**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake numbers MI00131454, MI00134210 and MI00130635. Based on observation, interview and record review, the facility failed to 1) follow Physician's Orders for medications for one (Resident #2) of three reviewed for medications; 2) assess, monitor and promptly act on a change in condition for one (Resident #3) of three reviewed for assessment and monitoring; 3) ensure appropriate monitoring of blood glucose (sugar) levels for one (Resident #14) of three reviewed for assessment and monitoring; and 4) ensure insulin was administered according to Physician's Orders for two (Resident #14 and #16) of three reviewed for medications, resulting in medications not being administered according to Physician's Orders and/or manufacturer instructions, delayed recognition and treatment for change in condition and lack of appropriate monitoring and management of diabetes. Findings include: Resident #3 (R3): Review of the medical record reflected R3 was admitted to the facility on [DATE], with diagnoses that included heart disease, dementia, atrial fibrillation and long-term (current) use of anticoagulants. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/22, reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R3 required limited to extensive assistance of one person for activities of daily living and received an anticoagulant (blood thinning medication) for seven days during the look-back period. A Discharge return anticipated MDS, with an ARD of 6/16/22, reflected R3 was sent to the hospital. R3 did not return to the facility. A Progress Note for 6/16/22 at 1:08 PM reflected R3 was sent to the hospital for suspected signs of a gastrointestinal (GI) bleed. An Emergency Medical Services (EMS) report, dated 6/16/22, reflected the call was received at 8:53 AM, EMS was en route at 8:54 AM and on scene at 8:58 AM. At 9:05 AM, R3's blood pressure was 72/37 mmHg and her pulse was 104 beats per minute (bpm). According to the report, EMS was dispatched for a resident coughing up blood. Staff (facility) stated R3 coughed up some bright red blood and had some pinkish blood in her stool. The report reflected R3's family member was on scene and reported R3 had been punky and a little confused since the day prior. According to facility staff, R3's blood pressure was usually in the 130's, and they had a reading of 109 systolic (top number) earlier. The report reflected when EMS arrived on scene, R3 was lethargic and weak, and her skin was pale and cool. An additional EMS report dated 6/16/22 (for the same dispatch) reflected R3 had vomited blood and passed blood in her stool. According to the report, R3 was verbal and reported she had been vomiting blood for the past two days. R3's last blood pressure recorded in the medical record was 118/68 mmHg on 6/15/22 at 7:01 PM. The last pulse in the medical record was 82 bpm on 6/15/22 at 7:01 PM. The last respiratory rate in the medical record was recorded on 5/31/22. A temperature of 97.7 degrees Fahrenheit was recorded by agency Licensed Practical Nurse (LPN) N on 6/16/22 at 1:31 AM. R3's medical record did not reflect notes or assessments pertaining to a change in condition. There was no documentation reflective of communication with a Physician. During a phone interview on 3/1/23 at 1:45 PM, Certified Nurse Aide (CNA) I reported recalling when R3 was sent to the hospital. CNA I reported that pretty quickly after getting on the floor for her shift, there was some commotion in R3's room. Other CNAs were in the room and stated R3 was bleeding from either her mouth or nose. CNA I reported observing some bleeding and some blood on R3's bed. The day shift nurse was made aware of R3's bleeding and complaints of pain, and R3 was sent to the hospital. According to CNA I, CNA J reported they had been concerned about R3 and reported it to their nurse (on the prior shift). CNA I stated it was unclear whether the midnight nurse had addressed it. According to CNA I, from the shift report she received, it sounded like something had been going on with R3 and was reported to the midnight nurse (the shift prior). CNA I reported that former Director of Nursing (DON) Q took a statement from her and wrote everything down on paper. According to facility schedules, agency LPN F was on duty when R3 was sent to the hospital on 6/16/22. Attempts to contact LPN F by phone on 2/23/23 at 12:17 PM and 2/28/23 at 11:18 AM were unsuccessful. According to facility schedules, agency LPN N was on duty the midnight shift of 6/15/22 to the morning of 6/16/22. An attempt to contact LPN N by phone on 3/1/23 at 2:48 PM was unsuccessful. During a phone interview on 3/1/23 at 12:04 PM, CNA J did not recall any vomiting or changes in R3's bowel movements around the time of her discharge to the hospital. During a follow-up interview on 3/1/23 at 2:23 PM, CNA J did not recall anything pertaining to bleeding for R3. If she had noticed, she would have immediately notified the nurse. Attempts to contact former DON Q by phone on 3/1/23 at 2:53 PM and 3/2/23 at 3:44 PM were unsuccessful. According to CNA I's statement obtained by former DON Q on 6/20/22, when CNA I arrived to work, she received report from CNA J from the night before. CNA J reported that R3 had called more than normal overnight because she was not feeling well and had a couple loose stools. Another CNA had answered R3's call light and stated R3 had a tissue with blood on it. According to the statement, it looked like it (blood) was coming from R3's mouth. LPN F went to check on R3 and contacted the doctor. When asked how she was doing, R3 stated it felt like her insides were burning. When taken to the bathroom, R3's stool was dark colored and watery. After being showered, R3 had another bowel movement that was dark in color. The nurse then called the doctor again, and R3 was sent to the hospital. Call light records reflected R3 used her call light 11 times between 3:51 AM and 9:25 AM on 6/16/22. According to CNA J's statement obtained by former DON Q on 6/21/22, CNA J was asked about the night she took care of R3, prior to her hospitalization on 6/16/22. CNA J reported caring for R3 on the midnight shift on 6/14/22 and 6/15/22. When she got to work on Tuesday (6/14/22), R3 seemed more unsteady and a bit more confused than normal but overall was good throughout the night. CNA J thought R3 was just tired. On 6/15/22, R3 still seemed confused. R3 got up a couple times during the night and had loose stool but not abnormal looking. CNA J's statement reflected she told the nurse, and he checked on R3. When day shift showed up, CNA J told them R3 did not seem like herself. According to hospital records for a start of care of 6/16/22, R3 had an International Normalized Ratio (INR/blood clotting test) of 8.4 (high) and had been vomiting blood since the night prior. According to the records, R3's goal INR was 2.5 to 3.5. Hospital notes reflected R3 likely had acute upper GI bleeding and supratherapeutic (above therapeutic range) INR. Resident #14 (R14): Review of the medical record reflected R14 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included other sequelae of cerebral infarction, altered mental status, multiple fractured ribs of the left side, acidosis, type 1 diabetes with diabetic chronic kidney disease, chronic kidney disease stage 3, hyperlipidemia, hypertension, type 2 diabetes with hypoglycemia without coma and dehydration. The admission MDS, with an ARD of 5/11/22, reflected R14 scored 14 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R14 required supervision to limited assistance of one person for most activities of daily living and extensive assistance of one person for bathing. The MDS history reflected a discharge return anticipated MDS, with an ARD of 5/17/22. According to the medical record, R14's blood glucose (sugar) was 617 mg/dL on 5/17/22, and she was sent to the hospital. R14 returned to the facility on 6/8/22 and was discharged back to the hospital on 6/10/22. R14 did not return to the facility. The May 2022 Medication Administration Record (MAR) reflected R14's blood sugars were scheduled to be checked daily at 7:00 AM, 11:00 AM and 4:00 PM. Humalog KwikPen insulin 100 units per milliliter (u/mL) was to be administered subcutaneously (under the skin) via sliding scale (dependent upon blood glucose levels), with meals, as follows: 150-200 mg/dL=2 units of insulin, 201-250 mg/dL=4 units of insulin, 251-300 mg/dL=6 units of insulin, 301-350 mg/dL=8 units of insulin, 351-400 mg/dL=10 units of insulin, 401-450 mg/dL=12 units of insulin. If the blood sugar was below 60 mg/dL or above 450 mg/dL, the Physician was to be notified. During an interview on 2/28/23 at 1:28 PM, LPN G reported she could not recall how close to a meal rapid acting insulin was to be administered and stated she was just going on the orders. According to the May 2022 MAR, R14's blood glucose was recorded by LPN C as 270 mg/dL for the 11:00 AM check on 5/7/22. A code of 5 was documented on the MAR, which indicated, Hold/See Nurse Notes. A Progress Note for 5/7/22 at 2:00 PM reflected R14 was refusing insulin due to not eating much for lunch. The note reflected R14 would be rechecked in one hour, and the need for insulin would be determined. R14's vital signs and Medication Administration Audit Report reflected the 5/7/22 blood glucose of 270 mg/dL was recorded at 2:00 PM, and the next check was at 5:08 PM, with a result of 257 mg/dL. According to R14's vital signs and a Medication Administration Audit Report, the 7:00 AM blood glucose for 5/8/22 was recorded as 225 mg/dL by LPN C at 9:52 AM. On 5/12/22, R14's 11:00 AM blood glucose was documented as 408 mg/dL at 2:07 PM (more than three hours after it was scheduled), according to the vital signs and a Medication Administration Audit Report. The May 2022 MAR reflected R14 had an order dated 5/12/22 for 21 units of Insulin Glargine (long acting insulin) 100 u/mL to be administered subcutaneously at bedtime. The MAR reflected the scheduled dose on 5/14/22 was documented as 5, which indicated, Hold/See Nurse Notes. A Progress Note for 5/14/22 reflected the dose was held due to a low blood sugar of 101 mg/dL. There was no documentation that the Physician had been notified or that an order had been given to hold the insulin. During a phone interview on 2/27/23 at 3:23 PM, LPN D reported the blood glucose value did not determine if a resident would receive their long acting insulin. She reported the long acting insulin would still be administered, and they would have to make sure the resident had a snack. During an interview on 3/2/23 at 9:14 AM, LPN Z reported if she was going to hold medication, she would contact the doctor. If she was holding insulin, she would never not let the doctor know. If a blood sugar was below 60 mg/dL or above 400 mg/dL, there were parameters to call the doctor. During an interview on 3/2/23 at 10:36 AM, DON B was asked if nurses could make an independent judgment to hold or administer insulin. DON B reported she would have to check the policy. She reported there were parameters, and if there was concerns, the doctor should be notified. She reported blood glucose levels were to be checked before a resident ate, and insulin was to be administered once the tray was delivered but before the resident ate. According to the vital signs and a Medication Administration Audit Report, the 7:00 AM blood glucose on 5/15/22 was recorded as 445 mg/dL at 10:42 AM. The May 2022 MAR reflected NA was documented for a blood glucose result for the 4:00 PM blood glucose on 5/15/22. There was no correlating documentation reflective of why R14's blood glucose was not checked. A Comprehensive Metabolic Panel (CMP/laboratory test) collected on 5/16/22 at 6:25 AM, with results reported on 5/16/22 at 10:51 AM, reflected a blood glucose of 609 mg/dL (HH) [a critical high value]. The vital signs and a Medication Administration Audit Report reflected the 7:00 AM scheduled blood glucose on 5/16/22 was recorded as 415 mg/dL at 8:59 AM. According to the vital signs and a Medication Administration Audit Report, the 11:00 AM blood glucose on 5/16/22 was documented as 337 mg/dL at 1:50 PM (almost three hours after the scheduled time). A Basic Metabolic Panel (BMP/laboratory test) collected on 5/17/22 at 6:21 AM, with results reported on 5/17/22 at 10:23 AM, reflected a blood glucose of 617 mg/dL (HH) [a critical high value]. The May 2022 MAR reflected the 7:00 AM blood sugar result on 5/17/22 was documented as 149 mg/dL by LPN C (indicating insulin was not to be administered per the sliding scale). The May 2022 MAR reflected the 11:00 AM blood sugar result on 5/17/22 was recorded as 617 mg/dL by LPN C. According to glucometer (device used to check blood sugar) Manufacturer Instructions provided by the facility, .If your blood glucose is above 600 mg/dL, you will receive a HI [no numbered result] . Attempts to contact LPN C via phone on 2/22/23 at 10:28 AM, 2/23/22 at 12:09 PM and 2/28/23 at 11:12 AM were unsuccessful. Voice messages were left, and no return call was received prior to the exit of the survey on 3/2/23. On 3/1/23 at 12:41 PM, Director of Nursing (DON) B reported LPN C was still a facility employee, but she did not think LPN C would be returning the phone call to the State Agency. During an interview on 3/2/23 at 10:36 AM, DON B reported that it looked like the laboratory report value for a blood glucose of 617 mg/dL on 5/17/22 was documented for R14's 11:00 AM blood glucose check on 5/17/22. DON B stated that based on what the glucometer manual said, it would not give a reading above 600 (mg/dL) and would read high (HI). According to the hospital After Visit Summary for 6/8/22, R14 was found to be in diabetic ketoacidosis (DKA/serious complication of diabetes). Additionally, there was documentation of, .Right cerebellar CVA [cerebrovascular accident/stroke] presented with altered mental status further worsened with DKA . According to the Centers for Disease Control and Prevention (CDC), .Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening .DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body .Causes of DKA Very high blood sugar and low insulin levels lead to DKA. The two most common causes are .Illness .Missing insulin shots, a clogged insulin pump, or the wrong insulin dose . (https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html) During an interview on 2/28/23 at 1:02 PM, Director of Nursing (DON) B was queried on the process for insulin administration via insulin pen and did not describe the process of priming the pen. DON B reported she had not used an insulin pen in a long time. During a phone interview on 3/1/23 at 4:01 PM, LPN Y was queried on the process of administration of insulin via an insulin pen. LPN Y did not describe the process of priming the insulin pen before administration of the ordered insulin dose. During an interview on 3/2/23 at 9:14 AM, LPN Z reported when priming an insulin pen, the dial was to be set to two units. When queried on the positioning of the insulin pen when priming, LPN Z reported she did not think there was a particular position to hold the pen. She then stated she guessed the pen was to be held in a downward position due to wanting the needle full and without air. According to the facility's Insulin Flex Pen Use Policy, with a review date of 5/27/21, .POLICY STATEMENT / PURPOSE To deliver accurate insulin does [sic] thru the flex pen .Remove the protective tab from disposable needle .Screw the needle tightly onto the flex pen .Pull off the big outer needle cap .Pull of the inner needle cap and dispose of it .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing .Turn the dose selector to select 2 units .Hold your flex pen with the needle pointing up .Keep the needle pointing upwards; press the push button all the way in .the dose selector returns to 0, a drop of insulin should appear at the needle tip. If not change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the flex pen .Turn dose selector to the number of units you need to inject .Insert the needle into the skin, inject the dose by pressing the push button all the way until the 0 lines up with the pointer .Keep the needle in the skin for at least 6 seconds and keep the push button pressed all the way until the needle has been pulled out of the skin. This will make sure the full dose has been given . Resident #16 (R16): Review of the medical record reflected R16 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hypertensive chronic kidney disease, type 2 diabetes, stage 4 chronic kidney disease, atrial fibrillation, long-term (current) use of anticoagulants, long-term (current) use of insulin and peripheral vascular disease. The Quarterly MDS, with an ARD of 12/15/22, reflected R16 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R16 did not walk and required supervision to extensive assistance of one person for activities of daily living. On 3/2/23 at 9:33 AM, R16 was observed seated in a wheelchair, in her room. She was appropriately dressed and groomed. A Physician's Order, dated 9/15/21, reflected R16 was to receive four units of 100 u/mL humalog insulin subcutaneously with meals. The insulin was to be held if R16 ate less than 50% of her meal. The 7:00 AM scheduled dose on 2/9/23 was documented as 9 by LPN AA, which indicated Other / See Nurse Notes. A Progress Note for 2/9/23 at 2:41 PM, pertaining to R16's 4 units of humalog insulin, reflected she missed the morning dose. During an interview on 3/2/23 at 11:14 AM, LPN AA reported the only reason she would not have given R16 her morning insulin was if R16 went to an activity or wasn't available to give the insulin, and it was running into the next meal. She reported the insulin was probably already late, so she did not want to give it. LPN AA stated she could not explain why the insulin was not given. Resident #2 (R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), renal disease, diabetes, arthritis, osteoporosis, fractures, chronic obstructive pulmonary disease, and depression. The MDS reflected R2 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two-person physical assist with bed mobility, transfers, locomotion, dressing, toileting, and one-person physical assist with eating, hygiene, and bathing. Review of intake, dated 8/9/22, reflected concerns R2 did not received medication for two days on admission. Review of the Electronic Medical record, dated 8/5/22 through 8/15/22, reflected R2 admitted to the facility on [DATE] from local hospital and discharged from facility on 8/15/22. Review of R2 Medication Administration Record (MAR), dated 8/1/22 through 8/31/22 redetected, R2 did not receive Physician orders Pravastatin on 8/5/22 or 8/6/22, three doses of Gabapentin(pain medication) on 8/6/22. Review of the Medication Admin Audit Report, dated 8/5/22 to 8/6/22, reflected R2 did not receive Physician ordered Pravastatin the evening of 8/5/22 or 8/6/22. The reported reflected R2 had Victoza (diabetic injectable medication) ordered at 7:00 a.m. and received at 10:24 a.m. on 8/6/22. Continued review of the report reflected R2 missed three doses of Physician orders Gabapentin on 8/6/22. Review of Nursing Progress Notes, dated 8/5/22 at 3:03 p.m., reflected vitals for R2 obtained at 4:15 p.m. Review of the Physician Progress Note, dated 8/6/2022 at 3:50 p.m., reflected, REASON FOR VISIT: s/p fall, complicated by type II odontoid cervical fracture status post nasal bone fracture, left knee (patella) fracture, HPI : [NAME]. Is a 78 y.o. Female with past med hx of HTN, Hypothyroidism, DM, hx of cervical fusion who was brought to [named hospital] ED after a fall .Patient reported that her insulin and other medications came late after her arrival into the facility. She finally got her pain medication and Victoza this morning. She is hoping that now her meds are in that she will receive medications promptly . Review of R2 Nursing Progress Note, dated 8/10/2022 at 10:55 a.m., reflected, writer spoke with Pt. daughter, [named], about her mother's care. She is very upset about multiple issues from nursing and therapy .She also states that staff have not been giving medications due to being out of supply . The note was written by Unit Manager U. During an telephone interview on 3/1/23 at 1:59 p.m., Afternoon Charge Nurse (ACN) V(nurse who completed R2 admission) reported did not recall R2 admission but reported usually if new admission from local hospital they send two days of medications to facility with residents. ACN V reported if medications given would expect staff to document as given on the MAR. During an interview on 3/1/22 at 2:30 p.m., Director of Nursing B and Nursing Home Administrator A present for interview. NHA A reported R2 arrived to facility on 8/5/22 at 3:03 pm. DON B reported they have pharmacy back up with medications and R2 diabetic medication should have been available for 8/6/22 morning dose. During an interview on 3/1/23 at 2:45pm, UM U reported spoke with R2 daughter by phone about complaints on 8/10/22 and informed R2 daughter that R2 received medications after reviewing the MAR. Review of R2 Physician Progress Notes, dated 8/6/2022 at 3:50 p.m., reflected, REASON FOR VISIT: s/p fall, complicated by type II odontoid cervical fracture status post nasal bone fracture, left knee (patella) fracture .Grief-she lost her mom about a week ago. She is gratified that she live a long life-over [AGE] years old. Well supported by family including her sister [named] and her friend [named] who were at bedside today. Sister requested antidepressant/anti-anxiety medication which I started-low-dose Cymbalta 20 milligrams daily may up titrate if needed .anxiety and depression 20 milligram Cymbalta was initiated today 08/06/2022. Monitor response Increase dose to 30 milligrams if well tolerated . Review of R2 Physician Progress Notes, dated 8/13/2022 at 10:52 a.m., reflected, [named R2] is seen for a follow up on anxiety, depression, review of ED notes from 8/12, sent for concerns of right arm fracture, redness under b/l breasts, requests change in bowel regimen .TODAY 8/13/2022 Patient was seen today resting comfortably in bed. She does tell me she is quite exhausted from the events yesterday of going to the ED for CT scan to confirm right humerus distal end closed fracture. She denies any current chest pain, shortness of breath, nausea, vomiting, or diarrhea. She requests to change the senna tablets to as needed, can continue on the scheduled MiraLax. She does complain of generalized pain from her initial injuries but more specifically her right arm has been bothering her in the elbow. She currently rates it a 6 to 7/10. She does report some relief taking the scheduled Tylenol and the p.r.n. oxycodone. She has an appointment with [NAME] Orthopedics on Tuesday. She does admit to a lot of anxiety, she reports that she has always been a worrier but since the accident she is having a difficult time keeping herself calm. She recently lost her mother and also going through the grief process. It does appear she was to start on 20 milligrams Cymbalta on 08/06/2022, that medication has not yet started so patient does agree to start that as well as she is requesting to have something else as needed if she develops more of a panic type attack. She does agree to a short course of p.r.n. Xanax. Social work report that they have consulted the psychiatric group who will be seeing patient this week. She denies any thoughts or plans to hurt herself. She feels that she just wants to start to get stronger and do more therapy . Review of the MAR, dated 8/1/22 through 8/31/22, reflected R2 did not receive Cymbalta as ordered by the physician on 8/6/22 until 8/14/22. During an telephone interview on 3/2/22 at 11:52 a.m., DON B reported R2's Pravastatin was not in pharmacy backup and delivery comes at midnight. DON B' verified R2 did not receive Pravastatin dose on 8/5/22 or 8/6/22. and reported would expect nurse to call physician related to missed dose and did not find evidence Physician had been notified. DON B reported R2 Victoza was ordered at 7 to 8 in the morning and was administered late and was unable to answer why. DON B reported would expect nurse to notify physician if medication administered outside one hour of order. DON B reported R2 missed three doses of Gabapentin 8/6/22 and reported was available in pharmacy backup but was not administered. DON B R2 cymbalta order was not entered into EMR by ordering Nurse Practitioner(NP) and should have been and reported would not expect nurse of UM to review NP notes. DON B reported overall Unit Manager were responsible for reviewing ancillary service Physician notes and orders. DON B verified R2 NP noted reflected order for R2 to start cymbalta 8/6/22 and was not started until 8/14/22.