**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards when residents were served an inappropriate therapeutic diet for 1 (Resident #45) of 10 residents reviewed for nutrition. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F805, F835, and F867. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. Review of Resident #45's Speech Therapy SLP [Speech Language Pathology] Evaluation & Plan of Treatment dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months . Objective tests/measures & additional analysis . additional analysis: Other: [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia; however, resident is exhibiting a severe deficit with oral phase of swallow . Assessment Summary: Skilled Justification: Reason for Skilled services: Skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume least restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration and weight loss. Review of Resident #45's Speech Therapy Treatment Encounter Notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM Staff R, Speech Therapist stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person aspiration pneumonia and an increased risk of hospitalization. During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:40 PM, the Registered Dietitian #1, stated, I consider the staff giving the wrong diet order and identifying it was the wrong diet order and not doing anything to correct it would be considered a mistake. It was a clinical error. He was a mechanical soft diet at that time. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. Review of the written statement authored by Staff J, LPN, dated 10/15/2024 read, Assisting in the Dining Rm [room] for lunch. [Resident #45's initials] had the ravioli and string beans but was asking for an alternative. He requested a hot dog. I had gotten the hot dog from the kitchen and brought it to the table. Took the hot dog and added condiments as per his request. The CNA, then cut up the hot dog for him to eat. Resident had eaten the hot dog without any difficulties. He was not coughing. Resident had same meal as everyone else therefore, I thought that he had a regular meal also. I stayed to observe the table to make sure he had no swallowing issues and no signs or symptoms of aspiration. When I realized I had made a mistake I panicked and did not remove the resident's food because I saw the surveyor standing there watching me and I did not want to raise any red flags by taking his food back, I felt as though she would sense something was wrong and I would cause more harm than good. Review of the written statement authored by Staff J, LPN, dated 10/16/2024 read, Yesterday I was asked to assist in the dining room, due to the increase in the resident population during lunchtime. Resident observed a fellow resident having a hot dog and decided that he would like to have one as well. I proceeded to the kitchen and requested a hot dog platter from the kitchen staff. I returned the plate to the residents' request; I then gave the resident condiments and the RN that was present pointed out that the resident was on a mechanical diet. Residents' meal was properly mechanicalized prior to him eating. Review of Employee Statement/ Interview Record authored by Staff I, RN, dated 10/16/2024 read, Date of Event 10/16/2024 . [Resident #45's name] requested alternative for lunch during lunch time in the dining room. Other LPN in dining room brought resident a full hot dog w/ [with] bun. Before she brought it to him and sat it in front of him. I told her [he] can't have it b/c [because] he is MS [Mechanical Soft] diet. She looked at me then looked at the state woman [State surveyor] standing in the corner and moved to grab a cart. I was running plates and assisting other residents upon returning to food counter [the] LPN began putting mustard on hot dog for resident [Resident #45's name] I said again he cannot have that he is mechanical soft you need to take it. LPN looked at me a slightly shrugged shoulder. I was called away again and when I returned a bite was taken out of [Resident #45's name] hot dog and he had it in his hands. LPN was gone resident [Resident #45's name] left dining room soon after. Review of the written statement authored by Staff Q, Cook, dated 10/16/2024 read, On October 15 between 12:30-12:45 pm I was serving the lunch line. A nurse came in saying she needed a hot dog. We asked who for? She said she needed it for the dining room. We asked what their diet was and she said she didn't know. I made the hot dog and then handed it to her. Review of the facility policy and procedure titled Accidents and Supervision with the last review date of 1/31/2024 read, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions . Hazards refers to elements of the resident environment that have the potential to cause injury or illness . Supervision/Adequate/Supervision refers to intervention and means of mitigating risk of an accident . Procedure: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility should make a reasonable effort to identify the hazards and risk factors for each resident . 5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders by 11/13/2024. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on accuracy of diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve food designed to meet individual needs for 1 (Resident #45) of 10 residents sampled who required mechanically altered diets. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant, cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the resident's needs led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on February 10, 2025, at 8:28 AM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F835, and F867. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. Review of Resident #45's Speech Therapy SLP [Speech Language Pathology] Evaluation & Plan of Treatment dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months . Objective tests/measures & additional analysis . additional analysis: Other: [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia; however, resident is exhibiting a severe deficit with oral phase of swallow . Assessment Summary: Skilled Justification: Reason for Skilled services: Skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume least restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration and weight loss. Review of Resident #45's Speech Therapy Treatment Encounter Notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM, Staff R, Speech Therapist, stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person, there is a risk of aspiration pneumonia and an increased risk of hospitalization. During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a hefty day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. Review of the written statement authored by Staff J, LPN, dated 10/15/2024 read, Assisting in the Dining Rm [room] for lunch. [Resident #45's initials] had the ravioli and string beans but was asking for an alternative. He requested a hot dog. I had gotten the hot dog from the kitchen and brought it to the table. Took the hot dog and added condiments as per his request. The CNA, then cut up the hot dog for him to eat. Resident had eaten the hot dog without any difficulties. He was not coughing. Resident had same meal as everyone else therefore, I thought that he had a regular meal also. I stayed to observe the table to make sure he had no swallowing issues and no signs or symptoms of aspiration. When I realized I had made a mistake I panicked and did not remove the resident's food because I saw the surveyor standing there watching me and I did not want to raise any red flags by taking his food back, I felt as though she would sense something was wrong and I would cause more harm than good. Review of the written statement authored by Staff J, LPN, dated 10/16/2024 read, Yesterday I was asked to assist in the dining room, due to the increase in the resident population during lunchtime. Resident observed a fellow resident having a hot dog and decided that he would like to have one as well. I proceeded to the kitchen and requested a hot dog platter from the kitchen staff. I returned the plate to the residents' request; I then gave the resident condiments and the RN that was present pointed out that the resident was on a mechanical diet. Residents' meal was properly mechanicalized prior to him eating. Review of Employee Statement/ Interview Record authored by Staff I, RN, dated 10/16/2024 read, Date of Event 10/16/2024 . [Resident #45's name] requested alternative for lunch during lunch time in the dining room. Other LPN in dining room brought resident a full hot dog w/ [with] bun. Before she brought it to him and sat it in front of him. I told her [he] can't have it b/c [because] he is MS [Mechanical Soft] diet. She looked at me then looked at the state woman [State surveyor] standing in the corner and moved to grab a cart. I was running plates and assisting other residents upon returning to food counter [the] LPN began putting mustard on hot dog for resident [Resident #45's name] I said again he cannot have that he is mechanical soft you need to take it. LPN looked at me a slightly shrugged shoulder. I was called away again and when I returned a bite was taken out of [Resident #45's name] hot dog and he had it in his hands. LPN was gone resident [Resident #45's name] left dining room soon after. Review of the written statement authored by Staff Q, Cook, dated 10/16/2024 read, On October 15 between 12:30-12:45 pm I was serving the lunch line. A nurse came in saying she needed a hot dog. We asked who for? She said she needed it for the dining room. We asked what their diet was and she said she didn't know. I made the hot dog and then handed it to her. Review of the facility policy and procedure titled Provide Diet to Meet Needs of Each Resident with the last review date of 1/31/2024 read, Policy: The purpose of the food and nutrition services (FNS)/dietary department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances and personal, religious and cultural preferences, based on reasonable effort. Therapeutic diets will be served as prescribed by the attending physicians or their designee. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on accuracy of diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident by failing to implement policies and procedures related to therapeutic diets. Resident #45 had a physician's order for a mechanical soft diet. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J, Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F805, and F867. Findings include: Review of the Job Description titled Administrator signed by the Administrator on 11/1/2024 read, Purpose of Your Job Position: The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Duties and Responsibilities: Administrative Functions . Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility . Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures. Review of the Job Description titled Director of Nursing Services signed by the Director of Nursing on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operations of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities. Review of the Job Description titled Dietitian signed by the Registered Dietitian #1 on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall clinical operation of the Food Services Department in accordance with current federal, state, and local standards guidelines, and regulations, that govern the Facility, and as may be directed by the Administrator, to assure the quality nutritional services are being provided on a daily basis . Duties and Responsibilities: Administrative Functions . Develop, implement, and maintain written departmental policies that apply to your area. Ensure staff is aware of and follows the established policies . Assist in planning regular and special diet menus as prescribed by the attending physician . Review therapeutic and regular diet plans and menus to assure they comply with physician orders. Review of the Job Description titled Food Service Supervisor signed by the Food Service Director on 10/1/2023 read, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop, and oversee the operations of the Nutritional Services/Food Services Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our Facility, and as may be directed by the Administrator or the Food Services Director to assure that quality nutritional services are provided on a daily basis and that the Nutritional Services/Food Department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities. Administrative Functions . Review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. Review of the Medical Director Retainer Agreement signed by the Medical Director on 2/23/2020 read, Consultant Responsibilities: Supervise the overall functions of our facility's medical services in that the medical director shall . Participate in the development of written policies, rules, and regulations to govern the nursing care and related medical and other health services provided. The medical director is responsible for seeing that these policies reflect an awareness of and have provisions for meeting the total needs of the residents. Ensure the residents receive adequate services appropriate to their needs. During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, muscle weakness (generalized), other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis and legal blindness. Review of Resident #45's Speech Theary SLP [Speech Language Pathologist] Evaluation & Plan dated 9/30/2023 read, Current Referral. Reason for Referral: Patient referred to ST [Speech Therapy] due to new onset of decreased oral function, risk for aspiration, decreased functional activity tolerance and dysphagia [difficulty swallowing] indicating the need for ST to analyze oral/pharyngeal function, minimize aspiration/risk of, develop & instruct in compensatory strategies, assess and determine least restrictive diet and design and implement strategies. Resident on a regular diet with thin liquids upon discharge to the hospital. He returned on a puree diet with thin liquids. Resident exhibiting a significant weight loss of 15.5% over the last 4 months .Objective tests/measures & additional analysis: .additional analysis: other [NAME] [[NAME] Assessment of Swallowing Ability] administered with a score of 176 indicating mild dysphagia however, resident is exhibiting a severe deficit with oral phase of swallow .Assessment Summary: Reason for skilled services: skilled SLP services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies, minimize risk of weight loss with swallow analysis, assess and determine the least restrictive diet and design and implement strategies in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs, efficiently consume restrictive diet, safely consume least restrictive diet, improve oral transit time and use strategies/compensatory techniques. Risk factors: due to the documented physical impairment and associated functional deficits, the patient is at risk for: aspiration and weight loss . Review of Resident #45's Speech Therapy Treatment encounter notes dated 10/10/2023 read, Swallow Tx [treatment]: instructions in alternating liquids/solids to increase pharyngeal clearance, analysis of /instruction in presentation techniques to increase safety & nutrition, modification to bolus sizes and order/method of food/liquid presentation and facilitation of body positioning to increase safety with intake. Swallow Tx: techniques to improve safe & efficient nutrition/hydration, analysis of diet texture to increase oral intake, therapeutic trial feedings to increase safety and development & training in use of compensatory strategies. Trial of mechanical soft consistency presented with modifications to bolus size and rate of intake. Resident is declining to eat puree diet consistency per nursing. Resident able to consume mechanical soft consistency without any s/s [signs/symptoms] of deficit in pharyngeal phase of swallow. Review of Resident #45 physician order dated 7/9/2024 read Physician ordered CCHO [Consistent Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. During an interview on 10/16/2024 at 11:53 AM, Staff I, RN, stated, [Resident #45's name] has a mechanical soft diet. Cutting the hot dog in half does not make it a mechanical soft diet. I am not sure if the cook said it was okay or not when she [Staff J] went to get it from the kitchen. During a telephonic interview on 10/17/2024 at 1:13 PM, Staff J, LPN, stated, He [Resident #45's name] asked me to get him another plate and I asked him what he wanted. He said maybe a hamburger or something like that. I went to the kitchen and told the cook I need an alternate and I mentioned his name [Residents #45's name]. The cook, I do not remember who it was, told me he had no hamburger, and they gave me a hot dog. I brought it out and [Resident #45's name] started eating the hot dog without a problem. When I turned around the nurse [Staff I] told me he [Resident #45] could not have a hot dog. I just didn't want to grab his plate. I just froze and kept looking at [Resident #45's name]. He finished the hot dog without a problem. I did not grab the plate because I did not want to make a big commotion. During an interview on 10/17/2024 at 1:28 PM, Staff K, CNA, stated, Residents' diets sometimes change. I saw him [Resident #45] sitting around and I went to help him out so [Resident #45's name] could start eating. I thought I cut it in multiple pieces for him to be able to eat it. Cutting the hot dog does not make it a mechanical soft diet. Usually, they have a ticket. I did not see a ticket next to him. I did not pay more attention to his meal. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. During an interview on 11/12/2024 at 8:44 AM, Staff I, RN, stated, I think I was a little overwhelmed and had a lot going on and when I told her [Staff J] No, he should not have it [referring to the hot dog meal served], nothing was done. I assumed she was going to take it away the second time I told her. It was busy. I would have taken it away, but I was doing a million things reading the tickets and handing out the meals, and I was just overwhelmed. When I noticed the second time, he [Resident #45] had the meal in front of him that I told her he should not have. I told her [Staff J] a second time. She turned around and looked at me and she heard what I said. I assumed she was going to take it from him [Resident #45]. Looking back, I should have owned it and removed his plate instead of expecting someone to do it. Some potential risk for the resident would be choking. You can say that about any resident but for him, he is at a higher risk. I would not say aspiration. During an interview on 11/12/2024 at 9:20 AM Staff R, Speech Therapist stated, If a resident is mechanical soft, they should not be given a meal outside of their recommendations. There is a possibility of coughing, choking, and aspiration. Depending on the health status of the person aspiration pneumonia and an increased risk of hospitalization. During an interview on 11/12/2024 at 9:37 AM, Staff Q, Cook, stated, We were serving the lunch line. A nurse came in asking for an alternate regular tray. I asked her who it was for and what the diet was. She said it was a regular diet for the dining room. I finished serving more on the line and remembered she was still there, and I gave her the hot dog. After that I realized she didn't say who it was for, but she never came back in, and I finished serving the lunch line. She did not have a meal ticket with her. During an interview on 11/12/2024 at 9:51 AM, the Food Service Director stated, Our procedure is that staff is informed to ask if they have a diet ticket and if they do not have the diet ticket, we ask for the name and room number and look in the book. If they are not in the book, they need to go to the nurse to verify. The book is updated daily. The nurse did not have a slip and at that time, the procedure was not followed that day. It has always been that way. We are to check for the diet and name, and it was just very chaotic that day and the nurse was just amending with the hot dog. Choking can be a concern if a mechanical soft diet resident gets a hot dog or any diet that is a regular diet. The food should not be placed in front of the resident until the nurses find out the proper diet for the residents. During an interview on 11/12/2024 at 9:56 AM, Registered Dietitian #1 stated, A resident who is on a mechanical soft diet should not get a whole hot dog not without being mechanically altered. Mechanically altered food particles should be reduced to less than one half of an inch or less. Choking is a potential harm they can face and/or aspiration. My expectation is if the staff has a misunderstanding or disagreement, the staff should pause and verify the correct diet and ask the resident not to consume the food. During an interview on 11/12/2024 at 10:15 AM, the Director of Nursing (DON) stated, The staff should know the patient diet and who it is for and the room number. Whoever is in the kitchen should verify looking at the person's ticket to make sure the diet is correct. I feel it was a breakdown of that individual. If she [Staff I] told her [Staff J] from the beginning that was not his [Resident #45's] diet, she should have taken the plate away from him or not even put it in front of the resident. If it was me as the RN, I would have taken it from him and had the LPN step out of the dining room and later address the incident with the staff. The LPN should have verified the diet before giving the resident the alternate. The nurses are responsible for making sure residents are taken care of safely. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a hefty day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:12 PM with the Administrator, when asked if identifying the wrong diet order served and not removing the meal was neglectful behavior, the Administrator stated, We took it as both ways because no action happened. We worked the event as a near miss. During an interview on 11/12/2024 at 12:13 PM, the Regional Nursing Consultant stated, We worked it as a near miss like if someone had a medical error. If we reported every near miss med error or error, we would be doing that every day. This was a [NAME] employee. A nurse who failed to act. During an interview on 11/12/2024 at 12:40 PM, the Registered Dietitian #1, stated, Choosing the word neglect makes it hard to answer since it's a legal term. Would I consider this a mistake or not following the procedure, yes. I do not feel comfortable answering and using that kind of language. A mistake is anything that occurs that is outside the realm of norm, deviation from the norm. I consider the staff giving the wrong diet order and identifying it was the wrong diet order and not doing anything to correct it would be considered a mistake. It falls under the definition I gave you of a deviation from the norm. It was a clinical error. He was a mechanical soft diet at that time. During an interview on 11/12/2024 at 12:45 PM with the Food Service Director, when asked if not removing the food item after identifying it was wrong diet order would be considered neglectful behavior, The Food Service Director stated, I do not feel comfortable answering the question. During an interview on 11/12/2024 at 1:32 PM, the Medical Director stated, I was notified of the incident. To be honest, it depends on the amount of dysphagia the patient has. This resident [Resident #45] has mental issues and will do things he is not supposed to do. He is followed by the speech therapist. A potential harm outcome all depends on the resident. He was a patient with failure to thrive and has improved. I understand your question if it was a weak patient or had dysphagia, it could cause aspiration pneumonia. When asked if the nurse's inaction after identifying the incorrect diet order and not removing the tray was neglectful, the Medical Director stated, I would consider this to be a situation with a nurse that needs to be suspended and educated. During an interview on 11/13/2024 at 9:57 AM, the Administrator stated, Part of the incident after looking at it, yes it was neglectful behavior. To me, neglect is the unwillingly action made against somebody. Since the staff was told twice, she should have removed it. During an interview on 11/13/2024 at 10:08 AM, the Medical Director stated, Neglect to me is to do something that would harm a patient on purpose. In this case, it was a request from a patient. Even if they have a lower BIMS [Brief Interview for Mental Status] than usual or dementia, but they understand they can ask and we have to respect them. We would consider those pleasure feed. Another staff tried to resolve the issue by cutting the hot dog. During an interview on 11/13/2024 at 12:01 AM, the DON, stated, Neglect is intentionally not taking care the patient. A dietary scenario that would be considered neglect would be not making sure that a patient got a meal. Referring to the two nurses not providing the best care for the patient, that would be neglect. We should have followed through. During an interview on 11/13/2024 at 12:20 PM, Food Service Director stated, The residents have the right to good and services. Basically, the situation that happened in the dining room with [Resident #45's name] and that nurse not removing the tray is considered neglect because it can possibly do harm to the resident. During an interview on 11/13/2024 at 12:26 PM, Registered Dietitian #1, stated, [Neglect is] the failure to provide goods and services as deemed medically necessary. I would consider the case you are here for neglect. I did not want to answer it yesterday until I was completely familiar with the situation and all the definitions. Review of the facility policy and procedure titled Nutrition and Hydration Assistance with the last review date of 1/31/2024 read, Policy: It will be the policy that this facility will provide the level of assistance required to the residents while maintain their highest practicable level of function and personal preferences. Staff will help ensure residents receive adequate assistance and provision of services for nourishment and hydration. Review of the facility policy and procedure titled Provide Diet to Meet Needs of Each Resident with the last review date of 1/31/2024 read, Policy: The purpose of the food and nutrition services (FNS)/dietary department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances and personal, religious and cultural preferences, based on reasonable effort. Therapeutic diets will be served as prescribed by the attending physicians or their designee. Review of the facility policy and procedure titled Accidents and Supervision with the last review date of 1/31/2024 read, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions . Hazards refers to elements of the resident environment that have the potential to cause injury or illness . Supervision/Adequate/Supervision refers to intervention and means of mitigating risk of an accident . Procedure: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility should make a reasonable effort to identify the hazards and risk factors for each resident . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024 and on 11/13/2024, residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, the facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements. On 11/12/2024, a performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin. On 11/13/2024, education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of the facility records showed the facility completed interviews and skin checks with all residents for identification of abuse/neglect on 10/16/2024 and 11/13/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders, and on abuse and neglect by 11/13/2024. Review of the education in-service attendance record dated 11/13/2024 showed the Administrator, Director of Nursing, Assistant Director of Nursing, and Registered Nursing Consultant received education by the Chief Nursing Officer on abuse and neglect, job description, monitoring of facility systems and 5 elements of QAPI. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on abuse/neglect and accuracy of diets. During interviews conducted on 11/13/2024, the Regional Nursing Consultant, the Administrator, and the DON verified having received education and verbalized understanding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility identified policies and procedures were not implemented for modified consistency diets. On 10/15/2024 at 12:20 PM, Resident #45 was sitting in the dining room. Resident #45 requested an alternative food item from Staff J, Licensed Practical Nurse. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Resident #45's diet was not verified in the kitchen. Staff I, Registered Nurse, stated to Staff J Resident #45 was not supposed to have a hot dog. Neither Staff I nor Staff J removed the food item after identifying the error. Staff I again instructed Staff J Resident #45 was not supposed to have a hot dog. Staff I and Staff J did not remove the food item. Staff K, Certified Nursing Assistant cut the hot dog in half for Resident #45 to consume. Resident #45 consumed the hot dog. The facility's failure to provide food in a form to meet the needs of Resident #45 led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #45 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 13, 2024, at 5:25 PM. The Immediate Jeopardy began on October 15, 2024, and was removed on site on November 13, 2024. Cross reference to F689, F805, and F835. Findings include: During an observation on 10/15/2024 at 12:20 PM, Resident #45 was sitting in the common dining room. Resident #45 called Staff J, Licensed Practical Nurse (LPN), and asked to have something else to eat than what had been served to him. Staff J went to the kitchen and returned with a hot dog in a hot dog bun on a plate. Staff J placed the plate in front of Resident #45 and Staff I, Registered Nurse (RN), stated to Staff J Resident #45 was not supposed to have a hot dog. Staff J did not remove the food item. Staff I mentioned again Resident #45 should not have a hot dog. Neither Staff I nor Staff J removed the food item. Resident #45 picked up the hot dog and put it in his mouth. Resident #45 placed the hot dog back down on the plate without chewing or swallowing any pieces of the hot dog. Staff K, Certified Nursing Assistant (CNA), came over and cut the hot dog in half. Resident #45 grabbed one of the halves and placed it in his mouth. Resident #45 placed the half of the hot dog back down on the plate without chewing or swallowing any portion of the hot dog. Review of Resident #45's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diastolic (congestive) heart failure, generalized muscle weakness, other reduced mobility, unspecified protein-calorie malnutrition, metabolic disorder, adjustment disorder with anxiety, chronic or unspecified gastric ulcer with hemorrhage (excessive bleeding), disorder of adult personality and behavior, type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, and legal blindness. Review of Resident #45's physician order dated 7/9/2024 read, CCHO [Controlled Carbohydrates] diet, Mechanical Soft texture, thin consistency [liquids] for nutrition and hydration. During an interview on 11/12/2024 at 8:36 AM while discussing Resident #45's therapeutic diet, the Administrator stated, We put the fault in every department. The issues came from the dining room, but the kitchen could have stopped it. Right now, when someone asks for something else, they have to show the dietary slip for the cook to release any food items. Every department involved got a disciplinary action and training. During an interview on 11/12/2024 at 10:26 AM, the Administrator stated, After all the investigation, it was an individual staff mistake. The RN herself who saw the situation and she did not act either. The food should have been taken away immediately from the resident. They are supposed to get the slip and get the diet order and mention who the patient was and say what the patient needs and what diet they were supposed to be. I know it was a hefty day, but that is no excuse at all. The staff was not recognizing the mistake and the level it can reach. This was the policy prior to the event. During an interview on 11/12/2024 at 12:12 PM with the Administrator, when asked if identifying the wrong diet order served and not removing the meal was neglectful, the Administrator stated, We took it as both ways because no action happened. We work the event as a near miss. During an interview on 11/12/2024 at 12:13 PM, the Regional Nursing Consultant stated, We worked it as a near miss like if someone had a medical error. If we reported every near miss med error or error, we would be doing that every day. This was a [NAME] employee. A nurse who failed to act. During an interview on 11/13/2024 at 9:57 AM, the Administrator stated, Part of the incident after looking at it, yes it was neglectful behavior. To me, neglect is the unwillingly action made against somebody. Since the staff was told twice, she should have removed it. After yesterday, we had a meeting and analyzed the situation and called it what it is. We filed the reportable and reported the staff members. A request was made for the policy and procedures for QAPI. Review of the provided document titled QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home read, What is QAPI? QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). Both involve using information, but differ in the key ways: QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better . Why QAPI is important? Once QAPI is launched and sustained, many people report that is a rewarding and even an enjoyable way of working. The rewards of QAPI include: Competencies that equip you to solve quality problems and prevent their recurrences; Competencies that allow you to seize opportunities to achieve new goals; Fulfillment for caregivers, as they become active partners in performance improvement; and above all, better care and better quality of life for your residents. The Immediate Jeopardy (IJ) was removed on site on 11/13/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 10/16/2024, Resident #45 was re-evaluated by the licensed nurse and the speech therapist. On 10/16/2024, Resident #45's chest x-ray was completed. On 10/16/2024 and on 11/13/2024, residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect. On 10/16/2024, facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out. On 10/16/2024, the DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet. On 10/17/2024, a root cause analysis was conducted and Ad Hoc [from the Latin and means for this] Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets. On 11/12/2024, the facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements. On 11/12/2024, a performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director. On 11/12/2024, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery. By 11/13/2024, 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin. On 11/13/2024, education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI. Beginning 10/18/2024, the facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process. Review of Resident #45's records showed the resident was evaluated on 10/16/2024 by X-Ray with no focal consolidation, effusion or pneumothorax. Review of Resident #45's SLP evaluation showed the resident was evaluated for oral and pharyngeal swallow function on 10/16/2024. Review of the facility records showed the facility completed interviews and skin checks with all residents for identification of abuse/neglect on 10/16/2024 and 11/13/2024. Review of Order Listing Report showed the Registered Nursing Consultant completed reconciliation of the dietary system with physician orders on 10/16/2024. Review of Education In-service Attendance Record showed the staff members received training through SNF Clinic on mechanically altered diets, accuracy of diet, and importance of correct diet orders, and on abuse and neglect by 11/13/2024. Review of the education in-service attendance record dated 11/13/2024 showed the Administrator, Director of Nursing, Assistant Director of Nursing, and Registered Nursing Consultant received education by the Chief Nursing Officer on abuse and neglect, job description, monitoring of facility systems and 5 elements of QAPI. Review of the facility records showed the facility held an Ad Hoc QAPI meeting on 10/17/2024 and conducted a root cause analysis for the concerns on accuracy of diets, held an Ad Hoc QAPI meeting on 11/12/2024 on accuracy of diets and abuse and neglect, and an Ad Hoc QAPI meeting 11/13/2024 on approval of removal plan and review of supervisor monitoring tool. During staff interviews completed on 11/13/2024, two RNs, two LPNs, three CNAs, two therapy staff, five dietary staff, and Social Services Assistant verified having received education and verbalized understanding on abuse/neglect and accuracy of diets. During interviews conducted on 11/13/2024, the Regional Nursing Consultant, the Administrator, and the DON verified having received education and verbalized understanding.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from medical neglect when the staff failed to notify the physician of elevated blood sugars for 1 of 5 residents, Resident #13, and failed to follow physicians' orders for the administration of long-acting insulin for 3 of 5 residents, Residents #100, #4, and #5, reviewed for long-acting insulin administration. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing sever hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulins; long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MAR reflects appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP [performance improvement plan]. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I did not receive training prior to last night for insulin. We talked about calling and documenting accuchecks. I know I should not hold long-acting insulin without parameters now. I should not have held the insulin and not let the doctor know. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to notify the physician of changes in condition for 1 of 5 residents, Resident #13, and failed to follow physicians' orders for the administration of long-acting insulins for 3 of 5 residents, Residents #100, #4, and #5. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing sever hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulins; long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. I did not receive any training related to long-acting insulin. Today we discussed long term insulin administration and that we don't ever hold the insulin unless we call the doctor and they just put in new parameters that say below 80 call the doctor. During an interview on 9/1/2023 at 1:30 PM, Staff N, LPN stated, I was not trained on long- acting insulin until today. I just was given the information about long-acting insulin today. I was not trained on this two weeks ago. During an interview on 9/1/2023 at 1:45 PM, Staff O, LPN stated, Two weeks ago I did not get any training on the types of insulin or when they peak. We just got that today along with long- acting insulin that it doesn't get held. That we need to call doctors if we hold insulin or if it's high and on neglect. I do understand that I shouldn't hold long-acting insulin and that I have to follow doctors' orders when it comes to insulin. During an interview on 9/1/2023 at 2:15 PM, Staff P, RN stated, I was not given insulin administration education information before today. They did not talk to use about long-acting insulin until today. I did get training on neglect, change of condition, following doctors' orders, the new orders to call a doctor if blood glucose is less than eighty today. I do understand how long-acting insulin works and that I shouldn't hold it. During an interview on 9/1/2023 at 2:25 PM, Staff Q, LPN stated, We got some training like two weeks ago making sure orders were in if they had blood sugars below 60 and what to do, like give glucagon. I was not trained on the types of insulin until today. We went over a printout that had the types of insulin, when they begin to work, that we don't have parameters on Lantus and Levemir insulins only the short acting ones. That we don't hold long-acting insulin, they also talked about following doctors' orders, calling doctors when we need to report things like blood sugars to them. Review of the policy and procedure titled P&P Diabetes/Hypo/Hyperglycemia issued on 4/1/2022 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other condition requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to physician order . 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders. 13 . Report noncompliance with physician orders to the physician and/or resident representative, if applicable. 14. Document pertinent information, regarding medication administration, changes in condition, education, or interventions in clinical record. Review of the policy and procedure titled P&P Medication Errors issued on 4/1/2022 read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Procedure: 1. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturers specifications for use, dose, administration, duration, and monitoring of the medication. b. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences to the resident's physician, governing agencies, and resident representative, if applicable . 4. Staff will document appropriately detailed accounts of any incidents/events on an appropriate report form or electronic database system for quality assurance. Review of the policy and procedure titled Medication Administration issued on 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in a timely manner and in accordance with the physician's orders . 5. Should a dose seem excessive considering the residents age and medical condition, or medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director . 12. Should a drug be withheld, refused, or given other than the scheduled time, the individual administering the medication will document this in the clinical record. Review of the policy and procedure titled P&P Change in Condition issued on 4/1/2022 read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to resident wishes and physician's orders . 6. Contact the primary physician to update/him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, abuse, and change in condition notification. Interview with the Administrator on 9/1/2023 verified training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical wellbeing of each resident when not assuming full responsibility for the day-to-day operations of the facility and failing to effectively implement a QAPI/QAA plan. The administration failed to identify medication errors for residents who were not administered long-acting insulin as ordered by the physician and failed to ensure physician notification when medication orders were not followed and residents had change of condition for 4 of 7 residents, Resident #13, #100, #4, and #5. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: Cross Reference to F867- QAPI/QAA (Quality Assurance and Performance Improvement/Quality Assessment and Assurance) Improvement Activities under survey event RQJA12. Review of the job description for the Administrator read, Purpose of your job position: The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities: Administrative functions: Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Review deficiencies noted during the exit conference. Assist in developing plans of correction for cited deficiencies. Ensure such plans incorporate timetables and methods of monitoring to ensure such deficiencies do not recur. Committee functions: Serve on various committees of the facility (i.e., Infection control, Quality Assurance & Assessment, etc ., assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies, evaluate and implement recommendations from the facility's committees as necessary. Safety and Sanitation: Review accident and incident reports (e.g., falls, injuries of unknown source, abuse, etc.) Monitor to determine effectiveness of facility's risk management program. Review of the Job description for the Director of Nursing Services read, Purpose of your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator to ensure the highest degree of quality care is maintained at all times. Delegation of Authority: You are charged with carrying out the resident care policies established by this facility. Administrative functions: Plan, develop, organize, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day function of the nursing service department. Make written and oral recommendations to the administrator concerning the operation of the nursing service department. Develop, implement, and maintain an ongoing quality assurance program for the nursing service department. Assist in developing and implementing appropriate plans of action to correct identified deficiencies. Monitor the facility's QI [Quality Improvement], QM [Quality Management], and survey reports. Assist in developing plans of action to correct potential or identified problem areas. Committee functions: Serve on, participate in, and attend various committees of the facility as appointed by the administrator. Evaluate and implement recommendations from established committees as they may pertain to nursing services. Staff Development: Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department. Develop, implement, and maintain an effective orientation program that orients new employees to the department, its policies and procedures, and to his/her job position and title. Review of the contractual agreement for the Medical Director read, The responsibilities of the Medical Director shall be without limitation, to perform the following duties, such duties to be solely administrative in nature and not including any direct medical services: Coordinate medical care in the facility, provide clinical guidance and oversight regarding the implementation of patient care policies and make good faith efforts to assure adequate medical care for patients. Coordinate and collaborate with facility leadership, staff, other practitioners, and consultants, including any other facility medical directors to help develop, implement and evaluate patient care policies and procedures that reflect current standards of practice and regarding administrative requests and patient care initiatives as specified in the agreement. Assist facility to identify, evaluate, address, resolve medical and clinical concerns and issues that affect patient care, medical care or quality of life or are related to the provision of services by physicians and other licensed healthcare practitioners including medical care consistent with applicable current standards of care and monitoring of the performance and practices of healthcare practitioners generally. Provide clinical leadership through active participation in the facilities quality assurance committee and quality assurance program and participate in all other activities which may be designated by the executive director of the facility from time to time to facilitate the cost-effective delivery of services at the facility. Assurance of and participation in the delivery of regular in-service training sessions for all facility staff. Participate in such case management and risk management activities and programs as the executive director of the facility may request from time to time. 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 5/31/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 16 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 6/1/2023 through 6/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 7 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 7/1/2023 through 7/31/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 10 days. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 7 days. Cross Reference to F884- Quality of Care. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 5 days. Cross Reference to F884- Quality of Care. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed the licensed nursing staff documented 4 (held per parameters) on 6 days. Cross Reference to F884- Quality of Care. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. Review of the policy and procedure titled P&P Diabetes/Hypo/Hyperglycemia issued on 4/1/2022 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other condition requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to physician order . 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders. 13 . Report noncompliance with physician orders to the physician and/or resident representative, if applicable. 14. Document pertinent information, regarding medication administration, changes in condition, education, or interventions in clinical record. Review of the policy and procedure titled P&P Medication Errors issued on 4/1/2022 read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Procedure: 1. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturers specifications for use, dose, administration, duration, and monitoring of the medication. b. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences to the resident's physician, governing agencies, and resident representative, if applicable . 4. Staff will document appropriately detailed accounts of any incidents/events on an appropriate report form or electronic database system for quality assurance. Review of the policy and procedure titled Medication Administration issued on 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in a timely manner and in accordance with the physician's orders . 5. Should a dose seem excessive considering the residents age and medical condition, or medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director . 12. Should a drug be withheld, refused, or given other than the scheduled time, the individual administering the medication will document this in the clinical record. Review of the policy and procedure titled P&P Change in Condition issued on 4/1/2022 read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to resident wishes and physician's orders . 6. Contact the primary physician to update/him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.

Based on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to take actions to fully implement a developed plan of correction and Performance Improvement Plan (PIP), which resulted in the facility's failure to identify licensed staff was not following physicians' orders for notification of elevated blood sugars for 1 of 5 residents, Resident #13, and failure to identify medication errors for 3 of 5 residents, Residents #100, #4 and #5, who were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Review of the progress notes on and about 8/2/2023 did not document a nurses note. Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. Review of the education provided to licensed staff dated 8/16/2023 read, F842 following physician orders and notifying physician of CIC [change in condition] as indicated. Ensure you complete all PCC [Point Click Care] documentation before the end of your shift. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance.