Every finding on record at Woodlawn Rehabilitation & Nursing Center

Based on record review and interview, the facility failed to document and adequately monitor a resident after an unwitnessed fall for 1 of 2 residents reviewed for falls (Resident #25 [R25]).Finding: A review of R25's clinical record revealed he/she sustained an unwitnessed fall on 7/1/26, 7/18/26, and 8/17/26.The facility's Neuro (Neurological) Check Sheet indicates that neurological monitoring is to be completed immediately at the time of the incident, every 15 minutes for the first hour following the incident, then every hour for 4 hours, then every 4 hours for 24 hours, and states, The neurological assessment will continue to be completed at least every 8 hours for the next 48 hours, consisting of a 72 hour monitoring period.A review of R25's Neuro (Neurological) Check Sheets for the above falls revealed the following:-The Neuro Check Sheet dated 7/1/26 indicated missed for the 15-minute checks due at 4:00 p.m. and 4:15 p.m. and lacked evidence that the 4:30 p.m. check was assessed.- The Neuro Check Sheet dated 7/18/26 lacked evidence that the 60-minute checks due at 4:30 a.m. and 5:30 a.m. and the 4 hour check due at 11:30 a.m. were assessed.- The Neuro Check Sheet dated 8/17/26 indicated missed for the 15-minute check due at 4:45 p.m. and lacked evidence that the 8-hour check due on 8/19/26 at 12:45 p.m. was assessed.On 8/26/26 at 2:41 p.m. the surveyor reviewed R25's Neuro Check Sheets with the Operations Consultant and confirmed that the above neurological checks were not completed.

Based on clinical record review and interview, the facility failed to provide timely pain management for 1 of 1 resident reviewed for pain management (Resident #47 [R47]).Finding:Clinical record review revealed R47 was admitted to the facility in January 2026 following a hospitalization for cervical spinal stenosis and cervical spine decompression surgery. The resident's diagnosis also included left distal radius and right foot pain.Clinical record indicated R47 had reported a pain level of 8 on a scale of 1 to 10 (1 being little to no pain and 10 is the worst pain imaginable). Review of the Medication Administration Record (MAR) revealed R47 received Oxycodone 10 milligrams (mg) on 1/29/26 at 4:11 p.m. At 5:21 p.m. documentation indicated the medication was effective and the resident's pain level was 3 out of 10.On 1/29/26 at 6:07 p.m. and 6:09 p.m. R47's pain level was documented as 7 out of 10. Another dose of Oxycodone 10 mg was available for administration at approximately 8:21 p.m.On 1/30/26 at 12:11 a.m. R47 pain level was documented as 10 out of 10, and Oxycodone 10 mgs was administered. At 2:08 a.m. documentation indicated the medication was effective and the resident's pain level was 2 out of 10.The clinical record lacked documentation of further pain assessment or pain intervention from 1/29/26 at 6:09 p.m. until 1/30/26 at 12:11 a.m. During an interview on 8/26/26 at 4:30 p.m., the Director of Nursing stated that the Oxycodone order was entered into the pharmacy system on 1/29/26 at 2:59 p.m. and a total of six 5 mg Oxycodone tablets were released from the emergency kit for use until the residents as needed medication arrived. The DON stated the medication was subsequently not sent because the order was cancelled.

Based on observations, record review, and interviews, the facility failed to ensure a resident's comprehensive care plan was developed and implemented to reflect the current needs of the resident in the area of smoking for 1 of 3 sampled residents reviewed during a complaint investigation (Resident #1).Finding:Facility policy, Smoking Policy-Residents, revised 3/2025 states, .Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan.Resident #1 has diagnoses including dementia and tobacco use.A review of Resident #1's Smoking and Safety Assessment, dated 2/24/26, states, Supervision, designated smoking location, and smoking times are determined by facility policy. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated and under Smoking Safety Notes, states, Resident goes off campus for smoking with friends or family as we are a non-smoking campus. Resident is unable to take self outside and off campus independently, requiring assistance. Resident has no desire to participate in a smoking cessation program.A review of Resident #1's Smoking and Safety Assessment, dated 6/5/26 indicated the following:-Poor vision or blindness- Limited or no ROM [range of motion] in arms or hands- Insufficient fine motor skills needed to securely hold tobacco or other smoking items- Unable to light tobacco or other smoking products safely- Unable to extinguish tobacco or other smoking products safely- Unable to use ashtray to extinguish tobacco or other smoking products.A review of Resident #1's care plan, reviewed 7/31/26, included a care area for Tobacco Use but lacked evidence that person-centered goals and interventions were developed and implemented related to Resident #1 smoking.On 8/17/26 at 3:30 p.m. during an interview, the Director of Nursing (DON) stated that the facility is non-smoking and that it determined that Resident #1 was not safe to smoke independently and stated that staff do not assist residents to go out to smoke, so Resident #1 must smoke under the supervision of family and/or friends and stated this is indicated on Resident #1's care plan. At this time, the surveyor discussed the above finding with the DON.

Based on record review, interview, and facility policy, the facility failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of 1 of 3 residents reviewed during a complaint investigation (Resident #1).Finding:Facility policy, Ordering and Receiving Non-Controlled Medications, dated 9/10 states, Medications and related products are received from the provider pharmacy on a timely basis. New medications.are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a .medication prior to pharmacy delivery.1. Resident #1 was admitted with diagnoses to include hypoosmolality (a low concentration of solutes, including sodium, in the blood plasma) and hyponatremia (low blood sodium levels).A review of Resident #1's clinical record revealed the following active physician orders:An order with a start date of 8/8/26 for Sodium Chloride Oral Tablet 1 GM [gram]. Give 1 tablet by mouth three times a day related to HYPO-OSMOLALITY AND HYPONATREMIAAn order with a start date of 1/2/26 for Torsemide Oral Tablet 20 MG [a diuretic medication] Give 1 tablet by mouth three times a day.A review of the facility's physician standing orders, dated 1/6/26 states, New Admissions.May Use Discharge summary as active orders.May hold unavailable medication x 2 doses until medication arrives from pharmacy if pt [patient] vital signs stable and clinically asymptomatic.A review of Resident #1's August 2026 Medication Administration Record (MAR) indicated the sodium chloride was scheduled to be given three times daily at 8:00 a.m., 1:00 p.m., and 8:00 p.m. Further review of the August MAR revealed Resident #1 did not receive the 8:00 p.m. dose of the medication on 8/8/26 and did not receive the 8:00 a.m. dose, 1:00 p.m. dose, or 8:00 p.m. dose on 8/9/26, and did not receive the 8:00 a.m. or 1:00 p.m. dose on 8/11/26, resulting in six consecutive missed doses.A review of the August MAR nursing progress notes for the missed sodium chloride doses revealed the following:A MAR progress note dated 8/8/26 at 8:45 p.m. states, .waiting for delivery.A MAR progress note dated 8/9/26 at 9:46 a.m. states, .UNAVAILABLE.WAITING FOR PHARMACY TO SEND.A MAR progress note dated 8/9/26 at 1:18 p.m. states, .UNAVAILABLE.MED NOT IN THE PYXIS .WAITING FOR THE PHARMACY TO SEND.A MAR progress note dated 8/9/26 at 9:06 p.m. states, .waiting for delivery from pharmacy.A MAR progress note dated 8/10/26 at 10:05 a.m. states, .waiting for delivery from pharmacy.A MAR progress note dated 8/10/26 at 1:36 p.m. states, .waiting for delivery from pharmacy.Review of the facility's Order Audit Report revealed that the sodium chloride tablets were ordered on 8/8/26 at 6:05 p.m. Review of the provider pharmacy Delivery Manifest Report indicated that the sodium chloride tablets were delivered on 8/10/26 at 11:58 p.m.A review of R1's provider progress notes revealed the following:A provider progress note dated 8/10/26 that states, .seen via telemedicine from the nursing facility for follow-up of a critical sodium level. [He/She] was sent to the emergency department on Thursday for low sodium and was admitted . During [his/her] hospitalization, [he/she] was found to have severe hyponatremia Diuretics were held with gradual improvement. [He/She] was advised that [he/she] remained significantly hyponatremic and was not medically ready for discharge.[He/She]. elected to leave against medical advice. was discharged on sodium chloride 1,000 mg TID [three times daily]. Discussed with nursing staff that [his/her] sodium chloride tablets have not arrived from the pharmacy per chart review. Asked nursing to call the pharmacy to check if it will be delivered tonight, and if not, to call back so the prescription can be sent to a local pharmacy. A repeat BMP has been ordered for Thursday, which is the next lab day, to reassess sodium levels.On 8/17/26 at 2:25 p.m., the surveyor discussed the above finding with the Director of Nursing (DON).

Based on record review, interview, and facility policy, the facility failed to follow their policy to notify a physician that medication was unavailable for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Finding:A review of the facility's physician standing orders, dated 1/6/26 states, New Admissions.May Use Discharge summary as active orders.May hold unavailable medication x 2 doses until medication arrives from pharmacy if pt [patient] vital signs stable and clinically asymptomatic.Resident #1 was admitted with diagnoses to include hypoosmolality (a low concentration of solutes, including sodium, in the blood plasma) and hyponatremia (low blood sodium levels).A review of Resident #1's clinical record revealed the following active physician orders:An order with a start date of 8/8/26 for Sodium Chloride Oral Tablet 1 GM [gram]. Give 1 tablet by mouth three times a day related to HYPO-OSMOLALITY AND HYPONATREMIAAn order with a start date of 1/2/26 for Torsemide Oral Tablet 20 MG [a diuretic medication] Give 1 tablet by mouth three times a day.A review of Resident #1's August 2026 Medication Administration Record (MAR) indicated the sodium chloride was scheduled to be given three times daily at 8:00 a.m., 1:00 p.m., and 8:00 p.m. Further review of the August MAR revealed Resident #1 did not receive the 8:00 p.m. dose of the medication on 8/8/26 and did not receive the 8:00 a.m. dose, 1:00 p.m. dose, or 8:00 p.m. dose on 8/9/26, and did not receive the 8:00 a.m. or 1:00 p.m. dose on 8/10/26, resulting in six consecutive missed doses.A review of the August MAR nursing progress notes for the missed sodium chloride doses revealed the following:A MAR progress note dated 8/8/26 at 8:45 p.m. states, .waiting for delivery.A MAR progress note dated 8/9/26 at 9:46 a.m. states, .UNAVAILABLE.WAITING FOR PHARMACY TO SEND.A MAR progress note dated 8/9/26 at 1:18 p.m. states, .UNAVAILABLE.MED NOT IN THE PYXIS .WAITING FOR THE PHARMACY TO SEND.A MAR progress note dated 8/9/26 at 9:06 p.m. states, .waiting for delivery from pharmacy.A MAR progress note dated 8/10/26 at 10:05 a.m. states, .waiting for delivery from pharmacy.A MAR progress note dated 8/10/26 at 1:36 p.m. states, .waiting for delivery from pharmacy.Further review of the MAR indicated that R1 received all scheduled doses of the Torsemide for the timeframe that the sodium chloride was not administered.Additional review of Resident #1's clinical record, including the nursing and provider progress notes, lacked evidence that the provider was notified that the sodium chloride tablets were unavailable after two doses of the medication were not administered. A review of R1's provider progress notes revealed the following:A provider progress note dated 8/10/26 that states, .seen via telemedicine from the nursing facility for follow-up of a critical sodium level. [He/She] was sent to the emergency department on Thursday for low sodium and was admitted . During [his/her] hospitalization, [he/she] was found to have severe hyponatremia with a serum sodium of 119 and serum osmolality of 274 hyponatremia was felt to be multifactorial in the setting of advanced CKD [chronic kidney disease], decreased oral intake, and substantial outpatient diuretic exposure with both torsemide and furosemide. Diuretics were held with gradual improvement. [He/She] was advised that [he/she] remained significantly hyponatremic and was not medically ready for discharge.[He/She]. elected to leave against medical advice. was discharged on sodium chloride 1,000 mg TID [three times daily]. Discussed with nursing staff that [his/her] sodium chloride tablets have not arrived from the pharmacy per chart review. Asked nursing to call the pharmacy to check if it will be delivered tonight, and if not, to call back so the prescription can be sent to a local pharmacy. A repeat BMP has been ordered for Thursday, which is the next lab day, to reassess sodium levels.A provider note dated 8/11/26 that states, . nurse reports the lab company called to report a critical lab value- Na [sodium] 120. Patient now reports vomiting, lower abdominal pain. [He/She] said [he/she] has had a seizure before but unknown when. Due to critical sodium level with symptoms will send to ED [Emergency Department] for evaluation.A provider note dated 8/13/26 that states, .sodium chloride tablets had not arrived from the pharmacy, leading to a critical sodium level of 120 on 8/11 and a return to the ED, where hypertonic saline improved [his/her] sodium to 125.On 8/17/26 at 2:25 p.m., the surveyor discussed the above finding with the Director of Nursing (DON). During an interview, the DON stated that the facility has standing physician orders to hold two doses if a medication is unavailable but that the nurse should have notified the provider and stated that if the nurse had notified the provider, it would have been indicated in a progress note.

Based on clinical record review, and interviews, the facility failed to ensure a resident's safety during care resulting in the resident rolling out of bed to the floor and sustaining a fractured left humerus (long bone in upper arm) for 1 of 1 resident reviewed for fall and fracture.Finding: On 7/22/26, a review of R1's clinical record was completed. Documentation in a nursing note, dated 4/25/26, a statement made by Certified Nurse Assistant #1 (C.N.A.1), indicated that while C.N.A.1 was changing R1's bed sheets, R1 rolled out of bed onto the floor. On 4/25/26, documentation made at the Emergency Department (ED) indicated the resident was seen due to a fall out of bed. Documentation in R1's active problem list indicated some of this/her problems are bipolar disorder, post traumatic stress disorder, anxiety, above the knee amputation (AKA) on left side, altered mental state, arthritis, memory loss, and unable to care for self. Documentation indicated that R1 told ED staff that his/her sheets were being changed and they had to roll over and when they did they fell over a pillow and landed on their left side. During this visit, an x-ray showed no injury to the left shoulder. On 5/15/26, twenty days after the fall out of bed, R1 was transported to the ED for complaints of abdominal pain/potential constipation. ED documentation indicated that R1 complained of hurting all over but especially the left shoulder. ED documentation indicated R1 fell out of bed 2 or 3 weeks ago and had been evaluated at this ED and no injury. On this 5/15/26 ED visit, an x-ray was done and it was discovered that R1 had a fractured left humerus.Documentation in the Physician's Progress note, dated 5/29/26, indicated previously R1 fell from bed on 4/25/26, landing on his/her left side resulting in left shoulder and elbow pain. A displaced left humerus fracture was identified by x-ray on 5/15/26.On 7/22/26 at 10:00 a.m., in an interview with the surveyor, R1 stated that a few weeks ago, they fell out of bed when rolling over for care and fractured their left shoulder. On 7/30/25 at 3:33 p.m., in a telephone interview with the surveyor, C.N.A.1. stated that R1 was a one-person assist at the time (4/25/26). R1 was able to roll over by themself. C.N.A.1 stated she thought there was a handrail on one side of the bed but couldn't remember if there was one on the side R1 rolled toward. C.N.A.1 stated she is 5 feet 1inch, so she did not have the bed up in a high position. C.N.A.1 stated she was going to change R1's bed sheet, and asked R1 to roll over onto his/her left side. C.N.A.1 stated before she could do anything, R1 rolled over so fast she couldn't stop R1. C.N.A.1 stated it all happened so fast and she did not remember R1 being close to the edge of the bed and did not remember if a pillow was placed between R1 and the edge of the bed. C.N.A.1 stated she is aware that R1 has an AKA on the left side, the side R1 was rolling onto too.There is no evidence in the clinical record that any safety interventions were put in place to ensure R1 did not roll off the bed prior to having R1 roll over onto the left side. There was no evidence that C.N.A.1 ensured that R1 was not too close to the edge of the bed or that a pillow or device was used to stabilize the resident when lying on their left side.

Based on record review and interviews, the facility failed to report an injury of unknown origin for a fracture identified on 5/15/26 to Licensing and Certification or Adult Protective for 1 of 1 resident reviewed for fractures. (Resident #1 [R1]).Finding: On 7/22/26, a review of R1's clinical record was completed. Documentation in a nurse note, dated 4/25/26, of a statement made by Certified Nurse Assistant #1 (C.N.A.1), indicated that while C.N.A.1 was changing R1's bed sheets, R1 rolled out of bed onto the floor. Documentation made by the Emergency Department (ED), dated 4/25/26 indicated the resident was there due to a fall out of bed. During this visit, an x-ray showed no injury to the left shoulder. On 5/15/26, R1 was transported to the ED for complaints of abdominal pain/potential constipation. During this ED visit, R1 complained of pain in the left shoulder. An x-ray was done and it was discovered that R1 had a fractured left humerus (long bone in upper arm). On 7/22/26 at 10:00 a.m., in an interview with the surveyor, R1 stated that a few weeks ago, he/she fell out of bed when rolling over for care and now has a fractured left shoulder. On 7/22/26 at 12:34 p.m., in an interview with the surveyor, the Director of Nursing (DON) stated she did not feel that the fractured left humerus discovered on 5/15/26 at the ED was related to R1's fall out of bed on 4/25/26. The DON stated that almost a month's time had passed and R1 goes out a lot to the parking lot and out with friends. The DON stated something could have happened during those times to cause the left humerus fracture. The DON stated she did not think of the fracture as an injury of unknown origin at that time the fractures was discovered and confirmed that she did not file an incident report for the injury of unknown origin with Licensing.There was no evidence in R1's clinical record that a report of an injury of unknown origin on 5/15/26 was sent to Licensing and Certification or Adult Protective.

Based on record review, facility Abuse Policy review, and interview, the facility failed to ensure that an investigation was completed for an undetermined injury of unknown origin (fracture of left arm) identified on 5/15/26 for 1 of 1 resident reviewed for fractures (Resident #1 [R1]). Finding: On 7/22/26, a review of R1's clinical record was completed. Documentation in a nurse note, dated 4/25/26, of a statement made by Certified Nurse Assistant #1 (C.N.A.1), indicated that while C.N.A.1 was changing R1's bed sheets, R1 rolled out of bed onto the floor. Documentation made by the Emergency Department (ED), dated 4/25/26 indicated the resident was there due to a fall out of bed. During this visit, an x-ray showed no injury to the left shoulder. On 5/15/26, R1 was transported to the ED for complaints of abdominal pain/potential constipation. During this ED visit, R1 complained of pain in the left shoulder. An x-ray was done and it was discovered that R1 had a fractured left humerus (long bone in upper arm). R1 was transported back to the facility with a shoulder sling and instructions for a follow-up with an orthopedic. On 7/22/26 at 10:00 a.m., in an interview with the surveyor, R1 stated that a few weeks ago, when they were rolling over in order to get personal care, they rolled out of bed and fractured their left shoulder. On 7/22/26 at 12:34 p.m., in an interview with the surveyor, the Director of Nursing (DON) stated she did not feel that the fractured left humerus discovered on 5/15/26 at the ED was related to R1's fall out of bed on 4/25/26. The DON stated that almost a month's time had passed and R1 goes out a lot to the parking lot and out with friends. The DON stated something could have happened during those times to cause the left humerus fracture. The DON stated she did not think of the fracture as an injury of unknown origin for the fracture identified on 5/15/26 and confirmed that she did not do an investigation into the potential cause of the fractured left humerus.On 7/22/26, a review of the facility Resident Abuse Prevention Policy and Procedure indicated under #5 Reporting/Response; c. reports of alleged abuse, neglect or exploitation will be reported to DHS Licensing and Certification. Reports of injuries of unknown origin should be immediately reported to the Administrator. #6 Investigations; any incident which may in fact be abuse, neglect or exploitation will be logged, assigned to the Director of Nursing or the Social Service Director to investigate . A copy of the report will be sent to DHS, Licensing and Certification.On 7/22/26 at 12:34 p.m., in an interview with the surveyor, the Director of Nursing (DON) confirmed that she did not investigate the injury of unknown origin/fractured left humerus identified on 5/15/26 for potential causative factors.

Based on observation, interviews, and facility policy, the facility failed to ensure medications were stored properly on 1 of 2 units (West unit).Finding: On 2/25/26 at 9:43 a.m., a surveyor observed an unattended medication (med) cart located outside of room [ROOM NUMBER] on the [NAME] Unit. A medication cup containing an unknown red liquid was on top of the med cart. Additionally, a clear plastic cup containing plastic sleeves used for crushing medications, with medication residue inside the plastic sleeves, was located on top of the med cart. At this time, the surveyor observed Resident #3 foot-propelling in his/her wheelchair in the hall by the med cart. At 9:50 a.m., Certified Nursing Assistant-Medication Tech (CNA-M) #1 returned to the med cart. At this time, during an interview, the surveyor discussed the above observation, and CNA-M #1 stated that the medication sleeves are trash and contain residue from meds she had crushed for a resident and that the red liquid in the med cup is Robitussin that she had poured for a resident, and that she should have placed the med in a locked drawer before leaving the med cart unattended.Facility policy Medication Labeling and Storage, revised 3/2025 states, The facility stores all medications and biologicals in locked compartments. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including but not limited to, drawers.carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.On 2/25/26 at 10:08 a.m., the surveyor discussed the above finding during an interview with the Director of Nursing (DON).

Based on observations and interviews, the facility failed to ensure the confidentiality of protected resident health information when a resident's electronic medication profile and residents' written medication information was left unattended on a medication (med) cart and a nursing assignment sheet containing resident health information was left unattended on the nurses' station countertop, leaving the residents' health information visible and accessible to residents and visitors on 1 of 2 units (West Unit).Findings:1. On 2/25/26 at 9:43 a.m., a surveyor observed an unattended med cart located outside of room [ROOM NUMBER] on the [NAME] Unit with an open laptop computer affixed to the cart and the electronic Medication Administration Record (eMAR) for Resident #4 visible on the computer screen. The visible information on the eMAR included but was not limited to Resident #4's name, photograph, date of birth , vital signs, and medication orders. The surveyor also observed a white sheet of paper, face-up on top of the med cart, listing 3 resident names with a medication name and strength under each resident's name. At 9:50 a.m., Certified Nursing Assistant-Medication Tech (CNA-M) #1 returned to the med cart. At this time, during an interview, the surveyor discussed the above observation, and CNA-M #1 stated that she should have closed her laptop and turned the resident info upside down before leaving the med cart unattended.On 2/25/26 at 10:08 a.m., the surveyor discussed the above finding during an interview with the Director of Nursing (DON).2. On 2/25/26 at 12:36 p.m., the surveyor observed a clipboard face-up on the countertop of the [NAME] Unit nurse's station. The assignment sheet on the clipboard included the names of 17 residents and their room numbers, meal intakes, and bathing information. A small sheet of paper also attached to the clipboard contained the names of 2 residents and listed their vital signs. There were no staff nearby at the time of the observation. On 2/25/26 at 12:37 p.m., the surveyor discussed the finding during an interview with the DON. At this time, the DON stated that she has previously educated the nursing staff that they cannot leave the clipboard on the countertop and that she will re-educate the staff.On 2/25/26 at 2:10 p.m., during a repeat observation, the unattended clipboard remained face-up and accessible to residents and visitors.

Based on observations, interviews, and record review, the facility failed to ensure that the resident's environment remains free of accident hazards by failing to clean up spilled liquids on an ambulatory resident's floor on 1 of 2 units observed during a complaint investigation (West Unit). Additionally, the facility failed to ensure that a metal threshold plate at an entrance used by residents was properly secured, creating a tripping hazard with the potential to affect multiple residents.Findings:1. Resident #2 was recently admitted with diagnoses to include legal blindness and syncope and collapse.On 2/25/26 at 8:36 a.m., a surveyor observed Resident #2 lying in bed and liquid on the floor next to his/her bed. During an interview at this time, Resident #2 stated that he/she had spilled his/her coffee and notified a staff member and that the staff member said she would clean it up but has not been back yet.On 2/25/26 at 8:55 a.m., during a repeat observation, Resident #2 was seated in his/her chair located next to his/her bed. During an interview at this time, Resident #2 stated that he/she transferred him/herself and ambulated to the chair using his/her walker. The surveyor observed that the floor remained wet with coffee. At this time, the surveyor discussed the above observations with the Director of Nursing (DON), and she stated that she will have housekeeping clean the floor now.2. On 2/11/26, the Division of Licensing received a complaint stating, .the threshold is broken at the first entrance and the client could not exit with [his/her] wheelchair in an emergency situation.On 2/25/26 at 1:40 p.m., a surveyor and the Maintenance Director observed a metal transition plate located at the main front entrance threshold. The outer edges of the threshold plate were not properly secured, creating gaps between the plate and the floor/ground, causing the plate to shift when weight was applied. During an interview at this time, the Maintenance Director confirmed that residents do exit and enter through this entrance when leaving with family or staff. The Maintenance Director then stated that he would repair the threshold immediately. On 2/25/26 at 4:00 p.m., the surveyor observed that the threshold plate was properly secured to the floor.

Based on interviews, and record review, the facility failed to follow their standing orders for bowel management for 1 of 3 residents reviewed for bowel management resulting in the resident having to be transferred to the hospital. (Resident #1)Findings:On 1/29/29 the Division of Licensing and Certification received a complaint regarding Resident #1. The complaint stated that Resident #1 was screaming in pain, when the complainant was able to figure out what was causing the pain, it was determined that Resident #1 had not had a bowel movement in 14 days. Resident #1 was then taken to the emergency room (ER) via ambulance.A review of the facilities standing orders for their bowel routine indicated that nursing staff had the ability to give Resident #1 a Bisacodyl laxative Rectal Suppository 10 milligrams: insert 1 suppository rectally as needed for bowel management every 3 days as needed, MiraLAX oral powder 17grams: give 17 grams by mouth as needed for bowel management once per day as needed, Senna 8.6 milligram tablet: Give 2 tablets by mouth as needed for bowel management at bedtime, Milk of Magnesia oral suspension 7.75%: give 30 milliliters by mouth as needed for constipation, and a Fleet oil rectal enema: insert 1 applicator rectally as needed for constipation every 3 days as needed.A review of Resident #1's clinical record showed he/she had a bowel movement on 1/9/26. On 1/16/26 (day 7 without a bowel movement) Senna (oral laxative) was given. On 1/24/26 (day 15 without a bowel movement) a Bisacodyl Suppository was given. On 1/24/26 at 11:56 a.m., a nursing progress note indicated that the suppository was ineffective. This note also stated that Resident #1's bowel sounds were hypoactive (slowed intestinal activity), and his/her abdomen was firm and tender. At this time, an order was obtained to transfer the resident to the ER. Further review of the clinical record shows a nursing note on 1/24/26 at 7 p.m., stating the resident returned from the ER and his/her constipation issue was rectified with an enema.Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 of 15, indicating he/she is cognitively intact.On 2/3/26 at 11:00 a.m., in an interview with Resident #1, he/she remembers going 2 weeks without a bowel movement. Stating he/she had bad pain. He/she informed the surveyor that they alerted multiple staff of his/her pain and discomfort.A review of Resident #1's medical administration record and treatment administration record under the column Pain monitoring- Assess for pain every shift from the dates 1/10/26 through 1/24/26 shows he/she experienced pain 2 times on day shift and 6 times on evening shift. On 2/3/26 at 11:30 a.m., during an interview with a Licensed Practical Nurse (LPN), a surveyor asked what process is in place to inform staff when residents go extended periods of time without a bowel movement. She stated that night shift prints off a list of all residents, which shows how long a resident has gone without a bowel movement. When follow up questions were asked, it was determined that the facility initiates bowel protocol after 3 days after no bowel movement. She states that first they start with prune juice, then go to senna, then milk of magnesia, then a suppository, and if none of that works, they do a fleet enema.On 2/3/26 at 11:45 a.m., during an interview with a Medication Tech who discussed the facilities bowel protocol starting after 3 days of no bowel movement. She states they start with the least invasive medication and work the way up to a fleet's enema, or until they get a bowel movement.On 2/3/26 at 12:30 p.m., during an interview with the Director of Nursing and Facility Administrator, they confirmed that bowel protocol starts after 3 days of no bowel movement. Furthermore, they confirmed that Resident #1's constipation was not appropriately managed.

Based on record review and interviews, the facility failed to obtain lab services in a timely manner for 1 of 1 resident reviewed for lab orders. In turn, this led to the resident needing to obtain treatment and receive care in the emergency room (ER). (Resident #1).Findings:A review of Resident #1's medical record shows an resident had ER visit on 1/24/26 for constipation, at the time labs were drawn. A review of the ER discharge summary stated resident had a moderately low sodium level of 125. The ER discharge summary indicated to redraw Resident #1's sodium level Monday 1/26/26. Resident #1's record lacked evidence of a lab draw occurring on 1/26/26. On 1/29/26 a nursing progress note stated he/she had a critical sodium level of 121 the on-call provider was notified, and the resident was transferred to the ER.On 2/3/26 at 12:30 p.m., during an interview with the Director of Nursing (DON) and Facility Administrator, the DON discussed how she spoke on the phone with the facility provider on 1/27/26 (no documentation in Resident #1 clinical record to show this conversation), and the sodium level was ordered to be drawn on Thursday 1/29/26, as Thursdays are the day lab is scheduled to come into the facility. During the interview the DON stated she could have drawn the lab herself when she became aware of it but didn't. The DON then confirms that the lab should have been drawn on 1/26/26 as indicated by the ER provider.

Based on observation and interview, the facility failed to ensure that emergency cart equipment and supplies were maintained in a clean, safe and ready-to-use condition for 1 of 1 emergency cart reviewed. Findings:On [DATE] at 3:30 pm, during an observation of the facility's emergency cart with the Director of Nursing (DON), the following concerns were identified: The adult manual resuscitator (Ambu bag) stored in a torn, cloudy plastic bag with the attached reservoir bag that was worn, discolored and consistent with prior use. The plastic resuscitation mask and oxygen tubing was discolored, yellow, and visibly dirty. A package of oxygen tubing had an expiration date of [DATE]. The suction machine on the cart was dusty, and the inspection sticker indicated the last inspection was completed on [DATE]. During an interview on [DATE] at 3:30 p.m., the DON stated that night shift staff were responsible for ensuring the emergency cart equipment and supplies were maintained in clean, functional and ready to use condition. She acknowledged that the suction machines inspection was overdue and that emergency respiratory equipment should not have been discolored, dirty or expired.

Based on observations and interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds. This has the potential to affect the safety of all residents.On 7/28/25 at 2:12 p.m., a surveyor observed in room [ROOM NUMBER], Resident #24 (R24)'s exposed bedframe at the head of the bed had a 4.83-inch wide by 4-inch long opening which created a risk for the entrapment of body parts. The foot of the bed had a 4-inch gap between the mattress and the footboard creating a risk for entrapment of body parts. The resident was not in bed at the time of the observation. At 2:15 p.m., during an interview with a surveyor and the Licensed Practice Nurse #1 (LPN1), R24's mattress was observed and confirmed to be offset from the bedframe, and the exposed the bedframe created the potential for entrapment of body parts. LPN1 stated the bed should have a bumper for the foot of the bed to prevent injuries. On 7/29/25 at 3:48 p.m., in room [ROOM NUMBER], two surveyors observed a resident sleeping in bed. A 5-inch space was observed between the mattress and footboard creating a potential space for entrapment of body parts. At 5:51 p.m., in room [ROOM NUMBER], two surveyors observed a Certified Nursing Assistant #1 (CNA1) assisting a resident in bed. The bed was observed to have a 5.5-inch space between the mattress and the footboard, partially filled with a 2-inch mattress extender. On 7/30/25 at 10:51 a.m., during an interview with two surveyors, the Maintenance Director stated he has never done bed assessments. He stated the facility has a Bionix System but only uses it for the handrails. He stated he does not know how to assess the bed mattresses and/or bed frames, or if there are specific measurements to know. At this time, two surveyors confirmed that there is not a maintenance program to identify areas of possible entrapment through regular inspection of all bed frames, mattresses, and bed rails.

Based on observations, interviews, facility documentation and manufacturer's instructions, the facility failed to ensure that the laundry room equipment was maintained according to manufacturer's instructions and in a correct and safe operating condition for 4 of 4 days of survey (7/28/25, 7/29/25, 7/30/25 and 7/31/25). This has the potential to affect all residents.The manufacturer's instructions, dated 2007, noted in the Safety and Maintenance Instructions:10. Do not tamper with the controls.18. Keep the washer in good condition. 24. Never operate the washer with any guards and/or panels removed.25. DO NOT operate the washer with missing or broken parts. 26. DO NOT bypass any safety devices. 27. Failure to install, maintain, and or operate this washer according to the manufacturer's instructions may result in conditions which can produce bodily injury and or property damage. Maintenance Instructions:1. Weekly-Check the machine for leaks. On 7/30/25 at 9:00 a.m., a surveyor observed the following in the laundry:The control panel keypad on the left washing machine was missing 4 buttons and the control panel keypad on the right washing machine was missing 1 button. There was a bucket under a leak from the left washing machine that also had a wire running from the washing machine and hanging down in the bucket and then running out a wall attached to other wires. On 7/30/25 at 9:05 a.m., in an interview, the Laundry/Housekeeping supervisor confirmed the findings. She went on to state that the control panels have been broken with holes in them for many months and that the left washer has leaked for many months. There is a bucket under the leak which overflows every night and floods the laundry room floor by morning. On 7/30/25 at 10:40 a.m., in an interview, the Maintenance Director stated that the two washers have been in their current broken state for four or five months. When asked by a surveyor, he stated that he has no documented preventive maintenance program for the washers, but he does get a reminder monthly on his computer to look at them. The Maintenance Director also stated that the company that services their washers has stated that they can't get the parts to repair the machines and that administration has known they are broken and not repairable. At this time, the Maintenance Director confirmed the finding that the two washing machines were not maintained in a safe operating condition. On 7/29/25 at 9:00 a.m., the surveyor observed both washing machine control panels keypads missing buttons and a leak from under the left washing machine.On 7/30/25 at 9:17 a.m., the surveyor observed both washing machine control panels keypads missing buttons and a leak from under the left washing machine.On 7/31/25 at 8:30 a.m., the surveyor observed both washing machine control panels keypads missing buttons and a leak from under the left washing machine.

Based on observations and interview, the facility failed to provide a safe and comfortable environment for 1 of 6 residents reviewed for accidents (Resident #24 [R24]). In addition, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a safe, sanitary, orderly, and comfortable environment on 2 of 2 units (East and West) and the main lobby for 1 of 1 facility tour (7/31/25). 1. On 7/28/25 at 2:30 p.m., during an interview with two surveyors and the Maintenance Director, R24's bed chord was observed crossing the floor from the foot of the bed to the opposite wall and confirmed to be a trip hazard. On 7/29/25 at 3:30 p.m., during an observation with two surveyors, the Licensed Practical Nurse (LPN1) and the Maintenance Director, the following was observed and confirmed in room [ROOM NUMBER]: The television cable was running along the floor at the foot end of R24's bed creating a trip hazard. The cable for the bed remote was on the floor at the foot end of the bed creating a trip hazard. The power cord for R24's bed was observed unplugged and resting on the floor creating a trip hazard. On 7/29/25 at 3:32 p.m., LPN1 stated the bed is unplugged because R24 walked around the bed and unplugged the bed to plug in his/her fan. LPN1 stated there are not enough outlets to accommodate R24's appliances (including the bed, nebulizer machine, cell phone charger, oxygen concentrator, and fan) without running them across the floor. On 7/29/25 at 3:35 p.m., during an interview with the two surveyors, the Maintenance Director stated he addressed these concerns with management, but they declined the installation of additional electrical outlets. At this time two surveyors confirmed the environment was unsafe when cords and cables were crossing the floor in an area where the resident ambulates, and R24 wants his/her fan to stay running to maintain a comfortable environment temperature. 2. On 7/31/25 from 9:45 a.m. to 10:10 a.m., an Environment Tour was completed with the Maintenance Director and a surveyor in which the following findings were observed: East Wing Shower Room/Bathroom - The floor was dirty around the base of the toilet. The ceiling was cracked and stained around the shower exhaust vent. Resident room [ROOM NUMBER] - The wooden windowsills were chipped/gouged and missing sealant exposing untreated wood. Main lobby- The lower part of the corner wall, in the main lobby headed toward the [NAME] Wing, was chipped/gouged and missing sealant exposing untreated wood. West Wing Shower room The patient sit-to-stand lift had dirt and food debris on the foot base area. The ceiling vent was hanging down, missing a screw and in disrepair. The inside of the entrance door had laminate that was ripped/torn creating an uncleanable surface. On 7/31/25 at 10:10 a.m., in an interview with a surveyor, the Maintenance Director confirmed the findings.

Based on observations, interviews, and review of the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the three-bay pot sink and the walk-in freezer. Additionally, the facility failed to ensure foods were dated and/or discarded after best used by date in the walk-in refrigerator and on a beverage cart on a unit for 2 of 2 tours (7/28/25, and 7/29/25). The facility's Food Storage policy/procedure, dated 3/4/25, noted under Procedure: …All containers or storage bags must be legible and accurately labeled and dated. Refrigerated Food Storage: All foods must be covered, labeled, dated and routinely monitored to assure foods are used by their use by dates or discarded. 1.On 07/28/25 from 11:10 a.m. to 11:55 a.m., two surveyors completed an initial kitchen tour in which the following findings were observed: - The maintenance man was observed in the kitchen with no hair or face protection for his facial and head hair. - The three bay pot sink had 2 chemical hoses hanging down in the sinks. - The dry storage room had two 46-ounce containers of thickened water that had best use date of May 26, 2025, available for use. - The walk-in refrigerator has a 16-ounce package of whipped topping with no thaw date. The manufacturer's directions noted the product was only good for 2 weeks after thawing. - The walk-in freezer had a large open box of hamburger buns on the floor and a package of bread sticks on a shelf, stored under the freezer compressor, that had ice buildup on and/or in them. On 07/28/2025 at 11:55 a.m., in an interview with the surveyor, the Food Service Director confirmed the findings. 2. On 7/29/25 at 8:08 a.m., a surveyor and the Director of Nursing [DON], observed an open container of thickened water with a best used by date of “MAY 26,2025”, on the beverage cart in the East Wing hallway, and available for use. At this time, the DON confirmed the finding.

Based on observations and interviews, the facility failed to ensure medications were stored in a locked compartment for 1 of 3 medication areas (East Medication Storage Room), opened insulin was labeled with an open date, and expired medications were removed from the available for use supply in 2 of 3 medication storage rooms (West Medication Storage Room and East Medication Storage Room).On 7/29/25 at 9:30 a.m., during an observation and interview with two surveyors and the Licensed Practical Nurse #1 (LPN1), the following were observed and confirmed to be on the shelf and available for use in the [NAME] Medication Storage room:1 open box containing 650 milligrams (mg) Acetaminophen Suppositories with an expiration date of 12/20241 tube containing 1 ounce (oz) Vagicaine Anti-itch Cream, with an expiration date of 6/30/241 box containing Miconazole Vaginal Antifungal 7 day treatment with an expiration date of 5/24/251 pre-filled 3mL insulin pen labeled Lantus Solostar (Insulin Glargine) 100u/mL , the pen was labeled with conflicting open dates (cap labelled with an open date of 6/27/25, pen base labelled as opened 6/25/25). LPN1 stated, insulin should be discarded 28 days after opening.2 open vials, 10 milliliter (mL) of insulin aspart 100 units (u)/mL,one vial had an open date of 6/18/25one vial was open and undated. LPN1 was unable to determined when the vial was opened or when it would expire.3 open vials, 10 mL of insulin glargine 100 u/ mL,one vial had an open date of 5/12/25one vial had an open date of 6/30/25one vial observed to be open and undated. LPN1 was unable to determined when the vial was opened or when it would expire. On 7/29/25 at 10:07 a.m., two surveyors observed and confirmed with LPN1 that insulin medications including vials, quick pens, needles and lancets were stored in an unlocked cabinet in an unsecured area behind the East Wing nurse station.On 7/29/25 at 10:08 a.m., during an observation with two surveyors and LPN1, the following was observed and confirmed, on the shelf and available for use in the East Wing Medication Storage area:1 open vial, 10mL insulin lispro 100ui/mL, with an open date of 6/24/251 tube of Halobetasol Propionate cream 0.05% with an expiration date of 4/2025

Based on record reviews, interviews, and facility policy review, the facility failed to update/implement interventions on the current comprehensive care plan for the areas of smoking for 1 of 2 residents reviewed for smoking (Resident [R]43), hearing aids and dental for 1 of 1 resident (R17) reviewed, nutrition for 1 of 2 (R1) residents reviewed, and mobility for 1 of 2 (R19) residents reviewed. 1.Review of R1's care plan updated 7/10/25 states Monitor and document intake and output as per facility policy. Review of R1's Nutrition: amount eaten lacked documented intakes during: Breakfast on 7/1/25, 7/6/25, 7/19/25, 7/20/25, 7/22/25, 7/23/25, 7/24/25, 7/30/25 Lunch on 7/1/25, 7/3/25, 7/6/25, 7/9/25, 7/14/25, 7/17/25, 7/23/25 Dinner on 7/11/25, 7/13/25, 7/27/25, 7/30/25 During an interview on 7/30/25 at 4:15 p.m., the above was discussed with Director of Nursing (DON). 2.Review of R17's care plan updated 7/17/25 care plan states: communication: ensure hearing aids are place appropriately. Observations of R17 on 7/28/25, 7/29/25 and 7/30/25 lacked evidence of hearing aid use. During an interview on 7/30/25 at 2:32 p.m., DON confirmed that R17 did have hearing aids that should be used. 3.Review of R17's clinical record revealed provider note dated 5/20/25 states: Patient lost filling in [his/her] right lower molar. [He/She] needs a referral to dentist. During an interview on 7/30/25 at 12:56 p.m., R17 stated that [his/her] tooth with the missing filling hurts whey eating and especially when [he/she] brushes, [his/her] teeth bleed. Review of R17 care plan lacks evidence it was updated to reflect any measures to take for missing filling. During an interview on 7/30/25 at 12:54 p.m. DON stated they did put a referral in for a dentist appointment, and they are waiting for an appointment, but they should have updated the care plan to put measures in place for the missing filling while they are waiting for the appointment. 4.R43 was admitted in July, 2025 and is an active cigarette smoker. Observations were made of R43's smoking outside on 7/26/25, 7/27/25, on 7/28/25, and 7/29/25. Review of R43's care plan lacked evidence that goals and interventions were placed in the area of smoking. During an interview on 7/29/25 at 4:35 p.m., R43 states he/she keeps cigarettes in the top drawer of the dresser and goes out to smoke approximately 2 times a day. R43 states he/she's been smoking since he/she was a small child. During an interview with a surveyor on 7/30/25 at 9:01 a.m. the above was discussed with DON. 5. Review of R19's Care Plan Report with a revision date of 3/26/25 states: Focus: Risk for Injury to self or other residents secondary to use of power chair (motorized wheelchair for mobility). On 7/31/25 at 1:35 p.m. in an interview with a surveyor, the DON stated that R19 no longer uses a power chair, hasn't used one for many months, due to safety, and confirmed that R19's care plan has not been updated to reflect that R19 does not use a power chair (motorized wheelchair for mobility).

Based on review of the Nursing Facility Reportable Incident Form, the facility's internal investigation, the facility transfers policy and procedure, and interviews, the facility failed to ensure a resident's safety during a Hoyer lift transfer which caused harm to the resident. The facility failed to follow their Hoyer lift policy and procedure which resulted in the resident falling to the floor from the Hoyer lift. From this fall, the resident sustained a closed head injury for 1 of 1 resident. Finding: On 4/12/24, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 4/9/24 at 10:30 a.m. Certified Nursing Assistant #1 (CNA) transferred Resident #1 alone in the Hoyer lift. (mechanical lift) Resident #1 became restless during the transfer and slipped out of the Hoyer pad onto the floor and hit his/her head. Resident #1 sustained swelling in the back of his/her head. A review of the Incident Report dated 4/9/24 at 11:17 a.m. indicates that Resident #1 had a fall and hit his/her head while the CNA was transferring the resident with a Hoyer lift. In addition, the Incident Report also indicates that the CNA was transferring the resident with a Hoyer lift without the assistance of a second CNA. Emergency Department notes, dated 4/9/24, indicate Resident #1 bumped the back of his/her head after falling during a Hoyer lift transfer. Resident #1 was diagnosed with a closed head injury and sent back to the facility the same day. Resident #1's Care plan, dated 3/2/24, indicates that the resident requires extensive assists with bathing, dressing, grooming, personal hygiene and bed mobility. The care plan instructs staff to assist the resident with transfers using a mechanical lift and two people. A review of the facility's 'Lifting Machine-Using a Portable' stated: Under General Guidelines, Page 1, number 1, stated, At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. On 4/23/24 at 11:00 a.m., during an interview with a surveyor, CNA #1 states that she was unable to find another CNA to assist her with transferring Resident #1 from the chair to the bed using a Hoyer lift. CNA #1 stated that Resident #1 became restless and his/her shoulders slipped out of the Hoyer pad during the transfer. Resident #1 hit the back of his/her head. CNA #1 acknowledged that the facility policy indicates At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. The Root Cause Analysis indicates under Contributing Factors lift policy not followed. On 4/23/24 at 3:00 p.m., a surveyor confirmed with the Administrator that the facility failed to follow their Hoyer lift policy and procedure which resulted in the resident falling to the floor from the Hoyer lift. As a result of this isolated incident, the following corrective actions were initiated with a completion date of 4/12/24 - One on One training with CNA #1 on the Lifting Machine policy and procedure that indicates At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. CNA #1 demonstrated competence. - Mandatory re-education on Hoyer Safety was initiated with all nursing staff. - Newly hired CNA's will demonstrate competency with Hoyer lift transfers.

Based on record review and interviews, the facility failed to ensure quality care and services relating to the assessment and monitoring for signs and symptoms of [DIAGNOSES REDACTED] was provided to 1 of 3 sampled residents with Diabetes (#1). This failure to assess and monitor for signs and symptoms of Hypoglucemia, resulted in Resident #1 experiencing acute mental changes, a blood sugar of less than 50 and being transferred to a hospital for treatment of [REDACTED]." Finding: Resident #1's care plan, dated 10/15/13, under the problem of "Potential for Fluctuating Blood Sugars" levels directed staff to notify the physician of abnormal glucose levels per "Diabetic Protocol" and to observe for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. On 10/15/13, Resident #1 had a "Comprehensive Metabolic Panel" (CMP), blood test drawn. The results of this blood test indicated a low Glucose level of 58 (the normal reference range is 70-105). The attending physician was not notified of this abnormal blood test until 10/17/13 (2 days later). The facility's Glucose Monitoring Policy indicates "if a diabetic resident experiences an acute or sub-acute change in level of consciousness, the nurse is authorized to obtain a "STAT" blood glucose test by finger stick. Follow up with the physician will be determined by the glucose level result and parameters that have been set by physician." The facility's "Diabetic Hyper-[DIAGNOSES REDACTED] Policy" statement indicates " when any resident with Diabetes exhibits altered behavior or changes in mental/physical function such as decreased level of consciousness consistent with [DIAGNOSES REDACTED] or [MEDICAL CONDITION], a finger stick blood sugar will be checked immediately by the licensed nurse and standing orders followed for values in the abnormal range. The physician will be notified of use of the Diabetic standing orders and abnormal glucose values. The procedure indicated when a resident with Diabetes Mellitus on insulin or oral medications exhibits tremors, [MEDICAL CONDITION] anxiety, dizziness, headache, clouding vision, [MEDICATION NAME] mental acuity, confusion, abnormal behavior, or tachypnea, the licensed nurse must perform a finger stick. If the glucose value is between 50-60, a glass of orange juice or apple juice is given and one tube of oral glucose. Repeat the blood glucose in 15 minutes. Notify physician of abnormal glucose below 60 and above 400 and interventions taken. If the resident is unable to take something by mouth or the glucose value is below 50 administer Intramuscular medication [MEDICATION NAME] as ordered in the standing orders. Notify physician of abnormal glucose and interventions taken. Record all test results on the Treatment Record (Medication Administration Record). Document abnormal episode and [MEDICATION NAME] result in the resident's record under progress notes." Resident #1 was admitted to the facility on [DATE], with Primary [DIAGNOSES REDACTED]. Resident #1's hospital Discharge Summary, dated 10/13/13, indicated that Resident #1 had Diabetes Mellitus. Resident #1 had an admitting physician's orders [REDACTED]. The Physician's progress note, dated 10/17/13, indicates that Resident #1 has Diabetes, is on an oral medication and directed staff to continue with Chemsticks (blood sugar testing by finger stick) to monitor for possible [DIAGNOSES REDACTED]. The physician did not write the order to continue the Chemsticks on the physician order [REDACTED]. Resident #1's electronic progress notes, dated 10/17/13 at 8:05 p.m., indicated that the resident was found to be unresponsive and snoring loudly, unable to arouse, and 911 was called. Resident #1 was transported to the hospital by ambulance and was admitted to the hospital. There was no documentation in Resident #1's clinical record to indicate at the time of this event that the resident was assessed for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] until the Emergency Medical System arrived at the facility. The Pre-hospital Care Report from the Emergency Medical System (EMS), dated 10/17/13, indicated the primary impression of Resident #1 was a Diabetic emergency. However, the nursing staff at the facility indicated to EMS that the resident was not diabetic. The EMS report indicated that Resident #1 was unresponsive and breathing, but his/her blood glucose was reading low. Resident #1 was transferred to hospital. The hospital's "Emergency Department Report," dated 10/17/13, indicated Resident #1 had decreased mental status and a low blood sugar. The Resident was lethargic, disoriented and in mild distress. Resident #1's blood sugar was initially reading 46. The resident was admitted to the hospital with [REDACTED]. The hospital Discharge Summary, dated 10/20/13, for Resident #1 indicates the reason for the hospital admission was unresponsiveness secondary to severe [DIAGNOSES REDACTED] secondary to Diabetic medication Glimepiride with decreased oral intake. On 12/5/13 at 4:15 p.m., a surveyor interviewed the Registered Nurse (RN) who was the Charge Nurse the evening that Resident #1 had the emergency event and resident was found to be unresponsive. The RN stated that she was not aware that the resident was diabetic until Emergency Medical System indicated that the resident had a low blood sugar. The RN stated she then reviewed the Resident #1's "Medication Administration Record" and found that the resident was on a Diabetic medication. The RN confirmed that no blood glucose monitoring had been completed. The surveyor discussed these findings with the Administrator and RN, Minimum Data Set Coordinator, on 12/24/13 at 11:20 a.m.

Based on record reviews and interviews, the facility neglected to ensure monitoring of blood sugar was completed for 1 of 3 sampled residents (#1). This failure resulted in Resident #1 experiencing a decreased level of consciousness and being transferred to a hospital. Finding: The facility's Glucose Monitoring Policy indicates "if a diabetic resident experiences an acute or sub-acute change in level of consciousness, the nurse is authorized to obtain a "STAT" blood glucose test by finger stick. Follow up with the physician will be determined by the glucose level result and parameters that have been set by physician." The facility's "Diabetic Hyper-[DIAGNOSES REDACTED] Policy" statement indicates " when any resident with diabetes exhibits altered behavior or changes in mental/physical function such as decreased level of consciousness consistent with [DIAGNOSES REDACTED] or [MEDICAL CONDITION], a finger stick blood sugar will be checked immediately by the licensed nurse and standing orders followed for values in the abnormal range. The physician will be notified of use of the diabetic standing orders and abnormal glucose values. The procedure indicates when a resident with diabetes mellitus on insulin or oral medications exhibits tremors, [MEDICAL CONDITION] anxiety, dizziness, headache, clouding vision, [MEDICATION NAME] mental acuity, confusion, abnormal behavior, or tachypnea, the licensed nurse must perform a finger stick. If the glucose value is between 50-60, a glass of orange juice or apple juice is given and one tube of oral glucose. Repeat the blood glucose in 15 minutes. Notify physician of abnormal glucose below 60 and above 400 and interventions taken. If the resident is unable to take something by mouth or the glucose value is below 50 administer Intramuscular medication [MEDICATION NAME] as ordered in the standing orders. Notify physician of abnormal glucose and interventions taken. Record all test results on the Treatment Record (Medication Administration Record). Document abnormal episode and [MEDICATION NAME] result in the resident's record under progress notes." Resident #1 was admitted to the facility on [DATE], with Primary [DIAGNOSES REDACTED]. Resident #1's hospital Discharge Summary, dated 10/13/13, indicated that Resident #1 had Diabetes Mellitus. Resident #1 had an admitting physician's orders [REDACTED]. Resident #1's care plan, dated 10/15/13, under the problem of "Potential for Fluctuating Blood Sugars" levels directed staff to notify the physician of abnormal glucose levels per "Diabetic protocol" and to observe for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. On 10/15/13, Resident #1 had a "Comprehensive Metabolic Panel" (CMP), blood test drawn. The results of this blood test indicated a low Glucose level of 58 (the normal reference range is 70-105). The attending physician was not notified of this abnormal blood test until 10/17/13 (2 days later). The Physician's progress note, dated 10/17/13, indicated that Resident #1 had Diabetes, was on an oral medication and directed staff to continue with Chemsticks (blood sugar testing by finger stick) to monitor for possible [DIAGNOSES REDACTED]. The physician did not write the order to continue the Chemsticks on the physician order [REDACTED]. Resident #1's electronic progress notes, dated 10/17/13 at 8:05 p.m., indicated that the resident was found to be unresponsive and snoring loudly, unable to be aroused and 911 was called. Resident #1 was transported to the hospital by ambulance and was admitted to the hospital. There was no documentation in Resident #1's clinical record to indicate at the time of this event that the resident was assessed for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] until the Emergency Medical System arrived at the facility. The Pre-hospital Care Report from the Emergency Medical System (EMS), dated 10/17/13, indicated the primary impression of Resident #1 was a Diabetic emergency. The nursing staff at the facility indicated to EMS that the resident was not diabetic. The EMS report indicated that Resident #1 was unresponsive and breathing, but his/her blood glucose was reading "low." Resident #1 was then transferred to the hospital. The hospital's "Emergency Department Report," dated 10/17/13, indicated Resident #1 had decreased mental status and a low blood sugar. The Resident was lethargic, disoriented and in "mild distress." Resident #1's blood sugar initial reading was 46. The resident was admitted to the hospital with [REDACTED]. The hospital Discharge Summary, dated 10/20/13, for Resident #1 indicated the reason for the hospital admission was unresponsiveness secondary to severe [DIAGNOSES REDACTED] secondary to Diabetic medication Glimepiride with decreased oral intake. On 12/5/13 at 4:15 p.m., a surveyor interviewed the Registered Nurse (RN) who was the Charge Nurse the evening that Resident #1 had the emergency event and resident was found to be unresponsive. The RN stated she was not aware that the resident was Diabetic until Emergency Medical System indicated that the resident had a low blood sugar. The RN stated she then reviewed the Resident #1's "Medication Administration Record" and found that the resident was on a Diabetic medication. The RN confirmed that no blood glucose monitoring had been instituted. The surveyor discussed these findings with the Administrator and RN, Minimum Data Set Coordinator, on 12/24/13 at 11:20 a.m.

Based on record review and interview, the facility failed to ensure that interventions outlined in the resident's care plan for Potential for Trauma-Falls were implemented for 1 of 1 sampled residents (#1). This failure resulted in Resident #1 sustaining a fall that caused hospitalization for a left femoral neck fracture. Finding: Documentation in Resident #1's clinical record indicated that Resident #1 had a history of [REDACTED]. The resident's care plan, dated 1/11/12, under the problem of Potential for Trauma-Falls, directed staff not to leave the resident alone when toileting. Documentation in the nurses's notes, dated 1/24/13, indicated that a Certified Nurses Aid (CNA) assisted the resident to the bathroom and helped him/her onto the toilet. The CNA left him/her unattended to assist another CNA with a transfer. Nurses notes indicated that both CNAs stated that the resident was only left unattended for 2 to 3 minutes. During this time the resident rang his/her call bell and when the CNA responded to the call bell and entered the room the resident was found on the floor of the bathroom. The resident complained of leg and left hip pain. The resident was admitted to the hospital with [REDACTED]. In an interview with the MDS Coordinator on 5/30/13 @ 10:37am, she confirmed that the resident's care plan directed staff not to leave the resident unattended when toileting and that the care plan was in place at the time of the incident. This finding was confirmed in an interview with the Director of Nurses and Administrator, on 5/30/13 at 11:10am. The surveyor confirmed that prior to the investigation date, the facility had taken immediate corrective action and conducted educational sessions for all staff regarding following residents' care plan. The facility provided all staff instructions on where to find care plan information and conducted random quizzes of staff to ensure that they could demonstrate their knowledge of residents' care plans. As a result of the facility's implementation of immediate corrective actions, the findings were determined to meet the definition of past non-compliance and the facility was in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. .