amputation may be the best option given his overall deconditioning. Review of the local hospital's Discharge Summary dated 2/11/13 revealed in part: Discharge Diagnosis: [REDACTED]. During the course of Resident #2 ' s hospital stay he was treated intravenously with [MEDICATION NAME] and [MEDICATION NAME]. A Peripherally Inserted Central Catheter (PICC line) was placed on 2/11/13 and the resident was transferred to a local LTAC center on 2/11/13. An interview was conducted with S10CNA on 2/13/13 at 1:28 p.m. She stated she rarely cared for the resident when he was admitted to the facility. She stated she was familiar with him because she assisted his assigned aide with transferring and repositioning him in bed. She stated he favored S11CNA a lot. An interview was conducted with S11CNA on 2/13/13 at 1:30 p.m. She stated she had an excellent rapport with the client and his family, that she would be called to assist with him even if she wasn't assigned to him. She stated she assisted him with bed baths, incontinent care, and supervision/set-up with meals. She stated he rarely refused every 2 hour repositioning, turning in bed, elevation of his legs or sitting up in his wheelchair. She stated when he refused it was due to occasion right side pain. She stated she never saw his legs because his legs were always wrapped in unna boots. An interview was conducted with S12LPN on 2/13/13 at 1:39 p.m. She stated she was the assigned nurse to care for the resident on the 6 a.m. - 10 p.m. shift. She stated Resident #2 was a diabetic that was non-compliant with eating, repositioning/turning in bed, and getting out of bed. She stated he would not eat the facility food but would eat the junk food his wife bought for him. She stated he had diabetic [MEDICAL CONDITION] and experienced problems with touch in his fingers and lower legs. She stated he favored S11CNA and would cooperate with her by getting out of bed into his chair and turning/repositioning in bed. She stated she had not assessed the resident's legs because of the unna boots. She stated the night RNs cared for his legs and the unna boots. She stated she became aware of issues with the resident's legs when S3RN requested that she follow-up with the resident's doctor for wound clinic orders. She stated she spoke with S4Physician and confirmed orders for a local wound clinic. A telephone interview was conducted on 2/13/13 at 2:26 p.m. with S3RN. She stated she was the 10 p.m.-6 a.m. RN Supervisor every Sunday -Thursday. She stated while on duty, she changed the resident's unna boots. She stated the resident was non-complaint with positioning and turning and sometimes changing of the unna boot. She stated after she removed the resident's boots on 12/9/12, she cleansed the legs with wound cleaner to remove the dead skin. She stated she noticed a skin tear on the resident's left posterior leg. She stated she attempted to notify the doctor, but had no success. She stated on 12/10/12, another nurse informed her to text the doctor and she did so. She stated he did text back to inform her that he would see the resident on the same day. She stated when she returned to work on the night of 12/13/12, she discovered the doctor had seen the resident on 12/13/12 instead on 12/10/12 as stated. She stated no new skin orders were written and she continued to use wound cleaner to cleanse the wound and continued application of the unna boots. She stated the wound remained open and without change until the end of January. She stated the wound worsened by becoming larger. She stated she attempted to notify the MD twice at the end of January but was unable to reach him. She stated she continued to use the wound cleanser to clean the resident's legs and re-wrapped the resident's legs with the unna boots. She stated about a week later, she returned to work and the wound had become even larger. She stated she spoke with the MD on the morning of 2/1/13 concerning the deterioration of the wound. She stated he ordered a referral to a local wound clinic. She stated when she last assessed the wound, she never saw exposed muscle nor bone. She stated she notified the oncoming nurse a few times of the deterioration of the wound and thought they would have followed up with the resident's doctor. She stated she never reported his treatment refusals, because he would always consent to the treatment the next night she worked. She stated she notified the DON about the wound when she received an order to transfer the resident to the local wound clinic. She stated she never notified the DON of the deterioration of the wound nor the inability to reach the resident's physician when she was unable to reach him. She stated she did not chart an assessment of the resident's leg wound each time she changed the unna boot, but she should have. A telephone interview was conducted with S4Physician on 2/14/13 at 10:00 a.m. He stated he initially started treatment on the patient in August 2012. He stated the resident had Diabetes and severe [MEDICAL CONDITION] to his lower extremities from the Diabetes. He stated the resident had a history of [REDACTED]. He stated the resident was noncompliant with getting out of the bed and walking. He stated he spoke with the resident and his wife several times regarding his immobility, but the client remained non-compliant. He stated he tried to relieve the [MEDICAL CONDITION] by elevating the resident's legs, medication, and compression stockings. He stated he received a call from one of the nurses back in the beginning of December 2012, requesting that he examine the resident's legs. He stated on 12/13/12, he assessed the resident and found that his legs were oozing form [MEDICAL CONDITION]. He stated at that time, he felt the only treatment was to continue the unna boots, elevate the resident's legs and to get the resident out of the bed. He stated at the end of January 2013, he received another phone call from a nurse stating the resident's legs were getting worse. He stated he gave the nurse an order to refer the resident to a local wound clinic. He stated he received a second phone call in February 2013 regarding dressing changes for the resident's wound. He stated he gave orders for wet to dry dressings for the resident's leg. He stated he was notified by the facility after the resident was admitted to the hospital after he was unable to be seen at the local wound clinic. He stated he had never been notified by the facility that the resident had been refusing unna boot treatments. He stated he was unaware the resident had exposed muscle and bone to his left leg when admitted to the hospital. An interview was conducted on 2/14/13 at 11:45 a.m. with S2 DON. She stated the resident admitted from the hospital to the facility in 8/12. She stated from his admission, the resident was non-compliant with care and his diet. She stated the resident was his own responsible party and often did not notify his wife of changes in his care. She stated the resident was admitted with stasis ulcers to his bilateral lower legs, but were healed by the end of August 2012. She stated the resident had been hitting his legs on the footplate of the

Based on record reviews and interviews, the facility failed to ensure periodic comprehensive, accurate assessments were done for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6, #7) residents receiving wound care for venous stasis ulcers. The facility failed to: 1. Ensure the Registered Nurse assessed and measured the venous ulcer weekly after the resident ' s physician assessed the resident to have a venous stasis ulcer instead of a skin tear on 12/13/12. (#2) Resident #2 was admitted to the facility on [DATE] with Stage II Decubitus Ulcers to his left lower extremity that healed on 8/31/12. Resident #2 was placed in Immediate Jeopardy on 12/13/12 when a [DIAGNOSES REDACTED]. After the [DIAGNOSES REDACTED]. From 12/9/12 to 2/4/13, there were four documented assessments of the venous stasis ulcer to the resident's left lower extremity. There was no other documented evidence provided by the facility showing where assessments that included meassurements were consistently done or notification to the Physician of the condition of the venous stasis ulcer to the resident's left lower extremity. The Immediate Jeopardy was lowered to a level three pattern when Resident #2 was admitted to a local hospital on [DATE] with exposed muscle and bone to his left lower extremity. The deficient practice remains at a level two with a potential for more than minimal harm for the other six residents with venous ulcers/pressure ulcers. Findings: Review of the facility's Change in a Resident's Condition or Status Policy revealed in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident ' s medical/mental condition or status. Review of the facility's Weekly Skin Assessment Record Policy revealed the following: Policy: Every resident regardless of score on the Pressure Ulcer Risk Assessment will be monitored for pressure ulcer prevention. All residents will have an entire body check completed on admission or re-admission and on a weekly basis by a Licensed Professional to ensure all potential and actual skin problems are identified, evaluated, and referred for treatment. Review of the record revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. An observation was not done of the resident throughout the survey because he remained hospitalized in a local hospital. Review of a physician progress notes [REDACTED]. C.C. (Chief Complaint) - Nurse called me and requested to evaluate legs regarding chronic venous stasis [MEDICAL CONDITION], circled + (positive) discharge. A/P (Assessment/Plan)- 1. Chronic venous stasis ulcers/legs 2. Multiple chronic pressure sores 3. Afib/ DM2 (Diabetes Mellitus) 4. Obesity/Diabetic [MEDICAL CONDITION] -Unfortunately bad outcome as pt. is completely immobile/bed bound. -Needs legs elevating, OOB (out of bed), -Guarded progress Review of a physician progress notes [REDACTED]. F/U DM2/Chronic Venous Stasis [MEDICAL CONDITION] C.C. (Chief Complaint) - Again discusses with pt. in length about need of frequent position change, physical activity, BIL (bilateral) legs elevated. A/P (Assessment/Plan)- 1. [MEDICAL CONDITION] bladder 2. DM/HTN (Hypertension) 3. Multiple chronic pressure sores 4. Chronic venous stasis [MEDICAL CONDITION] -Legs elevation daily -Physical activity daily -Reviewed meds -Guarded prognosis Review of a skin assessment performed by S4RN dated 8/2/12 at 8:30 p.m. revealed the resident was admitted with multiple scabbed areas to bilateral lower extremities, excoriations to his right and left posterior calf, a pink Stage II to right posterior calf measuring 2 cm (centimeter) (L- (Length)) x 0.4 (D)Depth)) cm and a pink Stage II to left posterior calf measuring 2 cm (L) x 0.2 cm (D). Review of the admission orders [REDACTED] Clean excoriations to posterior bilateral calves with normal saline and cover with 4 x 4. Stage II right and left calves, clean with normal saline, thin layer of [MEDICATION NAME] gel, cover with gauze. Review of the Clinical Wound Team Communication Form dated 8/3/12 revealed the area to the right calf had skin intact. Review of new orders for skin care included: -Clean left posterior calf Stage II Decubitus with wc (wound cleanser), apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. -Clean right calf skin tear with wc, apply [MEDICATION NAME] and cover with [MEDICATION NAME] daily. Review of a Dietary Communication Form dated 8/6/12 revealed orders for Zinc 220 mg, by mouth every day and Vitamin C 500mg by mouth twice a day. The indication for both was wound healing. Review of Wound Treatment Evaluation Records revealed treatment to the bilateral lower extremities was discontinued on 8/31/12 because the wounds had healed. Review of a Nursing Communication Form dated 8/31/12 revealed nurse comments that stated wounds to bilateral lower extremities were resolved but continued with stasis [MEDICAL CONDITION]. The form read unna boots per resident were requested. Review of the form revealed orders to discontinue treatment to bilateral lower extremities and apply unna boots that day (8/31/12) and change every Monday, Wednesday, and Friday. In an interview on 2/13/13 at 10:35 a.m., S6Wound Care Nurse stated the resident had a skin tear to his right calf instead of a Stage II Decubitus. She stated both ulcers healed on 8/31/12. She stated after 8/31/12, the resident was ordered unna boots per his request. She stated the treatment of [REDACTED]. She stated the night RNs were responsible for the application of the unna boots. Review of Weekly Skin Assessment Record Revealed the following by S9LPN: 11/1/12- Unna boots to lower bilateral extremities. 11/8/12- Unna boots to lower bilateral extremities. 11/15/12- Unna boots to lower bilateral extremities. 11/22/12 - 11/29/12- Unna boots to lower bilateral extremities. Stasis ulcers to bilateral legs. 12/6/12- Resident has unna boots applied to bilateral legs. 12/13/12- Resident has unna boots applied to bilateral legs. 12/20/12- Resident has unna boots applied to bilateral legs. No other skin issues. 12/27/12- Resident has unna boots applied to bilateral legs. 1/3/12- Resident has unna boots applied to bilateral legs, redness to sacral area, and skin missing from finger tips due to resident biting nails and skin also. 1/10/13- Unna boots applied to bilateral legs. Resident has skin missing to fingertips. Resident stated he bites his nails. 1/17/13- Resident has unna boots applied to bilateral legs. 1/24/13- Resident had unna boots applied to bilateral legs. 1/31/12- Resident has unna boots applied to bilateral legs. Review of the Medication Record from November 2012 - January 2013 revealed an order for [REDACTED]. A. Put initial in appropriate box when medication given B. Circle initials when medication refused C. State reason for refusal on nurse's notes Review of the Medication Records (MR) revealed the following documentation for the unna boot application: November 2012 11/2/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/5/12- Initialed by S3RN 11/7/12- Initialed by S3RN 11/9/12- Initialed by S7RN 11/12/12- Initialed by S3RN 11/14/12- Initialed by S3RN 11/16/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility s Punch Origin revealed S8RN was the night RN. 11/19/12- Initialed by S3RN 11/21/12- Initialed by S3RN 11/23/12- Initialed by S7RN 11/26/12- Initialed by S3RN 11/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 11/30/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/2/12- Initialed by S7RN 12/4/12- "Refused" . Review of the of the Nurse's Medication Notes on the back of the informed read the resident requested the unna boot to be changed the next day. 12/5/12- Initialed by S3RN 12/7/12- Initialed by S7RN 12/9/12- Initialed by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/9/12 by read S3RN noticed a skin tear 2 cm x 1 cm with one reddened area around the wound. The document read S3RN informed the resident of the change. There was no time noted. 12/10/12- Circled initials by S3RN- Review of the of the Nurse's Medication Notes on the back of the Medication Record dated 12/10/12 at 5:00 a.m. read S3RN sent a text message to S4Physician about the change in the state of the resident's left leg. The document read S4Physician texted her back saying that he would exam the resident that day. 12/12/12- Initialed by S3RN 12/14/12- "R" - Review of the of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/16/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation that indicated what circled "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/17/12- Initialed by S3RN 12/19/12- Initialed by S3RN 12/21/12- Circled "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what circled "R" meant. Review of the facility's Punch Origin revealed S7RN was the night RN. 12/22/12- Initialed by S7RN 12/24/12- Initialed by S3RN 12/26/12- Initialed by S7RN 12/28/12- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 12/31/12- Initialed by S3RN 1/2/13- Initialed by S3RN 1/5/13- Initialed by S7RN 1/7/13- Initialed by S3RN 1/9/13- Initialed by S3RN 1/11/13- "R" - Review of the Nurse's Medication Notes on the back of the Medication Record revealed no documentation to indicate what "R" meant. Review of the facility's Punch Origin revealed S8RN was the night RN. 1/14/13- Initialed by S3RN 1/16/13- Initialed by S3RN 1/18/13- Initialed by S8RN 1/21/13- Initialed by S3RN 1/23/13- Initialed by S3RN- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented the resident had an excoriated area to the left lateral aspect of the leg measuring 2 cm x 3 cm. 1/24/13- Review of the Nurse's Medication Notes on the back of the Medication Record timed for 10-6, revealed S3RN documented she was unable to reach S4Physician but had left a message for him to evaluate the resident's leg. 1/25/13- Initialed by S8RN 1/28/13- Initialed by S3RN 1/31/13- S3RN's initials circled. Review of the Nurse's Medication Notes on the back the Medication Record timed for 10-6 revealed S3RN documented she removed the resident's unna boot to find the resident's wound approximately 2 cm x 4 cm x ? cm. The document read the wound bed was pink, no drainage, with the skin around the wound red. The document read she cleansed the wound with wc, applied ABD (abdominal pad) and gauze to the left lateral aspect of the lower leg for the MD to assess. 2/1/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 12 a.m. by S3RN read the resident's unna boot was changed. The documentation read S3RN sent a text message to S4Physician requesting that he evaluate the resident's leg. S3RN documented S4Physician texted back an order to refer the resident to a local outpatient wound clinic. 2/4/13- Review of the Nurse's Medication Notes on the back of the Medication Record at 2:00 p.m. by S2DON revealed she reviewed the resident's left leg with an assessment per nurse notes. S2DON documented the resident's right calf skin was intact with pink shiny patches. She documented the wound nurse applied a wet to moist dressing per the physician's orders [REDACTED]. In an interview on 2/13/13 at 11:45 a.m., S2DON stated the "Rs" on the Medication Record indicated the resident had refused a treatment and or medication. She stated the nurse's were supposed to document what treatment or medication the resident refused on the back of the Medication Record or in the nurse's notes. Review of the Nurse's Notes revealed the following: 11/2/12- No assessment of the resident's bilateral lower extremities. 11/5/12- No assessment of the resident's bilateral lower extremities. 11/7/12- No assessment of the resident's bilateral lower extremities. 11/9/12- No assessment of the resident's bilateral lower extremities. 11/12/12- No assessment of the resident's bilateral lower extremities. 11/14/12- No assessment of the resident's bilateral lower extremities. 11/16/12- No assessment of the resident's bilateral lower extremities. 11/19/12- No assessment of the resident's bilateral lower extremities. 11/21/12- No assessment of the resident's bilateral lower extremities. 11/23/12- No assessment of the resident's bilateral lower extremities. 11/26/12- No assessment of the resident's bilateral lower extremities. 11/28/12- No assessment of the resident's bilateral lower extremities. 11/30/12- No assessment of the resident's bilateral lower extremities. 12/2/12- No assessment of the resident's bilateral lower extremities. 12/4/12- entry by at 10:40 by S3RN- Resident in bed asleep. Woke him to change his unna boots. Resident requested if they could be done next day because he was sleepy. Will try to change next day. 12/5/12- No assessment of the resident's bilateral lower extremities. 12/7/12- No assessment of the resident's bilateral lower extremities. 12/8/12- entry by S7RN (no time indicated)-Unna boots reapplied after cleaning wounds on both extremities. Pt (patient) needs to have doctor evaluate wounds. 12/12/12- No assessment of the resident's bilateral lower extremities. 12/14/12- No assessment of the resident's bilateral lower extremities. 12/16/12- No assessment of the resident's bilateral lower extremities. 12/17/12- No assessment of the resident's bilateral lower extremities. 12/19/12- No assessment of the resident's bilateral lower extremities. 12/21/12- No documentation why the resident refused unna boot application nor an assessment of the resident's bilateral lower extremities. 12/22/12- No assessment of the resident's bilateral lower extremities. 12/24/12- No assessment of the resident's bilateral lower extremities. 12/26/12- No assessment of the resident's bilateral lower extremities. 12/28/12- No assessment of the resident's bilateral lower extremities. 12/31/12- No assessment of the resident's bilateral lower extremities. 1/2/13- No assessment of the resident's bilateral lower extremities. 1/5/13- No assessment of the resident's bilateral lower extremities. 1/7/13- No assessment of the resident's bilateral lower extremities. 1/9/13- No assessment of the resident's bilateral lower extremities. 1/11/13- No assessment of the resident's bilateral lower extremities. 1/14/13- No assessment of the resident's bilateral lower extremities. 1/16/13- No assessment of the resident's bilateral lower extremities. 1/18/13- No assessment of the resident's bilateral lower extremities. 1/21/13- No assessment of the resident's bilateral lower extremities. 1/25/13- No assessment of the resident 's bilateral lower extremities. 1/28/13- No assessment of the resident's bilateral lower extremities. 2/4/13- entry by S3RN at 11 p.m.- Changed wound dressing on resident's left and right lower legs. Wound bed is pink and wet. Cleaned the wound with wc, covered with ABD and gauze. The resident stated he will be going to wound clinic next day. No c/o pain. 2/4/13- entry by 2DON at 1:30 p.m.- Summoned to resident room by wound care nurse. Wife present at bedside. Assessed left calf and noted what appeared to be a stasis wound measuring approximately 2 cm wide x 5 cm long x 0.5 cm depth. Wound bed pink and granulated tissue noted. Minimal serous drainage noted. No complaint of pain. Resident stated he was aware of wound and is going to wound clinic for eval (evaluation) on the next morning. Wife upset that wound had progressed without husband informing her not informing her of wound care clinic eval. Wife stated husband had lost a toe on left foot due to poor circulation and diabetes. Further eval of wound revealed no odor or redness to surrounding tissue. Contacted S4Physician and confirmed order for wound clinic eval on 2/5/13 and ok to apply wet to moist dressing until eval the next day. Dressing applied per wound care nurse. Wife given info (information) on wound care clinic eval (evaluation) and possible LTAC (Long Term Acute Care) placement as previously needed if wound does not respond to clinic treatment. Wife/resident voiced no other concerns. 2/5/13- entry by S2DON at 1:00 p.m. - Call received from out pt. wound clinic. Staff unable to assess wound due to being unable to transfer resident onto table. Will send to a local hospital emergency room for eval/tx ( treatment) per their MD (medical doctor). Wife present. 2/5/13- entry by S13LPN at 6:50 p.m. - Spoke with resident's wife. Informed me that resident is at local hospital emergency room and will be admitted . Transported there from his wound care appointment due to resident constantly sliding out of wheelchair. A telephone interview was conducted with the resident's wife on 2/18/13 at 9:35 a.m. She stated she was upset the registered nurse changed the resident's dressings in the middle of the night because the wound care nurse could not. She stated she was at the facility on 2/4/13, when her husband informed her of his wound care clinic appointment. She stated he had not informed her of the condition of his left leg either. She stated she asked the wound care nurse to remove the dressings to both of his legs. She stated when the dressing was removed to his left leg, " the flesh looked as if it was torn apart and the muscles, tendons, and bone were clearly exposed. It looked like a dog had chewed on it. " She stated she was so upset that his leg was in such bad shape. She stated S2 DON looked at the leg as well. She stated S2DON agreed the leg needed treatment but "down played the severity of the wound." She stated on 2/5/12, the resident went to his scheduled wound care clinic appointment. She stated he kept scooting down in the wheelchair and the doctor was unable to assess him. She stated the doctor ordered the resident to report to a local emergency room for treatment where he was admitted . She stated Resident #2 had been admitted to a local Long Term Acute Care (LTAC) on 2/11/13 to receive intravenous antibiotics for 25 days. She stated they were hopeful Resident #2 would need reconstructive surgery instead of an amputation. Review of a local hospital's ED (Emergency Department) Chart Review dated 2/5/13 at 13:51 (1:51 p.m.) revealed the resident's chief complaint was wound check. Review of the musculoskeletal listed under the Physical Exam by the physician revealed the resident's left lower left had an extensive posterior venous stasis ulcer with exposed bone and muscle. Review of the local hospital's History and Physical dated 2/5/13 revealed in part: Physical Examination: Skin: There is a left posterior wound with a 6-inch ulceration exposing the bone. Both lower extremities are hairless and shiny and cold to touch. Distal pulses are palpable in the posterior pedis distribution. Impression and Plan: This is a man who presents with a large left lower extremity ulcer with a history of chronic diabetes, [MEDICAL CONDITIONS]. 1. Large left lower extremity wound/ulceration [MEDICAL CONDITION]-substantiated by [MEDICAL CONDITION] leukocytosis and high likelihood of underlying osteo[DIAGNOSES REDACTED] as suggested by bone exposure. I suspect the mechanism for his wound formation is chronic pressure induced ischemic from immobilization with superimposed microvascular disease and chronic diabetes mellitus. Review of a vascular consultation at a local hospital dated 2/6/13 revealed in part: Impression: This is a [AGE] year old male with a history of diabetes and significant deconditioning. His ulcers appeared to be decubitus in nature with a likely venous stasis. Recommendations: At this point, we have no vascular options for the patient besides amputation. I have discussed with the patient and the patient ' s family possible plastic surgery evaluation for possible muscle flap or skin flap management of his wound. Otherwise an amputation may be the best option given his overall deconditioning. Review of the local hospital's Discharge Summary dated 2/11/13 revealed in part: Discharge Diagnosis: [REDACTED]. During the course of Resident #2 ' s hospital stay he was treated intravenously with [MEDICATION NAME] and [MEDICATION NAME]. A Peripherally Inserted Central Catheter (PICC line) was placed on 2/11/13 and the resident was transferred to a local LTAC center on 2/11/13. An interview was conducted with S11CNA on 2/13/13 at 1:30 p.m. She stated she had an excellent rapport with the client and his family, that she would be called to assist with him even if she wasn't assigned to him. She stated she assisted him with bed baths, incontinent care, and supervision/set-up with meals. She stated he rarely refused every 2 hour repositioning, turning in bed, elevation of his legs or sitting up in his wheelchair. She stated when he refused it was due to occasion right side pain. She stated she never saw his legs because his legs were always wrapped in unna boots. An interview was conducted with S12LPN on 2/13/13 at 1:39 p.m. She stated she was the assigned nurse to care for the resident on the 6 a.m. - 10 p.m. shift. She stated Resident #2 was a diabetic that was non-compliant with eating, repositioning/turning in bed, and getting out of bed. She stated he would not eat the facility food, but would eat the junk food his wife bought for him. She stated he had diabetic [MEDICAL CONDITION] and experienced problems with touch in his fingers and lower legs. She stated he favored S11CNA and would cooperate with her by getting out of bed into his chair and turning/repositioning in bed. She stated she had not assessed the resident's legs because of the unna boots. She stated the night RNs cared for his legs and the unna boots. She stated she became aware of issues with the resident's legs when S3RN requested that she follow-up with the resident's doctor for wound clinic orders. She stated she spoke with S4Physician and confirmed orders for a local wound clinic. An interview was conducted on 2/13/13 at 2:26 p.m. with S3RN. She stated she was the 10 p.m.-6 a.m. RN Supervisor every Sunday -Thursday. She stated while on duty, she changed the resident's unna boots. She stated the resident was non-complaint with positioning and turning and sometimes changing of the unna boot. She stated after she removed the resident's boots on 12/9/12, she cleansed the legs with wound cleaner to remove the dead skin. She stated she noticed a skin tear on the resident's left posterior leg. She stated she attempted to notify the doctor, but had no success. She stated on 12/10/12, another nurse informed her to text the doctor and she did so. She stated he did text back to inform her that he would see the resident on the same day. She stated when she returned to work on the night of 12/13/12, she discovered the doctor had seen the resident on 12/13/12 instead on 12/10/12 as stated. She stated no new skin orders were written and she continued to use wound cleaner to cleanse the wound and continued application of the unna boots. She stated the wound remained open and without change until the end of January. She stated the wound worsened by becoming larger. She stated she attempted to notify the MD twice at the end of January, but was unable to reach him. She stated she continued to use the wound cleanser to clean the resident's legs and re-wrapped the resident's legs with the unna boots. She stated about a week later, she returned to work and the wound had become even larger. She stated she spoke with the MD on the morning of 2/1/13 concerning the deterioration of the wound. She stated he ordered a referral to a local wound clinic. She stated when she last assessed the wound, she never saw exposed muscle nor bone. She stated she notified the oncoming nurse a few times of the deterioration of the wound and thought they would have followed up with the resident's doctor. She stated she never reported his treatment refusals, because he would always consent to the treatment the next night she worked. She stated she notified the DON about the wound when she received an order to transfer the resident to the local wound clinic. She stated she never notified the DON of the deterioration of the wound nor the inability to reach the resident's physician when she was unable to reach him. She stated she did not chart an assessment of the resident's leg wound each time she changed the unna boot, but she should have. A telephone interview was conducted with S4Physician on 2/14/13 at 10:00 a.m. He stated he initially started treatment on the patient in August 2012. He stated the resident had Diabetes and severe [MEDICAL CONDITION] to his lower extremities from the Diabetes. He stated the resident had a history of [REDACTED]. He stated the resident was noncompliant with getting out of the bed and walking. He stated he spoke with the resident and his wife several times regarding his immobility, but the client remained non-compliant. He stated he tried to relieve the [MEDICAL CONDITION] by elevating the resident's legs, medication, and compression stockings. He stated he received a call from one of the nurses back in the beginning of December 2012, requesting that he examine the resident's legs. He stated on 12/13/12, he assessed the resident and found that his legs were oozing form [MEDICAL CONDITION]. He stated at that time, he felt the only treatment was to continue the unna boots, elevate the resident's legs and to get the resident out of the bed. He stated at the end of January 2013, he received another phone call from a nurse stating the resident's legs were getting worse. He stated he gave the nurse an order to refer the resident to a local wound clinic. He stated he received a second phone call in February 2013 regarding dressing changes for the resident's wound. He stated he gave orders for wet to dry dressings for the resident's leg. He stated he was notified by the facility after the resident was admitted to the hospital after he was unable to be seen at the local wound clinic. He stated he had never been notified by the facility that the resident had been refusing unna boot treatments. He stated he was unaware the resident had exposed muscle and bone to his left leg when admitted to the hospital. An interview was conducted on 2/14/13 at 11:45 a.m. with S2 DON. She stated the resident admitted from the hospital to the facility in 8/12. She stated from his admission, the resident was non-compliant with care and his diet. She stated the resident was his own responsible party and often did not notify his wife of changes in his care. She stated the resident was admitted with stasis ulcers to his bilateral lower legs, but were healed by the end of August 2012. She stated the resident had been hitting his legs on the footplate of the wheelchair and/or his dresser and he had requested unna boots. She stated the unna boots also helped with the resident's [MEDICAL CONDITION], but primarily served as protection for the resident's legs. She stated the night registered nurses were responsible for the application of the unna boots. She stated if any skin issues occurred, then the nurse was responsible for documenting any problems. She stated the resident had a history with ulcers/wounds to his leg. She stated she became aware of issues with the resident's left leg on or around 1/31/13. She stated S3RN notified her that the resident's wound had worsened after she (S3RN) had received orders to transfer the resident to a local wound clinic. She stated she assessed the resident's wound on 2/4/13. She stated the resident had not informed his wife of his wound care clinic appointment and on 2/5/13 and the wife requested to look at the resident's leg. She stated she was called to assess the resident's wound. She stated she lifted the resident's leg while he was lying supine. She stated she assessed a slit in the resident's leg extending from his calf down the back of his leg. She stated she did not assess redness, but pink tissue, with no streaking, [MEDICAL CONDITION] nor an odor. She stated the wound was long, not deep and had straight edges. She stated no bone or muscle was visualized. She stated she then contacted S4Physician for wet to moist dressing changes until the resident went to his wound care clinic appointment on the next day. Copies of the November 2012 through January 2013 MRs were given to her for review of the documentation of the unna boot application. She verified the "Rs" documented on the MR for unna boot application indicated the resident had refused. She stated she was unaware the resident had refused his unna boot application. She stated after two consecutive refusals, the doctor should have been notified. After reviewing the Nurse's Medication Notes on the back of the December 2012 MR, she stated S3RN assessed that the resident only had a skin tear. She stated the nurses did not have to document the condition of the skin tear weekly. After she reviewed S4Physician's Progress Note dated 12/13/12, she stated the documentation under A/P on the Physician's Progress Note indicated the resident's history and not the resident's current condition. She reviewed a Stasis Ulcer care plan dated 12/13/12. She stated she was unsure who initiated the care plan, because the doctor had never communicated that the resident had a stasis ulcer. After she reviewed her Nurse's Note dated 2/4/13, she stated when she assessed the resident's wound on 2/4/13, the wound appeared to be a venous stasis wound. A telephone interview was conducted with S4Physician on 2/14/13 at 1:15 p.m. When asked about the assessment of the resident's leg on 12/13/12, he stated the resident had a stasis ulcer to his left lower leg. He stated he was sure he had communicated the finding to the nursing staff. He stated at the time of his assessment, unna boots, leg elevation, and out of bed activities was the treatment of [REDACTED]. During an interview with S2DON on 2/14/13 at 1:20 p.m., she was informed S4Physican stated during a telephone interview, that he assessed Resident #2 with a stasis ulcer to his left leg on 12/13/12. She stated an assessment of the resident's left leg including measurements should have been done at least weekly. She reviewed the resident's record from November 2012 -February 201

Based on record reviews and interviews, the facility failed to ensure that residents' clinical conditions were monitored and/or assessed according to professional standards for 1 (#4) of 7 (#1, #2, #3, #4, #5, #10, & #12) diabetic residents out of a sample of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, & #14). On [DATE] Resident #4 began having frequent loose bowel movements and low blood glucose. Resident #4's condition declined until he became unresponsive and went into cardiopulmonary arrest on [DATE]. On [DATE] and [DATE] the facility failed to provide the following needed care and services according to professional standards: 1. increased frequency of assessing his bowel movements and blood glucose levels to ensure accurate and timely assessments were made so that his physician would be timely consulted and needed medical care would be provided; 2. assessment of his caloric intake; 3. physician consultation regarding his frequent loose bowel movements and low, decreasing blood glucose; 4. immediate assessment when he became unresponsive; 5. immediate treatment when his blood glucose level was 31mg/dl; 6. assessments, interventions and communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes; 7. implementation of standing orders regarding loose bowels/diarrhea were carried out; 5. Immediately notify the in house RN supervisor of the resident's low blood sugars and subsequent interventions; loose BMs; and inability to reach the MD; 8. RN supervision of LPNs and intervention of treatment for [REDACTED]. 10. The facility failed to follow the Policy and Procedure for Recognizing Signs and Symptoms of Abuse / Neglect. 11. educate staff to not administer oral Gulcoburst to an unresponsive resident. This failure to provide care and services according to professional standards permitted Resident #4 to be harmed, placed Resident #4 in immediate jeopardy on two nursing shifts from 9:00 p.m. on [DATE] until his transfer to the hospital at 6:45 a.m. on [DATE] (9 ? hours). This failure had the potential to harm six other diabetic residents (#1, #2, #3, #5, #10, & #12) and placed them in immediate jeopardy. The administrator was informed of the immediate jeopardy on [DATE] at 11:44 a.m. A plan of removal was received on [DATE] which included the following: providing 24 hour RN coverage with the role of the RN Supervisors to provide clinical oversight to recognize and assess, define and implement and monitor and evaluate care and services delivered to facility residents. The facility will provide 24 hour RN supervision to ensure that the facility recognizes and assesses factors that could place a resident at risk for specific conditions, causes or problems and implements interventions, in accordance with resident's needs, goals and standards of practice. RN supervision will include evaluation of the results of the interventions and revise the interventions as necessary. The facility LPN's have been informed to notify RN of any changes in diabetic condition. At the beginning of each shift, the RN will inform the LPNs to contact the RN in regard to changes in diabetic condition. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. for the diabetic residents in the facility when surveyors determined the plan of removal was implemented. The deficient practice continued at a pattern of potential for more than minimal harm for the diabetics residing in the facility. Findings: According to the Standards of Nursing Practice cited by the American Nurses' Association, the collection of data about the health status of the client/patient is systematic and continuous, and the data is accessible, communicated, and recorded. Record Review of the policy titled Acute Condition Changes revised ,[DATE] was presented by S2DON. It revealed the following in part: 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident ' s current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour of less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 8. The Nurse and Physician will discuss the situation. Cause Identification 1. The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. if necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . Treatment/Management 1. The Physician will help identify and authorize appropriate treatments. a. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responded to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Review of the Policy and Procedure Nursing Care of the Resident with Diabetes Mellitus (Revised [DATE]) provided by S2DON revealed in part the following: Conditions Associated with Diabetes: 3. [DIAGNOSES REDACTED] (blood sugar below reference ranges). Signs and symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following: b. restlessness f. irritability j. (more severe) stupor, unconsciousness and/or convulsions; and k. (more severe) coma. If these, or other abnormal conditions exist, notify the physician (for [DIAGNOSES REDACTED], follow steps in Management of [DIAGNOSES REDACTED] below). Glucose Monitoring: 4. "Finger sticks" (capillary blood samples) measure current blood glucose levels. 5. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] ,[DATE]milligrams/deciliter (mg/dl) b. Moderate [DIAGNOSES REDACTED] ,[DATE]mg/dl c. Severe [DIAGNOSES REDACTED] <40mg/dl Management of [DIAGNOSES REDACTED]: 1. Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms. 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives); c. remain with the resident d. monitor vital signs; Documentation: Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital Signs as ordered: 2. Level of consciousness: 3. Assessment of the skin including the following: a. color, moisture, and temperature; and 5. Percentage of meals consumed: 6. Emotional reactions, moods: 8. Motor weakness; 9. Urinary symptoms including retention and incontinence; 10. Bowel dysfunction including diarrhea and constipation; Resident #4: Review of the Accumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed the following information: clear speech - distinct intelligible words; makes self understood; understands others; BIMS summary score of 15 (cognitively intact); Functional Status - bed mobility requires extensive assistance of 1 person, transfers requires extensive assistance of 2 persons, dressing requires extensive assistance of 1 person, eating requires supervision with setup help only, toilet use requires extensive assistance of 1 person, personal hygiene requires extensive assistance of 1 person, bathing requires physical help of 1 person; always continent of bladder; occasionally incontinent of bowel; and Active [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [DATE] Apply moisture barrier cream to buttocks and scrotum every (q) shift and as needed (prn) incontinent episodes. Review of the standing orders for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). An interview was held with S2DON on [DATE] at 10:25 a.m. She said that this meant the nurse is to call the doctor when the blood sugars are <50 or > 450. The standing orders also revealed the following for diarrhea: If < 4 bowel movements (BMs) in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet by mouth (po) every (q) ,[DATE] hours as needed (prn) X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify doctor (MD)/nurse practitioner (NP) in a.m. The standing orders also revealed Dr. C ... sliding scale Novo R Insulin unit for BS 160 - 200 give 3 units, 201 - 280 give 6 units, 281 - 340 give 9 units, 341 - 400 give 12 units. Recheck blood sugar (BS) in 2 hours after administration of sliding scale insulin. If BS > 400, give 15 units subcutaneous (SubQ) and re-check accu check in 3 hours. If BS not < 400, call NP / MD. [DATE] at approximately 9:00 am an interview was conducted with a family member of resident #4. The family member said that resident #4 had a cell phone and called family members daily throughout the day to talk. The family member said that on [DATE] the resident did not call family members. Review of the Nurse's Notes revealed the following: [DATE] 12 N complained of (c/o) pain to rectum - Preparation H applied. [DATE] 1:30 p.m. Had several bowel movements (BMs) this shift consistency - Paste-like. Redness noted to scrotum. New order noted - Moisture barrier cream to buttocks & scrotum every (Q) shift & as needed (PRN) incontinent episodes. [DATE] 6:45 p Resident lying in bed with eyes closed easily aroused to verbal tactile stimuli. No signs symptoms of distress noted. Continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident's leg hanging off bed, resident stated "I want to sit up" explained to him that he need assist to get up, he can fall & injury himself, put leg back in bed instructed him to call - light in reach. Resident took his medications without difficulties. Resident accu check was 61 at 4 p. Resident BMs have gone from pasty to loose doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor. [DATE] (no time documented) Resident alert & awake most of night. Still having BMs constantly. On call light assisted as need. 5:45 A Entered room to do BS - blood sugar. Results 51. Oxygen Saturation (O2 sat) 95% on O2. Tried to arouse. Resident unable to do so. 6:00 A - Informed supervisor of low blood sugar. Resident nonresponsive. 911 called. Family called. CPR started. Resident transported to hospital. [DATE] 11:00 a.m. Late entry (no date documented) 10:30p -11p Resident alert awake speaking with nurse. C/O loose stool water given for hydration. In no acute distress. [DATE] 11:00 a.m. Late entry (no date documented) 12:00 a.m. Rounds made Resident lying in bed eyes closed; no evidence of shortness of breath (SOB), no acute distress noted. [DATE] 11:00 a.m. Late entry (no date documented) 2:00 a.m. Resident alert, awake, speaking with nurse. Vital Signs (V/S) stable at ,[DATE], 62, 20. Requested water assisted with given water from bedside pitcher. Resident took a few sips stated he was done c/o loose stools. Asked nurse what was facility going to do about stools Nurse informed resident MD will be notified in a.m. Resident verbalized understanding. [DATE] 11:00 a.m. Late entry (no date documented) 2:30 a.m. CNAs stated resident unable to sleep in no acute distress nothing order for sleep at this time. [DATE] 11:00 a.m. Late entry (no date documented) 5:45 a.m. Resident found unresponsive grunting. Accu check 51, O2 sat 95%, O2 at 2 liters (L) minute. Attempts to give Gluoburst unsuccessful due to resident not swallowing RN Supervisor notified. Instructed by RN to call 911. Left RN at bedside. [DATE] 1:33 p.m. Late entry [DATE] 4 p.m. At this time accu check taken it was 56 orange juice with sugar given, res awake, alert & talking skin warm/dry to touch. 5p One hour later accu check retaken 61 at this time give more OJ with sugar resident remain alert. Instructed certified nurse aide (CNA) to make sure resident eats. By mouth (PO) fluids given consumed 180 cc. 5:45 p Resident CNA informed me that he assist with meal, consumed 50% of his supper, fluids was given from supper tray tolerated well. 7 p HS snack given, consumed 100% ? wheat peanut butter & jelly sandwich and 1 pack of graham crackers. VS blood pressure (b/p) ,[DATE], pulse (P) 59, O2 sat 96% on room air O2 probes out machine on at 3 L / minute cannula reinserted to nostril. Recheck accu check at this time blood sugar (BS) 86 continue to give mint to keep up. 8p Hemorrhoid cream applied at this time. Resident HS insulin held (Lavmir 12 units) d/t low accu checks. (Review of documentation did not reveal that the doctor was notified that the [MEDICATION NAME] was held.) 9 p CNA reported that resident had loose stool X 1 with foul odor. This nurse place call to nurse practitioner (NP) at this time to informed of resident condition loose stool X 1 with foul odor. No answer left message for return call. 9:30 p Recheck accu check it had come up to 90, resident stated he wanted some pie none available offered Hershey's kisses give him 2 that he consumed & left 3 & 2 lemon drops at bed side also gave 200 cc of water. No c/o pain or discomfort voiced. 10 p Report given to oncoming nurse regarding resident condition & his pasty stool & 1 loose stool, told her that a call was place to on call MD, left message to call me back. If doctor return call to let him know about resident stool & foul odor. Resident had several small smears during his pasty stools that was noted. Will continue to monitor. [DATE] 2:21 p.m. Late entry on [DATE] at 3:45 p.m. Charge nurse spoke with B ...A ..., NP, notified about barrier cream use, told floor nurse to report if stools become loose to MD, nurse verbalize understanding and assumed care of resident. Review of the EMS records dated [DATE] revealed the unit was dispatched at 06:04. The unit arrived at the scene at 06:08 and arrived at the patient at 06:12. The unit departed from the facility at 06:24 and arrived at hospital at 06:35. The Summary of Events revealed the following: [AGE] year old male found lying in a hospital bed unresponsive, with staff assisting ventilations and attempting CPR. Staff stated they went to check pt blood sugar and it registered low. An interview was held with T ... L ... Chief Operating Officer at EMS on [DATE] at 12:45 p.m. He stated an accu check reading of Low was indicative of a Blood Glucose of less than 20. On [DATE] S2DON provided employee statements regarding Resident #4 obtained by S2DON: 1. S2 DON's Telephone Interview with S7RNSupervisor revealed in part: Came on duty at 10:00 pm and made rounds through the facility. I reviewed the weekend report sheets left for me by S2DON. I also met with each nurse on duty, including S8LPN. I asked if they had any problems, anything I needed to know about. I informed each nurse that I was 'here' if they needed anything and to 'just let me know' . S8LPN did not inform me during the first or subsequent rounds that she was having any issues with Resident #4. Resident #4 was on the call light through the night but this was not unusual for him as every time I had worked, he was frequently awake during the night calling for staff. I did ask the staff if he was 'okay' and asked what he was calling about. The staff informed me that he was asking for S6CNA but nothing more. At the end of the shift, at approximately 5:,[DATE]:45 am, I was informed I was needed to Resident #4's room STAT. I quickly hurried down to the room and found S8LPN at the bedside. She informed me that his blood sugar was 31. I told her to go call an ambulance and she left the room. I was trying to arouse him but was unable to do so. He would not respond to any type of stimuli and his tongue was hanging out of his mouth. I immediately grabbed the crash cart and the day shift RN (S9RN) had entered the room, we initiated CPR and got the ambu bag ready and hooked to oxygen. Emergency Medical Services (EMS) entered the room pretty quickly. I told them what I knew, including that the nurse had told me his sugar was 31, but that they needed to speak with the nurse caring for him. I sent a CNA after her. EMS wanted to know the code status and I informed them that he was a full code. The nurse returned to the room and I asked for a second glucose level. EMS was starting an IV. I do not recall her getting a second capillary glucose level. When EMS placed him on the monitor, I saw the number 82 but I am not sure if that was his heart rate or not. Once EMS got the needed information, they transported him to the hospital. We were called a few minutes later to be told he had passed. After the event, I met with the staff. At this point, the nurse told me his sugar was 51, not 31. She also told me she had given him some Glucoburst when she first found him, before he became unresponsive. It was not until after he had left the building the staff informed me that he had been experiencing loose stools through the night. I asked if the nurse had administered [MEDICATION NAME] to which I was told she had not. At the end of her telephone interview, S2DON asked the following questions: When you were given report from S8LPN were you informed of the issues with his blood sugar during the previous shift or that the evening nurse had held his insulin? ANSWER-No, I was not. Were you informed that he had experienced a loose stool at the end of the ,[DATE] shift? ANSWER-No, I did not. Did you see Resident #4 during your shift? ANSWER-No, I did not. You are telling me he was using the call light a fair amount that night, why did you not see what was wrong? ANSWER-Every time I worked, he had frequently used the call light during the night for numerous reasons. This was not unusual for him at all. When I asked why he was calling, I was told he wanted S6CNA. Had you been informed of his loose stools during the shift, would you have done anything different? ANSWER- Yes, I would have seen if something was ordered for the stools and if not, had the nurse call and get an order for [REDACTED]. 2. S2DON's Face to Face Interview with S8LPN, 10p-6A LPN, conducted on [DATE] at 10 AM revealed in part: Came on duty at 10:00 p.m. and received report from the off going nurse. I started my first rounds between 10:30 p-11:00 and Resident #4 was one of the first people I saw. He was awake, alert, and talking to me. He stated he was experiencing some loose stools. I gave him some water to drink from his bedside pitcher and told him we had notified the doctor. He did not ask me for anything at that time. His skin was warm and dry and resident did not voice any other complaints. I continued with my rounds. At 12:00 am, I made my next set of rounds, passed medications and began checking my charts. When I checked on him, I "peeped in" . He was resting comfortably, lying supine in the bed but we did not speak. At this point, no one had reported he was having any issues with his stools. Between 1:30am-2:00am I saw him again. I took his vital signs. His B/P was ,[DATE], 62, 20. He and I spoke and he was stating he was continuing to have loose stools. He asked what we were going to do about it. I explained we would call the doctor in the morning. He asked for some water and I gave him some. He took approximately 100cc. At 2:30 a.m. the CNAs asked me if there was something I could give him to help him rest because he had been awake all night. I looked at the chart and told them there was nothing I could do. At 5:45 a.m., I went to get his morning accu check. He was grunting, and difficult to arouse. I checked his sugar and it was 31. His O2 sat was 95% on room air. I went to get Glucoburst from one of the medication carts in the med room. None of the medication carts had any so I went to the supply room. At almost 6:00 a.m., when I returned to his room, he did open his eyes and I attempted to give the Glucoburst but he would not swallow. I put the call light on and ran into the hall calling for help. The RN came immediately to the room and told me to call 911. I left the room to call 911. He lost his pulse while I was out of the room. When I came back to the room, emergency medical services (EMS) was there. S8LPN also told S2DON: At 1:30, she told Resident #4 we would call the doctor in the morning. At 2:30a.m. Resident #4 requested something to help him rest as he had been up due to having loose stools and his bottom burning. S8LPN said she did not ask the CNA how many stools, the last time he experienced one, or the consistency and/or smell of them? S8LPN said when she removed the MAR indicated [REDACTED]. S8LPN said she did not inform the RN on duty of the stools and did not inform the RN on duty about Resident #4's glucose levels during the previous shift? S8LPN said she did not think about implementing the physician's standing orders for [MEDICATION NAME]. S8LPN said she didn't check Resident #4's blood sugar before 6am because she was told by the ,[DATE]LPN that she had got his sugar up and the next accu check wasn't scheduled until 6:00 a.m. S8LPN said Resident #4 was talking to her like he always did and was alert and oriented.. S8LPN said when she attempted to give the Glucoburst and he was not swallowing she did not massage some of the gel into his mucus membranes of his mouth. She said Resident #4 wasn't conscious by this point. She said she called for the RN to come and she told me to get 911 here. S8LPN said she did not think to grab the injectable glucose. She said she had to get vital signs once a shift so since she was in the resident' room in the middle of the night she went ahead and did them. S8LPN said didn't think about monitoring his glucose level during the night and the Resident wasn't acting like his sugar was dropping. S8LPN said she though she documented everything during her shift and told S2DON she would add the rest if S2DON wanted her to. Documentation revealed that S2DON explained the proper way to make late entries into the medical record and watched while this nurse completed her documentation. When she was finished, S2DON explained in great length what concerns she had with her performance that night and how loose stools with any resident but especially a diabetic required her interventions beyond calling the MD in the morning. That she should have notified the RN in the house for direction, or even just informed her of the issue and let the RN determine the course of action. Documentation revealed that S8LPN became extremely emotional at this point crying hysterically and repeatedly apologizing and saying Oh God! I am so sorry". 3. S2DON's [DATE] at 9:34 a.m. face to face interview with S6CNA revealed in part: S6CNA stated she reported to work at 10:00 pm on [DATE]. Approximately 30 minutes after clocking in, Resident #4 turned his call light on. Upon answering the call light, he informed her he needed his adult brief changed. He had experienced a bowel movement, that was medium in size and the consistency a little thinner than peanut butter. He complained of not feeling well due to not being able to urinate. S6CNA placed the urinal between his legs and encouraged him to relax, stating, "it takes time". She waited at the bedside for ,[DATE] minutes while they discussed him feeling like he needed to urinate but could not. When asked if this was reported to the floor nurse, she stated she had not because this was "normal" for Resident #4. After approximately 5 minutes, he asked to have the urinal remain in the brief. She assisted him with positioning in the bed, turned off the room light and instructed him to call her if he needed her. The call light was attached to his hospital gown. She stated she was in the room for approximately ,[DATE] minutes. When asked if Resident #4 appeared unusual in any way, S6CNA stated he did not. He was alert, oriented and 'acted like himself' . When asked if his skin color was pale or if he was sweaty to the touch, she stated he was not. Approximately 10 minutes later (approximately 11:10 p.m.) he called her back, via the call light. He complained of not being able to urinate and was requesting to have the urinal removed. He voiced no other complaints. S6CNA removed the urinal, placed it on the table, within reach, and turned off the light, clipped the call light to his gown and left the room. Approximately 30 minutes later, he called for her again, stating he had experienced another bowel movement. S6CNA and S4CNASupervisor entered to clean him up. S6CNA reported the stool was of medium size and had the same consistency of the stool earlier in the shift: thinner than peanut butter but not watery, and there was 'form' to it. When asked if the stools had an unusual smell, she stated both stools smelled like 'normal BM' . She denied smelling anything unusual or the stool having the appearance of someone who 'was sick' . While the staff was cleansing him, Resident #4 asked for some money so he could get a candy bar. He informed the staff he was 'good for it' . As his son would 'pay them back'. S6CNA informed him that it was not about the money, but that she just did not have any change with her but that she would go check the snack cart and see what was available. When questioned, S6CNA denied Resident #4 specifying why he wanted candy bars but did state he was satisfied with her response and offer to find some type of snack. She stated she and S4CNASupervisor had just walked out of the room to find food for him when he immediately put the call light back on. He stated he had experienced another bowel movement. She and S4CNASupervisor went in to clean him up a second time. S6CNA confirmed he had experienced a small bowel movement. When asked to describe the BM, she replied it was like the others. She went on to state he had also urinated in the brief. After cleansing him up, he complained of his 'bottom burning' for which she applied the barrier cream. Once again, she positioned for comfort and ensured the call light was within reach. She stated she went to the snack cart at the main nursing station, and found a package of Graham crackers while S4CNASupervisor went to each nursing station to see if any sandwiches were left over from the HS snacks. She returned to the room with the Graham crackers and opened the package for him. Upon handing him the crackers, she noticed he had urinated on the sheets. She did not give him the crackers, placed them on the table and stated, "you urinated" . Resident #4 did not know he had but agreed to allow her to change the bed linens. Once completed, she positioned him for comfort, handed him the Graham crackers, and left the room. At this point, approximately 1:30a-2:00 am, she went to the floor nurse to inform her that Resident #4 was having "diarrhea" but that it was not "watery" . She stated the LPN acknowledged this by stating OK. She denied that the LPN asked for any further information or that she saw the nurse go see the resident. When asked why she didn't ask if the nurse had done anything for the stools, S6CNA replied, "They usually do and when she said OK, I thought she was taking care of it." When asked why she called the stools diarrhea when they were pasty formed stools, S6CNA replied because he had 2 stools " back to back" and that was why she reported the stools to the nurse. At this point, it was time for the 3 a.m. rounds, so she started her rounds. While on her rounds, he called for her, approximately 40 minutes after starting the rounds. He was requesting the urinal. She placed the urinal between his legs and waited approximately 5 minutes while talking to him. It was at this point, she noticed the empty wrappers from the Graham crackers. Resident #4 did not ask for any more food at this time. He was unable to urinate so she once again, removed the urinal, ensured the call light was within reach and left the room. When questioned, she denied that he looked or acted any 'different' than his 'normal self'. She informed S2DON that his skin was warm and dry; and that he was not 'sweaty' when she touched his skin. At approximately 5 a.m., she was called to the room due to him wanting to urinate. She handed him the urinal and he placed it in his brief. Once again, she waited at the bedside for ,[DATE] minutes, talking to the resident while he attempted to urinate. Resident #4 was not successful with urinating and asked her to remove the urinal. S6CNA denied that he voiced any further complaints or that he had experienced another bowel movement at this time. She removed the urinal, left it on his table where he could reach it, clipped his call bell on the gown, and left the room. She denied entering the room again until she was called down there when CPR was in progress. 4. S2DON [DATE] 1:00 p.m. Telephone Interview with S4CNASupervisor in part: Came on duty at 10:00pm and almost immediately after coming on, Resident #4 put his call light on. Both S5CNA and S6CNA answered the light. He was complaining about an upset stomach and that he had a bowel movement. They went down to clean him but he had not had a bowel movement. Shortly after this, he put the light on again. Myself and S6CNA answered the call light. Resident #4 was requesting chocolate, specifically a candy bar. I told S6CNA he is a diabetic, check with the nurse. S6CNA spoke with the nurse and was told he was a diabetic and chocolate was not the right choice of food. I went looking for a peanut butter and jelly sandwich on the snack cart but there weren't any left so we got him some graham crackers, 2 packs, and he said that would be fine and ate the graham crackers. We pulled him up in bed before we left the room. The third time resident #4 put on his light, S6CNA answered the light and this time he did have a bowel movement. S4CNASupervisor assisted her with cleaning him up. The stool was loose but not watery. The stool was brown, had no form but fecal matter was noted as opposed to water. The stool did not have any type of unusual or offensive odor beyond "normal" stool odor. Throughout the night, even when he wasn't using the call light, he was calling out for S6CNA. The fourth time he put the light on, I answered it. He had another stool. It was loose, had no form but did not have an unusual odor. He was complaining of his bottom burning so I put on barrier cream. When I informed S6CNA of this, she stated, "Another stool?" The fifth time he did not use the call light but was yelling out for S6

Based on record reviews, interviews, and observations, the facility failed to provide the necessary care and services to maintain the highest level of well-being for 1 (#4) of 7 (#1, #2, #3, #4, #5, #10, & #12) diabetic residents out of a sample of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, & #14). On [DATE] Resident #4 began having frequent loose bowel movements and low blood glucose. Resident #4's condition declined until he became unresponsive and went into cardiopulmonary arrest on [DATE]. On [DATE] and [DATE] the LPN staff the facility assigned to care for Resident #4 were unable or unprepared to provide the following needed care and services and there was no intervention by on-site RNs to ensure the following needed care and services were provided: 1. increased frequency of assessing his bowel movements and blood glucose levels to ensure accurate and timely assessments were made so that his physician would be timely consulted and needed medical care would be provided; 2. assessment of his caloric intake; 3. physician consultation regarding his frequent loose bowel movements and low, decreasing blood glucose; 4. immediate assessment when he became unresponsive; 5. immediate treatment when his blood glucose level was 31mg/dl; 6. assessments, interventions and communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes; 7. implementation of standing orders regarding loose bowels/diarrhea; 8. immediate notification to the in-house RN supervisor of the resident's low blood sugars and subsequent interventions; loose BMs; and inability to reach the MD; 9. RN supervision of LPNs and intervention in treatment for [REDACTED]. 10. staff education to prevent staff from administering oral Gulcoburst to an unresponsive resident; 11. immediately notify the physician and the RN Supervisor of holding Levimer Insulin due to low blood glucose readings; 12. Administer [MEDICATION NAME] as ordered when a request was made by the resident; 13. Administer [MEDICATION NAME] per Physician's standing order; 14. know which Physician/Nurse Practitioners were on call. This failure to provide care and services permitted Resident #4 to be harmed, placed Resident #4 in immediate jeopardy on two nursing shifts from 9:00 p.m. on [DATE] until his transfer to the hospital at 6:45 a.m. on [DATE] (9 ? hours). This failure had the potential to harm six other diabetic residents (#1, #2, #3, #5, #10, & #12) and placed them in immediate jeopardy. The administrator was informed of the immediate jeopardy on [DATE] at 11:44 a.m. A plan of removal was received on [DATE] which included the following: The facility will provide 24 hour RN supervision to ensure that the facility recognizes and assesses factors that could place a resident at risk for specific conditions, causes or problems and implements interventions, in accordance with resident's needs, goals and standards of practice. RN supervision will include evaluation of the results of the interventions and revise the interventions as necessary. The facility LPN's have been informed to notify RN of any changes in diabetic condition. At the beginning of each shift, the RN will inform the LPNs to contact the RN in regard to changes in diabetic condition. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. for the diabetic residents in the facility when surveyors determined the plan of removal was implemented. The deficient practice continued at a pattern of potential for more than minimal harm for the diabetics residing in the facility. Findings: Review of the Acute Condition Changes Policy and Procedure, revised ,[DATE], presented by S2DON revealed the following in part: 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 8. The Nurse and Physician will discuss the situation. Cause Identification 1. The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. if necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . Treatment/Management 1. The Physician will help identify and authorize appropriate treatments. a. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responded to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Review of the Nursing Care of the Resident with Diabetes Mellitus Policy and Procedure, (Revised [DATE]), provided by S2DON revealed in part the following: Conditions Associated with Diabetes: 3. [DIAGNOSES REDACTED] (blood sugar below reference ranges). Signs and symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following: b. restlessness f. irritability j. (more severe) stupor, unconsciousness and/or convulsions; and k. (more severe) coma. If these, or other abnormal conditions exist, notify the physician (for [DIAGNOSES REDACTED], follow steps in Management of [DIAGNOSES REDACTED] below). Glucose Monitoring: 4. " Finger sticks " (capillary blood samples) measure current blood glucose levels. 5. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] ,[DATE]milligrams/deciliter (mg/dl) b. Moderate [DIAGNOSES REDACTED] ,[DATE]mg/dl c. Severe [DIAGNOSES REDACTED] <40mg/dl Management of [DIAGNOSES REDACTED]: 1. Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms. 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives); c. remain with the resident d. monitor vital signs; Documentation: Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital Signs as ordered: 2. Level of consciousness: 3. Assessment of the skin including the following: a. color, moisture, and temperature; and 5. Percentage of meals consumed: 6. Emotional reactions, moods: 8. Motor weakness; 9. Urinary symptoms including retention and incontinence; 10. Bowel dysfunction including diarrhea and constipation; Resident #4: Review of the Face Sheet revealed that Resident #4 was admitted on [DATE] and was [AGE] years old with date of birth [DATE]. Review of the Accumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed the following information: clear speech - distinct intelligible words; makes self understood; understands others; BIMS summary score of 15 (cognitively intact); Functional Status - bed mobility requires extensive assistance of 1 person, transfers requires extensive assistance of 2 persons, dressing requires extensive assistance of 1 person, eating requires supervision with setup help only, toilet use requires extensive assistance of 1 person, personal hygiene requires extensive assistance of 1 person, bathing requires physical help of 1 person; always continent of bladder; occasionally incontinent of bowel; and Active [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [DATE] Accu checks before meals (AC) & at bedtime (HS); [MEDICATION NAME] R use per sliding scale orders: Blood Sugar (BS) 160 - 200 = 3 u, 201 - 280 = 6 u, 281 - 340 = 9 u, 340 - 400 = 12 u Recheck BS in 2 hours after administration of Sliding Scale insulin. [DATE] at 845 Chest X-ray stat, cardiac enzymes stat, increase [MEDICATION NAME] to 12 units subcutaneous (sq) hs, change accu checks to bid, increase [MEDICATION NAME] to 10 mg bid po, give [MEDICATION NAME] X 1 dose 1 mg now take blood pressure three times per day (tid) X 3 days [DATE]. Apply moisture barrier cream to buttocks and scrotum q shift and prn incontinent episodes. Review of the [DATE] physician's orders [REDACTED]. [MEDICATION NAME] 1 mg po q 12 hours Dx: hypertension [MEDICATION NAME] f/c 20 mg po hs Dx: Depression [MEDICATION NAME] 100 mg po bid Dx: constipation [MEDICATION NAME] f/c 800 mg po tid Dx: [MEDICAL CONDITION] [MEDICATION NAME] 100 mg po tid [MEDICATION NAME] 2 mg po q am before breakfast Dx: diabetes mellitus [MEDICATION NAME] 50 mg po q 8 hours Dx: hypertension [MEDICATION NAME] 100 micrograms (MCG) po q d Dx: [MEDICAL CONDITION] [MEDICATION NAME] 20 mg po bid Dx: hypertension [MEDICATION NAME] 50 mg po bid Dx: hypertension [MEDICATION NAME] .2 mg/hr patch apply to chest wall q d Dx: [MEDICAL CONDITION] with [MEDICAL CONDITION] [MEDICATION NAME] 40 mg po q d before breakfast Dx: gastro [MEDICAL CONDITION] reflux disease [MEDICATION NAME] 75 mg po q d Dx: [MEDICAL CONDITION] [MEDICATION NAME] .25 mg po tid prn anxiety [MEDICATION NAME] 5 mg po tid prn pain Alprazalon .5 mg po bid Dx: anxiety [MEDICATION NAME] 4 mg po q 6 hrs prn nausea [MEDICATION NAME] R 100 U / ML unit Use per sliding scale orders: ,[DATE] = 3 units; 201 - 281 = 6 units, 281 - 340 = 9 units; 340 - 400 = 12 units; Recheck in 2 hours after administration of sliding scale. Hydration checks - check for s/s of dehydration: (+) = good skin turgor/moist mucous membranes, (-) = problems / [MEDICATION NAME] 0.5 mg po bid for anxiety [MEDICATION NAME] 145 mg q d po stop [DATE] [MEDICATION NAME] 200 mg po q d start [DATE] [MEDICAL CONDITION] Weekly B/P on Tues (,[DATE]) due to antihypertensive therapy Accu check Ac + HS for 1 week [MEDICATION NAME] 10 units sq at HS [DATE] Call MD with results of accu checks X 1 week. Preparation H ointment please apply 4 times daily Diet: no concentrated sweets (NCS) / no added salt (NAS) Code Status: Full code Review of the standing orders (No date noted) for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). An interview was held S2DON on [DATE] at 10:25 a.m. She said that this meant the nurse is to call the doctor when the blood sugars are <50 or > 450. The standing orders also revealed the following for diarrhea: If < 4 BMs in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet po q ,[DATE] hours prn X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify MD/NP in a.m. May substitute generic equivalent. The standing orders also revealed Dr. C ... sliding scale Novo R Insulin unit for BS 160 - 200 give 3 units, 201 - 280 give 6 units, 281 - 340 give 9 units, 341 - 400 give 12 units. Recheck BS in 2 hours after administration of sliding scale insulin. If BS > 400, give 15 units subcutaneous (SubQ) and re-check accu check in 3 hours. If BS not < 400, call NP / MD. Review of Resident #4's Care Plan revealed the following: Diabetes Plan of Care - original date of [DATE] Problem: Potential for Hypo - [MEDICAL CONDITION] related to (r/t) [DIAGNOSES REDACTED]. Goals: Will adhere to prescribed diet; Will have no signs and symptoms of [DIAGNOSES REDACTED] Goal date: [DATE] Interventions: Provide substantial bedtime snack and record percentage; Accu checks as ordered; Monitor for noncompliance with therapeutic diet and report to RD or MD; counsel resident/family on modified diet; and Monitor for s/s hypo - [MEDICAL CONDITION]. Problem dated [DATE]: Consistent refusal of medical treatment. [DATE] at approximately 9:00 am an interview was conducted with a family member of resident #4. The family member said that resident #4 had a cell phone and called family members daily throughout the day to talk. The family member said that on [DATE] the resident did not call family members. Nurses Notes Review (Resident #4) revealed the following: [DATE] 12 N complained of (c/o) pain to rectum - Preparation H applied. [DATE] 1:30 p.m. Had several bowel movements (BMs) this shift consistency - Paste-like. Redness noted to scrotum. New order noted - Moisture barrier cream to buttocks & scrotum every (Q) shift & as needed (PRN) incontinent episodes. [DATE] 6:45 p Resident lying in bed with eyes closed easily aroused to verbal tactile stimuli. No signs symptoms of distress noted. Continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident's leg hanging off bed, resident stated "I want to sit up" explained to him that he needs assist to get up, he can fall & injury himself, put leg back in bed instructed him to call - light in reach. Resident took his medications without difficulties. Resident accu check was 61 at 4 p. Resident BMs have gone from pasty to loose doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor. [DATE] (no time documented) Resident alert & awake most of night. Still having BMs constantly. On call light assisted as need. 5:45 A Entered room to do BS (blood sugar). Results 51. Oxygen Saturation (O2 sat) 95% on O2. Tried to arouse. Resident unable to do so. 6:00 A - Informed supervisor of low blood sugar. Resident nonresponsive. 911 called. Family called. CPR started. Resident transported to hospital. An observation was made on [DATE] at 4:00 p.m. of the accu check machine used for Resident #4 on [DATE]. It revealed a date of [DATE] at 06:52 Eastern Time (per S2DON) with a result of 31. Review of the results did not reveal a reading of 51 on [DATE]. Nurses Notes Late Entries (Resident #4) revealed: [DATE] 1:33 p.m. Late entry [DATE] 4 p.m. At this time accu check taken it was 56 orange juice with sugar given, res awake, alert & talking skin warm/dry to touch. 5p One hour later accu check retaken 61 at this time give more OJ with sugar resident remain alert. Instructed certified nurse aide (CNA) to make sure resident eats. By mouth (PO) fluids given consumed 180 cc. 5:45 p Resident CNA informed me that he assist with meal, consumed 50% of his supper, fluids was given from supper tray tolerated well. 7 p HS snack given, consumed 100% ? wheat peanut butter & jelly sandwich and 1 pack of graham crackers. VS blood pressure (b/p) ,[DATE], pulse (P) 59, O2 sat 96% on room air O2 probes out machine on at 3 L / minute canula reinserted to nostril. Recheck accu check at this time blood sugar (BS) 86 continue to give mint to keep up. 8p Hemorrhoid cream applied at this time. Resident HS insulin held (Lavmir 12 units) d/t low accu checks. (Review of the documentation failed to reveal the MD was notified that the [MEDICATION NAME] was held.) 9 p CNA reported that resident had loose stool X 1 with foul odor. This nurse place call to nurse practitioner (NP) at this time to informed of resident condition loose stool X 1 with foul odor. No answer left message for return call. 9:30 p Recheck accu check it had come up to 90, resident stated he wanted some pie none available offered Hershey kisses give him 2 that he consumed & left 3 & 2 lemon drops at bed side also gave 200 cc of water. No c/o pain or discomfort voiced. 10 p Report given to oncoming nurse regarding resident condition & his pasty stool & 1 loose stool, told her that a call was place to on call MD, left message to call me back. If doctor return call to let him know about resident stool & foul odor. Resident had several small smears during his pasty stools that was noted. Will continue to monitor. [DATE] 2:21 p.m. Late entry on [DATE] at 3:45 p.m. Charge nurse spoke with B ...A ..., NP (Nurse Practitioner), notified about barrier cream use, told floor nurse to report if stools become loose to MD, nurse verbalize understanding and assumed care of resident. [DATE] 11:00 a.m. Late entry (no date documented) 10:30p -11p Resident alert awake speaking with nurse. C/o loose stool water given for hydration. In no acute distress. [DATE] 11:00 a.m. Late entry (no date documented) 12:00 a.m. Rounds made Resident lying in bed eyes closed; no evidence of shortness of breath (SOB), no acute distress noted. [DATE] 11:00 a.m. Late entry (no date documented) 2:00 a.m. Resident alert, awake, speaking with nurse. Vital Signs (V/S) stable at ,[DATE], 62, 20. Requested water assisted with given water from bedside pitcher. Resident took a few sips stated he was done c/o loose stools. Asked nurse what was facility going to do about stools Nurse informed resident MD will be notified in a.m. Resident verbalized understanding. [DATE] 11:00 a.m. Late entry (no date documented) 2:30 a.m. CNAs stated resident unable to sleep in no acute distress nothing order for sleep at this time. [DATE] 11:00 a.m. Late entry (no date documented) 5:45 a.m. Resident found unresponsive grunting. Accu check 51, O2 sat 95%, O2 at 2 liters (L) minute. Attempts to give Glucoburst unsuccessful due to resident not swallowing RN Supervisor notified. Instructed by RN to call 911. Left RN at bedside. Review of the EMS records dated [DATE] revealed the unit was dispatched at 06:04. The unit arrived at the scene at 06:08 and arrived at the patient at 06:12. The unit departed from the facility at 06:24 and arrived at hospital at 06:35. The Summary of Events revealed the following: [AGE] year old male found lying in a hospital bed unresponsive, with staff assisting ventilations and attempting CPR. Staff stated they went to check patient (pt) blood sugar and it registered lo. When they went back to check on pt. pt . was not responding and appeared to be in [MEDICAL CONDITION]. 911 called. Staff stated pt. had been down for approximately 20 minutes. Pt. pulseless and apneic. Pt. warm to the touch. Abdomen distended. Pt. incontinent. No trauma noted. IV established, meds given. Pt. had a very brief period of restore in pulse while moving pt. to ambulance. Pt. lost pulse CPR resumed. An interview was held with T ... L ... Chief Operating Officer at EMS on [DATE] at 12:45 p.m. He stated an accu check reading of Low was indicative of a Blood Glucose of less than 20. Interview with S2DON on [DATE] at 1:49 p.m. She said that she was called and informed of Resident #4's death on [DATE]. She said that she informed the S3ChargeNurse to place Resident #4's record on her desk and lock it up after the nurses finished with it. She said that she advised the evening shift and night shift nurses to document the late entries. She said after reviewing the nurses' documentation and interviewing the nurses, she felt there may be a possibility of neglect so she suspended S8LPN on [DATE] and initiated an OTIS report to the state. S2DON said that she suspended S8LPN due to her concerns with S8LPN failing to intervene with Resident #4. Review of the schedules revealed the following staff were assigned to Resident #4 on [DATE] day and eveining shift and [DATE] - [DATE] night shift: Day Shift Nurse S11LPN Day Shift CNA S13CNA Evening Shift Nurse S10LPN Evening Shift CNA S12CNA Night Shift Nurse S8LPN Night Shift CNA S6CNA On [DATE] S2DON provided employee statements regarding Resident #4 obtained by S2DON: 1. S2 DON's Telephone Interview with S7RNSupervisor revealed in part: Came on duty at 10:00 pm and made rounds through the facility. I reviewed the weekend report sheets left for me by S2DON. I also met with each nurse on duty, including S8LPN. I asked if they had any problems, anything I needed to know about. I informed each nurse that I was 'here' if they needed anything and to 'just let me know' . S8LPN did not inform me during the first or subsequent rounds that she was having any issues with Resident #4. Resident #4 was on the call light through the night but this was not unusual for him as every time I had worked, he was frequently awake during the night calling for staff. I did ask the staff if he was 'okay' and asked what he was calling about. The staff informed me that he was asking for S6CNA but nothing more. At the end of the shift, at approximately 5:,[DATE]:45 am, I was informed I was needed to Resident #4's room STAT. I quickly hurried down to the room and found S8LPN at the bedside. She informed me that his blood sugar was 31. I told her to go call an ambulance and she left the room. I was trying to arouse him but was unable to do so. He would not respond to any type of stimuli and his tongue was hanging out of his mouth. I immediately grabbed the crash cart and the day shift RN (S9RN) had entered the room, we initiated CPR and got the ambu bag ready and hooked to oxygen. Emergency Medical Services (EMS) entered the room pretty quickly. I told them what I knew, including that the nurse had told me his sugar was 31, but that they needed to speak with the nurse caring for him. I sent a CNA after her. EMS wanted to know the code status and I informed them that he was a full code. The nurse returned to the room and I asked for a second glucose level. EMS was starting an IV. I do not recall her getting a second capillary glucose level. When EMS placed him on the monitor, I saw the number 82 but I am not sure if that was his heart rate or not. Once EMS got the needed information, they transported him to the hospital. We were called a few minutes later to be told he had passed. After the event, I met with the staff. At this point, the nurse told me his sugar was 51, not 31. She also told me she had given him some Glucoburst when she first found him, before he became unresponsive. It was not until after he had left the building the staff informed me that he had been experiencing loose stools through the night. I asked if the nurse had administered [MEDICATION NAME] to which I was told she had not. At the end of her telephone interview, S2DON asked the following questions: When you were given report from S8LPN were you informed of the issues with his blood sugar during the previous shift or that the evening nurse had held his insulin? ANSWER-No, I was not. Were you informed that he had experienced a loose stool at the end of the ,[DATE] shift? ANSWER-No, I did not. Did you see Resident #4 during your shift? ANSWER-No, I did not. You are telling me he was using the call light a fair amount that night, why did you not see what was wrong? ANSWER-Every time I worked, he had frequently used the call light during the night for numerous reasons. This was not unusual for him at all. When I asked why he was calling, I was told he wanted S6CNA. Had you been informed of his loose stools during the shift, would you have done anything different? ANSWER- Yes, I would have seen if something was ordered for the stools and if not, had the nurse call and get an order for [REDACTED]. 2. S2DON's Face to Face Interview with S8LPN, 10p-6A LPN, conducted on [DATE] at 10 AM revealed in part: Came on duty at 10:00 p.m. and received report from the off going nurse. I started my first rounds between 10:30 p-11:00 and Resident #4 was one of the first people I saw. He was awake, alert, and talking to me. He stated he was experiencing some loose stools. I gave him some water to drink from his bedside pitcher and told him we had notified the doctor. He did not ask me for anything at that time. His skin was warm and dry and resident did not voice any other complaints. I continued with my rounds. At 12:00 am, I made my next set of rounds, passed medications and began checking my charts. When I checked on him, I "peeped in" . He was resting comfortably, lying supine in the bed but we did not speak. At this point, no one had reported he was having any issues with his stools. Between 1:30am-2:00am I saw him again. I took his vital signs. His B/P was ,[DATE], 62, 20. He and I spoke and he was stating he was continuing to have loose stools. He asked what we were going to do about it. I explained we would call the doctor in the morning. He asked for some water and I gave him some. He took approximately 100cc. At 2:30 a.m. the CNAs asked me if there was something I could give him to help him rest because he had been awake all night. I looked at the chart and told them there was nothing I could do. At 5:45 a.m., I went to get his morning accu check. He was grunting, and difficult to arouse. I checked his sugar and it was 31. His O2 sat was 95% on room air. I went to get Glucoburst from one of the medication carts in the med room. None of the medication carts had any so I went to the supply room. At almost 6:00 a.m., when I returned to his room, he did open his eyes and I attempted to give the Glucoburst but he would not swallow. I put the call light on and ran into the hall calling for help. The RN came immediately to the room and told me to call 911. I left the room to call 911. He lost his pulse while I was out of the room. When I came back to the room, emergency medical services (EMS) was there. S8LPN also told S2DON: At 1:30, she told Resident #4 we would call the doctor in the morning. At 2:30a.m. Resident #4 requested something to help him rest as he had been up due to having loose stools and his bottom burning. S8LPN said she did not ask the CNA how many stools, the last time he experienced one, or the consistency and/or smell of them? S8LPN said when she removed the MAR indicated [REDACTED]. S8LPN said she did not inform the RN on duty of the stools and did not inform the RN on duty about Resident #4's glucose levels during the previous shift? S8LPN said she did not think about implementing the physician's standing orders for [MEDICATION NAME]. S8LPN said she didn't check Resident #4's blood sugar before 6am because she was told by the ,[DATE]LPN that she had got his sugar up and the next accu check wasn't scheduled until 6:00 a.m. S8LPN said Resident #4 was talking to her like he always did and was alert and oriented.. S8LPN said when she attempted to give the Glucoburst and he was not swallowing she did not massage some of the gel into his mucus membranes of his mouth. She said Resident #4 wasn't conscious by this point. She said she called for the RN to come and she told me to get 911 here. S8LPN said she did not think to grab the injectable glucose. She said she had to get vital signs once a shift so since she was in the resident' room in the middle of the night she went ahead and did them. S8LPN said didn't think about monitoring his glucose level during the night and the Resident wasn't acting like his sugar was dropping. S8LPN said she though she documented everything during her shift and told S2DON she would add the rest if S2DON wanted her to. Documentation revealed that S2DON explained the proper way to make late entries into the medical record and watched while this nurse completed her documentation. When she was finished, S2DON explained in great length what concerns she had with her performance that night and how loose stools with any resident but especially a diabetic required her interventions beyond calling the MD in the morning. That she should have notified the RN in the house for direction, or even just informed her of the issue and let the RN determine the course of action. Documentation revealed that S8LPN became extremely emotional at this point crying hysterically and repeatedly apologizing and saying Oh God! I am so sorry". 3. S2DON's [DATE] at 9:34 a.m. face to face interview with S6CNA revealed in part: S6CNA stated she reported to work at 10:00 pm on [DATE]. Approximately 30 minutes after clocking in, Resident #4 turned his call light on. Upon answering the call light, he informed her he needed his adult brief changed. He had experienced a bowel movement, that was medium in size and the consistency a little thinner than peanut butter. He complained of not feeling well due to not being able to urinate. S6CNA placed the urinal between his legs and encouraged him to relax, stating, "it takes time". She waited at the bedside for ,[DATE] minutes while they discussed him feeling like he needed to urinate but could not. When asked if this was reported to the floor nurse, she stated she had not because this was "normal" for Resident #4. After approximately 5 minutes, he asked to have the urinal remain in the brief. She assisted him with positioning in the bed, turned off the room light and instructed him to call her if he needed her. The call light was attached to his hospital gown. She stated she was in the room for approximately ,[DATE] minutes. When asked if Resident #4 appeared unusual in any way, S6CNA stated he did not. He was alert, oriented and 'acted like himself' . When asked if his skin color was pale or if he was sweaty to the touch, she stated he was not. Approximately 10 minutes later (approximately 11:10 p.m.) he called her back, via the call light. He complained of not being able to urinate and was requesting to have the urinal removed. He voiced no other complaints. S6CNA removed the urinal, placed it on the table, within reach, and turned off the light, clipped the call light to his gown and left the room. Approximately 30 minutes later, he called for her again, stating he had experienced another bowel movement. S6CNA and S4CNASupervisor entered to clean him up. S6CNA reported the stool was of medium size and had the same consistency of the stool earlier in the shift: thinner than peanut butter but not watery, and there was 'form' to it. When asked if the stools had an unusual smell, she stated both stools smelled like 'normal BM' . She denied smelling anything unusual or the stool having the appearance of someone who 'was sick' . While the staff was cleansing him, Resident #4 asked for some money so he could get a candy bar. He informed the staff he was 'good for it' . As his son would 'pay them back'. S6CNA informed him that it was not about the money, but that she just did not have any change with her but that she would go check the snack cart and see what was available. When questioned, S6CNA denied Resident #4 specifying why he wanted candy bars but did state he was satisfied with her response and offer to find some type of snack. She stated she and S4CNASupervisor had just walked out of the room to find food for him when he immediately put the call light back on. He stated he had experienced another bowel movement. She and S4CNASupervisor went in to clean him up a second time. S6CNA confirmed he had experienced a small bowel movement. When asked to describe the BM, she replied it was like the others. She went on to state he had also urinated in the brief. After cleansing him up, he complained of his 'bottom burning' for which she applied the barrier cream. Once again, she positioned for comfort and ensured the call light was within reach. She stated she went to the snack cart at the main nursing stati

Based on record reviews, interviews, and observations, the facility failed to administer staff resources in a manner to ensure that a resident maintained their highest level of well being for 1 (#4) of 7 (#1, #2, #3, #4, #5, #10, & #12) diabetic residents out of a sample of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, & #14). On [DATE] Resident #4 began having frequent loose bowel movements and low blood glucose. Resident #4's condition declined until he became unresponsive and went into cardiopulmonary arrest on [DATE]. On [DATE] and [DATE] the LPN staff the facility assigned to care for Resident #4 were unable or unprepared to provide the following needed care and services and there was no intervention by the on -site RNs to ensure the following were provided: 1. increased frequency of assessing his bowel movements and blood glucose levels to ensure accurate and timely assessments were made so that his physician would be timely consulted and needed medical care would be provided; 2. assessment of his caloric intake; 3. physician consultation regarding his frequent loose bowel movements and low, decreasing blood glucose; 4. immediate assessment when he became unresponsive; 5. immediate treatment when his blood glucose level was 31mg/dl; 6. assessments, interventions and communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes; 7. implementation of standing orders regarding loose bowels/diarrhea were carried out; 8. immediate notification to the in-house RN supervisor of the resident's low blood sugars and subsequent interventions; loose BMs; and inability to reach the MD; 9. RN supervision of LPNs and intervention of treatment for [REDACTED]. 10. educate staff to not administer oral Glucoburst to an unresponsive resident; 11. immediately notify the physician and the RN Supervisor of holding Levimer Insulin due to low blood glucose readings; 12. Administer [MEDICATION NAME] as ordered when a request was made by the resident; 13. Administer [MEDICATION NAME] per Physician's standing order; 14. ensure the physician/NP called was actually on call. This failure to provide care and services permitted Resident #4 to be harmed, placed Resident #4 in immediate jeopardy on two nursing shifts from 9:00 p.m. on [DATE] until his transfer to the hospital at 6:45 a.m. on [DATE] (9 ? hours). This failure had the potential to harm six other diabetic residents (#1, #2, #3, #5, #10, & #12) and placed them in immediate jeopardy. The administrator was informed of the immediate jeopardy on [DATE] at 11:44 a.m. A plan of removal was received on [DATE] which included the following: The role of the RN Supervisors will be to provide clinical oversight to recognize and assess, define and implement and monitor and evaluate care and services delivered to facility residents. The facility will provide 24 hour RN supervision to ensure that the facility recognizes and assesses factors that could place a resident at risk for specific conditions, causes or problems and implements interventions, in accordance with resident's needs, goals and standards of practice. RN supervision will include evaluation of the results of the interventions and revise the interventions as necessary. The facility LPN's have been informed to notify RN of any changes in diabetic condition. At the beginning of each shift, the RN will inform the LPNs to contact the RN in regard to changes in diabetic condition. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. for the diabetic residents in the facility when surveyors determined the plan of removal was implemented. The deficient practice continued at a pattern of potential for more than minimal harm for the diabetics residing in the facility. Findings: Review of the Acute Condition Changes Policy, revealed the following in part: 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 8. The Nurse and Physician will discuss the situation. Cause Identification 1. The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. if necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . Treatment/Management 1. The Physician will help identify and authorize appropriate treatments. a. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responded to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. This policy does not address the acute condition change of a diabetic with diarrhea and decreasing blood glucose levels. The policy fails to address how the RN supervisor will supervise LPNs to ensure acute condition changes are addressed and needed care and services are provided. The policy fails to address emergencies that require an immediate call back from the physician. There is no policy and procedure instructing staff nurses to never stop at leaving a message for a physician. The policy fails to include the role of the RN Supervisor to ensure the Physician is contacted. The policy fails to address how nurses will ensure they are actually calling the physician/nurse practitioner that is on call. The facility failed to ensure staff knew to contact the medical director when no response is received from the physician. Interview [DATE] 3:45 PM with DON revealed: S2DON said S10LPN told her she did not know if B ...A ..., NP, was on call on [DATE] after 4 pm, and she did not check the on-call schedule posted in the medicine room. S2DON said that B ...A ..., NP, was not on call on [DATE] after 4 p.m. S2DON said that S10LPN told her that she did not notify the RN House Supervisor on her shift or the oncoming RN of Resident #4's BS and loose stool. The P&P failed to include checking the on call schedule and when the LPN is to notify the RN supervisor. An interview was held with S2DON on [DATE] at 9:42 a.m. The DON said that waiting 4 hours for Resident #4 to be checked on by a nurse ([DATE] - [DATE] ,[DATE] shift S8LPN) was not appropriate due to his low blood sugars (BS) on the previous shift and diarrhea. The P&P fails to address how often to assess a resident with low blood sugars and diarrhea. An interview was held with S2DON [DATE] at 3:45 p.m. She explained if a nurse calls and leaves a message for the doctor, and the call is not returned in 20 minutes, the nurse is to try to reach the doctor again or notify the House Registered Nurse (RN) to handle the situation. This is not addressed in the P&P regarding physician notification. Review of the Nursing Care of the Resident with Diabetes Mellitus Policy and Procedure (Revised [DATE]) revealed in part the following: Conditions Associated with Diabetes: 3. [DIAGNOSES REDACTED] (blood sugar below reference ranges). Signs and symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following: b. restlessness f. irritability j. (more severe) stupor, unconsciousness and/or convulsions; and k. (more severe) coma. If these, or other abnormal conditions exist, notify the physician (for [DIAGNOSES REDACTED], follow steps in Management of [DIAGNOSES REDACTED] below). Glucose Monitoring: 4. " Finger sticks " (capillary blood samples) measure current blood glucose levels. 5. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] ,[DATE]milligrams/deciliter (mg/dl) b. Moderate [DIAGNOSES REDACTED] ,[DATE]mg/dl c. Severe [DIAGNOSES REDACTED] <40mg/dl Management of [DIAGNOSES REDACTED]: 1. Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms. 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives); c. remain with the resident d. monitor vital signs; Documentation: Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital Signs as ordered: 2. Level of consciousness: 3. Assessment of the skin including the following: a. color, moisture, and temperature; and 5. Percentage of meals consumed: 6. Emotional reactions, moods: 8. Motor weakness; 9. Urinary symptoms including retention and incontinence; 10. Bowel dysfunction including diarrhea and constipation; The P&P fails to instruct nurses on what to administer by mouth for mild to moderate [DIAGNOSES REDACTED] and if candy should or should not be administered. The P&P instructs to immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME] per facility protocol but interview with the DON on [DATE] at 9:25 a.m.revealed there is no facility protocol for nurses to follow. The P&P fails to inform nurses where the oral glucose paste, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME] are kept. The P&P fails to address nursing care for each level of [DIAGNOSES REDACTED]. The P&P fails to define symptomatic and fails to address acute changes in condition with decreasing blood sugars and physician notification. The P&P incorrectly directs nurses to administer oral glucose past to an unresponsive resident. Resident #4: Review of the Face Sheet revealed that Resident #4 was admitted on [DATE] and was [AGE] years old with date of birth [DATE]. Review of the Accumulative [DIAGNOSES REDACTED]. Physicians orders revealed: [MEDICATION NAME] 2 mg po q am before breakfast Dx: diabetes mellitus [MEDICATION NAME] R 100 U / ML unit Use per sliding scale orders: ,[DATE] = 3 units; 201 - 281 = 6 units, 281 - 340 = 9 units; 340 - 400 = 12 units; Recheck in 2 hours after administration of sliding scale. Review of the standing orders (No date noted) for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). The standing orders also revealed the following for diarrhea: If < 4 BMs in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet po q ,[DATE] hours prn X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify MD/NP in a.m. May substitute generic equivalent. [DATE] at approximately 9:00 am an interview was conducted with a family member of resident #4. The family member said that resident #4 had a cell phone and called family members daily throughout the day to talk. The family member said that on [DATE] the resident did not call family members. Review of the Diabetic Monitoring Record for [DATE] revealed the following: [DATE] 6:30 a.m. refused, 11:30 a.m. ,[DATE] units, 4:30 p.m. ,[DATE] units; HS ,[DATE] U [DATE] 6:30 a.mXXX,[DATE] units, 11:30 a.m. 216- 6 units, 4:30 p.mXXX,[DATE] units; HS,[DATE] U [DATE] 6:30 a.m. ,[DATE] units, 11:30 a.m.refused, 4:30 p.m. refused; HS ,[DATE] U [DATE] 6:30 a.m. ,[DATE] units, 11:30 a.mXXX,[DATE] units, 4:30 p.mXXX,[DATE] units; HS ,[DATE] U [DATE] 6:30 a.m. ,[DATE] units, 11:30 a.mXXX,[DATE] units, 4:30 p.m. ,[DATE] units; HS ,[DATE]U [DATE] 6:30 a.m. ,[DATE] units, 11:30 a.mXXX,[DATE] units, 4:30 p.m. ,[DATE] units; HS ,[DATE] U [DATE] 6:30 a.m. ,[DATE] units [DATE] 4:30 p.m. 138 0 units [DATE] 6:30 a.m. 96 - 0 units 4:30 p.m. 112 - 0 units [DATE] 6:30 a.m. refused 4:30 p.m. 56 / 61 0 units gave OJ with sugar An interview with S31CNA on [DATE] at 11:30 a.m. revealed Resident #4 was total care, fed himself, was alert and oriented, usually ate breakfast in bed, ate lunch in dining room sometimes, usually had 2 BMs a day on the day. S31CNA said that he assisted with Resident #4 on [DATE]. He said that he kept having BMs and screaming his butt hurt. He said that he had 5 BMs before 9:00 a.m. Interview with S11LPN on [DATE] at 12:44 p.m. revealed resident #4 often refused his meals, was a diabetic, usually got out of bed during the day, would get up for lunch but not breakfast usually, was alert and oriented X 3. She said on [DATE], he refused to get up after breakfast and he was having bowel movements. She said that he never got out of bed Friday, [DATE], and this was unusual for him. She said that he had at least 6 if not more BMs on [DATE]. She said he may have had 8 BMs. She said this was not normal for him. Interview on [DATE] at 1:14 p.m. with S32ChargeNurse revealed she had been Resident #4's charge nurse for one month. She said Resident #4's daily routine was to get up by 9:00 a.m. and eat in his room or the dining room. She said he was a diabetic but not a brittle diabetic, that Resident #4's accu check results stayed around upper 100's. She said that Resident #4 was alert and oriented X 3 and he never mentioned that he could tell when (blood) sugar (was) up or down. Interview on [DATE] at 11:50 a.m. with S6CNA revealed she worked with Resident #4 the whole time he was at the facility. She said that he usually did not have a BM on her shift. She said she worked the night shift on [DATE]. She said when she came on duty at 10:00 p.m. Resident #4 had his call light on. She said she went in, and he had a bowel movement. She described the BM like a new born baby's first BMs. She said it was not formed, but it was not diarrhea. Interview on [DATE] at 2:16 p.m. with S10LPN revealed she was Resident # 4's routine evening shift nurse. She explained on [DATE] when she came on duty Resident #4 was still having pasty stools, and he was c/o a burning bottom. She said his accu check was 58 at 4 p.m., and she gave him orange juice and sugar. She said after Resident #4 at around 5:30 p.m. his accu check was 61 so she gave him some more orange juice with sugar. She said that she checked his BS again at 8:00 p.m., and it was 81. She said at 9:30 p.m. his BS was 90, and she gave 3 silver bells (chocolate candy), and she left 3 more silver bells and 2 lemon drops on his bed side table. She said he only had 1 loose stool on her shift, and it had a foul odor. She said that she reported to the oncoming nurse that she checked him because sugar was up and down. She said that she also told the oncoming nurse that she had called B ...A ...,NP, and left a message. S10LPN said that she told the night nurse that she was waiting on a call back from B ...A ..., NP. S10LPN said that resident 4 had about 5 stools and 1 loose stool on the 2 p.m. -10 p.m. shift on [DATE]. She said that she called the doctor to report that Resident #4 was still having stools and now 1 loose stool. Interview [DATE] 3:45 PM with DON revealed B ...A ..., NP, was not on call on [DATE] after 4 p.m. Interview was held with S13CNA on [DATE] at 8:30 a.m. revealed she had always taken care of Resident #4 when she worked. She said Resident #4 had 9 BMs on [DATE] which were formed, normal in color, and no unusual odor. She described Resident #4 as being fidgety and snappy on [DATE] which was not his normal behavior. She said that he was alert and oriented X 3. On [DATE] he didn ' t ' want to be bothered, and he did not get out of bed on [DATE]. She said that he usually got up. Interview with B ...A ..., NP (Nurse Practitioner), on [DATE] at 8:55 a.m. revealed he usually calls back in about 15 minutes (when he is called by a nurse at the facility). He said that there is an answering service that is used after 5 p.m. He said that if a resident's accu check was less than 70 or over 400 then the nurse should contact the doctor. Per [DATE] 11 AM late entry nurses notes and [DATE] 10 AM S2DON interview with S8LPN: on [DATE] and [DATE], S8LPN, the 11 p.m. to 7 a.m. charge nurse, failed to contact the physician, failed to contact the Medical Director and failed to inform the RN Supervisor of Resident #4's continued loose BMs. S8LPN failed to follow Facility Policy by not increasing assessments of Resident #4 including: level of consciousness, vital signs, bowel function, blood glucose levels, and general mental and physical condition. Per [DATE] 11 am nurses notes, on [DATE] at 5:45 p. m. Resident #4 was found unresponsive by S8LPN with a glucose of 31. S8LPN failed to remain with Resident #4 as per facility policy. Review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed the following information: clear speech - distinct intelligible words; makes self understood; understands others; BIMS summary score of 15 (cognitively intact); Functional Status - bed mobility requires extensive assistance of 1 person, transfers requires extensive assistance of 2 persons, dressing requires extensive assistance of 1 person, eating requires supervision with setup help only, toilet use requires extensive assistance of 1 person, personal hygiene requires extensive assistance of 1 person, bathing requires physical help of 1 person; always continent of bladder; occasionally incontinent of bowel; and Review of the physician's orders [REDACTED]. [DATE] Accu checks before meals (AC) & at bedtime (HS); [MEDICATION NAME] R use per sliding scale orders: Blood Sugar (BS) 160 - 200 = 3 u, 201 - 280 = 6 u, 281 - 340 = 9 u, 340 - 400 = 12 u Recheck BS in 2 hours after administration of Sliding Scale insulin. [DATE] at 845 Chest X-ray stat, cardiac enzymes stat, increase [MEDICATION NAME] to 12 units subcutaneous (sq) hs, change accu checks to bid, increase [MEDICATION NAME] to 10 mg bid po, give [MEDICATION NAME] X 1 dose 1 mg now take blood pressure three times per day (tid) X 3 days. [DATE]. Apply moisture barrier cream to buttocks and scrotum q shift and prn incontinent episodes. Review of the [DATE] physician's orders [REDACTED]. [MEDICATION NAME] 1 mg po q 12 hours Dx: hypertension [MEDICATION NAME] f/c 20 mg po hs Dx: Depression [MEDICATION NAME] 100 mg po bid Dx: constipation [MEDICATION NAME] 2 mg po q am before breakfast Dx: diabetes mellitus [MEDICATION NAME] 50 mg po q 8 hours Dx: hypertension [MEDICATION NAME] 20 mg po bid Dx: hypertension [MEDICATION NAME] orange s/f packet po q d Dx: constipation [MEDICATION NAME] 50 mg po bid Dx: hypertension [MEDICATION NAME] .2 mg/hr patch apply to chest wall q d Dx: [MEDICAL CONDITION] with [MEDICAL CONDITION] [MEDICATION NAME] 40 mg po q d before breakfast Dx: gastro [MEDICAL CONDITION] reflux disease [MEDICATION NAME] 75 mg po q d Dx: [MEDICAL CONDITION] [MEDICATION NAME] .25 mg po tid prn anxiety [MEDICATION NAME] 5 mg po tid prn pain Alprazalon .5 mg po bid Dx: anxiety Tylenol 650 mg po q 6 hrs prn mild pain [MEDICATION NAME] 2 mg po q am before breakfast Dx: diabetes mellitus [MEDICATION NAME] R 100 U / ML unit Use per sliding scale orders: ,[DATE] = 3 units; 201 - 281 = 6 units, 281 - 340 = 9 units; 340 - 400 = 12 units; Recheck in 2 hours after administration of sliding scale. [MEDICATION NAME] 0.5 mg po bid for anxiety [MEDICATION NAME] 145 mg q d po stop [DATE] [MEDICATION NAME] 200 mg po q d start [DATE] [MEDICAL CONDITION] Weekly B/P on Tues (,[DATE]) due to antihypertensive therapy Accu check Ac + HS for 1 week [MEDICATION NAME] 10 units sq at HS [DATE] Call MD with results of accu checks X 1 week. Preparation H ointment please apply 4 times daily Diet: no concentrated sweets (NCS) / no added salt (NAS) Code Status: Full code Review of the standing orders (No date noted) for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). An interview was held S2DON on [DATE] at 10:25 a.m. She said that this meant the nurse is to call the doctor when the blood sugars are <50 or > 450. The standing orders also revealed the following for diarrhea: If < 4 BMs in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet po q ,[DATE] hours prn X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify MD/NP in a.m. May substitute generic equivalent. The standing orders also revealed Dr. C ... sliding scale Novo R Insulin unit for BS 160 - 200 give 3 units, 201 - 280 give 6 units, 281 - 340 give 9 units, 341 - 400 give 12 units. Recheck BS in 2 hours after administration of sliding scale insulin. If BS > 400, give 15 units subcutaneous (SubQ) and re-check accu check in 3 hours. If BS not < 400, call NP / MD. Review of Resident #4's Care Plan revealed the following: Diabetes Plan of Care - original date of [DATE] Problem: Potential for Hypo - [MEDICAL CONDITION] related to (r/t) [DIAGNOSES REDACTED]. Goals: Will adhere to prescribed diet; Will have no signs and symptoms of [DIAGNOSES REDACTED] Goal date: [DATE] Interventions: Provide substantial bedtime snack and record percentage; Accu checks as ordered; Monitor for noncompliance with therapeutic diet and report to RD or MD; counsel resident/family on modified diet; and Monitor for s/s hypo - [MEDICAL CONDITION]. Nurses Notes Review (Resident #4) revealed the following: [DATE] 12 N complained of (c/o) pain to rectum - Preparation H applied. [DATE] 1:30 p.m. Had several bowel movements (BMs) this shift consistency - Paste-like. Redness noted to scrotum. New order noted - Moisture barrier cream to buttocks & scrotum every (Q) shift & as needed (PRN) incontinent episodes. [DATE] 6:45 p Resident lying in bed with eyes closed easily aroused to verbal tactile stimuli. No signs symptoms of distress noted. Continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident's leg hanging off bed, resident stated "I want to sit up" explained to him that he needs assist to get up, he can fall & injury himself, put leg back in bed instructed him to call - light in reach. Resident took his medications without difficulties. Resident accu check was 61 at 4 p. Resident BMs have gone from pasty to loose doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor. [DATE] (no time documented) Resident alert & awake most of night. Still having BMs constantly. On call light assisted as need. 5:45 A Entered room to do BS (blood sugar). Results 51. Oxygen Saturation (O2 sat) 95% on O2. Tried to arouse. Resident unable to do so. 6:00 A - Informed supervisor of low blood sugar. Resident nonresponsive. 911 called. Family called. CPR started. Resident transported to hospital. An observation was made on [DATE] at 4:00 p.m. of the accu check machine used for Resident #4 on [DATE]. It revealed a date of [DATE] at 06:52 Eastern Time (per S2DON) with a result of 31. Review of the results did not reveal a reading of 51 on [DATE]. Record review and interviews revealed S10 LPN failed to contact the Physician and the RN supervisor of the accu checks of 56 and of 61. The Policy on Diabetic Care instructs the nurse to notify the physician for symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter). Nurses Notes Late Entries (Resident #4): [DATE] 1:33 p.m. Late entry [DATE] 4 p.m. At this time accu check taken it was 56 orange juice with sugar given, res awake, alert & talking skin warm/dry to touch. 5p One hour later accu check retaken 61 at this time give more OJ with sugar resident remain alert. Instructed certified nurse aide (CNA) to make sure resident eats. By mouth (PO) fluids given consumed 180 cc. 5:45 p Resident CNA informed me that he assist with meal, consumed 50% of his supper, fluids was given from supper tray tolerated well. 7 p HS snack given, consumed 100% ? wheat peanut butter & jelly sandwich and 1 pack of graham crackers. VS blood pressure (b/p) ,[DATE], pulse (P) 59, O2 sat 96% on room air O2 probes out machine on at 3 L / minute canula reinserted to nostril. Recheck accu check at this time blood sugar (BS) 86 continue to give mint to keep up. 8p Hemorrhoid cream applied at this time. Resident HS insulin held (Lavmir 12 units) d/t low accu checks. (Review of the documentation failed to reveal the MD was notified that the [MEDICATION NAME] was held.) 9 p CNA reported that resident had loose stool X 1 with foul odor. This nurse place call to nurse practitioner (NP) at this time to informed of resident condition loose stool X 1 with foul odor. No answer left message for return call. On [DATE] at 6:45 pm, contrary to the Nurse Practitioner's order, documentation by S10LPN revealed the facility failed to contact the physician. S10LPN 's nurses notes: "continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident BMs have gone from pasty to loose doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor". Facility Policy instructs nurses to contact physician when a change in acute condition occurs. On [DATE] at 6:45 pm, S10LPN failed to discuss Resident #4's decline in condition with the RN supervisor. Facility policy fails to include notification of RN supervisor of a decline in condition. Interview on [DATE] at 2:16 p.m. with S10LPN revealed she told the oncoming nurse that she had called B ...A ...,NP, and left a message. S10LPN said that she told the night nurse that she was waiting on a call back from B ...A ..., NP. S10LPN said that resident 4 had about 5 stools and 1 loose stool on the 2 p.m. -10 p.m. shift on [DATE]. She said that she called the doctor to report that Resident #4 was still having stools and now 1 loose stool. The nurse failed to contact the medical director or the RN Supervisor and inform them of not contacting the resident's physician. The facility P&P failed to direct nurses regarding checking to ensure which physician/NP is on call and when to notify the medical director and RN supervisor. Nurses Notes Late Entries (Resident #4) continued: 9:30 p Recheck accu check it had come up to 90, resident stated he wanted some pie none available offered Hershey kisses give him 2 that he consumed & left 3 & 2 lemon drops at bed side also gave 200 cc of water. No c/o pain or discomfort voiced. 10 p Report given to oncoming nurse regarding resident condition & his pasty stool & 1 loose stool, told her that a call was place to on call MD, left message to call me back. If doctor return call to let him know about resident stool & foul odor. Resident had several small smears during his pasty stools that was noted. Will continue to monitor. [DATE] 11:00 a.m. Late entry (no date documented) 10:30p -11p Resident alert awake speaking with nurse. C/o loose stool water given for hydration. In no acute distress. [DATE] 11:00 a.m. Late entry (no date documented) 12:00 a.m. Rounds made Resident lying in bed eyes closed; no evidence of shortness of breath (SOB), no acute distress noted. [DATE] 11:00 a.m. Late entry (no date documented) 2:00 a.m. Resident alert, awake, speaking with nurse. Vital Signs (V/S) stable at ,[DATE], 62, 20. Requested water assisted with given water from bedside pitcher. Resident took a few sips stated he was done c/o loose stools. Asked nurse what was facility going to do about stools Nurse informed resident MD will be notified in a.m. Resident verbalized understanding. [DATE] 11:00 a.m. Late entry (no date documented) 2:30 a.m. CNAs stated resident unable to sleep in no acute distress nothing order for sleep at this time. [DATE] 11:00 a.m. Late entry (no date documented) 5:45 a.m. Resident found unresponsive grunting. Accu check 51, O2 sat 95%, O2 at 2 liters (L) minute. Attempts to give Glucoburst unsuccessful due to resident not swallowing RN Supervisor notified. Instructed by RN to call 911. Left RN at bedside. Review of the EMS records dated [DATE] revealed the unit was dispatched at 06:04 AM. The unit arrived at the scene at 06:08 AM and arrived at the patient at 06:12 AM. The unit departed from the facility at 06:24 AM and arrived at hospital at 06:35 AM. The Summary of Events revealed the following: [AGE] year old male found lying in a hospital bed unresponsive, with staff assisting ventilations and attempting CPR. Staff stated they went to check patient's blood sugar and it registered low. When they went back to check on patient, patient was not responding and appeared to be in [MEDICAL CONDITION]. 911 called. Staff stated patient had been down for approximately 20 minutes. Patient pulseless and apnea. Patient warm to the touch. Abdomen distended. Patient incontinent. No trauma noted. IV established, meds given. Patient had a very brief period of restore in pulse while moving patient to ambulance. Patient lost pulse, CPR resumed. An interview was held with T ... L ... Chief Operating Officer at EMS on [DATE] at 12:45 p.m. He stated an accu check reading of Low was indicative of a Blood Glucose of less than 20. Resident #4's Nurse Practitioner stated if a resident's accu check is less than 70 or over 400 then the facility should contact the doctor per interview with B ...A ..., NP (Nurse Practitioner), on [DATE] at 8:55 a.m.. He also said usually calls back in about 15 minutes (when he is called by a nurse at the facility). He said that there is an answering service that is used after 5 p.m. Interview with S2DON on [DATE] at 1:49 p.m. She said that she was called and informed of Resident #4's death on [DATE]. She said that she informed the S3ChargeNurse to place Resident #4's record on her desk and lock it up after the nurses finished with it. She said that she advised the evening shift and night shift nurses to document the late entries. Review of the schedules revealed the following staff were assigned to Resident #4 on [DATE] day and evening shift and [DATE] - [DATE] night shift: Day Shift Nurse S11LPN Day Shift CNA S13CNA Evening Shift Nurse S10LPN Evening Shift CNA S12CNA Night Shift Nurse S8LPN Night Shift CNA S6CNA On [DATE] S2DON provided employee statements regarding Resident #4 obtained by S2DON: 1. S2DON's Telephone Interview with S7RNSupervisor revealed in part: Came on duty at 10:00 pm and made rounds through the facility. I reviewed the weekend report sheets left for me by S2DON. I also met with each nurse on duty, including S8LPN. I asked if they had any problems, anything I needed to know about. I informed each nurse that I was 'here' if they needed anything and to 'just let me know' . S8LPN did not inform me during the first or subsequent rounds that she was having any issues with Resident #4. Resident #4 was on the call light thr

Based on record reviews and interviews, the facility failed to ensure each resident's right to be free from neglect for 1 (#4) of 7 (#1, #2, #3, #4, #5, #10, & #12) diabetic residents out of a sample of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, & #14). On [DATE] Resident #4 began having frequent loose bowel movements and low blood glucose. Resident #4's condition declined until he became unresponsive and went into cardiopulmonary arrest on [DATE]. On [DATE] and [DATE] the facility neglected to provide the following necessary care and services to Resident #4: 1. increased frequency of assessing his bowel movements and blood glucose levels to ensure accurate and timely assessments were made so that his physician would be timely consulted and needed medical care would be provided; 2. assessment of his caloric intake; 3. physician consultation regarding his frequent loose bowel movements and low, decreasing blood glucose; 4. immediate assessment when he became unresponsive; 5. immediate treatment when his blood glucose level was 31mg/dl; 6. assessments, interventions and communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes; 7. implementation of standing orders regarding loose bowels/diarrhea were carried out; 8. Immediately notify the in house RN supervisor of the resident's low blood sugars and subsequent interventions; loose BMs; and inability to reach the MD; 9. RN supervision of LPNs and intervention of treatment for [REDACTED]. 10. educate staff to not administer oral Gulcoburst to an unresponsive resident. This neglect in providing needed care and services permitted Resident #4 to be harmed, placed Resident #4 in immediate jeopardy on two nursing shifts from 9:00 p.m. on [DATE] until his transfer to the hospital at 6:45 a.m. on [DATE] (9 ? hours). This failure had the potential to harm six other diabetic residents (#1, #2, #3, #5, #10, & #12) and placed them in immediate jeopardy. The administrator was informed of the immediate jeopardy on [DATE] at 11:44 a.m. A plan of removal was received on [DATE] which included the following: providing 24 hour RN coverage with the role of the RN Supervisors to provide clinical oversight to recognize and assess, define and implement and monitor and evaluate care and services delivered to facility residents. The facility will provide 24 hour RN supervision to ensure that the facility recognizes and assesses factors that could place a resident at risk for specific conditions, causes or problems and implements interventions, in accordance with resident's needs, goals and standards of practice. RN supervision will include evaluation of the results of the interventions and revise the interventions as necessary. The facility LPN's have been informed to notify RN of any changes in diabetic condition. At the beginning of each shift, the RN will inform the LPNs to contact the RN in regard to changes in diabetic condition. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. for the diabetic residents in the facility when surveyors determined the plan of removal was implemented. The deficient practice continued at a pattern of potential for more than minimal harm for the diabetics residing in the facility. Findings: Review of the policy, Recognizing Signs and Symptoms of Abuse / Neglect, revealed in part the following: Policy Statement - Our facility will not condone any form of resident abuse or neglect. Policy Interpretation and Implementation - 2. " Neglect " is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of / Actual Physical Neglect: 6. Inadequate provision of care Review of the policy titled Acute Condition Changes revised ,[DATE] was presented by S2DON. It revealed the following in part: 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 8. The Nurse and Physician will discuss the situation. Cause Identification 1. The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. if necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . Treatment/Management 1. The Physician will help identify and authorize appropriate treatments. a. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responded to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Review of the Policy and Procedure Nursing Care of the Resident with Diabetes Mellitus (Revised [DATE]) provided by S2DON revealed in part the following: Conditions Associated with Diabetes: 3. [DIAGNOSES REDACTED] (blood sugar below reference ranges). Signs and symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following: b. restlessness f. irritability j. (more severe) stupor, unconsciousness and/or convulsions; and k. (more severe) coma. If these, or other abnormal conditions exist, notify the physician (for [DIAGNOSES REDACTED], follow steps in Management of [DIAGNOSES REDACTED] below). Glucose Monitoring: 4. " Finger sticks " (capillary blood samples) measure current blood glucose levels. 5. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] ,[DATE]milligrams/deciliter (mg/dl) b. Moderate [DIAGNOSES REDACTED] ,[DATE]mg/dl c. Severe [DIAGNOSES REDACTED] <40mg/dl Management of [DIAGNOSES REDACTED]: 1. Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms. 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives); c. remain with the resident d. monitor vital signs; Documentation: Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital Signs as ordered: 2. Level of consciousness: 3. Assessment of the skin including the following: a. color, moisture, and temperature; and 5. Percentage of meals consumed: 6. Emotional reactions, moods: 8. Motor weakness; 9. Urinary symptoms including retention and incontinence; 10. Bowel dysfunction including diarrhea and constipation; Resident #4: Review of the Accumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed the following information: clear speech - distinct intelligible words; makes self understood; understands others; BIMS summary score of 15 (cognitively intact); Functional Status - bed mobility requires extensive assistance of 1 person, transfers requires extensive assistance of 2 persons, dressing requires extensive assistance of 1 person, eating requires supervision with setup help only, toilet use requires extensive assistance of 1 person, personal hygiene requires extensive assistance of 1 person, bathing requires physical help of 1 person; always continent of bladder; occasionally incontinent of bowel; and Active [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [DATE] Apply moisture barrier cream to buttocks and scrotum every (q) shift and as needed (prn) incontinent episodes. Review of the [DATE] physician's orders [REDACTED]. Code Status: Full code Review of the standing orders (No date documented on standing orders) for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). An interview was held with S2DON on [DATE] at 10:25 a.m. She said that this meant the nurse is to call the doctor when the blood sugars are <50 or > 450. The standing orders also revealed the following for diarrhea: If < 4 bowel movements (BMs) in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet by mouth (po) every (q) ,[DATE] hours as needed (prn) X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify doctor (MD)/nurse practitioner (NP) in a.m. The standing orders also revealed Dr. C ... sliding scale Novo R Insulin unit for BS 160 - 200 give 3 units, 201 - 280 give 6 units, 281 - 340 give 9 units, 341 - 400 give 12 units. Recheck blood sugar (BS) in 2 hours after administration of sliding scale insulin. If BS > 400, give 15 units subcutaneous (SubQ) and re-check accu check in 3 hours. If BS not < 400, call NP / MD. [DATE] at approximately 9:00 am an interview was conducted with a family member of resident #4. The family member said that resident #4 had a cell phone and called family members daily throughout the day to talk. The family member said that on [DATE] the resident did not call family members. Review of the Nurse's Notes revealed the following: [DATE] 12 N complained of (c/o) pain to rectum - Preparation H applied. [DATE] 1:30 p.m. Had several bowel movements (BMs) this shift consistency - Paste-like. Redness noted to scrotum. New order noted - Moisture barrier cream to buttocks & scrotum every (Q) shift & as needed (PRN) incontinent episodes. [DATE] 6:45 p Resident lying in bed with eyes closed easily aroused to verbal tactile stimuli. No signs symptoms of distress noted. Continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident's leg hanging off bed, resident stated "I want to sit up" explained to him that he needs assist to get up, he can fall & injury himself, put leg back in bed instructed him to call - light in reach. Resident took his medications without difficulties. Resident accu check was 61 at 4 p. Resident BMs have gone from pasty to loose, doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor. [DATE] (no time documented) Resident alert & awake most of night. Still having BMs constantly. On call light assisted as need. 5:45 A Entered room to do BS - blood sugar. Results 51. Oxygen Saturation (O2 sat) 95% on O2. Tried to arouse. Resident unable to do so. 6:00 A - Informed supervisor of low blood sugar. Resident nonresponsive. 911 called. Family called. CPR started. Resident transported to hospital. An observation was made on [DATE] at 4:00 p.m. of the accu check machine used for Resident #4 on [DATE]. It revealed a date of [DATE] at 06:52 Eastern Time (per S2DON) with a result of 31. Review of the results did not reveal a reading of 51 on [DATE]. Reveiw of the nurses notes late entries: [DATE] 11:00 a.m. Late entry (no date documented) 10:30p -11p Resident alert awake speaking with nurse. C/O loose stool water given for hydration. In no acute distress. [DATE] 11:00 a.m. Late entry (no date documented) 12:00 a.m. Rounds made Resident lying in bed eyes closed; no evidence of shortness of breath (SOB), no acute distress noted. [DATE] 11:00 a.m. Late entry (no date documented) 2:00 a.m. Resident alert, awake, speaking with nurse. Vital Signs (V/S) stable at ,[DATE], 62, 20. Requested water assisted with given water from bedside pitcher. Resident took a few sips stated he was done, c/o loose stools. Asked nurse what was facility going to do about stools, Nurse informed resident MD will be notified in a.m. Resident verbalized understanding. [DATE] 11:00 a.m. Late entry (no date documented) 2:30 a.m. CNAs stated resident unable to sleep in no acute distress nothing order for sleep at this time. [DATE] 11:00 a.m. Late entry (no date documented) 5:45 a.m. Resident found unresponsive grunting. Accu check 51, O2 sat 95%, O2 at 2 liters (L) minute. Attempts to give Glucoburst unsuccessful due to resident not swallowing RN Supervisor notified. Instructed by RN to call 911. Left RN at bedside. [DATE] 1:33 p.m. Late entry [DATE] 4 p.m. At this time accu check taken it was 56 orange juice with sugar given, res awake, alert & talking skin warm/dry to touch. 5p One hour later accu check retaken 61 at this time give more OJ with sugar resident remain alert. Instructed certified nurse aide (CNA) to make sure resident eats. By mouth (PO) fluids given consumed 180 cc. 5:45 p Resident CNA informed me that he assist with meal, consumed 50% of his supper, fluids was given from supper tray tolerated well. 7 p HS snack given, consumed 100% ? wheat peanut butter & jelly sandwich and 1 pack of graham crackers. VS blood pressure (b/p) ,[DATE], pulse (P) 59, O2 sat 96% on room air O2 probes out machine on at 3 L / minute cannula reinserted to nostril. Recheck accu check at this time blood sugar (BS) 86 continue to give mint to keep up. 8p Hemorrhoid cream applied at this time. Resident HS insulin held ([MEDICATION NAME] 12 units) d/t low accu checks. (Review of documentation revealed no record of physician notification of not administering the [MEDICATION NAME].) 9 p CNA reported that resident had loose stool X 1 with foul odor. This nurse place call to nurse practitioner (NP) at this time to informed of resident condition loose stool X 1 with foul odor. No answer left message for return call. 9:30 p Recheck accu check it had come up to 90, resident stated he wanted some pie none available offered Hershey's kisses give him 2 that he consumed & left 3 & 2 lemon drops at bed side also gave 200 cc of water. No c/o pain or discomfort voiced. 10 p Report given to oncoming nurse regarding resident condition & his pasty stool & 1 loose stool, told her that a call was place to on call MD, left message to call me back. If doctor return call to let him know about resident stool & foul odor. Resident had several small smears during his pasty stools that was noted. Will continue to monitor. [DATE] 2:21 p.m. Late entry on [DATE] at 3:45 p.m. Charge nurse spoke with B ...A ..., NP, notified about barrier cream use, told floor nurse to report if stools become loose to MD, nurse verbalize understanding and assumed care of resident. Review of the EMS records dated [DATE] revealed the unit was dispatched at 06:04. The unit arrived at the scene at 06:08 and arrived at the patient at 06:12. The unit departed from the facility at 06:24 and arrived at hospital at 06:35. The Summary of Events revealed the following: [AGE] year old male found lying in a hospital bed unresponsive, with staff assisting ventilations and attempting CPR. Staff stated they went to check patient (pt) blood sugar and it registered low. When they went back to check on pt., pt. was not responding and appeared to be in [MEDICAL CONDITION]. 911 called. Staff stated pt. had been down for approximately 20 minutes. Pt. pulse-less and apneic. Pt. warm to the touch. Abdomen distended. Pt. incontinent. No trauma noted. IV established, meds given. Pt. had a very brief period of restore in pulse while moving pt. to ambulance. Pt. lost pulse CPR resumed. An interview was held with T ... L ... Chief Operating Officer at EMS on [DATE] at 12:45 p.m. He stated an accucheck reading of Low was indicative of a Blood Glucose of less than 20. Review of the Glucoburst package and paper revealed that it delivers 15 grams of glucose. The directions revealed: 1. Hold package upright and tear at the notch. 2. Slowly squeeze contents in mouth and swallow. 3. If no response in 15 minutes repeat dosage. 4. If no response after 2 doses seek medical attention. An interview was held with S2DON on [DATE] at 1:49 p.m. She said that she was called and informed of Resident #4's death on [DATE]. She said that she informed S3ChargeNurse to place Resident #4's record on her desk and lock it up after the nurses finished with it. Record Review of the schedules revealed the following staff were assigned to Resident #4 on [DATE] on the day and eveing shift and [DATE] through [DATE] on night shift: Day Shift Nurse S11LPN Day Shift CNA S13CNA Evening Shift Nurse S10LPN Evening Shift CNA S12CNA Night Shift Nurse S8LPN Night Shift CNA S6CNA On [DATE] S2DON provided employee statements regarding Resident #4 obtained by the S2DON: 1. S2DON's Telephone Interview with S7RNSupervisor revealed in part: Came on duty at 10:00 pm and made rounds through the facility. I reviewed the weekend report sheets left for me by S2DON. I also met with each nurse on duty, including S8LPN. I asked if they had any problems, anything I needed to know about. I informed each nurse that I was 'here' if they needed anything and to 'just let me know' . S8LPN did not inform me during the first or subsequent rounds that she was having any issues with Resident #4. Resident #4 was on the call light through the night but this was not unusual for him as every time I had worked, he was frequently awake during the night calling for staff. I did ask the staff if he was 'okay' and asked what he was calling about. The staff informed me that he was asking for S6CNA but nothing more. At the end of the shift, at approximately 5:,[DATE]:45 am, I was informed I was needed to Resident #4's room STAT. I quickly hurried down to the room and found S8LPN at the bedside. She informed me that his blood sugar was 31. I told her to go call an ambulance and she left the room. I was trying to arouse him but was unable to do so. He would not respond to any type of stimuli and his tongue was hanging out of his mouth. I immediately grabbed the crash cart and the day shift RN (S9RN) had entered the room, we initiated CPR and got the ambu bag ready and hooked to oxygen. Emergency Medical Services (EMS) entered the room pretty quickly. I told them what I knew, including that the nurse had told me his sugar was 31, but that they needed to speak with the nurse caring for him. I sent a CNA after her. EMS wanted to know the code status and I informed them that he was a full code. The nurse returned to the room and I asked for a second glucose level. EMS was starting an IV. I do not recall her getting a second capillary glucose level. When EMS placed him on the monitor, I saw the number 82 but I am not sure if that was his heart rate or not. Once EMS got the needed information, they transported him to the hospital. We were called a few minutes later to be told he had passed. After the event, I met with the staff. At this point, the nurse told me his sugar was 51, not 31. She also told me she had given him some Glucoburst when she first found him, before he became unresponsive. It was not until after he had left the building the staff informed me that he had been experiencing loose stools through the night. I asked if the nurse had administered [MEDICATION NAME] to which I was told she had not. At the end of her telephone interview, S2DON asked the following questions: When you were given report from S8LPN were you informed of the issues with his blood sugar during the previous shift or that the evening nurse had held his insulin? ANSWER-No, I was not. Were you informed that he had experienced a loose stool at the end of the ,[DATE] shift? ANSWER-No, I did not. Did you see Resident #4 during your shift? ANSWER-No, I did not. You are telling me he was using the call light a fair amount that night, why did you not see what was wrong? ANSWER-Every time I worked, he had frequently used the call light during the night for numerous reasons. This was not unusual for him at all. When I asked why he was calling, I was told he wanted S6CNA. Had you been informed of his loose stools during the shift, would you have done anything different? ANSWER- Yes, I would have seen if something was ordered for the stools and if not, had the nurse call and get an order for [REDACTED]. 2. S2DON's Face to Face Interview with S8LPN, 10p-6A LPN, conducted on [DATE] at 10 AM revealed in part: Came on duty at 10:00 p.m. and received report from the off going nurse. I started my first rounds between 10:30 p-11:00 and Resident #4 was one of the first people I saw. He was awake, alert, and talking to me. He stated he was experiencing some loose stools. I gave him some water to drink from his bedside pitcher and told him we had notified the doctor. He did not ask me for anything at that time. His skin was warm and dry and resident did not voice any other complaints. I continued with my rounds. At 12:00 am, I made my next set of rounds, passed medications and began checking my charts. When I checked on him, I "peeped in" . He was resting comfortably, lying supine in the bed but we did not speak. At this point, no one had reported he was having any issues with his stools. Between 1:30am-2:00am I saw him again. I took his vital signs. His B/P was ,[DATE], 62, 20. He and I spoke and he was stating he was continuing to have loose stools. He asked what we were going to do about it. I explained we would call the doctor in the morning. He asked for some water and I gave him some. He took approximately 100cc. At 2:30 a.m. the CNAs asked me if there was something I could give him to help him rest because he had been awake all night. I looked at the chart and told them there was nothing I could do. At 5:45 a.m., I went to get his morning accu check. He was grunting, and difficult to arouse. I checked his sugar and it was 31. His O2 sat was 95% on room air. I went to get Glucoburst from one of the medication carts in the med room. None of the medication carts had any so I went to the supply room. At almost 6:00 a.m., when I returned to his room, he did open his eyes and I attempted to give the Glucoburst but he would not swallow. I put the call light on and ran into the hall calling for help. The RN came immediately to the room and told me to call 911. I left the room to call 911. He lost his pulse while I was out of the room. When I came back to the room, emergency medical services (EMS) was there. S8LPN also told S2DON: At 1:30, she told Resident #4 we would call the doctor in the morning. At 2:30a.m. Resident #4 requested something to help him rest as he had been up due to having loose stools and his bottom burning. S8LPN said she did not ask the CNA how many stools, the last time he experienced one, or the consistency and/or smell of them? S8LPN said when she removed the MAR indicated [REDACTED]. S8LPN said she did not inform the RN on duty of the stools and did not inform the RN on duty about Resident #4's glucose levels during the previous shift? S8LPN said she did not think about implementing the physician's standing orders for [MEDICATION NAME]. S8LPN said she didn't check Resident #4's blood sugar before 6am because she was told by the ,[DATE]LPN that she had got his sugar up and the next accu check wasn't scheduled until 6:00 a.m. S8LPN said Resident #4 was talking to her like he always did and was alert and oriented.. S8LPN said when she attempted to give the Glucoburst and he was not swallowing she did not massage some of the gel into his mucus membranes of his mouth. She said Resident #4 wasn't conscious by this point. She said she called for the RN to come and she told me to get 911 here. S8LPN said she did not think to grab the injectable glucose. She said she had to get vital signs once a shift so since she was in the resident' room in the middle of the night she went ahead and did them. S8LPN said didn't think about monitoring his glucose level during the night and the Resident wasn't acting like his sugar was dropping. S8LPN said she though she documented everything during her shift and told S2DON she would add the rest if S2DON wanted her to. Documentation revealed that S2DON explained the proper way to make late entries into the medical record and watched while this nurse completed her documentation. When she was finished, S2DON explained in great length what concerns she had with her performance that night and how loose stools with any resident but especially a diabetic required her interventions beyond calling the MD in the morning. That she should have notified the RN in the house for direction, or even just informed her of the issue and let the RN determine the course of action. Documentation revealed that S8LPN became extremely emotional at this point crying hysterically and repeatedly apologizing and saying Oh God! I am so sorry". 3. S2DON's [DATE] at 9:34 a.m. face to face interview with S6CNA revealed in part: S6CNA stated she reported to work at 10:00 pm on [DATE]. Approximately 30 minutes after clocking in, Resident #4 turned his call light on. Upon answering the call light, he informed her he needed his adult brief changed. He had experienced a bowel movement, that was medium in size and the consistency a little thinner than peanut butter. He complained of not feeling well due to not being able to urinate. S6CNA placed the urinal between his legs and encouraged him to relax, stating, "it takes time". She waited at the bedside for ,[DATE] minutes while they discussed him feeling like he needed to urinate but could not. When asked if this was reported to the floor nurse, she stated she had not because this was "normal" for Resident #4. After approximately 5 minutes, he asked to have the urinal remain in the brief. She assisted him with positioning in the bed, turned off the room light and instructed him to call her if he needed her. The call light was attached to his hospital gown. She stated she was in the room for approximately ,[DATE] minutes. When asked if Resident #4 appeared unusual in any way, S6CNA stated he did not. He was alert, oriented and 'acted like himself' . When asked if his skin color was pale or if he was sweaty to the touch, she stated he was not. Approximately 10 minutes later (approximately 11:10 p.m.) he called her back, via the call light. He complained of not being able to urinate and was requesting to have the urinal removed. He voiced no other complaints. S6CNA removed the urinal, placed it on the table, within reach, and turned off the light, clipped the call light to his gown and left the room. Approximately 30 minutes later, he called for her again, stating he had experienced another bowel movement. S6CNA and S4CNASupervisor entered to clean him up. S6CNA reported the stool was of medium size and had the same consistency of the stool earlier in the shift: thinner than peanut butter but not watery, and there was 'form' to it. When asked if the stools had an unusual smell, she stated both stools smelled like 'normal BM' . She denied smelling anything unusual or the stool having the appearance of someone who 'was sick' . While the staff was cleansing him, Resident #4 asked for some money so he could get a candy bar. He informed the staff he was 'good for it' . As his son would 'pay them back'. S6CNA informed him that it was not about the money, but that she just did not have any change with her but that she would go check the snack cart and see what was available. When questioned, S6CNA denied Resident #4 specifying why he wanted candy bars but did state he was satisfied with her response and offer to find some type of snack. She stated she and S4CNASupervisor had just walked out of the room to find food for him when he immediately put the call light back on. He stated he had experienced another bowel movement. She and S4CNASupervisor went in to clean him up a second time. S6CNA confirmed he had experienced a small bowel movement. When asked to describe the BM, she replied it was like the others. She went on to state he had also urinated in the brief. After cleansing him up, he complained of his 'bottom burning' for which she applied the barrier cream. Once again, she positioned for comfort and ensured the call light was within reach. She stated she went to the snack cart at the main nursing station, and found a package of Graham crackers while S4CNASupervisor went to each nursing station to see if any sandwiches were left over from the HS snacks. She returned to the room with the Graham crackers and opened the package for him. Upon handing him the crackers, she noticed he had urinated on the sheets. She did not give him the crackers, placed them on the table and stated, "you urinated" . Resident #4 did not know he had but agreed to allow her to change the bed linens. Once completed, she positioned him for comfort, handed him the Graham crackers, and left the room. At this point, approximately 1:30a-2:00 am, she went to the floor nurse to inform her that Resident #4 was having "diarrhea" but that it was not "watery" . She stated the LPN acknowledged this by stating OK. She denied that the LPN asked for any further information or that she saw the nurse go see the resident. When asked why she didn't ask if the nurse had done anything for the stools, S6CNA replied, "They usually do and when she said OK, I thought she was taking care of it." When asked why she called the stools diarrhea when they were pasty formed stools, S6CNA replied because he had 2 stools " back to back" and that was why she reported the stools to the nurse. At this point, it was time for the 3 a.m. rounds, so she started her rounds. While on her rounds, he called for her, approximately 40 minutes after starting the rounds. He was requesting the urinal. She placed the urinal between his legs and waited approximately 5 minutes while talking to him. It was at this point, she noticed the empty wrappers from the Graham crackers. Resident #4 did not ask for any more food at this time. He was unable to urinate so she once again, removed the urinal, ensured the call light was within reach and left the room. When questioned, she denied that he looked or acted any 'different' than his 'normal self'. She informed S2DON that his skin was warm and dry; and that he was not 'sweaty' when she touched his skin. At approximately 5 a.m., she was called to the room due to him wanting to urinate. She handed him the urinal and he placed it in his brief. Once again, she waited at the bedside for ,[DATE] minutes, talking to the resident while he attempted to urinate. Resident #4 was not successful with urinating and asked her to remove the urinal. S6CNA denied that he voiced any further complaints or that he had experienced another bowel movement at this time. She removed the urinal, left it on his table where he could reach it, clipped his call bell on the gown, and left the room. She denied entering the room aga

Based on record reviews and interviews, the facility failed to ensure that the resident's physician was notified and consulted with regarding a resident's loose stools and low blood sugars for 1 (#4) of 7 diabetic residents (#1, #2, #3, #4, #5, #10, & #12) out of a sample of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, & #14). Resident #4 was admitted on [DATE]for rehab for an amputation. On [DATE] Resident #4 began having frequent loose bowel movements and low blood glucose. Resident #4's condition declined until he became unresponsive and went into cardiopulmonary arrest on [DATE]. On [DATE] and [DATE] Resident #4 was not provided the following: 1. physician consultation regarding his frequent loose bowel movements and low, decreasing blood glucose; 2. communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes; 3. notification to the physician that standing orders for diarrhea were not followed; 4. Immediate notification to the in-house RN supervisor of the inability to consult with the physician regarding the changes in the resident's condition; 5. RN supervision of LPNs to ensure communication with physicians in accordance with the facility's written Policy and Procedure regarding Acute Condition Changes and Nursing Care of the Resident With Diabetes. S10LPN ,[DATE] shift [DATE] called and left a message regarding resident #4's diarrhea and low blood glucose levels with a NP who was not on call. She failed to call the Physician/NP who was on call and failed to notify the RN supervisor and the medical director. This failure to consult with the resident's physician permitted Resident #4 to be harmed, placed Resident #4 in immediate jeopardy on two nursing shifts from 9:00 p.m. on [DATE] until his transfer to the hospital at 6:45 a.m. on [DATE] (9 ? hours). This failure had the potential to harm six other diabetic residents (#1, #2, #3, #5, #10, & #12) and placed them in immedate jeopardy. The administrator was informed of the Immediate Jeopardy on [DATE] at 11:44 a.m. A plan of removal was received on [DATE] which included the following: The facility will provide 24 hour RN supervision to ensure that the facility recognizes and assesses factors that could place a resident at risk for specific conditions, causes or problems and implements interventions, in accordance with resident's needs, goals and standards of practice. RN supervision will include evaluation of the results of the interventions and revise the interventions as necessary. The facility LPN's have been informed to notify RN of any changes in diabetic condition. At the beginning of each shift, the RN will inform the LPNs to contact the RN in regard to changes in diabetic condition. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. for the diabetic residents in the facility when surveyors determined the plan of removal was implemented. The deficient practice continued at a pattern of potential for more than minimal harm for the diabetics residing in the facility. Findings: Review of the policy titled Acute Condition Changes revised ,[DATE] was presented by S2DON. It revealed the following in part: 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour of less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 8. The Nurse and Physician will discuss the situation. Cause Identification 1. The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. if necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . Treatment/Management 1. The Physician will help identify and authorize appropriate treatments. a. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responded to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Review of the Policy and Procedure Nursing Care of the Resident with Diabetes Mellitus (Revised [DATE]) provided by S2DON revealed in part the following: 1. Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms. 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (<70mg/dl or less than the physician-ordered parameter): a. immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. if resident remains unresponsive, call 911 (in accordance with resident's advance directives); Resident #4: Review of the Accumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed the following information: clear speech - distinct intelligible words; makes self understood; understands others; BIMS summary score of 15 (cognitively intact); Functional Status - bed mobility requires extensive assistance of 1 person, transfers requires extensive assistance of 2 persons, dressing requires extensive assistance of 1 person, eating requires supervision with setup help only, toilet use requires extensive assistance of 1 person, personal hygiene requires extensive assistance of 1 person, bathing requires physical help of 1 person; always continent of bladder; occasionally incontinent of bowel; and Active [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the standing orders (No date documented on standing orders) for Resident #4 revealed abnormal blood sugars (< 50 or >450 call stat). An interview was held with S2DON on [DATE] at 10:25 a.m. She said that this meant the nurse is to call the doctor when the blood sugars are <50 or > 450. The standing orders also revealed the following for diarrhea: If < 4 bowel movements (BMs) in 24 hours, no treatment; If > 4 BMs in 24 hours, or persist for more than 24 hours, [MEDICATION NAME], one tablet by mouth (po) every (q) ,[DATE] hours as needed (prn) X 48 hours; If diarrhea persists > 8 hours, give clear liquid and add [MEDICATION NAME], one tablet po q 6 hours prn up to 4 doses. If diarrhea persists after 4 doses, notify doctor (MD)/nurse practitioner (NP) in a.m. [DATE] at approximately 9:00 am an interview was conducted with a family member of resident #4. The family member said that resident #4 had a cell phone and called family members daily throughout the day to talk. The family member said that on [DATE] the resident did not call family members. S2DON's interview on [DATE] at 3:45 pm with S10LPN revealed that S10LPN didn't know if B ...A ..., NP, was on call on [DATE] after 4 pm, and she did not check the on-call schedule posted in the medicine room. S2DON verified that that B ...A ..., NP, was not on call on [DATE] after 4 p.m. Review of the Nurse's Notes revealed the following: [DATE] 12 N complained of (c/o) pain to rectum - Preparation H applied. [DATE] 1:30 p.m. Had several bowel movements (BMs) this shift consistency - Paste-like. Redness noted to scrotum. New order noted - Moisture barrier cream to buttocks & scrotum every (Q) shift & as needed (PRN) incontinent episodes. [DATE] 6:45 p Resident lying in bed with eyes closed easily aroused to verbal tactile stimuli. No signs symptoms of distress noted. Continue to have consistent (paste-like) BMs, c/o burning to scrotum moisture barrier cream applied as ordered. Resident's leg hanging off bed, resident stated "I want to sit up" explained to him that he need assist to get up, he can fall & injury himself, put leg back in bed instructed him to call - light in reach. Resident took his medications without difficulties. Resident accu check was 61 at 4 p. Resident BMs have gone from pasty to loose doctor (MD) may need to be notified in a.m. if resident continue. May need some cultures due to (d/t) foul odor. [DATE] (no time documented) Resident alert & awake most of night. Still having BMs constantly. On call light assisted as need. 5:45 A Entered room to do BS - blood sugar. Results 51. Oxygen Saturation (O2 sat) 95% on O2. Tried to arouse. Resident unable to do so. 6:00 A - Informed supervisor of low blood sugar. Resident nonresponsive. 911 called. Family called. CPR started. Resident transported to hospital. An observation was made on [DATE] at 4:00 p.m. of the accu check machine used for Resident #4 on [DATE]. It revealed a date of [DATE] at 06:52 Eastern Time (per S2DON) with a result of 31. Review of the results did not reveal a reading of 51 on [DATE]. Review of the Nurse's Notes revealed the following late entries: [DATE] 11:00 a.m. Late entry (no date documented) 10:30p -11p Resident alert awake speaking with nurse. C/O loose stool water given for hydration. In no acute distress. [DATE] 11:00 a.m. Late entry (no date documented) 12:00 a.m. Rounds made Resident lying in bed eyes closed; no evidence of shortness of breath (SOB), no acute distress noted. [DATE] 11:00 a.m. Late entry (no date documented) 2:00 a.m. Resident alert, awake, speaking with nurse. Vital Signs (V/S) stable at ,[DATE], 62, 20. Requested water assisted with given water from bedside pitcher. Resident took a few sips stated he was done c/o loose stools. Asked nurse what was facility going to do about stools Nurse informed resident MD will be notified in a.m. Resident verbalized understanding. [DATE] 11:00 a.m. Late entry (no date documented) 2:30 a.m. CNAs stated resident unable to sleep in no acute distress nothing order for sleep at this time. [DATE] 11:00 a.m. Late entry (no date documented) 5:45 a.m. Resident found unresponsive grunting. Accu check 51, O2 sat 95%, O2 at 2 liters (L) minute. Attempts to give Glucoburst unsuccessful due to resident not swallowing RN Supervisor notified. Instructed by RN to call 911. Left RN at bedside. [DATE] 1:33 p.m. Late entry [DATE] 4 p.m. At this time accu check taken it was 56 orange juice with sugar given, res awake, alert & talking skin warm/dry to touch. 5p One hour later accu check retaken 61 at this time give more OJ with sugar resident remain alert. Instructed certified nurse aide (CNA) to make sure resident eats. By mouth (PO) fluids given consumed 180 cc. 5:45 p Resident CNA informed me that he assist with meal, consumed 50% of his supper, fluids was given from supper tray tolerated well. 7 p HS snack given, consumed 100% ? wheat peanut butter & jelly sandwich and 1 pack of graham crackers. VS blood pressure (b/p) ,[DATE], pulse (P) 59, O2 sat 96% on room air, O2 probes out, machine on at 3 L / minute, cannula reinserted to nostril. Recheck accu check at this time blood sugar (BS) 86 continue to give mint to keep up. 8p Hemorrhoid cream applied at this time. Resident HS insulin held (Lavmir 12 units) d/t low accu checks. Record review revealed no documentation that the doctor was notified that the [MEDICATION NAME] was held. 9 p CNA reported that resident had loose stool X 1 with foul odor. This nurse place call to nurse practitioner (NP) at this time to informed of resident condition loose stool X 1 with foul odor. No answer left message for return call. 9:30 p Recheck accu check it had come up to 90, resident stated he wanted some pie none available offered Hershey's kisses give him 2 that he consumed & left 3 & 2 lemon drops at bed side also gave 200 cc of water. No c/o pain or discomfort voiced. 10 p Report given to oncoming nurse regarding resident condition & his pasty stool & 1 loose stool, told her that a call was place to on call MD, left message to call me back. If doctor return call to let him know about resident stool & foul odor. Resident had several small smears during his pasty stools that was noted. Will continue to monitor. [DATE] 2:21 p.m. Late entry on [DATE] at 3:45 p.m. Charge nurse spoke with B ...A ..., NP, notified about barrier cream use, told floor nurse to report if stools become loose to MD, nurse verbalize understanding and assumed care of resident. Review of the EMS records dated [DATE] revealed the unit was dispatched at 06:04. The unit arrived at the scene at 06:08 and arrived at the patient at 06:12. The unit departed from the facility at 06:24 and arrived at hospital at 06:35. The Summary of Events revealed the following: [AGE] year old male found lying in a hospital bed unresponsive, with staff assisting ventilations and attempting CPR. Staff stated they went to check pt blood sugar and it registered low. An interview was held with T ... L ... Chief Operating Officer at EMS on [DATE] at 12:45 p.m. He stated an accu check reading of Low was indicative of a Blood Glucose of less than 20. Record Review of the schedules revealed the following staff were assigned to Resident #4 on [DATE] on day and evening shift and [DATE] - [DATE] night shift: Day Shift Nurse S11LPN Day Shift CNA S13CNA Evening Shift Nurse S10LPN Evening Shift CNA S12CNA Night Shift Nurse S8LPN Night Shift CNA S6CNA On [DATE] S2DON provided employee statements regarding Resident #4 obtained by S2DON: 1. S2 DON's Telephone Interview with S7RNSupervisor revealed in part: Came on duty at 10:00 pm and made rounds through the facility. I reviewed the weekend report sheets left for me by S2DON. I also met with each nurse on duty, including S8LPN. I asked if they had any problems, anything I needed to know about. I informed each nurse that I was 'here' if they needed anything and to 'just let me know' . S8LPN did not inform me during the first or subsequent rounds that she was having any issues with Resident #4. Resident #4 was on the call light through the night but this was not unusual for him as every time I had worked, he was frequently awake during the night calling for staff. I did ask the staff if he was 'okay' and asked what he was calling about. The staff informed me that he was asking for S6CNA but nothing more. At the end of the shift, at approximately 5:,[DATE]:45 am, I was informed I was needed to Resident #4's room STAT. I quickly hurried down to the room and found S8LPN at the bedside. She informed me that his blood sugar was 31. I told her to go call an ambulance and she left the room. I was trying to arouse him but was unable to do so. He would not respond to any type of stimuli and his tongue was hanging out of his mouth. I immediately grabbed the crash cart and the day shift RN (S9RN) had entered the room, we initiated CPR and got the ambu bag ready and hooked to oxygen. Emergency Medical Services (EMS) entered the room pretty quickly. I told them what I knew, including that the nurse had told me his sugar was 31, but that they needed to speak with the nurse caring for him. I sent a CNA after her. EMS wanted to know the code status and I informed them that he was a full code. The nurse returned to the room and I asked for a second glucose level. EMS was starting an IV. I do not recall her getting a second capillary glucose level. When EMS placed him on the monitor, I saw the number 82 but I am not sure if that was his heart rate or not. Once EMS got the needed information, they transported him to the hospital. We were called a few minutes later to be told he had passed. After the event, I met with the staff. At this point, the nurse told me his sugar was 51, not 31. She also told me she had given him some Glucoburst when she first found him, before he became unresponsive. It was not until after he had left the building the staff informed me that he had been experiencing loose stools through the night. I asked if the nurse had administered [MEDICATION NAME] to which I was told she had not. At the end of her telephone interview, S2DON asked the following questions: When you were given report from S8LPN were you informed of the issues with his blood sugar during the previous shift or that the evening nurse had held his insulin? ANSWER-No, I was not. Were you informed that he had experienced a loose stool at the end of the ,[DATE] shift? ANSWER-No, I did not. Did you see Resident #4 during your shift? ANSWER-No, I did not. You are telling me he was using the call light a fair amount that night, why did you not see what was wrong? ANSWER-Every time I worked, he had frequently used the call light during the night for numerous reasons. This was not unusual for him at all. When I asked why he was calling, I was told he wanted S6CNA. Had you been informed of his loose stools during the shift, would you have done anything different? ANSWER- Yes, I would have seen if something was ordered for the stools and if not, had the nurse call and get an order for [REDACTED]. 2. S2DON's Face to Face Interview with S8LPN, 10p-6A LPN, conducted on [DATE] at 10 AM revealed in part: Came on duty at 10:00 p.m. and received report from the off going nurse. I started my first rounds between 10:30 p-11:00 and Resident #4 was one of the first people I saw. He was awake, alert, and talking to me. He stated he was experiencing some loose stools. I gave him some water to drink from his bedside pitcher and told him we had notified the doctor. He did not ask me for anything at that time. His skin was warm and dry and resident did not voice any other complaints. I continued with my rounds. At 12:00 am, I made my next set of rounds, passed medications and began checking my charts. When I checked on him, I "peeped in" . He was resting comfortably, lying supine in the bed but we did not speak. At this point, no one had reported he was having any issues with his stools. Between 1:30am-2:00am I saw him again. I took his vital signs. His B/P was ,[DATE], 62, 20. He and I spoke and he was stating he was continuing to have loose stools. He asked what we were going to do about it. I explained we would call the doctor in the morning. He asked for some water and I gave him some. He took approximately 100cc. At 2:30 a.m. the CNAs asked me if there was something I could give him to help him rest because he had been awake all night. I looked at the chart and told them there was nothing I could do. At 5:45 a.m., I went to get his morning accu check. He was grunting, and difficult to arouse. I checked his sugar and it was 31. His O2 sat was 95% on room air. I went to get Glucoburst from one of the medication carts in the med room. None of the medication carts had any so I went to the supply room. At almost 6:00 a.m., when I returned to his room, he did open his eyes and I attempted to give the Glucoburst but he would not swallow. I put the call light on and ran into the hall calling for help. The RN came immediately to the room and told me to call 911. I left the room to call 911. He lost his pulse while I was out of the room. When I came back to the room, emergency medical services (EMS) was there. S8LPN also told S2DON: At 1:30, she told Resident #4 we would call the doctor in the morning. At 2:30a.m. Resident #4 requested something to help him rest as he had been up due to having loose stools and his bottom burning. S8LPN said she did not ask the CNA how many stools, the last time he experienced one, or the consistency and/or smell of them? S8LPN said when she removed the MAR indicated [REDACTED]. S8LPN said she did not inform the RN on duty of the stools and did not inform the RN on duty about Resident #4's glucose levels during the previous shift? S8LPN said she did not think about implementing the physician's standing orders for [MEDICATION NAME]. S8LPN said she didn't check Resident #4's blood sugar before 6am because she was told by the ,[DATE]LPN that she had got his sugar up and the next accu check wasn't scheduled until 6:00 a.m. S8LPN said Resident #4 was talking to her like he always did and was alert and oriented.. S8LPN said when she attempted to give the Glucoburst and he was not swallowing she did not massage some of the gel into his mucus membranes of his mouth. She said Resident #4 wasn't conscious by this point. She said she called for the RN to come and she told me to get 911 here. S8LPN said she did not think to grab the injectable glucose. She said she had to get vital signs once a shift so since she was in the resident' room in the middle of the night she went ahead and did them. S8LPN said didn't think about monitoring his glucose level during the night and the Resident wasn't acting like his sugar was dropping. S8LPN said she though she documented everything during her shift and told S2DON she would add the rest if S2DON wanted her to. Documentation revealed that S2DON explained the proper way to make late entries into the medical record and watched while this nurse completed her documentation. When she was finished, S2DON explained in great length what concerns she had with her performance that night and how loose stools with any resident but especially a diabetic required her interventions beyond calling the MD in the morning. That she should have notified the RN in the house for direction, or even just informed her of the issue and let the RN determine the course of action. Documentation revealed that S8LPN became extremely emotional at this point crying hysterically and repeatedly apologizing and saying Oh God! I am so sorry". 3. S2DON's [DATE] at 9:34 a.m. face to face interview with S6CNA revealed in part: S6CNA stated she reported to work at 10:00 pm on [DATE]. Approximately 30 minutes after clocking in, Resident #4 turned his call light on. Upon answering the call light, he informed her he needed his adult brief changed. He had experienced a bowel movement, that was medium in size and the consistency a little thinner than peanut butter. He complained of not feeling well due to not being able to urinate. S6CNA placed the urinal between his legs and encouraged him to relax, stating, "it takes time". She waited at the bedside for ,[DATE] minutes while they discussed him feeling like he needed to urinate but could not. When asked if this was reported to the floor nurse, she stated she had not because this was "normal" for Resident #4. After approximately 5 minutes, he asked to have the urinal remain in the brief. She assisted him with positioning in the bed, turned off the room light and instructed him to call her if he needed her. The call light was attached to his hospital gown. She stated she was in the room for approximately ,[DATE] minutes. When asked if Resident #4 appeared unusual in any way, S6CNA stated he did not. He was alert, oriented and 'acted like himself' . When asked if his skin color was pale or if he was sweaty to the touch, she stated he was not. Approximately 10 minutes later (approximately 11:10 p.m.) he called her back, via the call light. He complained of not being able to urinate and was requesting to have the urinal removed. He voiced no other complaints. S6CNA removed the urinal, placed it on the table, within reach, and turned off the light, clipped the call light to his gown and left the room. Approximately 30 minutes later, he called for her again, stating he had experienced another bowel movement. S6CNA and S4CNASupervisor entered to clean him up. S6CNA reported the stool was of medium size and had the same consistency of the stool earlier in the shift: thinner than peanut butter but not watery, and there was 'form' to it. When asked if the stools had an unusual smell, she stated both stools smelled like 'normal BM' . She denied smelling anything unusual or the stool having the appearance of someone who 'was sick' . While the staff was cleansing him, Resident #4 asked for some money so he could get a candy bar. She stated she and S4CNASupervisor had just walked out of the room to find food for him when he immediately put the call light back on. He stated he had experienced another bowel movement. She and S4CNASupervisor went in to clean him up a second time. S6CNA confirmed he had experienced a small bowel movement. When asked to describe the BM, she replied it was like the others. She went on to state he had also urinated in the brief. After cleansing him up, he complained of his 'bottom burning' for which she applied the barrier cream. Once again, she positioned for comfort and ensured the call light was within reach. She stated she went to the snack cart at the main nursing station, and found a package of Graham crackers while S4CNASupervisor went to each nursing station to see if any sandwiches were left over from the HS snacks. She returned to the room with the Graham crackers and opened the package for him. Upon handing him the crackers, she noticed he had urinated on the sheets. She did not give him the crackers, placed them on the table and stated, "you urinated" . Resident #4 did not know he had but agreed to allow her to change the bed linens. Once completed, she positioned him for comfort, handed him the Graham crackers, and left the room. At this point, approximately 1:30a-2:00 am, she went to the floor nurse to inform her that Resident #4 was having "diarrhea" but that it was not "watery" . She stated the LPN acknowledged this by stating OK. She denied that the LPN asked for any further information or that she saw the nurse go see the resident. When asked why she didn't ask if the nurse had done anything for the stools, S6CNA replied, "They usually do and when she said OK, I thought she was taking care of it." When asked why she called the stools diarrhea when they were pasty formed stools, S6CNA replied because he had 2 stools " back to back" and that was why she reported the stools to the nurse. At this point, it was time for the 3 a.m. rounds, so she started her rounds. While on her rounds, he called for her, approximately 40 minutes after starting the rounds. He was requesting the urinal. She placed the urinal between his legs and waited approximately 5 minutes while talking to him. It was at this point, she noticed the empty wrappers from the Graham crackers. Resident #4 did not ask for any more food at this time. He was unable to urinate so she once again, removed the urinal, ensured the call light was within reach and left the room. When questioned, she denied that he looked or acted any 'different' than his 'normal self'. She informed S2DON that his skin was warm and dry; and that he was not 'sweaty' when she touched his skin. At approximately 5 a.m., she was called to the room due to him wanting to urinate. She handed him the urinal and he placed it in his brief. Once again, she waited at the bedside for ,[DATE] minutes, talking to the resident while he attempted to urinate. Resident #4 was not successful with urinating and asked her to remove the urinal. S6CNA denied that he voiced any further complaints or that he had experienced another bowel movement at this time. She removed the urinal, left it on his table where he could reach it, clipped his call bell on the gown, and left the room. She denied entering the room again until she was called down there when CPR was in progress. 4. S2DON [DATE] 1:00 p.m. Telephone Interview with S4CNASupervisor in part: Came on duty at 10:00pm and almost immediately after coming on, Resident #4 put his call light on. Both S5CNA and S6CNA answered the light. He was complaining about an upset stomach and that he had a bowel movement. They went down to clean him but he had not had a bowel movement. Shortly after this, he put the light on again. Myself and S6CNA answered the call light. Resident #4 was requesting chocolate, specifically a candy bar. I told S6CNA he is a diabetic, check with the nurse. S6CNA spoke with the nurse and was told he was a diabetic and chocolate was not the right choice of food. I went looking for a peanut butter and jelly sandwich on the snack cart but there weren't any left so we got him some graham crackers, 2 packs, and he said that would be fine and ate the graham crackers. We pulled him up in bed before we left the room. The third time resident #4 put on his light, S6CNA answered the light and this time he did have a bowel movement. S4CNASupervisor assisted her with cleaning him up. The stool was loose but not watery. The stool was brown, had no form but fecal matter was noted as opposed to water. The stool did not have any type of unusual or offensive odor beyond "normal" stool odor. Throughout the night, even when he wasn't using the call light, he was calling out for S6CNA. The fourth time he put the light on, I answered it. He had another stool. It was loose, had no form but did not have an unusual odor. He was complaining of his bottom burning so I put on barrier cream. When I informed S6CNA of this, she stated, "Another stool?" The fifth time he did not use the call light but was yelling out for S6CNA. He did not have a stool but was complaining of his "bottom" hurting him. S6CNA applied the barrier cream on him and positioned for comfort. Throughout the night, he either used the light or called out for S6CNA. She was one of his favorite staff members. On last rounds, between 5:30am-6:00am, the call light was put on again. I was on the hall and saw the nurse enter the room so I did not head down and S6CNA was moving her barrels off the hall. A few seconds later, the nurse ran out of the room and said he was nonresponsive. S6CNa and I ran to the room. We hollered for S7RNSupervisor and S6CNA. The RN entered the room, saw him and grabbed the crash cart. The day shift S9RN was in the room too. We lowered the head of the bed, I slid the CPR board under him. CPR was initiated and 911 was called. S5CNA was doing compressions and H ... was using the ambu bag while the RN Supervisor was attaching it to the oxygen. While this was going on, S7RNSupervisor asked if he was a diabetic and what the blood sugar was S4CNASupervisor stated she thought S8LPN stated his sugar was 31. Emergency Medical Services (EMS) arrived and started an IV but would not take over chest compressions. I was told they wanted the paper work even though we had informed them that he was a full code. S5CNA and S9RN continued with CPR and bagging him. After they received the paperwork, EMS took over and left the facility with the resident. S4CNASupervisor said Resident #4 had ,[DATE] stools. She helped S6CNA with them and she and I discussed it. Some of these were small smear like stools but we cleaned him anyway and then he would immediately have another, like he wasn't finished. 5. S2DON's [DATE] 1:15pm interview with S10LPN regarding [DATE] ,[DATE] shift and Resident #4. The interview revealed in part: S10LPN stated she came on duty at 2 p.m. and received report from S11LPN. It was reported to her that Resident