**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance while providing care for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 received supervision when outside in his wheelchair. Resident #1 wheeled his way down the parking lot to the road, flipping his wheelchair where the parking lot met the roadway pinning Resident #1 on the roadway where he was unable to get up. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 12/31/2024 and ended on 01/02/2025. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. The findings included: Record review of Resident #1's admission record dated 06/17/2025 revealed he was a [AGE] year-old male with an admission date of 12/27/2024. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Record review of Resident #1's Care Plan dated 12/31/2024 revealed: FOCUS: o CANCELLED: Resident #1 is an elopement risk/wanderer r/t Dementia Date Initiated: 01/02/2025 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 GOALS: o CANCELLED: The resident's safety will be maintained through the review date. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Target Date: 01/15/2025 Cancelled Date: 01/31/2025 INTERVENTIONS/TASKS: o CANCELLED: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 ACTA CNA LN RN SS 01/31/2025 o CANCELLED: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 ACTA CNA 01/31/2025 o CANCELLED: Pt Wandering seeking to exit. Wander guard placed for safety and monitoring. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 LN RN SS 01/31/2025. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had severe cognitive impairment with a BIMS of 03. Wandering impact was blank. Resident #1 was substantial/maximal assistance (Helper does more than half the effort) for ADLs. Record review of Resident #1's Wandering Evaluation dated 12/27/2024 revealed Resident #1 was not a wandering risk. Record review of Resident #1's Progress Notes revealed on 12/31/24 at 01:15 PM, Resident #1 had an unwitnessed fall from his wheelchair outside the facility. Record review of 12/31/24 at 03:45 PM Progress Notes for Resident #1 revealed on assessment, Resident #1 sustained a 1-inch abrasion to his right elbow when he fell. Observation on 06/19/25 at 08:15 AM revealed from the front door of the facility to the road in front of the facility where Resident #1 fell out of his wheelchair, while unsupervised on 12/31/24 at 01:15 PM, is approximately 150 feet. The road outside the facility is a busy road with a hospital across the street with cars parked on both sides of the roadway making visibility difficult for oncoming cars. Review of the weather on 12/31/24 at 01:15 PM revealed it was 72 degrees and clear. Record review of Resident #1's Progress Notes dated 12/31/24 at 03:45 PM written by LVN F revealed Resident #1 had an unwitnessed fall outside. Resident #1 was assessed. The Doctor and RP were notified. The Doctor ordered STAT x-ray of skull, shoulders bilaterally, femur bilateral, hip bilaterally, humerus bilaterally, ankles bilaterally, elbows bilaterally, and wrist bilaterally. Results negative for fracture or injury. Resident #1 had no complaints of pain and verbalized refusal to take pain medication. Record review of Resident #1's Progress Notes dated 01/01/2025 at 05:55 AM written by LVN C revealed LVN C reported x-ray results to doctor. LVN C notes there were no new orders given. Record review of Resident #1's Progress Notes dated 12/31/2024 at 08:29 PM written by LVN C revealed S/P Fall 24 hours: Resident in his bedroom without complain of pain or discomfort. Resident continues with wander guard placed on the right ankle. No seeking behaviors noted at this time. Record review revealed between 12/31/2024 - 01/02/2025, staff and residents were interviewed, in-services on Abuse/Neglect, Elopement, Notifying Nurses of Residents Going Outside re-education for all staff was initiated and ongoing. Record review of Resident #1's Care Plan was updated on 01//02/2024 to include elopement risk/wanderer/ related to dementia with intervention of a wander guard. Record review of Resident #1's Progress Notes dated 01/06/2025 at 02/27 PM written by LVN W revealed Resident #1's wander guard to his right ankle was removed due to resident was not exit seeking. Resident #1's wander guard was removed, and a nonskid placement pad applied to the resident's wheelchair. Record review on 06/20/2025 revealed Receptionist JJ was not trained on Notifying Nurses of Residents Going Outside prior to the incident on 12/31/2024. In an interview on 06/1920/25 at 11:24 AM a visitor stated on 12/31/24 around 01:15 PM she was arriving at the facility to visit another resident. She said she was trying to find a parking spot when she noticed a resident in a wheelchair trying to escape down the parking lot. The visitor stated the resident reached the road, and his wheelchair hit the pothole between the parking lot and the road. She said the wheelchair tipped over and threw the resident out of the wheelchair, and it landed on top of him. She said she ran to him and took the wheelchair off him and helped him back into his wheelchair. The visitor stated she asked the resident where he was going, and he told her he was going downtown. She said at that time staff started coming down to help the resident. She did not know how the staff found out the resident had fallen. In an interview on 06/19/2025 at 01:08 PM BOM G stated the receptionist was the one who told her a resident had fallen outside. BOM G stated she when she went out, Resident #1 was on the ground with his wheelchair next to him. She said at the time, the visitor, the receptionist, ADON H, ADON I, and the Interim Administrator were there. BOM G stated Resident #1 said he was moving, tripped, and he was fine. In an interview on 06/19/2025 at 01:15 PM LVN F stated on 12/31/2024 he was at the nurse's station when he was told Resident #1 had fallen outside. LVN F stated he stayed at the nurse's station when the other nurses ran outside. LVN F stated he remembers when the resident came back in, and LVN F stated the resident was assessed by him and ADON I who was no longer working at the facility. LVN F stated he thinks he remembers a skin tear, but he was unsure. LVN F stated if a resident had a BIMS of 13 or more, they could sign themselves out of the building, but if the BIMS was less than 13, a family member, nurse, or CNA had to sign or take them out. He said sometimes Activities would take a resident out, but they had to clear it with the nurse before they would take them out. In an interview on 06/19/25 at 09:35 AM The DON stated Receptionist JJ was terminated on 01/14/2025 for taking Resident #1 outside and leaving him unsupervised. Termination papers along with file reviewed by surveyor. In an interview on 06/19/2025 at 04:55 PM, the DON stated if a resident wanted to go outside, the DON could take the resident outside. He said if a family member, with the RP's permission, could take their resident outside, or a CNA could, or a nurse could. The DON stated if the resident had a good BIMS of 13 or above, they could go outside alone and if the BIMS is less than 13, they would have to be supervised. The DON stated the door at the front was always locked so the receptionist had to screen before opening the door. The DON stated Code Yellow was announced for missing residents. He said the last in-services on elopement, residents going outside were last Monday (06/16/25) and they are on-going. In an interview on 06/19/2025 at 05:17 PM The Administrator stated a resident could go outside by themselves would depend on their BIMS. He said for a BIMS of 13 or above they can sign themselves out. If their BIMS was 13 or below, they cannot go outside unsupervised. The Administrator stated they had to be signed out by a family member, but the RP had to agree to a family member signing the resident out, by a nurse. The Administrator stated Code Yellow was announced to the facility if a resident was missing. He said they had monthly drills on elopement so everyone would know what to do in the event a resident was missing. The Administrator stated last Friday, 06/13/2025, he had an all staff meeting and went over elopements, residents going out by themselves (who can and who cannot), and abuse/neglect. The facility had corrected the noncompliance before the survey began as followed: Record review of the following interventions put into place: 1. Record review of Resident #1's medical record revealed Resident #1 was assessed by the nurse, findings reported to doctor, and x-rays ordered. 2. Record review of Resident #1's Wandering Evaluation dated 12/31/2024 revealed he was a wander risk. 3. Record review of Resident #1's skin assessment dated [DATE] revealed abrasion to right elbow with slight bleeding and a skin tear to his left knee details. 4. Record review of Resident #1's neurological checks dated 12/31/2024 revealed were started at 01:20 PM. 5. Record review of Resident #1's medical record showed wander guard was placed on 12/31/2024. 4. Record review of in-service education dated 12/31/2024-01/02/25 revealed all staff including direct care staff were in-serviced on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going Outside. 5. Record review of questionnaires dated 12/31/2024-01/02/2025 reflected all staff were quizzed on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going Outside. 6. Record review of Resident #1's Care Plan was updated to include wandering risk, wander guard, and injuries sustained with interventions. 7. Record review of revealed the facility investigated the incident and Receptionist JJ was terminated for taking and leaving Resident #1 outside unsupervised. 8. Record review revealed facility reported the incident to State within the correct timeframe. On 06/19/2025, 2 Receptionists, 1 Activity Aide and 1 Activity Director, 1 Human Resource Coordinator, 1 Housekeeper, 1 Medication Aide, 1 Hospitality Aide, 9 CNAs, 1 MDS LVN, 12 LVNs, 1 RN, the DON, and the Administrator were interviewed on policy/procedures on Abuse/Neglect, Elopement, and for residents going outside supervised and unsupervised, Code Yellow for missing residents, and in-services. All staff were able to state the correct policy/procedures. In an interview on 06/19/25 at 05:17 PM the Administrator stated they had an all staff meeting on Friday, 06/13/25, in-servicing on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going outside and the in-services were ongoing. He said they had monthly Elopement Drills with the staff. Record review of facility's policy titled Going Outside Policy undated, revealed The resident's stay with the facility is voluntary. The resident may leave the facility temporarily on therapeutic leave at any time. The resident or responsible party shall follow the facility rules regarding signing in and out of the facility whenever he or she leaves the facility. Record review of facility's policy Elopements and Wandering Residents dated 11/21/2022 revealed: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1.The facility may be equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 4.Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering d. Adequate supervision will be provided to help prevent accidents or elopements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to have physician orders for the resident's immediate care at time of admission for 1 of 4 residents (Resident #2) reviewed for physician admission orders. 1.Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for blood sugar checks and had an episode of low blood sugar on 04/08/25 that required him to be sent to hospital. 2.Resident #2 was readmitted to the facility on [DATE] and did not have wound care orders in place for identified impaired skin intergrity until 04/07/25. An IJ was identified on 05/06/25. The IJ template was provided to the facility on [DATE] at 5:18PM . While the IJ was removed on 05/08/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents by placing them at risk of not having orders for the staff to follow in order to provide care and treatment for identified health needs. The findings included: 1.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has Diabetes Mellitus and included a goal of the resident will have no complication related to diabetes and interventions including, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (Pale), Nervousness, Confusion, slurred speech, lack of coordination and Staggering gait. with initiation dates of 04/16/25. Record review of Resident #2's hospital document titled, Physician - Discharge Med Rec Order Lansc (Definition unknown) dated 04/03/25 stated to stop Resident #2's order for insulin sliding scale and did not include any orders related to blood sugar checks. Record review of Resident #2's hospital document titled; Discharge Medication dated 04/03/25 did not include any orders related to blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had no orders for blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had an order for dapagliflozin propanediol oral tablet 5MG 1 time a day every day and glipizide-metformin HCI oral tablet 5-500MG 2 times a day every day both with a start date of 04/04/25 and a discontinue date of 04/10/25. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's order audit report revealed he had previously had blood sugar checks ordered on 03/05/25 and discontinued on 03/15/25 when resident was sent to the hospital prior to re-admitting to facility on 04/03/25. Record review of Resident #2's blood sugar summary revealed his last blood sugar check was completed on 03/15/25 and was 174. Record review of Resident #2's change in condition completed by LVN A dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. Record review of Resident #2's hospital admission dated 04/08/25 revealed he was admitted for episodes of hypoglycemia. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated residents with diabetes and history of low of fluctuating blood sugars would absolutely have to have blood sugar checks. The NP did not recall the specific phone call with LVN A when Resident #2 returned to the facility on [DATE]. The NP stated he usually continues the hospital orders and resume hospital orders and the resident's orders. The NP did not recall saying specifically to check his blood sugars but stated Resident #2 has had episode of fluctuating blood sugars and would imagine the facility would be checking his blood sugar. The NP clarified that Resident #2 would require blood sugar checks. The NP did not know why he did not have any blood sugar checked from 04/03/25-04/08/25 and stated it would not make any sense to discontinue the glucometer checks on a diabetic and stated he was not aware of an order like that being given. The NP stated if a resident did not have their blood sugar checked there was a possibility of hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. During a telephone interview with LVN A on 04/16/25 at 12:36 p.m., she stated she went over the orders with the NP and stated there was no communication to the NP asking if he needed blood sugar checks and LVN A stated she did not ask if Resident #2 needed them because usually they would come on the medication list. LVN A stated there was not a reason why she did not ask for blood sugar checks for Resident #2 and stated she just did not and stated she just followed the order from the hospital. LVN A stated some people who had type 2 diabetes had to have blood sugar and stated some people do not check their blood. LVN A stated Resident #2 did not have blood sugar checks for a total of 5 days during his stay from 04/03/25-04/08/25. LVN A stated she did not know why Resident #2 did not have blood sugar checks. LVN A stated not having blood sugar checks could impact a resident negatively by their sugar dropping or going too high. LVN A stated she had not been trained in requesting or inputting orders for blood sugar checks and stated she just put in whatever orders were on the paper. LVN A did not know the facility policy regarding blood sugar checks or diabetic procedures. LVN A stated the only negative outcome Resident #2 had was on 04/08/25 he was complaining of shortness of breath and had his blood sugar was at 50. LVN A stated Resident #2 was sent out to the hospital. During an interview on 04/16/25 at 4:12 p.m. ADON E stated normally when a resident is on diabetic PO (by mouth) medication they will do blood sugar checks on them and stated they reviewed the hospital medication list that Resident #2 came in with on 04/03/25 and stated they had discontinued his sliding scale insulin. ADON E stated she did not know if LVN A thought his blood sugar checks were discontinued because the sliding scale was discontinued. ADON E stated LVN A did document that she verified the medications with the NP but she did not know exactly what LVN A verified and did not know why the glucose checks were dropped. ADON E was not sure if there was any communication about getting blood sugar checks for Resident #2 and stated it was not documented on LVN As note. ADON E did not know why LVN A did not ask for blood sugar checks for Resident #2 and stated residents with type 2 diabetes should be on blood sugar checks. ADON E stated she spoke with the NP today who said if they would have addressed it with him he would have given the blood sugar checks. ADON E stated Resident #2 was without blood sugar checks for 5 days from 04/03/25-04/08/25. ADON E stated herself and ADON G had trained staff over requesting and in putting orders and about checking blood sugar for diabetics. ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks and stated it was just nursing 101 to check diabetics blood sugars before meals. ADON E stated LVN A did not follow procedure in this situation. ADON E stated not getting blood sugar checks could negatively impact a resident by causing them to go hypoglycemic (low blood sugar). ADON E stated she believed Resident #2 was sent out due to him becoming hypoglycemic on 04/08/25 and stated she did not see him during that time. During an interview with the DON on 05/02/25 at 6:11pm he stated there was a progress note from LVN A on 04/03/25 that stated she went over Resident #2's orders with the NP. The DON stated that progress note did not include communication regarding blood sugar checks. The DON stated some physicians did not have residents on blood glucose checks and would instead check their A1C. The DON stated if a resident's blood glucose is controlled with diet and oral medication, they can be taken off blood glucose checks and if they are uncontrolled then you really cannot take them off blood glucose checks. The DON was asked if there was a reason why LVN A did not ask the NP for blood glucose checks for Resident #2 and he stated it depended on the order that came in with the resident from the hospital, and stated it they were on insulin they are on glucose checks regardless but stated sometimes they went in with PO (oral) medication and would use an A1C to check their glucose. The DON stated Resident #2 did not have any order from blood sugar checks during his stay from 04/03/25 through 04/08/25. The DON stated Resident #2 had no negative outcomes from not having his blood glucose checked during that time that he knew of. The DON stated he was not sure if staff had been trained prior to Resident #2 over blood glucose checks but stated they had been trained since and stated the training occurred prior to him starting to work at the facility. The DON stated yes, the facility had a policy regarding diabetic procedures and blood glucose checks but had to read it to give me information regarding what it stated. The DON stated LVN A followed the admission process. The DON stated if someone had a history of hypoglycemia and did not have blood glucose checks it could put their life in danger. The DON reviewed Resident #2's blood sugar summary and stated he only identified 1 episode of Resident #2's blood sugar at 50 on 02/16/25. During a follow up interview on 05/06/25 at 12:14pm The DON stated if a resident was responsive they could decompensate within 5 to 30 minutes if their blood glucose was at 50 and was not being monitored. Record review of facility Inservice training report dated 04/11/25 revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of LVN A's orientation and skills competency revealed a section titled, Physician Orders and a subsection titled, acquisition that indicated she had been evaluated over this area on 01/02/24 by a previous DON. There was no additional comments on comment section and was signed and dated by both LVN A and a previous DON on 01/02/24 Record review of facility in services revealed LVN A had been trained over medication reconciliation and verifying medication on 04/17/25. Record review of facility Ad HOC QAPI dated 04/11/25 revealed, blood glucose as an agenda item. During an interview on 04/16/25 at around 4:00pm the Regional Clinical Specialist stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 4:12pm ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 5:16pm the Administrator stated they did not have a facility policy for diabetic procedures or blood sugar checks. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary report revealed he had no treatment orders for his identified skin impairments when admitted on [DATE] until 04/07/25, which include the following: 1. Penile wound: clean with dakin's, dab dry with gauze, apply Mupirocin topically, LOTA (leave open to air) one time a day with an order date of 04/07/25 and a start date of 04/08/25. 2. Sacral MASD (moisture associated skin damage): clean with Dakin's, apply Medihoney and optifoam patch. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 3. Lt (left) heel wound: clean with Dakin's, apply Betadine cast followed by kerlix. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 4. Lt (left) dorsum foot: clean with Dakin's, apply Silvadene, cover with gauze dssg. (dressing) one time a day with an order date of 04/07/25 and a start date of 04/08/25. Record review of Resident #2's change in condition completed by LVN A and dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. During a telephone interview on 04/10/25 at 4:19 p.m., LVN A who was the admitting nurse for Resident #2 on 04/03/25 stated she recalled Resident #2 on 04/03/25 and recalled she did the initial nursing evaluation. LVN A stated she did not recall wounds too well and just put redness and discoloration. LVN A stated she did see redness on the sacrum and did not do anything, she stated she did not ask the doctor for any orders for the redness and stated it was more just on the sacrum. LVN A stated she did not know why she did not ask the doctor for any order. LVN A stated she just verified the medication list, LVN A stated they did not have an order for zinc and stated it was not on his medication list. LVN A stated LVN G assisted with the assessment of Resident #2. LVN A stated usually the wound care nurse would evaluate the resident the following day in the morning and stated if residents had wounds they usually came with order. During a follow up interview on 05/01/25 at 7:14pm with LVN A she stated when a resident arrived to the facility she would go and assess them, take vitals, verify orders and would complete a skin assessment that would be documented on a nursing note and stated she would complete a diagram as a reminder if they had things like a bruise. LVN A stated she did not open a new form for skin wound assessment when Resident #2 was admitted and stated she had since been educated to complete a wound form for new admissions. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated to determine skin or wound care orders the nurse would discuss any skin impairments with him or request orders from him which he would give if they were requested. The NP stated he did not recall if LVN A informed him of any skin impairments identified on Resident #2 when he was admitted on [DATE]. The NP stated not having wound care orders could potentially impact Resident #2 negatively due to being fragile elderly patient and could potentially have worsening wounds. During an interview on 04/16/25 at 4:12 p.m., ADON E stated when a resident or new admission is identified with skin impairments or wounds the admitting nurse was responsible for doing a full head to toe and going over the medication with the doctor. ADON E stated the admitting nurse had to do a skin evaluation and document any skin impairment and if they came in without orders from the hospital then the admitting nurse needed to review any findings with the doctor. ADON E stated when Resident #2 admitted on [DATE], LVN A was the nurse who completed the initial nursing evaluation. ADON E stated the initial nursing evaluation did include a skin assessment but stated the model on the nursing evaluation did not have anything documented. ADON E confirmed that staff marked yes that skin impairments were identified but stated there was nothing documented on the model and stated there should be something documented on there. ADON E stated she is assuming LVN A did not communicate any skin impairment findings to the doctor because there was no order in place for wound care upon admission of Resident #2 on 04/03/25. ADON E stated identified skin impairments and wounds are something they needed to call the doctor about and see what changes he wanted to make and stated the NP was very accessible and if staff would have addressed the skin impairment with him then he would have given orders. ADON E did not know why staff did not communicate Resident #2's skin impairment findings from 04/03/25 with the doctor. ADON E stated it was important to communicate any findings to make sure they were not left untreated. ADON E stated staff had recently been trained by her and ADON G on making notifications to the doctor and requesting orders from the doctor. ADON E stated LVN A did not follow the facility policy which stated anything out of the norm should be reporting for monitoring or treatment. ADON E stated Resident #2 went without wound care for 5 days and stated she did not believe Resident #2 was receiving wound care during those days and stated she did not have a baseline from 04/03/25 to say if there was any deterioration to his wounds during that time and stated there was not any negative impact that she knew of. ADON E stated not having wound care could negatively impact residents by causing wounds to get bigger or infected or go septic. During a follow up interview on 04/16/25 at 6:52 p.m., LVN A stated when a new admission is identified with skin impairments or wounds they would either get order from the medication list or the treatment nurse would assess the resident the following day. LVN A confirmed that she completed Resident #2's initial nursing evaluation when he admitted on [DATE]. She stated she thought the initial nursing evaluation included a skin assessment. LVN A stated she identified skin impairments to include redness to sacrum and scabs to feet. LVN A stated she did not communicate these findings to the NP and did not ask for orders based on her skin assessment and stated she only verified orders with the NP. LVN A stated skin impairments and wounds are something she should communicate with the doctor and stated that she knew of it being the treatment nurse who would communicate that but stated no one told her she was out. LVN A stated she did not communicate her findings with the doctor because she thought the treatment nurse would. LVN A stated it was important to communicate skin and wound findings to the doctor to make sure it would not get worse. LVN A stated she did not remember a training over reporting skin impairments or changes in condition but stated they had to report it to the DON and doctor. LVN A did not know her facility policy regarding communicating findings with the doctor. LVN A stated she did not know how many days Resident #2 went without wound care and stated she was off that following weekend and was not sure if he was receiving any kind of wound care and did not know if there was any deterioration to his wounds during that time. LVN A stated not getting wound care for 4 days could negatively impact the resident by causing the wounds to get infected. LVN A stated she should have notified the doctor if she had seen any signs or symptoms of infection and stated she should have asked him for wound care orders as time of assessment. During an interview and record review with the DON on 05/02/25 at 6:11pm he stated he started working at the facility on 04/21/25. The DON stated LVN A completed Resident #2's initial nursing evaluation on 04/03/25. The DON reviewed Resident #2's initial nursing evaluation from 04/3/25 and stated there was a section for skin integrity on there and stated LVN A marked yes to skin impairments but did not identify them on that form and instead did so on her progress note. The DON stated a skin form was not completed until 04/07/25. The DON stated that LVN A did communicate findings with the NP based off a note that stated she verified medications with NP. The DON stated LVN A's note did not include if she asked for orders based on her skin assessment and stated he would have to ask the LVN A or the NP. The DON stated staff should communicate any findings that warranted an order with the NP. The DON did not know why LVN A had not communicate her findings with the NP. The DON stated communicating findings with the NP and getting order for wound care and skin impairments was important because wounds and skin impairments could get worse, go septic or get infected. The DON stated he knew staff had been trained on making notifications to the NP and getting orders for wound care and skin impairments prior to him starting to work at the facility. The DON stated the facility policy stated to notify the NP of any change in condition and anything to the skin. The DON stated LNV A followed the admission process and stated he didn't know if she actually asked the NP about the wounds or scans. The DON stated Resident #2 was without wound care orders from day of readmission on [DATE] until they were put in on 04/07/25. The DON stated not having wound care treatment in place could negatively impact a resident by causing deterioration of the wound, going septic or getting an infection and having pain. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 3:59pm with no success. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:00pm, the call was answered, reason for call was explained, however while explaining the reason for call the person who answered the phone hung up the phone. The Treatment Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:01pm with no success. During an interview with ADON E on 05/05/25 at 4:08pm stated she stated the Treatment Nurse would have been the nurse who completed Resident #2's skin assessment on 04/07/25. ADON E reveiwed the skin assessments from 04/07/25 and stated the Treatment Nurse was indicated as the staff memeber who created the skin assessments on 04/07/25 for Resident #2. Record review of facility Inservice training report dated 04/11/25 (after incident occurred) revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. This was determined to be an Immediate Jeopardy (IJ) on 05/06/25 at 4:55 PM. The administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 05/06/25 at 5:18pm The following Plan of Removal (POR) submitted by the facility was accepted on 05/07/25 at 11:30 PM: [Facility] [Address] [Phone Number] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY May 6, 2025 Attention Sir or Madam: On May 6, 2025, the facility was notified by the surveyor that an Immediate Jeopardy had been called and the facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 635 admission Orders LVN A failed to obtain clarification orders for glucose checks upon readmission despite having a diagnosis of diabetes. R#2 complained of shortness of breath and suffered hypoglycemic episode with a blood glucose of 50 on 04/08/25. Actions for Resident Involved On 4/16/25, Resident #2 returned to the facility and orders were reviewed. Resident #2 was readmitted with Blood Glucose Check orders and was carried out as ordered. Identification of Others: On 4/10/25 and 5/6/2025 the DON/Designee conducted an audit of admissions/readmissions in the last 30 days to ensure that orders have been reconciled and reviewed by Medical Providers and carried out as ordered. On 4/10/25 and 5/6/2025, residents with diagnosis of type 2 diabetes mellitus were identified and referred to medical providers to review if additional orders are needed related to management of diabetes. Systemic Changes/ Education On 4/10/25 and 5/6/2025, the Director of Nursing/Designee initiated and completed 100% education with licensed staff. Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. Licensed Nurses were educated on the following: Admission/readmission order review process: o Medication reconciliation for admission/readmissions. Nurses to ensure all medications and orders upon admit/readmit have been verified with Medical Providers and carried out as ordered. o Compare Hospital Transfer orders to hospital records including review of diagnosis. The License nurse will contact the medical provider and obtain clarification orders as needed based on order review and nursing assessment. Diabetes Mellitus and Blood Glucose Checks Beginning 5/6/25 and ongoing, newly hired licensed nurses will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. Admission/readmission/ER (emergency room) visits orders will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital record and orders and the Medical Provider is notified of any orders requiring clarifications based on record review and/or nurse's assessment. Weekend RN Supervisor and/or ADON will complete and review Medication reconciliation for admission/readmissions over the weekend. Charge Nurses will ensure all medications and orders upon admit/readmit have been verified with Medical Providers and carried out as ordered. Monitoring Beginning 5/6/25 and going forward, The Director of Nursing/ designee will review new admissions /readmissions to ensure order reconciliation is completed and hospital records including the diagnosis are reviewed and medical provider is contacted if needed for clarifications based on order review and nursing assessment. Beginning 5/6/25 and going, the Director of Nursing or designee will

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents (Resident #2) reviewed for quality of care. 1.Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for wound care for MASD to sacrum, diabetic wound to left heel and left dorsum foot or abrasion to penis until 04/07/25. 2. Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for blood sugar checks and had an episode of low blood sugar on 04/08/25 that required him to be sent to hospital. An IJ was identified on 05/06/25. The IJ template was provided to the facility on [DATE] at 5:18PM . While the IJ was removed on 05/08/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary report revealed he had no treatment orders for his identified skin impairments when admitted on [DATE] until 04/07/25, which include the following: 1. Penile wound: clean with dakin's, dab dry with gauze, apply Mupirocin topically, LOTA (leave open to air) one time a day with an order date of 04/07/25 and a start date of 04/08/25. 2. Sacral MASD (moisture associated skin damage): clean with Dakin's, apply Medihoney and optifoam patch. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 3. Lt (left) heel wound: clean with Dakin's, apply Betadine cast followed by kerlix. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 4. Lt (left) dorsum foot: clean with Dakin's, apply Silvadene, cover with gauze dssg. (dressing) one time a day with an order date of 04/07/25 and a start date of 04/08/25. Record review of Resident #2's change in condition completed by LVN A and dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. During a telephone interview on 04/10/25 at 4:19 p.m., LVN A who was the admitting nurse for Resident #2 on 04/03/25 stated she recalled Resident #2 on 04/03/25 and recalled she did the initial nursing evaluation. LVN A stated she did not recall wounds too well and just put redness and discoloration. LVN A stated she did see redness on the sacrum and did not do anything, she stated she did not ask the doctor for any orders for the redness and stated it was more just on the sacrum. LVN A stated she did not know why she did not ask the doctor for any order. LVN A stated she just verified the medication list, LVN A stated they did not have an order for zinc and stated it was not on his medication list. LVN A stated LVN G assisted with the assessment of Resident #2. LVN A stated usually the wound care nurse would evaluate the resident the following day in the morning and stated if residents had wounds they usually came with order. During a follow up interview on 05/01/25 at 7:14pm with LVN A she stated when a resident arrived to the facility she would go and assess them, take vitals, verify orders and would complete a skin assessment that would be documented on a nursing note and stated she would complete a diagram as a reminder if they had things like a bruise. LVN A stated she did not open a new form for skin wound assessment when Resident #2 was admitted and stated she had since been educated to complete a wound form for new admissions. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated to determine skin or wound care orders the nurse would discuss any skin impairments with him or request orders from him which he would give if they were requested. The NP stated he did not recall if LVN A informed him of any skin impairments identified on Resident #2 when he was admitted on [DATE]. The NP stated not having wound care orders could potentially impact Resident #2 negatively due to being fragile elderly patient and could potentially have worsening wounds. During an interview on 04/16/25 at 4:12 p.m., ADON E stated when a resident or new admission is identified with skin impairments or wounds the admitting nurse was responsible for doing a full head to toe and going over the medication with the doctor. ADON E stated the admitting nurse had to do a skin evaluation and document any skin impairment and if they came in without orders from the hospital then the admitting nurse needed to review any findings with the doctor. ADON E stated when Resident #2 admitted on [DATE], LVN A was the nurse who completed the initial nursing evaluation. ADON E stated the initial nursing evaluation did include a skin assessment but stated the model on the nursing evaluation did not have anything documented. ADON E confirmed that staff marked yes that skin impairments were identified but stated there was nothing documented on the model and stated there should be something documented on there. ADON E stated she is assuming LVN A did not communicate any skin impairment findings to the doctor because there was no order in place for wound care upon admission of Resident #2 on 04/03/25. ADON E stated identified skin impairments and wounds are something they needed to call the doctor about and see what changes he wanted to make and stated the NP was very accessible and if staff would have addressed the skin impairment with him then he would have given orders. ADON E did not know why staff did not communicate Resident #2's skin impairment findings from 04/03/25 with the doctor. ADON E stated it was important to communicate any findings to make sure they were not left untreated. ADON E stated staff had recently been trained by her and ADON G on making notifications to the doctor and requesting orders from the doctor. ADON E stated LVN A did not follow the facility policy which stated anything out of the norm should be reporting for monitoring or treatment. ADON E stated Resident #2 went without wound care for 5 days and stated she did not believe Resident #2 was receiving wound care during those days and stated she did not have a baseline from 04/03/25 to say if there was any deterioration to his wounds during that time and stated there was not any negative impact that she knew of. ADON E stated not having wound care could negatively impact residents by causing wounds to get bigger or infected or go septic. During a follow up interview on 04/16/25 at 6:52 p.m., LVN A stated when a new admission is identified with skin impairments or wounds they would either get order from the medication list or the treatment nurse would assess the resident the following day. LVN A confirmed that she completed Resident #2's initial nursing evaluation when he admitted on [DATE]. She stated she thought the initial nursing evaluation included a skin assessment. LVN A stated she identified skin impairments to include redness to sacrum and scabs to feet. LVN A stated she did not communicate these findings to the NP and did not ask for orders based on her skin assessment and stated she only verified orders with the NP. LVN A stated skin impairments and wounds are something she should communicate with the doctor and stated that she knew of it being the treatment nurse who would communicate that but stated no one told her she was out. LVN A stated she did not communicate her findings with the doctor because she thought the treatment nurse would. LVN A stated it was important to communicate skin and wound findings to the doctor to make sure it would not get worse. LVN A stated she did not remember a training over reporting skin impairments or changes in condition but stated they had to report it to the DON and doctor. LVN A did not know her facility policy regarding communicating findings with the doctor. LVN A stated she did not know how many days Resident #2 went without wound care and stated she was off that following weekend and was not sure if he was receiving any kind of wound care and did not know if there was any deterioration to his wounds during that time. LVN A stated not getting wound care for 4 days could negatively impact the resident by causing the wounds to get infected. LVN A stated she should have notified the doctor if she had seen any signs or symptoms of infection and stated she should have asked him for wound care orders as time of assessment. During an interview and record review with the DON on 05/02/25 at 6:11pm he stated he started working at the facility on 04/21/25. The DON stated LVN A completed Resident #2's initial nursing evaluation on 04/03/25. The DON reviewed Resident #2's initial nursing evaluation from 04/3/25 and stated there was a section for skin integrity on there and stated LVN A marked yes to skin impairments but did not identify them on that form and instead did so on her progress note. The DON stated a skin form was not completed until 04/07/25. The DON stated that LVN A did communicate findings with the NP based off a note that stated she verified medications with NP. The DON stated LVN A's note did not include if she asked for orders based on her skin assessment and stated he would have to ask the LVN A or the NP. The DON stated staff should communicate any findings that warranted an order with the NP. The DON did not know why LVN A had not communicate her findings with the NP. The DON stated communicating findings with the NP and getting order for wound care and skin impairments was important because wounds and skin impairments could get worse, go septic or get infected. The DON stated he knew staff had been trained on making notifications to the NP and getting orders for wound care and skin impairments prior to him starting to work at the facility. The DON stated the facility policy stated to notify the NP of any change in condition and anything to the skin. The DON stated LNV A followed the admission process and stated he didn't know if she actually asked the NP about the wounds or scans. The DON stated Resident #2 was without wound care orders from day of readmission on [DATE] until they were put in on 04/07/25. The DON stated not having wound care treatment in place could negatively impact a resident by causing deterioration of the wound, going septic or getting an infection and having pain. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 3:59pm with no success. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:00pm, the call was answered, reason for call was explained, however while explaining the reason for call the person who answered the phone hung up the phone. The Treatment Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:01pm with no success. During an interview with ADON E on 05/05/25 at 4:08pm stated she stated the Treatment Nurse would have been the nurse who completed Resident #2's skin assessment on 04/07/25. ADON E reveiwed the skin assessments from 04/07/25 and stated the Treatment Nurse was indicated as the staff memeber who created the skin assessments on 04/07/25 for Resident #2. Record review of facility Inservice training report dated 04/11/25 (after incident occurred) revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2. Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has Diabetes Mellitus and included a goal of the resident will have no complication related to diabetes and interventions including, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (Pale), Nervousness, Confusion, slurred speech, lack of coordination and Staggering gait. with initiation dates of 04/16/25. Record review of Resident #2's hospital document titled, Physician - Discharge Med Rec Order Lansc (Definition unknown) dated 04/03/25 stated to stop Resident #2's order for insulin sliding scale and did not include any orders related to blood sugar checks. Record review of Resident #2's hospital document titled; Discharge Medication dated 04/03/25 did not include any orders related to blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had no orders for blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had an order for dapagliflozin propanediol oral tablet 5MG 1 time a day every day and glipizide-metformin HCI oral tablet 5-500MG 2 times a day every day both with a start date of 04/04/25 and a discontinue date of 04/10/25. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's order audit report revealed he had previously had blood sugar checks ordered on 03/05/25 and discontinued on 03/15/25 when resident was sent to the hospital prior to re-admitting to facility on 04/03/25. Record review of Resident #2's blood sugar summary revealed his last blood sugar check was completed on 03/15/25 and was 174. Record review of Resident #2's change in condition completed by LVN A dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. Record review of Resident #2's hospital admission dated 04/08/25 revealed he was admitted for episodes of hypoglycemia. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated residents with diabetes and history of low of fluctuating blood sugars would absolutely have to have blood sugar checks. The NP did not recall the specific phone call with LVN A when Resident #2 returned to the facility on [DATE]. The NP stated he usually continues the hospital orders and resume hospital orders and the resident's orders. The NP did not recall saying specifically to check his blood sugars but stated Resident #2 has had episode of fluctuating blood sugars and would imagine the facility would be checking his blood sugar. The NP clarified that Resident #2 would require blood sugar checks. The NP did not know why he did not have any blood sugar checked from 04/03/25-04/08/25 and stated it would not make any sense to discontinue the glucometer checks on a diabetic and stated he was not aware of an order like that being given. The NP stated if a resident did not have their blood sugar checked there was a possibility of hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. During a telephone interview with LVN A on 04/16/25 at 12:36 p.m., she stated she went over the orders with the NP and stated there was no communication to the NP asking if he needed blood sugar checks and LVN A stated she did not ask if Resident #2 needed them because usually they would come on the medication list. LVN A stated there was not a reason why she did not ask for blood sugar checks for Resident #2 and stated she just did not and stated she just followed the order from the hospital. LVN A stated some people who had type 2 diabetes had to have blood sugar and stated some people do not check their blood. LVN A stated Resident #2 did not have blood sugar checks for a total of 5 days during his stay from 04/03/25-04/08/25. LVN A stated she did not know why Resident #2 did not have blood sugar checks. LVN A stated not having blood sugar checks could impact a resident negatively by their sugar dropping or going too high. LVN A stated she had not been trained in requesting or inputting orders for blood sugar checks and stated she just put in whatever orders were on the paper. LVN A did not know the facility policy regarding blood sugar checks or diabetic procedures. LVN A stated the only negative outcome Resident #2 had was on 04/08/25 he was complaining of shortness of breath and had his blood sugar was at 50. LVN A stated Resident #2 was sent out to the hospital. During an interview on 04/16/25 at 4:12 p.m. ADON E stated normally when a resident is on diabetic PO (by mouth) medication they will do blood sugar checks on them and stated they reviewed the hospital medication list that Resident #2 came in with on 04/03/25 and stated they had discontinued his sliding scale insulin. ADON E stated she did not know if LVN A thought his blood sugar checks were discontinued because the sliding scale was discontinued. ADON E stated LVN A did document that she verified the medications with the NP but she did not know exactly what LVN A verified and did not know why the glucose checks were dropped. ADON E was not sure if there was any communication about getting blood sugar checks for Resident #2 and stated it was not documented on LVN As note. ADON E did not know why LVN A did not ask for blood sugar checks for Resident #2 and stated residents with type 2 diabetes should be on blood sugar checks. ADON E stated she spoke with the NP today who said if they would have addressed it with him he would have given the blood sugar checks. ADON E stated Resident #2 was without blood sugar checks for 5 days from 04/03/25-04/08/25. ADON E stated herself and ADON G had trained staff over requesting and in putting orders and about checking blood sugar for diabetics. ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks and stated it was just nursing 101 to check diabetics blood sugars before meals. ADON E stated LVN A did not follow procedure in this situation. ADON E stated not getting blood sugar checks could negatively impact a resident by causing them to go hypoglycemic (low blood sugar). ADON E stated she believed Resident #2 was sent out due to him becoming hypoglycemic on 04/08/25 and stated she did not see him during that time. During an interview with the DON on 05/02/25 at 6:11pm he stated there was a progress note from LVN A on 04/03/25 that stated she went over Resident #2's orders with the NP. The DON stated that progress note did not include communication regarding blood sugar checks. The DON stated some physicians did not have residents on blood glucose checks and would instead check their A1C. The DON stated if a resident's blood glucose is controlled with diet and oral medication, they can be taken off blood glucose checks and if they are uncontrolled then you really cannot take them off blood glucose checks. The DON was asked if there was a reason why LVN A did not ask the NP for blood glucose checks for Resident #2 and he stated it depended on the order that came in with the resident from the hospital, and stated it they were on insulin they are on glucose checks regardless but stated sometimes they went in with PO (oral) medication and would use an A1C to check their glucose. The DON stated Resident #2 did not have any order from blood sugar checks during his stay from 04/03/25 through 04/08/25. The DON stated Resident #2 had no negative outcomes from not having his blood glucose checked during that time that he knew of. The DON stated he was not sure if staff had been trained prior to Resident #2 over blood glucose checks but stated they had been trained since and stated the training occurred prior to him starting to work at the facility. The DON stated yes, the facility had a policy regarding diabetic procedures and blood glucose checks but had to read it to give me information regarding what it stated. The DON stated LVN A followed the admission process. The DON stated if someone had a history of hypoglycemia and did not have blood glucose checks it could put their life in danger. The DON reviewed Resident #2's blood sugar summary and stated he only identified 1 episode of Resident #2's blood sugar at 50 on 02/16/25. During a follow up interview on 05/06/25 at 12:14pm The DON stated if a resident was responsive they could decompensate within 5 to 30 minutes if their blood glucose was at 50 and was not being monitored. Record review of facility Inservice training report dated 04/11/25 revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of LVN A's orientation and skills competency revealed a section titled, Physician Orders and a subsection titled, acquisition that indicated she had been evaluated over this area on 01/02/24 by a previous DON. There was no additional comments on comment section and was signed and dated by both LVN A and a previous DON on 01/02/24 Record review of facility in services revealed LVN A had been trained over medication reconciliation and verifying medication on 04/17/25. Record review of facility Ad HOC QAPI dated 04/11/25 revealed, blood glucose as an agenda item. During an interview on 04/16/25 at around 4:00pm the Regional Clinical Specialist stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 4:12pm ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 5:16pm the Administrator stated they did not have a facility policy for diabetic procedures or blood sugar checks. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary repo[TRUNCATED]