**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the necessary care and services were provided to one of ten residents (R1) reviewed for quality of care by not monitoring R1's blood glucose levels and by not administering insulin as ordered. This failure contributed to R1 experiencing an elevated blood glucose level which required an admission to the local hospital. The findings include: R1's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, dependence on renal dialysis, cognitive communication deficit, and type two diabetes mellitus with diabetic neuropathy. R1's discharge/admitting orders from the local hospital to the facility dated August 30, 2023 shows, Check blood sugar fasting, before meal, and bedtime. (Continuous blood glucose monitoring device) receive-Lantus 22 units every day, Humalog three times a day per sliding scale: 9 units bgm 150-250, 11 units 251-350, 13 units blood sugar >350. Adjust mealtime dose per blood glucose level. Insulin syringe-needle-use with Lantus nightly. R1's Medication Administration Record (MAR) dated August 1, 2023-August 31, 2023 shows no insulin was ordered or administered nor was any blood glucose levels performed. R1's Initial Nursing assessment dated [DATE] does not show any continuous blood glucose monitoring machine was noted. R1's electronic MAR notes dated August 31, 2023 shows the (continuous blood glucose monitoring device) was pending delivery. R1's MAR dated September 1, 2023-September 30, 2023 shows no insulin was ordered or administered with the exception of September 5, 2023 (Day that R1 was transferred to the local hospital) when a STAT order for insulin was obtained due to an elevated blood glucose level. There were no blood glucose levels documented. R1's Lab Results Report dated September 5, 2023 shows R1's glucose level was 383. R1's Nurses notes dated September 5, 2023 at 3:18 PM, entered by V6 LPN (License Practical Nurse) shows she placed a call to the provider via telephone related to R1's laboratory results and accucheck of high. R1's Nurses notes dated September 5, 2023 at 3:22 PM, entered by V6 shows the ambulance company was contacted and will send a crew over to transport R1. STAT insulin was given at this time. R1's Progress Notes dated September 5, 2023 at 5:18 PM, entered by V6 shows, This writer placed the (Continuous blood glucose monitoring device) this PM as it arrived evening of August 31, 2023 at change of shift. Same applied initial reading was high. R1's Progress Notes dated September 5, 2023 at 9:47 PM, entered by V6 shows R1 was admitted to the local hospital for hyperglycemia. On October 23, 2023 at 11:28 AM, V6 LPN (Nurse taking care of R1 on the day she was transferred to the local hospital with an elevated blood glucose level.) said that she could not remember taking blood glucose levels on R1 nor did she remember any glucose reading numbers. V6 said that she did not remember the day that V6 sent R1 to the hospital. V6 said she did not remember getting an order for a stat insulin. (This was all found in R1's progress notes entered by V6 on 9/5/23). V6 could not recall any events from the day that she transferred R1 out to the hospital. On October 24, 2023 at 9:05 AM, V14 NP (Nurse Practitioner) said R1 had an order for a continuous blood glucose monitoring device, but V14 did not know if R1 had the device on. V14 said that R1 had a (continuous blood glucose monitoring device) placed at some point because it gave a reading of high. V14 said she gave the nurse a one-time order of insulin STAT and to recheck R1's blood sugar. V14 said that after the insulin, R1's blood sugar still read high. V14 said R1's original admission orders should have been clarified when R1 was admitted to the facility on [DATE]. V14 said if the orders had been clarified she would have ordered Lantus long-acting insulin daily and Humalog sliding scale insulin three times per day with blood glucose monitoring four times per day. At 12:00 PM V14 said if a resident's blood sugar gets too high, diabetic ketoacidosis can occur which could place a resident in a coma. On October 23, 23 at 10:29 AM, V2 (Director of Nursing) said the orders from the hospital did not have blood sugar checks on there or anything about insulin on there. R1's sister mentioned to V2 that R1 wasn't getting blood glucose monitoring done. V2 said she did not know if R1 was admitted to the facility with the (continuous blood glucose monitoring system). V2 said if residents are admitted with (continuous blood glucose monitoring device), blood glucose levels should be checked before meals and at bedtime. V2 said if the nurse performs a blood glucose level for a resident, then it should be documented in the residents' medication administration record. On October 24, 2023 at 12:00 PM, V2 said if a resident's blood glucose level is higher than 450, the machine will read high but not give a numerical value. R1's local hospital emergency room Records dated September 5, 2023 at 7:14 PM shows, Patient apparently has not had blood sugar checks done on a routine basis at the nursing facility. R1's blood glucose level in the local emergency room on 9/5/23 was 591 and required insulin treatment. The facility's Diabetes Management policy dated September 2020 shows, Recognize signs and symptoms of hyperglycemia or hypoglycemia. Recognize, treat or prevent complication commonly associated with diabetes. The facility's New admission policy dated March 2021 shows, Medications for newly admitted residents are ordered, provided by the pharmacy if they are not brought in by the resident, and initiated on a timely basis. The facility nurse will verify all admission/move-in orders provided with the attending physician before they are submitted to pharmacy or entered into an electronic system, per facility policy. For facilities using electronic medication administration records for which pharmacy entered orders automatically transmit through an interface to the facility's electronic system, the nurse will sign and date the admission orders, noting that the order were verified with the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to supervise a confused resident with a hot tray for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. This failure resulted with the resident sustaining first and second degree burns to her neck and chest. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia and dementia. R1's 4/5/23 quarterly assessment documents she has severe cognitive impairment. She requires extensive assistance of two persons for bed mobility and transfers between surfaces. She also requires supervision with eating and drinking after setting up her tray. R1's nursing progress notes for 2/27/23 at 6:29 PM documents R1 had a dinner tray containing hot bouillon broth and was at on the bedside table next to the bed and she was laying down and attempted to drink the broth and spilled on her neck and chest area. The area was the right side of the neck to center part of her chest just above the right breast line was red in color with a small open area, no bleeding noted. On 5/4/23 at 10:30 AM, R1 said she did not recall the incident or if she had any pain associated with the burn. She said V4 (Certified Nursing Assistant/CNA) helped her with breakfast this morning. She had hot coffee but not too hot. And she needs to sit up straight in the bed to eat or drink. R1 was observed sitting up in her geriatric chair with a bedside table next to her. She reached out and picked up her coffee cup from the table and was able to drink on her own. On 5/4/23 at 10:30, V4 said R1 needs to be sitting up straight in bed to eat or drink, and the meal tray is put on the bedside table in front of her. V4 said if she has foods or liquids that are too hot, the tray should be held back until it is cooled down because she is able to reach out and grab at the tray. On 5/4/23 at 2:10 PM, V10 (CNA) said on the evening of 2/27/23 she was passing meal trays and placed R1's tray on the bedside table. She thought the tray was out of R1's reach. She said the tray was placed at a distance because R1 requires supervision when she is eating and needs to be placed in an upright position in bed. V10 said shortly after placing the tray in R1's room she could hear a voice calling out for the nurse. She found R1 had somehow reached out, grabbed her soup, and had spilled it over herself. V10 said she was passing all the trays to the residents and planned on returning to R1 to assist her with the meal, but she had already grabbed and spilled her soup before she could get back to her. On 5/4/23 at 10:45 AM, V5 (Registered Nurse/RN) said R1 can feed herself, after she is positioned straight up in the bed or chair. She recalls the incident of 2/27/23 occurring at the end of her shift. She could hear a voice yelling for the nurse, and she found R1 in bed calling out. V5 said R1 had reached out and grabbed hot liquid from the meal tray and spilled it over her chest. V5 said upon assessment the skin was reddened but no open areas were visible and no blistering. On 3/2/23, V11 (Nurse Practitioner) documents she saw R1 following a nursing report of a new burn injury that occurred when she was in bed and spilled her soup onto her chest. She reached for it off her tray. The assessment shows R1 to have a first degree and area of second degree burn on her anterior (front) chest, blistered and open with pink area. The facility's 9/2020 policy for meal service documents 4. To assure that each resident receives the amount of assistance necessary. Procedure: 1. Assist resident to a comfortable position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide services, equipment, and assistance to maintain mobility and range of motion (ROM) for 1 of 4 residents (R64) reviewed for ROM/mobility in the sample of 32. This failure resulted in R64 developing left foot drop and experiencing tightness in her left shoulder and left hand. The findings include: On 9/6/22 at 10:52 AM, R64 was sitting up in her wheelchair, visiting with her roommate (R59). R64's left arm was flaccid and resting in her lap. R64's fingers on her left hand were curled in towards the palm of her hand. R64 stated, I had a stroke, and my left side doesn't work anymore. They call this a rehab facility, but they don't do much rehab here. Nobody has done anything with my hand or arm in a while. I asked to speak to OT (Occupational Therapy) a while ago and I never got to see her. I wanted to ask if there were any tricks make it easier to use just one hand for things. My shoulder socket is getting stuck like this. (Resident demonstrated that her left arm is tight against her left side). And my hand keeps going into a claw, but they won't give me a brace for it. I will tell them about it, and they say, We'll see. My left arm is so tight to my side now. It barely moves. I painfully, open my left hand every day with my right hand and massage it. I don't think I have a Restorative Program. My left ankle is freezing up in one spot. When my shoes are off, it feels like I would walk on the outside of my foot. It's getting really tight. If it curls up at night, then I just use my right foot to straighten out the left foot. Nobody comes in here to do exercises with me. I try to do some myself. I can wheel myself around in this chair, but it's very tiring and hard. I use my right arm to move the wheel and guide with my right leg. I had a doctor at the other rehab facility, and he said that I would be walking again with time. I don't see that happening now. It's very disappointing. It's been 1-2 months since I had PT (Physical Therapy) or OT. I think they check us quarterly for that. I've asked for a walker to practice getting up and sitting down to strengthen my legs, but he wouldn't leave it. I'm not sure why. Maybe because I'm just too weak. If they worked with me, then I would do the exercises. It's the only way to get better. I was hoping to go home, but they said I have to stay here because I need 24-hour care. I was in my own apartment before I had the stroke. On 9/07/22 at 11:36 AM, R64 said she was surprised she wasn't getting more therapy. R64 stated, I was getting it every day at the other place and that doctor told me that I would walk again. Here they tell me I can't walk. R64's lunch tray was in front of her. R64 was having difficulty opening the plastic lid, on a styrofoam cup. R64 became frustrated and stated, I can't get that lid off! The edges of the plastic lid were bent, but the lid was still intact on top of the cup. R64 stated, It's so hard with one hand. I have a lot of trouble. R64's Face sheet dated 9/8/22 showed diagnoses to include, but not limited to stroke with left sided hemiplegia and hemiparesis; dysarthria; chronic obstructive pulmonary disease; dysphagia; diabetes; Crohn's Disease; schizoaffective disorder, bipolar type; depression; anxiety; Post-Traumatic Stress Syndrome (PTSD); congestive heart failure; fibromyalgia; and chronic kidney disease (Stage 3). R64's facility assessment dated [DATE] showed she had moderate cognitive impairment; did not exhibit rejection of care behaviors; required extensive assistance of two or more staff for bed mobility and transfers; required extensive assistance of one staff for dressing, toilet use, and personal hygiene; required supervision of one staff for eating; and had impairment to one upper extremity and both lower extremities. R64's Post-acute Rehabilitation paperwork dated 12/20/21 showed an estimated length of stay (LOS) of 2-3 weeks at the facility and the resident should be able to return home with home health care and assistance in the community. These documents showed R64 had good rehab and medical prognosis. R64 had left hemiparesis and was very focused on improving facility of left-side motor return as well as incorporation with left extremity in daily tasks. R64 had a deficit in mobility, self-care, and safety. R64 should work with PT and OT to improve bed mobility, transfer, ambulation, and self-care activity. The plan included PT comprehensive evaluation and goal setting to include the following: energy-strength, balance, ROM, and endurance; improve mobility skills in bed, transfer skills, wheelchair, bed, commode, mat activities, weight training with and without assistive device, carpeted surfaces, indoors, outdoors, stair climbing; improve static and dynamic sitting and standing balance; family/caregiver training; and equipment. The plan included OT to include the following: comprehensive evaluation, goal setting; instruct patient on energy conservation, joint-protection skills, upgrade upper limb strength, balance, ROM, and endurance; improve self-care skills including oral/facial hygiene; upper and lower limb dressing, bathing, feeding, toileting; upgrade homemaking and meal prep skills; home-environment evaluations; and family care giver training. R64 was agreeable to all forms of therapy (PT, OT, ST) at post-acute rehab facility. R64's Physical Therapy Notes started 1/8/22 showed, . Patient goals: I want to be functionally independent to get to (assisted living facility). Potential for Achieving Goals: Patient demonstrates excellent rehab potential as evidenced by high PLOF (Prior Level of Function), stable medical condition, motivated to participate and motivation to return to PLOF . Reason for referral: Patient is . admit from (post-acute rehab facility) due to acute multiple left infarct involving [NAME], corpus callosum, external capsule resulting in left sided weakness. Patient referred to PT due to new onset of decrease strength, decrease in functional mobility, increased need for assistance from others and reduced ADL participation placed resident at risk for decreased ability to return to prior level of assistance, falls, further decline in function and increased dependency on caregivers . Prior Living Environment = Patient resided in private residence . Strength/Manual Muscle Testing: LLE strength = 2/5 (Part moves partial range on a gravity eliminated plane). LUE Strength 2/5 . Balance: Static Sitting = Fair (maintains balance unsupported without LOB (loss of balance) or UE (upper extremity) support); Dynamic Sitting = Fair (maintains balance with minimal assist or UE support . Tone and Posture . LE Muscle Tone = Normal (hypotonic muscle tone on LLE) . Gross Motor Coordination = Intact . Clinical Impressions: Patient has new onset left sided weakness due to stroke and is currently needing max-dep assistance in all aspects of mobility and ADLs, currently unable to transfer and ambulate due to impairments, and will be needing skilled services to address needs . Risk Factors: Due to documented physical impairments and associated functional deficits, the patient is at risk for: compromised general health, contracture(s), decreased ability to return to prior level of assistance, decrease in level of mobility, decreased participation with functional tasks, decreased skin integrity, falls, further decline in function, increased dependency upon caregivers and limited out-of-bed activity . R64's Physical Therapy Discharge summary dated [DATE] showed, .Prognosis to Maintain CLOF (Current Level of Function) = Good with consistent staff follow-through . Discharge recommendations: 24-hour care. R64's Physical Therapy Notes started 7/9/22 showed, Resident is in SNF (Skilled Nursing Facility) with a history of CVA (stroke) resulting in left sided hemiplegia since January 2022, referred to PT for quarterly evaluation and treatment due to risk for further functional decline, increased caregiver burden, and decreased ability to transfer . Strength/Manual Muscle Testing . LLE (left lower extremity) = 1/5 (Tension is palpated in muscle or feeble contraction is felt but no visible motion occurs in joint). Static Sitting - Poor (maintains balance with max assist and upper extremity support); Dynamic Sitting: Unable (total dependence).Static Standing = Unable (total dependence) . Tone and Posture . LE (Left Extremity) Muscle Tone = Flaccid . Gross Motor Coordination = Impaired . Clinical Impressions: Patient is currently below baseline level of function and has shown significant decline in functional mobility, reduced participation in OOB (out of bed) activities, and increased need for caregiver assistance . (These notes showed a decrease in mobility and ROM from R64's initial Therapy notes). R64's Physical Therapy Discharge summary dated [DATE] showed, Prognosis to Maintain CLOF = Good with consistent staff follow-through . Discharge Recommendations: Patient discharged to LTC (long-term care) with referral to restorative nursing for continued daily bed to/from wheelchair transfers using sit to stand machine . R64's OT Discharge summary dated [DATE] - 2/22/22 showed, . Discharge Recommendations: Assistive device for safe functional mobility, elevated toilet seat/3 in 1 commode, environmental modifications, reacher and long handled sponge. RNP (Restorative Nursing Program): To facilitate patient in maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): bed mobility, dressing, transfers, ROM (Active) and ROM (Passive). R64's Task List printed on 9/8/22 showed the only Restorative Programs R64 had were Bed mobility and Dressing. R64's Restorative Nursing assessment dated [DATE] was not completed. (This would have been a quarterly assessment). R64's Restorative Nursing assessment dated [DATE] showed R64 required a mechanical sit to stand lift for transfers; did not have any orthotic or adaptive equipment in place; and had ROM (Range of Motion) limitations to her left shoulder, wrist, hand, and ankle. This assessment showed, Based on the assessment the Residents priority programs will be: c. Bed mobility/walking . e. dressing/grooming . (the options a. PROM/AROM. b. Splint or Brace Assistance . and d. transfers were not chosen for R64.) This assessment showed no changes were made to R64's Restorative Program. R64's Nursing Rehab: Bed Mobility: R64 will roll side to side during cares and repositioning with use of 1/4 side rails and staff cues and assist as needed Task from 8/10/22 - 9/8/22 showed this program was not documented on 8/20, 8/25, 9/3, or 9/4. R64's Nursing Rehab: Dressing: R64 will dress in clean pants and shirt daily and PRN with staff cues and assist PRN Task from 8/10/22 - 9/8/22 showed this program was not documented on 8/20, 8/25, 9/3, or 9/4. R64's Task did not include AROM or PROM. R64's Care Plan initiated 1/24/22 showed, R64 requires ADL assistance secondary to CVA (stroke) . Interventions/Tasks: . Provide range of motion (ROM) to affected extremity as ordered . Refer to therapies as indicated . R64's Care Plan initiated 1/16/22 showed, R64 requires assist from staff to dress daily . Interventions/Tasks: . Monitor for changes in ROM when dressing extremities . R64's Provider Notes dated 8/2/22 showed, . The resident is able to express their needs, wants, and answers questions appropriately . Left hemiplegia/hemiparesis with footdrop (this was not present on 4/8/22 provider note) .Alert, oriented to person, place, time, speech is clear . Calm, cooperative . Mood and affect at baseline . Assessment: . Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Chronic. Continue supportive care. Ok for restorative program and therapy as indicated . R64's Progress Notes were reviewed since admission [DATE]). There was no documentation of refusals of therapy or Restorative Nursing Programs. On 9/8/22 at 11:42 AM, V12 (CNA - Certified Nursing Assistant) said R64 is alert and oriented but can have some episodes of confusion. R64 is able to make her needs know and uses her call light. R64 isn't able to use her left side because of her stroke, but she does use the right side. R64 uses her right leg to move her left leg. She can't move her left leg. She can't open her left hand herself, but I can open it. I've never seen any splints on R64. She can't lift up her left arm either. I have to lift it up for her, when she gets dressed. The Restorative Aide does the exercises, ROM, and Restorative Programs with the residents. They should chart it in the Tasks. I haven't had R64 refuse any care for me. On 9/8/22 at 11:51 AM, V8 (Restorative Nurse) said Restorative Assessments are completed on admission, 7 days after admission, quarterly, and with any significant change. I'm not sure why R64's 4/14/22 (Quarterly) Restorative Assessment wasn't completed. These assessments are done to evaluate the resident's progress and make changes to their programs, as needed. R64 is a LTC (long-term care) resident. Every resident on LTC should have at least two restorative programs. If a resident is having an issue with a specific ADL or mobility issue, then I will try to tailor their restorative program to their needs the best I can. The restorative programs can improve or maintain the residents' functional abilities. When a resident is discharged from therapy, then I will follow the therapy recommendations. I take their recommendations to heart. This is their lane. I'm going to listen to what they say. I don't know why I didn't place R64 on transfer, AROM or PROM programs (as recommended by OT). AROM and PROM programs would be important for stroke residents with hemiplegia. The goal is to keep their strength on their good side and prevent contracture on the bad side. The Restorative Aide isn't the only staff that can perform ROM exercises. All programs should be completed at least daily, but the more the better. The additional training will help with muscle memory and the repetition keeps it locked. I was not aware of R64's request for a brace. Braces are usually ordered by therapy for contractures. I don't determine what a contracture is and/or the proper treatment. That is beyond my scope. A hand splint may be appropriate if I notice a contracture, or a closed fist is starting to develop. If I notice this, then we can place a washcloth in the resident's hand without a physician order and get an evaluation for a brace. AROM and PROM are helpful for residents with hemiplegia (R64) to prevent development of contractures and maintain joint mobility. If a resident has foot drop, then a foot/ankle brace may be necessary. I was not aware that R64 had foot drop. (Documented by NP on 8/2/22). The surveyor informed V8 of R64's complaints of, tightness in my hand, shoulder, and ankle; feels like her arm is pinned to her side; and her foot curls out and feels like she would walk on the outside of her foot, especially when her shoe is off. On 9/8/22 at 12:54 PM, V13 (Therapy Director/PTA) said when residents are discharge from therapy, the therapist will make recommendations for Restorative Nursing Programs (RNPs). I'm not familiar with R64, but I can review her records. V13 said R64's notes showed that R64 wished to be independent and got to (an assisted living facility). I don't see any reports of refusal of therapy or non-compliance in R64's therapy notes. R64 saw therapy for a long time after admission. I would assume she was seen so long because she was working. R64 would definitely have a better chance of maintaining her strength and abilities if her RNP programs were implemented and performed. It would be difficult for a resident to perform PROM without assistance. I'm not aware of R64 being evaluated for splints or braces. That information would be in the EMR, not in the therapy computer system. Decreased ROM is a precursor to contractures. R64's left sided flaccidity puts her at risk for contractures, bed sores, and an overall decline in transfer status. I would expect the RNP recommendations from the therapists to be implemented by the Restorative Nurse. On 9/8/22 at 3:07 PM, V14 (Nurse Practitioner) said R64 had left footdrop and tightness in her arm is developing. We talked about stretching and exercises. She acknowledges an understanding, but not sure if she does exercises. I don't remember anyone asking me about braces or splints for R64. I noticed R64's footdrop a few months ago. R64 is on a Restorative Program, and I would expect it to be completed. The residents should be evaluated quarterly by Restorative. If a resident is unable to meet therapy goals, then it is important to do RNPs. It provides the resident with more time to develop a tolerance point to do more therapy. R64's goal was to return home. R64's mobility and functional ability may have been affected by the facility's failure to follow therapy recommendations and complete RNP programs as ordered. The facility's Restorative Nursing Program Policy dated 3/10/22 showed, It is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible. Increased independence fosters self-esteem and promotes quality of life for residents . Policy Interpretation: 1. The purpose of a Restorative Nursing Program is to: a. Restore to original status or improve level of independence after a decline in Activities of Daily Living (ADLs), and/or b. Stabilize the primary problem, and/or c. Prevent secondary complications, and/or d. Maintain or improve functional abilities in ADLs, and/or e. Promote ability and wellness and where possible, prevent decline or loss of independence, and/or f. Enable residents to attain or maintain their highest practicable level of functioning. 2. A Restorative Nursing Program may be established: .b. When restorative needs arise during the course of a longer-term stay, or c. In conjunction with formalized rehabilitation therapy. 3. Activities provided by restorative nursing staff include: a. Range of Motion: i. Passive; ii. Active. b. Splint or Brace Assistance; c. Bed mobility; d. transfer; e walking; f. Dressing and/or Grooming . Procedure: 1. admission and periodic functional assessment (via the RAI schedule) will be conducted by IDT. Findings will assist in determining the resident's potential for maintaining or increasing their functional capabilities . 7. The restorative nurse will review the functional assessment and care plan with involved nursing staff and therapy to assure specific needs are identified, plan implemented, and resident placed in the appropriate restorative program(s) . 9. Program goals will be documented in POC task section. Restorative, nursing, therapy, and/or any other trained personnel will document the resident's participation . 11. The restorative nurse will complete a periodic evaluation at least quarterly that will reflect the resident's tolerance and progress towards goals .