Every finding on record at Zebulon Park Health and Rehabilitation

Based on observations, staff interviews, and review of facility policies titled Storage Areas and Cleaning and Sanitizing, the facility failed to securely wrap, label, date, and discard opened/leftover foods and failed to prevent wet nesting of stored steam table pans, which had the potential to cause bacterial growth. These deficient practices had the potential to place the 65 residents who received nutrition and hydration from the kitchen at increased risk of contracting a foodborne illness. Findings include: Review of the facility policy titled Storage Areas revealed items should be covered, sealed, labeled, and dated appropriately.Review of the facility policy titled Cleaning and Sanitizing revealed that all smallware equipment should be stored in a self-draining position that allows it to air dry.1. Observation on 9/26/2025 at 8:20 am of the walk-in refrigerator revealed a large, rectangular-shaped disposable aluminum pan covered with foil that had no label or date.During an interview on 9/26/2025 at 8:20 am, the Certified Dietary Manager (CDM) confirmed that the large aluminum pan stored on the shelf had no label or date. The CDM stated that activities had brought the pan to the kitchen. The CDM revealed that the pan should have been labeled and dated. The CDM revealed that all dietary staff were responsible for labeling and dating items placed in the walk-in refrigerator.Observation on 9/26/2025 at 8:26 am of the dry storage area revealed an open two-pound bag of powdered sugar on the shelf, and it was not securely wrapped and had no open date.During an interview on 9/26/2025 at 8:26 am, the CDM confirmed that the bag of powdered sugar was not securely wrapped and had no open date. The CDM revealed that dietary staff were to use plastic wrap to secure the open bag, and staff should have used a sticker to indicate the open date.Observation on 9/26/2025 at 8:30 am of a low three-door refrigerator, located outside of the dry storage area, revealed a rectangular tan-color clamshell-type container. The top lid of the container had a resident's name and the date 9/14/2025.During an interview on 9/26/2025 at 8:30 am, the CDM confirmed that the tan-color clamshell-type container had a date of 9/14/2025 and should have been discarded. The CDM revealed that some residents prefer to store food items in the kitchen, and if they are stored in the kitchen, they should be discarded the next day or within two days of storage. The CDM stated that she was responsible for ensuring food items were labeled, dated, and discarded in this refrigerator. 2. Observation on 9/26/2025 at 8:35 am of the pot and pan rack revealed there were several stacks of steam table pans. A stack of three small rectangular pans was pulled apart, and the top pan had moisture inside. Another stack of two small rectangular steam table pans was pulled apart, and the inside of the top pan had a white colored substance that streaked from the top to the bottom of the pan. During an interview on 9/26/2025 at 8:35 am, the CDM confirmed that the one steam table pan had moisture inside and confirmed that the other pan had not been cleaned properly since it had a white substance streaked inside. The CDM revealed that dietary staff typically allow pans to air dry overnight before stacking and should check the inside to ensure they are clean and dry before stacking.Observation on 9/28/2025 at 9:40 am of the pot and pan rack revealed that a stack of 4 small rectangular steam table pans was pulled apart, and the pan that was second from the bottom had moisture inside.During an interview on 9/28/2025 at 9:40 am, the CDM confirmed that the inside of the steam table pan had moisture inside. The CDM stated that she was the one who stacked the pans this morning, and did it quickly, and did not look inside to make sure it was dry.

Based on interviews and record review, the facility failed to ensure allegations of potential abuse were thoroughly investigated for one of three residents (R) (R4) who had an injury of unknown origin.Finding included:A review of the facility policy, last revised on 12/27/2024, titled Abuse Prohibition - Reporting and Investigating, documented that interviews will be conducted with pertinent parties. Written signed statements from any parties involved will be obtained if possible . a signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, the person making accusations, the patient involved, reliable patients who may have witnessed the incident, and any other persons who may have credible, pertinent information. Identify any possible conflicts between witnesses.A review of the electronic medical record (EMR) revealed that R4 was admitted to the facility on [DATE] and was discharged on 6/16/2025 with medical diagnoses that included, but were not limited to, hypertensive heart disease with heart failure, difficulty in walking, gout, and Type 2 diabetes mellitus with diabetic neuropathy.A review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/4/2025 revealed that R4 was assessed to present with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R4's cognition was moderately impaired. A review of the facility report revealed that R4 had an unwitnessed fall on 6/13/2025 and was assessed at that time to have no injuries following the fall. It was documented that on 6/16/2025, R4 reported pain in the lower right extremity. An order was obtained on 6/16/2025, and the results revealed the right femoral neck fracture. A review of the facility follow-up report, documented by the Director of Nursing (DON) and Administrator, revealed that they reviewed the documents from the fall and interviewed staff involved. It was reported that R4 reported he had fallen when trying to get up and that R4 had a moderate impairment that affects his safety awareness. It was further documented that he was cognitively aware enough to provide an accurate account of what happened.A review of the facility follow-up investigations revealed no written staff interviews for employees who worked with R4 from 6/13/2024 through 6/19/2024 regarding leg pain and unknown injury.During an interview on 9/3/2025 at 2:02 pm with the Director of Nursing (DON), she stated that the Administrator was responsible for the reportable investigations, and she would assist if any assistance was needed. The DON stated Licensed Practical Nurse (LPN)1 was the nurse working that Friday (6/13/2025) when R4 fell, and she believed she talked to her about the incident. She stated that LPN1 said that R4's pain was stable, and then he had an acute change in pain, but she couldn't recall when that acute change in pain was. The DON stated she knows it wasn't that Friday or Saturday after the fall. The DON confirmed that R4's pain levels should have been documented in his medical record.During an interview on 9/3/2025 at 2:29 pm, the administrator stated she was the Abuse and Neglect Coordinator and responsible for conducting all facility investigations. The administrator stated R4 fell on 6/13/2025, and no injury or pain was noted at that time. The administrator stated that on 6/16/2025, R4 started reporting increased pain. She stated that the nurse practitioner was in the facility, saw him, and ordered X-rays. The administrator stated R4 was at the hospital during their investigation, but they did interview staff who were assigned to R4 on 6/13/2025. The administrator stated she did not get statements from any of the staff; she just verbally interviewed them due to the written statements being very lengthy.During a follow-up interview on 9/3/25 at 2:44 pm, the DON stated they followed up with LPN1 on 6/16/2025 to see if R4 had any pain over the weekend, and LPN1 stated there was no increase in pain during her shifts over the weekend. The DON denied following up with other staff regarding R4's pain but stated that pain is monitored on medication administration records.A review of the electronic medical record (EMR) revealed that there was no pain documented for R4 from 6/13/2025 until 6/16/2025.

Based on staff interviews, record review, a review of the facility's policy titled Dialysis Resident, and a review of the facility-provided document titled Dialysis Pre/Post Communication Report, the facility failed to consistently complete clinical assessments after dialysis treatments for one of three residents (R) receiving dialysis outside of the facility (R263). Findings include: A review of the facility policy titled Dialysis Resident, with a review date of 12/29/2023, revealed the intent and procedure was to promote continuity of care for the dialysis patient. A review of a facility-provided document titled Dialysis Pre/Post Communication Report revealed a section should be completed by the facility staff before transport to dialysis and sent with the resident to the dialysis center, a section completed by the dialysis staff after dialysis treatment and returned to the facility with the resident, and a section completed by the facility staff upon the residents' return to the facility after dialysis treatment. The three sections included an assessment of vital signs. A review of R 263's Face Sheet revealed diagnoses including, but not limited to, end-stage renal disease. A review of R263's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section I (Active Diagnoses) documented a diagnosis of end-stage renal disease and section O (Special Treatments and Programs) documented the resident received hemodialysis while a resident. A review of R263's care plan revealed a focus area of R263 received dialysis. The goal was the resident would not experience complications secondary to dialysis. A review of the Dialysis Pre/Post Communication Report documents for R263 revealed the documents dated 5/30/2024, 6/1/2024, 6/4/2024, 6/6/2024, 6/18/2024, and 6/22/2024 did not have documentation of the post-dialysis assessment. In an interview on 9/12/2024 at 2:48 pm, the Director of Nursing (DON) and Administrator confirmed there was no documentation of a post-dialysis assessment for R263 after each dialysis treatment. The DON acknowledged the Dialysis Pre/Post Communication Report should be completed with each dialysis treatment.

Based on observations, staff interviews, record review, and review of the facility policy titled Use of Oxygen Therapy , the facility failed to ensure that one (1) of 13 residents (R) R#17 was administered oxygen (O2) therapy in accordance with the Physician's order. The deficient practice had the potential to affect the overall respiratory status for residents receiving oxygen therapy. Findings include: Review of the facility policy titled Use of Oxygen Therapy review date 12/30/2022, revealed: Under Intent: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Under Guideline: Physician's order for oxygen should be obtained and include: oxygen with liter (L) flow or percentage ordered. Review of R#17 diagnoses included but not limited to acute respiratory failure with hypoxia, congestive heart failure (CHF), obstructive sleep apnea, and dependence on other enabling machines and devices. Review of R#17 Quarterly Minimum Data Set (MDS) revealed: Section C (Cognitive Pattern) Brief interview of Mental Status (BIMS) score of 15 indicating no cognitive deficit. Review of #17 Care Plan revealed respiratory changes related to CHF and respiratory failure and the need for O2. Interventions include administer medications and/or treatment as ordered and O2 at 4 L via nasal canula. Review of R#17 Physician's orders revealed: Oxygen: nasal cannula at 4 L per minute nasally check every shift. Review of R#17 Medication Administration Record (MAR) revealed: MAR checked 6/23/2023 and the MAR showed R#17's O2 concentrator was checked on day shift and night shift. Observation on 6/20/2023 at 2:36 p.m., revealed R#17 was asleep in bed with O2 per nasal cannula at 5L. Observation On 6/21/2023 at 8:33 a.m. revealed R#17 was in the bed and had just finished breakfast and his call light was on. Certified Nursing Assistant (CNA) came in at 8:35 a.m. R#17 had on BiPAP and his O2 had not been taken off and changed to his O2 concentrator. R#17's O2 concentrator was set on 5L per minute. The Licensed Practical Nurse (LPN) LPN AA checked his O2 concentrator and verified the O2 concentrator was set at 5L per minute and changed it to 4L per minute. Interview on 6/20/2023 at 9:00 a.m. with Medication Technician (Med Tech) Med Tech BB revealed O2 concentrators are maintained every shift, if a nasal cannula hits the floor, it is thrown away and replaced with a new one, tubing is stored in a plastic bag. Interview on 6/21/2023 at 9:10 a.m. with LPN CC revealed O2 machines are checked for O2 flow per MAR, scheduled tube changes per MAR, O2 tubes are changed monthly or as needed (PRN). Interview on 6/21/2023 at 11:38 a.m. with Director of Nursing (DON) revealed it is the nurse's responsibility to check the Physician's orders on the MAR on every shift to verify that the O2 is at the right liter.

Based on observations, staff interviews, and record review the facility failed to ensure that the care plan for one (1) of 13 residents (R) R#17 was followed related to oxygen (O2) therapy not being administered in accordance with the Physician's order. Specifically, the facility failed to ensure that the plan of care was followed related to the administration of oxygen therapy for R#17 by not ensuring oxygen settings were maintained as ordered by the physician. Findings include: Review of R#17 diagnoses included but not limited to acute respiratory failure with hypoxia, congestive heart failure (CHF), obstructive sleep apnea, and dependence on other enabling machines and devices. Review of R#17 Quarterly Minimum Data Set (MDS) revealed: Section C (Cognitive Pattern) Brief interview of Mental Status (BIMS) score of 15 indicating no cognitive deficit. Review of #17 Care Plan revealed respiratory changes related to CHF and respiratory failure and the need for O2. Interventions include administer medications and/or treatment as ordered and O2 at 4 L via nasal canula. Review of R#17 Physician's orders revealed: Oxygen: nasal cannula at 4 L per minute nasally check every shift. Observation on 6/20/2023 at 2:36 p.m., revealed R#17 was asleep in bed with O2 per nasal cannula at 5L. Observation On 6/21/2023 at 8:33 a.m. revealed R#17 was in the bed and had just finished breakfast and his call light was on. R#17's O2 concentrator was set on 5L per minute. The Licensed Practical Nurse (LPN) LPN AA checked his O2 concentrator and verified the O2 concentrator was set at 5L per minute and changed it to 4L per minute. Interview on 6/21/2023 at 11:38 a.m. with Director of Nursing (DON) revealed it is the nurse's responsibility to check the Physician's orders on the MAR on every shift to verify that the O2 is at the right setting. Interview on 6/21/2023 2:56 p.m. with MDS Registered Nurse (RN) RN DD and MDS RN EE revealed they would expect the nurses to follow the Physicians orders and follow the care plan.

Based on observation, record review and review of the policy titled Routes of Drug Administration, and staff interviews, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#6); failed to ensure that the urinary catheter bag and tubing were kept off the floor for one resident (#21); and failed to keep personal items off clean linen in the laundry room. Findings include: 1. A review of the policy titled Routes of Drug Administration revealed that when eye drops were administered the first step was to wash hands, the cap to the bottle was to be sat on a clean dry surface, and after eye drops were administered, the hands were to be washed again. An observation on 11/14/19 at 8:43 a.m. of Licensed Practical Nurse (LPN) AA administering eye drops to R#6 revealed that she donned gloves and didn't sanitize her hands or wash with soap/water prior to donning her gloves. She touched multiple objects with her gloves on. She sat the eye drops on a napkin that was already on the table. She took a cup that the resident handed her with her gloved hand and did not remove the gloves, sanitize, and don a clean pair of gloves. She then touched the bedside table with her gloved hands and then administered eye drops without washing her hands, sanitizing or changing gloves. The LPN confirmed that she donned gloves on entering the resident's room, touched multiple surfaces without washing her hands, sanitizing or donning clean gloves. She stated that the purpose of wearing gloves when administering eye drops was to keep the rate of infection down. An interview on 11/14/19 at 9:54 a.m. with the Director of Nursing (DON) revealed that she expected the nurses to verify and follow the physician order [REDACTED]. During a follow-up interview on 11/14/19 at 10:33 a.m. the DON confirmed that not sanitizing hands and touching other surfaces was an infection control issue. She stated that she did not know why the nurse did not sanitize or change gloves after touching multiple objects in the room. Further interview at 11:58 a.m. with the DON revealed that the Infection Control Nurse had not done any audits related to administration of eye drops because no issues had been identified during tracking and trending of infections. She stated that they have a corporate nurse that comes in periodically and watches medication administration with no issues or concerns identified. 2. Review of electronic medical record (EMR) for R#21 revealed an unhealed pressure ulcer on the sacrum. R#21 also had [DIAGNOSES REDACTED]. Observation on 11/12/19 at 11:36 a.m. revealed R#21 in a low bed in room with the catheter in dignity bag and the dignity bag touching the floor. Observation on 11/12/19 at 3:17 p.m. revealed R#21 in a low bed with the catheter tubing touching the floor. Observation on 11/13/19 at 1:24 p.m. revealed the catheter bag and tubing for R#21 was on the floor on the right side of the bed. Observation on 11/13/19 at 3:00 p.m. revealed the catheter bag and tubing for R#21 was on the floor. Observation on 11/14/19 at 10:59 a.m. revealed the catheter bag cover touching the floor for R#21. During an interview on 11/15/19 at 11:17 a.m., Resident Care Coordinator (RCC) CC confirmed that the dignity bag for R#21 was on the floor and should be kept off the floor. Interview on 11/15/19 at 1:28 p.m. with the Assistant Director of Nursing (ADON) revealed that neither the catheter or the tubing should be on the floor at any time. 3. During tour of the laundry room on 11/15/19 at 9:29 a.m., Laundry Aide GG was observed folding clean towels. It was noted that a cell phone was sitting on a towel that had been folded on one end of the table and at the other end of the table there was a purse and a [NAME]et. Laundry Aide GG confirmed that the cell phone, purse, and [NAME]et belonged to her. It was further reported that the items were kept there because she did not have any other place for them. Once the green [NAME]et was moved there was a stack of table cloths under the [NAME]et. Laundry Aide GG reported that the towel and table cloths would have to be rewashed. During an interview with the Environmental Services Supervisor on 11/15/19 at 9:53 a.m. she confirmed that staff's personal items should be kept in either a locker or a closet. The Environmental Supervisor acknowledged the personal items for Laundry Aide GG on the table and further reported the items would have to be rewashed.

Based on observations, record review, and staff interviews, the facility failed to follow Physician's Orders for one of five [MEDICAL TREATMENT] residents (R) (#154) with fluid restrictions. Findings include: Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in room. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a Precautions Order for no free water or water at bedside beginning on 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee were in resident's room. R#154 had both a cup of coffee and a cup of water in the room. However, she instructed the CNA to move the water cup from the over bed table but not out of the room. LPN DD confirmed the order for no water at the bedside and acknowledged that she was not aware of the order for no water at bedside.

Based on observations, record review, and staff interviews the facility failed to follow the care plan for two of 32 sampled residents (R) (#154 and R#28). Findings include: 1. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a care plan for altered nutritional status related to no free-standing water with an onset date of 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction and this information is listed on resident's care plan. Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in R#154's room. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee was in resident's room. LPN DD was not aware that the care plan indicated no water at the bedside. Cross Refer to F684. 2. A review of the medical record for R#28 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the care plan, revised on 9/26/19, revealed that R#28 is at fall risk related to history of falls, with a fall risk score of 12. Continued review revealed that the resident has a scoot chair, and balance concerns, along with impaired memory. Review of the Interventions include, but not limited to the following: non-skid socks/non-skid shoes; place resident in an open area for maximum observation opportunities; anticipate resident's needs; check on resident frequently; and have a fall mat on both sides of bed. Observation on 11/12/19 at 12:07 p.m., R#28 was observed seated in a scoot chair, leaning forward in the day room, without nonskid sole socks and/or shoes. Observation on 11/13/19 at 8:51 a.m., resident was observed sitting in scoot chair in day room alone, leaning forward with eyes closed, without non-skid sole socks and/or shoes. Another observation at 1:23 p.m., revealed that R#28 was lying in bed awake, with a fall mat on left side only of bed and another fall mat leaning on wall. At 3:14 p.m., R#28 was lying in bed with eyes closed, fall mat on left side of bed, and another fall mat leaning on wall. Observation on 11/14/19 at 10:58 a.m., R#28 observed in day room sitting in scoot chair, awake without non-skid socks and/or shoes. Interview on 11/15/19 at 12:31 p.m. with the Director of Nursing (DON), says she expects her staff to review and implement residents Activities of Daily Living (ADL) plan of care/care plans daily at the start of their shift in order to provide the care needed for the residents. Interview on 11/15/19 at 1:50 p.m. with Licensed Practical Nurse (LPN) CC stated that she as well as other staff, are responsible for completing plan of care/care plans for residents, so that the Certified Nursing Assistants (CNA) may review. She confirmed that non-skid socks were on both the ADL plan of care and care plans.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #45). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 5/25/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #45 was discharged off skilled services on 6/25/18, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#45. During interview on 7/18/18 at 3:01 p.m. with Case Manager it was reported that if she notifies the family member via telephone she does not typically send a letter. Case Manager further reported that the SNFABN is typically provided to residents who discharge to home in the event they decide to stay an extra day in the facility. However, the SNFABN has not been provided to residents remaining in the facility that were going to be long term. Case Manager confirmed that she did not provide SNFABN forms for R#9 and R#45.

Based on observation, staff interview, and record review the facility failed to ensure the meat slicer was cleaned and sanitized after usage to prevent cross contamination. This deficient practice had the potential to effect all fifty four (54) residents receiving an oral diet. Findings include: Observation on 06/16/16 at 10:30 a. m. in the kitchen, the meat slicer revealed that it was covered with a white frosted plastic bag. The plastic bag was removed from the slicer which revealed food particles, tan and brown in color on the underside of the blade. The Dietary Manager (DM) removed the top blade guard which revealed more food substance that covered the inside top of blade which was tan and brown in color. Interview on 06/16/16 at 10:30 a. m. with Dietary Manager revealed she confirmed that the meat slicer had a plastic bag covering the machine. She confirmed that when a plastic bag is placed over a piece of equipment it indicates that the equipment is clean and ready for use. The DM confirmed that there was tan and brown food particles on the top and bottom of the slicer blade. She expects staff to properly clean and wash the slicer and inspect the slicer before placing the plastic bag over the top. The DM revealed that turkey was sliced last evening and expected the cook to clean the slicer better. She revealed that she does not have a policy for kitchen cleaning and that the cleaning schedule was the policy. Further interview with the DM revealed that she confirmed that evening dietary staff have not initialed on the daily cleaning schedule when tasks have been completed for the past three (3) days. She expects staff to complete cleaning tasks and initial the form when they are completed. Review of the Daily Cleaning Schedule for the week of June 13-19th revealed that the evening dietary sheet was blank, staff had not initialed any kitchen equipment had been cleaned for the week. Review documentation revealed that the dietary staff had an in-service conducted on 03/31/16 and staff were educated on the slicer.

Based on observation, interview and record review, the facility failed to accurately document medication administration leaving blanks/holes on the Medications Administration Records (MARs) for seven (7) residents (#236, #71, #234, #1, #80, #73, and #135) out of 12 residents receiving sliding scale insulin. The census sample size was thirty-three (33). 1. Resident #135 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Vitamin B12 deficiency, [MEDICAL CONDITION]/[MEDICAL CONDITIONS] Disease, [MEDICAL CONDITION], and [MEDICAL CONDITION], Review of the medical record revealed that the physician had ordered for the resident to have Finger Stick Blood Sugar (FSBS) completed at 6:30 a. m. and 4:30 p. m. The physician ordered [MEDICATION NAME], ten (10) units subcutaneously at bedtime daily as well as [MEDICATION NAME] Sliding Scale Insulin: 201-250 four (4) units, 251-300 six (6) units, 301-350 eight (8) units, and 351-450 10 units. Review of the June 2016 Medical Administration Record (MAR) revealed on 06/13/16 at 4:30 p. m. the Finger Stick Blood Sugar (FSBS) check the resident had a blood sugar reading of two hundred forty four (244). Continued review of the MAR revealed the units of sliding scale insulin for that blood sugar reading was blank. Review of the May 2016 MAR revealed that the resident Fasting Blood Sugar (FSBS) on 05/07/16 at 4:30 p. m. was blank. Continued review of the May MAR revealed on 05/08/16 at 4:30 p. m. the resident had a FSBS of two hundred seventy (270), the MAR was blank for the amount of sliding scale insulin the resident was to receive. Further review of the May MAR revealed on 05/22/16 the FSBS for 6:30 a. m. was blank. Review of the April 2016 MAR revealed on 04/17/16, 04/25/16, and 04/30/16 the MAR was blank. Review of the laboratory results in the medical record revealed the resident had a Hemoglobin A1C (HbA1C) lab completed on 04/26/16. The results of (9.3) which indicated high (range less than 6.5). The physician was notified and questioned the resident noncompliance with diet. Continued review of the lab results revealed that the resident had another HbA1C completed on 06/06/16. The results were nine point four (9.4). The physician reviewed the results and revealed that he reviewed the FSBS which are 150-250 range consist, adequate control for a [AGE] year old, [DIAGNOSES REDACTED] if increase insulin, continue current dose. Interview on 06/16/16 at 3:45 p. m. with the Registered Corporate Clinical Nurse revealed that the facilities Resident Care Coordinator (RCC) complete chart audits several times a month. She revealed that part of the chart audit includes reviewing residents MAR ' s. The Registered Nurse (RN) was not aware that there was a documentation issue with the nursing staff leaving blanks on the MAR's. Interview on 06/17/16 at 12:45 p. m. Director of Nursing (DON) and the Administrator revealed that they both confirmed that the residents MAR had blanks that were not completed by nursing and that the expectations are for the nurses are to complete the MAR entirely during their shift. 2. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record revealed that the physician had ordered for the resident to have Finger Stick Blood Sugar (FSBS) completed in the morning and at bedtime, hold if blood sugar is less than one hundred fifty (150). The physician ordered for the resident to receive Humalog Insulin fourteen (14) units subcutaneously (SubQ) at 7:00 a. m., Humalog Insulin thirteen (13) units SubQ at 11:30 a. m., Humalog Insulin eleven (11) units SubQ at 5:00 p. m., and [MEDICATION NAME] Insulin thirty (30) units SubQ at bedtime. Review of the Medication Administration Record (MAR) since the resident's admission revealed on 05/15/16 the Humalog Insulin at 11:30 a. m. was blank, 05/17/16 at 5:00 p. m. Humalog Insulin was blank on the MAR and 05/29/16 at 5:00 p. m. Humalog Insulin was also left blank on the MAR. Review of the MAR for June 2016 revealed that on 06/02/16 the FSBS at 4:30 p. m. was blank. The June 2016 MAR revealed that on 06/06/16 and 06/07/16 the MAR was blank for Humalog 14 units at 7:00 a. m. Interview on 06/17/16 at 12:45 p. m. Director of Nursing (DON) and the Administrator revealed that they both confirmed that the residents MAR had blanks that were not completed by nursing and that the expectations are for the nurses to complete the MAR entirely during their shift. 3. Review of resident #234's 6/1/16 physician's orders [REDACTED]. Review of the 6/1/16 physician's orders [REDACTED].m and [MEDICATION NAME] 70/30 administer 10 units sq at bedtime and Finger Stick Blood Sugars (FSBS) twice daily (bid). Review of the June Medication Administration Record (MAR) revealed the absence of documentation of medication administration for resident #234: On 6/3 and 6/5 at 9:00 p.m. [MEDICATION NAME] 70-30 10 units sq at bedtime not documented as administered. On 6/4, 6/5, 6/6 and 6/10 at 6:30 a.m. [MEDICATION NAME] 70-30 20 units sq twice daily not documented as administered, On 6/10 and 6/13 4:30 p.m. [MEDICATION NAME] 70-30 20 units sq twice daily not documented as administered. Review of the FSBS bid revealed the following: 6/10 at 4:30 p.m. no FSBS documented During an interview on 6/16/16 at 3:49 p.m. the Director of Nurses (DON) the DON confirmed the above [MEDICATION NAME]and FSBS was not documented on the MAR as administered. The DON revealed it it is not documented as administered it is not given. The DON further revealed she expects the nurses to document on the MAR by putting their initials in the space that they have administered the medication. Review of resident #234's Admission History and Physical dated 6/6/16 revealed [DIAGNOSES REDACTED]. Review of resident #234's 6/1/16 Admission Physicians orders revealed an order for [REDACTED].=4 units. 251-300 =6 units,301-350 = 8 units, 315-400 =10 units, 401-450 =12 units prn (as necessary) Review of the June MAR revealed the absence of documentation of the Sliding scale Humalog insulin being administered and the absence of documentation of the number of units of the sliding scale administered according to the sliding scale parameters for FSBS of 201 and greater per sliding scale parameters as follows: on 6/4 06:30 a.m. FSBS 250, on 6/5 06:30 a.m. FSBS 246, on 6/6 06:30 a.m. FSBS 230, on 6/7 at 06:30 a.m. FSBS 247, and 4:30 p.m. FSBS 383, on 6/9 at 4:30 p.m. FSBS 215, on 6/10 at 06:30 a.m. FSBS 214 and at 4:30 p.m. FSBS not documented, sliding scale Humalog also no documentation as administered on 6/11 06:30 a.m. FSBS 238 and 4:30 p.m. FSBS 373, on 6/12 at 06:30 a.m FSBS 286 and 4:30 p.m. FSBS 396 and on 6/13 0630 FSBS 212, 4:30 FSBS 315. Further review of the June MAR revealed the absence of documentation of the Humalog 16 units sq three times a day being administered and [MEDICATION NAME] 48 units sq every day as follows: on 6/7 7:30 a.m. and 11:30 a.m. and 6/10, 6/11, 6/12 at 11:30 a.m. And on 6/5 at 9:00 a.m. the ordered [MEDICATION NAME] of 48 units sq there was no documentation as administered. During an interview on 6/14 at 3:15 p.m, 4:05 p.m. and 6:05 p.m. with LPN, MM she revealed that the resident receives Humalog sliding scale insulin according to the sliding scale order and it is administered with the scheduled Humalog insulin. MM revealed that on 6/13 at 4:30 p.m. she administered the Humalog sliding insulin 8 units for FSBS of 315 and administered the scheduled Humalog 16 units but failed to document the the amount of sliding scale administered. MMconfirmed there is no documentation on the MAR of sliding scale being administered and the MAR is blank for the sliding scale insulin. MM revealed the procedure for documenting the amount (units) of sliding scale insulin administered depends on the nurses who write the orders on the MAR. Further interview with LPN MMrevealed she overlooked documenting the sliding scale Humalog that she administered on 6/13 at 4:30 p.m. because they have so much to do. During an interview on 6/14 at 3:20 p.m. with the DON she revealed and confirmed that there was no documentation on the MAR next to the Humalog sliding scale prn 201-250 = 4 units, 251-300= 6 units, 301-350=8 units, 351-400= 10 units , 401-450=12 units of the sliding scale being administered and the number of units administered. The DON further revealed the number of units administered per sliding scale should be documented on the MAR. During an interview and review of the MAR on 6/15 at 8: 20 a.m. with the Resident Care Coordinator HH she conformed the above dates and times the Sliding scale Humalog insulin, Humalog 16 units before meals, [MEDICATION NAME] 48 units sq bedtime and FSBS were not documented as administered. During an interview on 6/15 at 9:00 a.m. with the resident's physician he revealed he had spoken with the facility to obtain better documentation sheets for units and blood sugars. He further revealed that he is unable to tell what sliding scale was given by looking at the MAR and he should be able to tell by looking at the MAR. The resident's physician further revealed he bases his orders for insulin on the FSBS and number of units of sliding scale insulin required. 5. Review of resident #73's 5/21/16 physician's orders [REDACTED]. Review of the 5/21/16 Admission Physician orders [REDACTED]. Further record review revealed a 5/23/16 clarification order for FSBS twice daily. A physician's orders [REDACTED]. 200-250=4 units, 251-300= 6 units, 301-350= 8 units, 351-400=10 units and 401-450=12 units. Review of the May MAR revealed no documentation Humalog 4 units sq before meals was administered as follows: 5/22 6:30 a.m. and on 5/27 and 5/31 at 6:30 a.m. Further review of the MAR revealed no documentation of Humalog sliding scale insulin was administered according to the sliding scale parameters as follows: On 5/25 4:30 p.m. FSBS 210 Review of the 6/1/16 Physician orders [REDACTED].= 4 units, 251-300 = 6 u, 301-350 = 8 u, 351- 400 = 10 units and 401-450= 12 u. Review of the June MAR revealed no documentation of the Humalog 4 units sq three times daily before meals was documented: On 6/1 6:30 a.m. and 11:30 a.m. On 6/2 11:30 a.m. On 6/3 6:30 a.m. and 11:30 a.m. On 6/7 at 6:30 a.m.,11:30 a. m. and 4:30 p.m. or on 6/10 6:30 a.m. Further review of the Jun MAR revealed no documentation of [MEDICATION NAME] 38 units sq at bedtime was administered as follows: On 6/3 at 9:00 pm Review of the June MAR revealed no documentation that the Humalog sliding scale insulin was administered according to the ordered parameters of Humalog 100 units/ml 200-250=4 units, 251-300=6 u, 301-350=8 u, 351-400 =10 u, 401-450 =12 u. as follows:On 6/3 9:30 pm. FSBS 231, On 6/4 6:30 am FSBS 201 and at 9:30 p.m. FSBS 227. On 6/5 at 6:30 a.m. FSBS 201 or at 9:30 p.m. FSBS 210. On 6/6 9:30 p.m. FSBS 253. On 6/7 9:30 p.m. FSBS 303. On 6/8 at 9:30 p.m. FSBS 294. On 6/9 at 9:30 p.m. FSBS 205, on 6/10 9:30 p.m. FSBS 230, on 6/12 at 9:30 p.m. FSBS 333 or on 6/13 9:30 p.m. there was no FSBS documented and no Humalog sliding scale documented as being administered. During an interview on 6/15 at 5:00 p.m. with the DON she confirmed the above dates and times that there was no documentation the Humalog sliding scale insulin, the [MEDICATION NAME] 38 units or the Humalog 4 units was administered. During an interview on 6/15 at 7:48 p.m. with the DON she revealed the nurses needed serious education related to documentation. The DON further revealed if not documented they did not administer. 6. Review of resident # 71's Admission Minimum Data Set Assessment(MDS) dated ,[DATE] revealed section I [DIAGNOSES REDACTED], [MEDICAL CONDITION] Fibrosis and [DIAGNOSES REDACTED] section N Insulin, Anticoagulant and Diuretic. Review of the 5/24 Admission Physician orders [REDACTED]. Review of the Client [DIAGNOSES REDACTED]. Review of the May MAR revealed no documentation the Humalog sliding scale insulin was administered as ordered according to the scale scale insulin parameters as follows: On 5/24 at 6:30 a.m. FSBS 257, on 5/25 at 6:30 a.m FSBS 264, on 5/26 at 6:30 a.m. FSBS 312 and on 5/27 at 6:30 a.m. FSBS 232. Review of the June Physician orders [REDACTED]. Cover with sliding scale insulin 201-250=4 u, 251-300=6 u, 301-350= 8 u, 351-400=10 u and 401-450= 12 u, [MEDICATION NAME] 15 units sq daily. Review of the June MAR revealed no documentation the Humalog sliding scale insulin was administered as ordered according to the scale scale insulin parameters as follows: On 6/2 at 6:30 a.m. FSBS 220, on 6/3 at 9:30 p.m. FSBS 349, on 6/8 at 6:30 a.m. FSBS 211 and at 9:30 p.m. FSBS 365, On 6/13 at 11:30 a.m. 306 and at 11:30 a.m. FSBS 293, on 6/14 6:30 a.m. 267 and at 4:30 p.m. FSBS 294. During an interview on 6/17 at 3:15 p.m. the DON she confirmed the above dates, times the insulin was not documented as being administered. During a telephone interview on 6/17 at 4:37 p.m with LPN GG, she revealed she administered the sliding scale insulin on 5/24, 5/25, 5/26 and 5/27 at 6:30 am. because the resident has a sliding scale ordered for FSBS 200 or greater. GG,LPN revealed she doesn't know why she failed to document that she gave the sliding scale on the MAR but she should have. 7. Review of the Admission Minimum Data Sets ((MDS) dated [DATE] revealed that resident #80 has an active [DIAGNOSES REDACTED].#80 revealed a [DIAGNOSES REDACTED]. Review of Admission Facesheet revealed that resident #80 was admitted on [DATE] Review on of resident #80s Careplan revealed the potential for hyperglycemic or hypoglycemic episodes secondary to diabetes. Resident #80 needed a therapeutic Reduced Concentrated Sweet Diet/Renal Diet due to a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#80 had orders for Finger Stick Blood Sugar (FSBS) before meals and at bed time, [MEDICATION NAME] Insulin twenty (20) units twice daily and Humalog sliding scale insulin. Review on 06/17/2016 at 8:30 a.m. of June, 2016 Medication Administration Record (MAR) for resident #80 revealed that FSBS were not documented as obtained on 6/6/16, 6/7/16 and 6/10/16 at 11:30 a.m., 6/3/16, 6/7/16, 6/10/16 at 4:30 p.m. and on 6/5/16 at 9:30 p.m. and on 6/10/16 the scheduled dose of [MEDICATION NAME] Insulin was not signed as given or on 6/10/16 at 7:30 a.m. and on 6/7/16, 6/8/16, 6/9/16, 6/10/16, 6/11/16, 6/12/16, 6/13/16 the scheduled dose of Humalog insulin was not signed as given. Also, the sliding scale insulin on 6/2/16 at 6:30 a.m. with a FSBS 233, number of units was not signed as given. The sliding scale insulin on 6/5/16 at 6:30 a.m. FSBS was 231, number of units was not signed as given. The sliding scale insulin on 6/7/16 at 6:30 a.m. FSBS was 244, number of units was not signed as given. The sliding scale insulin on 6/13/16 at 6:30 a.m. FSBS was 243, number of units was not signed as given. And the sliding scale insulin on 6/1/16 at 4:30 p.m., FSBS was 400, number of units was not signed as given. 8. Review on 06/15/2016 at 6:36 p.m. of the June, 2016 MAR for resident #236 revealed that the number of units of sliding scale insulin given was not documented on 6/13/16. A new order for FSBS AC & HS, [MEDICATION NAME] 30 units at hour of sleep and sliding scale Humalog insulin was obtained on 6/13/16. Review on 06/15/2016 6:46 p.m. of Admission Facesheet revealed that resident #236 was initially admitted on [DATE]. then after hospital stay Review of was readmitted on [DATE]. Review of the Medication Disinformation Records for June for resident #236 revealed the following: On 6/10/16 at 6:30 a.m. no FSBS documented as being done, on 6/10/16 at 4:30 p.m. blood sugar of 330 documented with # of units given not documented, on 6/10/16 at 6:30 a.m. no FSBS obtained and number of units given, documented and on 6/13/16 at 9:30 p.m. recorded blood sugar of 261 and number of units given not documented. During an interview on 06/17/2016 at 9:50 a.m. with the DON she revealed to confirm the missing FSBSs, missing documentation for units of insulin given for resident #236 and resident #80. Also, she did confirm that there was a problem with documentation.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents (#97, #110, and #224). From a sample size of thirty-three (33). The reviewed were the resident's discharged from skilled Medicare services and remained in the facility. Findings include: A review of the Liability Notices for residents #97, #110, and #224 was conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed the only notice provided to the residents was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN (Centers of Medicare/Medicaid Services - CMS form ) notice to the residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 06/17/16 at 9:20 a. m. with the Case Manager (CM)/Discharge Planner revealed that he/she was not familiar with the CMS form . Continued interview revealed that he/she provided residents with a verbal notice of their right to appeal. The CM confirmed that no training on providing CMS form had been provided by previous CM. The CM confirmed that the three (3) residents reviewed were only provided the non-coverage form and were not provided the SNFABN form. The CM confirmed that there is no facility policy on providing the CMS form .

Based on observation, staff interview, and record review of the facities Policy, Fall Management at a Glance the facility failed to ensure interventions were in place to prevent falls for one (1) resident (#233) from a total sample of thirty- three (33) residents. Findings include: Review of the facility Policy Fall Guidelines provided by the facility revealed: 1. Intent: The Falls program is an interdisciplinary approach to the management of patients at high risk for falls. 2. Goal: Our goal is to be proactive in our efforts to identify risk factors that reduce the frequency of falls and serious injuries. 3 .Program Process : a. Comprehensive Falls Assessment to be completed on Admission, Readmission, Quarterly, Annually and as clinically indicated. b. Falls Intervention Plan (FIP)- Based on the findings from the Comprehensive Falls Assessment , implement appropriate interventions on the FIP. c. Should a Fall occur: Event management form will be completed. Investigation and assessment of fall circumstances needs to be captured on the Event Management form. Nursing documentation will reflect the following, complete Situation, Background , Assessment, Recommendation(SBAR) if applicable: i. Circumstances of the fall to paint an accurate picture(who,what,when,where and why) will be described in the Interdisciplinary Team (IDT) note, along with head to toe nursing assessment, immediate intervention(s) initiated and documentation of the effectiveness of that intervention for seventy- two (72) hours to ensure effectiveness. ii. The nurse responsible for the patient's care at time of a fall needs to implement an immediate intervention on the FIP targeted to protect patient safety and /or serious injury. iii. Subsequent documentation for the next seventy - two (72) hours, or longer if indicated, should address: complete head to toe nursing assessment , site of injury if applicable, interventions initiated related to current fall event, effectiveness ineffectiveness of intervention initiated, and any change or additions to FIP. iv. Fall should be recorded on twenty-four (24) hour report to ensure communication and follow through. v. Director of Nurses (DON) and/or designee will ensure updates occur on FIP, 24 hour report and Accunurse. d. All falls should be reviewed daily in morning meeting with the medical record available to ensure appropriate documentation, interventions and any other ongoing concerns. e. Patients with recurring falls may require further review in Patient at Risk (PAR) meeting. Record review revealed resident #233 was originally admitted on [DATE] and was discharged to the hospital on 5/27 and was readmitted to this facility on 5/30/16. Review of the 6/1/16 Physician orders for resident #233 revealed [DIAGNOSES REDACTED]. Review of the Admission and Readmission Care Plan for resident #233 dated 5/30/16 revealed a problem identified Fall/Safety Risk. Interventions listed included; call light within reach, provide orientation to center, observe for any safety concerns and wandering tendencies, monitoring system and safety equipment. Review of the interventions revealed an area Describe and there was not an description. Review of the Fall Intervention Plan (FIP) dated 5/18/16 listed interventions; low bed, call light in reach, consider cognition, call light educate patient how to use, consider cognition and foot wear provide non skid socks. Further review revealed there was no documentation the FIP was reviewed at the time of readmission to the facility on [DATE] and no interventions had been added despite the resident experiencing falls on 6/8, 6/10 and 6/12. Review of the Comprehensive Fall assessment dated [DATE] revealed section A; ChangeCondition, Medication/Labs, Mobility, Cardiac, Infection, Hydration, Pain, and Behaviors was blank. Section B; revealed review and revise FIP for effectiveness as appropriate, Section C; Summary revealed resident and family education on fall prevent and call lights. Fall mats at bedside and bed in low position. Review of the Certified Nurses Assistant (CNA) Activities of Daily Living (ADL) Plan of Care 6/16/16 revealed Caution: fall potential and unsteady gait. Positioning: bed mobility uses low bed with floor mat , high risk for falls, two or more person physical assist. Transfers: monitoring: test and reapply bed or chair alarm. special equipment standing lift. Record review revealed the resident experienced a fall without injury on 6/8 and 6/10/16 . Further record review revealed a fall on 6/12/16 and received a small skin tear on the right upper arm at elbow. Review of the 6/8/16 2:30 a.m. SBAR note revealed the resident was observed sitting on the floor by the bed with bowel movement on the floor and the bed. No injuries were observed. Review of the SBAR notes and FIP revealed no immediate interventions were initiated according to the Fall Policy. Review of the 6/10/16 7:25 p.m. SBAR note revealed resident noted on floor without injuries. Further review of the SBAR revealed a head to toe assessment was not performed at the time of the fall as the sections of mental status evaluation, behavioral evaluation and respiratory evaluation were not completed as required in the fall policy . Review also revealed the SBAR note did not include where the fall occurred therefore an accurate picture was not documented as required in the facility policy. Review of the SBAR note and FIP revealed no immediate interventions were initiated as required on the fall policy. Review of the 6/12/16 1:00 p.m. SBAR note revealed resident found on the bathroom floor, little skin tear noted on right upper arm at elbow. Cleaned with normal saline and dry dressing applied. Review of the SBAR note and FIP revealed no immediate interventions put in place as required in the fall policy. Review of the IDT notes from 6/9 through 6/16 revealed a 6/10 9:30 a.m. note which documented resident alert with periods of confusion and tearful at times. An IDT note on 6/12 at 1:53 a.m. revealed documentation resident alert with confusion, noted to have frequent episodes of confusion. Continues to attempt to get out of bed without assistance. Bed alarm in place and working properly. IDT note on 6/13 at 1:38 a.m. documented alert, oriented times one (1),confusion present. Review of the SBAR notes, FIP and IDT notes reveal no documentation of when the use of the fall mat and bed alarm were initiated and the only documentation noted was of the bed alarm being in use and functioning was on 6/12/16 at 1:53 a.m. Observation of the resident on 6/15 and 6/16 at 7:15 a.m. revealed the resident in bed without a fall mat present on the floor. Observation on 6/15 at 9:00 a.m. revealed the resident sitting in a recliner chair and a fall mat was not present on the floor. During an interview on 6/16 at 9:00 a.m. with Certified Nurses Assistant (CNA), KK she revealed the resident is total care and is unable to put weight on her leg because she has a cast. KK further revealed that the resident transfers with the hoyer lift and two (2) CNAs unless with Physical Therapy. The CNA further revealed the resident is able to make her needs known and uses the call button to call for assistance . KK further revealed the resident is a fall risk and has a bed alarm and an alarm for the chair. During an interview on 6/16 at 10:00 a.m. with the Director of Nursing (DON) she revealed that a Fall Assessment should have been done on readmission on 5/30/16 and confirmed the only Fall Assessment completed was dated 5/18. During further interview the DON revealed it would have been fine to use the 5/18 FIP but new interventions should have been added after each fall on 6/8, 6/10 and 6/12 and the nurses failed to do so after any of these falls. The DON further revealed the FIP should have been updated and the nurses failed to do so. The DON further revealed the nurse who is working at the time of the fall should put new interventions in place on FIP at the time of the fall. The DON further revealed that the monitoring system and safety equipment listed as interventions on the Admission and Readmission Care Plan should have been specified because it could not be determined from the care plan what safety equipment and monitoring system was to be used. During an interview on 6/16 at 12:30 p.m. with Resident Care Coordinator HH, she revealed that from looking at the Readmission Care Plan for Fall risk the only monitoring system the facility has are bed alarms and chair alarms so she would assume one or both of those is what is meant to be used for this resident. HH further revealed that the only safety equipment the facility uses are fall mats. She stated that the Readmission Care Plan specified safety equipment and that would mean fall mats. HH stated she would expect the specific monitoring system and safety equipment to be listed. During an interview on 6/16 at 1:00 p.m. with Licensed Practical Nurse (LPN) FF she revealed the resident has not had fall mats before but she just put the fall mats down. During an interview on 6/16 at 2:15 p.m with the DON she revealed the facility was not following the policy for documentation of new interventions on the SBAR note, or the FIP and nursing notes and failed to document a head to toe assessment on the 6/10 SBAR. The DON further revealed the FIP should have been updated immediately after each fall with the new interventions. The DON further revealed that from the care plan and FIP by looking at it, it could not be determined if the resident was suppose to have fall mats, a bed alarm and a chair alarm. The DON further revealed a low bed was an intervention after the 6/8 fall, the 6/10 fall should have been been fall mats and after the 6/12 fall the intervention was a bed alarm. She confirmed there was no documentation on FIP or SBAR note of these interventions. The DON further revealed at the time of the fall the nurse is expected to implement new interventions and document the interventions in the nurses note and on the FIP. She further revealed the falls are reviewed in morning meeting and they are going to start having regular Patient At Risk (PAR) meetings after the morning meeting to review the falls and make sure interventions are in place . During an interview on 6/16 at 2:45 p.m with CNA KK she revealed she knows what to do for this resident because the nurse tells her every morning and she has the ADL sheet also. KK further revealed the resident is suppose to have a bed alarm when she in bed, a chair alarm on the wheelchair and fall mats.

Based on observation, record review, and staff interview the facility failed to apply the correct treatment dressing during observation of wound care treatment for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of Quarterly Minimum Data Sets (MDS) revealed that resident #43 had an unhealed pressure ulcer that was unstageable and one pressure area that was a stage three (3). [DIAGNOSES REDACTED]. Review of the Medical record for resident #43 revealed that the Braden Scale was done quarterly and was last done on 3/11/16 with the resident being assessed to have a Braden Score of 12, indicating that the resident was at high risk for developing a pressure ulcer. Review of the Treatment Record for resident #43 dated May, 2016 revealed that the sacral pressure ulcer was being staged as a stage three (3) and the wound base tissue type was granulation tissue. The treatment record documented that the sacral pressure ulcer was responding to treatment. The treatment record revealed treatment was started on 3/2/16. Review of measurements for the month of May documented no change in size of wound. On 5/4/16 wound measured 0.5 x 0.2 x 0.1 centimeters. On 5/25/16 the wound measured 0.5 x 0.2 x 0.1 centimeters. Review of the June 2106 physician order [REDACTED].#43 revealed a physician's orders [REDACTED]. Review of the Careplan for resident #43 revealed that the resident had a stage three (3) pressure ulcer to the sacrum. Review also revealed that the physician's wound orders were to be followed. Review of resident #43s Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1 x 0.5 x 0.1 centimeter. An observation on 06/15/2016 at 7:45 a.m. revealed resident #43 was asleep in bed, lying on her back in a low bed with an air mattress and a fall mat beside the bed. Observation and interview on 06/15/2016 at 12:44 p.m. of dressing change for resident #43 with Registered Nurse (RN), AA revealed that she cleaned the wound with Normal Saline, placed calcium alginate over the wound bed and covered it with Allevyn Foam Dressing. RN, AA verified during the observation that she cleaned the wound with Normal Saline, placed calcium alginate on the wound bed and covered Allevyn Foam Dressing. Interview also revealed that there was approximately 40 % slough covering the wound and it measured 1.0 x 0.5 x 0.1 centimeter. No concerns were observed with technique. RN AA stated she was uncertain about staging the wound. Further observation and Interview with RN, AA revealed that she was the part time treatment nurse and stated that she had one class to further her education about wound care, when she first accepted this position. She stated that at that time that the course did not mean that much and that it was the only education that had been provided. Interview with Wound Care Nurse, RN, AA on 06/15/2016 at 1:02 p.m. revealed that she thought that Calcium Alginate and collagen dressing were the same thing. Interview on 06/15/2016 at 2:00 p.m. with Wound Care Nurse, RN, AA revealed that she spoke with the Wound Care Nurse and was able to locate the collagen dressing. She stated that she had removed the dressing that she initially applied during the observation and replaced it with the collagen dressing and covered it with the Allevyn Foam dressing. Interview on 06/15/2016 at 2:44 p.m. with the DON confirmed that she would expect the nurse doing treatments to follow physicians orders, clarify what type of dressing to be used or to order the dressing, if there was none available and clarify with the physician what could be substituted until it was received. Cross refer to F-282 and F309.

Based on record review and staff interview the facility failed to notify the physician according to facility policy, Medication Administration General Guidelines for a resident who refused sliding scale insulin administration for one (1) resident (#234) of twelve (12) residents receiving sliding scale insulin. The census sample was thirty-three (33). Findings include: Review of the facility's policy and procedure for Medication Administration General Guidelines revealed the following: If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the Medication Administration Record [REDACTED]. If two consecutive doses of a medication are withheld or refused, the physician should be notified. Review of the 5/28/16 admission Minimum Data Set (MDS) assessment for R#73, noted in section I the following [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Fingerstick Blood Sugar (FSBS) before meals (AC) and hour sleep (HS). Sliding Scale Humalog 100 u/milliliter (ml) Notify Medical Doctor (MD) / Nurse Practitioner (NP) if blood sugar less than 60 or greater than 400. 200-250=4 units, 251-300= 6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units. Review of the June 2016 MAR indicated [REDACTED]. Review of the back of the June 2016 MAR indicated [REDACTED].m Further review of the MAR indicated [REDACTED]. During an interview on 6/15/16 at 7:45 p.m. with (LPN), LL she stated that the resident refuses the Sliding Scale Insulin at 9:00 p.m. and stated that she usually documents the refusal on the back of the MAR. Further interview revealed that the resident refused the ordered sliding scale insulin when she attempted to administer the insulin for FSBS's 200 or greater on 6/2, 6/7, 6/10, 6/11, 6/12 and 6/14 . Continued interview with LPN LL revealed she did not notify the Medical Doctor (M.D.), or Nurse Practitioner (NP) of the resident refusing the sliding scale insulin on 6/2, 6/7, 6/10, 6/11, 6/12 or 6/14., and revealed there is a communication book the nurses use to communicate with the NP/MD however, she did not document the refusals in this book. During an interview with the Director of Nurses (DON) on 6/15/16 at 8:03 a.m., the DON revealed she would expect the MD or NP to be notified after the first refusal according to her nursing judgment and confirmed there is no documentation of the MD/ NP being notified of the refusals on the above dates, time. The DON further revealed she did not know the facility policy for notification of refusal of medication. During an interview with R#73 on 6/16/16 at 7:45 a.m., the resident revealed she refuses her sliding scale insulin at night when it is close to the [MEDICATION NAME] 38 units because she does not want to bottom out her blood sugar. The resident further revealed she is not going to take any Insulin within two (2) hours of her [MEDICATION NAME] . R#73 further revealed the only time she has taken the sliding scale at night is if she didn't know what she was getting and further revealed she never takes another insulin close to the bedtime [MEDICATION NAME]. During an interview with R#73's physician on 6/16/16 at 2:48 p.m. he revealed that he expects the nurse to notify the NP or provider of the refusal by putting in the communication book after several refusals so it can be addressed. The physician further revealed if he or the NP is not notified of refusals he can not address it. .

Based on observation, interview and record review, the facility failed to follow the careplan for one (1) resident (#73) recieving anticoagulant medication and one (1) resident (resident #43) receiving treatment for [REDACTED]. Findings include: 1. Review of R#73's Plan of Care dated 6/2/16 revealed a Problem Resident at risk for abnormal bleeding and may bruise easily related to anticoagulant therapy. The interventions included to give anticoagulant medications as ordered. However, review of the resident's 6/3 Physician orders [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview with the Director of Nurses (DON) on 6/17/16 at 9:30 a.m. the DON confirmed the nurses failed to follow the Plan of Care for the Problem identified to administer medication as ordered. 2. Review of resident #43 Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1x0.5x0.1 centimeter . Observation on 06/15/2016 at 12:44 p.m. of dressing change of resident #43 with Registered Nurse (RN), AA revealed that she cleaned the wound with Normal Saline, placed calcium alginate over the wound bed and covered with Allevyn Foam Dressing. RN, AA verified during the observation that she cleaned the wound with Normal Saline, placed calcium alginate on the wound bed and covered Allevyn Foam Dressing. Interview also revealed that there was approximately 40 % slough covering the wound and it measured 1.0 x0.5 x 0.1 cm. RN, AA was uncertain about staging the wound. Interview on 06/15/2016 at 1:02 p.m. with Wound Care Nurse, RN, AA revealed that she thought that Calcium Alginate and collagen dressing were the same product. Interview on 06/15/2016 at 2:00 p.m. with Wound Care Nurse, RN, AA revealed that she spoke with the Wound Care Nurse who held the full-time position and after speaking with this nurse, she was able to locate the collagen dressing. She stated that she had removed the dressing that she initially applied during the observation and replaced it with the collagen dressing and covered it with the Allevyn Foam dressing. Review of Careplan on 06/15/2016 at 3:01 p.m. revealed that resident #43 had a stage 3 pressure ulcer to sacrum. Review also revealed that physician's wound orders were to be followed. Review of the June 2106 physician order [REDACTED].#43 revealed a physician's orders [REDACTED].

Based on observation, staff interview, and review of the Facilities Medication Administration Policy, the facility failed to follow the Physician order's for administration of an Anticoagulant medication for one (1) resident (#73), administration of Sliding Scale Insulin and one (1) resident (#234) a pressure wound dressing for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of the facilities Medication Administration General Guidelines revealed the following: Medications are administered in accordance with written orders of the attending physician. 1. Review of resident #73's 5/21/16 Physician order's revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 3.5 mg by mouth (po) every day. Recheck International Normalized Ratio (INR) 6/6/16. Review of the INR control sheet dated 6/3/16 revealed INR 1.2, [MEDICATION NAME] dose at time of test 3.0 mg po every day. Increase 3.5 mg. Review of the June Medication Administration Record [REDACTED]. However review of the physician's orders [REDACTED]. During an interview with the Director of Nurses (DON) on 6/15/16 at 6:28 p.m. she confirmed the nurses failed to follow the 6/3/16 physician's orders [REDACTED].The DON revealed that the [MEDICATION NAME] 3.5 mg po should have been started on 6/3. The DON further revealed it is her expectation the nurses follow the Physician orders. 2. Review of resident #234's History and Physical dated 6/6/16 revealed [DIAGNOSES REDACTED]. Review of the June Admission Physician orders [REDACTED].=4 units, ,251-300=6 units,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Review of the physician's orders [REDACTED].=4 units, 251-300=6 units ,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Less than 60 or greater than 400 call Medical Doctor(MD) . Humalog 100 units/milliliter (ml) Give 16 units sq three times a day before meals at 0730 a.m., 11:30 a.m., 4:30 p.m. Review of the June Medication Administration Record [REDACTED]=4 units, 251-300=6 units, 301-350=8 units, 351-400 =10 units, 401- 450 =12 units prn with no Humalog sliding scale documented as administered in that section of the MAR. Review of the Accucheck twice daily 06:30 a.m. and 4:30 p.m. revealed documentation of the sliding scale insulin administered three times from June 4-14 in the section Accucheck were recorded. During an interview with Licensed Practical Nurse (LPN) FF on 6/15/16 at 11:45 a.m. she revealed that on 6/ 6 at 4:30 p.m. the Fingerstick Blood Sugar (FSBS) for resident #234 was 335 and she administered Humalog 16 units ordered before meals and the sliding scale Humalog insulin 8 units for the FSBS of 335. During further interview and review of the MAR, LPN FF revealed on 6/7, 6/11 and 6/12 at 4:30 p.m. she did not administer the Humalog sliding scale insulin because she administered the scheduled Humalog 16 units that was ordered before meals and because the resident stated her blood sugar dropped fast. FF revealed the order was not clear if the resident was suppose to get the Humalog sliding scale insulin and the scheduled Humalog insulin 16 units at 4:30. LPN FF further revealed the MAR indicated [REDACTED]. FF revealed she did not clarify the physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. During an interview with the resident's Physician on 6/15 at 9:00 a.m. he revealed the resident was to receive the sliding scale Humalog insulin based on the Accucheck as well as the scheduled Humalog 16 units 3 times before meals. During an interview with the Director of Nursing (DON) on 6/15/16 at 1:30 p.m. she revealed the 6/3 physician's orders [REDACTED]. During an interview with the resident's Physician on 6/16/16 at 2:45 p.m., the Physician revealed he would expect the nurse to clarify an order if they were not sure of what medication to administer or if the order was not clear. 3. Review of the June 2106 physician order [REDACTED].#43 revealed a physician's orders [REDACTED]. Review of the Careplan for resident #43 revealed that the resident had a stage three (3) pressure ulcer to the sacrum. Review also revealed that the physician's wound orders were to be followed. Interview with Wound Care Nurse RN, AA on 06/15/2016 at 1:02 p.m. regarding the dressing ordered and used on resident #43 revealed that she thought that Calcium Alginate and collagen dressing were the same thing. Interview on 06/15/2016 at 2:00 p.m. with Wound Care Nurse, RN AA revealed that she spoke with the Wound Care Nurse and was able to locate the collagen dressing. She stated that she had removed the dressing that she initially applied during the observation and replaced it with the collagen dressing that was ordered and covered it with the Allevyn Foam dressing. Interview on 06/15/2016 at 2:44 p.m. with the Director of Nursing (DON) confirmed that she would expect the nurse doing treatments to follow physician's orders [REDACTED].

Based on observation, staff interview and record review the facility failed to revise the Fall Intervention Plan (FIP) to reflect fall interventions for two (2) residents #224 and #233 from a total sample of thirty three (33) residents. Findings include: 1. Resident #224 was a ninety six (96) year old long term care resident that was admitted to the facility on [DATE] after a hospitalization for general weakness. Her [DIAGNOSES REDACTED]. Review of the Admission Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 6 which indicates serve cognitive impairment. Continued review of the MDS revealed that the resident required extensive assistance with transfers, Activities or Daily Living (ADL) and Walking. The resident was assessed as total dependent for locomotion on and off of the unit. Review of the Fall Intervention Plan (FIP) revealed that the following interventions were initiated on 06/06/16: Low bed, call light in reach, educate how to use call light, encourage to call for assistance to toilet at first urge to void, encourage use of non-skid shoes/socks, foot wear, provide non-skid socks, hydration - fluids of choice within reach, medications - consider medication side effects, medications - review regimen and times given, and vision - keep glasses available. The following interventions were initiated on 06/07/16: Alarm, pressure sensitive on bed and fall mat at one side of bed. Review of the Comprehensive Falls Assessment revealed that nursing staff signed the form on 06/06/16 and only indicated that the resident was a new admit. Further review of the assessment form revealed the boxes that were to be checked regarding the resident risk for falls were blank. Review of the medical record revealed that an SBAR was completed on 06/13/16 due to a fall, Vital signs were obtained. The nurse ' s notes revealed that resident was heard calling for help and upon staff entering the room the resident was found on the floor lying on his/her left side near the bathroom. The resident had disconnected the alarm (per resident) found by Administrator and Certified Nursing Assistant (CNA). Resident assessed with [REDACTED]. Review of the Interdisciplinary Progress Notes in the medical record revealed nursing staff documented on 06/14/16 that the resident was impulsive, poor safety awareness and bed/chair alarm in place. The nurse revealed that the resident was post fall. The progress note dated 06/15/16 revealed day two post fall, continue to monitor and call light within reach. The progress note dated 06/16/16 revealed that it was day three post fall, monitoring for changes and call light within reach. Review of the Fall Management Policy revealed that a comprehensive fall assessment is to be completed on admission, readmission, quarterly, annually and as clinically indicated. Continued review of the policy revealed that after a fall immediate intervention(s) are initiated and documentation of the effectiveness of that intervention for seventy-two (72) hour to ensure effectiveness. The policy revealed that the nurse responsible for the resident's care at the time of a fall needs to implement an immediate intervention on the Fall Intervention Plan (FIP) targeted to protect resident safety and/or serious injury. Interview on 06/17/16 at 3:25 p. m. with the Director of Nursing (DON) he/she stated that the Situation, Background, Assessment, Recommendation (SBAR) for the resident's fall on 06/13/16 was not completed entirely. DON stated he/she expected staff to complete the entire SBAR form and to document interventions in the resident's medical record on the day the fall occurs. The DON further stated that he/she recalled the day that the resident had fallen on 06/13/16 and recalled that staff added a chair alarm as an intervention. The DON stated that there was not any documentation found to indicate the intervention was put into place for the fall on 06/13/16. 2. Record review revealed R#233 was admitted to the facility on [DATE] with status [REDACTED]. Review of the Care Plan revealed that the specific safety equipment and monitoring systems were not listed. Review of the resident's Fall Intervention Plan(FIP) noted only interventions dated 5/18 which was a previous admission according to review of the MDS. Further record review revealed that R#233 experienced a fall on 6/8, 6/10 and 6/12/16. According to the 6/1216 Situation Background Assessment, Recommendation (SBAR) form the resident sustained [REDACTED]. Review of the Certified Nurses Assistant (CNA) Activities of Daily Living (ADL) Plan of Care for R#233 noted: Cautions fall potential, unsteady gait, Positioning Bed M mobility uses low bed with floor mat, Cautions high risk for falls, extensive assistance two or more people physical assist. Further review of the ADL sheet noted transfer cautions due to pain in the right leg, monitoring test and reapply bed or chair alarm. During an interview on 6/16/16 at 9:00 a.m., CNA KK stated that the resident is a fall risk and had a bed and a chair alarm. However review of the 5/18/16 FIP does not include these interventions During an interview on 6/16/16 at 10:00 a.m. the Director of Nurses (DON) stated that it would be fine to use the 5/18/16 FIP but new interventions should have been added after each fall. The DON stated there was not any documentation on the FIP that interventions were added on readmission on 5/30/16 or after the resident experienced falls on 6/8/16, 6/10/16 and 6/12/16. The DON further stated the 5/18/16 FIP should have been updated and the nurses failed to do so. In addition, the DON stated after review of the 5/30/16 admission and readmission care plan he/she could not determine what monitoring systems and safety equipment was to be used and that the care plan should have listed what safety equipment and monitoring systems were to be used. During interview on 6/16/16 at 2:15 p.m. the DON stated a low bed was an intervention after the 6/8/16 fall, after the 6/10/16 fall the intervention should have been been fall mats and after the 6/12/16 fall the intervention was the bed alarm. The DON stated that there was not any documentation on the FIP or SBAR forms of these interventions and stated the new interventions should have been put in the nurses notes at the time of the fall and put on the FIP. ,.

Based on record review and staff interviews, the facility failed to follow Physician's orders for two (2) residents (#152, #65) related to inappropriate behaviors and sliding scale Insulin coverage. The sample size was twenty (20) residents. Finding include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the Physician's Order dated 2/6/15 revealed to get a Psychiatric Consult for behaviors. This order was noted on 2/6/15 by Registered Nurse (RN) "AA". Interview conducted with RN "AA" on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN "AA" further revealed that she could not get an available Psychiatrist to see the resident or, an available bed at the psychiatric facility to have the resident placed. RN "AA" confirmed that the nurse's notes did not indicate her efforts. Continued interview revealed that after the Nurse Practioner (NP) adjusted the resident's medications on 2/13/15 no other episodes of behaviors were noted by the resident and she did not see the need to have a Psychiatrist evaluate. 2. Review of the February 2015 Physician's Order for resident #65 dated 2/13/15 revealed a Sliding Scale clarification for Humalog 100 units/vial to give as follows: Blood Glucose (BG)=201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units and to call the physician if BG is less than 60 or greater than 400 mg/dl. Review of the Medication Administration Record [REDACTED] On 2/25/15 an accucheck blood sugar was done at 4:30 p.m., with a result of 467 milligrams per deciliter (mg/dl). On 3/16/15 an accucheck blood sugar was done at 5:30 p.m.,with a result of 417 mg/dl. Review of the clinical records revealed that there was no evidence that licensed staff had notified the physician of the elevated blood sugar results on 2/25/15 and 3/16/15. Interview with RN "AA" on 3/25/15 at 10:56 a.m. revealed that resident #65 was a Diabetic that required Insulin per sliding scale. RN "AA" confirmed that the MAR indicated [REDACTED]. RN "AA" further confirmed that there was no evidence of documentation in the clinical record that the Nurse Practitioner (NP) or the Physician were notified. Continued interview revealed that the physician orders for resident # 65 was that if the accucheck blood sugar was greater than 400 mg/dl the physician should have been called.

Based on record review and staff interviews, the facility failed to ensure that care and services were provided according to the care plan for one (1) resident (#152) related to inappropriate behaviors, and one (1) resident (#65) related to sliding scale Insulin coverage from a sample of twenty (20) residents. Findings include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the physician's orders [REDACTED]. This order was noted on 2/6/15 by Registered Nurse (RN) "AA". Interview conducted with RN "AA" on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN "AA" further revealed that she could not get an available Psychiatrist to see the resident or, an available bed at the psychiatric facility to have the resident placed. RN "AA" confirmed that the nurse's notes did not indicate her efforts. Continued interview revealed that after the Nurse Practioner (NP) adjusted the resident's medications on 2/13/15 no other episodes of behaviors were noted by the resident and she did not see the need to have a Psychiatrist evaluate. 2. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed that resident #65 had a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated 7/30/13 revealed that resident #65 had a potential for hyperglycemic or hypoglycemic episodes secondary to Diabetes. The goal was that the resident would have relief of hypo/hyperglycemic episodes within thirty (30) minutes of interventions. The interventions included to obtain labs as ordered, report abnormal findings to the physician with follow up as indicated, and to check blood sugar levels per physician's orders [REDACTED]. Review of the February 2015 physician's orders [REDACTED].=201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units and to call the physician if BG is less than 60 or greater than 400 mg/dl. Review of the Medication Administration Record [REDACTED] On 2/25/15 an accucheck blood sugar was done at 4:30 p.m., with a result of 467 milligrams per deciliter (mg/dl). On 3/16/15 an accucheck blood sugar was done at 5:30 p.m.,with a result of 417 mg/dl. Review of the clinical records revealed that there was no evidence that licensed staff had notified the physician of the elevated blood sugar results on 2/25/15 and 3/16/15. Interview with RN "AA" on 3/25/15 at 10:56 a.m. revealed that resident #65 was a Diabetic that required Insulin per sliding scale. RN "AA" confirmed that the MAR indicated [REDACTED]. RN "AA" further confirmed that there was no evidence of documentation in the clinical record that the Nurse Practitioner (NP) or the Physician were notified. Continued interview revealed that the physician orders [REDACTED]. Cross-Refer to F309