Avir at Azalea Heights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for accident hazards (Resident #3).<BR/>The facility failed to ensure Resident #3 had no history of elopement before accepting her as resident (the facility did not have a secure unit nor a wander guard system and thus would not accept residents with a history of elopement). <BR/>The facility did not accurately assess Resident #3's physical ability to leave the facility upon her admission on [DATE]. <BR/>This failure could place residents with recent at risk for inadequate supervision elopement and significant injury. <BR/>Findings included: <BR/>Record review of the face sheet for Resident #3 dated 4/26/24 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Dementia, high blood pressure, atherosclerosis (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), osteoporosis (A condition in which bones become weak and brittle) and high cholesterol. <BR/>Record review of the baseline care plan for Resident #3 dated 4/24/24 indicated Resident #3 had a diagnosis of Dementia and would be provided care and safety checks throughout each shift. The care plan was updated on 4/25/24 and indicated Resident #3 was exit seeking and at risk for elopement and/or wandering with unsafe boundaries. The care plan indicated Resident #3 had a history of actual attempts to leave the facility unattended. The care plan interventions included 1 on 1 observation (1 staff member with the Resident at all times) until she could be transferred to a memory care unit.<BR/>Record review of the nursing note dated 4/25/24 at 11:30 a.m. for Resident #3 indicated the nurse heard the D hall alarm go off the nurse responded to the alarm and saw Resident #3 walking across the parking lot. The nursing note indicated the nurse followed Resident #3 and asked her to come back to the facility but Resident #3 continued heading down the sidewalk when another employee joined her and was able to catch up to Resident #3. The note indicated the facility staff were able to convince Resident #3 to come back to the facility and call her family. The nursing note indicated upon return to the facility Resident #3 was placed on 1 to 1 observation. <BR/>During an interview on 4/26/24 at 1:00 p.m., RN A said Resident #3's elopement incident occurred early in the morning on 4/25/24 at approximately 7:45 a.m. RN A said she was at the nursing station when the D hall alarm went off. RN A said she went to the D hall exit door and looked outside and saw Resident #3. RN A said Resident #3 was approximately 20 feet from the exit door walking briskly and started across the parking lot. RN A said she just couldn't keep up with her and said she could not run to get her. RN A said she continued to follow Resident #3 across the parking lot when human resources staff E pulled into the parking lot. RN A said Resident #3 crossed the side street and started onto the sidewalk (across the side street from the facility). RN A said human resources staff E ran and got Resident #3 by the hand. RN A said human resources staff E stood talking with Resident #3 until she (RN A) could reach her (Resident #3). RN A said Resident #3 was then taken back into the facility. RN A said she immediately notified the DON who instructed her to ensure Resident #3 was placed on 1 to 1 observation. RN A said 1 to 1 observation meant a staff member was to stay with Resident #3 at all times and have no other assignment. RN A said she knew nothing of Resident #3's elopement history.<BR/>During an interview on 4/26/24 at 1:10 p.m., human resources staff E said as she arrived to the facility at approximately 7:45 a.m. on 4/25/24, she saw Resident #3 walking across the parking lot. Human resources staff E said she was not sure at first that Resident #3 was a resident and thought perhaps she was just someone out walking, cutting across the parking lot. Human resources staff E explained Resident #3 was walking at a brisk pace and did not seem confused or lost. Human resources staff said as she pulled into her parking spot Resident #3 had crossed the side street and started onto the sidewalk. Human resources staff E said she saw RN A walking across the parking lot and asked her if the lady walking was a resident. Human resources staff E said RN A yelled Yes, and so she ran up to Resident #3 held her hand and started talking to her. Human resources staff E said RN A caught up to them and they took her (Resident #3) back into the facility. <BR/>During an observation and interview on 4/26/24 at 1:40 p.m., Resident #3 said she just left the facility because she needed to call her family. Resident #3 sat smoking a cigarette in the smoking area with staff beside her. Resident #3 was asked again about leaving the facility and she said, Oh I don't know about that. <BR/>During an interview on 4/26/24 at 2:09 p.m. Resident #3's family member #2 said she spoke with the admissions coordinator last Friday (4/19/24) and sent over all the necessary paperwork to have her admitted . Family member #2 said Resident #3 was admitted to facility in the afternoon on 4/25/24 but could not say exactly what time. Family member #2 said the facility contacted her on 4/26/24 and told her Resident #3 had eloped from the facility. Family member #2 said they were keeping someone with Resident #3 at all times and would do so until they could find a facility with a secure unit for her. <BR/>During an interview on 4/26/24 at 2:13 p.m., Resident #3's family member said Resident #3 was admitted into the facility on 4/25/24 sometime after 1:30 p.m. in the late afternoon. Resident #3's family member said he had been contacted and told Resident #3 had eloped from the facility and that the facility was seeking out a home that could provide a secured unit for Resident #3. The family member said he understood the need for a secured unit and had no problem with the transfer but was a little frustrated because the whole reason the family sought long-term care was because Resident #3 had wandered off from her apartment and was found by the police. The family member said they (the family) was upfront with the facility and had told them of the event. <BR/>Record review of Resident #3's admission paperwork found no documentation of elopement history or the incident described by Resident #3's family member in which she left her apartment and was found by police. <BR/>During an interview on 4/26/24 at 3:20 p.m., admissions coordinator B said she had talked to the Resident #3's family member #2 last Friday (4/19/24) regarding an admission for Resident #3. Admissions coordinator B said when she spoke with family member #2, she told her the family was seeking admission into long term care because she (Resident #3) had reached a point she would call family members constantly and the care she needed was just too much for them. Admissions coordinator B said family member #2 said she/he worked during the day and could not check on Resident #3 as often was needed and could not take her calls as often as she would call. Admissions coordinator B said the family seemed to be in a rush to get her admitted and had all the necessary paperwork to them on Friday (4/29/24). Admissions coordinator B said the facility used a centralized admission process. She explained that once all the necessary paperwork was gathered it was sent to the company's central office for review. Admissions coordinator B said sometimes the central office will send back notes or conditions after reviewing the paperwork. Admissions coordinator B said for example a nurse may have to go out and evaluate the potential resident. Admissions coordinator B said this was not the case for Resident #3 as the central office had cleared her for admission. Admissions coordinator B said family member #2 said nothing to her about Resident #3 having eloped from her independent living apartment and being found by the police. Admissions coordinator B said the facility did not take Residents with a history of elopement. <BR/>During an interview on 4/26/24 at 3:32 p.m., the DON said she knew nothing of Resident #3's history of elopement and there was nothing in the records received regarding a history of elopement. The DON said the facility simply would not have accepted Resident #3, had they known about the elopement history. The DON said the facility did not have a wander guard system nor a secured unit and therefore did not accept residents with an elopement history. The DON said the facility had secured placement for Resident #3 in a facility with a secured unit, but the facility could not take her until Monday (4/29/24). The DON said Resident #3 would remain on 1 on 1 observation until she was transferred to the facility with the secured unit. <BR/>During an interview on 4/29/24 at 10:40a.m., Resident #1's family member said the family had decided Resident #3 needed to be placed in long term care because she had left her apartment and was found by the police on 4/18/24. The family member said Resident #3 lived independently in her apartment until that incident. The family member said the facility had been contacted regarding possible admission and all the required paperwork was sent 4/19/24. The family member said admissions coordinator B, business office manager C and social worker D all were aware of Resident #3's history of eloping from her apartment and being found by the police on 4/18/24. <BR/>During an interview on 4/29/24 at 10:50 a.m., admissions coordinator B said she had spoken with family member #2 and it was never relayed to her that Resident #3 had eloped form her apartment. Admissions coordinator B said the facility just would not have taken her and had just denied someone placement last week because they had a history of elopement. <BR/>During an interview on 4/29/24 at 10:55 a.m., business office manager C said the family had not told her anything about Resident #3's elopement history. Business office manager C said she had only discussed financial aspects and payor sources with the family as that was what her job entailed. <BR/>During an interview on 4/29/24 at 11:04 a.m., social worker D said the family had not said anything to her about Resident #3 having a history of elopement. Social worker D said she helped the family complete a DNR and completed PASRR paperwork and the family never mentioned Resident #3 had left her apartment and was found by police. <BR/>Record review of the admission assessment dated [DATE] at 4:08 p.m. section L Exit seeking tool, indicated Resident #3 did not have the physical ability to leave the building on her own. This section of the admission assessment had no further assessment questions answered as the tool stated . (1) Is the resident physically able to leave the building on their own? If no, disregard remaining questions. This assessment was completed by LVN F. <BR/>During an interview on 4/29/24 at 1:30 p.m., ADON G said she could not say why LVN F would have marked no on the admission assessment, as Resident #3 had the physical ability to leave the building but said she did not feel this assessment would have prevented Resident #3 from eloping the facility. ADON G said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. ADON G said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The ADON said she knew nothing of Resident #3's elopement history. ADON G said the facility does not accept resident with exit seeking behavior. <BR/>During an interview on 4/29/24 at 1:35 p.m., the DON said Resident #3 had been transferred to a facility with a secured unit. The DON said she had always taken the question on the admission assessment under section L Exit seeking tool to mean would the resident leave the building on their own. The DON said after re-reading the question she understood the question to ask whether or not a resident had the physical ability to leave the building. The DON said she did not feel the assessment would have prevented Resident #3's elopement from the building. She said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. The DON said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The DON said she knew nothing of Resident #3's elopement history. The DON said had she have known Resident #3 had a history of elopement the facility would have not accepted her. <BR/>During an interview on 4/29/24 at 2:17 p.m., LVN F said she marked no on the admission assessment under section L Exit seeking tool because she understood the question to mean would the resident leave the building on their own. LVN F said Resident #3 had been in the facility a few hours but had not displayed any exit seeking behaviors and was content in her room when she cared for her. <BR/>Record review of the facility policy and procedure revised January 2023, titled Elopement Response & Exit Seeking Management stated, .A. Elopement Response: Unable to locate resident (1) If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises B. Response following the location of the resident: (1) Once located and safety confirmed, conduct an assessment. (2) Place resident on enhanced monitoring, consider 1:1 for a specified time as needed to ensure the safety of resident or consider placement in secured unit for continued monitoring and safety. The facility policy and procedure did not detail the facility would not accept Resident's with a history of elopement. <BR/>During an interview on 4/29/24 at 2:20 p.m., the corporate RN said the facility did not have a policy and procedure that specifically addressed the accurate completion of admission assessments or regarding the centralized admission process. <BR/>Record review of the facility policy and procedure revised January 2023, titled Professional Standards of Care, stated, .Nurses should conduct assessments or evaluations and document nurses' notes in the following instances: 1) routine charting for residents should reflect the recipient's ability as assessed upon admission, re-admission and as clinically indicated; and 2) at the time of accidents, incidents or change in condition. All exceptions to stable, baseline or usual status should be recorded as exceptions and included in the clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were completed and accurately documented for 1 of 4 residents (Resident #281) reviewed for medical records accuracy.<BR/>The facility failed to ensure an order for enteral feedings (liquid nutrition delivered via a tube inserted into the body) from the hospital was documented in Resident #281 s physician's orders at the facility. <BR/>The facility failed to document the administration of liquid nutrition for 4 consecutive days after Resident #281 was admitted to the facility. <BR/>These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included: <BR/>Record review of Resident #281's face sheet and physician's orders dated 09/17/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included, dysphagia (difficulty swallowing), gastrostomy tube (a tube inserted through the abdominal wall, into the stomach for the purpose of delivering liquid nutrition), cardiac arrest, respiratory failure, and hypertension. <BR/>Record review of the physician's orders dated 09/13/2024 indicated there was no order for Resident #281 to receive any enteral nutrition. <BR/>Record Review of Resident #281's MAR for September 2024, indicated there was no documentation he received Jevity 1.2 @ 70 ml/hour with 60 ml water flushes every 4 hours on 9/13/2024, 9/14/2024, 9/15/2024, 9/16/2024, and 9/17/2024.<BR/>Record review of Resident #281's Hospital Discharge Records indicated an order for him to receive Jevity 1.2 at 70ml/hour with a water flush of 30ml/hour via the gastrostomy tube.<BR/>During an observation on 09/16/2024 at 10:20 a.m., Resident #281 was non-interview able and was observed to be lying in bed with his eyes closed with the head of the bed elevated approximately 30 degrees. A container of Jevity 1.2 (liquid nutrition) was noted to be hanging from a metal pole and infusing via a tube leading to the resident's stomach at a rate of 70ml/hour. Resident #281 was again observed to be receiving the same liquid nutrition on 09/16/2024 at 3:30 p.m., on 09/17/2024 at 9: 30 a.m., and on 09/18/2024 at 10:00 a.m .<BR/>During an interview on 09/18/2024 at 1:30 p.m., the MDS RN said a physician order for Jevity 1.2 @ 70 ml/hr. with 60 ml water flush every 4 hours, was entered into electronic health records, and on the MAR but it was entered late at 3:30 p.m., as a start date for 09/17/2024 .<BR/>During an interview on 09/18/2024 at 2:30 p.m., the Director of Clinical Operations Nurse said, LVN B received report at the change of shift from the day shift agency nurse and completed the New admission form. She said LVN B failed to enter Resident #281's physician order for external feedings into his EHR. She said all of Resident #281's other admission orders were entered into his EHR accurately .<BR/>During an interview on 09/18/2024 at 4:30 p.m., LVN B said he had worked for the facility for 13 years, he stated on 09/13/2024, he received, and accepted report at the change of shift from the day shift agency nurse, she had received a verbal order from the hospital for the external feeding. LVN B stated, the agency nurse had completed the setup and the external feeding (Jevity 1.2 @ 70 ml/hour.), it was already hanging. LVN B stated he proceeded with the admission assessment and failed to enter Resident #281's external feeding order into his EHR. LVN B said all other orders were entered into the electronic health records accurately . <BR/>During an interview on 09/18/2024 at 5:30p.m., the DON, said the two facility's ADON's were responsible for checking and reviewing all new admissions, re-admissions, check lists, and physician orders to ensure orders were put in accurately. She said the ADON's were responsible for ensuring Medication administration orders were entered into the EHR for the correct patient, correct time, correct route, correct dose, correct medication, and the correct documentation accurately . <BR/>Reviewed the facility Professional Standard of Care Policy dated implemented 02/2017 and revised on 01/2024 stated, . Nurses should conduct assessments or evaluations and document within the medical record in the following instance: 1) admission, re-admission, and as clinically indicated. 2) at the time of an incident or change in conditions. 3) when exceptions are identified. 4) as otherwise directed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 2 of 3 residents reviewed for ADLs (Resident's #1 and Resident #2). <BR/>The facility failed to ensure Resident #1's received a bath until 5 days after his admission. <BR/>The facility failed to ensure Resident #2 received a bath/shower for 4 weeks. <BR/>This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life.<BR/>Findings included:<BR/>Record review of the face sheet dated 4/22/24 for Resident #1 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease, high blood pressure, restlessness and agitation, anxiety disorder, heart disease, neuropathy (Weakness, numbness, and pain from nerve damage), visual hallucinations, major depressive disorder, agoraphobia (Fear of places and situations that might cause panic, helplessness, or embarrassment), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down). <BR/>Record review of the MDS for Resident #1 dated 4/6/24 indicated he usually made himself understood and usually understood others. The MDS indicated Resident #1 had short-term and long-term memory problems. The MDS indicated he had severely impaired cognitive skills for decision machining. The MDS indicated he had no behavior of rejecting care. The MDS indicated he was dependent on staff for eating, oral hygiene, toileting, showers/bathing, dressing (both the upper and lower body), putting on footwear, and personal hygiene. The MDS indicated he was always incontinent of bowel and bladder. <BR/>Record review of the care plan dated 4/2/24 indicated Resident #1 was at risk for self-care deficit. The care plan interventions included 2-person assistance with bed mobility, hygiene, transfers, and toileting. <BR/>During an interview on 4/25/24 at 10:39 a.m., Resident #1's family member said she visited Resident #1 every day while he was in the facility. Resident #1's family member said he remained in the same clothes for the first 4 days he was in the facility (4/1/24 to 4/4/24) and did not think he had received a shower. <BR/>Record review of Resident #1's ADL documentation did not indicate he had received a shower or bath from 4/1/24 to 4/5/24. <BR/>2. Record review of the face sheet for Resident #2 dated 4/26/24 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs), COPD (group of lung diseases that block airflow and make it difficult to breathe), artificial openings of the urinary tract status, colostomy (an opening in the large intestine, or the surgical procedure that creates one. The opening is formed by drawing the healthy end of the colon through an incision in the anterior abdominal wall and suturing it into place), and depression. <BR/>Record review of the MDS dated [DATE] for Resident #2, indicated he made himself understood and understood others. The MDS indicated he had no cognitive impairment (BIMS of 15). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #2 required substantial/maximal assistance with toileting. The MDS indicated he was dependent on staff for shower/bathing. <BR/>During an observation and interview on 4/26/24 at 12:40 p.m., revealed Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath in 4 weeks. Resident #2 said he had not asked any staff about not receiving a bath or shower but knew he was supposed to receive them. Resident #2 said he felt staff had not provided him a shower because doing so was a bit of process. Resident #2 explained he had to be lifted from the bed with a mechanical lift and lowered onto a shower bed. Resident #2 said he felt staff just didn't want to go through the process of providing him a shower. <BR/>During an interview and observation on 4/29/24 at 9:35 a.m., Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath since 4/26/24. Resident #2 said his gown was changed but he was not given a shower. Resident #2 said he asked for a washcloth to wash his face and arm pits but was not provided one. Resident #2 said he did not know the name of the CNA he asked for a washcloth. <BR/>Record review of the ADL documentation for Resident #2 from 4/13/24 to 4/29/24 indicated he received a bath/shower on the following dates: <BR/>*4/27/24- documented by CNA L <BR/>*4/25/24- documented by CNA M<BR/>*4/20/24- documented by CNA N<BR/>*4/18/24- documented by CNA O<BR/>*4/16/24- documented by CNA P<BR/>During an interview on 4/29/24 at 1:26 p.m., CNA M said she did not give a bath or shower to Resident #2 on 4/25/24. CNA M said she was not even assigned to him on that day. CNA M said she gave her sign in information to agency staff so they could document and that was why the documentation reflected she had documented Resident #2 had received a bath on that day (4/25/24). CNA M said she could not remember the agency staff members name. CNA M said she had given her sign in information to multiple agency staff. <BR/>During an interview on 4/29/24 at 2:37 p.m., CNA L said she had provided Resident #2 a bed bath when she worked on 4/27/24. CNA L said Resident #2 received a bed bath on 4/27/24 because he refused to a shower. <BR/>An interview with CNA N regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>An interview with CNA O regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>An interview with CNA P regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>During an interview on 4/29/24 at 2:15 p.m., CNA L said it was important residents received scheduled bathing/showers in order to maintain hygiene and identify any skin changes. CNA L said the administration of showers/baths were documented in EMR record.<BR/>During an interview on 4/29/24 at 2:17 p.m., LVN F said it was important for residents to receive showers/baths to ensure good hygiene and make the resident feel better. <BR/>During an interview on 4/29/24 at 2:37 p.m., the DON said she expected CNAs to provide residents with showers/baths. The DON said it was important for residents to receive their showers/baths to promote hygiene. <BR/>Record review of the facility policy and procedure titled Activities Daily Living revised January 2023 stated .each resident's abilities to perform activities of daily living will not diminish .Activities of daily living include: personal hygiene . <BR/>The facility policy and procedure did not specifically address ensuring dependent resident received showering/bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for accident hazards (Resident #3).<BR/>The facility failed to ensure Resident #3 had no history of elopement before accepting her as resident (the facility did not have a secure unit nor a wander guard system and thus would not accept residents with a history of elopement). <BR/>The facility did not accurately assess Resident #3's physical ability to leave the facility upon her admission on [DATE]. <BR/>This failure could place residents with recent at risk for inadequate supervision elopement and significant injury. <BR/>Findings included: <BR/>Record review of the face sheet for Resident #3 dated 4/26/24 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Dementia, high blood pressure, atherosclerosis (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), osteoporosis (A condition in which bones become weak and brittle) and high cholesterol. <BR/>Record review of the baseline care plan for Resident #3 dated 4/24/24 indicated Resident #3 had a diagnosis of Dementia and would be provided care and safety checks throughout each shift. The care plan was updated on 4/25/24 and indicated Resident #3 was exit seeking and at risk for elopement and/or wandering with unsafe boundaries. The care plan indicated Resident #3 had a history of actual attempts to leave the facility unattended. The care plan interventions included 1 on 1 observation (1 staff member with the Resident at all times) until she could be transferred to a memory care unit.<BR/>Record review of the nursing note dated 4/25/24 at 11:30 a.m. for Resident #3 indicated the nurse heard the D hall alarm go off the nurse responded to the alarm and saw Resident #3 walking across the parking lot. The nursing note indicated the nurse followed Resident #3 and asked her to come back to the facility but Resident #3 continued heading down the sidewalk when another employee joined her and was able to catch up to Resident #3. The note indicated the facility staff were able to convince Resident #3 to come back to the facility and call her family. The nursing note indicated upon return to the facility Resident #3 was placed on 1 to 1 observation. <BR/>During an interview on 4/26/24 at 1:00 p.m., RN A said Resident #3's elopement incident occurred early in the morning on 4/25/24 at approximately 7:45 a.m. RN A said she was at the nursing station when the D hall alarm went off. RN A said she went to the D hall exit door and looked outside and saw Resident #3. RN A said Resident #3 was approximately 20 feet from the exit door walking briskly and started across the parking lot. RN A said she just couldn't keep up with her and said she could not run to get her. RN A said she continued to follow Resident #3 across the parking lot when human resources staff E pulled into the parking lot. RN A said Resident #3 crossed the side street and started onto the sidewalk (across the side street from the facility). RN A said human resources staff E ran and got Resident #3 by the hand. RN A said human resources staff E stood talking with Resident #3 until she (RN A) could reach her (Resident #3). RN A said Resident #3 was then taken back into the facility. RN A said she immediately notified the DON who instructed her to ensure Resident #3 was placed on 1 to 1 observation. RN A said 1 to 1 observation meant a staff member was to stay with Resident #3 at all times and have no other assignment. RN A said she knew nothing of Resident #3's elopement history.<BR/>During an interview on 4/26/24 at 1:10 p.m., human resources staff E said as she arrived to the facility at approximately 7:45 a.m. on 4/25/24, she saw Resident #3 walking across the parking lot. Human resources staff E said she was not sure at first that Resident #3 was a resident and thought perhaps she was just someone out walking, cutting across the parking lot. Human resources staff E explained Resident #3 was walking at a brisk pace and did not seem confused or lost. Human resources staff said as she pulled into her parking spot Resident #3 had crossed the side street and started onto the sidewalk. Human resources staff E said she saw RN A walking across the parking lot and asked her if the lady walking was a resident. Human resources staff E said RN A yelled Yes, and so she ran up to Resident #3 held her hand and started talking to her. Human resources staff E said RN A caught up to them and they took her (Resident #3) back into the facility. <BR/>During an observation and interview on 4/26/24 at 1:40 p.m., Resident #3 said she just left the facility because she needed to call her family. Resident #3 sat smoking a cigarette in the smoking area with staff beside her. Resident #3 was asked again about leaving the facility and she said, Oh I don't know about that. <BR/>During an interview on 4/26/24 at 2:09 p.m. Resident #3's family member #2 said she spoke with the admissions coordinator last Friday (4/19/24) and sent over all the necessary paperwork to have her admitted . Family member #2 said Resident #3 was admitted to facility in the afternoon on 4/25/24 but could not say exactly what time. Family member #2 said the facility contacted her on 4/26/24 and told her Resident #3 had eloped from the facility. Family member #2 said they were keeping someone with Resident #3 at all times and would do so until they could find a facility with a secure unit for her. <BR/>During an interview on 4/26/24 at 2:13 p.m., Resident #3's family member said Resident #3 was admitted into the facility on 4/25/24 sometime after 1:30 p.m. in the late afternoon. Resident #3's family member said he had been contacted and told Resident #3 had eloped from the facility and that the facility was seeking out a home that could provide a secured unit for Resident #3. The family member said he understood the need for a secured unit and had no problem with the transfer but was a little frustrated because the whole reason the family sought long-term care was because Resident #3 had wandered off from her apartment and was found by the police. The family member said they (the family) was upfront with the facility and had told them of the event. <BR/>Record review of Resident #3's admission paperwork found no documentation of elopement history or the incident described by Resident #3's family member in which she left her apartment and was found by police. <BR/>During an interview on 4/26/24 at 3:20 p.m., admissions coordinator B said she had talked to the Resident #3's family member #2 last Friday (4/19/24) regarding an admission for Resident #3. Admissions coordinator B said when she spoke with family member #2, she told her the family was seeking admission into long term care because she (Resident #3) had reached a point she would call family members constantly and the care she needed was just too much for them. Admissions coordinator B said family member #2 said she/he worked during the day and could not check on Resident #3 as often was needed and could not take her calls as often as she would call. Admissions coordinator B said the family seemed to be in a rush to get her admitted and had all the necessary paperwork to them on Friday (4/29/24). Admissions coordinator B said the facility used a centralized admission process. She explained that once all the necessary paperwork was gathered it was sent to the company's central office for review. Admissions coordinator B said sometimes the central office will send back notes or conditions after reviewing the paperwork. Admissions coordinator B said for example a nurse may have to go out and evaluate the potential resident. Admissions coordinator B said this was not the case for Resident #3 as the central office had cleared her for admission. Admissions coordinator B said family member #2 said nothing to her about Resident #3 having eloped from her independent living apartment and being found by the police. Admissions coordinator B said the facility did not take Residents with a history of elopement. <BR/>During an interview on 4/26/24 at 3:32 p.m., the DON said she knew nothing of Resident #3's history of elopement and there was nothing in the records received regarding a history of elopement. The DON said the facility simply would not have accepted Resident #3, had they known about the elopement history. The DON said the facility did not have a wander guard system nor a secured unit and therefore did not accept residents with an elopement history. The DON said the facility had secured placement for Resident #3 in a facility with a secured unit, but the facility could not take her until Monday (4/29/24). The DON said Resident #3 would remain on 1 on 1 observation until she was transferred to the facility with the secured unit. <BR/>During an interview on 4/29/24 at 10:40a.m., Resident #1's family member said the family had decided Resident #3 needed to be placed in long term care because she had left her apartment and was found by the police on 4/18/24. The family member said Resident #3 lived independently in her apartment until that incident. The family member said the facility had been contacted regarding possible admission and all the required paperwork was sent 4/19/24. The family member said admissions coordinator B, business office manager C and social worker D all were aware of Resident #3's history of eloping from her apartment and being found by the police on 4/18/24. <BR/>During an interview on 4/29/24 at 10:50 a.m., admissions coordinator B said she had spoken with family member #2 and it was never relayed to her that Resident #3 had eloped form her apartment. Admissions coordinator B said the facility just would not have taken her and had just denied someone placement last week because they had a history of elopement. <BR/>During an interview on 4/29/24 at 10:55 a.m., business office manager C said the family had not told her anything about Resident #3's elopement history. Business office manager C said she had only discussed financial aspects and payor sources with the family as that was what her job entailed. <BR/>During an interview on 4/29/24 at 11:04 a.m., social worker D said the family had not said anything to her about Resident #3 having a history of elopement. Social worker D said she helped the family complete a DNR and completed PASRR paperwork and the family never mentioned Resident #3 had left her apartment and was found by police. <BR/>Record review of the admission assessment dated [DATE] at 4:08 p.m. section L Exit seeking tool, indicated Resident #3 did not have the physical ability to leave the building on her own. This section of the admission assessment had no further assessment questions answered as the tool stated . (1) Is the resident physically able to leave the building on their own? If no, disregard remaining questions. This assessment was completed by LVN F. <BR/>During an interview on 4/29/24 at 1:30 p.m., ADON G said she could not say why LVN F would have marked no on the admission assessment, as Resident #3 had the physical ability to leave the building but said she did not feel this assessment would have prevented Resident #3 from eloping the facility. ADON G said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. ADON G said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The ADON said she knew nothing of Resident #3's elopement history. ADON G said the facility does not accept resident with exit seeking behavior. <BR/>During an interview on 4/29/24 at 1:35 p.m., the DON said Resident #3 had been transferred to a facility with a secured unit. The DON said she had always taken the question on the admission assessment under section L Exit seeking tool to mean would the resident leave the building on their own. The DON said after re-reading the question she understood the question to ask whether or not a resident had the physical ability to leave the building. The DON said she did not feel the assessment would have prevented Resident #3's elopement from the building. She said the remaining questions on the exit seeking tool if the question, Is the resident physically able to leave the building on their own? was marked yes asked about wandering, wandering history, exit seeking, exit seeking history, and the display of behaviors related to wandering and exit seeking. The DON said at the time the assessment had been completed Resident #3 had been in the facility a few hours and Resident #3 had not displayed any of those behaviors. The DON said she knew nothing of Resident #3's elopement history. The DON said had she have known Resident #3 had a history of elopement the facility would have not accepted her. <BR/>During an interview on 4/29/24 at 2:17 p.m., LVN F said she marked no on the admission assessment under section L Exit seeking tool because she understood the question to mean would the resident leave the building on their own. LVN F said Resident #3 had been in the facility a few hours but had not displayed any exit seeking behaviors and was content in her room when she cared for her. <BR/>Record review of the facility policy and procedure revised January 2023, titled Elopement Response & Exit Seeking Management stated, .A. Elopement Response: Unable to locate resident (1) If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises B. Response following the location of the resident: (1) Once located and safety confirmed, conduct an assessment. (2) Place resident on enhanced monitoring, consider 1:1 for a specified time as needed to ensure the safety of resident or consider placement in secured unit for continued monitoring and safety. The facility policy and procedure did not detail the facility would not accept Resident's with a history of elopement. <BR/>During an interview on 4/29/24 at 2:20 p.m., the corporate RN said the facility did not have a policy and procedure that specifically addressed the accurate completion of admission assessments or regarding the centralized admission process. <BR/>Record review of the facility policy and procedure revised January 2023, titled Professional Standards of Care, stated, .Nurses should conduct assessments or evaluations and document nurses' notes in the following instances: 1) routine charting for residents should reflect the recipient's ability as assessed upon admission, re-admission and as clinically indicated; and 2) at the time of accidents, incidents or change in condition. All exceptions to stable, baseline or usual status should be recorded as exceptions and included in the clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate monitoring) for 1 (Resident # 1) of 4 residents whose medications were reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #1 was consistently and adequately monitored for adverse side effects of Lorazepam (medication used to treat anxiety, lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves [central nervous system] to produce a calming effect). <BR/>This failure could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.<BR/>Findings included:<BR/>Record review of the face sheet dated 4/22/24 for Resident #1 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease, high blood pressure, restlessness and agitation, anxiety disorder, heart disease, neuropathy (Weakness, numbness, and pain from nerve damage), visual hallucinations, major depressive disorder, agoraphobia (Fear of places and situations that might cause panic, helplessness, or embarrassment), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down). <BR/>Record review of the MDS for Resident #1 dated 4/6/24 indicated he usually made himself understood and usually understood others. The MDS indicated Resident #1 had short-term and long-term memory problems. The MDS indicated he had severely impaired cognitive skills for decision machining. The MDS indicated he had no behavior of rejecting care. The MDS indicated he had no indicators of psychosis and displayed no physical or verbal behaviors towards others or himself. The MDS indicated he was dependent on staff for ADLS. <BR/>Record review of the care plan dated 4/2/24 indicated Resident #1 required the use of anti-anxiety medication, the care plan interventions included administer medications per MD orders, monitor/document/report to the MD any adverse reactions to anti-anxiety therapy (drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking, and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision) or unexpected side effects (mania, hostility, rage, aggressive or impulsive behavior, hallucinations). <BR/>Record review of Resident #1's physician order dated 4/1/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth at bedtime for anxiety hold for sedation. This order was discontinued on 4/10/24.<BR/>Record review of Resident #1's physician order dated 4/2/24 indicated Resident #1 was to be monitored for the following Antianxiety Side Effects Monitoring: sedation/drowsiness, increased falls/dizziness, hypotension, anxiety/agitation, blurred vision, sweating/rashes, weakness, headache, dystonia, urinary retention/hesitancy, anticholinergic symptoms, cardiac abnormalities, hangover effect. The order indicated any other side effects noted should be documented in a progress note. This order was discontinued on 4/10/24. <BR/>Record review of Resident #1's physician order dated 4/10/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth three times a day for anxiety hold for sedation. This order was discontinued on 4/14/24. <BR/>Record review of Resident #1's physician order dated 4/14/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth two times a day for anxiety hold for sedation. This order was discontinued on 4/18/24. <BR/>Record review of Resident #1's physician order dated 4/18/24 indicated he was to be administered Lorazepam Oral Tablet 0.5 MG by mouth at bedtime for anxiety hold for sedation. This order was discontinued on 4/23/24. <BR/>Record review of Resident #1's MAR for April 2024 indicated he had been administered his Lorazepam as ordered by the physician from 4/1/24 to 4/18/24. <BR/>Record review of the MAR indicated Resident #1 was monitored for the following Antianxiety Side Effects Monitoring: sedation/drowsiness, increased falls/dizziness, hypotension, anxiety/agitation, blurred vision, sweating/rashes, weakness, headache, dystonia, urinary retention/hesitancy, anticholinergic symptoms, cardiac abnormalities, hangover effect, from 4/2/24 to 4/10/24. The MAR did not indicate Resident #1 was monitored for the antianxiety side effects from 4/11/24 to 4/19/24. <BR/>Record review of Resident #1's nurse's notes dated 4/11/24-4/13/24 found the following documentation related to antianxiety side effects monitoring: <BR/>*4/11/24 at 3:00 a.m., no adverse effects of lorazepam <BR/>*4/12/24 at 1:39 a.m., no adverse effects of lorazepam<BR/>*4/13/24 - no notes related to antianxiety side effects monitoring were documented<BR/>Record review of Resident #1's nursing note dated 4/14/24 at 1:34 p.m., stated .resident responding to verbal and physical stimuli very slowly. Resident family requesting that Ativan (brand name for lorazepam) be put on hold until resident is more alert. Notified MD .received new order . <BR/>Record review of Resident #1's nurse's notes dated 4/15/24-4/17/24 found the following documentation related to antianxiety side effects monitoring: <BR/>*4/15/24 - no notes related to antianxiety side effects monitoring were documented<BR/>*4/16/24- no sedation noted <BR/>*4/17/24- no notes related to antianxiety side effects monitoring were documented<BR/>Record review of Resident #1's nursing progress note dated 4/18/24 at 1:34 p.m., indicated an order for all psychotropic medications to be put on hold had been obtained due to lethargy. <BR/>During an interview on 4/24/24 at 12:14 p.m., LVN J said she took care of Resident #1 regularly. LVN J said she took care of Resident #1 on 4/13/24. LVN J said there were a lot of changes with Resident #1's lorazepam. LVN J said nurses should assess residents on antianxiety medications at least once a shift and document on the MAR. LVN J said there was a place to document antianxiety side effects monitoring on the MAR. LVN J said it would be especially important to assess/document for antianxiety side effects monitoring for residents having changes in dosage like Resident #1. LVN J said if for some reason the antianxiety side effects monitoring was not on the MAR the nurse should document the antianxiety side effects monitoring on a nursing progress note. LVN J said she had not realized she had not documented antianxiety side effects monitoring for Resident #1 on 4/13/24. LVN J said she did document when Resident #1 was found over sedated and notified the MD on 4/14/24. LVN J said Resident #1 was not over sedated on 4/13/24 or she would have documented and notified the MD at that time. <BR/>During an interview on 4/24/24 at 1:26 p.m., LVN K said she took care of Resident #1 on 4/17/24. LVN K said there was a place to document antianxiety side effects monitoring on the MAR. LVN K said it would be especially important to assess/document for antianxiety side effects monitoring for residents having changes in dosage like Resident #1. LVN K said if for some reason the antianxiety side effects monitoring was not on the MAR, she would document the antianxiety side effects monitoring on a nursing progress note. LVN K said she had not realized she had not documented antianxiety side effects monitoring for Resident #1 on 4/17/24.<BR/>During an interview on 4/24/24 at 1:30 p.m., ADON I said he had spoken to the MD and received the order for the increase of Resident #1's lorazepam on 4/10/24. ADON I said he had dc'd the old order for the lorazepam but did not realize the side effect monitoring was dc'd at the time. ADON I said it was important to monitor residents on antianxiety medications especially after an increase in dosage to ensure they were not overly sedated or experiencing any adverse effects. ADON I said he wasn't sure if he had to enter the monitoring as a separate order or if it was coupled with lorazepam order. <BR/>During an interview on 4/24/24 at 3:30 p.m., the DON said she expected nurses to monitor and document for adverse effects/side effects of antianxiety medications at least once a shift. The DON said she did not understand how the antianxiety side effect monitoring was removed from Resident #1's MAR. The DON said antianxiety side effect monitoring should have remained on the MAR the entire time Resident #1 was on the antianxiety medication. The DON said it was especially important for antianxiety side effect monitoring to be performed with the increase in dosage Resident #1 was ordered. The DON said there had not been a specific system in place to ensure nurses were monitoring/documenting for psychotropic adverse/side effects prior to 4/19/24. The DON said she was know monitoring resident's receiving psychotropic medications weekly to ensure they received appropriate monitoring. <BR/>A facility policy and procedure regarding the monitoring residents on psychotropic medications was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's interdisciplinary team failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 5 residents (Resident #74) and failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #74) reviewed for care plan revisions.<BR/>The facility failed to review and revise Resident #74's baseline care plan within the required timeframe with a comprehensive care plan.<BR/>This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. <BR/>Findings included:<BR/>Record review of Resident #74's face sheet dated 08/09/23 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included protein-calorie malnutrition, physical debility, diabetes, stage 4 (wound to the bone) pressure ulcer of sacral region, chronic peripheral venous insufficiency (narrowed blood vessels causing reduced blood flow in the limbs), glaucoma (eye condition that can cause blindness), high blood pressure, and osteomyelitis (inflammation of the bone caused by infection) of the vertebra, sacral and sacrococcygeal region.<BR/>Review of Resident #74's quarterly MDS dated [DATE] indicated she had clear speech, could understand and be understood by others, a BIMS of 11 indicating a mild cognitive decline, required extensive assistance of 1-2 staff with ADLs, had an indwelling urinary catheter, was incontinent of bowel, had a feeding tube, and had a stage 4 pressure sore on the sacral region and a stage 4 pressure sore on the right heel.<BR/>During an interview and record review on 08/09/23 at 09:30 AM the DON pulled up Resident #74's care plan in the EMR. The DON said she was responsible for care plans. She said when the 48-hour (baseline) care plans are initiated by the charge nurses on admission she reviews and signs them. She said the facility has not had an MDS coordinator for over a year and MDS reviews have been done remotely by different individuals. She said she thought they had had a care plan meeting with Resident #74 but could not remember for certain. She said the SW planned the meetings. She said because they have not had a consistent MDS coordinator there had not been any generation of the care plans. She said when the comprehensive resident assessment was done for Resident #74, no care plans were generated at that time. She reviewed the EMR and it indicated Resident #74 had an admission MDS on 04/14/23 and Quarterly MDS on 07/15/23 and 07/28/23 and no care plans were initiated or reviewed within that period. She said the resident had some care plans initiated on 08/05/23 by a corporate registered nurse.<BR/>During an interview on 08/09/23 at 09:45 AM the SW said she remembered meeting with Resident #74's husband and trying to set up a formal care plan meeting with him and his wife. She said he did not really wish to attend a formal meeting and said to just have it with his wife. She said Resident #74's husband came to the facility almost daily and she and other staff may discuss things with him when he visited but none of those interactions were documented. She said she had tried to schedule the meeting after the 07/15/23 quarterly assessment and he could not attend and then she said she moved it to 07/28/23 and she said different circumstances that kept her from scheduling and meeting on that date. She said a care plan meeting was not currently scheduled. <BR/>A review of Resident #74's electronic record indicated there was no comprehensive care plans initiated and reviewed during the two quarterly MDS assessments on 07/15/23 and 07/28/23. The record indicated only a baseline care plan initiated by the charge nurse on admission [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #15) reviewed for gastrostomy tube management.<BR/>The facility failed to ensure Resident #15's head of bed was elevated at a minimum of 30-degree angle during medication administration via gastrostomy tube (G-tube) (a tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #15's face sheet dated 08/08/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Rett's syndrome (genetic condition that affects brain development and causes severe impairments in movement, communication and cognition), aphasia (disorder that affects how you communicate), dysphagia (difficulty in swallowing food or liquid), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication).<BR/>Record review of Resident #15's MDS, dated [DATE] revealed she had severely impaired cognition was not able to answer questions. She had a feeding tube used for nutrition. <BR/>Record review of Resident #15's care plan dated 05/03/23 and last reviewed on 06/21/23 indicated she required a feeding tube related to dysphagia and interventions included the head of bed should be elevated when in bed, avoid flat while feeding is on/pump running. <BR/>Record review of Resident #15's physician order dated 05/04/23 revealed an order for Phenobarbital 60mg (prevent and control seizures) tablet and to give one tablet via G-Tube (a tube directly inserted through the skin to the stomach to deliver nutrition and medications) two times a day. <BR/>During an observation and interview on 08/08/23 at 8:19 a.m., LVN C prepared Resident #15's medication then entered her room. Resident #15 was in bed with the head of bed elevated. Resident #15 was slouched downwards with her torso in the middle of the bed lying flat on her back. LVN C did not reposition Resident #15 and administered her medication. Resident #15 was not elevated at least 30 degrees when LVN C administered her medication. LVN C said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from aspirating (fluid or food enter the lungs accidently). LVN C said she did not have Resident #15 elevated at 30-degrees when she administered her medication. LVN C said Resident #15 was at risk for aspirating and she should have repositioned her before she administered her medication. <BR/>During an interview on 08/08/23 at 9:06 a.m., the DON said LVN C notified her she did not have Resident #15 elevated at 30-degrees when she administered her medication. The DON said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from aspirating and expected the staff to do so. The DON said Resident #15 was at risk for aspirating when LVN C administered her medication without elevating her first. <BR/>Record review of the facility's Medication Administration via Enteral Tube policy dated 03/15/19 indicated, .To administer medication through an enteral tube in an accurate, safe, timely and sanitary manner .Guidelines: .6. Elevate head of bed to Fowler's position (elevating the head and upper body at a 30 to 45-degree angle to reduce the risk of aspiration) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for resident rights. <BR/>The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110)<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m. the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>This failure could result in diabetic residents suffering injury, hospitalization, or death related elevated blood sugars.<BR/>Findings Include:<BR/>1. Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure).<BR/>Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired.<BR/>Record review of Resident #1's care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as<BR/>frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor.<BR/>Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23.<BR/>Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m.<BR/>Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings.<BR/>Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar.<BR/>Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI (blood sugar reading greater than 600) and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946.<BR/>Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack).<BR/>During an interview on 10/4/23 at 1:49 p.m., the NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.- 6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received the blood sugar results, she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later, the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater.<BR/>During an interview on 10/6/23 at 2:59 p.m., LVN C said she worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital.<BR/>During an interview on 10/6/23 at 3:17 p.m., the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. <BR/>Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders .<BR/>The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m.<BR/>The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included:<BR/>Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. <BR/>Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. <BR/>Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. <BR/>Date commenced: 10/4/23<BR/>Date of completion: 10/4/23<BR/>The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. <BR/>Date completed: 10/4/2023 <BR/>The Director of Nursing Services/Assistant Director of Nursing conducted and education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. <BR/>Date commenced: 10/4/23<BR/>Date to be completion: 10/4/2023<BR/>Risk Response:<BR/>All residents who are diabetic may potentially be affected by the deficient practice. <BR/>Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. <BR/>Date of Completion: 10/5/2023<BR/>Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin.<BR/>Date completed: 10/4/2023 <BR/>The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. <BR/>Date Commenced: 10/4/23<BR/>Date to be completion: 10/4/2023<BR/>Systemic Response:<BR/>Inservice training & re-education will be provided to all licensed nurses regarding topics: <BR/>Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. <BR/>assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. We are using the education on abuse, neglect, and exploitation as an opportunity for our team members.<BR/>Date completed: 10/4/2023 10:00PM<BR/>Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. <BR/>Date completed 10/4/2023.<BR/>Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. <BR/>Date of completed: 10/5/2023. <BR/>All staff will be in-serviced on Abuse, Neglect and Exploitation- Prevention, Identification, Protecting and Reporting. This is used for educational purposes.<BR/> Date Commenced: 10/4/2023<BR/>Date to be completion: 10/5/2023<BR/>Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. <BR/>Monitoring Response<BR/>The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. <BR/>The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. <BR/>Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. <BR/>This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months.<BR/>On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia.<BR/>Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters.<BR/>Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure.<BR/>Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification.<BR/>Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. <BR/>On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 9 (Resident #5) residents reviewed for care plans,<BR/>The facility failed to ensure Resident #6's refusal of care was care planned. <BR/>This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 10/6/23 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joint) of the right wrist, contracture of the right hand, and weakness.<BR/>Record review of the MDS assessment dated [DATE] indicated Resident #5 was usually understood by others and usually understood others. The MDS indicated Resident #5 had a BIMS score of 03 and was severely cognitively impaired. The MDS indicated Resident #5 required extensive assistance with dressing, toileting, and personal hygiene.<BR/>Record review of the care plan dated 8/6/23 indicated Resident #5 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist.<BR/>Record review of the Documentation Survey Report dated August 2023 indicated Resident #5 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. The Documentation Survey Report indicated Resident #5 refused her scheduled showers on 8/1/23, 8/8/23, 8/10/23, 8/12/23, 8/15/23, 8/17/23, 8/22/23, 8/26/23, and 8/29/23. <BR/>Record review of the Documentation Survey Report dated September 2023 indicated Resident #5 refused her scheduled showers on 9/2/23, 9/7/23, 9/12/23, 9/14/23, and 9/21/23.<BR/>During an interview on 10/6/23 at 10:35 a.m. LVN J said if a resident refused it should have been reported to the nurse. LVN J said the nurse should reapproach the resident and ask them about taking a shower. LVN J said if the resident continued to refuse the nurse should document the refusal. LVN J said if something was not documented it could not be proved it was done. LVN J said a resident who repeatedly refused their showers should have the refusal of care in their care plan. <BR/>During an interview on 10/6/23 at 3:17 p.m. the DON said if a resident refused their scheduled shower the charge nurse was supposed to go ask the resident again. The DON said sometimes when the CNA askedhe resident about taking a shower the resident refuses because the resident wants their shower at a different time. The DON said the CNAs did not always make it back at a later time to provide the resident with their shower. The DON said when a resident routinely refuses their showers the facility would speak with the resident's family to get them to assist in getting the resident to take their shower. The DON said continuous refusals should be care planned. The DON said Resident #5 refused showers but would receive bed baths. The DON said a bed bath and a shower would be documented in the same place on the Documentation Survey Report. The DON said she was not sure why Resident #5's refusals had not been care planned. The DON said the nursing management was responsible for the resident care plans. The DON said the importance of care planning refusals was so staff would know exactly what was going on with a resident. <BR/>Record review of the facility's Activities of Daily Living policy dated February 2017 indicated, Each resident's abilities to perform activities of daily living will not diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include: personal hygiene .Residents who refuse care and treatment will be offered alternative treatment options and be advised of the negative impact of the continued refusal to accept treatment and care<BR/>Record review of the facility's Care Plans policy dated February 2017 indicated, The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial need that are identified and in the comprehensive assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 2 of 3 residents reviewed for ADLs (Resident's #1 and Resident #2). <BR/>The facility failed to ensure Resident #1's received a bath until 5 days after his admission. <BR/>The facility failed to ensure Resident #2 received a bath/shower for 4 weeks. <BR/>This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life.<BR/>Findings included:<BR/>Record review of the face sheet dated 4/22/24 for Resident #1 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease, high blood pressure, restlessness and agitation, anxiety disorder, heart disease, neuropathy (Weakness, numbness, and pain from nerve damage), visual hallucinations, major depressive disorder, agoraphobia (Fear of places and situations that might cause panic, helplessness, or embarrassment), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down). <BR/>Record review of the MDS for Resident #1 dated 4/6/24 indicated he usually made himself understood and usually understood others. The MDS indicated Resident #1 had short-term and long-term memory problems. The MDS indicated he had severely impaired cognitive skills for decision machining. The MDS indicated he had no behavior of rejecting care. The MDS indicated he was dependent on staff for eating, oral hygiene, toileting, showers/bathing, dressing (both the upper and lower body), putting on footwear, and personal hygiene. The MDS indicated he was always incontinent of bowel and bladder. <BR/>Record review of the care plan dated 4/2/24 indicated Resident #1 was at risk for self-care deficit. The care plan interventions included 2-person assistance with bed mobility, hygiene, transfers, and toileting. <BR/>During an interview on 4/25/24 at 10:39 a.m., Resident #1's family member said she visited Resident #1 every day while he was in the facility. Resident #1's family member said he remained in the same clothes for the first 4 days he was in the facility (4/1/24 to 4/4/24) and did not think he had received a shower. <BR/>Record review of Resident #1's ADL documentation did not indicate he had received a shower or bath from 4/1/24 to 4/5/24. <BR/>2. Record review of the face sheet for Resident #2 dated 4/26/24 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs), COPD (group of lung diseases that block airflow and make it difficult to breathe), artificial openings of the urinary tract status, colostomy (an opening in the large intestine, or the surgical procedure that creates one. The opening is formed by drawing the healthy end of the colon through an incision in the anterior abdominal wall and suturing it into place), and depression. <BR/>Record review of the MDS dated [DATE] for Resident #2, indicated he made himself understood and understood others. The MDS indicated he had no cognitive impairment (BIMS of 15). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #2 required substantial/maximal assistance with toileting. The MDS indicated he was dependent on staff for shower/bathing. <BR/>During an observation and interview on 4/26/24 at 12:40 p.m., revealed Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath in 4 weeks. Resident #2 said he had not asked any staff about not receiving a bath or shower but knew he was supposed to receive them. Resident #2 said he felt staff had not provided him a shower because doing so was a bit of process. Resident #2 explained he had to be lifted from the bed with a mechanical lift and lowered onto a shower bed. Resident #2 said he felt staff just didn't want to go through the process of providing him a shower. <BR/>During an interview and observation on 4/29/24 at 9:35 a.m., Resident #2 laid in his bed. His hair appeared greasy. Resident #2 had a faint smell of body odor. Resident #2 said he had not received a shower or bed bath since 4/26/24. Resident #2 said his gown was changed but he was not given a shower. Resident #2 said he asked for a washcloth to wash his face and arm pits but was not provided one. Resident #2 said he did not know the name of the CNA he asked for a washcloth. <BR/>Record review of the ADL documentation for Resident #2 from 4/13/24 to 4/29/24 indicated he received a bath/shower on the following dates: <BR/>*4/27/24- documented by CNA L <BR/>*4/25/24- documented by CNA M<BR/>*4/20/24- documented by CNA N<BR/>*4/18/24- documented by CNA O<BR/>*4/16/24- documented by CNA P<BR/>During an interview on 4/29/24 at 1:26 p.m., CNA M said she did not give a bath or shower to Resident #2 on 4/25/24. CNA M said she was not even assigned to him on that day. CNA M said she gave her sign in information to agency staff so they could document and that was why the documentation reflected she had documented Resident #2 had received a bath on that day (4/25/24). CNA M said she could not remember the agency staff members name. CNA M said she had given her sign in information to multiple agency staff. <BR/>During an interview on 4/29/24 at 2:37 p.m., CNA L said she had provided Resident #2 a bed bath when she worked on 4/27/24. CNA L said Resident #2 received a bed bath on 4/27/24 because he refused to a shower. <BR/>An interview with CNA N regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>An interview with CNA O regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>An interview with CNA P regarding Resident #2 was attempted on 4/29/24 but was not completed due to no returned phone call. <BR/>During an interview on 4/29/24 at 2:15 p.m., CNA L said it was important residents received scheduled bathing/showers in order to maintain hygiene and identify any skin changes. CNA L said the administration of showers/baths were documented in EMR record.<BR/>During an interview on 4/29/24 at 2:17 p.m., LVN F said it was important for residents to receive showers/baths to ensure good hygiene and make the resident feel better. <BR/>During an interview on 4/29/24 at 2:37 p.m., the DON said she expected CNAs to provide residents with showers/baths. The DON said it was important for residents to receive their showers/baths to promote hygiene. <BR/>Record review of the facility policy and procedure titled Activities Daily Living revised January 2023 stated .each resident's abilities to perform activities of daily living will not diminish .Activities of daily living include: personal hygiene . <BR/>The facility policy and procedure did not specifically address ensuring dependent resident received showering/bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #1) residents reviewed for quality of care.<BR/>1. The facility failed to monitor Resident #1's condition following elevated blood sugar readings.<BR/>2. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110)<BR/>3. The facility's Diabetic Management policy failed to address high blood sugars. <BR/>4. The facility failed to include blood sugar parameters for physician notification in Resident #1's physician orders.<BR/>These failures resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These failures could result in diabetic residents suffering injury, hospitalization, or death related elevated blood sugars<BR/>Findings include:<BR/>Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure).<BR/>Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired.<BR/>Record review of the care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as<BR/>frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor.<BR/>Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23.<BR/>Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m.<BR/>Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. <BR/>Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she had, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. I checked the resident's blood sugar and the reading was HI [blood sugar reading greater than 600] . Call placed to [the physician] and received voicemail that instructed me to text and<BR/>wait for response. Awaiting response.<BR/>Record review of the nursing progress dated 9/25/23 at 4:20 a.m. written by RN A indicated Spoke with [the NP]. Order received to recheck blood glucose [on Resident #1]. Blood glucose rechecked and still reads HI. 4:40 a.m. called [the NP] and new order received. 4:50 a.m. [Resident #1] was given 10units of Humalog Insulin.<BR/>Record review of the nursing progress note dated 9/25/23 at 5:50 a.m. written by RN A indicated Recheck of [Resident #1's] blood glucose revealed glucometer still reading HI. Call placed to [the NP] and was instructed to send resident to hospital. EMS called and resident transferred to [hospital].<BR/>Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946.<BR/>Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack).<BR/>During an interview on 10/4/23 at 1:45 p.m. RN B said the facility did not have standing orders to add blood sugar parameters of when to notify the physician for blood sugar readings if too high or too low. RN B said some residents did have individualized parameters in place for when to notify the physician regarding their blood sugars. RN B said blood sugar parameters of when to notify the physician were normally if the blood glucose level was less than 60 or greater than 400. RN B said if she had a resident who had a blood sugar of 400, 500, or 600 she would notify the physician. RN B said physician notification and new orders should have been documented.<BR/>During an interview on 10/4/23 at 1:49 p.m. The NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received to blood sugar results she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. <BR/>During an interview on 10/5/23 at 12:38 p.m. RN A said she was employed at the facility since March 2023. RN A said on 9/25/23 at approximately 4:00 a.m., the nurse who worked the 2:00 p.m.-10:00 p.m. shift on 9/24/23 called and informed her she had forgot to tell her Resident #1's blood sugar was high. RN A said she immediately went to take Resident #1's blood sugar and it only read high. RN A said she called the physician and when he did not answer she waited approximately 30 minutes and then called the on-call for the administration. RN A she spoke RN B who was on-call for administrative call and was told to call the NP. RN A she called the NP and was told to administer 10u of Humalog and recheck in 1 hour RN A said Resident #1 was not very responsive when she administered the Humalog. After re-checking the blood sugar and it was still HI, she reported to NP, and called 911. She said Resident #1 was semi-conscious when she left for the hospital. RN A said she was unsure whether the facility had standing parameters of when to notify a physician regarding blood sugars. RN A said the physician or NP should have been notified if the glucometer read HI when checking a blood sugar. RN A said a glucometer reading of HI was usually over 600. RN A said she would probably notify the physician of a blood sugar reading of 400 or 500.<BR/>During an interview on 10/6/23 at 2:59 p.m. LVN C worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital.<BR/>During an interview on 10/6/23 at 3:17 p.m. the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. <BR/>Record review of the undated EvenCare G2 Blood Glucose Monitoring System's Healthcare Professional Operator's Manual indicated a reading of HI meant the patient's blood glucose was greater than 600.<BR/>Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders .<BR/>The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m.<BR/>The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included:<BR/>Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident #1 was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. <BR/>Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. <BR/>Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. <BR/>Date commenced: 10/4/23.<BR/>Date of completion: 10/4/23<BR/>The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. <BR/>Date completed: 10/4/2023.<BR/>The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medical record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/2023.<BR/>Date to be completion: 10/4/2023.<BR/>Risk Response:<BR/>All residents who are diabetic may potentially be affected by the deficient practice.<BR/>Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. <BR/>Date to be completed: 10/5/2023.<BR/>Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin.<BR/>Date completed: 10/4/2023.<BR/>The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. <BR/>Date completed: 10/4/2023. <BR/>Systemic Response:<BR/>Inservice training & re-education will be provided to all licensed nurses regarding topics: <BR/>Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. <BR/>assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly.<BR/>Date completed: 10/4/2023. 10:00PM <BR/>Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. <BR/>Date completed: 10/4/2023.<BR/>Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As, and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date completed: 10/5/2023<BR/>All staff will be in-serviced on Abuse, Neglect and Exploitation, Prevention, Identification, Protecting and Reporting. This is for educational purposes for our employees.<BR/>Date Commenced: 10/4/2023<BR/>Date to be completion: 10/5/2023<BR/>Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. <BR/>Monitoring Response for the plan of correction.<BR/>The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. <BR/>The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. <BR/>Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. <BR/>This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months.<BR/>On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia.<BR/>Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters.<BR/>Record review of Resident #1's physician orders for insulin indicated she had insulin orders starting 10/4/23 which included diabetic parameters to notify the physician for blood sugar readings of less than 60 or greater than 400.<BR/>Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure.<BR/>Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification.<BR/>Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. <BR/>On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #15) reviewed for gastrostomy tube management.<BR/>The facility failed to ensure Resident #15's head of bed was elevated at a minimum of 30-degree angle during medication administration via gastrostomy tube (G-tube) (a tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #15's face sheet dated 08/08/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Rett's syndrome (genetic condition that affects brain development and causes severe impairments in movement, communication and cognition), aphasia (disorder that affects how you communicate), dysphagia (difficulty in swallowing food or liquid), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication).<BR/>Record review of Resident #15's MDS, dated [DATE] revealed she had severely impaired cognition was not able to answer questions. She had a feeding tube used for nutrition. <BR/>Record review of Resident #15's care plan dated 05/03/23 and last reviewed on 06/21/23 indicated she required a feeding tube related to dysphagia and interventions included the head of bed should be elevated when in bed, avoid flat while feeding is on/pump running. <BR/>Record review of Resident #15's physician order dated 05/04/23 revealed an order for Phenobarbital 60mg (prevent and control seizures) tablet and to give one tablet via G-Tube (a tube directly inserted through the skin to the stomach to deliver nutrition and medications) two times a day. <BR/>During an observation and interview on 08/08/23 at 8:19 a.m., LVN C prepared Resident #15's medication then entered her room. Resident #15 was in bed with the head of bed elevated. Resident #15 was slouched downwards with her torso in the middle of the bed lying flat on her back. LVN C did not reposition Resident #15 and administered her medication. Resident #15 was not elevated at least 30 degrees when LVN C administered her medication. LVN C said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from aspirating (fluid or food enter the lungs accidently). LVN C said she did not have Resident #15 elevated at 30-degrees when she administered her medication. LVN C said Resident #15 was at risk for aspirating and she should have repositioned her before she administered her medication. <BR/>During an interview on 08/08/23 at 9:06 a.m., the DON said LVN C notified her she did not have Resident #15 elevated at 30-degrees when she administered her medication. The DON said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from aspirating and expected the staff to do so. The DON said Resident #15 was at risk for aspirating when LVN C administered her medication without elevating her first. <BR/>Record review of the facility's Medication Administration via Enteral Tube policy dated 03/15/19 indicated, .To administer medication through an enteral tube in an accurate, safe, timely and sanitary manner .Guidelines: .6. Elevate head of bed to Fowler's position (elevating the head and upper body at a 30 to 45-degree angle to reduce the risk of aspiration) .

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen.<BR/>The facility failed to ensure the large ice machine in the main dining area was clean. <BR/>This failure could place residents who ate meals prepared in the kitchen at risk of food being served in unsanitary conditions and for food-borne illnesses.<BR/>The findings included:<BR/>During an observation of the main dining area on 06/20/22 at 9:45 a.m., the large ice machine in the main dining area was observed with black, slimy scum on the back inner most portion of the large ice machine door. <BR/>During an interview with the Dietary Manager on 06/20/22 at 10:06 a.m., she said the large ice machine should have been cleaned last week. She said maintenance was responsible for cleaning it every Wednesday, but she was not sure if it was cleaned. <BR/>During an interview with the Administrator on 06/21/22 at 5:05 p.m., she said it was the Dietary Manager's responsibility to see that the ice machine was cleaned. <BR/>During an interview with the Maintenance Director on 06/22/22 at 10:44 a.m., he said he was responsible for changing the filter and getting air conditioning repairs made to the large ice machine. The Director produced a log, indicating dates the filter was changed in the large ice machine. He said he does not clean the ice machine; dietary was responsible for cleaning the ice machine. <BR/>During an interview with the Dietary Manager on 06/22/22 at 10:48 a.m., she said dietary was responsible for cleaning the ice machine. She said the ice machine was last cleaned on 06/15/22. When asked, the Dietary Manager did not produce a scheduled cleaning log for the large ice machine. <BR/>Review of the facility provided an undated cleaning policy titled FourCooks Senior Care, LLC, Section 9 - Dietary/Food Services - Policy: Cleaning #1 All equipment, food contact surfaces and utensils shall be cleaned: #7 Refrigerator units and ice machines must be cleaned monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 5 residents (Resident # 21) reviewed for accuracy of MDS assessments. <BR/>The facility failed to accurately code Resident # 21's antipsychotic medication usage on the MDS assessment. <BR/>This failure could place residents at risk for not receiving needed care and services. <BR/>Findings include: <BR/> A review of Resident #21's face sheet for August 2023 indicated Resident # 21 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), Parkinson's disease, and paranoid schizophrenia. <BR/>A review of Resident #21's Quarterly MDS, dated [DATE] revealed he was coded as receiving antipsychotic medication on each of the 7 days of the observation period. <BR/>A review of the physician's orders noted an order on 04/11/2023 to discontinue the administration of Olanzapine, an antipsychotic drug. A review of the April 2023 Medication Administration Record (MAR) indicated the drug was discontinued as ordered. <BR/>There was no record of Resident #21 receiving any antipsychotic medication after 04/11/2023. <BR/>During an interview with the DON on 07/07/2023, she said the facility did not have a full time MDS Coordinator.

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen.<BR/>The facility failed to ensure the large ice machine in the main dining area was clean. <BR/>This failure could place residents who ate meals prepared in the kitchen at risk of food being served in unsanitary conditions and for food-borne illnesses.<BR/>The findings included:<BR/>During an observation of the main dining area on 06/20/22 at 9:45 a.m., the large ice machine in the main dining area was observed with black, slimy scum on the back inner most portion of the large ice machine door. <BR/>During an interview with the Dietary Manager on 06/20/22 at 10:06 a.m., she said the large ice machine should have been cleaned last week. She said maintenance was responsible for cleaning it every Wednesday, but she was not sure if it was cleaned. <BR/>During an interview with the Administrator on 06/21/22 at 5:05 p.m., she said it was the Dietary Manager's responsibility to see that the ice machine was cleaned. <BR/>During an interview with the Maintenance Director on 06/22/22 at 10:44 a.m., he said he was responsible for changing the filter and getting air conditioning repairs made to the large ice machine. The Director produced a log, indicating dates the filter was changed in the large ice machine. He said he does not clean the ice machine; dietary was responsible for cleaning the ice machine. <BR/>During an interview with the Dietary Manager on 06/22/22 at 10:48 a.m., she said dietary was responsible for cleaning the ice machine. She said the ice machine was last cleaned on 06/15/22. When asked, the Dietary Manager did not produce a scheduled cleaning log for the large ice machine. <BR/>Review of the facility provided an undated cleaning policy titled FourCooks Senior Care, LLC, Section 9 - Dietary/Food Services - Policy: Cleaning #1 All equipment, food contact surfaces and utensils shall be cleaned: #7 Refrigerator units and ice machines must be cleaned monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 2 residents (Resident #29) reviewed for oxygen therapy, in that:<BR/>Resident #29's oxygen was set to 3 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician.<BR/>This failure could place residents who receive oxygen therapy at risk for respiratory distress. <BR/>The findings were:<BR/>Review of Resident #29's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including cerebral palsy and hypertension. Review of Resident #29's MDS assessment dated [DATE] indicated she scored a 15/15 on her BIMS which indicated she was cognitively intact.<BR/>A review of Resident #29's s physician orders for August 2023 indicated she was to receive oxygen via nasal canula at 2 LPM (liters per minute) as needed. <BR/>During observations Resident #29 was receiving oxygen at 3 LPM on the following dates and times:<BR/>- 08/07/2023 at 03:50 PM, <BR/>-08/08/2023 at 07:50 AM, <BR/>-08/08/2023 at 03:30 PM, and <BR/>- 08/09/2023 at 11:01 AM.<BR/>During an interview on 08/09/2023 at 11:20 AM with LVN D, she said Resident #29's oxygen rate was ordered for 3 LPM. When asked to clarify, LVN D reviewed the physician's orders and said the oxygen rate was ordered for 2 LPM. LVN D went to Resident # 29's room, inspected the oxygen setting, and said it was set at 3 LPM. The nurse lowered the setting to 2 LPM. LVN D could not identify any risks for a resident receiving oxygen at a rate higher than what is ordered by the physician. LVN B said Resident #29 had been receiving oxygen therapy since she was admitted . <BR/>During interviews with ADON A and ADON B on 08/09/2023 at 10:05 AM, they both said the charge nurses were responsible for monitoring oxygen administration. <BR/>During an interview on 08/09/2023 at 10:30 AM, charge nurse, LVN C, said the charge nurses were responsible for monitoring oxygen therapy to ensure flow rates are set as ordered by the physician. <BR/>A review of the facility's Oxygen Administration Policy dated 03/14/2019 indicated the following: <BR/>3. Obtain physician orders for oxygen administration. Orders should include the following:<BR/> c. flow rate delivery .