**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, facility investigation review, facility document review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provide supervision for 1 of 3 (Resident #1) sampled residents reviewed for accidents. On 12/27/2023, Resident #1 had an unwitnessed fall from an elevated bed and sustained bilateral lower extremity compound fractures of the tibia and fibula and a comminuted fracture of the left patella. Resident #1 was transferred via air ambulance (helicopter) to a level 1 trauma center for emergent care. The emergency department record dated 12/28/2023 for Resident #1 revealed, .reported fall from bed with bilateral lower extremity deformity and reported 'near amputation' left leg . The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) to Resident #1. The Administrator was notified of the Immediate Jeopardy for F689 (J) on 2/29/2024 at 6:52 PM, in the Administrator's office. The facility was cited at F-689 with a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy began on 12/27/2023 and is ongoing. A partial extended survey was done on 3/4/2024 - 3/13/2024. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility policy titled, INCIDENT AND ACCIDENT PROCESS, revised 8/13/2013, revealed, .Investigation into the incident/accident .Obtain information on what happened-what was actually seen or heard .Document all known facts, results of assessment including a complete description of injuries, treatment, notification of physician and family .Institute Alert Charting System .Review the Care plan for any possible/updates that might be required related to a change/update .Accidents not resulting in injuries should still be reported .Injuries can be found or develop later .Documentation that addresses the status and/or progress of the patient in relation to the incident/accident is to be completed at least every shift for 72 hours . Review of the RAI Manual Version 3.0 dated 10/2024, revealed, . GG0130: Self-Care .Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity .GG0170: Mobility Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity . 2. Review of Hospital #3's History and Physical (H&P) for Resident #1 dated 10/30/2021 revealed, .Disorientation .Patient is neurologically non-focal other than the generalized weakness .presented to our ED [Emergency Department] after being found down in her yard from a reported fall and unable to get up. Per the patient she slipped because the floor was wet, without LOC [level of consciousness]. Femur X-Ray 10/29/21 .Status post total RIGHT hip arthroplasty without evidence of fracture to the RIGHT femur .Pelvis .Severe osteopenia .Thoracic Spine .Diffuse osteoporosis . The hospital H&P note review above reveals Resident #1 had a history of falls prior to her admission to Facility #1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Spondylosis without myelopathy or radiculopathy and Epilepsy. Continued review of the medical record revealed Resident #1 displayed gradual functional decline in her physical mobility, as well as her mental status, following admission to the facility. Review of therapy notes dated 1/12/2022 through 2/22/2022, revealed Resident #1 was unable to progress in ambulation due to increased pain and her inability to tolerate weight on her left leg. Orthopedics evaluated Resident #1 on 3/1/2022, documented that she had experienced a significant functional decline, and determined the screw that was placed during her previous left hip surgery had shifted and was coming out of the femoral head (highest part of the thigh bone). Resident #1's family declined the extensive surgical repair that would be necessary to correct the previous surgical fixation. A second Orthopedic Physician evaluated Resident #1 on 9/9/2022 and 10/9/2022 and documented that surgical repair would be highly risky considering her poor health and dementia diagnosis. Review of the Progress Notes dated 3/21/2023 for Resident #1 revealed, .received report that pt was trying to get up as she [was] told by her roommate [Resident #9] to get out of bed and that she got a skin tear by doing so. Went to pt and found .skin tear on LLE [left lower extremity] with a small amount of blood she knows she was not supposed to get up and will stay in bed . Resident #1 was moderately cognitively impaired. There were no interventions in Resident #1 and Resident #9's care plan to address the unsafe behaviors noted in the review above, which placed both residents at a greater risk of falls. Review of the Occupational Therapy (OT) Progress Note dated 4/28/2023 revealed, .Pt [Patient, Resident #1] continues to require encouragement to participate in out of bed tasks d/t [due to] pain in L hip . Review of the Morse Fall Scale dated 5/1/2023 revealed Resident #1 was high risk for falls due to a history of falling, gait impaired, and overestimates/forgets limitations. Review of the Social Service note dated 5/1/2023 revealed, .She [Resident #1] enjoys laying [lying] in bed, visiting with her roommate . Review of the Progress Note dated 6/26/2023 revealed, .Pt [Resident #1] allowed this nurse to place shoes on bedside dresser .Bed in low position, locked with floor mat in place beside bed . Review of the Progress Note dated 6/27/2023 for Resident #1 revealed, .Pleasant mood Max [maximum] assist x [times] 2 with bed MOB [mobility] Max assist with ADLs [activities of daily living] .Able to turn self in bed slightly . Review of Hospice Palliative Care #1's note dated 6/30/2023 for Resident #1 revealed, .pt lying in bed .She attempts to answer questions when prompted .but exhibits confusion and memory loss .She has contracture [shortening and stiffening of the joints or muscles that prevents normal movement] of left hand .Has h/o [history of] falls and has previously fallen out of bed at facility .Musculoskeletal .Spine, rib and pelvis: reduced ROM [range of motion] .Right upper extremity: reduced ROM .Left upper extremity: reduced ROM .Right lower extremity .reduced ROM .Left lower extremity .reduced ROM .Psychiatric: Insight: poor insight .Implement fall prevention measures-maintain bed at lowest level .Primarily bed bound and unable to ambulate . Review of the Progress Note dated 7/31/2023 revealed, .Pt [Resident #1] continues to require encouragement to participate in out of bed tasks d/t pain in L [left] hip . Review of the Social Services note dated 7/31/2023 revealed, .[Named Resident #1] alert, oriented with confusion .She enjoys laying in bed . Review of the Morse Fall Scale dated 8/8/2023 revealed Resident #1 was low risk for falls due to gait normal/Bed Rest/Wheelchair and overestimates/forgets limitations. Resident #1's Morse Fall Scale for 1/30/2023 and 5/1/2023 were high risk for falls. Review of Hospice Palliative Care #1's note dated 8/21/2023 for Resident #1 revealed, .At baseline, pt exhibits s/s [signs/symptoms] of advanced dementia including memory loss, weakness, loss of mobility .primarily bed bound .She has contracture to left hand and stiffness of right hand .Musculoskeletal: limited motion, muscle weakness, arthralgias/joint pain and swelling in extremities . Review of the Progress Note dated 9/18/2023 for Resident #1 revealed, .Max assist with ADLs, bed MOB . Review of the Morse Fall Scale dated 10/20/2023 revealed Resident #1 was low risk for falls due to gait normal/Bed Rest/Wheelchair and overestimates/forgets limitations. Review of the OT note dated 10/31/2023 revealed, .Pt [Resident #1] continues to require encouragement to participate in out of bed tasks d/t pain in L hip . Review of the OT Functional Abilities assessment dated [DATE] revealed, .Putting on/taking off footwear .Dependent [on staff] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition, with no behaviors noted over the last 7 days. Continued review of the MDS revealed Resident #1 was dependent for toileting hygiene, putting on/taking off footwear, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Further review of the MDS revealed Resident #1 required substantial/maximal assistance with sit to lying and lying to sitting on side of bed. Review of the Progress Note for Resident #1 revealed, .[Recorded as Late Entry on 12/29/2023 03:04 PM] .12/27/2023 at 10:55 PM .Patient Fall with BLE [Bilateral Lower Extremity] injury/fractures .Patient found sitting beside bed, screaming in pain. Large pool of blood noted to LLE, but unable to assess full extremity as patient was sitting on part of extremity. Pressure applied to stop bleeding. RLE [right lower extremity] when assessed was noted to have bone sticking thru skin. 911 called and patient sent out via [by way of] ambulance .Upon EMS [Emergency Management Service] arrival, and further assessment patient determined to have compound f/x [fracture] of BLE. EMS transported patient to heliport to be medevac'd [taken to hospital via helicopter] to Acute trauma center . Note transcribed by Licensed Practical Nurse (LPN) #1. Review of the census for Resident #1 revealed she continued to be in the room with Resident #9 until her fall from bed on 12/27/2023. Resident #1 remained in the room with Resident #9 with a known history of unsafe interactions between the 2 residents. Review of the FSI (fall scene investigation) Report dated 12/27/2023 for Resident #1 revealed an unwitnessed fall at 10:55 PM. The Fall Description Details for the fall was marked for factors observed at time of fall .resident slipped [the fall was unwitnessed] .Bed height not appropriate . Resident #1 was found on the floor in her room. Continued review of the Fall Description Details for the fall was marked for the question What was resident doing during or just prior to fall . attempting self-transfer . (the fall was unwitnessed) . What type of assistance was resident receiving at time of fall .alone and unattended . (Resident #9 was up in the room in her wheelchair). Further review of the FSI revealed Resident #1 stated, I don't know what happened. I was trying to get out of bed and felt my left leg slip and then I fell. The FSI report noted Resident #1's footwear at the time of fall was shoes, she was last toileted at 10:00 PM, and medications given in the last 8 hours prior to the fall was a narcotic. The FSI report question What appears to be the root cause of the fall .patient attempting to get out of bed without assistance, appears patient raised bed to (arrow up sign) position which contributed to fall/Injuries . The FSI report noted initial interventions to prevent future falls, .N/A [not applicable] patient sent out via 911 . The FSI report revealed a drawn picture of patient on the floor laying on a fall mat parallel to the bed with head midway of the bed with her left leg under the resident and right leg bent up (LPN #1's Progress Note post fall noted 'Right extremity was stretched out in front of her') with a circled area indicating the compound fracture location. The picture further noted injury #2 as left leg knee area which EMS later reported as compound fractures as well. Review of the comprehensive care plan dated 12/27/2023 for Resident #1 revealed, .Problem Start Date .1/11/2022 [Named Resident #1] is At risk for Falls with Injury. She has a h/o falls and is unsteady. She has dementia and poor safety awareness, she can be impulsive .Approach Start Date .10/01/2022 Right side of bed against wall to help with spatial awareness .Approach Start Date .1/11/2022 Call light and personal items within reach .Ensure a safe environment, free of clutter and obstacles .Fall risk assessment .Approach Start Date .1/12/2022 Fall mat to left side of bed while in bed .Bed in low safe position .Problem Start Date .1/11/2022 revealed [Named Resident #1] has an altercation in ADL performance. She has weakness, unsteadiness, and dementia. She is incontinent of B&B [Bowel and Bladder] .Approach Start Date .1/11/2022 Staff to assist her with ADL needs .bathing, dressing, grooming, hygiene, toileting . The comprehensive care plan did not reveal any safety measures or interventions related to Resident #1's history of getting up unassisted, Resident #9's (Resident #1's roommate) history of attempting to assist her with shoes and attempting to assist her with getting out of bed, or safety concerns with use of bed controls with raising her bed to an unsafe elevated position. Review of the EMS report dated 12/27/2023 for Resident #1 revealed, .Primary Impression Injury of Lower Leg Secondary Impression Hemorrhage .Chief Complaint BILATERAL BELOW THE KNEE INJURY .Signs & Symptoms .Extremity Pain .Injury .Fall from bed - 4 ft [foot]-Nursing home 12/27/2023 .Mechanism of Injury Blunt .Trauma .Initial Patient Acuity Critical .Time 23:42 [11:42 PM] BP [Blood pressure] 130/107 Pulse 82 .23:50 [11:50 PM] 58/36 [BP] .Pulse 83 .23:52 [11:52 PM] 54/35 .Extremities .Left Leg .Deformity .Motor Function Absent .Pulse Abnormal .Right Leg .Deformity .Motor Function Absent .Pulse Abnormal .DISPATCHED TO AN 86 YOF [YEAR OLD FEMALE] WITH AN HEMORRHAGING AMPUTATION, IMMEDIATE EMERGENCY RESPONSE TO NURSING HOME. REQUESTED LFD [local fire department] RESPONSE EN ROUTE SQUAD 1 ARRIVED JUST PRIOR TO EMS. MET WORKERS FROM THE NURSING HOME AT THE 100 HALL AND PROCEEDED TO [Resident #1's room] WITH EMS EQUIPMENT. UPON ENTERING THE ROOM WE FOUND .FEMALE AT THE BASE OF A RAISED BED. BED APPEARED TO BE AT ITS HIGHEST LEVEL, PT WAS LYING SUPINE PARTIALLY ON A PADDED FLOOR MAT .WITH HER LEFT LEG BENT AT KNEE BACK BEHIND HER AT AN AWKWARD ANGLE WITH A LARGE POOL OF BLOOD UNDER THE KNEE-AND STILL BLEEDING, RT [right] LEG IS BENT AT A 45 DEGREE ANGLE WITH OBVIOUS OPEN TIB/FIB FX [Tibia/Fibula Fracture - a fracture in the lower leg that happens when a fall or blow places more pressure on the bones than they can withstand], STILL SLOWLY BLEEDING. AS WE APPROACH PT, SHE IS PALE IN COLORING WITH NO OBVIOUS INCREASED WOB [work of breathing], AEMT [advanced emergency medical technicians] GOES STRAIGHT TO LEFT EXT [extremity] TO TRY AND CONTROL BLEEDING .LFD APPLIES A NC [nasal cannula] AT 6 LPM [liters per minute] DUE TO [NAME] [mechanism of injury], AND TO PRE-OXYGENATE SINCE EMS WAS PREPARING TO GIVE MEDICATIONS, LFD .CHECKS THE STATUS OF THE CLOSEST AIR CRAFT, WITH AE9 [air evac] ACCEPTING-THEIR BASE IS THE CLOSEST .LFD .COVERING OPEN FX WITH TRAUMA DRESSING TO CONTROL TIB/FIB BLEED. LEFT LEG IS NOW VERY OBVIOUSLY A DETACHED/OPEN BONE INJURY AT THE KNEE, WITH LARGE OPEN WOUND ALMOST A PARTIAL AMPUTATION .PLACING A TOURNIQUET TO CONTROL THE BLEEDING AT THIS TIME .TRYING TO FIND AN IV [INTRAVENOUS] SITE-WITHOUT BEING ABLE TO LOCATE ANYTHING IN THE UPPER EXT'S. MEDICINE'S JUST TO MOVE PT VIA AN EMERGENCY LIFT WITH A MEGA-MOVER [portable transfer patients or to rescue patients from areas inaccessible to stretchers] OUT OF THE FLOOR .STILL TRYING TO FIGURE OUT PACKAGING FOR PT. 100MCG [microgram] OF FENTANYL [narcotic to treat severe pain] PREPARED FOR PT. PT HAS BEEN INCONSOLABLE REPORTING 10/10 [highest pain level] PAIN SINCE OUR ARRIVAL. 50MCG (1ML) [milliliter] GIVEN PER NARE. NC REPLACED HOPING THAT IT WILL HELP TO INCREASE UPTAKE OF MEDICINE. PT IS STILL IN IMMENSE AMOUNT OF PAIN AND ANXIETY. 2.5MG [milligram] OF VERSED GIVEN IN PT'S LEFT NARE TO HELP POTENTIATE NARCOTIC AND TO HELP WITH HER ANXIETY ABOUT HAVING TO MOVE HER TO GET HER ONTO THE MEGA MOVER AND OUT OF THE FLOOR. PT IS THEN SLIGHTLY LOG ROLLED ONTO THE MEGA MOVER THEN LIFTED ONTO THE COT. WE ARE SCARED TO STRAIGHTEN THE LEFT EXT DUE TO THE BLEEDING BEING STOPPED AT THIS TIME. PT IS SECURED TO THE COT IN A SLIGHT RT [right] LATERAL SUPINE POSITION. COT IS SECURED IN THE UNIT. YELLOW HUMERAL IO [intraosseous] [used anytime vascular access is difficult in emergent, urgent, or medically necessary cases to provide peripheral venous access with central venous catheter performance] ESTABLISHED IN THE LEFT ARM .LIDOCAINE [used to relieve pain and numb the skin] GIVEN SLOWLY, 50 MG PUSHED AND ALLOWED TO SATURATE WITH THE SECOND 50MG THEN BEING PUSHED, FOLLOWED BY A 10ML NS [normal saline - mixture of sodium chloride and water IV fluids] WITH PRESSURE BAG ATTACHED AND 250ML INFUSED EN ROUTE TO THE [NAME] [Pre-designated emergency landing area] .FURTHER DETAILED ASSESSMENT PERFORMED EN ROUTE. BLEEDING HAS STOPPED WITH THE LEFT INJURY SITE AND IS STARTING TO CLOT OFF. DISTAL INJURY STILL FEELS WARM TO THE TOUCH BUT UNABLE TO CHECK FOR PEDAL PULSE DUE TO ANGLE IT IS RESTING AT. RT EXT DISTAL INJURY FEELS COLD TO TOUCH AND UNABLE TO FEEL A PULSE OR GET ANY RESPONSE TO TOUCH-BUT NOT TRYING HARD DUE TO INJURY. PT HAS BECOME HYPOTENSIVE AT THIS POINT AND IS BEING GIVEN FLUID CHALLENGE. PT IS STILL RESPONSIVE TO PAIN/AND SOME VERBAL STIMULATION .AE9 ./RN [Registered Nurse] .PARAMEDIC ENTER THE UNIT AT THE BASE THE HANDOFF BEGINS TO THEM. EMS HELPS WITH MOVING PT OVER TO THEIR EQUIPMENT, AND TO THEIR STRETCHER, PT THEN MOVED TO THE AIRCRAFT AND SECURED . Review of the Progress Note dated 12/28/2023 at 12:59 AM (post fall note completed by LPN #1) revealed, .At 1055pm [10:55 PM] This nurse was sitting at nurses station charting, when I heard very loud scream. Upon arriving at Patients [Resident #1] room, patient was found half-sitting, lying on floor. A large pool of blood was noted to be forming around her left lower extremity. Upon assessment, nurse unable to see complete extremity as she was sitting on it. Her Right extremity was stretched out in front of her, and bone was seen protruding from skin just below knee. Immediately had CNA apply pressure to LLE to slow down bleeding. I then went and called 911. Returned to room and continued to assess patient. Patient reported that she had attempted to get up from bed, but felt her left leg 'Twist on something, and the next thing I knew, I was falling down.' Patient has a history of trying to get up by herself, and has repeatedly been educated to use call light before trying to get up by herself. Patient had her shoes on, and upon questioning CNA's, they report that they had just changed patient about 30 minutes prior to fall, and that her shoes were off at that time. Ambulance and first responders arrived and Patient loaded onto stretcher. EMS report they will be sending patient to hospital via helicopter as patient appears to have tibia/fibula fx to BLE . LPN #1 documents Resident #1's description of what happened differently in other documentation. Resident #1 had a BIMS score of 10 (moderate cognitive impairment) which could render repeated education ineffective for impulsive behaviors. Review of the Point of Care History (Certified Nursing Assistant (CNA) documentation) dated 12/25/2023-12/31/2023 for Resident #1 revealed no documentation for ADL care performed on 12/27/2023-12/28/2023 for the 3-11 shift or the 11-7 shift for Resident #1. Review of Facility #1's Incident Investigation dated 12/28/2023 (post fall 12/27/2023) revealed .[Named Resident #1] .Incident: Patient was found on the floor beside patient's bed .appears the patient was attempting to exit bed unassisted. The patient was found directly beside bed on fall mat with left leg bent at knee under patient and right leg out in from [front] of patient with open fracture noted below knee on right leg. Investigation: After review of fall scene investigation, Incident Report, Interviews with partners assigned to patients care on 12/27/2023 at 10:55pm, along with medical record review for this patient, it appears that the patient was attempting to exit her bed unassisted. The CNA's [Named Nurse Aide (NA) #1 and CNA #1] had been in patient's room approximately 30 minutes prior and provided incontinent care and removed patient's shoes from feet as the patient had placed them on because as [Named Resident #1] stated: 'I need to go home' CNA [Named NA #1] was able to redirect the patient during this interaction and remove shoes, shoes were left in the patients reach per her request. At approximately 10:55pm the Nurse and CNAs were called to the room by a loud noise to find [Named Resident #1] directly beside her bed with left knee bent under the patient and her right leg straight out in front of her on fall mat, the patient had on her left shoe and the right shoe was found behind the patient. After review of the patients medical record/history, interviews with partners, and review of Fall Investigation including illustration of the position and location the patient was found in on the floor following the fall, it appears .the patient had been sitting [on] edge of bed prior to being found on the floor and had attempted to stand to exit the bed her left leg buckled due to Nonunion of left proximal femur fracture with hardware failure and the patient went directly down to the fall mat. During the investigation it was unable to be determined if the patient's bed height had been left at an inappropriate level by the CNA or if the patient had elevated the bed height but regardless of this factor it appeared the injury would have occurred with any type of weight being placed on her lower extremity as the patient had been non-weight bearing to left leg with use of transfers via .lift since 2022 .Result: Nurse provided first aide and summoned EMS .Care Plan will be reviewed upon patients return for needed additional interventions. Education/In-services immediately started related to appropriate bed heights with all partners . Further review of the facility investigation revealed a written statement dated 12/27/2023 from LPN #2 which noted, .Upon going to 100 hall .I found [Named Resident #1] on the floor on top of the fall mat with two CNAs on the floor with one CNA .applying pressure with a sheet to the left lower leg. Other CNA [Named NA #1] exited room to get vital sign machine .Bed height was raised all the way up, when I asked CNA's if the bed was that high when patient fell, they said yes. I then asked if they were providing care to patient since the bed was high and they said 'no', that they were not in the room with patient and had changed her 30 minutes prior. I was notified that EMS was on the way so I cleared patient's roommate and anything in the way . Continued review of the facility investigation revealed a written statement dated 12/27/2023 from LPN #3 which noted, .notified that a fall just occurred on 100 hall, once entering room I seen two other techs on the ground with patient, one CNA .was applying pressure to left leg with towels/sheet, other CNA [Named NA #1] asked to leave room stating she felt 'sick' noticed bed in a high position, asked CNA about height of bed, stating they forgot to lower it back down after providing patient care . Review of NA #1's employee file revealed a Certificate of Successful Completion dated 10/6/2024 for Nursing Assistant studies for 40 classroom hours and 40 clinical hours. Continued review of NA #1's employee file revealed a hire date of 10/18/2023. Further review of employee file revealed a CNA Competency Checklist dated 12/29/2023 (2 days after Resident #1's fall) which included Bed mobility, Turning and Repositioning, and Falls Prevention, signed and dated by employee, Wound Care Nurse, and the Director of Nursing (DON). Review of education (post-accident) provided to staff dated 12/28/2023, 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/3/2024, and 1/5/2024 revealed, .Appropriate Bed Height for Patients When providing direct care it is appropriate to raise the patient's bed to an appropriate working level. Once you have completed the patient care task before leaving the patients ' bedside you should lower the patient's bed to the safest position .Low Bed with Fall Mats- Position of the bed in lowest possible position closest to the floor with fall mats in place . Continued review of the education revealed, .In-Service Record .Brief Summary: A fall mat will let you know the bed should be in the lowest position . All staff were educated on appropriate bed height for patients. Review of Hospital #2's Trauma History and Physical dated 12/28/2023 for Resident #1 revealed, .86 y/o F [female], reported fall from bed with bilateral lower extremity deformity and reported near amputation left leg. Level 1 trauma activation [life threatening injuries - level one is the most serious injuries] from scene due to tourniquet placed LLE .Blood products started for hypotension .Intubated in ER [Emergency Room] for pain control R IJ [intrajugular, right vein in neck] central line [catheter placed in a large vein] also placed by ER MD. Bilateral lower extremities were reduced, wounds irrigated with saline and betadine before dressed with set gauze and splinted .Patient complaint of bilateral lower extremity pain prior to intubation .Chief Complaint Both my legs are killing me ' .Review of Systems .bleeding .Neuro .numbness (LLE) .Extremities: large deformity to left knee with bone exposure and soft tissue defect > [greater than] 10cm [centimeters], smaller laceration to right knee with bone exposure .Neck: cervical collar, c-spine precautions .Skin: laceration to left knee and smaller to right knee, bone exposed, muscle exposed .Psychiatry: anxious . Review of Hospital #2's Operative Report Narrative dated 12/28/2023 revealed, .Closed treatment with splint application with manipulation right type 2 open proximal tibial shaft fracture .Close treatment with manipulation type 3 open left proximal tibial shaft fracture .Debridement [removing dead skin and foreign material from a wound] skin subcutaneous tissue and bone associated with open fracture left tibia .Debridement skin subcutaneous tissue and bone associated with open fracture right tibia .Pre-procedure diagnosis .Right type 2 open with a 6 cm [centimeter] anterior wound comminutes proximal tibia fracture with associated proximal fibula fracture in the setting of severe disuse osteopenia .Left type 3 open proximal tibial shaft fracture with a 21 cm complex anterior laceration in the setting of extreme osteopenia from disuse .Findings: Moderate instability noted through both proximal tibia fractures but acceptable alignment for a non ambulator was able to be obtained and maintained in the coronal plane [vertical plane running from front to back]. Extremely challenging skin quality that tore with attempts at suturing .I performed a very limited excision of some of the obviously necrotic [death of cells of tissue through disease or injury] skin at the site of the open fracture and then excised some .bone from the periosteum [connective tissue] and other soft tissue attachments .I turned my attention to the left leg this was a much more significant anterior wound extending 21 cm just distal to the site of the tibial tubercle [a bony bump on the upper part of the shin where the patellar tendon attaches the quadriceps muscles to the leg) .very limited skin excision was carried out only of the obvious necrotic tissue and then the subcutaneous tissues and .larger areas of .bone were excised as part of my debridement of the open fracture .The tissue was then reapproximated to cover the exposed anterior compartment muscle and tibia again this was extremely challenging as the skin would repeatedly tear if it was placed under any tension at all to reapproximate the skin edges .Ultimately I was able to reapproximate about 85% of the wound . Review of the PT Acute INP [inpatient] Progress Note dated 1/1/2024 for Resident #1 revealed, .She report increased pain .Pt rolled .with total A [assist] .Pt hollered in pain with all movement .Pt reports 8/10 pain at resident in BLE's .10/10 with movement . Review of Hospital #2's Discharge summary dated [DATE] for Resident #1 revealed, .Status Post: 12/28/23: bilateral tibia I&D [irrigation and debridement] with fracture manipulation and splinting .Problem List .Fall .Hypertension .Fracture of right tibia and fibula .Fracture of left tibia and fibula .Impaired mobility and ADLs .Depression .Fracture of tibia with fibula, left, open .Tibia and fibula open fracture, right .12/30/23 .Orthopedic evaluation pending for bilateral lower extremity fractures .Neurosurgery consulted for lumbar fractures .12/31/23 .Received 2U (units) packed red cells .1/1/24 .Transfer to PCU [Progressive Care Unit] .1/3/24 .She is c/o [complaining of] leg pain but no other complaints .Plan to repeat CTA [Computed Tomography Angiography] neck tomorrow .1/04/2024 .She mentions that her legs are still hurting .CTA is stable from prior imaging .1/5/24 .CM [case manager] has sent out referrals to different skilled nursing facilities. Pending SNF [skilled nursing facility] acceptance .1/06/24 .transfer to SNF today .Treatments & Procedures .Bilateral open tib/fib fx .NWB [Non-Weight Bearing] BLE .Dressings BLE .Multiple compression deformities, age indeterminate [not exactly known]. T3 [Third thoracic vertebra, thoracic spine around the rib cage area], T4 [Fourth thoracic vertebra], T5 [Fifth thoracic vertebra], T6 [Sixth thoracic vertebra], L1 [First lumbar vertebra lower end of the spinal column], L2 [Second lumbar vertebra], L3 [Third lumbar vertebra], L4 [Fourth lumbar vertebra] [prior history of wedge compression fracture of first lumbar vertebrae and second lumbar vertebrae upon admission to SNF #1 but not the other areas] . Review of the medical record revealed Resident #1 was readmitted to Facility #1 on 1/6/2024 with diagnoses which included Unspecified Fracture of shaft of Right Tibia, Unspecified Fracture of shaft of Left Fibula, Unspecified Fracture of shaft of Right Fibula, Unspecified Fracture of shaft of Left Tibia, and Unspecified Fracture of Left Patella. Review of the care plan dated 1/7/2024 (post fall) for Resident #1 revealed, .Problem Start Date .1/11/2022 [Named Resident #1] is At risk for Falls with Injury. She has a h/o falls and is unsteady. She has dementia and poor safety awareness, she can be impulsive .Approach Start Date .12/27/2023 (date of fall) Staff to ensure that the patient's bed is in the lowest appropriate position .Call light and personal items within reach .Falls risk assessment .Approach Start Date .1/6/2024 Fall mat to side of bed open to room .Side of bed against wall to help with spatial awareness . Review of the care plan post fall revealed only a change in wording of approach, Staff to ensure that patient's bed is in the lowest appropriate position which a low bed was already an active approach prior to her fall on 12/27/2023. The care plan does not address Resident #1's safety concern with use of bed control. Review of Facility Medical Doctor (MD) #1's note dated 1/8/2024 for Resident #1 r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of ANA's [American Nurses Association] Principles for Nursing Documentation, medical record review, observation, and interview, the facility failed to identify and report a change in condition for a resident to the resident's physician and/or resident's representative for 2 of 11 (Resident #1 and 13) sampled residents. Resident #1 was found unresponsive on [DATE] at approximately 11:50 AM by RN #1. RN #1 performed a fingerstick blood sugar for Resident #1 with a result of 25 milligrams/deciliter (mg/dL). Resident #1 was transported to Hospital #1 and admitted with diagnoses which included hypoglycemia (blood sugar less than 70 mg/dL), pyuria (purulent urine), volume depletion (liquid portion of the blood is too low), and urinary tract infection. Resident #1 died on [DATE] while a patient at the hospital. The facility's failure to identify a change in condition and notify the resident's physician resulted in Immediate Jeopardy for Resident # 1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional [NAME] President, Regional Nurse, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-580 on [DATE] at 10:40 PM in the Conference Room. The facility was cited at F-580 at a scope and a severity of J. The survey team exited on [DATE]. The survey team re-entered the facility on [DATE] per CMS request to re-open the survey, and the survey team exited on [DATE]. The Immediate Jeopardy existed on [DATE] and is ongoing. The findings include: 1. Review of the facility's undated policy titled Nurses Notes or Progress Notes revealed, .Progress notes also document .Any occurrences which are not consistent with the routine care of the Patient .Nursing intervention in these occurrences .Patient response to the interventions .Measures taken to prevent recurrences . Review of facility's policy titled MEDICAL RECORD MANUAL .LATE ENTRY PROCEDURE revised 1/2017 revealed, .POLICY: All medication and treatment entries are to be made at the time the care is rendered .Late entries ARE NOT considered a routine documentation procedure and should only be used when absolutely necessary .Narrative Entries .Write Late Entry for (date/time). (Date and time med/tx [medication/treatment] was actually given.) Briefly explain the reason for the late entry .If the person making the entry cannot accurately recount the circumstances, no entry is to be made . Review of facility's policy titled Insulin Administration undated revealed, .fingersticks ordered before meals, (AC) [before meals], will be drawn no earlier than 30 minutes before the meal .Novolin R or Humulin R Sliding Scale Insulin ordered based on before meals (AC) fingersticks will be given within a time range of no greater than 30 minutes before a meal through no later than 30 minutes post consumption of the meal. Novalog or Humalog Sliding Scale Insulin ordered based on before meals (AC) fingersticks will be given within a time range of no greater than 15 minutes before a meal through no later than 30 minutes post consumption of the meal . Review of the facility's policy titled SECTION II: DOCUMENTATION ERRORS dated reviewed and updated [DATE] revealed, .LATE ENTRIES All documentation entries are to be made as close to the time the care is rendered as possible .Late Entries are not considered a routine documentation procedure .No entry in the medical record is to be back dated . Review of the facility's policy titled POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS, revised 2/2022, revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative . 2. Review of ANA's [American Nurses Association] Principles for Nursing Documentation dated 2010, revealed, .The Uses of Nursing Documentation .Nurses document their work and outcomes for a number of reasons: the most important is for the communicating within the health care team .Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential .Foremost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of the patient care .Assessments .Medication records (MAR) .Nursing Documentation Principles .Principle 1. Documentation Characteristics .High quality documentation is: Accurate, relevant, and consistent. Clear, concise, and complete. Timely, contemporaneous, and sequential. Reflective of the nursing process .Principle 5. Documentation Entries .Entries into organization documents or the health record (including but not limited to provider orders) must be: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry . 3. Medical record review for Resident #1 revealed an admission date of [DATE] with diagnoses which included Secondary Malignant Neoplasm of Brain, Long Term Use of Insulin, Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of a physician's order dated [DATE] revealed orders for a fingerstick blood sugar and Novolog (rapid-acting insulin) per sliding scale before meals at 7:30 AM, 11:30 AM, and 4:30 PM, and at bedtime at 8:00 PM. Review of the Resident Progress Notes dated [DATE] revealed, .Pt [patient] arrived via ambulance .Pt is alert and oriented able to answer questions .Takes meds whole . Review of Baseline Care Plan with a start date of [DATE] for Resident #1 revealed, .Problem .at risk for alterations in Blood Glucose levels related to type 2 diabetes .GOAL .Will have s/s [signs and symptoms] of hypo [hypoglycemia - blood sugar less than 70 milligrams per deciliter (mg/dL)]/hyperglycemia [blood sugar greater than 125 mg/dL] identified with interventions initiated to treat blood glucose levels . with interventions to include .Administer oral antidiabetics per orders .Observe for s/s of hyperglycemia .Observe for s/s of Hypoglycemia: lethargy, fatigue/weakness . There were no interventions on the baseline care plan for the treatment of hypoglycemia (). Continued review of the Baseline Care Plan revealed, .Problem .@ [at] risk for Cognitive/Communication complications, Secondary malignant neoplasm of brain .Approach .Observe for any changes in cognitive status .Problem .at risk for Cardiac compromise related to CHF [congestive heart failure], Supraventricular tachycardia [a faster than normal heart rate beginning above the heart's two lower chambers], Dilated cardiomyopathy [when the heart chambers enlarge and lose their ability to contract] .Approach .Observe for variations in BP [blood pressure] readings and sudden increase/decrease in HR [heart rate] .Problem .At risk for GU [genitourinary] complications related to Chronic Kidney Disease stage 4 [last stage of kidney disease before kidney failure indicated by a severe loss of kidney function] .Approach .Assess for FVO [fluid volume overload] .lethargy .report as needed .Assess mental status daily .Problem .At risk for Cancer complications related to Neoplasm Brain, lung, large intestine .Approach .Assess vital signs as ordered and as needed. Notify MD [medical doctor] as needed . Review of the Resident Progress Notes dated [DATE] revealed, .patient is alert and oriented, consumes medications whole with no difficulty at this time, dependent diner with fair appetite . Review of the medical provider Visit Form dated [DATE] revealed, .Patient seen today for follow-up fatigue .Patient reports feeling better today .Physical Exam .Awake, cooperative, NAD [no apparent distress] . Review of the Resident Progress Notes dated [DATE] revealed, .wife in room with pt .pt sitting up in chair .no signs or pain or discomfort . Review of the medical provider Visit Form dated [DATE] revealed, .Patient seen today for f/u [follow-up] lethargy. Patient was awake during visit. Patient denies symptoms of dysuria, flank pain, suprapubic pain, hematuria .Physical Exam .Awake, cooperative, NAD . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had clear speech, was able to express ideas and wants and was able to understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Review of the Resident Progress Notes dated [DATE] at 12:47 AM revealed, .tired little energy but easily aroused for med [medication] admin [administration] took meds whole po [by mouth] without difficulty . Review of the Resident Progress Notes dated [DATE] at 1:23 PM revealed, .wife in room with pt pt sleeping but easily woken up .no signs of pain or discomfort . Review of the Resident Progress Notes dated [DATE] at 3:22 PM revealed, .The concern or situation: bp decreased .Blood Pressure 98/52 [documented as taken on [DATE] at 3:21 PM] [normal blood pressures are 90-120 millimeters (mm) of mercury (Hg) systolic (pressure exerted when blood is ejected into arteries) and 60-80 mm/Hg diastolic (pressure blood exerts within arteries between heartbeats) .new orders per [Nurse Practitioner (NP) #1] to hold next dose of hydralazine [medication used to treat high blood pressure] pt has no other symptoms easily awakened . Review of the Medication Administration History revealed, LPN # 6 documented on [DATE] at 3:44 PM that the 6:00 PM dose on [DATE] was Not Administer: On Hold .held times one dose per np [Nurse Practitioner] . Review of the Medication Administration History revealed LPN #34 documented administration of hydralazine 25 mg by mouth on [DATE] at 10:00 PM. There was no documentation nursing staff reassessed Resident #1's blood pressure on [DATE]. The next documented blood pressure for Resident #1 was on [DATE] at 11:22 AM (20 hours 1 minute after the low blood pressure of 98/52 was taken). Review of the Resident Progress Notes dated [DATE] at 10:28 PM revealed, .A&O [alert and oriented]. Took hs [hour of sleep] meds whole without diff [difficulty] .Able to verbalize needs . There were no Resident Progress Notes from [DATE] at 10:28 PM to [DATE] at 2:45 AM and no documentation of Resident #1's condition, level of consciousness, or responsiveness on [DATE] by nursing staff. Review of the Physician Order Report revealed, XXX[DATE] .ertapenem [antibiotic] .1 gm [gram] daily IM [intramuscular] x [times] 14 days for UTI [urinary tract infection] .Once A Day .10:00 AM . Review of the Medication Administration History dated [DATE] at 11:05 AM, revealed the Assistant Director of Nursing (ADON) documented the administration of ertapenem (first dose), Late Administration: Charted Late .Comment: late entry with no time documented when the medication was administered. Review of the Vital Signs Report dated [DATE] for Resident #1 revealed the fingerstick blood sugar taken at 10:13 PM was 78 milligrams [mg]/deciliter [dL]. There was no documentation nursing staff provided any bedtime snacks for Resident #1. Review of the Resident Progress Notes dated [DATE] at 2:45 AM revealed, .Pt [patient] has been resting with eyes closed. Took meds whole in applesauce. Difficulty sucking water through a straw .Pt is unable to follow simple instructions due to lack of physical strength .Will continue to monitor .e-Signed [electronically signed] By .[Assistant Director of Nursing (ADON)] . This is the first documentation that Resident #1 had to take medications with applesauce, had difficulty sucking through a straw, and was unable to follow simple instructions. There was no documentation RN #1 performed the 7:30 AM fingerstick blood sugar on [DATE] as ordered by the physician. Review of the Resident Progress Notes dated [DATE] at 4:13 PM revealed, .approx. [approximately]; 11.50 [11:50 AM] I [RN #1] went into the room to given [sic] [Resident #1] morning meds -I could not arouse [Resident #1] - with verbal or non verbal stimuli - Breaths approx. 12/ min. [per minute] skin warm/'sweating [sic] - ck [checked] B/S [blood sugar] - 25 [mg/dL] Immediately called NP [NP #2] appraised her of evaluation/ B/S and we were transferring to hospital Report called to [Hospital #1] .EMS [emergency medical services] arrived and transported to [Hospital #1] . There was no documentation RN #1 or any licensed nursing staff checked vital signs (temperature, blood pressure, pulse, or oxygen saturation level) when Resident #1 was found unresponsive or at any time on [DATE]. Review of the Medication Administration History revealed RN #1 documented Administered Late for Resident #1 on [DATE] at 12:05 PM and that she administered the following medications: glipizide (anti-diabetic medication) 5 mg by mouth at 7:00 AM; amiodarone (medication used to treat heart rhythm problems) 200 mg by mouth, atorvastatin (medication used to treat high cholesterol and triglyceride levels) 20 mg by mouth, corvedilol (medication used to treat high blood pressure and heart failure) 12.5 mg by mouth, hydralazine 25 mg by mouth, isosorbide mononitrate (medication used to prevent cardiac chest pain) extended release 30 mg by mouth, levetiracetam (anticonvulsant used to treat seizures) 500 mg by mouth, pregabalin 50 mg by mouth, and ertapenem (antibiotic) 1 gram by intramuscular injection at 10:00 AM. Review of the Resident Progress Notes dated [DATE] at 4:13 PM revealed RN #1 documented that she found Resident #1 unresponsive at 11:50 AM when she went into the room to give Resident #1 the scheduled morning medications. During an interview on [DATE] at 1:00 PM, when asked about Resident #1's morning medications, the Former Interim Director of Nursing (DON) stated RN #1 reported in an interview that she did not administer the medications she signed off for Resident #1 on the morning of [DATE]. Review of the SNF [skilled nursing facility]/NF [nursing facility] to Hospital Transfer Form (completed by RN #2) dated [DATE] revealed, .Usual Mental Status/Cognitive Function before the Acute Change in Condition .Alert, disoriented, but can follow simple instructions . The transfer form did not include any documentation of code status, relevant diagnosis, most recent pain level, most recent pain medication, or any vital signs. Review of the EMS Patient Care Record for Resident #1 dated [DATE] revealed, .Inside of [ambulance number], the patient's vitals are taken immediately. The patient does present hypotensive and his oxygen saturation still presents low .An additional blood glucose is assessed via finger stick and presents 'low' on the glucometer .25g [grams] of D-50 [ampule of 50% dextrose-type of sugar used to treat hypoglycemia and restore blood glucose levels] .The family is asked what the patient's normal state is and they explain that the patient will normally sit up right and speak without any issues .Upon the first initial assessment after administering the D-50, the patient's glucose level reads at 215 [mg/dL]. However, during transport and upon arrival at [Hospital #1], the patient's glucose levels continue to lower and the final assessment reads at 98 [mg/dL]. The patient does become increasingly responsive throughout the transport .The patient does now respond to pain and will open his eyes when his name is called . Continued review of the EMS Patient Care Record for Resident #1 revealed EMS was called by Facility #1 on [DATE] at 12:38 PM (48 minutes after Resident #1 was found unresponsive by RN #1). EMS arrived at the facility on [DATE] at 12:46 PM. Resident #1's vital signs per EMS on [DATE] at 12:55 PM were as follows: blood pressure 73/31, pulse 68, respirations 10, oxygen saturation 85%, and low blood glucose. EMS administered the D-50 at 1:04 PM. Nursing staff at the facility failed to provide any treatment for Resident #1's hypoglycemia, and Resident #1 went without any treatment for hypoglycemia from [DATE] at 11:50 AM when the resident was found unresponsive by RN #1 and had a blood sugar of 25 mg/dL to 1:04 PM when the D-50 was administered by EMS (1 hour 14 minutes). Review of the medical record from Hospital #1 for Resident #1 revealed, .History and Physical Reports XXX[DATE] .17:33 [5:33 PM] .Reason for Admit .altered mentation, low blood glucose .History is obtained from the patient's wife at bedside, as the patient is lethargic and confused .Wife went to visit him yesterday [[DATE]] and found him to be less responsive, but he was able to cooperate with her, and she fed him lunch [there was no documentation by nursing staff of an assessment of Resident #1's condition, level of consciousness, or responsiveness on [DATE]] .Today [[DATE]] she went to visit him after church and found him laying in bed and nonresponsive. She says that he was covered in sweat, and was nonresponsive even to sternal rub. At that point the nursing facility staff checked his blood sugar and it was found to be 25 [mg/dL] .The wife reports that he did have some abnormal movements of his upper body yesterday [[DATE]] that lasted for several hours, during that time he was confused with nonsensical speech, but was able to follow her directions to eat. Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated [DATE] revealed, .it was identified an agency CNA [certified nursing assistant] failed to report patient change in condition to the nurse in regards to the patient [Resident #1] not eating breakfast [Resident #1 was scheduled to receive breakfast at 7:15 AM] . RN #1 did not discover the resident change in condition until 11:50 AM on [DATE] (4 hours 35 minutes after Resident #1 was scheduled to receive breakfast tray). During an interview on [DATE] at 11:50 AM, the Regional Nurse (Interim DON) stated during the investigation of Resident #1 being found unresponsive, RN #1 was asked why she did not do the blood sugar check at 7: 30 AM, and RN #1 responded I don't know. The Regional Nurse stated RN #1 reported that the medications she (RN #1) signed out on the morning of [DATE] were not given. The Regional Nurse stated that RN #1 never corrected the MAR. The Regional Nurse stated that Resident #1 was not alert enough to take the morning medications on [DATE]. The Regional Nurse stated the expectation was for all documentation must be completed by the end of the shift. During an interview on [DATE] at 10:15 AM, the Regional Nurse confirmed there was no documentation of a nursing assessment or vitals for Resident #1 on [DATE] for the 7:00 AM to 7:00 PM shift prior to Resident #1 being transferred to the hospital. During an interview in the conference room on [DATE] at 3:06 PM, the ADON confirmed she provided care for Resident #1 on [DATE] for the 7:00 PM-7:00 AM shift. The ADON stated she remembered Resident #1's blood sugar being 78 at bedtime on [DATE]. The ADON stated, I wasn't sure if that was normal for him. I remember he could not sip through the straw, and I worried about his blood sugar at that time . The ADON confirmed that she left the facility at 5:00 AM (on [DATE]) when her work was completed and handed over her residents and report to another nurse. During an interview on [DATE] at 5:17 PM, the DON stated the facility had a procedure to go by if a resident's blood sugar was low. The DON stated, If a nurse finds a diabetic resident having signs and symptoms of hypoglycemia, I expect the nurse to check the blood sugar and offer orange juice and crackers. If the resident was unresponsive the nurse should call the doctor .could administer the emergency glucagon with an order .complete an assessment, and check vital signs. During an interview on [DATE] at 7:20 AM, LPN #2 stated, If I found a Diabetic resident unresponsive. I would first check his blood sugar and vital signs. Then I would call the doctor so I could give the Glucagon if the sugar was low. I would then recheck the blood sugar again to see if it improved. 4. Medical record review for Resident #12 revealed original admission date of [DATE] and readmission date of [DATE] with diagnoses which included Epilepsy, Spina Bifida with Hydrocephalus, Type 2 Diabetes Mellitus (DM) with Diabetic Neuropathy, and long term use of oral Hypoglycemic drugs. Review of the Annual MDS dated [DATE] revealed Resident #12 had a BIMS score of 15 which indicated no cognitive impairment. Review of the comprehensive care plan dated [DATE] revealed Resident #12 had a problem focus for .[Named Resident #12] is at risk for Neurological/Neuromuscular deficits related to epilepsy .Approach .Administer pertinent medications as ordered .Obtain Vital Signs and Report Abnormalities to MD/NP .In the event of seizure activity, loosen any tight constrictive clothing, maintaining safety .observe and document seizure activity, and notify md .Observe post-seizure for possible complications such as hypoxia or aspiration . Review of Resident #12's progress note dated [DATE] at 6:18 PM revealed, .pt [patient] did have what appeared to be seizure like activity for roughly 30 sec [seconds] to 1 min [minute] pt unable to respond even with sternal rub np [NP #2] made aware np here to follow up [NAME] [tomorrow] no new orders pt did come out of seizure activity ok and awake XXX[DATE] at 10:33 AM pt does have slight bruising to mid chest due to sternal rub . The progress note revealed Resident #12's representative was not notified of the seizure activity, or the bruising noted to chest. Review of the Vitals Report dated [DATE] for Resident #12 revealed vital signs were obtained at 6:22 PM after the seizure with results as follows: temperature 97.6, pulse 102 (normal 60-100), respirations 17, blood pressure 132/84 no further vital signs were noted until [DATE]. Review of Observation Detail List Report dated [DATE] for Resident #12 revealed, .Creator [NP #3] .completed date [DATE] 01:04 PM .Patient see today for f/u of epileptic episode yesterday. Patient has been complaint to Lacosamide 50 mg BID [twice a day], Levetiracetam 1500 mg BID. Reports feeling tired today and some soreness to sternal area due to sternal rub. Vital signs reviewed . During an interview on [DATE] at 2:00 PM, NP #1 confirmed Resident #12 was seen the next day after her seizure activity on [DATE]. NP #1 confirmed Resident #12 should have been monitored closely post seizure, and the pulse documented as 102 post seizure on [DATE] should have been rechecked and monitored. During an interview on [DATE] at 5:05 PM, the DON confirmed there was no documentation that the family was notified when Resident #12 had a seizure. The DON confirmed the progress note for the seizure would be considered for a change of condition. DON confirmed I would expect the nurse to recheck the vital signs when a resident's pulse was noted to be 102.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility document review, review of ANA's [American Nurses Association] Principles for Nursing Documentation, medical record review, observation, and interview, the facility failed to provide competent nursing staff to identify a change in condition for a resident, follow a physician's order to obtain a fingerstick blood sugar (FSBS), and notify the resident's physician of the change in condition for 1 of 1 (Resident #1) sampled residents who was found unresponsive. This resulted in Immediate Jeopardy (IJ) when nursing staff failed to identify a change in condition for Resident #1, and Resident #1 was found unresponsive with a blood glucose result of 25 mg/dL (milligram per deciliter). The facility failed to provide competent nursing staff to administer medications and accurately document medication administration and fingerstick blood sugars for 10 of 10 (Resident #1, 3, 5, 6, 7, 8, 9, 10, 11, and 12) sampled diabetic residents and 1 of 1 (Resident #13) sampled random resident. Failure to administer medications and accurately document medication administration and fingerstick blood sugars did not rise to the level of an IJ. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional [NAME] President, Regional Nurse, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-726 on 7/6/2023 at 10:40 PM in the Conference Room. The facility was cited at F-726 at a scope and a severity of J. The survey team exited on 6/6/2023. The survey team re-entered the facility on 6/27/2023 per CMS request to re-open the survey, and the survey team exited on 7/6/2023. The Immediate Jeopardy existed on 4/23/2023 and is ongoing. The findings include: 1. Review of facility's policy titled Glucose Monitoring undated revealed, .Each patient with finger stick blood sugar checks ordered will be monitored as indicated by the physician .For blood sugars results of below 70 give patient orange juice (if patient is unresponsive do not give anything by mouth, notify MD [medical doctor]) . Review of the facility's undated policy titled Nurses Notes or Progress Notes revealed, .Progress notes also document .Any occurrences which are not consistent with the routine care of the Patient .Nursing intervention in these occurrences .Patient response to the interventions .Measures taken to prevent recurrences . Review of facility's policy titled MEDICAL RECORD MANUAL .LATE ENTRY PROCEDURE revised 1/2017, revealed, .POLICY: All medication and treatment entries are to be made at the time the care is rendered .Late entries ARE NOT considered a routine documentation procedure and should only be used when absolutely necessary .Narrative Entries .Write Late Entry for (date/time). (Date and time med/tx [medication/treatment] was actually given.) Briefly explain the reason for the late entry .If the person making the entry cannot accurately recount the circumstances, no entry is to be made . Review of facility's policy titled Network Pharmacy Policy and Procedure .Medication Administration-General Guidelines revised on 1/1/2019, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes before and after the medication administration record (MAR) scheduled times .At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented . Review of facility's policy titled Insulin Administration undated revealed, .fingersticks ordered before meals, (AC) [before meals], will be drawn no earlier than 30 minutes before the meal .Novolin R or Humulin R Sliding Scale Insulin ordered based on before meals (AC) fingersticks will be given within a time range of no greater than 30 minutes before a meal through no later than 30 minutes post consumption of the meal. Novalog or Humalog Sliding Scale Insulin ordered based on before meals (AC) fingersticks will be given within a time range of no greater than 15 minutes before a meal through no later than 30 minutes post consumption of the meal . Review of facility's policy titled CONSISTENT CARBOHYDRATE DIET dated 10/2023, revealed, .An evening snack of patient's/resident's choice should be offered. Snacks with one carbohydrate serving and one protein serving are recommended . Review of the facility's policy titled SECTION II: DOCUMENTATION ERRORS dated October 2021, revealed, .LATE ENTRIES All documentation entries are to be made as close to the time the care is rendered as possible .Late Entries are not considered a routine documentation procedure .No entry in the medical record is to be back dated . 2. Review of the (named electronic health record company) Care Manual revealed .Medication Administration .Late medications administrations are not acceptable and prior to medications being late you must timely notify other nurses within the center that you need assistance before medication administrations are late .tasks: the expectation and requirement are that tasks ( .vitals, FSBS) be obtained immediately prior to the administration or within the allotted timeframe .for example, sliding scale insulin [progressive increase in an insulin dose based on pre-defined blood sugar ranges] ordered before meals, the FSBS must be obtained within 30 minutes of the patient receiving their meal tray .the nurse is to obtain the FSBS and document that vital in the medication administration record immediately after obtaining the FSBS result .if you select Other or Charted late you must enter a Comment explaining that late administration reason .you can add a Comment to all other reasons by selecting a reason and then selecting the Add Comment and check box .a Comment field opens and you can enter Comments regarding order or the administration .if you administer an order early you need to select the Early Administration Reason . Review of facility document titled Job Description: Licensed Practical Nurse [LPN] dated 5/20/2008 revised 11/02/2021, revealed, .Job Knowledge and Capabilities .Utilizes the nursing process in assessment, planning and implementing care .Exhibits organizational ability related to workflow, prioritizing to meet the patient care needs .Integrates current standards of practice as well as local, state, and federal regulations related to nursing services in the care of patients .Specific Duties and Responsibilities Required Accurate patient assessment .That doctors and families are being notified of changes in the patients' condition Assume responsibility for assisting with meds and treatments as needed . Review of facility document titled Job Description: Registered Nurse [RN] dated 5/20/2008 revised 11/2/2021, revealed, .Job Knowledge and Capabilities Utilizes the nursing process in assessment, planning and implementing care Exhibits organizational ability related to workflow, prioritizing to meet the patient care needs Specific Duties and Responsibilities Required .To assure accurate patient assessment Monitor unit/units to ensure that appropriate nursing care (according to established policies and procedures) is being provided and that doctors and families are being notified of changes in patients' condition Assume responsibility for assisting with meds and treatments as needed Supervise LPNs and other nursing partners as assigned . 3. Review of ANA's [American Nurses Association] Principles for Nursing Documentation dated 2010, revealed, .The Uses of Nursing Documentation .Nurses document their work and outcomes for a number of reasons: the most important is for the communicating within the health care team .Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential .Foremost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of the patient care .Assessments .Medication records (MAR) .Nursing Documentation Principles .Principle 1. Documentation Characteristics .High quality documentation is: Accurate, relevant, and consistent. Clear, concise, and complete. Timely, contemporaneous, and sequential. Reflective of the nursing process .Principle 5. Documentation Entries .Entries into organization documents or the health record (including but not limited to provider orders) must be: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry . 4. Medical record review for Resident #1 revealed an admission date of 4/13/2023 with diagnoses which included Secondary Malignant Neoplasm of Brain, Long Term Use of Insulin, Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of a physician's order dated 4/14/2023 revealed orders for a fingerstick blood sugar and Novolog (rapid-acting insulin) per sliding scale before meals at 7:30 AM, 11:30 AM, and 4:30 PM, and at bedtime at 8:00 PM. Review of the Resident Progress Notes dated 4/13/2023 revealed, .Pt [patient] arrived via ambulance .Pt is alert and oriented able to answer questions .Takes meds whole . Review of Baseline Care Plan with a start date of 4/14/2023 for Resident #1 revealed, .Problem .at risk for alterations in Blood Glucose levels related to type 2 diabetes .GOAL .Will have s/s [signs and symptoms] of hypo [hypoglycemia - blood sugar less than 70 milligrams per deciliter (mg/dL)]/hyperglycemia [blood sugar greater than 125 mg/dL] identified with interventions initiated to treat blood glucose levels . with interventions to include .Administer oral antidiabetics per orders .Observe for s/s of hyperglycemia .Observe for s/s of Hypoglycemia: lethargy, fatigue/weakness . There were no interventions on the baseline care plan for the treatment of hypoglycemia (). Continued review of the Baseline Care Plan revealed, .Problem .@ [at] risk for Cognitive/Communication complications, Secondary malignant neoplasm of brain .Approach .Observe for any changes in cognitive status .Problem .at risk for Cardiac compromise related to CHF [congestive heart failure], Supraventricular tachycardia [a faster than normal heart rate beginning above the heart's two lower chambers], Dilated cardiomyopathy [when the heart chambers enlarge and lose their ability to contract] .Approach .Observe for variations in BP [blood pressure] readings and sudden increase/decrease in HR [heart rate] .Problem .At risk for GU [genitourinary] complications related to Chronic Kidney Disease stage 4 [last stage of kidney disease before kidney failure indicated by a severe loss of kidney function] .Approach .Assess for FVO [fluid volume overload] .lethargy .report as needed .Assess mental status daily .Problem .At risk for Cancer complications related to Neoplasm Brain, lung, large intestine .Approach .Assess vital signs as ordered and as needed. Notify MD [medical doctor] as needed . Review of the Resident Progress Notes dated 4/19/2023 revealed, .patient is alert and oriented, consumes medications whole with no difficulty at this time, dependent diner with fair appetite . Review of the medical provider Visit Form dated 4/19/2023 revealed, .Patient seen today for follow-up fatigue .Patient reports feeling better today .Physical Exam .Awake, cooperative, NAD [no apparent distress] . Review of the Resident Progress Notes dated 4/20/2023 revealed, .wife in room with pt .pt sitting up in chair .no signs or pain or discomfort . Review of the medical provider Visit Form dated 4/20/2023 revealed, .Patient seen today for f/u [follow-up] lethargy. Patient was awake during visit. Patient denies symptoms of dysuria, flank pain, suprapubic pain, hematuria .Physical Exam .Awake, cooperative, NAD . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had clear speech, was able to express ideas and wants and was able to understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Review of the Resident Progress Notes dated 4/21/2023 at 12:47 AM revealed, .tired little energy but easily aroused for med [medication] admin [administration] took meds whole po [by mouth] without difficulty . Review of the Resident Progress Notes dated 4/21/2023 at 1:23 PM revealed, .wife in room with pt pt sleeping but easily woken up .no signs of pain or discomfort . Review of the Resident Progress Notes dated 4/21/2023 at 3:22 PM revealed, .The concern or situation: bp decreased .Blood Pressure 98/52 [documented as taken on 4/21/2023 at 3:21 PM] [normal blood pressures are 90-120 millimeters (mm) of mercury (Hg) systolic (pressure exerted when blood is ejected into arteries) and 60-80 mm/Hg diastolic (pressure blood exerts within arteries between heartbeats) .new orders per [Nurse Practitioner (NP) #1] to hold next dose of hydralazine [medication used to treat high blood pressure] pt has no other symptoms easily awakened . Review of the Medication Administration History revealed, LPN # 6 documented on 4/21/2023 at 3:44 PM that the 6:00 PM dose on 4/21/2023 was Not Administer: On Hold .held times one dose per np [Nurse Practitioner] . Review of the Medication Administration History revealed LPN #34 documented administration of hydralazine 25 mg by mouth on 4/21/2023 at 10:00 PM. There was no documentation nursing staff reassessed Resident #1's blood pressure on 4/21/2023. The next documented blood pressure for Resident #1 was on 4/22/2023 at 11:22 AM (20 hours 1 minute after the low blood pressure of 98/52 was taken). Review of the Resident Progress Notes dated 4/21/2023 at 10:28 PM revealed, .A&O [alert and oriented]. Took hs [hour of sleep] meds whole without diff [difficulty] .Able to verbalize needs . There were no Resident Progress Notes from 4/21/2023 at 10:28 PM to 4/23/2023 at 2:45 AM and no documentation of Resident #1's condition, level of consciousness, or responsiveness on 4/22/2023 by nursing staff. Review of the Physician Order Report revealed, .04/22/2023 .ertapenem [antibiotic] .1 gm [gram] daily IM [intramuscular] x [times] 14 days for UTI [urinary tract infection] .Once A Day .10:00 AM . Review of the Medication Administration History dated 4/22/2023 at 11:05 AM, revealed the Assistant Director of Nursing (ADON) documented the administration of ertapenem (first dose), Late Administration: Charted Late .Comment: late entry with no time documented when the medication was administered. Review of the Vital Signs Report dated 4/22/2023 for Resident #1 revealed the fingerstick blood sugar taken at 10:13 PM was 78 milligrams [mg]/deciliter [dL]. There was no documentation nursing staff provided any bedtime snacks for Resident #1. Review of the Resident Progress Notes dated 4/23/2023 at 2:45 AM revealed, .Pt [patient] has been resting with eyes closed. Took meds whole in applesauce. Difficulty sucking water through a straw .Pt is unable to follow simple instructions due to lack of physical strength .Will continue to monitor .e-Signed [electronically signed] By .[Assistant Director of Nursing (ADON)] . This is the first documentation that Resident #1 had to take medications with applesauce, had difficulty sucking through a straw, and was unable to follow simple instructions. There was no documentation RN #1 performed the 7:30 AM fingerstick blood sugar on 4/23/2023 as ordered by the physician. Review of the Resident Progress Notes dated 4/23/2023 at 4:13 PM revealed, .approx. [approximately]; 11.50 [11:50 AM] I [RN #1] went into the room to given [sic] [Resident #1] morning meds -I could not arouse [Resident #1] - with verbal or non verbal stimuli - Breaths approx. 12/ min. [per minute] skin warm/'sweating [sic] - ck [checked] B/S [blood sugar] - 25 [mg/dL] Immediately called NP [NP #2] appraised her of evaluation/ B/S and we were transferring to hospital Report called to [Hospital #1] .EMS [emergency medical services] arrived and transported to [Hospital #1] . There was no documentation RN #1 or any licensed nursing staff checked vital signs (temperature, blood pressure, pulse, or oxygen saturation level) when Resident #1 was found unresponsive or at any time on 4/23/2023. Review of the Medication Administration History revealed RN #1 documented Administered Late for Resident #1 on 4/23/2023 at 12:05 PM and that she administered the following medications: glipizide (anti-diabetic medication) 5 mg by mouth at 7:00 AM; amiodarone (medication used to treat heart rhythm problems) 200 mg by mouth, atorvastatin (medication used to treat high cholesterol and triglyceride levels) 20 mg by mouth, corvedilol (medication used to treat high blood pressure and heart failure) 12.5 mg by mouth, hydralazine 25 mg by mouth, isosorbide mononitrate (medication used to prevent cardiac chest pain) extended release 30 mg by mouth, levetiracetam (anticonvulsant used to treat seizures) 500 mg by mouth, pregabalin 50 mg by mouth, and ertapenem (antibiotic) 1 gram by intramuscular injection at 10:00 AM. Review of the Resident Progress Notes dated 4/23/2023 at 4:13 PM revealed RN #1 documented that she found Resident #1 unresponsive at 11:50 AM when she went into the room to give Resident #1 the scheduled morning medications. During an interview on 5/31/2023 at 1:00 PM, when asked about Resident #1's morning medications, the Former Interim Director of Nursing (DON) stated RN #1 reported in an interview that she did not administer the medications she signed off for Resident #1 on the morning of 4/23/2023. Review of the SNF [skilled nursing facility]/NF [nursing facility] to Hospital Transfer Form (completed by RN #2) dated 4/23/2023 revealed, .Usual Mental Status/Cognitive Function before the Acute Change in Condition .Alert, disoriented, but can follow simple instructions . The transfer form did not include any documentation of code status, relevant diagnosis, most recent pain level, most recent pain medication, or any vital signs. Review of the EMS Patient Care Record for Resident #1 dated 4/23/2023 revealed, .Inside of [ambulance number], the patient's vitals are taken immediately. The patient does present hypotensive and his oxygen saturation still presents low .An additional blood glucose is assessed via finger stick and presents 'low' on the glucometer .25g [grams] of D-50 [ampule of 50% dextrose-type of sugar used to treat hypoglycemia and restore blood glucose levels] .The family is asked what the patient's normal state is and they explain that the patient will normally sit up right and speak without any issues .Upon the first initial assessment after administering the D-50, the patient's glucose level reads at 215 [mg/dL]. However, during transport and upon arrival at [Hospital #1], the patient's glucose levels continue to lower and the final assessment reads at 98 [mg/dL]. The patient does become increasingly responsive throughout the transport .The patient does now respond to pain and will open his eyes when his name is called . Continued review of the EMS Patient Care Record for Resident #1 revealed EMS was called by Facility #1 on 4/23/2023 at 12:38 PM (48 minutes after Resident #1 was found unresponsive by RN #1). EMS arrived at the facility on 4/23/2023 at 12:46 PM. Resident #1's vital signs per EMS on 4/23/2023 at 12:55 PM were as follows: blood pressure 73/31, pulse 68, respirations 10, oxygen saturation 85%, and low blood glucose. EMS administered the D-50 at 1:04 PM. Nursing staff at the facility failed to provide any treatment for Resident #1's hypoglycemia, and Resident #1 went without any treatment for hypoglycemia from 4/23/2023 at 11:50 AM when the resident was found unresponsive by RN #1 and had a blood sugar of 25 mg/dL to 1:04 PM when the D-50 was administered by EMS (1 hour 14 minutes). Review of the medical record from Hospital #1 for Resident #1 revealed, .History and Physical Reports .04/23/2023 .17:33 [5:33 PM] .Reason for Admit .altered mentation, low blood glucose .History is obtained from the patient's wife at bedside, as the patient is lethargic and confused .Wife went to visit him yesterday [4/22/2023] and found him to be less responsive, but he was able to cooperate with her, and she fed him lunch [there was no documentation by nursing staff of an assessment of Resident #1's condition, level of consciousness, or responsiveness on 4/22/2023] .Today [4/23/2023] she went to visit him after church and found him laying in bed and nonresponsive. She says that he was covered in sweat, and was nonresponsive even to sternal rub. At that point the nursing facility staff checked his blood sugar and it was found to be 25 [mg/dL] .The wife reports that he did have some abnormal movements of his upper body yesterday [4/22/2023] that lasted for several hours, during that time he was confused with nonsensical speech, but was able to follow her directions to eat. Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 4/24/2023 revealed, .it was identified an agency CNA [certified nursing assistant] failed to report patient change in condition to the nurse in regards to the patient [Resident #1] not eating breakfast [Resident #1 was scheduled to receive breakfast at 7:15 AM] . RN #1 did not discover the resident change in condition until 11:50 AM on 4/23/2023 (4 hours 35 minutes after Resident #1 was scheduled to receive breakfast tray). During an interview on 5/31/2023 at 11:50 AM, the Regional Nurse (Interim DON) stated during the facility's investigation of Resident #1 being found unresponsive, RN #1 was asked why she did not do the blood sugar check at 7: 30 AM, and RN #1 responded I don't know. The Regional Nurse stated RN #1 reported that the medications she (RN #1) signed out on the morning of 4/23/2023 were not given. The Regional Nurse stated that RN #1 never corrected the MAR. The Regional Nurse stated that Resident #1 was not alert enough to take the morning medications on 4/23/2023. The Regional Nurse stated the expectation was for all documentation must be completed by the end of the shift. During an interview in the conference room on 5/31/2023 at 1:00 PM, the Former Interim DON stated that RN #1 was interviewed about the incident on 4/23/2023 involving Resident #1. RN #1 stated she did not administer the medications signed off and did not know why she didn't perform the 7:30 AM ordered blood glucose. RN #1 did not assess the resident, did not give medications documented, did not obtain a fingerstick blood sugar at 7:30 AM that was the fail on the nurse's (RN #1) part. The Former Interim DON stated she was not notified Resident #1 was sent out until 7:58 PM was not notified the blood glucose was 25. The Former Interim DON stated the expectation is that the nurse is to notify the provider and use nursing judgement in emergencies when to call 911. During an interview in the conference room on 5/31/2023 at 3:31 PM, Certified Nursing Assistant (CNA) #2 stated her last day of employment at the facility was on 4/23/2023. CNA #2 stated she was told during shift report that Resident #1 was actively dying and on hospice. CNA #2 stated Resident #1's family had entered Resident #1's room before 10:00 AM (on 4/23/2023), and the resident was sleepy and would not eat his breakfast tray. CNA #2 stated when she went into Resident #1's room (unable to recall time), she alerted the nurse of Resident #1's unresponsiveness. CNA #2 stated RN #1 had entered the room a few times on the morning of 4/23/2023. CNA #2 stated she was called about this instance by the facility the next day, and she was blamed for what happened to Resident #1. During an interview on 5/31/2023 at 6:20 PM, the Regional Nurse (Interim DON) with the Administrator present stated the expectation was when a resident to be transferred from the facility to the hospital that the transfer form was to be filled out completely by the nursing staff to include vital signs. Upon further interview the Regional Nurse (Interim DON) confirmed that the transfer sheet for Resident #1 on 4/23/2023 was not fully completed. Both the Administrator and the Regional Nurse stated nursing staff were to obtain blood sugars as ordered and document the result immediately after the procedure. During an interview on 6/1/2023 at 11:34 AM, the Medical Director stated she has been the Medical Director since January of 2023. The Medical Director stated her expectations of a nurse when a resident's blood glucose was low was to treat the resident and then to call the MD (Medical Doctor) or NP (Nurse Practitioner). The Medical Director stated If I was called [for Resident #1's unresponsiveness and blood glucose of 25 mg/dL], I would have told the nurse to give glucose gel or to give glucagon. We probably would have still sent the patient out to the hospital. He [Resident #1] was very sick and had a UTI [urinary tract infection]. I believe he [Resident #1] was on [named antibiotic] for the UTI. He [Resident #1] had a urine culture approx. 2-3 days prior to event. The Medical Director stated Hospice was not involved for Resident #1 while at the facility due to Resident #1's spouse elected not to as she wanted him to get stronger and start chemotherapy again.The Medical Director stated that a reasonable expectation of any facility is to check vital signs when any resident is unresponsive. During an interview on 6/1/2023 at 10:15 AM, the Regional Nurse confirmed there was no documentation of a nursing assessment or vitals for Resident #1 on 4/23/2023 for the 7:00 AM to 7:00 PM shift prior to Resident #1 being transferred to the hospital. During an interview on 6/1/2023 at 10:30 AM, RN #2 confirmed working on the 300 Hall on 4/23/2023 and was responsible for Rooms 309 to 318. RN #2 stated RN #1 was responsible for the cart on the 300 Hall which included Resident #1's room. RN #2 stated at the completion of her medication pass, she went to assist RN #1 with her medication pass. RN #2 stated the electronic MAR turned red when a medication administration time was one hour or more late, and the nurse could not tell what time the medication was due to be administered. RN #2 stated there were some reds on RN #1's MAR. RN #2 stated .I pulled Resident #1's meds up and told [Named RN #1] that the 7:30 AM glucometer check was not done and asked her to do it right now. [Named RN #1] went into the room to take [Named Resident #1's] medication and [named Resident #1] was unarousable. I reminded RN #1 to check his glucose and it was 25 or 26 . RN #2 stated she (RN #2) called 911 and went into the room to assess Resident #1 to make sure he was breathing. RN #2 stated, I did not document that assessment. The family was at bedside and came out to the hall and asked to send [Named Resident #1] to the hospital. I don't think they were at bedside that long as they did not say anything prior to checking to glucose. I did not check any vital signs as I knew the ambulance was going to be there quickly. I did not check his respirations I saw he [Resident #1] was breathing shallow and not real well anyways. I had trouble getting blood the other day on [named Resident #1]. I was simply there just to help RN #1 do her meds . During an interview on 6/1/2023 at 12:21 PM, the Nurse Practitioner (NP #1) stated has worked at the facility since January 2023. NP#1 denied being on-call on 4/23/2023. NP #1 stated she saw Resident #1 on 4/20/2023 at the request of his wife because resident was fatigued and lethargic. Resident #1 was in facility to strengthen up before the next round of chemotherapy. NP #1 stated on 4/20/2023 Resident #1 was fairly lethargic but was able to respond and would quickly drift back off the sleep while NP #1 was speaking with his wife. NP #1 stated [Named Resident #1] was on 75 mg of [Named Medication] for neuropathy, and I reduced it to 50 mg due to sleepiness, lethargy are side effects of [Named Medication]. NP #1 stated no changes were made to his diabetic medications. NP #1 stated the expectation was that nursing staff were to check blood sugars before meals and at bedtime. NP #1 stated If a resident is nonresponsive and cannot take anything by mouth, I expect staff to recheck to make sure it's an accurate reading then call to get an order to give glucagon and then to send the resident to the hospital, if the resident is non-responsive. I would expect the staff to take a set of vitals for a resident that is non-responsive. During a telephone interview on 6/1/2023 at 2:36 PM, Nurse Practitioner (NP #2) confirmed being on call on 4/23/2023. NP #2 confirmed there was no standing order at the facility for administering glucagon to a resident who was unresponsive. NP #2 stated that a nurse should immediately do an assessment to any resident found unresponsive. NP #2 stated I do expect to get a briefing [from nursing staff] on the patient, assessment, any allergies, vitals and information about that resident when I am not familiar with them. During an interview on 6/1/2023 at 3:06 PM, the ADON confirmed she provided care for Resident #1 on 4/23/2023 for the 7:00 PM-7:00 AM shift. The ADON stated she remembered Resident #1's blood sugar being 78 at bedtime on 4/22/2023. The ADON stated, I wasn't sure if that was normal for him. I remember he could not sip through the straw, and I worried about his blood sugar at that time . The ADON confirmed that she left the facility at 5:00 AM (on 4/23/2023) when her work was completed and handed over her residents and report to another nurse. The ADON stated if a patient was found unresponsive, the MD or NP should be called right away. During an interview on 6/6/2023 at 4:35 PM, the DON stated the expectation is when a resident has a change in condition the nurse should assess the resident, obtain vital signs, notify the physician, and family, and then transport resident to hospital if condition indicates. The DON stated when a resident is transferred to the hospital it is expected to provide a set of vital signs, code status, baseline information such as SBAR (Situation, Background, Assessment and Response) to include the change in condition and what occurred. During an interview on 6/27/2023 at 5:17 PM, the DON stated the facility had a procedure to go by if a resident's blood sugar was low. The DON stated, If a nurse finds a diabetic resident having signs and symptoms of hypoglycemia, I expect the nurse to check the blood sugar and offer orange juice and crackers. If the resident was unresponsive the nurse should call the doct[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility protocol review, medical record review and interview, the facility failed to notify the Medical Doctor (MD)/Nurse Practitioner (NP) for 4 of 4 insulin dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed for hyperglycemia. Nursing staff failed to notify the MD/NP for blood sugar levels equal to or greater than 400 mg (milligram)/dL (deciliter). Failure to report blood sugar levels equal to or greater than 400 mg/dL could cause acute/chronic conditions which resulted in organ failure, coma, and/or death, which placed the residents in Immediate Jeopardy IJ (a situation in which the providers non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility failed to notify the MD/NP/Resident Representative for 2 of 3 sampled residents (Resident #14 and Resident #24) reviewed for falls. Failure to notify the MD/NP/Resident Representative did not rise to the level of an IJ. The facility census on entrance was 91. The Administrator was notified of the Immediate Jeopardy on 3/4/2023 at 11:08 AM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-580 at a scope and severity of K. The Immediate Jeopardy began on 11/2/2021 and removed on 2/28/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2023 at 3:35 PM. The Immediate Action Removal Plan was initiated by the facility on 2/28/2023 during the extended survey, and the corrective actions were validated on site by the surveyor on 3/4/2023 at 4:00 PM. The facility's non-compliance at F-580 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility policy titled, POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS, revision/review date 2/2022, revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition .charge nurse will then assess the patient's condition and notify the physician or physician extender . Review of the facility's undated policy titled, VITAL SIGNS TEMPERATURE, PULSE, AND RESPIRATIONS (TPR), revealed, .Designated partner will take temperature, pulse and respirations to maintain a record of vital signs for proper assessment and treatment of the patient . Review of the facility policy titled, Nurses Notes or Progress Notes, reviewed 2/2021, revealed, .Nurses Notes/Progress Notes are used to record the patient's status and to track changes in conditions .General Guidelines for progress notes .Describe patient problems .Pertinent nursing observations .Nursing interventions .Nursing assessments . Review of the facility's policy titled, Incident and Accident Process, revised on 8/13/2013, revealed, .Investigation into the incident/accident .Notify physician .Notify family member and document time . Review of the undated facility protocol Glucose Monitoring revealed, .For blood sugar results greater than 400, notify M.D . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Infection and Inflammatory Reaction, Osteomyelitis of Vertebra, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the care plan for Resident #11 dated 10/7/2021 revealed a problem/assessment for Type 2 Diabetes Mellitus. Interventions included observe for signs/symptoms of increased/decreased blood sugar and report significant findings to MD/NP (Nurse Practitioner) as necessary. Review of the documented blood sugar levels for Resident #11 revealed, .11/2/2021 5:36 AM Blood Sugar 410 mg/dL [milligrams per deciliter] .11/2/2021 12:13 PM Blood Sugar 411 mg/dL .11/2/2021 9:36 PM Blood Sugar 411 mg/dL .11/4/2021 9:01 AM Blood Sugar 480 mg/dL .11/8/2021 8:43 PM Blood Sugar 403 mg/dL .11/10/2021 1:42 PM Blood Sugar 543 mg/dL .11/10/2021 8:58 PM Blood Sugar 515 mg/dL .11/15/2021 9:15 PM Blood Sugar 450 mg/dL .11/17/2021 8:51 PM Blood Sugar 505 mg/dL .11/18/2021 9:35 AM Blood Sugar 501 mg/dL .11/18/2021 1:37 PM Blood Sugar 452 mg/dL .11/19/2021 6:03 AM Blood Sugar 407 mg/dL .11/24/2021 9:01 PM Blood Sugar 401 mg/dL .11/26/2021 6:17 AM Blood Sugar 509 mg/dL .11/30/2021 11:38 AM Blood Sugar 482 mg/dL .12/07/2021 9:17 AM Blood Sugar 415 mg/dL .12/14/2021 8:24 AM Blood Sugar 419 mg/dL .12/20/2021 9:02 AM Blood Sugar 481 mg/dL .12/23/2021 5:18 PM Blood Sugar 420 mg/dL .12/27/2021 5:31 PM Blood Sugar 434 mg/dL . Review of the Resident Progress Notes for Resident #11 dated 11/2/2021-1/29/2022 revealed on 11/2/2021, 11/4/2021, 11/8/2021, 11/10/2021, 11/15/2021, 11/17/2021, 11/18/2021, 11/18/2021, 11/19/2021, 11/24/2021, 11/26/2021, 11/30/2021, 12/07/2021, 12/14/2021, 12/20/2021, 12/23/2021, and 12/27/2021, there was no documentation that Resident #11's MD/NP was notified of the blood sugar levels greater than 400 mg/dL. Review of the Resident Orders for Resident #11 revealed, .[Start Date] 10/7/2021 [End Date] 11/26/2021 Humalog [NAME] Kwikpen [disposable single-patient-use prefilled insulin pen] .10 UNITS; subcutaneous With Meals .if greater than 200 .[Start Date] 11/26/2021 [End Date] 12/1/2021 Humalog [NAME] Kwikpen .12 UNITS; subcutaneous With Meals .if greater than 200 .[Start Date] 12/1/2021 [End Date] 2/3/2022 Humalog [NAME] Kwikpen .15 UNITS; subcutaneous With Meals .if greater than 200 . During a telephone interview on 2/8/2023 at 9:55 PM, NP #2 stated, I worked in the facility from 11/2/2021-1/21/2022. I was not notified of [Resident #11]'s Blood Sugar levels of 400 mg/dL and above per protocol. It is imperative that the nurse notify the provider when blood glucose is 400 mg/dL and above to obtain orders for an intervention. Blood glucose levels of 400 mg/dL risks include but are not limited to Diabetic Ketoacidosis (DKA), excessive buildup of acid in the blood .which can be fatal. During an interview on 2/14/2023 at 1:04 PM, Registered Nurse (RN) #6 stated the protocol for hyperglycemia was to notify the MD/NP and contact the Unit Manager for readings of 400 mg/dL and above. During an interview on 2/14/2023 at 3:40 PM, the Director of Nursing (DON) stated she had reviewed the medical record for Resident #11 and confirmed there was no documentation of provider notification for blood sugars 400 mg/dL and above between 11/2/2021 and 1/29/2022. She confirmed the facility protocol required MD/NP notification of blood sugars above 400 mg/dL. During an interview on 2/15/2023 at 10:20 AM, RN #5 stated the protocol for hyperglycemia was to notify the MD/NP and contact the Unit Manager for readings of 400 mg/dL and above. During an interview on 2/28/2023 at 12:34 PM, LPN #8 stated, Anytime a resident's blood sugar reads 400 or above the nurse calls the doctor or NP. There is a nurse communication book, but the blood sugar has to be called right then, unless there are orders to say otherwise. I am not sure why I didn't document or call about [Named Resident #11]'s, I should have called to get an order for a one time dose of insulin. During an interview on 2/28/2023 at 1:30 PM, Medical Doctor #1 (Resident #11's doctor) stated, Procedure for notification in the facility was for staff to notify the NP with abnormal labs or blood sugar greater or equal to 400 mg/dL. I do not recall being notified of [Resident #11]'s hyperglycemia. During an interview on 3/3/2023 at 12:30 PM, Medical Director stated, Staff calls the NP or MD when a blood sugar is 400 or above. Some orders specify when to notify the MD/NP, for example over 400, give x amount of insulin and recheck, if recheck 400 or greater then notify the MD. Orders to notify the MD are necessary in order to give the MD the opportunity to make changes in treatment. I would give an order to treat blood sugar 400 or greater. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Hyperglycemia and Long Term (Current) Use of Insulin. Review of the Vitals Report for Resident #13 revealed, .11/4/2022 9:33 PM Blood Sugar 485 mg/dL .11/10/2022 7:53 PM Blood Sugar 414 mg/dL .11/11/2022 9:45 PM Blood Sugar 448 mg/dL .11/18/2022 8:53 PM Blood Sugar 500 mg/dL .12/2/2022 9:18 PM Blood Sugar 443 mg/dL .12/31/2022 11:02 PM Blood Sugar 408 mg/dL .2/28/2023 4:36 AM Blood Sugar high . Review of the Resident Progress Notes for Resident #13 dated 11/4/2022, 11/10/2022, 11/11/2022, 11/18/2022, 12/2/2022, and 12/31/2022, revealed there was no documentation Resident #13's MD/NP was notified of the blood sugar levels greater than 400 mg/dL. During a telephone interview on 3/3/2023 at 5:34 PM, LPN #11 stated, To be honest with you, I really thought the notification was for blood sugar over 500. She confirmed she had not notified the MD/NP with blood sugars equal to or greater than 400. During a telephone interview on 3/3/2023 at 5:41 PM, RN #3 stated, We really didn't have to notify the NP when [Named Resident #13]'s blood sugar was over 400 because he didn't stay that high for long periods of time, then he would go down. When asked why it was important to notify the MD/NP with blood sugars equal to or greater than 400 she said, well, they might have to change their treatment, but [Resident #13]'s blood sugar was always up and down so we didn't have to notify the NP. When asked if she knew what the risks were for a diabetic with blood sugar equal to or above 400, she stated, no, not right off hand. She paused for a moment and then replied, Diabetic Ketoacidosis. During an interview on 3/3/2023 at 6:34 PM, the DON reviewed Resident #13's progress notes dated 11/4/2022, 11/10/2022, 11/11/2022, 11/18/2022, 12/2/2022, and 12/31/2022, and confirmed there was no documentation Resident #13's MD/NP was notified of the blood sugar levels greater than 400 mg/dL. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Mild Non proliferative Diabetic Neuropathy, Type 2 Diabetes Mellitus with Foot Ulcer-Diabetic Ulcer to Right Heel, and Long Term Use of Insulin. Review of the Resident Orders for Resident #22 revealed, .Start Date 11/27/2021 End Date 2/11/2022 Humalog Kwikpen Insulin .Per Sliding Scale .If Blood Sugar is 151 to 200, give 2 units .If Blood Sugar is 201 to 250, give 4 units .If Blood Sugar is 251 to 300, give 6 units .If Blood Sugar is 301 to 350, give 8 Units .If Blood Sugar is 351 to 400, give 10 Units .If Blood Sugar is 401 to 450, give 12 Units .If Blood Sugar is 451 to 500, give 15 Units .If Blood Sugar is greater than 500, call MD .Special Instructions: If BS [blood sugar] is >400, give insulin and recheck in one hour. If still >400, call MD. If >500, call MD on first check .Humalog U-100 Insulin (insulin lispro) solution; 100 unit/mL [milliliter]; amt [amount]: 10 units; subcutaneous Special Instructions: FSBS [finger-stick blood sugar] once a day with insulin as ordered Once A Day .[Start date] 07/26/2022 [End Date] 01/02/2023 .Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL; amt: 15 units; subcutaneous Special Instructions: FSBS twice a day with insulin as ordered, Hold if BS < 100 Twice A Day .[Start Date] .07/26/202 .[End Date] 01/02/2023 . Review of the Vitals Report for Resident #22 revealed, .2/13/2022 12:00 PM Blood Sugar 418 mg/dL .10/3/2022 4:16 PM Blood Sugar 400 mg/dL .10/4/2022 4:36 PM Blood Sugar 435 mg/dL . Review of the Resident Progress Notes for Resident #22 dated 2/13/2022, 10/3/2022, and 10/4/2022, revealed there was no documentation Resident #22's MD/NP was notified of the blood sugar levels greater than 400 mg/dL. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Moderate Nonproliferative Diabetic Retinopathy with Macular Edema, and Long Term (Current) Use of Insulin. Review of the Resident Orders for Resident #27 revealed, .insulin lispro solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is 401 to 450, give 12 Units. If Blood Sugar is 451 to 500, give 15 Units .Special Instructions: If blood sugar is greater than 400 recheck in 1 hr [hour], if recheck is greater than 400 notify NP/MD .Before Meals and At Bedtime .[Start Date]12/28/2022 [End Date] 01/13/2023 .insulin lispro solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is 401 to 450, give 12 Units. If Blood Sugar is 451 to 500, give 15 Units .Special Instructions: FSBS AC [before meals] and HS [hour of sleep, bedtime] with sliding scale as ordered; If blood sugar is greater than 400 recheck in 1 hr [hour], if recheck is greater than 400 notify NP/MD .Before Meals and At Bedtime .[Start Date] 01/13/2023 [End Date] Open Ended . Review of the Vitals Record for Resident #27 revealed, 1/10/2023 8:44 PM Blood Sugar 482 mg/dL .1/18/2023 9:05 PM Blood Sugar 427 . Review of the Resident Progress Notes for Resident #27 dated 1/10/2023-1/18/2023 revealed there was no documentation Resident #27's MD/NP was notified of the blood sugar levels greater than 400 mg/dL or Resident #27's blood sugar was rechecked as ordered by the physician. Review of the Medication Administration Record for Resident #27 dated 1/1/2023-1/31/2023 revealed there was no documentation for recheck of blood sugar greater than 400 on 1/10/2023 and 1/18/2023. During an interview on 3/3/2023 at 6:15 PM, the DON stated she had reviewed the medical record of Resident #27. She confirmed there was no documentation of a blood sugar recheck on 1/10/2023 and 1/18/2023 as per MD order for blood sugar greater than 400 mg/dL. She stated, There is no documentation that the nurse checked her [Resident #27] blood sugar again and no documentation of notification to the MD/NP. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included History of Falling, Bradycardia, and Overactive Bladder. Review of the Event Reports for Resident #14 revealed, .11/26/2021 Fall Found on floor .Physician Notified: No .Resident Representative Notified: No .12/3/2021 Fall Found on floor .Physician Notified: No .1/8/2022 Fall Witnessed fall .Physician Notified: No .Resident Representative Notified: No .3/21/2022 Fall Roll from low bed to mat .Physician Notified: No . During a telephone interview on 2/8/2023 at 9:55 PM, NP #2 stated, I was not notified of [Resident #14]'s falls on 11/26/2021, 12/3/2021, and 1/8/2021. Notification at the time of a fall/incident is important in determining whether a change in care or if more extensive evaluation of the resident is needed at that time. Evaluation days after a fall/incident would risk missing key factors related to cause or effect of the fall/incident. During an interview on 2/14/2023 at 1:04 PM, RN #6 stated when a resident falls the MD/NP and family/Resident Representative would be notified and documented on the Event Report. During an interview on 2/15/2023 at 5:30 PM, the DON stated she had reviewed the medical records and Event Reports for Resident #14. She confirmed there was no documentation for notification related to falls to the MD/NP and/or Resident Representative on 11/26/2021, 12/3/2021, 1/8/2022, and 3/21/2022. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease, History of falling, and Muscle Weakness. Review of the Event Report for Resident #24 revealed, . 11/14/2021 Fall Roll from low bed to mat .Physician Notified: No .Resident Representative Notified: No . Review of the Resident Progress Notes for Resident #24 dated 11/14/2021-11/20/2021 revealed there was no documented notification to MD/NP and Resident Representative related to the fall on 11/14/2021. During an interview on 2/28/2023 at 11:30 AM, LPN #2 stated, When a resident falls, the nurse is required to notify the physician and the resident's family. I do not recall why I did not notify the physician for [Named Resident #14]'s fall on December 3rd, 2021. During an interview on 3/1/2023 at 9:55 AM, LPN #12 stated, I usually do notify the physician and family when a resident falls. Honestly, I do not know why I would not have notified them when [Named Resident #14] fell on November 26th, 2021. Maybe I got busy and forgot to notify them, it would be in the progress notes if I did the notification or asked someone else to notify [No documentation found in progress notes]. The surveyor verified an acceptable Immediate Action Removal Plan on 3/4/2023 at 4:00 PM by: [Named facility #1] ensures the need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). On 2/28/2023, the Regional Nurse verified the DON's competency on the center's Glucose Monitoring policy. On 2/28/2023, the DON educated the MDSC (Minimum Data Set Coordinator) on the center's Glucose Monitoring policy. On 2/28/2023, the DON and MDSC began conducting in-services with the licensed nurses regarding the center's Glucose Monitoring policy. All licensed nurses that were scheduled to work on 2/28/2023 completed the in-service training on 2/28/2023. All other nurses were in-serviced prior to their next scheduled shift. How We Have Identified Other Residents Having The Potential To Be Affected By The Same Practice And What Corrective Action Has Been Taken: Beginning on 2/28/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/1/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/2/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/3/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. The Measures we have put In Place and Systematic Changes We Have Made to Ensure That the Practice Does Not Recur: On 2/28/23, the Regional Nurse met with and verified the Director of Nursing's competency regarding the Center's Glucose Monitoring. Overseen by the Director of Nursing, in-service training was conducted by the MDSC, on the Center's Glucose Monitoring policy, began on 02/28/2023 for all licensed nurses. In-service training emphasized the employees understanding of the Glucose monitoring policy and documentation. The licensed nurses that are unavailable/on leave will be interviewed and in-serviced prior to their next shift worked. Beginning on 2/28/2023 and continuing through the time of this narrative on 03/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. Beginning on 3/4/2023, any newly hired licensed nurses will have competency checks to verify understanding of the center's glucose monitoring policy. The Corrective Actions Will Be Monitored To Ensure the Practice Will Not Recur: The DON or designee will complete in-service training on the center's Glucose Monitoring policy for licensed nurses [NAME] were unavailable/on leave prior to their next shift worked. On 2/28/2023, the Regional Nurse and Assistant Regional Nurse reviewed with the Director of Nursing the Quality Assurance Monitors that will begin March 6, 2023. Monitors reviewed include: The DON or designee will complete quality assurance monitors for at least 5 patients weekly with fingerstick blood sugars to verify the Glucose Monitoring policy is followed. This QA review will start 3/6/2023 and extend for at least 4 weeks or until substantial compliance is met. The Regional Nurse will review the Quality Assurance monitors with the Director of Nursing each month. All Quality Assurance monitors will be reported to the center's Quality Assurance Committee consisting of the Administrator, Director of Nursing, Medical Director, QA Physicians, Dietician, Social Service Director, and HIM Director monthly. In-service training and Quality Assurance monitors will continue as directed by the Quality Assurance Committee and the Regional Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility document review, employee file review, medical record review, and interview, the facility failed to ensure that licensed nurses were competent and proficient to provide care consistent with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for transfer to the emergency department. Nursing staff failed to recognize and properly assess Resident #2's change in condition. Failure to recognize and properly assess Resident #2's change in condition resulted in continued deterioration of her condition, and she was transferred via emergency transport to the local emergency department where she expired. Nursing staff also failed to recognize the effects of and notify the MD/NP for intervention of blood sugar levels equal to or greater than 400 mg/dL for 4 of 4 insulin dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed for hyperglycemia. Failure to report blood sugar levels equal to or greater than 400 mg/dL could cause acute/chronic conditions which resulted in organ failure, coma, and /or death. The facility's failure to ensure proficient and competent nursing staff placed the residents in Immediate Jeopardy IJ (a situation in which the providers non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to notify the Medical Doctor (MD)/Nurse Practitioner (NP)/Resident Representative for 2 of 3 sampled residents (Resident #14 and Resident #24) reviewed for falls. Failure to notify the MD/NP/Resident Representative did not rise to the level of an IJ. The facility census on entrance was 91. The Administrator was notified of the Immediate Jeopardy on 3/4/2023 at 11:05 AM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-726 at a scope and severity of K. The Immediate Jeopardy began on 11/2/2021 and removed on 2/28/2023 . An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2023 at 3:35 PM. The Immediate Action Removal Plan was initiated by the facility on 2/28/2023 during the extended survey, and the corrective actions were validated on site by the surveyor on 3/4/2023 at 4:20 PM. The facility's non-compliance at F-726 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility policy titled, POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS, revision/review date 2/2022, revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition .charge nurse will then assess the patient's condition and notify the physician or physician extender . Review of the facility's undated policy titled, VITAL SIGNS TEMPERATURE, PULSE, AND RESPIRATIONS (TPR), revealed, .Designated partner will take temperature, pulse and respirations to maintain a record of vital signs for proper assessment and treatment of the patient . Review of the facility policy titled, Nurses Notes or Progress Notes, reviewed 2/2021, revealed, .Nurses Notes/Progress Notes are used to record the patient's status and to track changes in conditions .General Guidelines for progress notes .Describe patient problems .Pertinent nursing observations .Nursing interventions .Nursing assessments . Review of the facility document titled, Licensed Practical Nurse [LPN], reviewed date of 11/7/2022, revealed, .JOB DESCRIPTION--LICENSED PRACTICAL NURSE .Utilizes the nursing process in assessment, planning and implementing care .Integrates current standards of practice .Make rounds, with specific attention to high acuity patients .Assures the personal dignity and physical safety of each patient . Review of the employee file for LPN #2 revealed a current LPN license, abuse registry and background check with no concerns. Continued review revealed a corrective action document dated 11/10/2019 for failure to complete vital signs. A Licensed Nurse Competency revealed, .Date Of Hire LPN 10/2021 .Partner Focus .Charting (Events, Observations, Progress Notes, Preventative Health) .admission Observation and Discharge . Continued review there was not a date of completion for these competencies. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Displaced Intertrochanteric Fracture of Right Femur, Unspecified Atrial Fibrillation, and Chronic Kidney Disease, Stage 3. Review of the Medication Administration Record (MAR) for Resident #2 dated 1/1/2023-1/31/2023, revealed she received an administration of promethazine (Phenergan - antiemetic which can cause drowsiness) 12.5 mg (milligrams) intramuscularly on 1/29/2023 at 7:04 PM and a scheduled administration of pregabalin (Lyrica - anticonvulsant and analgesic which can cause drowsiness) 75 mg by mouth on 1/29/2023 at 10:00 PM. Review of the care plan focus/problem for Resident #2 dated 1/18/2023 revealed, .Cardiac/Respiratory Complications; at risk for related to CAD [coronary artery disease], HTN [Hypertension-high blood pressure], A-FIB [Atrial fibrillation - an irregular, often rapid heart rate that commonly causes poor blood flow], CHF [Congestive Heart Failure], HX [history] of clotting disorder, Probable OSA [obstructive sleep apnea]. Approach/interventions included, Auscultate lung sounds prn [as needed] .Check 02 [Oxygen level] sat [oxygen blood saturation] as needed .Observe for increased/acute sob [shortness of breath], pulmonary congestion, cyanosis [a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood], desats [when the amount of oxygen in the blood-O2 drops below normal- can be life-threatening depending on how low the level drops], increased edema, weight gain, worsening fatigue, mental status changes .Notify MD as needed .observe for increased pulmonary congestion .hypo/hypertension [hypotension, low blood pressure], desats [desaturation, decreasing oxygen blood saturation], sob, cyanosis, changes in loc [level of consciousness], restlessness/agitation, diminished/absent breath sounds, sputum production, cough, fever, accessory muscle use, increase/decrease in hr [heart rate] .Vital signs as ordered and as needed. Observe for variations in B/P [blood pressure] readings and sudden increase/decrease in HR . Review of the Resident Progress Notes for Resident #2 revealed, .1/29/2023 6:58 PM moderate amount of undigested food vomited. NP [nurse practitioner] notified with order for Phenergan 12.5 mg .1/29/2023 11:53 PM denies any nausea at present time .Nurse will continue to monitor patient during shift for changes in status and needs .1/30/2023 10:14 AM RESPONDED TO NURSING CONCERN OF UNRESPONSIVENESS PT SEEN WITH 2 LPM [liters per minute] NC [nasal cannula] ON WITH RAPID SHALLOW BREATHING NOTED. RR [respiratory rate]-28-20 [sic] BPM [breaths per minute] AND HR [heart rate] AND SPO2 [measurement of oxygen carried in the blood] WERE UN-READABLE ON MULTIPLE ATTEMPTS. WAS ABLE TO FINAL GET ONE READING ON EAR-HR 55, SPO2 76%-87% .Respiratory Therapy .1/30/2023 11:49 AM [late entry - actual time was not documented] went to give morning medications, pt [patient] could not respond to any verbal arousal or sternum rub. Could not assess a manual BP [blood pressure], latest O2 reading at 87%, Pt cold/clammy skin to touch, pupils nonreactive to light, blood sugar reading 180. Sent to [Named Emergency Room], NP made aware . Review of the vital signs documented for Resident #2 dated 1/29/2023-1/30/2023 revealed the last vital signs for BP 120/72, pulse 78, respirations 18, Temperature 97.4 degrees Fahrenheit, and oxygen saturation 97%, were documented on 1/29/2023 at 10:38 AM. Review of the Observation Detail List Report [Medical Director's observation report] for Resident #2 dated 1/30/2023, revealed, .Seen by NP last week wanting her Lyrica resumed for neuropathic pain, per nurse she also asked for Phenergan last night. O2 sat 79 percent, mouth breathing, only able to get up to 84% with equipment her and unable to get BP 911 immediately called . Continued review revealed, .other; -Breathing, pulse palpable, not responsive, will not withdraw to pain .neither [pupils] are responsive .other; -+1 BLE [bilateral lower extremities] edema. Toes both feet cyanotic .Severe likely metabolic encephalopathy .-cannot do full neuro [neurological] exam .Suspected OSA .Nurse unable to get blood pressure .Possibly worsened from sedating Lyrica and Phenergan .Acute respiratory failure-likely hypercarbic [high level of carbon dioxide in the blood] and hypoxic [low level of oxygen in the blood] from above . Review of the facility document titled, SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, revealed Resident #2 was transferred to (Named Emergency Room) on 1/30/2023. Continued review revealed Resident #2 was unresponsive, and there were no vital signs documented on the transfer form. Review of the EMS (Emergency Medical Services) Patient Care Record dated 1/30/20 23 revealed, .Pt [patient] found in bed in rm [room] [Named room number] .Pt has a NRB [non-rebreather- mask used to deliver extra oxygen] @ [at] 15 LPM [liters per minute] .staff [from facility] did not readily advise EMS of pt's current complaints or pt's med [medication] hx [history] .staff had to be prompted by EMS to get any pt infor [information] .Pt is unresponsive with shallow, rapid, regular breaths & [and] SPO2 [oxygen saturation in blood] is 96% on NRB @ 15 LPM .staff advise that pt was found unresponsive this am [morning] .bilateral lower extremity pulses being weak with bilateral feet being blue/black & [and] cold to touch .Pt's nurse tells EMS that pt was given lyrica [nerve pain medication] PO [by mouth] & phenergan IM [intramuscular], & her insulin @ bedtime & that she was normal @ the time she was given these meds . Continued review revealed EMS received call at 9:42 AM on 1/30/2023, and Resident #2 arrived at the emergency room at 10:08 AM. EMS vital signs at 9:53 AM, no bp, pulse 151, respirations 29, SPO2 97%, 9:56 AM no bp, pulse 135, respirations 34, SPO2 96%, 10:02 AM bp 132/83, pulse 140, respirations 28, SPO2 96%. Review of emergency room documentation on 1/30/2023 revealed, .T [temperature] 39.7 C [Celsius- 103.46 Fahrenheit] [last documented temperature at the facility was on 1/29/2023 at 10:38 AM with a reading of 97.4 degrees Fahrenheit], HR 80 (monitored) RR 28, BP 46/36 Spo2 92% .Oxygen Therapy: Ventilator .Neurology: Unresponsive, no gag reflex; does not respond to painful stimuli; no spontaneous movement; does not spontaneously open eyes .69 yr [year] old female is brought from the nursing home by EMS for being unresponsive .We cannot find details on how long the patient's been unresponsive .Upon arrival here in the ER [emergency room] patient was tachycardia had a low blood pressure had no gag reflex . Continued review revealed Resident #2 expired, and the time of death was 1/30/2023 at 1:44 PM. During an interview on 2/6/2023 at 4:08 PM, the Medical Director stated she was called to Resident #2's room on 1/30/2023 due to the resident's unresponsive status. She stated, [Resident #2] was unresponsive, and her fingernails were cyanotic. I do not recall looking at her [Resident #2's] feet [an observation report she wrote detailed BLE toes cyanotic]. Staff was unable to obtain vital signs initially, and a Respiratory Therapist had placed a non-rebreather on [Resident #2] and obtained an oxygen reading of 90% [in observation report she documented 84%]. I gave orders to send her [Resident #2] emergency transport to the hospital. There were no vital signs documented when she [Resident #2] was first reported [between 5:45 AM-6:00 AM on 1/30/2023] with poor response and/or unresponsive status. It would have been ideal to have those vital signs to complete the assessment of [Resident #2]. During an interview on 2/7/2023 at 10:06 AM, Certified Nursing Assistant (CNA) #2 stated she went to Resident #2's room on 1/30/2023 around 5:45 AM to provide care and see if she could bathe her early. She stated, [Resident #2] would not respond to her name being called or a gentle shake to wake her up. I used a sternal rub to wake her [Resident #2], and she mumbled something, then went back to sleep. Her [Resident #2] breathing seemed off to me, not regular. I immediately went to notify the nurse [LPN #6] and she told me [Resident #2] had gotten medications the night before and that it was probably causing her to be drowsier. The nurse [LPN #6] asked me to get [Resident #2]'s vital signs, and I couldn't get a blood pressure or oxygen reading at first, and I had to use a manual cuff [CNA #2 did not remember the specific vital signs]. I gave the vital signs to the nurse [LPN #6]. Me and [CNA #7] changed her [Resident #2] at about 6:15 AM, and I checked her vital signs again, and her BP and oxygen levels were normal [CNA #1 did not recall specific vital signs]. I went back to [Resident #2]'s room between 8:00 AM and 8:15 AM after passing breakfast trays to make sure she woke up to eat. She [Resident #2] was still not waking up unless I used a sternal rub, and even then she would go back to sleep. I checked her vitals again, and her [Resident #2] heart rate was low [CNA #2 did not recall the rate]. I went to the nurse [LPN #2] and told her [Resident #2] was not responding unless I used a sternal rub. [Named LPN #2] told me she would check on her when she finished passing medicine. She [LPN #2] said Resident #2 was probably just sleeping because of the medicine she had been given the night before. I went on to a meeting we were having. Later, I saw people running to [Resident #2]'s room, and I ran to see what was happening. She stated it was around 9:30 AM when she saw staff running to Resident #2's room. During a telephone interview on 2/7/2023 at 1:46 PM, the emergency room (ER) Physician stated she had provided services to Resident #2 on 1/30/2023. She stated she had concerns with Resident #2's care at the nursing facility. She stated, We did not get an adequate report from the facility, specifically no one could tell me how long Resident #2 had been unresponsive or what her initial assessment found, and the facility could not produce or report vital signs taken prior to transfer, or the hours before transfer. She [Resident #2] had been given Phenergan the night before because she was vomiting, and yet no one had taken vital signs, listened to lung sounds, et cetera [and other similar things] . they [facility staff] didn't report whether she had a temperature. EMS [Emergency Medical Services] could not give us a good history because they didn't get a good history when they got on the scene. During an interview on 2/7/2023 at 2:30 PM, LPN #2 (day shift nurse) stated on 1/30/2023 between 7:00 AM and 7:30 AM, LPN #6 (night shift nurse) told her Resident #2 had been poorly responsive that morning. She stated LPN #6 told her it was probably due to the medication she had been given the evening of 1/29/2023. She stated LPN #6 told her she had been able to give her sips of water. She stated, [Named CNA #2] did tell her that she could not wake for breakfast. I thought it probably was still the medication from the night before. I finished passing meds [medications] and went to [Resident #2's] room. She confirmed it was approximately 30 to 45 minutes after CNA #2 had told her Resident #2 would not wake up for breakfast. She confirmed she had not been in to assess Resident #2 prior to 9:20 AM. She stated, when I went into [Resident #2]'s room, she was unresponsive, and her extremities were blue. I was unable to get a blood pressure and oxygen level reading and notified [Registered Nurse (RN) #4] to assess her [Resident #2]. She confirmed she had not documented Resident #2's vital signs and did not document the name of the nurse she gave report to in the ER. LPN #2 stated the signs and symptoms of sepsis [reported cause of death for Resident #2 from the Medical Examiner's report] were fever and low blood pressure. When asked how nurses assess a patient with an acute change in condition, LPN #2 stated, There are assessment tools in Interact [medical software] that can be filled out, also there is a Stop and Watch paper [facility documentation form] anyone can fill out if they notice a change. LPN #2 confirmed on 1/30/2023 there was not an Interact assessment tool or Stop and Watch paper completed for Resident #2. During a telephone interview on 2/8/2023 at 8:15 AM, Registered Nurse (RN) #4 stated, On January 30th at 9:28 AM I received a text message from [LPN #2]. [LPN #2] wanted me to assess [Resident #2] because she was unresponsive. The text said [Resident #2]'s oxygen level was fine, but her blood pressure and heart rate were low. I immediately went to [Resident #2]'s room and found she was unresponsive, and staff could not get a blood pressure. [Resident #2] was cyanotic, and I told [LPN #2] we have to get her out of here. During a telephone interview on 2/14/2023 at 9:32 AM, a Lab Technician #1 stated she completed a blood draw on Resident #2 on 1/30/2023. She stated Resident #2 did not respond to verbal stimuli and did not respond to pain stimuli during the venipuncture. She stated at approximately 7:00 AM, she reported Resident #2's unresponsiveness to one of the CNAs (Lab Technician #1 did not remember the name of the CNA). During an interview on 2/14/2023 at 11:56 AM, the Director of Nursing (DON) confirmed she expected nursing staff to assess a resident immediately after receiving notification of poor responsiveness. She confirmed she would expect a nurse to assess high risk residents prior to routine medication administration. When asked what kind of assessment a nurse would complete for a resident's change in condition the DON replied, Nurses use an Interact assessment tool to complete assessments for a change in condition. No one completed an Interact assessment tool for [Resident #2] on 1/30/2023. During a telephone interview on 2/14/2023 at 5:29 PM, CNA #7 stated on 1/30/2023 at approximately 6:00 AM, she went to Resident #2's room to assist CNA #2 with routine care. She stated, [Resident #2] was unresponsive when [CNA #2] tried to wake her for morning care. [CNA #2] called her [Resident #2] name several times and touched her arm trying to wake her. [CNA #2] did a sternal rub and she [Resident #2] finally woke and said what then right back to sleep. Her [Resident #2] feet were uncovered, and kind of blue in color. We covered her feet up and went to get the nurse [LPN #6]. The nurse [LPN #6] had a hard time waking her [Resident #2] up and asked us to get her vital signs. Her [Resident #2] blood pressure would not read on the automatic machine, so we had to take her blood pressure manually [CNA #7 did not recall specific vital signs]. I made my rounds during the night, but I did not wake her [Resident #2] up. I did not get vital signs on her [Resident #2] during the night because the nurse did not ask me to take them. During a telephone interview on 2/15/2023 at 11:24 AM, Respiratory Therapy #1 stated on 1/30/2023 she noticed staff rushing into Resident #2's room and went to see if she could assist. She stated, [Resident #2] was unresponsive and they [nurses] could not get her vital signs. I attempted to obtain an oxygen saturation [level of oxygen in blood] and wasn't able to get a reading. I placed a non-rebreather oxygen mask on her [Resident #2] and finally got a reading of 87%. Her [Resident #2] feet and toes were blue, cyanotic, and cold. [Medical Director] came into the room and ordered staff to call 911 (emergency response). During a telephone interview on 2/15/2023 at 2:56 PM, LPN #6 stated she worked in the facility through an agency. She stated Resident #2 had nausea and vomiting on 1/29/2023 and had been given Phenergan (medication used to prevent nausea) and she was fine during the night. She stated, I even checked her vital signs, and they were normal. The following morning [1/30/2023] [CNA #2] reported [Resident #2] was not responsive and her breathing was not right. I went in to assess her [Resident #2] and I had to use a sternal rub to wake her up. I asked the tech [CNA #2] to get her vital signs. I went and asked the other two nurses [LPN #5 and LPN #7] in the facility to come and look at her because I wasn't familiar with her. She [Resident #2] was difficult to wake, and I wasn't sure if that was normal for her. After I used a sternal rub on her, she [Resident #2] did wake and speak to me. She [Resident #2] told me to stop and leave her alone. She [Resident #2] drank some water from her cup for me [LPN #6 stated she gave her some water, but LPN #5 and LPN #7 stated the resident did not receive water while they were in the room] and went back to sleep. Her [Resident #2] vital signs were normal [LPN #6 could not recall specific vital signs]. I went back to her [Resident #2] room after giving report to the on-coming nurse and she [Resident #2] was sleeping without any signs of distress. She stated she did not see a lab technician on 1/30/2023. During a telephone interview on 2/15/2023 at 3:38 PM, LPN #7 stated on 1/30/2023 between 6:45 AM and 7:00 AM, LPN #6 asked her to come to Resident #2's room to assess her because she was not familiar with the resident. LPN #7 stated, I really wasn't familiar with her [Resident #2] either, and I told her [LPN #6] I didn't know the resident. The resident [Resident #2] was hard to wake and [Named LPN #6] used a sternal rub. She [Resident #2] did wake briefly and told her [LPN #6] stop rubbing her chest. I told her [LPN #6] it was up to her [LPN #6] but she [Resident #2] should be monitored close. She stated she did not witness Resident #2 drink water while she was in the room [LPN #6 statement was that Resident #2 drank a few sips of water while LPN #5 and LPN #7 were in the room]. During a telephone interview on 2/15/2023 at 6:25 PM, LPN #5 stated on 1/30/2023 LPN #6 requested her to accompany her to Resident #2's room. She stated, She [LPN #6] told me [Resident #2] was hard to wake and she wasn't familiar with her. She wanted my opinion on an assessment of her [Resident #2]. When we entered the room I said she [Resident #2] does not look good, her [Resident #2] color isn't right. She [LPN #6] had to use a sternal rub to arouse her responded some, not like she should, and told [LPN #6] to leave her alone. She [Resident #2] did not wake completely and she mumbled her words and went right back to sleep. Her [Resident #2] feet felt cold and were blue. I covered her feet and told [LPN #6 and LPN #7] it was their decision whether or not to send her out and the nurse decided to leave her in the facility and monitor. We left the room and went back to give report. We were a little late to give report because it was after 7:00 AM. She stated Resident #2 did not drink water during the observation with 3 nurses present [LPN #6 statement was that Resident #2 drank a few sips of water while LPN #5 and LPN #7 were in the room]. During an interview on 3/1/2023 at 2:20 PM, LPN #10 stated, A sternal rub is used when a patient will not respond to normal attempts to wake someone. I have never been told a CNA cannot do a sternal rub, I think that they do if its needed. If a sternal rub is needed to wake someone then a nurse should be there to assess that patient. During an interview on 3/1/2023 at 2:42 PM, LPN #9 stated, I am not sure if a sternal rub is a scope of practice for a CNA. If a resident was unresponsive and required a sternal rub to wake, a nurse should be present to do an assessment because it might indicate something serious is going on with them. During a telephone interview on 3/1/2023 at 4:47 PM, This surveyor read LPN #6 a statement to that the DON had provided which indicated she had remembered Resident #2's vital signs on 1/30/2023. LPN #6 stated, After our conversation [surveyor and LPN #6] I found some vital signs on my personal notebook that I carry to work with me. I realized the vital signs were for the patient [Resident #2] that I took care of on January the 30th [1/30/2023]. There wasn't a name written down with them [vital signs], but I remembered taking them [she stated previously that the CNA had taken the vital signs] when I came across them in my book. LPN #6 confirmed the vital signs she had given to the DON during a phone call were as follows; BP 118/72, HR 76, at O2 96-97 % on oxygen (LPN #6 did not recall what O2 setting was set at) and RR 18. No temperature reading was given by LPN #6. She confirmed the statements she made during or telephone interview on 2/15/20223 at 2:56 PM, were true and correct. She stated, The only difference in the conversation with the DON was that I found the vital signs and gave them to her. I reported to the on-coming nurse [LPN #2] that morning [1/30/2023] and told her she needed to go and assess the patient [Resident #2] first thing because she was more familiar with her normal level of consciousness. I told her she had to be woke with a sternal rub and she talked to me, but she went right back to sleep, so I wanted her [LPN #2] to see if that was her normal reaction. She stated she had not been in-serviced or received training to recognize symptoms of sepsis. During a telephone interview on 3/2/2023 at 3:30 PM, Police Detective #1 stated the cause of death listed on the Medical Examiner's report for Resident #2 was sepsis. The completed Medical Examiner's report was unavailable to the surveyor at the time of the investigation. During an interview on 3/3/2023 at 12:30 PM, the Medical Director was asked if the nurse should have notified her when Resident #2 was reported as unresponsive at 6:00 AM on the morning of 1/30/2023 prior to being found unresponsive at 9:20 AM. She stated, I did not see any notes related to her [Resident #2] condition earlier that morning, that is all just hearsay, and I am not going to comment on it. During a previous interview the Medical Director commented on the absence of the vital signs during the reported unresponsive period. Review of the undated facility protocol Glucose Monitoring revealed, .For blood sugar results greater than 400, notify M.D. [Doctor of Medicine] . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Infection and Inflammatory Reaction, Osteomyelitis of Vertebra, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the care plan for Resident #11 dated 10/7/2021 revealed a problem/assessment for Type 2 Diabetes Mellitus. Interventions included observe for signs/symptoms of increased/decreased blood sugar and report significant findings to MD/NP as necessary. Review of the documented blood sugar levels for Resident #11 revealed, .11/2/2021 5:36 AM Blood Sugar 410 mg/dL [milligrams per deciliter] .11/2/2021 12:13 PM Blood Sugar 411 mg/dL .11/2/2021 9:36 PM Blood Sugar 411 mg/dL .11/4/2021 9:01 AM Blood Sugar 480 mg/dL .11/8/2021 8:43 PM Blood Sugar 403 mg/dL .11/10/2021 1:42 PM Blood Sugar 543 mg/dL .11/10/2021 8:58 PM Blood Sugar 515 mg/dL .11/15/2021 9:15 PM Blood Sugar 450 mg/dL .11/17/2021 8:51 PM Blood Sugar 505 mg/dL .11/18/2021 9:35 AM Blood Sugar 501 mg/dL .11/18/2021 1:37 PM Blood Sugar 452 mg/dL .11/19/2021 6:03 AM Blood Sugar 407 mg/dL .11/24/2021 9:01 PM Blood Sugar 401 mg/dL .11/26/2021 6:17 AM Blood Sugar 509 mg/dL .11/30/2021 11:38 AM Blood Sugar 482 mg/dL .12/07/2021 9:17 AM Blood Sugar 415 mg/dL .12/14/2021 8:24 AM Blood Sugar 419 mg/dL .12/20/2021 9:02 AM Blood Sugar 481 mg/dL .12/23/2021 5:18 PM Blood Sugar 420 mg/dL .12/27/2021 5:31 PM Blood Sugar 434 mg/dL . Review of the Resident Progress Notes for Resident #11 dated 11/2/2021-1/29/2022 revealed on 11/2/2021, 11/4/2021, 11/8/2021, 11/10/2021, 11/15/2021, 11/17/2021, 11/18/2021, 11/18/2021, 11/19/2021, 11/24/2021, 11/26/2021, 11/30/2021, 12/07/2021, 12/14/2021, 12/20/2021, 12/23/2021, and 12/27/2021, there was no documentation that Resident #11's provider/NP was notified of the blood sugar levels greater than 400 mg/dL. During a telephone interview on 2/8/2023 at 9:55 PM, NP #2 stated, I worked in the facility from 11/2/2021-1/21/2022. I was not notified of [Resident #11]'s Blood Sugar levels of 400 mg/dL and above per protocol. It is imperative that the nurse notify the provider when blood glucose is 400 mg/dL and above to obtain orders for an intervention. Blood glucose levels of 400 mg/dL risks include but are not limited to Diabetic Ketoacidosis (DKA), excessive buildup of acid in the blood .which can be fatal. During an interview on 2/14/2023 at 1:04 PM, RN #6 stated the protocol for hyperglycemia was to notify the MD/NP and contact the Unit Manager for readings of 400 mg/dL and above. During an interview on 2/14/2023 at 3:40 PM, the DON stated she had reviewed the medical record for Resident #11 and confirmed there was no documentation of provider notification for blood sugars 400 mg/dL and above between 11/2/2021 and 1/29/2022. She confirmed the facility protocol required MD/NP notification of blood sugars above 400 mg/dL. During an interview on 2/15/2023 at 10:20 AM, RN #5 stated the protocol for hyperglycemia was to notify the MD/NP and contact the Unit Manager for readings of 400 mg/dL and above. During an interview on 2/28/2023 at 12:34 PM, LPN #8 stated, Anytime a resident's blood sugar reads 400 or above the nurse calls the doctor or NP. There is a nurse communication book, but the blood sugar has to be called right then, unless there are orders to say otherwise. I am not sure why I didn't document or call about [Resident #11]'s, I should have called to get an order for a one time dose of insulin. During an interview on 2/28/2023 at 1:30 PM, Medical Doctor #1 (Resident #11's Doctor) stated, Procedure for notification in the facility was for staff to notify the NP with abnormal labs or blood sugar greater or equal to 400 mg/dL. I do not recall being notified of [Resident #11]'s hyperglycemia. During an interview on 3/3/2023 at 12:30 PM, Medical Director #1 stated, Staff calls the MD or NP when a blood sugar is 400 or above. Some orders specify when to notify the MD/NP, for example over 400, give x amount of insulin and recheck, if recheck 400 or greater then notify the MD. Orders to notify the MD are necessary in order to give the MD the opportunity to make changes in treatment. I would give an order to treat blood sugar 400 or greater. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Hyperglycemia and Long Term (Current) Use of Insulin. Review of the Vitals Report for Resident #13 revealed, .11/4/2022 9:33 PM Blood Sugar 485 mg/dL .11/10/2022 7:53 PM Blood Sugar 414 mg/dL .11/11/2022 9:45 PM Blood Sugar 448 mg/dL .11/18/2022 8:53 PM Blood Sugar 500 mg/dL .12/2/2022 9:18 PM Blood Sugar 443 mg/dL .12/31/2022 11:02 PM Blood Sugar 408 mg/dL .2/28/2023 4:36 AM Blood Sugar high . Review of the Resident Progress Notes for Resident #13 dated 11/4/2022, 11/10/2022, 11/11/2022, 11/18/2022, 12/2/2022, and 12/31/2022, revealed there was no documentation Resident #13's MD/NP was notified of the blood sugar levels greater than 400 mg/dL. During a telephone interview on 3/3/2023 at 5:34 PM, LPN #11 stated, To be honest with you, I really thought the notification was for blood sugar over 500. S[TRUNCATED]

Based on job description review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. Administration failed to provide oversight to ensure nursing staff notified the Medical Doctor (MD)/Nurse Practitioner (NP) for intervention of blood sugar levels equal to or greater than 400 mg/dL for 4 of 4 insulin dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed. Administration failed to ensure competent nursing staff provided care consistent with professional standards of practice for 1 resident (Resident #2) when nursing staff failed to appropriately assess Resident #2's change in condition. The Administration also failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program that identified systemic opportunities for improvement and implemented actions to address those opportunities. The failures by Administration placed residents that resided in the facility in Immediate Jeopardy IJ (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility census on entrance was 91. The Administrator was notified of the Immediate Jeopardy on 3/4/2023 at 12:20 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835 at a scope and severity of K. The Immediate Jeopardy began on 11/2/2021 and removed on 2/28/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2023 at 3:35 PM. The Immediate Action Removal Plan was initiated by the facility on 2/28/2023 during the extended survey, and the corrective actions were validated on site by the surveyor on 3/4/2023 at 4:40 PM. The facility's noncompliance at F-835 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The findings include: Review of the job description for the Administrator revealed, .The Administrator has complete administrative and managerial responsibilities within the health care center, acting as liaison, motivator, coordinator, and support person for Department Directors, other partners, patients .Ensures a caring, quality motivated facility .Coordinate Quality Assurance program for all departments .Assures compliance with State and Federal Regulations and [Corporate Company] and Center policies . Review of the job description for the Director of Nursing (DON) revealed, .The roll of the Director of Nursing is to provide an administrative and overall managerial authority for all functions of the Nursing Department including but not limited to care delivery and service functions, training .The Director of Nursing is accountable to the center's administrator for the management of the Nursing Department .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills .Utilizes the nursing process in assessment, planning and implementing care needs .Ability to interpret and implement regulations (state and federal) .Maintains a system to ensure knowledge of patient status .Monitors to see that treatments and medications are administered as ordered .Monitors to see that there is accurate and adequate documentation in the medical record including electronic health record .Serves as an active member of the center's QAPI Committee . During an interview on 2/7/2023 at 12:58 PM, the Regional Medical Director stated, [NP #2] had poor communication with the nursing staff and administration .She had complained about not getting lab results and nursing staff not notifying her with issues . When asked if the communication issue was discussed in QAPI he stated, I talked about it in QAPI with [Administrator and Director of Nursing (DON)], and I think the Nurse Practitioner [NP #2] fixed a communication book for the nurses. The communication book was implemented to notify the MD/NP of issues when the MD/NP came to the floor but did not address the immediate notification of the MD/NP by nursing staff. There was no documentation that QAPI addressed the communication deficits between nursing and the MD/NP concerning elevated blood sugars. During an interview on 3/1/2023 at 5:31 PM, the Administrator confirmed he governed the QAPI meetings. He stated, [Regional Medical Director] had talked about [NP #2] having complaints of communication with the nursing staff related to lab results. The Administrator confirmed there was not a plan of action documented in the QAPI meeting minutes for 1/5/2022. He stated, The reason there wasn't a follow up in the following month's QAPI meeting, was because she [NP #2] was already gone [not working in the facility anymore]. The Administrator confirmed there was not an ad Hoc [as needed] meeting related to nursing staff competency when Resident #2 was sent to the emergency department and expired. During an interview on 3/1/2023 at 5:40 PM, the DON confirmed [NP #2] complained about the lack of communication between the nursing staff and her. When asked if the nursing staff reported Resident #11's blood sugar that was equal to or greater than 400 mg/dL to the provider, the DON paused and confirmed the blood sugar level had not been reported to the MD/NP. When asked if the failure to notify the MD/NP was a communication problem, the DON did not answer. Administration failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff notified the MD/NP of residents' elevated blood sugar values and falls to maintain residents' highest practicable well-being. Refer to F-580. Administration failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff were competent and proficient in practice to maintain residents' highest practicable well-being. Administration failed to provide oversight to ensure competent nursing staff provided care consistent with professional standards of practice. Refer to F-726. Administration failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program that identified systemic opportunities for improvement and implemented actions to address those opportunities related to competent nursing staffing and notification of change in condition. Refer to F-867. The surveyors verified an acceptable Immediate Action Removal Plan on 3/4/2023 at 4:40 PM by: [Healthcare Facility #1] ensures maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. On 2/13/2023, the Regional Nurse verified the DON's competency of the center's Interact process related to identifying a change in patient's condition and documentation. On 2/13/2023 the Assistant Regional Nurse verified the MDSCs competency of the center's Interact process related to identifying a change in patient's condition and documentation. On 2/13/2023, the Assistant Regional Nurse and the DON initiated in-servicing of licensed nurses on Acute Change in Condition Assessment utilizing the Interact process and documentation. On 2/28/2023, the Regional Nurse verified the DON's competency on the center's Glucose Monitoring policy. On 2/28/2023, the DON educated the MDSC (Minimum Data Set Coordinator) on the center's Glucose Monitoring policy. On 2/28/2023, the DON and MDSC began conducting in-services with the licensed nurses regarding the center's Glucose Monitoring policy. All licensed nurses that were scheduled to work on 2/28/2023 completed the in-service training on 2/28/2023. All other nurses were in-serviced prior to their next scheduled shift. On 3/4/2023, the Administrator's competency in the governing of the QAPI process was verified by the Regional Manager and Regional QA Nurse. On 3/4/2023 the Assistant Regional QA (Quality Assurance) Nurse conducted QAPI training to the Administrator, DON, Director of Maintenance, Director of Health Information, Director of Social Services, Director of Food and Nutrition Services, Director of Life Enrichment, ADON (Assistant Director of Nursing, Business Office Manager, Director of Environmental Services, Director of Rehab, QA physician, Medical Director, and NP (Nurse Practitioner,) covering CMS (Centers for Medicare and Medicaid Services)'s five elements of QAPI. How We Have Identified Other Residents Having The Potential To Be Affected By The Same Practice And What Corrective Action Has Been Taken: Beginning on 2/28/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 2/28/2023, the DON and Assistant Regional Nurse reviewed all acute transfers to the hospital occurring in December 2022, January 2023, and February 2023, were reviewed for delays in identifying change in patients' condition. On 3/1/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/2/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/3/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. The Measures we have put In Place and Systematic Changes We Have Made to Ensure That the Practice Does Not Recur: On 2/13/2023, the Assistant Regional Nurse and DON initiated in-servicing of licensed nurses on Acute Change in Condition Assessment utilizing the Interact process and documentation. The MDSC also assisted in conducting the in-service trainings. All nurses scheduled to work completed the in-service training on 3/4/2023. The licensed nurses that are unavailable/on leave will be interviewed and in-serviced prior to their next shift worked. On 2/28/2023, the Regional Nurse met with and verified the Director of Nursing's competency regarding the Center's Glucose Monitoring. Overseen by the Director of Nursing, in-service training was conducted by the MDSC, on the center's Glucose Monitoring policy, began on 2/28/2023 for all licensed nurses. In-service training emphasized the employees understanding of the Glucose monitoring policy and documentation. The licensed nurses that are unavailable/on leave will be interviewed and in-serviced prior to their next shift worked. Beginning on 2/28/2023 and continuing through the time of this narrative on 3/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 2/28/2023, the Regional Nurse and Assistant Regional Nurse reviewed all acute transfers to the hospital occurring in December 2022, January 2023, and February 2023, were reviewed for delays in identifying change in patient's condition. On 3/4/2023, the Assistant Regional QA Nurse conducted QAPI Training for CLT [Current Leadership Team] members covering CMS (Centers for Medicare and Medicaid Services)'s five elements of QAPI. Beginning 3/4/2023, any newly hired licensed nurses will have competency checks to verify understanding of the center's glucose monitoring policy and the use of Interact process for identifying, notifying the MD/NP and documenting changes in a patient's condition. The Corrective Actions Will Be Monitored To Ensure the Practice Will Not Recur: The DON or designee will complete in-service training on the center's Glucose Monitoring policy for licensed nurses that were unavailable/on leave prior to their next shift worked. On 2/28/2023, the Regional Nurse and Assistant Regional Nurse reviewed with the Director of Nursing the Quality Assurance Monitors that will begin March 6, 2023. Monitors reviewed include: The DON or designee will complete quality assurance monitors for at least 5 patients weekly with fingerstick blood sugars to verify the Glucose Monitoring policy is followed. This QA review will start 3/6/2023 and extend for at least 4 weeks or until substantial compliance is met. The Regional Nurse will review the Quality Assurance monitors with the Director of Nursing each month. All Quality Assurance monitors will be reported to the center's Quality Assurance Committee consisting of the Administrator, Director of Nursing, Medical Director, QA Physicians, Dietician, Social Service Director, and HIM Director monthly. In-service training and Quality Assurance monitors will continue as directed by the Quality Assurance Committee and the Regional Nurse. The DON or designee will complete in-service training on the center's Acute Change in Condition Assessment utilizing the Interact process and documentation for licensed nurses that were unavailable/on leave prior to their next shift. The DON or designee will complete quality assurance monitors of 3 patients with acute change in condition that transferred to the hospital weekly to review for delays in identifying change in patients' condition. This QA review will start 3/6/2023 and extend for at least 4 weeks or until substantial compliance is met. The Regional Nurse will review the Acute Change in Condition Quality Assurance monitors of patients transferred to the hospital with the Director of Nursing each month. All Quality Assurance monitors will be reported to the center's Quality Assurance Committee overseen by the Administrator. The committee consist of the Director of Nursing, Medical Director, QA physicians, Dietician, Social Services Director, and HIM Director monthly. In-service training and Quality Assurance monitors will continue as directed by the Administrator, the Quality Assurance Committee, and the Regional Nurse. A Regional Support partner will review the Quality Assurance Performance Improvement meeting minutes monthly for 3 months and provide feedback as applicable.

Based on facility policy review, Quality Assurance and Performance Improvement (QAPI) meeting documentation review, medical record review, and interview, the QAPI committee failed to ensure an effective QAPI program that identified opportunities for improvement. The QAPI Committee failed to provide oversight to ensure nursing staff notified the Medical Doctor (MD)/Nurse Practitioner (NP) for intervention of blood sugar levels equal to or greater than 400 mg/dL for 4 residents (Resident #11, Resident #13, Resident #22, and Resident #27). The QAPI Committee failed to ensure competent nursing staff provided care consistent with professional standards of practice for 1 resident (Resident #2) when nursing staff failed to appropriately assess Resident #2's change in condition and failed to notify the MD/NP when 4 of 4 insulind dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed had blood sugar levels equal to or greater than 400 mg/dL. The QAPI Committee failed to ensure Administration enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the resident when there was not an ad Hoc [as needed] QAPI meeting to address the deficiencies in competent and proficient nursing staff, and communication deficiencies between nursing staff, and the NP was not addressed effectively after being identified in the QAPI meeting. The failure of the QAPI committee to identify opportunities for improvement placed all residents in Immediate Jeopardy IJ (a situation in which the providers non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility census on entrance was 91. The Administrator was notified of the Immediate Jeopardy on 3/4/2023 at 12:33 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-867 at a scope and severity of K. The Immediate Jeopardy began on 11/2/2021 and removed on 2/28/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2023 at 3:35 PM. The Immediate Action Removal Plan was initiated by the facility on 2/28/2023 during the extended survey, and the corrective actions were validated on site by the surveyor on 3/4/2023 at 4:46 PM. The facility's non-compliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The findings include: Review of the facility policy titled, PURPOSE STATEMENT/GUIDING PRINCIPLES, revised date 1/29/2020, revealed, .To retain our position as the industry leader in customer and investor satisfaction, [Named healthcare company #1]'s Quality Assurance and Performance Improvement (QAPI) Program will focus on key patient outcomes and critical business measures to assure that every patient receives the right care in the right way every time .Senior Leaders (center, region and corporate) value, support and model the performance improvement process to prioritize, guide and direct operations .Continuous improvement goals are data driven, including feedback from customers and partners, as well as internal and external benchmarks .Through broad monitoring we pro-actively identify opportunities for systems to be fine-tuned . Review of the Quality Assurance and Performance Improvement meeting minutes dated 1/5/2022 revealed, .[Regional Medical Director] was here in attendance. Discussed some communication issues that need to be resolved with nursing and the new NP [NP #2]. This included lab communication issues, and nursing communication. [Regional Medical Director] reminded us to work as a team, be affable, accountable, and available. Remember it is a journey to excellence. Continued review of minutes for QAPI meetings dated 2/2022-4/6/2022 revealed QAPI did not address the potential negative outcome or development, implementation, and monitoring of a plan of action related to the communication deficits between nursing and the MD/NP. During an interview on 2/7/2023 at 12:58 PM, the Regional Medical Director stated, [NP #2] had poor communication with the nursing staff and administration .She had complained about not getting lab results and nursing staff not notifying her with issues . When asked if the communication issue was discussed in QAPI he stated, I talked about it in QAPI with [Administrator and Director of Nursing (DON)], and I think the Nurse Practitioner [NP #2] fixed a communication book for the nurses. The communication book was implemented to notify the MD/NP of issues when the MD/NP came to the floor but did not address the immediate notification of the MD/NP by nursing staff. There was no documentation that QAPI addressed the communication deficits between nursing and the MD/NP concerning elevated blood sugars. During an interview on 3/1/2023 at 5:31 PM, the Administrator confirmed he governed the QAPI meetings. He stated, [Regional Medical Director] had talked about [NP #2] having complaints of communication with the nursing staff related to lab results. The Administrator confirmed there was not a plan of action documented in the QAPI meeting minutes for 1/5/2022. He stated, The reason there wasn't a follow up in the following month's QAPI meeting, was because she [NP #2] was already gone [not working in the facility anymore]. The Administrator confirmed there was not an ad Hoc [as needed] meeting related to nursing staff competency when Resident #2 was sent to the emergency department and expired. During an interview on 3/1/2023 at 5:40 PM, the DON confirmed [NP #2] complained about the lack of communication between the nursing staff and her. When asked if the nursing staff reported Resident #11's blood sugar that was equal to or greater than 400 mg/dL to the provider, the DON paused and confirmed the blood sugar level had not been reported to the MD/NP. When asked if the failure to notify the MD/NP was a communication problem, the DON did not answer. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff notified the NP/MD of residents' elevated blood sugar values and falls to maintain residents' highest practicable well-being. Refer to F-580. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff were competent and proficient in practice to maintain residents' highest practicable well-being. Refer to F-726. The QAPI Committee failed to maintain oversight, failed to establish and implement policies and procedures, failed to ensure the Administration consistently followed policies and procedures, failed to provide oversight of nursing staff, failed to identify, and failed to ensure systems and processes were developed and consistently followed by facility staff. Refer to F-835. The Immediate Action Removal plan was accepted and verified on 3/4/2023 at 4:46 PM by: [Healthcare Facility #1] ensures maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. On 2/13/2023, the Regional Nurse verified the DON's competency of the center's Interact process related to identifying a change in patient's condition and documentation. On 2/13/2023 the Assistant Regional Nurse verified the MDSCs competency of the center's Interact process related to identifying a change in patient's condition and documentation. On 2/13/2023, the Assistant Regional Nurse and the DON initiated in-servicing of licensed nurses on Acute Change in Condition Assessment utilizing the Interact process and documentation. On 2/28/2023, the Regional Nurse verified the DON's competency on the center's Glucose Monitoring policy. On 2/28/2023, the DON educated the MDSC (Minimum Data Set Coordinator) on the center's Glucose Monitoring policy. On 2/28/2023, the DON and MDSC began conducting in-services with the licensed nurses regarding the center's Glucose Monitoring policy. All licensed nurses that were scheduled to work on 2/28/2023 completed the in-service training on 2/28/2023. All other nurses were in-serviced prior to their next scheduled shift. On 3/4/2023, the Administrator's competency in the governing of the QAPI process was verified by the Regional Manager and Regional QA Nurse. On 3/4/2023 the Assistant Regional QA (Quality Assurance) Nurse conducted QAPI training to the Administrator, DON, Director of Maintenance, Director of Health Information, Director of Social Services, Director of Food and Nutrition Services, Director of Life Enrichment, ADON (Assistant Director of Nursing, Business Office Manager, Director of Environmental Services, Director of Rehab, QA physician, Medical Director, and NP (Nurse Practitioner,) covering CMS (Centers for Medicare and Medicaid Services)'s five elements of QAPI. How We Have Identified Other Residents Having The Potential To Be Affected By The Same Practice And What Corrective Action Has Been Taken: Beginning on 2/28/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 2/28/2023, the DON and Assistant Regional Nurse reviewed all acute transfers to the hospital occurring in December 2022, January 2023, and February 2023, were reviewed for delays in identifying change in patients' condition. On 3/1/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/2/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/3/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 3/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood (blood sugar) to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. The Measures we have put In Place and Systematic Changes We Have Made to Ensure That the Practice Does Not Recur: On 2/13/2023, the Assistant Regional Nurse and DON initiated in-servicing of licensed nurses on Acute Change in Condition Assessment utilizing the Interact process and documentation. The MDSC also assisted in conducting the in-service trainings. All nurses scheduled to work completed the in-service training on 3/4/2023. The licensed nurses that are unavailable/on leave will be interviewed and in-serviced prior to their next shift worked. On 2/28/2023, the Regional Nurse met with and verified the Director of Nursing's competency regarding the Center's Glucose Monitoring. Overseen by the Director of Nursing, in-service training was conducted by the MDSC, on the center's Glucose Monitoring policy, began on 2/28/2023 for all licensed nurses. In-service training emphasized the employees understanding of the Glucose monitoring policy and documentation. The licensed nurses that are unavailable/on leave will be interviewed and in-serviced prior to their next shift worked. Beginning on 2/28/2023 and continuing through the time of this narrative on 3/4/2023, the DON and Assistant Regional Nurse reviewed all current patients with documented fingerstick blood to ensure patients with fingerstick blood sugars greater than 400 without parameters as prescribed by the MD/NP had follow-up as outlined in the center's Glucose Monitoring policy. On 2/28/2023, the Regional Nurse and Assistant Regional Nurse reviewed all acute transfers to the hospital occurring in December 2022, January 2023, and February 2023, were reviewed for delays in identifying change in patient's condition. On 3/4/2023, the Assistant Regional QA Nurse conducted QAPI Training for CLT [Current Leadership Team] members covering CMS (Centers for Medicare and Medicaid Services)'s five elements of QAPI. Beginning 3/4/2023, any newly hired licensed nurses will have competency checks to verify understanding of the center's glucose monitoring policy and the use of Interact process for identifying, notifying the MD/NP and documenting changes in a patient's condition. The Corrective Actions Will Be Monitored To Ensure the Practice Will Not Recur: The DON or designee will complete in-service training on the center's Glucose Monitoring policy for licensed nurses that were unavailable/on leave prior to their next shift worked. On 2/28/2023, the Regional Nurse and Assistant Regional Nurse reviewed with the Director of Nursing the Quality Assurance Monitors that will begin March 6, 2023. Monitors reviewed include: The DON or designee will complete quality assurance monitors for at least 5 patients weekly with fingerstick blood sugars to verify the Glucose Monitoring policy is followed. This QA review will start 3/6/2023 and extend for at least 4 weeks or until substantial compliance is met. The Regional Nurse will review the Quality Assurance monitors with the Director of Nursing each month. All Quality Assurance monitors will be reported to the center's Quality Assurance Committee consisting of the Administrator, Director of Nursing, Medical Director, QA Physicians, Dietician, Social Service Director, and HIM Director monthly. In-service training and Quality Assurance monitors will continue as directed by the Quality Assurance Committee and the Regional Nurse. The DON or designee will complete in-service training on the center's Acute Change in Condition Assessment utilizing the Interact process and documentation for licensed nurses that were unavailable/on leave prior to their next shift. The DON or designee will complete quality assurance monitors of 3 patients with acute change in condition that transferred to the hospital weekly to review for delays in identifying change in patients' condition. This QA review will start 3/6/2023 and extend for at least 4 weeks or until substantial compliance is met. The Regional Nurse will review the Acute Change in Condition Quality Assurance monitors of patients transferred to the hospital with the Director of Nursing each month. All Quality Assurance monitors will be reported to the center's Quality Assurance Committee overseen by the Administrator. The committee consist of the Director of Nursing, Medical Director, QA physicians, Dietician, Social Services Director, and HIM Director monthly. In-service training and Quality Assurance monitors will continue as directed by the Administrator, the Quality Assurance Committee, and the Regional Nurse. A Regional Support partner will review the Quality Assurance Performance Improvement meeting minutes monthly for 3 months and provide feedback as applicable. An ad Hoc QAPI meeting was held on 3/4/2023 at 4:15 PM. The Administrator and Regional Nurse reviewed quality deficiencies which included notification of change in condition of residents, competent and proficient nursing staff, Administration, and QAPI. Allegations of Compliance with an action plan for immediate removal of the IJ's was discussed and reviewed with attendees for feedback.