Does WESTERN HILLS HEALTHCARE RESIDENCE have any serious inspection findings?

Yes, WESTERN HILLS HEALTHCARE RESIDENCE has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 29 total deficiencies from recent inspections.

What are the staffing levels at WESTERN HILLS HEALTHCARE RESIDENCE?

WESTERN HILLS HEALTHCARE RESIDENCE has a two-star staffing rating from CMS with 0.33 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is WESTERN HILLS HEALTHCARE RESIDENCE located?

WESTERN HILLS HEALTHCARE RESIDENCE is located in COMANCHE, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does WESTERN HILLS HEALTHCARE RESIDENCE have?

WESTERN HILLS HEALTHCARE RESIDENCE has 158 certified beds.

Who owns WESTERN HILLS HEALTHCARE RESIDENCE?

WESTERN HILLS HEALTHCARE RESIDENCE is a for profit - limited liability company facility and is part of the CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY chain.

WESTERN HILLS HEALTHCARE RESIDENCE

Name: WESTERN HILLS HEALTHCARE RESIDENCE
Address: 400 OLD SIDNEY RD, COMANCHE, TX, 76442, US
Telephone: (325) 356-2571
Rating: 2.0

400 OLD SIDNEY RD, COMANCHE, TX 76442 · (325) 356-2571

For profit - Limited Liability company 158 Beds CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#887 of 1168 in TX

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Western Hills Healthcare Residence has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #887 out of 1168 facilities in Texas places it in the bottom half, and it is the lowest-ranked option in Comanche County. Although the facility is showing improvement, having reduced issues from 16 in 2024 to 6 in 2025, it still struggles with staffing, earning a 2-star rating and a turnover rate that is slightly above average at 58%. There are serious concerns regarding care practices, including failures to notify physicians about critical diabetes management for several residents, which could potentially endanger their health. Additionally, the facility has incurred $62,078 in fines, which raises alarms about compliance issues that may affect the quality of care residents receive.

Trust Score: F
In Texas: #887/1168
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $62,078 in fines. Lower than most Texas facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 29 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 16 issues

2025: 6 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below Texas average (2.8)

Below average - review inspection findings carefully

Staff Turnover: 58%

12pts above Texas avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $62,078

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: CORYELL COUNTY MEMORIAL HOSPITAL AU

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (58%)

10 points above Texas average of 48%

The Ugly 29 deficiencies on record

3 life-threatening

May 2025 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 15 residents (Resident #48) reviewed for antipsychotic medication consents. The facility failed to ensure Resident #48's HHSC Form 3713 for Risperdal (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability) was signed by Resident #48 or Resident #48's responsible party, prior to resident receiving the medication. This failure could affect residents who received antipsychotics by placing them at risk of not being informed of their treatment options , to make informed decisions regarding their care. Findings included: Record review of Resident #48's electronic face sheet dated 12/04/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: Alzheimer's disease (common cause of dementia characterized by a progressive decline in memory, thinking and behavior), dementia (group of symptoms affecting memory, thinking and social abilities), Major Depressive disorder and anxiety disorder. Record review of Resident #48's Significant change MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #48 had a BIMS score of 2 (meaning severe cognitive impairment); Section N-Medications: Resident #48 had received antipsychotic medications during the previous 7-day period. Record review of Resident #48's physician order dated 05/14/2025 revealed: Risperdal oral tablet .5mg (Risperidone) Give .5 prescriber tablet by mouth two times a day related to Dementia . with a start date of 05/09/2025. Record review of Resident #48's Medication Administration Record dated May 2025 revealed Resident #48 received Risperdal twice per day on 05/10/2025, 05/11/2025, 05/12/2025 and 05/13/2025. Record review of Resident #48's HHSC Form 3713 for Risperdal revealed no evidence of a signature by Resident #48 or their representative prior to 05/14/2025. During an interview on 05/13/25 at 3:06 PM the DON stated he did not have a signed HHSC form 3713 for Resident #48's Risperdal that was started on 05/09/2025. The DON stated he did get verbal consent from Resident #48's representative and had mailed the consent to Resident #48's representative. During an interview on 05/13/25 at 3:03 PM Resident #48's representative stated he had received a phone call, from the DON, and was notified Resident #48 was ordered new medications. Resident #48's representative stated he was not told Resident #48 was prescribed an antipsychotic and was not told the risks and benefits of the new antipsychotic. During an interview on 05/14/2025 at 1:45 PM the DON stated he had called Resident #48's Representative and told him there was a new order for Risperdal. The DON stated he did not tell Resident #48's Representative that Risperdal was an antipsychotic and did not tell him the risks and benefits of the medication. The DON stated he did not know you could not get a verbal consent for the HHSC Form 3713. The DON stated he thought he could have mailed the HHSC Form 3713. The DON stated after further reading his expectation was that the HHSC Form 3713 should have been signed prior to start of an antipsychotic medication. The DON stated the nurse that took the new medication order was responsible for ensuring the HHSC Form 3713 was signed prior to the antipsychotic medication being given. The DON stated he was responsible to monitor and that he monitored by running reports of new medications. The DON stated the effect on residents could have been residents were not aware of all the side effects of a new medication. The DON stated what led to the failure was oversight on his part, and he did not know a verbal consent would not be sufficient for an antipsychotic medication. During an interview on 05/14/2025 at 2:30 PM the ADMN stated her expectation was that residents and/or their representative should have been notified when given a new antipsychotic medication. The AMDN stated they should have been notified of what the new medication was, why it was being given, what the risk and benefits of the new medication were and should have signed an HHSC consent form prior to the antipsychotic being given. The ADMN stated the nurse who received the order was responsible to ensure the consent was signed prior to giving a new antipsychotic. The ADMN stated the DON was responsible to monitor that consent forms were completed prior to giving antipsychotics. The ADMN stated residents could have been affected because they may not have all information needed about new medications. The ADMN stated what led to the failure was oversight by DON. The ADMN stated the DON did not know that a verbal consent would not be sufficient for an antipsychotic and that the HHSC Form had to be signed prior to administration of medication. Record review of facility policy titled Antipsychotic Medication Use dated July 2022 revealed: Residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 05/14/2025 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed Under 26 TAC §554.1207, a resident receiving antipsychotic or neuroleptic medications must provide written consent. Written consent can also be given by a person authorized by law to consent on the resident's behalf. Consent for antipsychotic and neuroleptic medications must be documented on Texas Health and Human Services Commission (HHSC) Form 3713 . If the antipsychotic or neuroleptic medication is being prescribed to a resident for the first time, a NF must complete Form 3713 before the first dose is administered. Review of drugs.com accessed on 05/16/2025 at https://www.drugs.com, revealed Risperdal was a Drug class: Atypical antipsychotics.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 1 of 15 residents (Resident #6) reviewed for misappropriation and exploitation, in that: The facility failed to ensure that Resident #6 was not subject to financial misappropriation or exploitation from the BOM. The BOM accepted $3700 cash from Resident #6 on 11/18/2024 and failed to apply the money too Resident #6's account. The noncompliance was identified as Past Non-Compliance. The noncompliance began on 11/18/2024 and ended on 04/14/2025. The facility had corrected the non-compliance before the survey began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. Findings Included: Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: diabetes, infection, anxiety, and depression. Review of Resident #6's Annual MDS dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #6's receipts reflected on 11/18/24 the BOM received $3700 cash from Resident #6 for Room and board. Review of Facility Journal Entry Report for April 2025 ran on 05/14/2025 revealed Resident #6 had a bad debt total of $3780. During an interview on 05/14/2025 at 1:00 pm, the Administrator stated that she had observed to her what seemed like suspicious behavior from the BOM. She stated that the facility had several Medicaid pending residents for a longer time than expected. She stated she and the Corporate Revenue Cycle Director started an audit of Medicaid applications which were to be completed by the BOM. She discovered multiple Medicaid applications that the BOM had said had been completed were never started. She stated she then when looking through receipt booklets and she discovered that several cash payments had been accepted by the BOM. She stated there was a receipt for Resident #6 for $3700 that had not been applied to Resident #6's account or deposited into the facility bank account. She stated the BOM stated she was not aware that she could not take cash payments and that she bought money orders with the cash, and she must have lost the money orders. She stated the BOM denied stealing the cash. Administrator then stated she discovered that monthly account statements were not being sent out to residents which was why no residents or family members were aware of their accounts being delinquent. During an interview on 05/14/2025 at 1:00 pm, Resident #6 stated she was not aware of all of the details regarding the missing money and that her family takes care of all her financials. She stated that she had given the BOM #3700 cash on 11/18/2024. During an interview on 05/14/2025 at 1:10 pm, Resident #6's family member stated she was informed that the cash that Resident #6 had given to the BOM was never applied to Resident #6's account and that the facility made it right. She stated that she was not upset and that no harm was caused. She stated that she had received one monthly account statement since Resident #6's account debt had been cleared. Review of facility policy titled; Abuse/Neglect, revised 10/04/22 revealed in part: The resident has the right to be free from abuse, misappropriation of resident property, and exploitation as defined in this subject. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It was determined this failure placed the facility in Past Non-Compliance from 11/18/2024 to 04/14/2025. The facility took the following actions to correct the non-compliance: Review of Facility Investigation Report form 3613-A, dated 04/18/2025, revealed: Facility Investigation Findings: Confirmed. Provider Action Taken Post-Investigation: in conducting an audit of [Resident #6's] account it was confirmed that payment made in cash of $3700 on 11/18/2024and was not applied to Resident #6's account. Corporate Revenue Cycle Director conducted an audit of facility deposits and no matching $3700 was deposited into facility accounts. The BOM was terminated immediately for misappropriation of funds and Medicaid applications not being completed. Police Department is investigating report of alleged misappropriation of funds. Corporate Revenue Cycle Director is completing audit on all resident accounts at this time. In-service regarding abuse and neglect was completed by staff. Corporate Revenue Cycle Director adjusted [Resident #6's] account to reflect deposit of $3780. Review of facility in-service titled, Abuse, Neglect, and Misappropriation, dated 04/14/2025, revealed 19 signatures. During interviews on 05/14/2025 from 1:30-2:30 pm, 6 staff members stated they had been in-serviced and understood abuse and neglect and misappropriation of property. Review of Resident #6's account summary, dated 04/18/2025 revealed a credit of $3780 and no outstanding balance. Review of Employee Disciplinary Report, dated 04/14/2025, signed by the BOM, revealed termination of employment. Review of police report revealed on 04/11/2025 a report of possible fraud was received. During an interview on 05/14/2025 at 3:10 pm, The COO stated the misappropriation was corrected in the following ways: audits were performed, the family of Resident #6 was notified, Resident #6's account was credited, and the BOM was terminated. He stated actions put in place to prevent further failure were weekly financial reviews, and segregation of duties between the person receiving the monies and the person depositing the monies. He stated money will be taken by the medical records person and then given to the business office to deposit. He stated there currently was not a BOM for the facility, but a new person had been hired but had not started yet.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 2 (Residents #10, and Resident #34) of 6 residents reviewed for smoking safety. The facility failed to ensure Resident #10's lighter and cigarettes were not stored on their person. The facility failed to ensure Resident #34's lighter and cigarettes were not stored on their person. These failures could affect residents who smoke by putting them at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #10 Record review of Resident #10's electronic face sheet dated 12/08/2023 revealed resident was a [AGE] year-old male who was initially admitted on [DATE] with a recent readmission date of 03/27/2025. Resident #10 was admitted with medical diagnoses of paraplegia, muscle wasting, non-insulin dependent diabetes, mood disorder, nicotine dependence, major depressive disorder, anxiety, intermittent explosive disorder, gout, high blood pressure, 3 pressure ulcers, blood clots, respiratory disease, dysfunctional bladder, and heartburn. Review of Resident #10's Annual MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Summary Score, a score of 15 out of 15 indicating intact cognition. For Section J Health Conditions, subsection J1300 Current Tobacco Use, 1. Yes was entered. Record review of Resident #10's Safe Smoking assessment dated [DATE] revealed: This Resident is safe to smoke unsupervised, at this time. Record review of Resident #10's Comprehensive Care Plan dated 11/21/24, reviewed/revised 02/07/25, revealed Focus: [Resident] is an active smoker at this time and requires no monitoring when smoking. Goal [Resident] will be able to state understanding of smoking rules of the facility through next review date. Interventions/Tasks [Resident] may have his smoking materials with him and keep at nurses' station or med room, [Resident] will have a safe smoking assessment completed at least quarterly. Record review of Resident #10's electronic medical records revealed Resident #10 signed a document titled Smoking Policy - Residents on 02/10/25. During an observation on 05/14/25 at 10:10 AM, Resident #10 wheeled himself outside to the designated smoking area. Resident #10 asked for a light. Resident #10 was informed he had to get a light from a staff member. Resident #10 went back inside the building then came out with a staff member. The staff member lit his cigarette with a disposable lighter. Resident #10 did not have signs of damage to his clothing or exposed skin related to cigarettes or a lighter. Record review of Resident #10's weekly skin assessments from 12/15/23 to current revealed no documentation of wounds related to cigarettes or a lighter. Resident #34 Record review of Resident #34's electronic face sheet dated 05/16/2023 revealed resident was a [AGE] year-old male initially admitted on [DATE] with medical diagnoses of Alzheimer's disease, anxiety, weakness, high blood pressure, dementia, major depressive disorder, heart failure, and a cardiac pacemaker (an implanted medical device that regulates heart rhythm). Review of Resident #34's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns, subsection C0500. BIMS Summary Score, Resident #34 had a BIMS score of 14 out of 15 indicating intact cognition. Record review of Resident #34's Safe Smoking assessment dated [DATE] revealed: This resident is safe to smoke unsupervised, at this time., All smoking materials will be kept at the nurses station, Care Plan up to date or updated, and The evaluation has been discussed with the resident. Record review of Resident #34's Comprehensive Care Plan last revised on 02/07/2025 revealed: Focus: [Resident] is an active smoker at this time and requires monitoring at smoke times. Goal [Resident] will be able to state understanding of smoking rules of the facility through the next review date. Interventions/Tasks [Resident] has signed and understands the smoking policy, [Resident] will have a safe smoking assessment completed quarterly., [Resident] prefers his cigarettes to be kept at the nurse's station or med room. Record review of Resident #34's electronic medical records revealed Resident #34 signed a document titled Smoking Policy - Residents on 02/07/25. During an observation and interview on 05/13/25 at 10:11 AM, Resident #34 wheeled himself out to the designated smoking area. No staff were present. Observed as Resident #34 pulled a cigarette and disposable lighter out of his shirt pocket and lit the cigarette. No staff member was present to supervise the resident. Resident #34 stated he kept his cigarettes and lighter in his room and was able to come out to the smoking area when he wants without supervision. At approximately 10:14 AM, observed Resident #10 wheel himself out to the smoking area. Resident #10 had a cigarette and lighter on his lap. Resident #10 stated he was also permitted to have his cigarettes and lighter in his room and smoke when he wants unsupervised. Resident #10 was not observed smoking at this time. During an observation on 05/13/25 at 10:48 AM, noted the facility Safe Smoking - Residents policy posted in the front lobby. During an observation and interview on 05/14/25 at 08:32 AM, Resident # 34 wheeled himself outside to the designated smoking area. Resident #34 pulled a pack of cigarettes and a disposable lighter out of the pocket on the upper left sleeve of his jacket. No staff was present to supervise Resident #34. Resident #34 lit the cigarette. Resident #34 stated he kept his cigarettes and lighter in the jacket pocket. During an observation on 05/14/25 at 10:15 AM, no supplemental oxygen was in Resident #34's room. During an observation and interview on 05/14/25 at 09:50 AM, Resident #34 had no signs of damage to his clothing or exposed skin related to a lighter or cigarettes. Resident #34 appeared to have no tremors when holding his cigarette. Resident #34 denied burning himself. Record Review of Resident #34's weekly skin assessments from 02/06/25 to current revealed no documentation of wounds related to cigarettes or a lighter. Record review of grievances for previous 6 months revealed no complaints related to smoking or residents having a lighter in their room. During an observation and interview on 05/14/25 at 08:58 AM, the DON stated the facility's policy was for smokers to have a safe smoking evaluation done upon admission. He explained residents were not permitted to have cigarettes or lighters in their room. The DON stated tobacco products and supplies must be locked in the medication rooms at each nurse' station. He stated his expectations were for staff to report to the DON or Administrator if a resident was found with cigarettes or lighter in their room. The DON stated the staff assigned to a smoker's hall, or staff that was available, would be responsible for supervising during scheduled smoking times. He stated the responsibility for monitoring for safe smoking practices was all staff members. He stated training on safe smoking practices included staff reviewing the information for each resident on the summary of resident tasks and the care plan. The DON denied knowledge of incidents in the facility related to smoking paraphernalia. Accompanied the DON to Resident # 10's room. The DON explained Resident #10 was approved to roll his own cigarettes in his room. He stated Resident #10 requested the supplies from the nurses. He rolled cigarettes in his room then returned the supplies to the nurse. Upon entering Resident #10's room, the resident was lying in bed listening to music. Resident #10 told the DON his supplies were in the 2nd drawer of his nightstand and gave permission for the DON to look. A clear plastic bag of tobacco and a cigarette pack were in the drawer. Resident #10 stated his lighter was in the 2nd right side drawer of the dresser. The DON located the lighter, and explained to the resident that he could ask for it at the nurses' station before he went outside to smoke and needed to return the lighter to the nurse when he came back in. Resident #10 did not have a roommate and was not on supplemental oxygen. Accompanied the DON to the locked unit to check smoking supplies. A long safety lighter was in a drawer at the nurse's station. Cigarettes and smokeless tobacco were stored in a clear plastic box in the locked medication room. During an interview on 05/14/25 at 09:16 AM, the Administrator stated residents were evaluated for safe smoking prior to approval to smoke ad lib. She stated cigarettes and lighters were kept at the nurse's station. Her expectations of staff if a resident was found with cigarettes and/or lighter was for staff to report to her or DON and remove the item(s) from the resident's possession. She stated she or the DON would talk with the resident, review the smoking policy with the resident and complete a safe smoking evaluation. The Administrator stated she had worked in the facility for 3 years and could not recall an incident related to a resident possessing a lighter. She stated staff was in-serviced on safe smoking procedures by herself and/or the DON. She stated she and the DON were responsible for training and monitoring for compliance. During an interview on 05/14/25 at 11:25 AM, LVN A, Treatment Nurse, stated she was responsible for weekly skin assessments. She stated she had not discovered a wound on a resident who smoked that appeared to be caused by a cigarette or lighter. LVN A stated potential consequences of having a lighter in a resident room may be if a roommate was on oxygen the lighter could be a fire danger. She stated the reason for the failure to keep residents from having lighters in their room was because family and visitors were unaware of the policy. She added, some residents go out on pass with family and could return with a lighter without staff knowing. During an interview on 05/14/25 at 11:43 AM, LVN B stated was not aware Resident # 10 had a lighter in his room. She stated the cause of the failure may be because Resident #10's family brought him groceries, cigarettes, and loose tobacco to roll his own cigarettes. She stated Resident #10 also ordered tobacco supplies online. LVN B stated potential consequences of residents keeping smoking supplies in their room may be a resident would smoke in the room, trigger the fire alarm, or set a fire. She explained training was provided via in-services and information on resident smoking assessments was available to staff in the electronic medical records. She stated the DON was responsible for monitoring for training compliance. LVN B stated she had not noticed burns on the clothing or skin of a resident who smoked. During an interview on 05/14/25 at 11:49 AM with the DON and VPCS, the VPCS stated facility expectations were for a smoking assessments to be completed on admission and routinely. He stated some residents were approved to smoke at will. The VPCS stated smoking items were kept by the nurses. The DON explained a re-assessment of smoking safety was done when the resident had a change in status. The DON stated the reason for the failure was visitors giving residents cigarettes and/or lighters. The DON stated the facility supplied safety lighters that are kept at each nurse's station. The VPCS stated when smoking supplies were found on a resident or in a resident's room, the resident was re-educated, and a safe smoking evaluation was done. He stated each resident that smoked signed the smoking policy during the admission process. The VPCS and the DON did not directly answer potential consequences of a resident having a lighter in their room. Record review of facility policy Smoking Policy - Residents Policy Interpretation and Implementation, Item 13. Resident may not keep cigarettes, e-cigarettes, or lighters (those items must be kept at the nursing station). Smokeless tobacco items can be kept by the resident as deemed appropriate. Care plans will specify if resident is utilizing cigarettes, e-cigarettes, or smokeless tobacco items.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 4 (Resident #1, Resident #3, Resident #14, and Resident #28) of 15 residents reviewed for unnecessary medications. The facility failed to ensure Resident #1's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #3's PRN Lorazepam was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #14's PRN Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #28's PRN Lorazepam was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, lung disease, and kidney failure. Review of Resident #1's Annual MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #1 had taken anti-anxiety medications during the last 7 days. Review of Resident #1's Comprehensive Care Plan review completed 04/21/2025, revealed: Focus: Resident uses anti-anxiety medications (lorazepam) r/t anxiety disorder. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Resident will show decreased episodes of s/s of anxiety. Interventions: Give anti-anxiety medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #1's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 2 hours as needed for anxiety 365 day stop date, order date 10/09/2024, and Lorazepam Oral Tablet 0.5 MG Give 2 tablet by mouth every 2 hours as needed for anxiety 365 day stop date, order date 10/09/2024. Review of Resident #1's April 2025 MAR revealed 10 doses of Lorazepam were administered. Review of Resident #1's May 2025 MAR up until 05/13/2025, revealed 3 doses of Lorazepam were administered. Review of Resident #1's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Review of Drugs.com for Lorazepam accessed on 05/14/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, and depression. Review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #3 had taken anti-anxiety medications during the last 7 days. Review of Resident #3's Comprehensive Care Plan review completed 04/10/2025, revealed: Focus: Resident uses anti-anxiety medications (lorazepam) r/t hospice. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: Give anti-anxiety medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #3's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 0.5 mg by mouth every 2 hours as needed for anxiety give 1-2 tablets, order date 04/07/2025. Review of Resident #3's April 2025 MAR revealed 3 doses of Lorazepam were administered. Review of Resident #3's May 2025 MAR up until 05/13/2025, revealed no evidence of Lorazepam being given for the entire month. Review of Resident #3's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Resident #14 Review of Resident #14's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, infection to lower leg, and kidney failure. Further review revealed no evidence of an insomnia diagnoses. Review of Resident #14's admission MDS dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #14 had taken anti-anxiety medications during the last 7 days since entry. Review of Resident #14's Comprehensive Care Plan review completed 05/13/2025, revealed: Focus: Resident uses anti-anxiety medication Diazepam r/t anxiety disorder and sleep. Goal: Resident will show decreased episodes of s/s of anxiety. Interventions: .Give anti-anxiety medications ordered by physician (Diazepam). Monitor/document side effects and effectiveness . Review of Resident #14's electronic Physicians Orders revealed: Diazepam Oral Tablet 2 MG Give 1 tablet by mouth every 12 hours as needed for insomnia, order date 04/23/2025. Review of Resident #14's April 2025 MAR revealed Diazepam was administered daily since ordered. Review of Resident #14's May 2025 MAR up until 05/13/2025, revealed 9 doses of Diazepam were administered. Review of Resident #14's physician progress notes revealed no evidence of documented rationale to order PRN Diazepam for more than 14 days. Review of Drugs.com for Diazepam accessed on 05/14/2025 at https://www.drugs.com/diazepam.html revealed: Diazepam belongs to a class of medications called benzodiazepines. Diazepam is used in a to treat anxiety disorders, or alcohol withdrawal symptoms. Resident #28 Review of Resident #28's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: dementia, Parkinson's, and muscle weakness. Review of Resident #28's Quarterly MDS dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #28 had not taken any anti-anxiety medications during the last 7 days. Review of Resident #28's Comprehensive Care Plan review completed 03/25/2025, revealed no evidence of anxiety or resident taking antianxiety medications. Review of Resident #28's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 2 hours as needed for anxiety for 365 Days, order date 01/08/2025, and Lorazepam Oral Tablet 0.5 MG Give2tablet by mouth every 2 hours as needed for anxiety for 365 Days, order date 01/08/2025. Review of Resident #28's April 2025 MAR revealed no evidence of Lorazepam being given for the entire month. Review of Resident #28's May 2025 MAR revealed no evidence of Lorazepam being given for the entire month. Review of Resident #28's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. During an interview on 05/14/25 at 10:40 AM, the Administrator stated she was not aware that there had to be a documented rationale for the need to continue psychotropic PRN medications longer than 14 days. During an interview on 05/14/25 at 10:47 AM, the DON stated PRN psychotropics can only be for 14 days unless the resident was on hospice, and they can order them for a year. He stated there is no documented rationale for the continued need of the medication by the physician. He stated he was not aware the documentation was required. Review of facility policy titled; Psychotropic Medication Use dated July 2022 revealed in part: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. Review of facility policy titled; Abuse/Neglect, revised 10/04/22 revealed in part: The resident has the right to be free from abuse, misappropriation of resident property, and exploitation as defined in this subject. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #1, Resident #3, and Resident #28) of 15 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident are addressed and met 24 hours per day to ensure Resident #1, Resident #3, and Resident #28 received adequate end-of-life care. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day and to have a physician certification and recertification of the terminal illness for Resident #1, Resident #3, and Resident #28. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old female admitted to the facility on hospice services on 04/01/2023 with diagnoses to include: anxiety, lung disease, and kidney failure. Review of Resident #1's Annual MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section O: revealed Resident #1 was on hospice care. Review of Resident #1's Comprehensive Care Plan review completed 04/21/2025, revealed: Focus: Resident has an order for Do Not Resuscitate (DNR). Goal: Resident decision for DNR will be honored. Interventions: Resident receives services from hospice. Review of Resident #1's electronic Physicians Orders revealed: Admit to Hospice DX: Ends Stage Renal Failure (kidney failure), dated 04/01/2023. Review of Resident #1's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #1. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, and depression and admitted to hospice services on 03/04/2025. Review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Review of Section O revealed Resident #3 was on hospice care. Review of Resident #3's Comprehensive Care Plan review completed 04/10/2025, revealed: Focus: Resident has an order for Do Not Resuscitate (DNR). Goal: Resident decision for DNR will be honored. Interventions: Resident receives services from hospice. Review of Resident #3's electronic Physicians Orders revealed: Hospice to evaluate and admit if indicated, date 03/04/2025. Review of Resident #3's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #3. Resident #28 Review of Resident #28's electronic face sheet revealed an [AGE] year-old male admitted to the facility on hospice services on 11/04/2020 with diagnoses to include: dementia, Parkinson's, and muscle weakness. Review of Resident #28's Quarterly MDS dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Review of Section O revealed Resident #28 was on hospice care. Review of Resident #28's Comprehensive Care Plan review completed 03/25/2025, revealed: Focus: Resident has been placed on hospice services. Goal: Residents needs will be met, and comfort will be maintained. Interventions: Work cooperatively with hospice team to ensure residents spiritual, emotional, intellectual, physical, and social needs are met. Review of Resident #28's electronic Physicians Orders revealed: Admit to Hospice Services with diagnoses End Stage Parkinson's disease, date 11/04/2020. Review of Resident #28's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #28. During an interview on 05/13/25 at 02:51 PM, the DON stated there was no documentation of communication between hospice and the facility. He stated the facility staff, and the hospice staff communicate verbally. He stated the facility did not have hospice binders. He stated he was not aware that there had to be written documentation and that he was not aware of the required documents from hospice. During an interview on 05/14/25 at 10:40 AM, the Administrator stated the facility should have had hospice binders for each resident on hospice. She stated it should have included the certification of terminal illness and all communication regarding care provided by the hospice providers. She verified that there was no communication forms and no certifications of terminal illness and that she has reached out to the hospice company. She stated the negative effect of not having the binders would be poor communication regarding resident care. Review of facility policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 05/12/2025 between 10:45AM and 11:30 AM of the kitchen revealed: Dry Storage: 1. Cheerios type cereal out of the original container not labeled with a use by date. 2. Raisin bran type cereal out of the original container not labeled with a use by date. 3. Rice crispy type cereal out of the original container not labeled with a use by date. 4. Corn Flakes type cereal out of the original container not labeled with a use by date. Refrigerator: 1. 3 containers of strawberries were not labeled with a received or a use by date. 2. 1 container of blueberries was not labeled with a received or use by date. 3. 1 opened container of thickened sweet tea was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 4. 1 opened container of thickened tea was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 5. 1 opened container of thickened apple juice was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. 6. 1 opened container of thickened cranberry was not labeled with an open date, with manufacture instructions, Discard if not used within 7 days of opening. Freezer #1: 1. 8 packages of hot dog buns out of the original container not labeled with a food description or a use by date. 2. 4 bags of tater tots out of the original container not labeled with a food description or a use by date. Freezer #2: 1. 4 packages of chopped chicken out of the original container not labeled with a food description or a use by date. 2. 4 package of chicken pieces out of the original container not labeled with a food description or a use by date. The DM stated food items should have been labeled with a food item description, a receive date, open date, and a use by date. The DM stated all staff were responsible for labeling food. The DM stated she was responsible to monitor, and she monitored by looking thru the refrigerators and freezers weekly. The DM stated residents could have gotten sick if they had received food that was not labeled correctly. The DM stated what led to failure was staff had gotten into a rush and forgot to label food items. During an interview on 05/13/25 at 9:27 AM the Dietician stated her expectation was food should have been labeled with a food description and a receive date, open date and use by date. The Dietitian stated staff that either received food, removed food from the original package or was putting food items back into the refrigerator/freezer were responsible to ensure food items were labeled appropriately. The Dietitian stated the DM was responsible to monitor that food was being labeled correctly. The Dietitian stated she monitored on her monthly visits, by looking thru the kitchen. The Dietician stated that she would address with DM any concerns she found and staff would be in-serviced on the issues that needed to be addressed. The Dietician stated the effect on residents, for food not labeled, could have been a resident could have received a food the resident was allergic to, or could have received food that was past its use by date which could have led to a resident becoming ill. The Dietician stated she did not have an explanation to what led to failure of items not being labeled correctly. During an interview on 05/14/2025 at 2:30 PM the ADMN stated her expectation was that food should have been labeled with a description of the food item, received date, open date and use by date. The ADMN stated the kitchen staff that received food items, removed food items from original containers or opened a food item were responsible to ensure the food items were labeled correctly. The ADMN stated the DM was responsible to ensure food was labeled appropriately. The ADMN stated residents could have become ill from food that was past its use by date. The ADMN stated oversight by the DM led to the failure of food not being labeled correctly. Record review of the facility policy titled Food Storage, without a date, revealed: Food should be dated as it placed on the shelves .Date marking should include date opened, and use by. Review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 05/14/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date.

Mar 2024 16 deficiencies 3 IJ (3 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Notification of Changes (Tag F0580)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a system in place to monitor that nursing staff were notifying the physician for 4 of 6 residents (Resident #3, Resident #11, Resident #31, Resident #38) when insulin was held and resident blood glucoses over 250 for 2 of 6 (Resident #38, Resident #31) residents reviewed for diabetic care. 1. The facility failed to notify the physician when Resident #3's Insulin Glargine and Insulin Lispro were held without a physician order 13 times during a 3-month review (January 2024, February 2024, March 2024). 2. The facility failed to notify the physician when Resident #11's Insulin Glargine and Novolin R Solution was held without a physician order 4 times during a 1-month review (March 2024). 3. The facility failed to notify the physician when Resident #31's Insulin Glargine and Novolin R Solution was held without a physician order 3 times during a 1-month review (March 2024). 4. The facility failed to notify the physician of Resident #31's blood glucoses that were greater than 400 3 times during a 1-month review (March 2024). 5. The facility failed to notify the physician of Resident #38's blood glucoses that were greater than 250 34 times during a 3-month review period (January 2024, February 2024, March 2024). 6. The facility failed to notify the physician when Resident #38's Insulin Glargine was held without a physician order 32 times during a 3-month review (January 2024, February 2024, March 2024). An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of delayed medical treatment and diabetic complications. Findings include: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses included: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed the resident had a BIMS score of 10 meaning moderate cognitive impairment and Section N-Medications received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; [Resident #3] will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician's order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Further review of physician's orders revealed no order for blood sugar checks or orders about notification to the physician. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM revealed Resident #3 was in his wheelchair and talking with the nurse while she checked his blood glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information, Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses reflected Diabetes Mellitus, high blood pressure; and Section N-Medications reflected Resident 131 received insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: [Resident #11] has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: [Resident #11] will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 [Resident #11] will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 [Resident #11] will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor (metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician's order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Further review of physician's orders revealed no order for blood sugar checks or orders about notification to the physician. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 units held at 4:30PM with no evidence of documentation of rationale for holding or who held the medication. 4. 03/20/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN N. Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses, Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); and Section N-Medications reflected Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021. Record review of Resident #31's physician's orders revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March 2024 MAR revealed Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. 2. 03/09/2024 at 1630 blood glucose of 480 recorded by LVN F, physician not notified. 3. 03/14/2024 at 1630 blood glucose of 439 recorded by LVN F, physician not notified. Review of Resident #31's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on the secure unit on 03/18/2024 at 11:14 AM revealed Resident #31 was sitting at table in dining room watching television and appeared to not be in distress. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); and Section N-Medications reflected Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022. Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024. Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022. Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (unhealthy pale appearance), Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing (abnormal breathing pattern), acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022. Offer substitutes for foods not eaten. Date Initiated: 11/28/2022 . Record review of Resident #38's physician's orders revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250. Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN N. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A . 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. Record Review of Resident #38's January 2024, February 2024 and March 2024 MARs the following blood glucose: 1. 01/11/2024 at 8:00 PM blood glucose of 282 recorded by LVN E. 2. 01/12/2024 at 8:00 PM blood glucose of 295 recorded by LVN P. 3. 01/15/2024 at 8:00 PM blood glucose of 285 recorded by LVN N. 4. 01/18/2024 at 9:00 AM blood glucose of 255 recoded by LVN O. 5. 01/19/2024 at 8:00 PM blood glucose of 322 recorded by Staff Q. 6. 01/21/2024 at 9:00 AM blood glucose of 409 recorded by LVN E 7. 01/24/2024 at 8:00 PM blood glucose of 428 recorded by LVN N. 8. 01/26/2024 at 8:00 PM blood glucose of 282 recorded by LVN P. 9. 01/27/2024 at 8:00 PM blood glucose of 260 recorded by RN A. 10. 01/28/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 11. 01/30/2024 at 8:00 PM blood glucose of 293 recorded by LVN E. 12. 01/31/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 13. 02/06/2024 at 8:00 PM blood glucose of 352 recorded by LVN E. 14. 02/07/2024 at 9:00 AM blood glucose of 283 recorded by LVN E. 15. 02/07/2024 at 8:00 PM blood glucose of 326 recorded by LVN O. 16. 02/12/2024 at 8:00 PM blood glucose of 362 recorded by LVN E. 17. 02/14/2024 at 8:00 PM blood glucose of 380 recorded by RN A. 18. 02/15/2024 at 8:00 PM blood glucose of 280 recorded by RN A. 19. 02/17/2024 at 8:00 PM blood glucose of 314 recorded by LVN O. 20. 02/18/2024 at 8:00 PM blood glucose of 266 recorded by LVN O. 21. 02/21/2024 at 8:00 PM blood glucose of 399 recorded by LVN O. 22. 02/22/2024 at 8:00 PM blood glucose of 344 recorded by LVN O. 23. 02/24/2024 at 8:00 PM blood glucose of 370 recorded by RN A. 24. 02/25/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 25. 02/27/2024 at 8:00 PM blood glucose of 336 recorded by LVN O. 26. 02/29/2024 at 8:00 PM blood glucose of 332 recorded by LVN E. 27. 03/02/2024 at 8:00 PM blood glucose of 350 recorded by RN C. 28. 03/03/2024 at 8:00 PM blood glucose of 384 recorded by RN C. 29. 03/04/2024 at 8:00 PM blood glucose of 375 recorded by RN C. 30. 03/05/2024 at 8:00 PM blood glucose of 287 recorded by LVN B. 31. 03/11/2024 at 9:00 AM blood glucose of 285 recorded by LVN L. 32. 03/13/2024 at 8:00 PM blood glucose of 309 recorded by RN C. 33. 03/14/2024 at 9:00 AM blood glucose of 284 recorded by LVN E. 34. 03/14/2024 at 8:00 PM blood glucose of 318 recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin or when blood glucose was above 250 per physician's order. During an interview on 03/19/24 05:02 PM, the DON stated that the blood sugars should have been documented in the resident's chart. The DON stated she did not know why blood sugars were not entered. She stated if documentation was not in the chart there was not another way to prove it had been completed. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his family member stated the Lantus should have been held if blood glucose was less than 120mg/dL because he would bottom out (blood glucose would drop low). RN C stated she used her nursing judgement about holding the insulin and had not contacted the physician to verify. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated if the orders stated to contact doctor for blood glucoses over 250mg/dL doctor should have been contacted. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held or that Resident #38 had any blood glucoses over 250. The MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in the physician's orders. The DON stated her expectation would be for nurses to contact the physician if the order stated to contact he physician for blood glucose being above 250. She stated nurses should document in the chart when the physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could have caused adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect the blood glucose reading hours after the insulin was held. Physician D stated the registered nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify the physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician's orders should have been followed. LVN L stated not giving insulin per orders and not contacting the physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact the physician when insulin was held, and would hold if the resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long- acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that were ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted the physician when held insulin for Residents #3 and #38. LVN F did not provide a response for not contacting the physician or why held the insulin. Attempted telephone follow up interview on 03/22/2024 at 6:25 PM with the MD. The MD did not answer and a message to return the call was left. The MD did not return the call. Attempted telephone interview on 03/22/2024 at 6:38 PM with LVN K. LVN K did not answer and a message to return the call was left. LVN K did not return the call. Attempted telephone interview on 03/22/2024 at 6:39 PM with RN A. RN A did not answer and a message to return the call was left. RN A did not return the call. Attempted telephone interview on 03/22/2024 at 6:41 PM with LVN B. LVN B did not answer and a message to return the call was left. LVN B did not return the call. During a follow-up interview on 03/23/2024 at 3:07PM, the DON stated her expectation was that nurses should have notified the physician with every change of condition and document their attempts. The DON stated herself and the ADON were responsible for monitoring, by talking with nurses and reviewing resident charts. The DON stated the effect on residents could have led to a possible decline. The DON stated what led to the failure was that nursing staff in the past were allowed to use nursing judgement. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated his expectation was that staff follow the policy and notify the physician of a change in the resident's status. The ADMN stated the DON was responsible to monitor. The ADMN stated staff not contacting the physician could have resulted in resident not getting care in a timely manner. The ADMN stated what led to failure was lack of follow up and oversight of management. Record review of facility policy titled, Nursing Policy and Procedure Manual 2003 date March 11, 2023 revealed, The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident' s clinical record . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician' s orders and the resident' s status and response to interventions. This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 2:45 PM. The Administrator was informed of the IJ. The Administrator was provi

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0726 (Tag F0726)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for Diabetic care. 1. The facility failed to ensure RN C notified the physician that Resident #38's blood glucose was over 250, 5 times during a 3-month review period. 2. The facility failed to ensure RN C administered Resident #3's Insulin Glargine 3 times during a 3-month review period and Resident #38's Insulin Glargine 2 times during a 3-month review period, per physician order. 3. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period, per physician order. 4. The facility failed to ensure LVN L notified the physician that Resident #38's blood glucose was over 250, 1 time during a 3-month review period. 5. The facility failed to ensure LVN L administered Resident #38's Insulin Glargine 7 times during a 3-month review period and Resident #11's Insulin Glargine 1 time during a 1-month review period, per physician order. 6. The facility failed to ensure LVN F administered Resident #3's Insulin Lispro 1 time during a 3-month review period, per physician order. 7. The facility failed to ensure LVN F notified physician that Resident #38 blood glucose was over 250 per physician order, 2 times during a 3-month review period and Resident #31's blood glucose was over 400 per physician order 2 times during a 1-month review period. 8. The facility failed to ensure that LVN F administered Resident #31's Insulin Novolin per physician order 1 time during a 1-month review period. 9. The facility failed to ensure LVN E notified physician that Resident #38 blood glucose was over 250 per physician order, 8 times during a 3-month review period. 10. The facility failed to ensure LVN E administered Resident #3's Insulin Lispro 2 times during a 3-month review period, per physician order. 11. The facility failed to ensure LVN B notified physician that Resident #38 blood glucose was over 250, 1 time during a 3-month review period. 12. The facility failed to ensure LVN B administered Resident #3's Insulin Lispro 1 time during a 3-month review period, per physician order. 13. The facility failed to ensure LVN B administered Resident #3's Insulin Glargine 1 time during a 3-month review period, per physician order. 14. The facility failed to ensure LVN B administered Resident #38's Insulin Glargine one time during a 3-month review period, per physician order. 15. The facility failed to ensure LVN E notified physician that Resident #38 blood glucose was over 250 per physician order, 8 times during a 3-month review period. 16. The facility failed to ensure RN A notified physician that Resident #38's blood glucose was over 250 per physician order, 7 times during a 3-month review period. 17. The facility failed to ensure RN A notified physician that Resident #38 blood glucose was over 250 per physician order, 7 times during a 3-month review period. 18. The facility failed to ensure RN A administered Resident #38's Insulin Glargine 14 times during a 3-month review period, per physician order. 19. The facility failed to ensure LVN K administered Resident #38's Insulin Glargine 4 times during a 3-month review period, per physician order. An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment; Section N-Medications Resident #3 received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; Resident #3 will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM, Resident #3 was in his wheelchair and talking with nurse while she checked his blood glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses of Diabetes Mellitus, high blood pressure; Section N-Medications Resident #11 received Insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: Resident #11 has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: Resident #11 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor(metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin R Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 units held at 4:30PM with no evidence of documentation of rationale for holding or who held medication. 4. 03/20/2024 Novolin R Solution 10 units held at 6:30AM with blood glucose of 323 documented by LVN N Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident # 31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); Section N-Medications Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021 Record review of Resident #31's physician reviewed on 03/22/2024 revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March 2024 MAR revealed no evidence that physician was notified when Resident #31's Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. 2. 03/09/2024 at 1630 (4:30 PM) blood glucose of 480 recorded by LVN F, physician not notified. 3. 03/14/2024 at 1630 (4:30 PM) blood glucose of 439 recorded by LVN F, physician not notified. Review of Resident #31's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 11:14 AM, Resident #31 was sitting at table in dining room watching television. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); Section N-Medications Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022 Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024 Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022 Offer substitutes for foods not eaten. Date Initiated: 11/28/2022. Record review of Resident #38's physician order reviewed on 03/20/2023 revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250. Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed no evidence that the physician was notified when insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN N. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A. 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. Record Review of Resident # 38's January 2024, February 2024 and March 2024 MARs revealed no evidence that physician was notified for the following blood glucose: 1. 01/11/2024 at 8:00 PM blood glucose of 282 recorded by LVN E. 2. 01/12/2024 at 8:00 PM blood glucose of 295 recorded by LVN P. 3. 01/15/2024 at 8:00 PM blood glucose of 285 recorded by LVN N. 4. 01/18/2024 at 9:00 AM blood glucose of 255 recoded by LVN O. 5. 01/19/2024 at 8:00 PM blood glucose of 322 recorded by Staff Q. 6. 01/21/2024 at 9:00 AM blood glucose of 409 recorded by LVN E 7. 01/24/2024 at 8:00 PM blood glucose of 428 recorded by LVN N. 8. 01/26/2024 at 8:00 PM blood glucose of 282 recorded by LVN P. 9. 01/27/2024 at 8:00 PM blood glucose of 260 recorded by RN A. 10. 01/28/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 11. 01/30/2024 at 8:00 PM blood glucose of 293 recorded by LVN E. 12. 01/31/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 13. 02/06/2024 at 8:00 PM blood glucose of 352 recorded by LVN E. 14. 02/07/2024 at 9:00 AM blood glucose of 283 recorded by LVN E. 15. 02/07/2024 at 8:00 PM blood glucose of 326 recorded by LVN O. 16. 02/12/2024 at 8:00 PM blood glucose of 362 recorded by LVN E. 17. 02/14/2024 at 8:00 PM blood glucose of 380 recorded by RN A. 18. 02/15/2024 at 8:00 PM blood glucose of 280 recorded by RN A. 19. 02/17/2024 at 8:00 PM blood glucose of 314 recorded by LVN O. 20. 02/18/2024 at 8:00 PM blood glucose of 266 recorded by LVN O. 21. 02/21/2024 at 8:00 PM blood glucose of 399 recorded by LVN O. 22. 02/22/2024 at 8:00 PM blood glucose of 344 recorded by LVN O. 23. 02/24/2024 at 8:00 PM blood glucose of 370 recorded by RN A. 24. 02/25/2024 at 8:00 PM blood glucose of 300 recorded by RN A. 25. 02/27/2024 at 8:00 PM blood glucose of 336 recorded by LVN O. 26. 02/29/2024 at 8:00 PM blood glucose of 332 recorded by LVN E. 27. 03/02/2024 at 8:00 PM blood glucose of 350 recorded by RN C. 28. 03/03/2024 at 8:00 PM blood glucose of 384 recorded by RN C. 29. 03/04/2024 at 8:00 PM blood glucose of 375 recorded by RN C. 30. 03/05/2024 at 8:00 PM blood glucose of 287 recorded by LVN B. 31. 03/11/2024 at 9:00 AM blood glucose of 285 recorded by LVN L. 32. 03/13/2024 at 8:00 PM blood glucose of 309 recorded by RN C. 33. 03/14/2024 at 9:00 AM blood glucose of 284 recorded by LVN E. 34. 03/14/2024 at 8:00 PM blood glucose of 318 recorded by RN C. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his wife stated the Lantus should have been held if blood glucose was less than 120 would hold because he would bottom out (blood glucose would drop low). RN C stated Resident #38 refused offered snack when she held the insulin. RN C stated she used her nursing judgement about holding the insulin. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated she will text the doctor with updates but does not always. RN C stated the doctor would get mad if they contacted him with everything. RN C stated if the orders stated to contact doctor for blood glucoses over 250, then the doctor should have been contacted. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/21/2024 at 7:53 PM, Resident #38 stated he had snacks in his room, and a refrigerator. Resident #38 stated he will usually ask if he needs more snacks in the evenings before bed. During an observation and interview on 03/23/2024 at 10: 15 AM, Resident #38 was coming into the building from the outside smoking area. Resident #38 stated he had been out on smoke break and no concerns expressed. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held or that Resident #38 had any blood glucoses over 250. The MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in physician order. The DON stated her expectation would be for nurses to contact physician if physician order stated to contact physician for blood glucose being above 250. She stated nurses should document in chart when physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could cause adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect blood glucose reading hours after the insulin was held. Physician D stated Registered Nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician orders should have been followed. LVN L stated not giving insulin per order and not contacting physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact physician when insulin was held and would hold if resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long-acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that was ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted physician when holding insulin for Resident # 3 and #38. LVN F did not provide a reason for why she did not contact the doctor. During an attempted t

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0760 (Tag F0760)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to remain free of significant medication errors for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for medication administration. 1. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 6 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #38's Insulin Glargine 1 times during a 3-month review period (January 2024, February 2024, March 2024)., per physician order. 2. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period (January 2024, February 2024, March 2024). 3. The facility failed to ensure LVN L administered Resident #38's Insulin Glargine 7 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #11's Insulin Glargine 1 time during a 1-month review period (March 2024), per physician order. 4. The facility failed to ensure LVN F administered Resident #3's Insulin Lispro 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician order. 5. The facility failed to ensure LVN F administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician order. 6. The facility failed to ensure that LVN F administered Resident #31's Insulin Novolin per physician order 1 time during a 1-month review period (March 2024). 7. The facility failed to ensure LVN E administered Resident #3's Insulin Lispro 2 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 8. The facility failed to ensure LVN B administered Resident #3's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 9. The facility failed to ensure LVN B administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 10. The facility failed to ensure RN A administered Resident #38's Insulin Glargine 14 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 11. The facility failed to ensure LVN K administered Resident #38's Insulin Glargine 4 times during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 12. The facility failed to ensure LVN N administered Resident #38's Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. 13. The facility failed to ensure LVN N administered Resident #11's Novolin Solution 1 time during a 1-month review period (March 2024) per physician's order. 14. The facility failed to ensure LVN O administered Resident #38 Insulin Glargine 1 time during a 3-month review period (January 2024, February 2024, March 2024) per physician's order. An Immediate Jeopardy (IJ) was identified on 03/22/2024. The IJ Template was provided to the facility on [DATE] at 3:45pm. While the IJ was removed on 03/24/2024 at 2:07 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure placed residents that received insulin at risk illness, hospitalizations, and exacerbation of their disease processes. Findings included: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 10/03/2023. Resident #3's diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment.Section N-Medications Resident #3 received Insulin. Record review of Resident #3's care plan dated 03/19/2024 with the revised date of 03/17/2024, revealed; Resident #3 will have no complications related to diabetes through the review date of 04/09/2024. Interventions for Resident #3 revealed: Diabetes medication as ordered by doctor (insulin glargine, insulin lispro, metformin). Monitor/document for side effects and effectiveness. Date Initiated: 03/17/2024, Revision on: 03/17/2024. Record review of Resident #3's physician order dated 03/22/2024 revealed: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously in the evening related to Type 2 Diabetes . Insulin Lispro Solution 100 Unit/ML (Insulin Lispro) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes. Record review of Resident #3's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed insulins being held: 1. 01/22/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 117 recorded by RN C. 2. 01/26/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 142 and note that he refused snack recorded by RN C. 3. 01/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 118 and note held for FS of 118 recorded by LVN F. 4. 01/30/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 139 and note that he refused snack recorded by RN C. 5. 02/05/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 213, chart code 11=no insulin required recorded by LVN E. 6. 02/12/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 130 and note that he refused snack recorded by RN C. 7. 02/13/2024 Insulin Glargine 15 units held at bedtime with blood glucose of 126 recorded by LVN B. 8. 02/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 126 recorded by LVN B. 9. 02/29/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 151. Chart code 11=no insulin required recorded by LVN E. 10. 03/02/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 136 and note that he refused snack, recorded by RN C. 11. 03/03/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 125 (chart code 9=see progress notes) Nothing noted, recorded by RN C. 12. 03/13/2024 Insulin Lispro 5 units held at bedtime with blood glucose of 115 and note that he refused snack, recorded by RN C. 13. 03/13/2024 Insulin Glargine15 units held at bedtime with blood glucose 116 and note that he refused snack recorded by RN C. Review of Resident #3's electronic progress notes for January 2024, February 2024, and March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation and interview on 03/18/2024 at 10:58 AM, Resident #3 was in his wheelchair and talking with nurse while she checked his Blood Glucose. Resident #3 stated he felt fine at this time. Resident #3 was laughing and talking with no signs of distress noted. Resident #11 Record review of Resident #11's quarterly MDS dated [DATE] revealed, Section A- Identification Information Resident #11 was a [AGE] year-old male admitted on [DATE]; Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section I - Active Diagnoses of Diabetes Mellitus, high blood pressure; Section N-Medications Resident #11 received Insulin. Record review of Resident #11's Care Plan dated 03/15/2024 revealed: Focus: Resident #11 has Diabetes Mellitus Date Initiated: 01/13/2021 Revision on: 01/13/2021 Goal: Resident #11 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Resident #11 will have no complications related to diabetes through the review date. Date Initiated: 01/13/2021 Revision on: 11/09/2022 Target Date: 03/21/2024 Interventions: o Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Diabetes medication as ordered by doctor(metformin, lantus). Monitor/document for side effects and effectiveness. Date Initiated: 01/13/2021 Revision on: 03/15/2024 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Educate regarding medications and importance of compliance. Have resident verbally state an understanding. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/13/2021 Revision on: 01/13/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/13/2021 Revision on: 01/13/2021 Record review of Resident #11's physician order dated 03/22/2024 revealed, Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 IU subcutaneously in the afternoon related to Type 2 Diabetes . Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 301 - 350 = 10 units; 351 - 400 = 12 units; 401 - 500 = 14 units 401 and up 14 units, subcutaneously every 012 hours as needed for hyperglycemia related to Type 2 Diabetes. Record review of Resident #11's electronic MAR for the month of March 2024 revealed: 1. 03/02/2024 Insulin Glargine 30 units held at 4:30 PM with blood glucose of 108, documented by LVN L. 2. 03/10/2024 Novolin Solution 10 units held at 6:30 AM with blood glucose of 323 documented by LVN G. 3. 03/19/2024 Insulin Glargine 30 unites held at 4:30PM with no evidence of documentation of rationale for holding or who held the medication. 4. 03/20/2024 Novolin Solution 10 units held at 0630 with blood glucose of 323 documented by LVN N. Review of Resident #11's electronic progress notes for March 2024 revealed no evidence of notification of physician for holding ordered insulin. During an observation on 03/18/2024 at 12:35 PM, Resident #11 was sitting in room in wheelchair watching television with game controller in hands. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment); Section N-Medications Resident #31 received Insulin. Record review of Resident #31's care plan dated 01/22/2024 revealed: Focus: Resident #31 has Diabetes Mellitus Date Initiated:01/28/2021, Revision on: 02/08/2021 Goal: Resident #31 will be free from any s/sx of hyperglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will be free from any s/sx of hypoglycemia through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024; Resident #31 will have no complications related to diabetes through the review date. Date Initiated: 01/28/2021 Revision on: 11/09/2022 Target Date: 01/19/2024 Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Date Initiated: 01/28/2021 Diabetes medication as ordered by doctor (glimepiride, humalog, novolin R). Monitor/document for side effects and effectiveness. Date Initiated: 01/28/2021 Revision on: 02/08/2023 Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/28/2021 Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/28/2021 Don't use over the counter remedies for corns and calluses, refer to podiatrist to treat. Date Initiated: 01/28/2021 Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/28/2021 Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 01/28/2021 Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: 01/28/2021 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/28/2021 Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. Date Initiated: 01/28/2021 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 01/28/2021 Monitor compliance with diet and document any problems. Date Initiated: 01/28/2021 Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Date Initiated: 01/28/2021Offer substitutes for foods not eaten. Date Initiated: 01/28/2021 Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Date Initiated: 01/28/2021 Record review of Resident #31's physician reviewed on 03/22/2024 revealed: Novolin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 0-150 =0 units No coverage required. Notify MD for any FS below 60.; 151-200= 4 units SQ; 201-250= 6 units SZ; 251-300= 8 units SQ; 301-350 + 10 units SQ; 351-400 =12 units SQ; 401-450 +14 units SQ. Notify MD for FS above 400., subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia. Record review of Resident #31's March MAR dated revealed no evidence that physician was notified when Resident #31's Novolin R was held and when blood glucose was over 400: 1. 03/09/2024 Novolin R was held at 4:30 PM with blood glucose of 480 recorded by LVN F. During an observation on 03/18/2024 at 11:14 AM, Resident #31 was sitting at table in dining room watching television. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11(moderate cognitive impairment); Section N-Medications Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 has Diabetes Mellitus Date Initiated:11/28/2022, Revision on: 11/28/2022 Goal: [Resident #38] will be free from s/sx of complications related to diabetes through the review date. Date initiated: 11/28/2023, Revision on 03/07/2024, Target Date: 05/28/2024 Interventions/tasks: Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022 Revision on: 11/28/2022 Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022 Offer substitutes for foods not eaten. Date Initiated: 11/28/2022 Record review of Resident #38's physician order reviewed on 03/20/2023 revealed, Insulin Glargine Solution 100 UNIT/ML Inject 25 unit subcutaneously in the morning for diabetes and Inject 15 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus . glucoscan every AM and every PM every morning and at bedtime related to Type 2 Diabetes Mellitus without Complications Report any findings >250 Record review of Resident #38's electronic MAR for the months of January 2024, February 2024 and March 2024 revealed no evidence that the physician was notified when insulin was held: 1. 01/03/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 165 recorded by RN A. 2. 01/05/2024 Insulin Glargine (Lantus) 25 units held in am with blood glucose of 74 recorded by LVN K. 3. 01/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 65 recorded by LVN K. 4. 01/07/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 88 recorded by LVN C. 5. 01/08/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 103 recorded by RN A. 6. 01/13/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 182 recorded by RN A. 7. 01/14/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 140 recorded by RN A. 8. 01/17/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 9. 01/18/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 189 recorded by RN A. 10. 01/21/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 130 recorded by RN A. 11. 01/22/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 94 recorded by RN A. 12. 01/23/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 175 recorded by RN A. 13. 01/30/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN K. 14. 01/31/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 73 recorded by LVN O. 15. 02/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 199 recorded by RN A. 16. 02/05/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 95 recorded by LVN F. 17. 02/05/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 188 recorded by RN A 18. 02/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 160 recorded by RN A. 19. 02/20/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 180 recorded by RN A. 20. 02/22/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 74 recorded by LVN K. 21. 02/24/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 77 recorded by LVN F. 22. 02/28/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 67 recorded by RN A. 23. 03/01/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 116 recorded by RN C. 24. 03/02/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 25. 03/03/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 70 recorded by LVN L. 26. 03/07/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 80 recorded by LVN L. 27. 03/10/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 86 recorded by RN C. 28. 03/11/2024 Insulin Glargine (Lantus) 15 units held at bedtime with blood glucose of 131 recorded by LVN L. 29. 03/12/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 88 recorded by LVN L. 30. 03/13/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 66 recorded by LVN L. 31. 03/15/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 98 recorded by LVN L. 32. 03/19/2024 Insulin Glargine (Lantus) 25 units held at am with blood glucose of 78 recorded by LVN B. During an interview on 03/21/2024 at 7:53 PM, Resident #38 stated he had snacks in his room, and a refrigerator. Resident #38 stated he will usually ask if he needs more snacks in the evenings before bed. During an observation and interview on 03/23/2024 at 10:15 AM, Resident #38 was coming into the building from the outside smoking area. Resident #38 stated he had been out on smoke break and no concerns expressed. During an interview on 03/20/2024 at 3:02 PM, RN C stated she held the Insulin glargine (Lantus) for Resident #38 because his family member stated the Lantus should have been held if blood glucose was less than 120mg/dL because he would bottom out (blood glucose would drop low). RN C stated she had not verified family's request and used her nursing judgement. RN C stated when Resident #38 refused the snack that she offered, so she held the insulin if the blood sugar was low. RN C stated she used her nursing judgement about holding the insulin. RN C stated there should have been parameters to hold insulin. RN C stated if the doctor was notified then it should have been documented in progress notes. RN C stated she would send the doctor a text with updates but does not always. RN C stated the doctor would get mad if they contacted him with everything. RN C stated she did not have any documentation that she had notified the doctor. During an interview on 03/20/2024 at 4:02 PM, the MD stated he had not been notified of Resident #38's insulin being held. MD stated Lantus was not a sliding scale insulin and should have not been held. During an interview on 03/20/2024 at 4:45 PM, the DON stated she did not see an issue for holding insulin without having parameters to hold. She stated she expected nurses to use their nursing judgement for holding insulin if no parameters were listed in physician order. The DON stated her expectation would be for nurses to contact physician if physician order stated to contact physician for blood glucose being above 250. She stated nurses should document in chart when physician had been contacted. She stated the physician would not give routine laboratory orders. The DON stated holding insulin could have caused adverse reactions to residents. During an interview on 03/21/2024 at 2:15 PM, Physician D stated Lantus was a long-acting insulin and should not be held, if there were not orders that had parameters to hold. Physician D stated holding Lantus would affect blood glucose reading hours after the insulin was held. Physician D stated Nurses should not hold any medications including insulin without contacting the physician. Physician D stated holding insulin could create severe thirst, weight loss, fatigue, and vision changes. Physician D stated his expectation was that staff follow orders and notify physician of any changes from the orders. During an interview on 03/22/2024 at 4:25 PM, LVN L stated physician's orders should have been followed. LVN L stated not giving insulin per orders and not contacting the physician could have resulted in diabetic residents having prolonged low or high blood sugars. LVN L stated Hyperglycemia or Hypoglycemia could have caused organ failure if not treated appropriately. LVN L stated she did not always contact the physician when insulin was held, and would hold if the resident's blood sugar was too low and was refusing to eat snack or meal. LVN L stated Insulin Glargine was a long- acting insulin and did not affect immediate blood glucoses. During an interview on 03/22/24 at 4:43 PM, LVN F stated medication that was ordered without parameters to hold, should have not been held without calling a doctor. LVN F stated she should have contacted physician when holding insulin for Resident #3 and #38. LVN F did not provide a response for why she did not contact the doctor or held the insulin. During an attempted telephone follow-up interview on 03/22/2024 at 6:25 PM with the MD, MD did not answer and a message to return call was left. The MD did not return the call. During an attempted telephone interview on 03/22/2024 at 6:38 PM with LVN K, LVN K did not answer and a message to return call was left, LVN K did not return call. During an attempted telephone interview on 03/22/2024 at 6:39 PM with RN A, RN A did not answer and message to return call was left, RN A did not return call. During an attempted telephone interview on 03/22/2024 at 6:41 PM with LVN B, LVN B did not answer and message to return call was left, LVN B did not return call. During a follow-up interview on 03/23/2024 at 3:07PM, the DON stated her expectation was if nurses used their nursing judgment they needed to follow up with the physician and document in the resident's chart. The DON stated herself and the ADON were responsible for monitoring, by talking with nurses and reviewing resident charts The DON stated the effect on residents could have led to possible decline of residents. The DON stated what led to failure was that nursing staff in the past were allowed to use nursing judgement. The DON stated the nursing process they followed was the Texas Board of Nursing. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated his expectation was nurses were to follow physician orders. The ADMN stated the DON was responsible for monitoring. The ADMN stated staff not contacting the physician could have resulted in residents not getting care in a timely manner. The ADMN stated what led to failure was lack of follow up and oversight of management. Record review of facility policy titled Adverse Consequences and Medication Errors, dated February 2023, revealed, Examples of medications errors include: Omission - a drug is ordered but not administered Unauthorized drug- a drug is administered without a physician's order; Wrong dose (e.g. , Dilantin 12 mL ordered, [NAME]/in 2 mL given); Wrong route of administration (e.g. , ear drops given in eye ); Wrong dosage form (e .g., liquid ordered, capsule given); Wrong drug (e.g., vibramycin ordered, vancomycin given). A significant medication-related error is defined as: a. Requiring medication discontinuation or dose modification. (Consult the current list of medications that should not be abruptly discontinued.) b. Requiring hospitalization or extending a hospitalization. c. Resulting in disability. d. Requiring treatment with a prescription medication. e. Resulting in cognitive deterioration or impairment. f. Life threatening. g. Resulting in death. Review of drugs.com website, https://www.drugs.com accessed on 03/27/2024 revealed, Insulin glargine is a long-acting insulin used to treat type 1 and type 2 diabetes in certain patients to improve and maintain blood glucose levels. Insulin glargine is a man-made form of human insulin that is used once daily to provide a base level of insulin that keeps working for 24 hours or longer. Insulin Lispro is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. According to the Texas Board of Nursing website, https://www.bon.texas.gov accessed on 03/22/2024 revealed, A nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/practice_dept_, accessed on 03/22/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 03/22/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 2:45 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/22/2024 at 3:45 PM. Record review of Plan of Removal accepted on 03/23/2024 at 3:17 PM reflected the following: The Facility failed to ensure residents were free of significant medication errors when nursing staff held

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked when unattended by RN-H. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During observation on 03/18/24 at 11:12 AM, the treatment cart was unlocked facing outward on hall one by room [ROOM NUMBER]. There were visitors and residents that walked past the cart that were within approximately one to two feet away. The same treatment cart on hall one was again observed at 11:23 AM by room [ROOM NUMBER], facing outward and left unlocked. During an interview on 03/18/2024 at 11:25 AM, RN-H stated the treatment cart was her responsibility and should have been locked. She stated residents could possibly have gotten stuff out of it and harmed themselves such as wound care cream, tape, and scissors which she stated, that would be the worst thing residents could get to and harm themselves. She also stated there were multiple tubes of Mupirocin Ointment USP, 2%, Nystatin Cream USP, and zinc oxide ointment with OTC drugs as well as Prescription drugs (Mupericin 2% ointment, and Ammonium Lactate). She stated all of the medications would all be harmful to the resident if ingested. During an interview on 03/22/24 at 8:41 AM, LVN-M stated all carts should be locked. She stated if left unlocked a resident could get into it as well as visitors or possibly other staff members and have a drug diversion or possibly harm themselves; medications, bandages, scissors that could harm the resident and disinfectants which could harm the resident or visitors if ingested or cut. LVN-M stated it was not acceptable to leave a treatment or any cart unlocked. During an interview on 03/22/24 at 8:53 AM, the DON stated the treatment cart should be locked at all times unless there were staff directly in front of it for monitoring. She stated all nurses and staff should monitor the treatment and medication carts to make sure they were kept locked. She stated there would be a negative impact to a resident with medications possibly being ingested. She stated the trainings and in-services varied between staff, and in that situation, all nursing staff were trained in keeping all carts locked when not in use. The DON stated her expectations were to keep all carts locked, and not to walk away from them if unlocked. Record Review of facility policy Storage of Medication dated 2003 revealed: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: 2. Only licensed nurses, and consultant pharmacist, and those lawfully authorized to administer medication (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 1 resident (Resident #38) reviewed for labs. The facility failed to provide evidence they obtained routine labs for Resident #38's Hcb HGB A1C levels (common blood test to show average blood sugar over past two to three months) as ordered by the physician. This failure could place resident at risk of a delay in receiving the necessary interventions to treat their medical condition(s). Findings included: Record review of Resident #38's face sheet dated 03/22/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); and Section N-Medications reflected Resident #38 received Insulin. Record review of Resident #38's care plan dated 02/13/2024 revealed: Focus: Resident #38 had Diabetes Mellitus, Date Initiated: 11/28/2022 and revised on: 11/28/2022 Goal: Resident #38 will be free from s/sx of complications related to Diabetes through the review date. Date initiated: 11/28/2023, Revised on 03/07/2024 and a Target Date of: 05/28/2024. Interventions/tasks: Resident #38's Diabetes medication as ordered by doctor (Trulicity, insulin glargine). Monitor/document for side effects and effectiveness. Date Initiated:11/28/2022, Revised on: 11/28/2022. Fasting Serum Blood Sugar as ordered by the doctor. Date Initiated: 11/28/2022 If infection is present, consult doctor regarding any changes in diabetic medications. Date Initiated: 11/28/2022. Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (pale skin), Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 11/28/2022 Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace), acetone breath (smells fruity), stupor, coma. Date Initiated: 11/28/2022. Offer substitutes for foods not eaten. Date Initiated: 11/28/2022. Record review of Resident #38's physician's order dated 12/21/2023 revealed HGB A1C due to be drawn on 12/28/2023. Record review of Resident #38's laboratory reported dated 12/28/2023 revealed no evidence of HGB A1C lab was tested. During an interview on 03/23/24 at 2:40 PM, LVN-M stated if there was an order from the physician for lab work, the electronic health record system should have flagged the resident's nurse that the labs were due. She stated the electronic health system would keep flagging her daily until they were completed. She stated the HGB A1C lab for diabetics was very critical. LVN-M stated the HGB A1C lab should have been completed if ordered. She stated if not drawn, the diabetic resident could get too much, or too little diabetic medication (insulin) based off their labs. She stated the HGB A1C needed to be monitored for medication dose reduction and management. LVN-M stated the failure would have fallen on the nurse for that resident and if there was an order for the lab, it should not had been missed. LVN-M stated she did not know who should have been monitoring, and stated, if they were being completed, it began with the nurse for that resident. During an interview on 03/23/2024 at 3:02 PM the DON stated the physician should have had an order for the HGB A1C's, and when done so, she expected it to be done. She stated in not doing so, the residents were not getting the most accurate care needed. The DON stated it would be herself as the DON who should have monitored if they had been completed. She stated her expectations were for the labs to be completed. Record Review of facility policy Nursing Care of the Older Adult with Diabetes Mellitus dated November 2020 revealed: Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. Record Review of the American Diabetes Association, Standards of Medical Care in Diabetes, https://professional.diabetes.org/sites/default/files/media/ada-factsheet-understandingyourHgb A1Ctest.pdf accessed 03/26/2024 revealed: The HGB A1C is a blood test tells you what your average blood sugar (blood glucose) levels have been for the past two to three months. It measures how much sugar is attached to your red blood cells. If your blood sugar is frequently high, more will be attached to your blood cells. Because you are always making new red blood cells to replace old ones, your HGB A1C changes over time as your blood sugar levels change. Usually, your doctor will measure your HGB A1C at least twice a year. If your medication is changing, you are making other changes in how you take care of yourself, or other things might be affecting your blood sugar, you may have it checked more often. Record review of https://diabetes.org/about-diabetes/Hgb A1C accessed 03/26/2024 accessed 03/26/2024 revealed: The HGB A1C test can be used to diagnose diabetes or help you know how your treatment plan is working by giving you a picture of your average blood glucose (blood sugar) over the past two to three months.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 4 of 13 residents (Resident #6, #33, #54) reviewed for abuse. The facility failed to conduct a thorough investigation and report findings from their investigation of pharmaceutical services and misappropriation of property within 5 working days regarding Resident #6. The facility failed to conduct a thorough investigation and report findings from their investigation of abuse within 5 working days regarding Resident #33. The facility failed to conduct a thorough investigation and report findings from their investigation of neglect within 5 working days regarding Resident #54. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Resident #6 Record Review of the resident #6's Face Sheet dated 03/19/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 06/18/2023 with the diagnoses of shortness of breath, heart failure, and chest pain. Review of Resident #6's MDS, dated [DATE], Section C revealed a BIMS score of 15 (cognitively intact). Review of Resident #6's Care Plan dated 03/07/2024 revealed: Focus: Resident #6 requires pain management r/t pain, date initiated 10/05/2023 and a revised on 10/05/2023. Goal: Resident #6 will not have an interruption in normal activities due to pain through the review date. Date initiated: 10/05/2023, Target date of 05/15/2024. Interventions: Administer analgesia (oxycodone-APAP, Tylenol) as per orders. Give ½ hours before treatments or care. Date initiated: 10/05/2023, Target date of 03/08/2024. Record review of an Incident report dated 02/27/2024 revealed an allegation of Pharmaceutical Services and Misappropriation of Property of Resident #6, At approximately 1:15 PM on 02/26/2024, the facility ADMN was notified by facility DON, that two facility nurses reported a drug diversion incident regarding a residents' medication. Review of an investigation file revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 with the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment). Record review of Resident #33's care plan dated 3/7/2024 revealed, Resident #33 has a behavior problem r/t delusion. Resident #33 has misconceptions and beliefs that staff are talking about her. She firmly believes that staff intentionally ignore her. Date Initiated: 11/30/2021. Goal: will have fewer episodes of misconceptions/beliefs by next review date. Date Initiated: 11/30/2021. Revision on: 11/16/2022, and a Target date: 05/19/2024 .Interventions/Tasks:.Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention, remove from situation, and take alternate location as needed, Date initiated: 11/30/2021. Record review of Incident report dated 02/13/2024 revealed an allegation of Abuse of Resident #33, At approximately 10:45 PM on 02/10/2024, the facility administrator was notified by LVN E that an agency nurse was speaking to a resident in a verbally inappropriate manner Review of investigation file revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #54 Record review of Resident #54's face sheet dated 03/21/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admission date of 08/22/2023 with the following diagnosis Pneumonia, muscle wasting, lack of coordination, Parkinson's Disease with a history of falling and cognitive communication deficit. Record review of Resident #54's Annual MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns BIMS score of 0 (severe cognitive impairment). Record review of Resident #54's Care Plan dated 02/26/2024 revealed; Focus: Resident #54 has had an actual fall with injury, minor injury, r/t poor balance, poor communication/comprehension 08/19/23, 08/20/23, 10/5/23, 10/16/23, 10/22/23, 10/23/23, 10/25/23, 10/29/23, and 10/30/23. 11/21/23, 11/23/23, 11/27/23, 12/25/23, 01/09/24, 1/28/24 (x2), 1/30/24 with fracture date initiated: 01/30/2024, Revision on 02/26/2024 with a cancel date of 02/26/2024. Goal: Resident #54 will resume usual activities with further incident through the review date. Interventions: For apparent acute injury, determined and address causative factors of the fall. Record review of Incident report dated 02/06/2024 revealed an allegation of Neglect of Resident #54 At approximately 7:45 PM on 02/05/2024, the facility ADMN was notified that a radiology report was received for Resident #54 which indicated a left femoral neck fracture. The resident had two falls on 02/02/2024 and 02/03/2024. Review of facility's investigations revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. During an interview on 03/19/2024 at 09:25 AM, the ADMN stated a thorough investigation included, witness interviews, resident medical information and performing in-services to staff involved. The ADMN stated he was waiting to turn in the form 3613-A self-report investigations to HHSC. The ADMN stated he should have immediately started the investigations when the incidents were reported to him. He stated he had 24 hours to report incidents to HHSC when there was no injury but if there was, he would have two hours after the incident happened. He stated he had investigated and found confirmation that the incidents did occur or not, with having 5 business days to complete and submit reports to HHSC. The ADMN stated the reason he had not completed those four intakes was because he had waited on documents from agencies to give him the completed documents needed for those intakes. He stated he himself as ADMN monitored the reports in making sure they were being completed for a timely submission. He stated the negative impact on residents would be different for each, as it depended on the allegation. He stated his expectations for self-reporting would have been to submit to HHSC with-in 5 business days as per facility policy and procedures. During an interview on 03/22/2024 at 8:57 AM, the DON stated the ADMN as well as herself investigated the previous facility self-reports together and depended on what the allegations were. She stated the self-reports should have been completed in a timely manner as it helps in preventing any further allegations with protecting the residents as well. She stated with investigating in a timely manner, it aided in correcting the problems that arise. The DON stated after the allegations were investigated, they should be followed up with in-services and trainings. She stated the facility self-reports were put into place to protect residents further from whatever the allegations may have been. She stated she believed the facility investigations should have been completed and turned into HHSC with 5 business days with all of the evidence for investigation gathered as well as the conclusion of the outcome. Record Review of facility policy Form 3613-A, SNF updated date of 03/23/2023 revealed: Purpose: The purpose to this form is to furnish a standardized format for long-term care (LTC) providers to document their self-reported incident investigation summary, analysis and finding(s) in accordance with regulatory requirements. Procedure: After making an oral via 800#, submit Form 3613-A, Provider Investigation Report, with statements and other relevant documentation, within the applicable regulatory time frame: Five working days for NF's Investigation Report Fax Cover Sheet should include: HHSC Intake ID No, Provider Type, Incident Category, Incident Date, Time and Location, Individual(s) or Resident(s) Involved in the Incident, Alleged Perpetrator(s), Witness(es), Description of the Allegation, Investigation Summary, Investigation Findings, Provider Action Post-Investigation and Signature Section. Record Review of facility Inservice Training Attendance Roster dated 03/19/2024 revealed: One-on-One Inservice Training topic: 3913-A Instructor: Facility RCO Employee attendance: ADMN Follow-Up Activities: Will CC Regional RCO on all reports. Record review of facility policy Abuse/Neglect dated 2003 with a revision date of 10/04/2022 revealed: The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility E. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC . .4. A report to the appropriate agency will include the following: e. the nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of resident or misappropriation of resident property. f. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form 8. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property by the companies employees as set forth in state law (including to the state survey and certification agency).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care for 2 (Resident #110 and Resident #258) of 6 residents reviewed for baseline care plans. The facility failed to complete Resident #110 and Resident #258's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Resident #110 Record review of Resident #110's face sheet dated 03/23/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 03/02/2024, with the following diagnoses: Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), iron deficiency anemia (insufficient iron), dementia, insomnia (inability to sleep), hypertension (high blood pressure), constipation, and difficulty in walking. Record review of Resident #110's entry MDS dated [DATE] revealed resident was admitted on [DATE] with no evidence of BIMS score. Record review of Resident #110's baseline care plan dated 03/18/2024 revealed care plan was completed on 03/18/2024 more than 48 hours after admission, he could not communicate easily with staff, he was able to understand staff, he wore glasses, he had DNR (do not resuscitate) code status, he had allergies to the following medications: iodine and povidone iodine, and his goals were to remain in facility. Resident #258 Record review of Resident # 258's face sheet dated 03/23/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 03/08/2024 and the following diagnoses: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Parkinsonism (slow movement, rigidity and problems with walking), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). Record review of Resident #258's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 9 meaning moderate cognitive impairment. Record review of Resident #258's baseline care plan dated 03/19/2024 revealed care plan was completed on 03/19/2024 more than 48 hours after admission, he could communicate easily with staff, he was able to understand staff, he wore glasses and hearing aids, he was a full code meaning wanted resuscitation, he had allergies to the following medications: codeine, Lexapro, and Vasotec, and his goal was to return to community. During an interview on 03/23/2024 at 3:07 p.m., the DON stated she was responsible for completing baseline care plans. She stated baseline care plans needed to be completed within the first 24 hours after admission. She stated the failure occurred because of multiple nurses quitting that caused her to work as a direct care staff that lead to her being behind on her duties. The DON stated the effect of not completing baseline care plans timely could cause resident needs not being readily available to nursing staff. Record review of facility policy titled; Care Plans revised on 10/04/2022 revealed: The facility will develop a Base Line Care Plan within 48 hours of each resident's admission that includes but not limited to a short-term and long-term objective and timetables to meet resident's medical, nursing, and mental and psycho-social needs that are identified on admission care plan will be reviewed and approved by an R.N.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #30, Resident #33, and Resident #38) of 6 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plan that included preventative pressure ulcer interventions for Resident #30. The facility failed to update care plan with current dental care needs for Resident # 33. The facility failed to develop care plan that included smoking care needs for Resident #38. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #30 Record review of Resident #30's face sheet dated 03/21/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 11/04/2020 and the following diagnoses: Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), contracture of right and left hands (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), and cognitive communication deficit. Record review of Resident #30's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior BIMS score of 1 (severe cognitive impairment); Section GG- Functional Abilities and Goals revealed helper does all of the effort for rolling left and right in bed, sit to lying, and chair to bed transfer; Section M- Skin Conditions revealed resident was at risk of developing pressure ulcers and had no pressure ulcers but used pressure reducing device for chair. Record review of Resident #30's care plan dated 10/16/2023 revealed: Resident #30 had an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility with Goal: will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Date initiated: 11/17/2020 Revision on: 06/25/2021 Target date: 10/05/2023 .Interventions/Tasks: requires skin inspection q (every) week. Observe for redness, open area, scratches, cuts, bruises and report changes to the Nurse .requires lifter sheet to turn and reposition .resident is totally dependent on staff for repositioning and turning in bed. Resident #30 had limited physician mobility r/t (related to) disease process Parkinson's Disease with Goal: will remain free of complications related to immobility, including .skin-breakdown .Interventions/Tasks: requires (2) staff participation for mobility Date initiated: 11/17/2020 Revision on 06/25/2021. PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN (as needed) Date Initiated: 11/17/2020. Record review of Resident #30's care plan dated 01/11/2024 revealed: Resident #30 had stage 3 pressure ulcer to his buttocks due to hx (history) of ulcers, immobility, and incontinence of bowel and bladder. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date .Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness Date Initiated: 12/28/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 12/28/2023. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 12/28/2023. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 12/28/2023. Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 12/28/2023. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 and the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness, and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment); Section L- Oral/Dental Status mouth or facial pain, discomfort or difficulty with chewing. Record review of Resident #33's care plan dated 3/7/2024 revealed Resident #33 had oral/dental health problems r/t recent tooth extractions; mouth pain Date Initiated: 8/10/2021 Revision on: 11/16/2022. During an observation and interview on 03/19/24 9:14 a.m., Resident #33 stated her teeth were removed when she was admitted on 08/2021. Resident #33 stated she had received dentures, but they did not fit and were sent back over the summer. Resident #33 showed her teeth, gums appeared to be healed, no irritation or bleeding. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment); Section J- Health Conditions revealed resident used tobacco. Record review of Resident #38's care plan dated 02/13/2024 revealed no evidence of smoking monitoring or care. During an observation and interview on 03/23/2024, Resident #38 was coming in from outside. Resident #38 stated he had been out on smoke break, no concerns expressed. During an interview on 03/21/2024 at 9:56 a.m., RN H stated when a new wound was reported to her, she would assess wound and LVN M would update the care plan. She stated she had been working as the treatment nurse for the last 3 weeks and had attempted to update care plans when she discovered the care plans needed updating .She was able to update the care plans, but LVN M updated more since RN H performed the MDS assessments. During an interview on 03/22/2024 at 8:29 a.m., LVN M stated she performed the MDS assessments. She stated she does look in residents record to make sure Braden risk assessment had been performed so that she would know how much at risk a resident was for pressure ulcers prior to documenting on assessment. She stated if a resident had a risk for skin breakdown, it should have been care planned. She stated not having the risk for pressure ulcers on care plan could cause harm to resident such as pressure ulcer formation from staff not knowing that resident was at risk or interventions to perform. LVN M stated she and the DON monitored care plans. She stated when a care plan needed to be updated prior to MDS assessment, she or the treatment nurse could update. She does not know why pressure ulcer prevention was not mentioned on care plan prior to pressure ulcer formation. During a follow up interview on 03/23/2024 at 2:48 p.m., LVN M stated she was responsible for ensuring care plans were completed. She stated care plans should include anything related to resident care, active diagnosis, and medications. She stated when acute needs occur, the interdisciplinary team updates care plans. The effect of care plans not being accurate would have on residents could make them not receive care they want or treatment against their wishes. LVN M stated smoking status and code status should be incorporated in care plans. LNV M stated goals should be updated and resolved in care plans. She stated that she had overlooked Resident #38s smoking status. During an interview on 03/23/2024 at 3:07 p.m., the DON stated LVN M was responsible for comprehensive care plans. She stated her expectation was the resident's needs, medications, and active diagnosis be incorporated in the care plans. She stated smoking status and pressure ulcer prevention should be incorporated in care plans. She stated care plans not being updated with current needs could cause resident to not have quality of care they deserve. She felt the failures occurred due to lack of communication between staff members and MDS coordinator LVN M. She stated care plans are updated as new concerns arise and quarterly. She stated an interdisciplinary team included MDS coordinator, DON, Social Worker, Therapy, Dietary, and Activities review care plans. Record review of facility policy titled Care Plans revised on 10/04/2022 revealed: The facility will develop a Comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident=s medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment. Record review of facility policy titled Skin Integrity Management revised on 03/07/2007 revealed: Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure sores must be completed. The Director of Nurses or designee does this.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 3 of 3 residents (Residents #1, #2, and #6) reviewed for respiratory care. The facility failed to ensure that Residents #1, #2 and #6 oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen at risk of respiratory complications and/or possible respiratory infections. Findings included: Resident #1 Record Review of the resident #1's Face Sheet dated 03/23/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 02/18/2023. Resident #3 had a Diagnoses of COPD (Chronic obstructive pulmonary disease, a group of diseases that cause airflow blockage and breathing-related problem). Resident #1's MDS, dated [DATE], Section C revealed a BIMS score of 09 (moderately impaired). Section O revealed Resident #1 was on Oxygen therapy while a Resident, 7 number of days this therapy was administered for at least 15 minutes a day in the last 7 days. Resident #1's Care Plan dated 02/08/2024 revealed: Focus-Congestive Heart Failure, Goal-Will have clear lung sounds .within normal limits. Will verbalize less difficulty breathing (Dyspnea) and be more comfortable. Interventions- Oxygen therapy 2-4 L/min titrate to keep sats > 90 %as ordered. Resident #1's physician orders dated 03/13/2024 revealed: Oxygen @ 5L/min via NC q shift every shift and Change Oxygen and Nebulizer tubing and clean concentrator filter every 2 weeks on Sundays every night shift every 2 weeks on Sunday. During observations on 03/18/2024 at 10:42 AM, Resident #1 had Oxygen on via nasal cannula with undated oxygen tubing. During interview on 03/18/2023 at 10:42 AM, Resident #1 was unable to answer due to cognitive impairment when the tubing had been changed. Resident # 2 Record Review of the Resident #2's Face Sheet dated 03/19/2024, revealed she was a [AGE] year-old female, admitted to the facility on [DATE], with an initial admit on 09/17/2019. Resident #2 had a diagnosis of Acute Pulmonary Edema (the heart is not able to pump efficiently, blood can back up into the veins) and Respiratory Failure. Review of Resident #2's MDS, dated [DATE], Section C revealed a BIMS score of 08 (moderately impaired). Resident #2 was on Oxygen therapy while a Resident. During interview on 03/18/2023 at 10:42 AM, Resident #2 was unable to answer due to cognitive impairment when the tubing had been changed. Review of Resident #2's Care Plan dated 03/07/2024 revealed: Focus- Oxygen Therapy r/t respiratory illness with date Initiated: 11/20/2022. Goal-will have no s/sx of poor oxygen absorption. Interventions- . provide extension tubing or portable oxygen apparatus. Monitor for s/sx of respiratory distress. Resident #2 has, O2 via nasal prongs @ 2-5L/min to keep sats >90%. Review of Resident #2's physician orders dated 03/13/2024 revealed: Monitor oxygen saturation every shift. Apply PRN O2 AT 2-5L/MIN VIA N/C as per PRN order. During an observation on 03/18/2024 at 10:35 AM, Resident #2 had oxygen on via nasal cannula with undated oxygen tubing. Resident #6 Record Review of the resident #6's Face Sheet dated 03/19/2024, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with initial admit on 06/18/2023. Resident #3 had a diagnosis of shortness of breath, and heart failure, and chest pain. Resident #6's MDS, dated [DATE], Section C revealed a BIMS score of 15 (cognitively intact). Resident #6's Care Plan dated 03/07/2024 revealed: Focus-altered cardiovascular status r/t HTN, heart failure. Goal- will be free from s/sx of complications of cardiac problems through the review date 05/15/2024. Interventions-Give oxygen as ordered by the physician. Focus- altered respiratory status r/t allergies, congestion, shortness of breath. Goal- Resident #6 will have no s/sx of poor oxygen absorption. Intervention- Monitor for s/sx of respiratory distress and Monitor/document/report abnormal breathing patterns. Resident #6's physician orders dated 03/07/2024 revealed: May use oxygen @2-3 l/m via nasal canula PRN to keep O2 sats > 90 % every 8 hours as needed. During observation on 03/19/2024 at 3:45 PM, Resident #6 had Oxygen on via nasal cannula with undated oxygen tubing. During an interview on 03/19/2024 at 11:21 AM, LVNG stated the Oxygen tubing had to be dated when changed out. She stated the nurses should change them out on the night shift on Sundays but would have depended on the physician order. LVNG stated if the tubing was not changed out it could cause the resident harm with a possible respiratory infection. She stated she did not know who monitored if the tubing was dated. She stated if the tubing was not dated, the nurse taking care of that resident would not have known exactly when it was changed. During an interview on 03/22/2024 at 8:36 AM, LVNM stated the facility policy for dating the oxygen tubing was that it should have been changed out at least every 7 days, but ultimately depended on the physician's order. She stated monitoring should had been the charge nurse for that resident in making sure all oxygen tubing was dated when changed. LVNM stated this could harm the residents that used oxygen causing them to have respiratory infections. She stated the failure occurred with the charge nurses, with her expectations being to date all oxygen tubing when changed out. During an interview on 03/22/2024 at 8:49 AM, the DON stated the oxygen tubing should have been changed out on the night shift every Sunday and dated when done so. She stated it should be dated as to know when it needed to be changed out. She stated it was the charge nurses who monitored the oxygen tubing, but ultimately it was her as the DON who should monitor. She stated the negative impact to residents could have been the growing of bacteria in the oxygen lines. She stated the failure occurred with the nurses, with her expectations were that staff follow the order of the physicians. Record review of facility policy Oxygen Administration dated 2003 with Revision date of 02/13/2007 revealed: Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 3. The resident will be free from infection. Procedure: . 11. Change device and tubing when needed. Oxygenation administration equipment will be changed weekly and PRN.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed the ensure physician visits were conducted once every 30 days for 2 of 24 residents (Resident #3, Resident #20) and every 60 days for 4 of 24 residents (Resident #31, Resident #33, Resident #38, Resident #45) who were review for physician visits. The facility failed to have Resident #3 seen by physician at least once every 30 days for the first 90 days after admission since 10/03/2023. The facility failed to have Resident #20 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. Resident #20 was last seen on 11/09/2023. The facility failed to have Resident #31 seen by physician at least every 60 days after the first 90 days for the past year from 02/2023. Resident #31 was last seen 04/16/2023. The facility failed to have Resident #33 seen by physician at least every 60 days for the past year from 02/2023 and received one visit from facility physician on 11/07/2023. The facility failed to have of Resident #38's seen by a physician with a missed visit in 10/2023 and no physician visits after 11/21/2023. The facility failed to have Resident #45 seen by physician at least every 60 days after the first 90 days after admission on [DATE]. Resident #45 was last seen on 09/25/2023. This deficient practice could lead to a decline in health status or untreated conditions. Findings included: Resident #3 Record review of Resident #3's face sheet dated 03/23/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on [DATE]. Resident #3's diagnoses include: type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), Acidosis (Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration), Disorientation, and Hyperglycemia (high blood glucose). Record review of Resident #3's entry MDS dated [DATE] revealed resident was admitted on [DATE] with a BIMS score of 10 meaning moderate cognitive impairment. Record review of Resident #3 Physician Progress Notes revealed no time stamp when he was last seen by primary physician from last admission of 10/03/2023. Resident #20 Record review of Resident #20's facesheet revealed she was admitted to the facility on [DATE], with an initial admit date of 05/01/2023 with a diagnosis of lack of coordination Heart failure Pneumonia, Respiratory Failure and Urinary Tract Infections. Record review of Resident #20's MDS dated [DATE] revealed a BIMS of 09 (moderately impaired). Record review of Resident # 20's physician visits revealed she did not have an initial admission visit by a Physician and was not visited by a physician until 11/09/2023. Resident #31 Record review of Resident #31's face sheet dated 03/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes and high blood pressure. Record review of Resident #31's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (severe cognitive impairment). Record review of physician visit documentation revealed Resident #31 had missing physician visit between dates 4/16/2023 - 8/25/2023, & 9/25/2023 - 3/20/2024. The facility provided no evidence of physician visits for Resident #31 from 4/16/2023 to current date. Resident #33 Record review of Resident #33's face sheet dated 03/22/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 11/09/2021 and the following diagnoses: multiple sclerosis (neurological condition that causes damage to myelin producing symptoms like muscle weakness, vision changes, numbness, and memory issues), insomnia, muscle weakness, major depressive disorder, and anxiety. Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 10 (moderate cognitive impairment). Record review of Resident #33's electronic charting and paper review revealed: since February of 2023 there was one visit on 11/07/2023 with a facility physician. Resident #38 Record review of Resident #38's face sheet dated 03/22/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 05/16/2023, with the following diagnosis Type 2 Diabetes and Congestive Heart Failure. Record review of Resident #38's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 11 (moderate cognitive impairment). Record review of Resident #38's physician visits revealed a missed visit in 10/2023 and no physician visits after 11/21/2023. Resident #45 Record review of Resident #45's Facesheet dated 03/23/2024 revealed resident was a 72 yr-old female with an admission date of 03/13/2023 and a diagnosis of Dementia, Cognitive Communication deficit, and Hypertension. Record review of Resident #45 revealed resident was admitted on [DATE] and did not have an initial admission visit. The facility physicians last visit for Resident #45 was on 02/16/2024. The facility provided no evidence of resident's physician visits for 03/13/2023 through 09/25/2023. During an interview on 03/23/2024 at 3:59 PM, the ADMN stated it was his expectation that all residents be seen by the Physician per facility policy. He stated it was the responsibility of the DON, MDS and ADMN to monitor physician visits. The negative effect for residents could be diagnoses being missed or possible medications needed. The ADMN stated in missed visits, it could have presented challenges to the resident and their plan of care. He stated the failure was due to the lack of follow up with physicians getting their documentation entered or submitted into the resident electronic records. During an interview on 03/23/24 at 4:26 PM, the DON stated the physician was to see the resident within the first 24-72 hours for a new admission with in-putting progress notes at least every 60 days. She stated Medical Records was to monitor physician visits. The DON stated all physician visits and progress notes should have been in the resident electronic charting, but the physicians were not great about turning them in to her and sometimes have to call the Medical Director and ask for them. She stated the negative impact to residents were the possibility of residents having issues that could be elevated or escalated before the physician can see them. The DON stated her expectations were for the physician to visit at least every 30 days and documenting in the resident medical records in a timely manner. Record review of facility policy Physician Services Guidelines with the revised date if 10/04/2022 revealed: Physician Visits: Medical care of each resident must be supervised by a physician. The physician must visit based on a frequency noted below and must review the resident's total program of care, including medications and treatments, at each visit and write, sign and date progress notes. Also, all orders must be signed and dated. 1. The initial comprehensive visit may not be performed by a PA, NP, or CNS. 2. admission order may not be performed by a PA, NP or CNS. 3. Other required visits and orders may be performed and signed by PA, MP or CNS. Physician Orders: Monthly orders can be reviewed and signed on each scheduled visit. Oral/telephone order should be signed and dated by the position in a timely manner. Physician Progress Notes: The progress note should reflect the review of the resident's total program of care and should include the following items as applicable: 1. Change in diagnosis 2. Cognitive status 3. Change in weight 4. Progress and problems in meeting care plan goals 5. Measures taken to reach highest practical functional level (rehabilitative/restorative progress) 6. Status of specialized treatments and medical indications i.e., urinary catheter, tube feedings, decubitus care, etc.) Frequency: The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required and as indicated. Physician attendance at care plan meetings is not a prerequisite of participation. The physician my sign the care plan or add an ancillary order stating Care plan reviewed and approved.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 3 (Resident #24, Resident #41, and Resident #49) of 4 residents reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #24, Resident #41 and Resident #49's medication regimen review which had pharmacy recommendations. The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Resident #24 Record review of Resident #24's face sheet dated 03/20/2024 revealed a [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 12/17/2018 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), repeated falls, and anxiety. Record review of Resident #24's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 00 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #24's physician orders reviewed on 03/23/2024 revealed Ativan Tablet 0.5mg (lorazepam) give 1 tablet by mouth every 8 hours as needed for anxiety start date 12/14/2022 with no end date. Record review of Resident #24's medication administration record January 2024 - March 2024 revealed: -Ativan Tablet 0.5mg given on 1/1/2024 at 6:50 p.m., -Ativan Tablet 0.5mg given on 3/5/2024 at 10:00 p.m., and -Ativan Tablet 0.5mg given on 3/10/2023 at 12:03 p.m. Record review of Resident #24's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #24's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendation dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Resident #41 Record review of Resident #41's face sheet dated 03/20/2024 revealed an [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 02/28/2023 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), major depressive disorder, anxiety disorder, insomnia, and type 2 diabetes mellitus. Record review of Resident #41's annual MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 3 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder; Section N- Medications Antipsychotics were received on a routine basis and physician documented GDR as clinically contraindicated. Record review of Resident #41's physician orders reviewed on 03/20/2024 revealed: Quetiapine fumarate 25mg tablet (Seroquel) give 1 tablet by mouth at bedtime related to insomnia start date 2/28/2023 with no end date. Trazodone tablet 100mg give 1 tablet by mouth at bedtime for depression start date 02/28/2023 with no end date. Lorazepam tablet 0.5mg (lorazepam) give 1 tablet by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Lorazepam tablet 0.5mg give 2 tablets by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Record review of Resident #41's medication administration record January 2024 - March 2024 revealed: Resident #41 received quetiapine fumarate 25mg 1 tablet every night at 9:00 p.m. and trazodone 100mg tablet every night at 9:00 p.m. Resident #41 received lorazepam 0.5mg 1 tablet on 2/29/2024 at 10:00 a.m. Record review of Resident #41's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 5/15/2023. Physician signature with rational Patient is on hospice documented but no indication of duration observed. Record review of Resident #41's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #41's pharmacy recommendations dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #41's pharmacy recommendations dated 02/23/2024 revealed that pharmacist recommended: Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Trazodone 100mg qhs since 223 consider 50mg qhs. Seroquel 25mg qhs since 223 consider d/c? If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Resident #49 Record review of Resident #49's face sheet dated 03/20/2024 revealed a [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 09/25/2023 and the following diagnoses: morbid obesity, vascular dementia (dementia caused by blood flow issues), adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood, altered mental status, and weakness. Record review of Resident #49's quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 6 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #49's physician orders reviewed on 03/20/2024 revealed: Lorazepam Tablet 1mg give 1 tablet by mouth every 8 hours as needed for anxiety start date 10/24/2023 with no end date. Record review of Resident #49's medication administration record January 2024 - March 2024 revealed: Lorazepam Tablet 1mg given on 1/1/2024 at 2:45 a.m. Lorazepam Tablet 1mg given on 1/4/2024 at 2:00 a.m. and 4:21 p.m. Lorazepam Tablet 1mg given on 1/5/2024 at 7:26 p.m. Lorazepam Tablet 1mg given on 1/6/2024 at 11:52 a.m. Lorazepam Tablet 1mg given on 1/7/2024 at 6:41 p.m. Lorazepam Tablet 1mg given on 1/8/2024 at 3:00 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 1/10/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 1/11/2024 at 11:23 p.m. Lorazepam Tablet 1mg given on 1/12/2024 at 8:57 a.m. Lorazepam Tablet 1mg given on 1/13/2024 at 9:07 a.m. Lorazepam Tablet 1mg given on 1/16/2024 at 12:00 a.m. Lorazepam Tablet 1mg given on 1/18/2024 at 12:45 a.m. and 10:45 p.m. Lorazepam Tablet 1mg given on 1/20/2024 at 6:31 a.m. Lorazepam Tablet 1mg given on 1/21/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 1/24/2024 at 9:32 a.m. Lorazepam Tablet 1mg given on 1/25/2024 at 7:49 a.m. Lorazepam Tablet 1mg given on 1/28/2024 at 4:00 a.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 1/29/2024 at 9:41 a.m. Lorazepam Tablet 1mg given on 1/30/2024 at 10:30 a.m. Lorazepam Tablet 1mg given on 2/1/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 2/2/2024 at 10:30 p.m. Lorazepam Tablet 1mg given on 2/3/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/5/2024 at 8:01 a.m. and 9:21 p.m. Lorazepam Tablet 1mg given on 2/6/2024 at 7:01 a.m. Lorazepam Tablet 1mg given on 2/9/2024 at 8:56 a.m. Lorazepam Tablet 1mg given on2/11/2024 at 11:00 a.m. Lorazepam Tablet 1mg given on 2/12/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/13/2024 at 9:21 a.m. Lorazepam Tablet 1mg given on 2/15/2024 at 7:10 a.m. Lorazepam Tablet 1mg given on 2/16/2024 at 4:21 p.m. Lorazepam Tablet 1mg given on 2/18/2024 at 4:32 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 2/19/2024 at 8:09 a.m. Lorazepam Tablet 1mg given on 2/21/2024 at 8:07 a.m. and 4:16 p.m. Lorazepam Tablet 1mg given on 2/22/2024 at 4:54 p.m. Lorazepam Tablet 1mg given on 2/24/2024 at 4:48 a.m. Lorazepam Tablet 1mg given on 2/25/2024 at 1:00 a.m. and 6:15 p.m. Lorazepam Tablet 1mg given on 2/26/2024 at 12:34 p.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 2/28/2024 at 1:37 a.m. and 7:08 p.m. Lorazepam Tablet 1mg given on 3/1/2024 at 4:11 p.m. Lorazepam Tablet 1mg given on 3/2/2024 at 8:42 a.m. and 11:20 p.m. Lorazepam Tablet 1mg given on3/3/2024 at 10:45 p.m. Lorazepam Tablet 1mg given on 3/4/2024 at 11:45 p.m. Lorazepam Tablet 1mg given on 3/8/2024 at 12:30 a.m. Lorazepam Tablet 1mg given on 3/9/2024 at 10:10 a.m. Lorazepam Tablet 1mg given on 3/10/2024 at 10:10 a.m. and 11:30 p.m. Lorazepam Tablet 1mg given on 3/12/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 3/16/2024 at 12:15 a.m. Lorazepam Tablet 1mg given on 3/17/2024 at 1:30 a.m. Lorazepam Tablet 1mg given on 3/19/2024 at 1:30 a.m. Record review of Resident #49's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Lorazepam since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #49's pharmacy recommendations dated 01/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 1mg PRN since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. During an interview on 03/19/2023 at 3:32 p.m., the DON stated she was responsible for ensuring pharmacy recommendations were completed. The DON stated when she received pharmacy recommendations, she faxed them to the physician's office and wrote pending down on recommendation form. The DON stated she did not follow up after she had faxed the recommendation to the physician. She did not state a negative outcome. She stated that she was unsure if facility policy had any timeframes on when she was expected to follow up with physician. Record review of facility policy titled Consultant Pharmacist Drug Regimen Review with no date reviewed on 03/19/2024 revealed: The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director of Nursing, the responsible physician, and the Medical Director, where appropriate .The Consultant Pharmacist provides the report to the responsible physician and the Director of Nursing within seven working days of review. The physician provides a written response to the report to the facility within (one month) after the report is sent. A copy of the report is kept by the facility until the physician's signed responses is returned. The physician response is provided to the Consultant Pharmacist for review and then filed by the facility. The facility maintains copies of signed reports on file for (at least one year).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #24, Resident #41, and Resident #49) of 4 residents reviewed for unnecessary medications. The facility failed to ensure Resident #24's, Resident #41's and Resident #49's PRN Ativan/lorazepam (medicine used to treat the symptoms of anxiety) were discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident #24 Record review of Resident #24's face sheet dated 03/20/2024 revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 12/17/2018 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), repeated falls, and anxiety. Record review of Resident #24's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 00 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #24's physician orders reviewed on 03/23/2024 revealed Ativan Tablet 0.5mg (lorazepam) give 1 tablet by mouth every 8 hours as needed for anxiety start date 12/14/2022 with no end date. Record review of Resident #24's medication administration record January - March 2024 revealed: Ativan Tablet 0.5mg given on 1/1/2024 at 6:50 p.m. Ativan Tablet 0.5mg given on 3/5/2024 at 10:00 p.m. Ativan Tablet 0.5mg given on 3/10/2023 at 12:03 p.m. Record review of Resident #24's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #24's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Record review of Resident #24's pharmacy recommendation dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 0.5mg q8hr PRN since 12/14/22. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing documented. Resident #41 Record review of Resident #41's face sheet dated 03/20/2024 revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date 02/28/2023 and the following diagnoses: dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), major depressive disorder, anxiety disorder, insomnia, and type 2 diabetes mellitus. Record review of Resident #41's annual MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 3 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder; Section N- Medications Antipsychotics were received on a routine basis and physician documented GDR as clinically contraindicated. Record review of Resident #41's physician orders reviewed on 03/20/2024 revealed: Lorazepam tablet 0.5mg (lorazepam) give 1 tablet by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Lorazepam tablet 0.5mg give 2 tablets by mouth every 2 hours as needed for Anxiety start date 12/28/2023 with no end date. Record review of Resident #41's medication administration record January - March 2-24 revealed: Resident #41 received lorazepam 0.5mg 1 tablet on 2/29/2024 at 10:00 a.m. Record review of Resident #41's pharmacy recommendations dated 10/19/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 5/15/2023. Physician signature with rational Patient is on hospice documented but no indication of duration observed. Record review of Resident #41's pharmacy recommendations dated 1/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #41's pharmacy recommendations dated 2/23/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. Lorazepam 0.5mg q2hr PRN since 12/28/2023. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Resident #49 Record review of Resident #49's face sheet dated 03/20/2024 revealed [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 09/25/2023 and the following diagnoses: morbid obesity, vascular dementia (dementia caused by blood flow issues), adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood, altered mental status, and weakness. Record review of Resident #49's quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 6 (severe cognitive impairment); Section I- Active Diagnoses including anxiety disorder. Record review of Resident #49's physician orders reviewed on 03/20/2024 revealed: Lorazepam Tablet 1mg give 1 tablet by mouth every 8 hours as needed for anxiety start date 10/24/2023 with no end date. Record review of Resident #49's medication administration record January - March 2024 revealed: Lorazepam Tablet 1mg given on 1/1/2024 at 2:45 a.m. Lorazepam Tablet 1mg given on 1/4/2024 at 2:00 a.m. and 4:21 p.m. Lorazepam Tablet 1mg given on 1/5/2024 at 7:26 p.m. Lorazepam Tablet 1mg given on 1/6/2024 at 11:52 a.m. Lorazepam Tablet 1mg given on 1/7/2024 at 6:41 p.m. Lorazepam Tablet 1mg given on 1/8/2024 at 3:00 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 1/10/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 1/11/2024 at 11:23 p.m. Lorazepam Tablet 1mg given on 1/12/2024 at 8:57 a.m. Lorazepam Tablet 1mg given on 1/13/2024 at 9:07 a.m. Lorazepam Tablet 1mg given on 1/16/2024 at 12:00 a.m. Lorazepam Tablet 1mg given on 1/18/2024 at 12:45 a.m. and 10:45 p.m. Lorazepam Tablet 1mg given on 1/20/2024 at 6:31 a.m. Lorazepam Tablet 1mg given on 1/21/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 1/24/2024 at 9:32 a.m. Lorazepam Tablet 1mg given on 1/25/2024 at 7:49 a.m. Lorazepam Tablet 1mg given on 1/28/2024 at 4:00 a.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 1/29/2024 at 9:41 a.m. Lorazepam Tablet 1mg given on 1/30/2024 at 10:30 a.m. Lorazepam Tablet 1mg given on 2/1/2024 at 11:00 p.m. Lorazepam Tablet 1mg given on 2/2/2024 at 10:30 p.m. Lorazepam Tablet 1mg given on 2/3/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/5/2024 at 8:01 a.m. and 9:21 p.m. Lorazepam Tablet 1mg given on 2/6/2024 at 7:01 a.m. Lorazepam Tablet 1mg given on 2/9/2024 at 8:56 a.m. Lorazepam Tablet 1mg given on2/11/2024 at 11:00 a.m. Lorazepam Tablet 1mg given on 2/12/2024 at 10:15 p.m. Lorazepam Tablet 1mg given on 2/13/2024 at 9:21 a.m. Lorazepam Tablet 1mg given on 2/15/2024 at 7:10 a.m. Lorazepam Tablet 1mg given on 2/16/2024 at 4:21 p.m. Lorazepam Tablet 1mg given on 2/18/2024 at 4:32 a.m. and 4:30 p.m. Lorazepam Tablet 1mg given on 2/19/2024 at 8:09 a.m. Lorazepam Tablet 1mg given on 2/21/2024 at 8:07 a.m. and 4:16 p.m. Lorazepam Tablet 1mg given on 2/22/2024 at 4:54 p.m. Lorazepam Tablet 1mg given on 2/24/2024 at 4:48 a.m. Lorazepam Tablet 1mg given on 2/25/2024 at 1:00 a.m. and 6:15 p.m. Lorazepam Tablet 1mg given on 2/26/2024 at 12:34 p.m. and 11:00 p.m. Lorazepam Tablet 1mg given on 2/28/2024 at 1:37 a.m. and 7:08 p.m. Lorazepam Tablet 1mg given on 3/1/2024 at 4:11 p.m. Lorazepam Tablet 1mg given on 3/2/2024 at 8:42 a.m. and 11:20 p.m. Lorazepam Tablet 1mg given on3/3/2024 at 10:45 p.m. Lorazepam Tablet 1mg given on 3/4/2024 at 11:45 p.m. Lorazepam Tablet 1mg given on 3/8/2024 at 12:30 a.m. Lorazepam Tablet 1mg given on 3/9/2024 at 10:10 a.m. Lorazepam Tablet 1mg given on 3/10/2024 at 10:10 a.m. and 11:30 p.m. Lorazepam Tablet 1mg given on 3/12/2024 at 11:30 p.m. Lorazepam Tablet 1mg given on 3/16/2024 at 12:15 a.m. Lorazepam Tablet 1mg given on 3/17/2024 at 1:30 a.m. Lorazepam Tablet 1mg given on 3/19/2024 at 1:30 a.m. Record review of Resident #49's pharmacy recommendations dated 12/18/2023 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Lorazepam since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. Record review of Resident #49's pharmacy recommendations dated 01/21/2024 revealed that pharmacist recommended: PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order: Ativan 1mg PRN since 10/24/23. Further review of pharmacy recommendation revealed no evidence of physician signature, rational for not reducing or discontinuing observed. During an interview on 03/19/2023 at 3:32 p.m., the DON stated that she was responsible for ensuring pharmacy recommendations were completed. The DON stated when she received pharmacy recommendations, she faxed them to the physician's office and wrote pending down on order form. The DON stated she did not follow up after she had faxed the recommendation to the physician. She did not state a negative outcome. The DON stated that some of the failures occurred as physicians have not wanted to discontinue the medications or put a stop date on the medications. Review of facility policy titled Psychotropic Medication Use dated February 1, 2022, revealed: A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Anti-psycotics Anti-depressants Anti-anxiety medications; and Hypnotics. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure the menu was followed for 9 of 9 (Residents #5, #12, #21, #19, #25, #30, #34, #15, #24) residents who received a pureed meal reviewed during the lunch meal. The facility failed to ensure residents receiving a pureed texture diet were provided the food according to the menu, including a garlic biscuit. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: During an observation on 03/18/024 at 10:15 AM, revealed a daily posted menu that reflected hamburger steak, brown gravy, zucchini, mashed potatoes, and a garlic biscuit. Record review of facility provided list of residents with Pureed diets revealed: Resident #5, Resident #12, Resident #21, Resident #19, Resident #25, Resident #30, Resident #34, Resident #15, and Resident #24 received a pureed diet. During an observation and interview on 03/18/2024 at 12:30 PM, revealed trays for residents who received a pureed diet did not receive a pureed garlic biscuit. The DM stated she had gotten busy and forgot to make the puree bread. The DM did not puree bread or substitute the pureed bread. The DM stated the residents that received a pureed diet should have received the pureed biscuit. The DM stated the effects on residents could have been weight loss and not getting the required calories and nutrients. The DM stated the supervisor should ensure the trays were accurate when they left the kitchen, and the nurses should check trays before food was passed to residents. The DM stated what led to failure of the bread not being pureed was she was running behind and forgot to puree the bread. During an interview on 03/20/24 at 10:33 AM, the Dietician stated residents who received a puree diet should have received all items listed on the menu. The Dietitian could not give a reason as to why the pureed bread was missed. The Dietician stated the effect on residents could have been the residents would not have received all their designated carbohydrates and calories. The Dietician stated the DM was responsible for monitoring. During an interview on 03/23/2024 at 3:52 PM the ADMN stated his expectation was that residents who received a puree diet received everything listed on the puree diet menu. The ADMN stated the effect on residents could have been potential for residents not receiving all their nutritional needs. The ADMN stated the DM was responsible for monitoring and ensuring that residents received all items on their menu. The ADMN stated oversite by the cook for that shift not looking at menu thoroughly led to failure of residents not receiving the pureed bread. Record review of facility polity titled, Resident Menus dated 2012, revealed Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutritional Board, National Research Council, adjusted to the age, activity, and environment of the group involved.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #30) of 6 residents reviewed for medical records. The facility failed to ensure Resident #30 had accurate weekly skin assessments and accurate pressure ulcer assessments. These failures place residents at risk of health and safety due to inaccurate assessments. Findings included: Record review of Resident #30's face sheet dated 03/21/2024 revealed an [AGE] year-old male originally admitted on [DATE] with most recent readmission on date 11/04/2020 and the following diagnoses: Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), dementia, muscle wasting and atrophy (a wasting or thinning of muscle mass), contracture of right and left hands (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), and cognitive communication deficit. Record review of Resident #30's annual MDS dated [DATE] revealed, Section C- Cognitive Behavior BIMS score of 1 (severe cognitive impairment); Section GG- Functional Abilities and Goals revealed helper did all of the effort for rolling left and right in bed, sit to lying, and chair to bed transfer; Section M- Skin Conditions revealed the resident was at risk of developing pressure ulcers and had no pressure ulcers but used a pressure reducing device for the chair. Record review of Resident #30's care plan dated 10/16/2023 revealed: Resident #30 had an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility with Goal: will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Date initiated: 11/17/2020 Revision on: 06/25/2021 Target date: 10/05/2023 .Interventions/Tasks: requires skin inspection q (every) week. Observe for redness, open area, scratches, cuts, bruises and report changes to the Nurse .requires lifter sheet to turn and reposition .resident is totally dependent on staff for repositioning and turning in bed. Resident #30 had limited physician mobility r/t (related to) disease process Parkinson's Disease with Goal: will remain free of complications related to immobility, including .skin-breakdown .Interventions/Tasks: requires (2) staff participation for mobility Date initiated: 11/17/2020 Revision on 06/25/2021. PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN (as needed) Date Initiated: 11/17/2020. Record review of Resident #30's care plan dated 01/11/2024 revealed: Resident #30 had stage 3 pressure ulcer to his buttocks due to hx (history) of ulcers, immobility, and incontinence of bowel and bladder. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date .Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness Date Initiated: 12/28/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 12/28/2023. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 12/28/2023. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 12/28/2023. Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 12/28/2023. Record review of Resident #30's physician's orders dated 03/21/2024 revealed: Assess all areas of skin. This should be done weekly. Record review of Resident #30's weekly skin assessment page revealed no evidence that skin assessments were performed as ordered on: 07/07/2023, 09/29/2023, 10/13/2023, 10/20/2023, 11/10/2023, 12/22/2023, 1/26/2024, 2/2/2024, 2/16/2024, and 3/8/2024. Record review of Resident #30's weekly pressure ulcer assessment page revealed no evidence that a pressure ulcer assessment was performed on 3/8/2024. During an interview on 03/20/2024 at 3:40 p.m., LVN K stated that she was not responsible for doing the weekly skin assessments. She stated the treatment nurse was who performed the weekly skin assessments. During an interview on 03/21/2024 at 9:31 a.m., LVN L stated charge nurses had been responsible for weekly skin assessments prior to March 2024 but now the treatment nurse performed. She stated she was unsure why weekly skin assessments were not documented on 7/7/2023, 9/8/2023, 9/29/2023, 10/13/2023, 10/20/2023, 11/10/2023, 12/22/2023, 1/26/2024, 2/2/2024, 2/16/2024, and 3/8/2024 for Resident # 30. She believed that skin assessments were probably done but that the nurse failed to document in the resident's chart. She stated that skin assessments should have been documented weekly in resident's chart. She stated that she did not know why pressure ulcer assessment had not been performed on 3/8/2024 and stated that she was unsure if she worked on that day. During an interview on 03/21/2024 at 9:56 a.m., RN H stated she was the treatment nurse. She stated she did weekly skin assessments when she was in the building. She stated that prior to her working at facility, the charge nurses were doing the weekly skin assessments. She stated she had worked for facility for 3 weeks and one week (the week of 3/8/2024) she had not worked because she was sick. During an interview on 03/21/2024 at 12:58 p.m., the DON stated her expectation would be that skin assessments be performed weekly by the treatment nurse. She stated that herself and the ADON monitored that skin assessments were done by performing random chart audits. The DON stated charge nurses were responsible for performing weekly skin assessments when treatment nurse not present and performed prior to her position being filled. She stated she was unaware why skin assessments had not been performed. She would not state a negative effect missing skin assessments would have on Resident #30. She stated she believed that skin assessments were being performed and that she had witnessed it by walking down the hall. She did not know why the assessments had not been documented in the resident's chart. Review of facility policy titled Skin Integrity Management revised on 03/07/2007 revealed: Skin Integrity management will be maintained by weekly skin assessments completed by charge nurse.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (CNA I, LVN L and RN H) of 6 staff and 2 of 2 linen carts reviewed for infection control practices. The facility failed to ensure CNA I and RN H performed hand hygiene when changing gloves at the appropriate times while providing resident care. The facility failed to ensure LVN L sanitized the glucometer in between residents when obtaining blood sugars. The facility failed to ensure clean linens remained in clean and covered environment free from cross contamination from residents. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: During an observation and interview on 0/18/2024 at 2:20 p.m., revealed RN H performed wound care. She sanitized her hands and put on gloves prior to setting up the wound care supplies on wax paper. She removed her gloves and carried the wound care supplies into the resident's room. She put on another pair of clean gloves without performing hand hygiene. RN H provided wound care and replaced her gloves two more times during wound care without performing hand hygiene. RN H stated she was unsure if hand hygiene needed to be performed when changing out gloves. She stated she had worked for the facility for 3 weeks and she believed that she had training on infection control. RN H stated that not following infection control protocol during wound care could cause wound infection. During an observation and interview on 03/19/2024 at 1:20 p.m., revealed CNA I performed catheter care. She performed hand hygiene prior to putting on clean gloves. She replaced her gloves once during catheter care without performing hand hygiene in between the glove change. She stated that she had had infection control training. She stated she did not perform hand hygiene when changing out her gloves and that there was no ABHR dispensers in the resident's room. She stated the facility did not provide portable hand sanitizer, but it would have been in a large container. She stated she did not know what the facility policy stated regarding if hand hygiene would be needed in between changing out gloves. During an observation and interview on 03/18/2024 at 10:58 a.m., revealed LVN L performed blood sugar checks with a glucometer for 2 residents. She did not sanitize the glucometer before or after obtaining the blood sugar from each resident. LVN L stated the glucometer should have been cleaned before and after each resident. She did not know why she did not sanitize it but realized she did not when she sat down at the nurses' station. LVN L stated failing to sanitize equipment could cause transferring of bacteria from one resident to another. During an observation and interview on 03/20/2024 at 5:02 p.m., revealed Resident #33 sitting in a wheelchair on unit 1 touching the clean laundry after she flipped up the overlapping plastic flap of the linen cart. She then pulled the flap back into place and wheeled herself to a second clean laundry cart where she flipped up the overlapping plastic flap and went through the linens. The DON also observed the resident going through the clean laundry and no staff intervened. The DON stated it was not appropriate for the resident to get clean laundry from the cart. During a telephone interview on 03/21/2024 at 11:40 a.m., LVN F stated that she was the infection preventionist at the facility. She stated her expectation would be for staff to wipe down the glucometer in between resident use with sanitizing wipes in purple tops for no less than 2 minutes. She stated she felt being nervous from being observed led to the failure of LVN L not sanitizing the glucometer. She stated that the effect of not sanitizing equipment could lead to the spread of infection. She stated she monitored that staff were sanitizing equipment weekly with check offs. LVN F stated she expected staff would perform hand hygiene in between changing out their gloves. She stated she felt being nervous from being observed led to both CNA I and RN H not performing hand hygiene in between glove changes. She stated that ABHR was not available in the residents' rooms. LVN F stated the facility had portable ABHR that staff can ask for to carry in their pockets and it had been passed out to them in the past. She stated that staff are trained on infection control and she posts the master infection control policy at both nurses' stations for staff to refer to. She monitors that they are following the policy by performing weekly check offs. She stated the negative effect on the residents would be spreading infection. LVN F stated that it was not appropriate for residents to go through clean linen carts on the hallway. She stated that residents have been informed not to do so and she was not sure why the resident felt need to go through clean linen. She stated it could lead to contamination of linens that could spread infection. Record review of facility in-service titled Disinfecting Small Equipment dated 10/06/2023 revealed: Cleaning of small equipment related to disinfecting. All small equipment to include but not limited to: 1. Thermometer 2. Pulse Ox 3. Glucometer 4. Blood pressure cuff, etc. Must be cleaned between clients. Process or disinfecting is to wipe the device completely, outer and inside surfaces with available disinfecting wipe. Please use wipes and apply designated kill times to ensure adequate time is taken between use. LVN L's signature was on the attendance sign in sheet. Record review of the facility policy titled Infection Control Policy & Procedure Manual dated 2003 revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene .before and after assisting a resident with personal care .before and after changing a dressing .after removing gloves or aprons .Gloving. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves .Resident care equipment and articles .non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistance.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly. The facility failed to ensure that food items were disposed of properly. The facility failed to ensure the freezer was free from loose food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 03/18/2024 between at 10:15 AM too 10:45 AM of the kitchen revealed: Refrigerator 1. 2 gallon jugs of sweet tea without an open or use by date 2. 29 individual containers of chocolate milk with an expiration date of 3/17/2024 3. 9 individual foam containers with lids without a label identifying the item and were not dated Dry Storage 1. 1 package of taco seasoning in a plastic bag with a zipper not labeled with an open date 2. 1 plastic container filled with opened graham cracker crumbs with an open date of 03/13/2023 3. 15 opened loaves of bread not in the original box, not labeled with an item description, an open date or used by date 4. 15 opened packages of hamburger buns not in the original box, not labeled with an item description, an open date or used by date. 5. 10 opened packages of hotdog buns not in the original box, not labeled with an item description, an open date or use by date. Small chest freezer 1. Chunks of loose frozen chicken in bottom of freezer and a piece chicken stuck to the rim of the top of the freezer. During an interview on 03/18/2023 at 11:00 AM, the DM stated food removed from the original package should have been labeled with a receive date, open date and use by date. The DM stated items in the original package should have an open date. The DM stated items should have been disposed of if they were past the expiration date. The DM stated the effect on residents could have made them ill. The DM stated what led to failure was that staff forgot to label items and overlooked the dates. The DM stated that there should not have been loose food in the freezer, that if someone had spilt something they would have needed to clean it up. During an interview on 03/20/24 at 10:33 AM, the Dietician stated food items out of original package should have been labeled with an open date, use by date and item description date. The Dietician stated the DM was responsible for monitoring the kitchen. The Dietician could not provide a reason for what led to failure and she stated that everything needed to be labeled. The Dietician stated the failures could have caused adverse effects to the residents. The Dietician stated the freezer should not have loose food; all food should be sealed in a container. The Dietician stated if someone had spilled food into the freezer they should have cleaned it up when spilled. During an interview on 03/23/24 at 3:52 PM, the ADMN stated his expectation was that food be stored appropriately per policy and food should have been discarded when past use by date. The ADMN stated the DM was responsible for monitoring. The ADMN stated the effect on residents could have caused possible illness. The ADMN stated what led to failure was oversight and staff failing to verify storage areas for dates. Record review of facility policy titled, Food Safety, dated 2012 revealed: Food is to be tightly wrapped or sealed and covered in clean container. Open food shall be labeled, dated and stored properly .Do not keep potentially hazardous food in refrigerator pas the labeled expiration date. Record review of facility policy titled Storage Refrigerators dated 2012 revealed: Storage refrigerator shall be kept clean and organized. Spills are to be wiped up immediately. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 03/23/2023 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Feb 2023 7 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in 1 of 2 medication rooms in that: The facility failed to ensure that all medications were properly stored on Hall 200 storeroom medications were not past their expiration dates. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Observation of 1 of 1 medication storage room on 02/08/2023 at 10:39 AM revealed the following medications were found to be expired: 1. 8 syringes that contained ABH Gel (Ativan 1mg/Benadryl 12.5mg/Haldol 1 mg) Gel, in medication refrigerator, with expiration date of 10/21/2022. 2. 6-1000mg IV fluid bags of 0.9% Sodium Chloride Inj. USP with an expiration date of 04/2022. An interview on 02/08/2023 at 10:50 AM, LVN A stated, the charge nurses were responsible for their own medication rooms on their shifts. She also stated she did not usually use IV bags for residents other than when COVID-19 first came out in 2022. She said the expired IV bags must have been there since then. An interview on 02/08/2023 at 10:55 AM, the DON stated the charge nurses and/or med aides should check the med rooms for expired and discontinued meds on a monthly basis. She stated the negative impact to residents could have been a drug diversion. She stated each nurse's responsibility was to oversee the cleanliness and destroy expired medications. The DON stated she should have followed up with the storage rooms to make sure the nurses were monitoring and updating them when needed. She said the failures were, the nurses had not been monitoring the medication storage rooms closely enough. She stated it fell on all nurses and herself to follow up monthly, and said, she had not been doing that. Review of the facility policy titled Storage of Medications dated 2003, revealed; Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents of 2 of 3 medication carts reviewed for storage in that: The facility failed to ensure that all medications were properly stored in Hall 200 medication cart. The facility failed to ensure that all medications and supplies stored on Hall 100 cart were properly stored. This failure could result in a drug diversion. Findings included: Observation on 02/08/2023 at 09:36 AM with LVN-B of medication cart for #1 of 2 on hall 1, revealed: inthe 2nd drawer two loose pills, identified as: 1. 1 amitriptyline (antidepressant) 2. 1 lasix (water pill) An interview on 02/08/23 at 09:55 AM, LVN B stated there should be no loose pills in the cart. LVN B stated the cart was to be monitored every shift by the charge nurse or the nurse whose cart it belonged to for that shift. She also stated loose medications in the cart could be a cause for drug diversion. Observation on 02/08/2023 at 10:28 AM of 1 of 1 medication carts on hall 2 revealed the following medications were found to be loose in the second drawer of the medication cart: 1. 1 amitriptyline (antidepressant) 2. 2 Lasix (water pill) 3. Memantine HCL (antipsychotic) An interview on 02/08/2023 at 10:50 AM, LVN A stated, the charge nurses were responsible for their own medication carts on their shifts. An interview on 02/08/2023 at 10:55 AM, the DON stated the charge nurses and/or med aides should check the med carts for loose pills with every shift. She stated the negative impact to residents could have been a drug diversion. She stated each nurse's responsibility was to oversee the cleanliness of the carts including any loose meds and her as DON should have followed up with the medication carts being cleaned. She said the failures were the nurses had not been monitoring the medication carts. She stated it fell on all nurses and herself to follow up monthly, and said, she had not been doing that. Review of the facility policy titled Storage of Medications dated 2003, revealed; Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist residents to obtain or provide dental service for 1 of 1 resident (Resident #36) reviewed for dental service in that: The facility failed to arrange transportation for Resident #36 to her dental appointment. This failure could cause resident to have dental problems, which could cause pain, complications, and a poor quality of life. Findings include: Record review of Resident #36's admission Record, printed on 02/08/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Huntington's disease (neurological desease), and dysphasia (unable to speak clearly). Record review of Resident #36's Quarterly MDS, section L-Oral/Dental Status, dated 08/16/2022, revealed no natural teeth or tooth fragments. Record review of Resident #36's Care Plan, last updated 11/21/2022, revealed no updated information to clarify her dental plan. An interview on 02/06/23 at 01:44 PM, Resident #36 was unable to be understood while speaking, partly due to her diagnosis, (Huntington's disease) as well as her dentures being unsecure in her mouth. The resident's family member stated she was supposed to have had a dental appointment the morning of 02/06/2023 and asked the Admin why Resident #36 had not been transported. He also stated her gums were sore and painful due to her dentures being unsecure. An interview on 02/07/23 at 03:11 PM, the SW stated she had to reschedule Resident #36's dental appointment she missed the morning of 02/06/2022 due to staff being unavailable to transport her to the appointment. The SW stated the facility kept a calendar at the nurse's station, with residents' scheduled appointments and was supposed to had been reviewed, by the staff, the day before, or the morning of, to make arrangements for transportation. She said it was a complete oversite on the facility's part for Resident #36's denture follow-up and no excuses should be made, and they did not have a permanent driver since her hire date in 06/2022. An interview on 02/08/23 at 02:43 PM, the Admin stated the facility had been looking to hire transportation personnel but had not been successful. The Administrator stated they kept a transportation calendar at the nurse's station and it was a team effort to get residents to their appointments. The Admin stated it was unfortunate, the morning of 02/06/2023, things were busy, and the appointment was overlooked. He stated he had no previous concerns until the resident #36's family member approached him. The Admin stated the negative impact were to the residents health if they missed their appointment on a regular basis. He stated he felt his system was working even though a resident's appointment was missed and did not represent a trend. He also stated, it was a team effort to monitor who transported residents, but was ultimately his responsibility to make sure it was being done. He stated the failures were miscommunication between Admin as himself and all other upper management staff. His expectations were for the residents to be transported to their necessary appointments when scheduled. Record review of the facility's policy on Dental Services dated 01/2022 revealed It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. 'Emergency dental services' includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist . 'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g, taking impressions for dentures and fitting dentures.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 5 (Resident #10, Resident #103, Resident #203) residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #10's supra pubic catheter (a catheter placed directly in the urinary bladder through an ostomy, or hole, in the lower abdomen) identified in the comprehensive assessment. The facility failed to develop a comprehensive person-centered care plan to meet goals and address Resident #103's active diagnoses and care areas identified on Resident #103's MDS. The facility failed to develop a comprehensive person-centered care plan to meet goals and address Resident #203's active diagnoses and care areas identified on Resident 203's MDS. These failures placed residents at risk for not receiving the care needed to assist in attaining or maintaining their highest practicable well-being and prevent avoidable decline. Findings included: A record review of Resident #10's electronic face sheet, dated 01/11/23, revealed a [AGE] year-old male initially admitted on [DATE] and readmission on [DATE]. Resident #10's diagnoses included inability to move his legs, Type 2 diabetes, anxiety, chronic ulcers on both lower legs, depression, and problems with the nerves and muscles of his urinary bladder. Review of Resident #10's Annual MDS Section C Cognitive Patterns, line C0500. BIMS Summary Score revealed a BIMS score of 12 indicating mild cognitive impairment. The MDS Section H. Bladder and Bowel, H0100. Appliances, revealed A. Indwelling catheter and C. Ostomy were selected. Review of Resident #10's physician's orders dated 08/10/21 revealed Foley catheter 18F 10 CC care every shift. Check placement of catheter securing device, replace if missing or soiled to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. The physician's order dated 01/02/2022 revealed Keep area to S/P [supra pubic] catheter insertion clean and dry. Change 4x4 gauze and secure with tape daily and prn. Record review of Resident #10's Initial care plan dated 08/02/20 revealed in Item F. ADL Toileting: Unable to toilet self or self-manage incontinence; needs colostomy/catheter assist; requires formal bowel/bladder incontinence program. Section H. Incontinent Bladder, Indwelling foley/SP catheter was selected. Record review of Resident #10's Care Plan with last care plan review completed date of 01/02/23 revealed the catheter and ostomy care were not addressed. During an interview on 02/07/23 at 9:50 AM Resident #10 stated he had had the supra pubic catheter for a few months. He stated he had pain with the urethral catheter. Observation on 02/20/23 at 9:45 AM of Resident #10 revealed a urinary catheter with a closed drainage system hanging below the level of the tubing insertion site. Review of Resident #103's electronic face sheet revealed a [AGE] year-old female admitted [DATE]. Resident #103's diagnoses included dementia, unsteadiness on feet, difficulty communicating, osteoporosis, high blood pressure, weakness, high cholesterol, and arthritis. Review of Resident #103's admission MDS dated [DATE] revealed in Section B Hearing, Speech, and Vision, subsection B1200. Corrective Lenses 1. Yes, was selected. Section C Cognitive Patterns, subsection C0500 BIMS Summary Score of 2 indicating severe cognitive impairment. Section G. Functional Status subsection G0100. Activities of Daily Living (ADL) Assistance revealed Resident 103 required extensive assistance in the following areas: A. changing position in bed, B. transferring to or from bed, chair, and wheelchair, G. Dressing, and I. Toilet Use. Section G Functional Status, subsection G0600. Mobility Devices, C. Wheelchair was selected. Section H Bladder and Bowel, subsection H0300. Urinary Continence, 2. Frequently incontinent was selected, subsection H0400. Bowel Continence, 1. Occasionally incontinent was selected. Section J Health Conditions, subsection J0700. Fall History on Admission/Entry or Reentry, Yes was selected indicating the resident had a fall within 2-6 months prior to admission or reentry. Section K Swallowing/Nutritional Status, subsection K0510. Nutritional Approaches, C. Mechanically altered diet was selected. Section L Oral/Dental Status, Subsection L0200. Dental, B. No natural teeth or tooth fragment(s) was selected. Section M Skin Conditions, Subsection M0150. Risk of Pressure Ulcers/Injuries, Yes, resident is at risk of developing pressure ulcers/injuries was selected. Review of Resident #103's physician's orders dated 02/06/23 revealed Obtain weekly vital signs every evening shift every Monday, and Pain assessment q shift using PAINAD/Dementia Scale 0-10 Pain Intensity Goals 0-2 every shift. Review of Resident #103's initial care plan dated 01/16/23 revealed in section C. Vision and Hearing 2. Hearing: Hearing impaired in right ear and left ear was selected. Review of Resident #103's comprehensive care plan dated 01/20/23 revealed a focus of risk for contracting COVID-19. No additional focus areas were listed. Record review of Resident #203's electronic face sheet revealed resident was an [AGE] year-old female admitted on [DATE]. Resident #203's diagnoses included a fractured left upper leg, weakness, difficulty walking, weakness, difficulty communicating, low thyroid function, dementia, and anxiety. Review of the Resident #203's admission MDS dated [DATE] revealed in Section C Cognitive Patterns, Subsection C0500 BIMS Summary Score of 12 indicating moderate cognitive impairment. Section G. Functional Status Subsection G0100. Activities of Daily Living (ADL) Assistance revealed Resident #203 required extensive assistance in the following areas: A. changing position in bed, B. transferring to or from bed, chair, and wheelchair, and I. Toilet use. Resident 203 required limited assistance, one-person physical assist with G. Dressing, and J. Personal Hygiene. Subsection G0600. Mobility Devices: C. Wheelchair was selected. Section GG Functional Abilities and Goals subsection GG0130 Self-Care revealed Resident 203 required substantial/maximal assistance with C. Toileting hygiene, E. Shower/bathe self, G. Lower body dressing, and H. Putting on/taking off footwear. Section J. Health Conditions, subsection J0700 Fall History on Admission/Entry or Reentry revealed A. the resident had a fall within the last months prior to admission, and C. the resident had a fracture related to a fall in the 6 months prior to admission. Section L Oral/Dental Status, subsection L0200. Dental - D. Obvious or likely cavity or broken natural teeth was selected. Review of Resident #203's physician's orders dated 01/12/23 revealed Weight bearing as tolerated with assistance, Pain assessment q shift using PAINAD/Dementia Scale 0-10 Pain Intensity Goals 0-2 every shift, and Strict contact/droplet isolation. Resident to stay in room at all times, all meals, therapy, activities and ADL's to be completed in room. Review of Resident #203's initial care plan dated 01/11/23 revealed in section C. Vision and Hearing 1. Vision: Vision appliance used, 1c1. Glasses was entered. Section 2. Functional Status, subsection A. Functional Abilities and Goals - Self Care, Item 2. Personal Hygiene, One-person physical assist was selected, Item 3. Toilet use, Two+ persons physical assist was selected, Item 4. Dressing, One-person physical assist was selected, and Item 5. Bathing, one-person physical assist was selected. Subsection B Functional Abilities and Goals - Mobility, Item 1 Bed Mobility, Two + persons physical assist was selected, and 2. Transfer, Two+ persons physical assist was selected. Subsection C. Mobility Devices, 3. Wheelchair was selected. Section 3. Health Conditions, Subsection H. Safety Risks, 1. History of falls - b. Yes was selected. Section 4. Dietary, Therapy and Social Services, subsection A. Dietary/Nutritional Status, 7. Dietary risks, a. Risk for weight loss was selected. Review of Resident #203's comprehensive care plan dated 01/20/23 revealed a focus of risk for contracting COVID-19. No additional focus areas were listed. During an observation on 02/06/23 at 03:30 PM revealed Resident #203 was in a wheelchair in the hall drinking coffee. Resident #203 was aimlessly wandering and was unable to answer questions appropriately. During an interview on 02/08/23 at 09:06 AM LVN B stated the MDS coordinator was responsible for entering data to create a resident's care plan. She explained the data entered into the system populated a task list for CNAs and nurses. She stated the CNAs and nurses used the care plans to know what care a resident needed. LVN B stated resident information not included in a care plan could affect the quality of care a resident received such as putting a resident at risk for infection. During an interview on 02/08/23 at 02:40 PM LVN C, the MDS coordinator, stated she was responsible for creating care plans for an RN to review. She stated when a resident was admitted , she opened the care plan and began adding commonly used nursing diagnoses such as COVID-19 risk, diet, and code status. LVN C stated a majority of the information for the care plan came from the Care Area Assessment, Section V on the MDS. LVN C stated the system notified her when the care plan and updates were due. She explained when she created a care plan she addressed every diagnosis, medication, and used the physician's orders. She stated the corporate nurse developed a checklist to help capture all resident care needs on the care plan. LVN C stated she had 21 days from when the baseline care plan was created to complete a comprehensive care plan. She stated she may be a day or two late at times. LVN C stated the failure to enter all care needs could be due to human oversight. During an interview on 02/08/23 at 03:00 PM the DON stated training on care plans was done by the corporate nurse. The DON stated she was responsible for spot checking care plans for completeness. The DON explained the admission Coordinator started the admission process before a resident was admitted ensuring all necessary information was collected on the resident. The DON stated the nursing staff worked together to build the care plan and check to make sure nothing was missed. The DON acknowledged mistakes could happen. She stated the consequences of care areas not being addressed on a care plan could be infection, poor pain control, or adverse events. She stated her expectation was for the nursing staff to work together to build an accurate care plan. Review of facility policy titled Care Plans revised 02/13/2007 Item 1.The facility will develop a Comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident's medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment. Item 3. The Comprehensive care plan must be developed within seven days after the completion of the comprehensive assessment.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 4 (DS C, DS E, DS F and DM) of 9 dietary staff reviewed for Food Handler's certificates. The facility failed to ensure that dietary staff DS C, DS E, DS F and DM serving in the kitchen were working with a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses due to lack of dietary staff training. Findings included: Record review of DS C's employee file revealed a hire date of 04/18/2022 and no evidence of a Food Handler's Certificate prior to 02/08/2023 . Record review of DS E's employee file revealed a hire date of 10/03/2022 and no evidence of Food Handler's Certificate prior to 02/07/2023. Record review of DS F's employee file revealed a hire date of 07/26/2022 and no evidence of Food Handler's Certificate prior to 02/07/2023. Record review of the DM's employee file revealed a hire date of 09/30/2019 and no evidence of Food Handler's Certificate prior to 02/07/2023. During an interview on 02/07/2023 at 9:45 AM the DM provided a few of her staff's food handler's certifications and stated she would have to look for the others. The DM stated some of her staff were missing their food handlers certificates because previous employers would not give them a copy. During an interview on 02/07/2023 at 11:30 AM the DM provided some of her staff's food handler's certificates that were dated today, 02/07/2023. The DM stated they were not able to locate certificates so they completed certificates today. During an interview on 02/08/23 at 11:01 AM the Dietician stated staff should have food handlers certifications, but she was not sure what the facility policy was or what the city code was. if what the city code is. The Dietician stated if the city code indicated they had to had it then they should have a food handler's certificate. She stated she didn't know what the different counties required since she had several facilities. During interview on 2/08/23 at 1:19 PM the ADMIN stated dietary staff should have their Food Handler's Certificates and the DM should maintain copies of current certificates. The ADMN stated the DM is responsible to ensure staff completed their Food Handler's Certificate and obtain a copy for the employee file. The ADMiN stated there was no affect to residents that he has seen. The ADMIN stated what led to failure was it was a process that needed to be managed by the DM and Human Relations. Review of Texas Food Establishment Rules accessed https://www.dshs.texas.gov/sites/default/files/foodestablishments/pdf/GuidanceDocs/TFER-2021_TAC-228_August-2021.pdf 02/09/2023 revealed on page 10: (d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. This requirement does not apply to temporary food establishments. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of the DM's employee file revealed a hire date of 09/30/19 as a DS, and a hire date of 3/29/2022 as the DM. There was no documented evidence of a Dietary Manager Certificate found in the file. During an interview on 02/07/2023 at 9:45 AM the DM stated she did not have her dietary manager certification. The DM stated she started working on her certification a few months ago, it was an online course. The DM stated she did not know when she would have it completed but thought it would be done by end of year. During an interview on 02/08/23 at 11:01 AM the Dietician stated she was working with the DM to complete her dietary manager certification. The Dietician stated she was not sure what the policy was for having a dietary manager. The Dietician stated she was not sure how much longer the DM had to complete the certification. During an interview on 2/08/23 at 1:19 PM the ADMIN stated it was his understanding it was best practice for the DM to have a certification. The ADMIN stated when she was hired, she did not have her certification and enrolled in a class and the expectation was she would complete the program within year. The ADMN stated the course was a self-pace online program. The ADMN stated he had not seen an effect on residents due to the DM not having her dietary manger certification. The ADMIN did not provide a reason for the failure of the DM not having her certification and his intention was to not have an uncertified person but to get them certified . Record review of Job Description Dietary Service Manager signed by the DM on 3/29/2023 revealed Current certification by state as required.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 02/06/2023 at 10:55 AM revealed DS E opened the door to the hallway and received a container of food from a resident. DS E sat the container on counter, then covered the pan of meat with foil and then placed it in the oven. DS E then touched his forehead, got vegetables out of the oven, dished vegetables out of the pan to another container to puree, and then put gloves on his hands, without performing hand hygiene the entire time. During an observation on 02/06/2023 at 11:30 AM revealed DS E did not perform hand hygiene or place gloves on his hands before he started to take the temperatures of the food. While taking temperatures of the food DS E placed cornbread in the oven, touched his phone, went back to taking food temperatures, took cornbread out of oven, touched his phone, touched his face, cut cornbread and then put gloves on his hands without performing hand hygiene. During an observation on 02/07/2023 between 11:20 AM and 11:45 AM revealed DS E setting up the food to serve for lunch. DS E put gloves on his hands without performing hand hygiene and started serving lunch. DS E picked up a roll with his gloved hand, then touched his face with his gloved hand and picked up another roll with the same gloved hand without performing hand hygiene or changings gloves. DS E repeated this several times while serving the lunch meal. DS E was observed washing his hands at one time but only used cold water to wash hands; turned the water off with his washed hands and then got a paper towel to dry hands. During an interview on 2/6/2023 at 11:00 AM the DM stated hand hygiene should happen any time the change tasks. The DM stated hands should be washed after touching the face, adjusting a mask or touching a phone . During an interview on 02/07/2023 at 9:45 AM the DM stated hand hygiene should happen every time they changed tasks. The DM stated failing to perform hand hygiene could affect residents by spreading bacteria to their food. The DM stated she monitors staff by watching staff while they are working, and also have hand hygiene checks weekly. The DM stated what lead to failure of staff not using proper hand hygiene was that staff were nervous because state was watching them. During an interview on 02/07/2023 at 10:00 AM DS E stated he had received training on proper hand hygiene . DS E stated he should have washed his hands after touching his face or phone and when he finished a task. DS E did not provide a reason for not washing his hands. During an interview on 02/08/23 at 11:01 AM the Dietician stated staff should have performed hand hygiene when they move from one task to another, when they change gloves, touch their face, or touch their phone. The Dietician stated failure to use appropriate hand hygiene could have caused residents to be exposed to foodborne illness. During interview on 2/08/23 at 1:19 PM the ADMIN stated his expectation was that staff follow hand hygiene policy. The ADMIN stated the DM was responsible to ensure that staff followed hand hygiene policy. The ADMIN stated what led to failure was staff needed additional training to be more aware. Review of CMS form 672 date 1/09/2023 revealed that 31 of 31 residents eat out of kitchen. Record review of the facility policy titled, Fundamentals of Infection Control Precautions dated 10/21/2022 revealed, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty; Before and after eating or handling food (hand washing with soap and water); After removing gloves or aprons; and after completing duty. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), $62,078 in fines, Payment denial on record. Review inspection reports carefully.
• 29 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $62,078 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Western Hills Healthcare Residence's CMS Rating?

CMS assigns WESTERN HILLS HEALTHCARE RESIDENCE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Western Hills Healthcare Residence Staffed?

CMS rates WESTERN HILLS HEALTHCARE RESIDENCE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Western Hills Healthcare Residence?

State health inspectors documented 29 deficiencies at WESTERN HILLS HEALTHCARE RESIDENCE during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 26 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Western Hills Healthcare Residence?

WESTERN HILLS HEALTHCARE RESIDENCE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY, a chain that manages multiple nursing homes. With 158 certified beds and approximately 58 residents (about 37% occupancy), it is a mid-sized facility located in COMANCHE, Texas.

How Does Western Hills Healthcare Residence Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, WESTERN HILLS HEALTHCARE RESIDENCE's overall rating (2 stars) is below the state average of 2.8, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Western Hills Healthcare Residence?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Western Hills Healthcare Residence Safe?

Based on CMS inspection data, WESTERN HILLS HEALTHCARE RESIDENCE has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Western Hills Healthcare Residence Stick Around?

Staff turnover at WESTERN HILLS HEALTHCARE RESIDENCE is high. At 58%, the facility is 12 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 57%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Western Hills Healthcare Residence Ever Fined?

WESTERN HILLS HEALTHCARE RESIDENCE has been fined $62,078 across 1 penalty action. This is above the Texas average of $33,700. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Western Hills Healthcare Residence on Any Federal Watch List?

WESTERN HILLS HEALTHCARE RESIDENCE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 158
Avg. Residents: 58
Occupancy: 36.7%
Ownership: For profit - Limited Liability company
Chain: CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -5
3 Immediate Jeopardy citations: -36
29 Deficiencies: -10
Fines ($62,078): -10
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 455602