**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history if eloping and wore a wandergaurd, was provided with adequate supervision to prevent him from eloping from the facility on 03/28/25. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. 2. The facility failed to complete an elopement assessment for Resident #1 prior to his elopement on 03/28/25 The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 03/28/25 and ended on 04/01/25. The facility had corrected the non-compliance before the survey began. These failures placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's Face Sheet, dated 05/06/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: dementia, gout (a form of inflammatory arthritis caused by the buildup of uric acid crystals in the body, leading to sudden, severe pain, swelling, and redness in one or more joints), acute kidney failure, Type 2 diabetes, oropharyngeal dysphagia (difficulty swallowing that specifically occurs in the oral cavity and throat), lack of coordination, and major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 03/11/25, revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. In Section P0200. Alarms indicated Resident #1 had a Wander/elopement alarm. Record review of Resident #1' Care Plan, dated 02/21/25, revealed: Focus: [Resident #1] use psychotropic medications r/t Dementia. Date Initiated: 06/20/2024 Revision on: 04/18/2025 Cancelled Date: 04/16/2025 Goal: [Resident #1] will be/remain free of drug related complications. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Discuss with MD, family re ongoing need for use of medication. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Monitor/record occurrence for target behavior symptoms like pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. Date Initiated: 06/20/2024 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1] is an elopement risk/wanderer. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 [Resident #1's] safety will be maintained through the review date. Date Initiated: 03/28/2025 Revision on: 04/16/2025 Target Date: 04/07/2025 Cancelled Date: 04/16/2025 Assess for fall risk. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate [sic]. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 WANDER ALERT: Device # Model Date Initiated: 03/27/2025 Revision on: 04/16/2025 Cancelled Date: 04/16/2025 Record review of Resident #1's Social History and Initial Assessment revealed on Page 2, Question 9. Current Behavioral Status was checked as No behavioral Concerns. The document was signed and dated by the previous Social Worker on 06/24/24. Resident #1's family member provided the information to the previous Social Worker for the Social History and Initial Assessment. Record review of the Order Summary for Resident #1 revealed a Physician Telephone Order on 01/21/2025 for WANDERGUARDS: LEFT ANKLE.CHECK FOR PLACEMENT AND PROPER WORKING FUNCTION every shift. Record review of Resident #1's MAR for January 2025 - March 2025 revealed that Resident #1's Wanderguard Checklist was marked with a check markevery day during the Day, Evening and Night Shifts and was in operable condition. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day, Evening, and Night Shifts on 03/27/25. The MAR did not reveal any timestamps for Resident #1's Wanderguard Checklist for the Day and Evening Shifts on 03/28/25. Record review of Resident #1's Elopement Evaluation on 03/28/25 revealed, an Assessment Outcome Score of 9 indicating Resident #1 was at Risk of Elopement. Record review of Resident #1 Assessments revealed that there was not an Elopement Evaluation for him prior to 03/28/25. Record review of an email from the Administration on 05/07/25 revealed that Resident #1 only had 1 Elopement Evaluation on 03/28/25. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:33 AM, revealed: resident was seen sitting in w/c in day area on when coming from helping another resident, he was gone down the hallway walking and pushing his w/c down by the breakroom area. then vanishes when no one seen him or heard any alarms. [Staff] begins to look for him along with nurses notified police, don, and family. resident was located across from facility ground in apartment complex. resident was brought back and evaluated with minor scratch on his chin and his left hand ring finger resident has no complaints. resident is in b/r laying down in bed resting with eyes closed with staff member doing 15 minutes check while asleep WCTM. Record review of Nurse Progress Notes from LVN A on 03/28/25 at 3:48 PM, revealed: Elopement Evaluation: History of elopement while at home: Yes. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 9.0. Record review of Nurse Progress Notes from the SW's Late Entry on 03/31/25 at 12:30 PM, Effective: 03/28/25 at 12:26 PM revealed, This writer called representative to inform her of resident needing to be placed at another facility due to elopement risk. Resident representative stated she got a call from other facility regarding accepting him and I informed yes referral sent out to see if there would be anyone who would accept him. Record review of Nurse Progress Notes from CNA B's Late Entry on 03/28/25 at 13:42 [1:42 PM], Effective 03/28/25 at 12:44 PM revealed, The resident transferred to [another facility's] Secure Nursing Unit via wheelchair transport with medications and personal belongings at this time. The resident was cooperative prior to exiting the facility. No noted signs and symptoms of respiratory distress and denies discomfort prior to exiting the facility. Report called to [staff] at [another facility's] memory Care Unit. Record review of the facility's Provider Investigation Reports Fax Cover Sheet dated 04/03/25 revealed the following: Intake ID No: NO SR # received - Called in by [DON] on hotline. Record review of the facility's Provider Investigation Report revealed the following: Incident Date: 03/28/25. Time of Incident 3:20 AM. Staff reported [Resident #1], eloped from the facility to the apartment complex across the road. Record review of the facility's Provider Investigation Report's Investigation Summary section of the report reflected: [Resident #1] was brought back to the facility by the DON. Resident received treatment for his scrapes to his chin and finger. Resident placed on Q:15 minute checks. Family notified of need for secure unit and family in agreement. Facility transferred [Resident #1] to [another facility] on 03/28/2025 with resident belongings. The police department were notified about the incident. Record review of the facility's Provider Investigation Report's Facility Investigation Findings section of the report reflected: Confirmed. Record review of the facility's Provider Investigation Report's, Provider Action Taken Post-Investigation section reflected: Elopement In-Service, Wanderguard system checked with no issues identified. Record review of the facility's Provider Investigation Report's view of TULIP on 05/07/25 at 12:00 PM reflected, the wandering of Resident #1 on 03/28/25 from the facility to the apartment complex approximately100 feet across the street from the facility was not uploaded. In a telephone interview on 05/05/25 at 2:25 PM, with Resident #1's family member, she stated that Resident #1 was a resident at the facility for almost 1 year. She stated that prior to Resident #1 being admitted to the facility, he was living with the family member and he had about 2-3 elopement incidents, in which a decision was made to have Resident #1 reside at a Nursing Facility. She stated that initially Resident #1 was admitted to the facility after a hospital stay, which led to him needing physical therapy. She stated that during Resident #1's stay at the facility, she realized that Resident #1 had to be at the facility long term due to his dementia and exit seeking. The family member stated that she did not initially inform the facility that Resident #1 had exit seeking behaviors and had previously eloped from home prior to being admitted to the facility. She stated that no one asked her if Resident #1 was exit seeking or had some elopement incidents while he was staying at her home. She stated that no one asked her about Resident #1's previous elopement history, therefore she did not tell them. The family member stated that Resident #1 had a Wanderguard brace on his ankle due to him exit seeking at the facility. The family member stated that on 03/28/25 at approximately 3 AM, another family member notified her via telephone informing her that their family member had exited the facility although he was wearing a Wanderguard on his ankle and was found at the apartment complex across the street attempting to climb a fence. The family member stated that the neighbor at the apartment complex across observed Resident #1 and asked him, what are you doing? Resident #1 replied, I am trying to go to work, and you can call my [family member], he will come and get me. Resident #1 provided the telephone number for his family member. The neighbor at the apartment complex across the street from the the facility, then called 911 and told them about the incident and then telephoned Resident #1's family member. According to the family member, Resident #1's other family member called the facility and notified the staff at the facility that Resident #1 was not in the facility and the staff were unaware that Resident #1 had eloped from the facility. The family member stated that the police arrived at the apartment complex across the street from the facility and returned the resident to the facility. Resident #1 was then transferred to another facility on 03/28/25, the same day of his elopement. According to the family member, Resident #1 did not receive any serious injuries from eloping from the facility. On 05/06/25 at 12:00 PM an attempt to interview the previous DON via telephone was unsuccessful. On 05/06/25 at 12:15 PM an attempt to interview LVN A via telephone was unsuccessful. On 05/06/25 at 12:17 PM an attempt to interview CNA D via telephone was unsuccessful. In an interview with the SW on 05/06/25 at 4:31, she stated that she was not at work when Resident #1 eloped from the facility on 03/28/25 due to the incident occurring around 3 AM. The SW stated that she received a telephone call during the night by the previous DON stating that during the night shift of 3/27/25 and early morning of 03/28/25. She stated that she was asleep during the original voicemail from staff and in the morning, she woke up and listened to her voicemail message. She stated that she later learned that staff noticed that Resident #1 was missing, and they looked inside the building, and he was not in the building. The SW stated that staff went to look for Resident #1 outside the facility and he was found across the street at an apartment complex. The SW stated that Resident #1 had a Wanderguard on his leg and was exit seeking according to staff but had never exited the facility prior to the incident when he eloped on 03/28/25. The SW stated that according to the staff's records for Resident #1 had a Wanderguard Test on on 03/27/25 and 03/28/25 and it was working properly. She stated that staff sent an alert made for Resident #1 due to his eloping from the facility and then the staff began looking for him She stated that the facility was not aware that the resident had any elopement issues. She stated that if the facility was informed during Pre-admission that any resident had any previous elopement issues, the facility would have not admitted that person to the facility. She stated that there are not any Power of Attorneys on file for Resident #1 and he was his own RP. The SW stated that she and staff were In-Serviced on Abuse, Neglect and Elopement Procedures and Guidelines after the incident involving Resident #1 eloping from the facility. In an interview with the Administrator on 05/06/25 at 4:53 PM, she stated that she was on vacation when Resident #1 eloped from the facility during the evening shift on 03/28/25. She stated that she is the Abuse Coordinator for the facility and when she returned to work at the facility, the previous DON updated her on the situation involving Resident #1's elopement on 03/28/25. The Administrator stated that the previous DON told her that Resident #1 exited the facility using the front door and was found across the street at an apartment complex. She stated that a man that lived in the apartment complex across the street witnessed him and law enforcement was notified. The previous DON went across the street to get Resident #1 and brought him back to the facility. She stated that Resident #1 did not have any serious injuries according to his head to toe assessment that was given by LVN A. She stated that Resident #1 was placed on 1:1 observation, (a healthcare practice where a staff member provides continuous, one-to-one attention to a patient), after the incident and a staff member was always with him. She stated that the previous DON stayed with Resident #1 until the next shift began at 6 AM. The Administrator stated that Resident #1's Emergency Contacts, Doctor and Behavioral Health were notified of Resident #1's elopement. She reported that Resident #1 had been at the facility for approximately 1 year and there was not any previous history of Resident #1 having any elopement issues or concerns prior to him being admitted to the facility. She stated that if the facility learned that Resident #1 was exit seeking or had any prior elopement concerns, he would not have been admitted to the facility because the facility is not equipped to have a Secured Unit. She stated that the SW then began to find placement for Resident #1 at a facility that had a Secure Unit. She stated that Resident #1 was discharged to another facility with a Secured Unit on 03/28/25. She stated that Resident #1 had a Wanderguard per his doctor's order and his Wanderguard was tested 3 times a day, per his doctor's orders. She stated that no one knows how Resident #1 was able to exit the facility on 03/28/25 due to his Wanderguard and the exterior doors working in proper order. She stated that the staff were In-Serviced on abuse, neglect, and elopement procedures after Resident #1's elopement form the facility. In an interview with the Maintenance Supervisor on 05/06/25 at 5:45 PM, he stated that he had been employed at the facility since 04/12/25. He stated that he was not aware of the elopement incident on 03/28/25 by Resident #1. He stated that there was not any documentation showing that there were any issues with any of the exterior doors at the facility on 03/27/25 and 03/28/25. He stated that he does daily checks on all the doors in the facility. He stated that the exterior doors to the building have a fire alarm and will alert if they are opened. He stated that the front door of the facility will alert and made a ringing sound if a resident with a Wanderguard attempts to exit the front door. He stated that he and other facility staff regularly receive In-Service Trainings on Abuse, Neglect and Elopement Procedures and Protocols. In an interview with CNA C on 05/07/25 at 10:44 AM, she stated that she had been employed at the facility for 1 year. She stated that she was not at the facility on 03/28/25 due to being off duty. She stated that Resident #1 had dementia and during her shifts was observed coming close to the side door on his hallway. She stated that he had not observed Resident #1 exit any doors from the facility. She stated that when she returned to work, she was informed by staff that Resident #1 had exited the building during the night shift on 03/27/25 - 03/28/25. She stated that the night shift duty hours are 10 PM - 6 AM. She stated that Resident #1 did not receive any serious injuries according to his skin assessment on 03/28/25. She stated that all staff receive trainings throughout each week on abuse, neglect, and elopement. She stated that she remembered that she received an In-Service Training on Elopement after the incident on 03/28/25 when Resident #1 eloped from the facility. On 05/07/25 at 11:16 AM an attempt to interview LVN A via telephone was unsuccessful. On 05/07/25 at 11:18 AM an attempt to interview CNA D via telephone was unsuccessful. This was determined to be a Past Non-Compliance Immediate Jeopardy on 05/07/25 at 2:50 PM. The Administrator was notified. The Administrator was provided with the IJ template via email on 05/07/25 at 2:57 PM. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the facility's In-Service Trainings revealed that all staff were in-serviced on the facility's abuse, neglect and elopement policies and procedures, elopement, risk assessments, skin assessments, notification to PCP and RP on 04/01/25. Record review of the facility's In-Service Trainings revealed all staff were in-serviced on the facility's abuse and neglect and policies and procedures on 04/23/25. The In-Service Training paperwork states, All staff if you see or suspect any forms of abuse/neglect towards a resident immediately remove the resident/report to the abuse coordinator [Administrator]. On 05/07/25 at 3:00 PM an observation was made of Resident #2 with a Wanderguard exiting the front door. Resident #2's Wanderguard was operating properly and there was an alarm that sounded. Staff in the Office were able to hear the alarm and staff at the Nurses Station were able to hear the alarm. The Staff in the Administration Offices at the front of the facility were observed walking towards the front door of the facility when the alarm sounded. The Staff on the hallways were observed walking towards each fire door after the fire alarm sounded. In an interview and observation on 05/07/25 at 3:14 PM, the Maintenance Director stated he was not present at the time of Resident #1's elopement and could not state whether or not a door alarm sounded. The Maintenance Director was observed opening the interior fire exit doors on the hallways throughout the facility and the front door. The fire alarms alerted each time the Maintenance Director opened each door. The fire alarms could be heard by staff throughout the building. The Staff at both Nurses Stations and on the hallways stated that there were able to her the fire alarms from their locations. Record review of the facility's Resident Rights policy dated, December 2024 revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; . b. be free from abuse, neglect . Record review of the facility's Elopements policy dated, December 2024 revealed: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: . 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, c. If the resident is not located, notify the Administrator and Director of Nursing Services, the resident's legal representative . 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: c. Notify the resident's legal representative; . e. Complete and file an incident report and self-report to your regulatory agency; and f. Document relevant information in the resident's medical record. The facility's Elopements Policy did not include any information regarding Supervision, Accidents and Preventing Elopements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the residents' physicians when there was a significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications; or when there is a need to alter treatment significantly, for two (Residents ##3 and #4) of five residents reviewed for resident rights. 1. The facility failed to consult with the physician when Resident #3 had a change in condition which resulted in a dangerously low blood sugar of 40. Resident #3 died at the facility unexpectedly within 24 hours of his change of condition. 2. The facility failed to notify the physician [MD O] or physician extender [NP M] of Resident #4's x-ray results when he had a change in condition on [DATE]. The x-ray results indicated there were abnormal findings which included widespread bilateral nodular lung opacities and small right pleural effusion opacities which was consistent with severe pulmonary edema or pneumonia. Resident #4 died at the facility unexpectedly within 24 hours of his change of condition. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 PM. The IJ template was provided to the facility's VPCO on [DATE] at 1:30 PM. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: 1) Record review of Resident #3's Face Sheet (not dated) reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnosis of Diabetes Type 2 without complications. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he had no hearing, speech or vision issues and a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 has no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #3 had limited function range of motion in both of his lower extremities, used a wheelchair for mobility and required substantial/maximum assistance from staff for all ADLs. He had an ostomy and indwelling catheter and was always incontinent of bowel and bladder. Resident #3 had identified shortness of breath when laying flat (dyspnea), was five feet two and weight 162 pounds. Resident #3 has one unhealed and unstageable pressure ulcer and one arterial/venous stasis ulcer. He received high-risk drug medication that included an anticoagulant, a diuretic and hypoglycemic medication. Resident #3 did not receive hospice services. Record review of Resident #3's care plan dated [DATE] reflected, Focus Area: Diabetes Mellitus-I will be free from any s/sx of hypoglycemia through the review date; Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #3's [DATE] physician orders reflected he was prescribed Metformin HCI Oral Tablet 500 MG two tablets by mouth two times a day for diabetes (start date [DATE]). Resident #3 also had the following orders, 1. If blood sugar below 70 and resident unable to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as ordered, and re-check BS in 15 minutes and may repeat protocol if indicated remaining with the resident, keep resident comfortable and safe and monitor VS. Hold all diabetic medications and if no improvement notify MD; 2. If blood sugar is less than 70 and patient is ABLE to swallow immediately give 4 oz juice or 5-6 oz soda recheck BS in 15 minutes and repeat juice if needed. If resident is UNABLE to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as directed and re-check BS in 15 minutes remaining with the resident, keep comfortable and safe, monitor VS, hold all diabetic medications and notify MD as needed; 3. If BS less than 70 and patient is unresponsive immediately administer oral glucose paste, glucagon as directed. Remain with resident, monitor VS, keep safe and hold all diabetic (medication). Further review revealed Resident #3 did not have a physician's order to check his blood sugar routinely or PRN. Record review of Resident #3's clinical chart reflected the following blood sugar readings were documented in his e-chart: [DATE] (40), [DATE] (100), [DATE] (139) (Note: Hypoglycemia occurs when the sugar level in the blood is below 60 mg; extremely low blood sugar can trigger seizures, loss of consciousness, impaired cognitive function and increased risk of falls). Record review of Resident #3's [DATE] MAR reflected he was administered the Metformin as ordered for diabetes. Record review of Resident #3's prealbumin, CMP and CBC dated [DATE] reflected abnormal values: for *pre-albumin of 11 which was considered low (reference range was 17-34); *creatinine low at 0.5 (reference range was 07-1.3); *glucose was high at 144 (reference range was 74-109); *white blood cell count was high at 10.6 (reference range was 3.6-10.20, *red blood cell count was low at 2.81 (reference range was 4.6-5.63) and *platelet count was high at 469 (reference range was 152-348). Further review revealed PA I was notified by the charge nurse and no new orders were given related to the labs. Record review of Resident #3's nursing progress notes reflected: -[DATE]- Resident was readmitted back into the facility at 7pm from [hospital] on a stretcher with eyes open respiration even heart sound normal- Dx Sepsis, Diabetes , HTN, Asthma ,and decompressive laminectomies. Resident is alert and oriented x 1 able to make needs known wound noted on the coccyx and the left tibia, swollen to both hand and staples to the neck and back was removed, trach was intact, catheter was draining at gravity , resident was resting calmly in his room with no difficulty MD notified and the DON [e-signed by LVN B]. -[DATE]-eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition-At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 108/76 Position: Lying r/arm; Pulse: 68, Respirations 18.0, Temp 97.6, Weight 165.1 lb, Pulse Oximetry: O2 96%, Blood Glucose 40.0-[DATE] 08:15; .Resident/Patient had the following medications changes in the past week: no; .Resident/Patient is on: Hypoglycemic medication(s)/Insulin; Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other, Functional Status Evaluation: General Weakness, Behavioral Status Evaluation: [blank] Respiratory Status Evaluation: [blank], Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50, Abdominal/GI Status Evaluation: [blank], GU/Urine Status Evaluation: [blank], Skin Status Evaluation: [blank], Pain Status Evaluation: Does the resident/patient have pain? [blank]; Neurological Status Evaluation: [blank]; Nursing observations, evaluation, and recommendations are: Pt b/s is up to 81; Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: continue to monitor pt.; B. New Testing Orders: Other-- glucagon Injection; C. New Intervention Orders: Other- glucagon injection [e-signed by DON and LVN K]. -[DATE] (2:05 AM): Nurse making round at this time, noticed resident not responsive, assessed by nurse, resident did not respond to touch /verbal command. This nurse call code blue, CPR initiated while other nurse call 911. [e-signed by LVN L]. -[DATE]: 911 crew arrived and took over from nurse [e-signed by LVN L]. -[DATE]: 911 crew left the facility after all efforts made by them to resuscitate resident failed [e-signed by LVN L]. -[DATE]: Upon assessment resident noted without active signs of life. skin cool and dry no respirations no rise and fall of the chest, no carotid or apical pulse no blood pressure pupils non-reactive to light. death pronounced at 4:12 A.M/ [e-signed by the DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a resident's blood sugar was low when checked, the charge nurse was supposed to check the physician's standing orders for blood sugar, if it got to a certain level, then orange juice was given if the resident was able to swallow and there was also glucagon. LVN A stated when the blood sugar was checked and below a certain level, there were protocols to follow and the doctor had to be notified. LVN A stated a dangerously low blood sugar was anything below 70. She stated blood sugar checks were documented on the MAR, as well as in a nursing progress notes if it had to be re-checked. LVN A stated a change of condition was anything that was not ordinary for the resident, such as a change in consciousness, labs, blood pressure and blood sugar changes. When a change of condition occurred, LVN A stated a change of condition form, nursing note and SBAR had to be completed. LVN A stated that she had been the nurse for Resident #3 in the past and thought he had recently come back from a hospital visit and all she remembered was he had a trach and was always pleasant. She stated she was not working with him on the day his blood sugar was 40. An interview with LVN B on [DATE] at 2:49 PM revealed Resident #3 was on her hall and he had a recent surgery on his back the week prior. He had gone to the hospital to for a planned appointment to remove staples from his neck and was there for three to four days when the hospital had originally stated it would only take one day. When he re-admitted to the facility, LVN B stated he was not the same as he was prior but did not give specifics. She stated she was working the 2-10pm shift the day of his death and he had been in the dining room for dinner eating. She brought him back to his room after dinner and rounded on him again before her shift was over and everything was okay. The next morning, she found out he had died after her shift. LVN B stated, There was nothing acute happening with him on my shift. He did not have a low blood sugar on my shift. If he had a low blood sugar, he was in the dining room, I fed him .even if it went low, he would have been given Glucagon after my shift was over. We checked his blood sugars. He can talk, he can tell us what he wants. There was nothing out of the ordinary for me. He ate, I didn't have any reason to worry. LVN B stated if a resident's blood sugar was 40, she would have called the doctor but already be in the process of sending the resident out to the hospital even before the doctor said so, because 40 is too low on my watch, that is an automatic send out for me unless the doctor says to keep and give medications. But 40 is too low for glucagon to help enough. LVN B stated symptoms of low blood sugar could be nausea and vomiting, aggression, sweating and sleeplessness. LVN B stated the protocol for a low blood sugar reading was for the nurse to initial the MAR to ensure that the blood sugar was checked and was okay. If the blood sugar was not okay and low, then the nurse would administer Glucagon, document in nursing notes and do and E-Interact form. LVN B stated there was not a place on the MAR to indicate emergency glucose was given, only in the nursing notes. If the nurse administered glucagon, the nurse was supposed to re-check it in 15 minutes to see where blood sugar level was and document it in a nursing progress note because it was an issue and also document in the 24 hour report. The doctor would also be contact and if the blood sugar value did not elevate with intervention, notify doctor again to get further orders. LVN B stated she did not remember being told on that date of the low blood sugar of 40 ([DATE]) that there had been a change of condition. She said if an agency nurse was working that morning, she would not have rounded with them because they are always wanting to leave, so I don't remember anything about a low blood sugar. LVN B stated when a resident's blood sugar was low, the charge nurse was supposed to consult with the doctor, then give Glucagon or an orange juice supplement that can push the blood sugars back up, then re-assess the resident. LVN B stated a dangerously low blood sugar was anything below 70. She said blood sugars were documented on the MAR. LVN B stated a change of condition was if a resident's vitals were below their norm or they were restless or in pain. An interview with LVN L on [DATE] at 3:21 PM LVN L stated she was the charge nurse for Resident #3 on the night he died. She had picked up the overnight shift and came in around 11:00 PM on [DATE]. She stated nothing had been reported to her by the afternoon/evening nurse [LVN B]. She said during her first rounds, Resident #3 was asleep in his room but woke up and said hello when LVN L came into the room. Then on her second round about two in the morning, LVN L stated she went into his room and discovered he was not breathing. She said most of the time when she rounded, she went into the residents' rooms and turned the light on and pat them and say hello, just checking. When she did that with Resident #3, she said papacita, when nothing, he did not respond and he had no pulse. LVN L stated they started CPR and someone called 911. EMTs arrived and worked on him for a long time but could not bring him back. LVN L stated there were protocols for hypoglycemia on every resident and if the resident could still talk and was alert, the first protocol was to give oral glucose and if the blood sugar did not come up, Glucagon was available. If the resident was still unresponsive, the nurses could then use glucose gel. She stated it was whatever the facility protocol said on the MAR and it had to be followed step by step. LVN L stated a dangerously low blood sugar was anything less than 70. Once Glucagon was given, LVN L stated the nurse would go back and check the blood sugar in 15 minutes, document the findings in a nursing note all that had been done, call 911 if the blood sugar does not rise and notify the doctor. LVN L stated a change of condition was anything different from the residents' norm. An interview with the DON on [DATE] at 4:40 PM revealed she was working at the facility the morning of [DATE], Resident #3's low blood sugar reading of 40. She stated a CNA came to tell her one of the nurses wanted her help. When the DON got to Resident #3's room, the nurse was at the door and said his blood sugar reading was 40. The DON assessed Resident #3 and his breathing and vitals at that time were normal, But he was doing what they do when their blood sugar is low, like they try to respond but can't, but want to. I told him [Resident #3] he was fine and his blood sugar was low. The DON stated Resident #3 was given Glucagon, and she told the nurse [LVN K] to check it again in 10-15 minutes. When LVN K checked it again, she gave a glucagon injectable, did not know remember what the blood sugar value was. The DON stated, When someone's blood sugar is in the 40s, they can't swallow so I don't like using the gel. The DON stated, So he came back around and it was a normal day after that. The DON stated she felt Resident #3 died because of his disease process. She stated his health was already poor and he had been getting treatment for multiple venous/stasis ulcers and wound care for pressure ulcers. An interview with CNA D on [DATE] at 12:30 PM revealed she was working the morning on [DATE] when Resident #3's blood sugar was 40. CNA D stated she was passing breakfast trays to the rooms and went into Resident #3's room and he was snoring but would not wake up when she tried to rouse him; she felt something was not right. She knew he was a diabetic so went to tell the nurse who was a PRN nurse (LVN K) who came to his room. LVN K also tried to wake Resident #3 up, but he would not wake up and it was then they knew something was wrong. The charge nurse checked his blood sugar and it was 40. CNA D stated she was present when the reading of 40 was done. She said LVN K did the glucose gun on him twice. After that, he woke up, was thirsty and wanted to get up out of bed. Soon after, a family member was present who sat with him in the dining room while he ate, he was talking and chatting with the family member and staff. CNA D stated Resident #3 told LVN K thank you so much for helping him while he was in the dining room, So he perked back up. CNA D stated LVN K told the family member about the low blood sugar and that he needed to be watched by the following shifts and she would leave a note for the nurses on the shifts. CNA D stated she remembered the morning PRN charge nurse telling the afternoon oncoming charge nurse [LVN B] to check Resident #3's blood sugar because it had been 40. Then the very next day, CNA D stated that Resident #3 was gone and they had already picked up his body by the time she got into work CNA D was worried Resident #3 may have died from a diabetic coma and said, I know from experience you need to monitor at least 48 hours. An attempt to interview MD H on [DATE] at 1:34 was unsuccessful; there was no option to leave a voice mail. An attempt to interview PA I on [DATE] at 1:36 PM was unsuccessful and there was no option to leave a voice mail. An interview with the secondary physician extender listed on Resident #3's Face Sheet [PA J] occurred on [DATE] at 1:43 PM. PA J stated she stopped going to the facility three weeks prior and her role was to work in physiatry and rehab only. However, speaking in general terms, PA J stated from a provider's point of view, the facility should notify the doctor for any low blood sugar, they had standing order to follow which included glucose tablet, then they should re-check the blood sugar and call the doctor back to see what they want to do. An interview with ADON E on [DATE] at 1:53 PM revealed she was week new to the facility so her information was limited. ADON E stated for a low blood sugar of 40, the resident would be at risk of a diabetic coma, so the doctor should be contacted to let them know what the charge nurse's interventions were, the blood sugar reading, the medications administered and then find out what they want the charge nurse to do. ADON E stated that for a blood sugar of 40, her nursing judgement would have sent Resident #3 to the hospital. ADON E stated Resident #3 should have been monitored after his change of condition for three days. She said the charge nurse would monitor and look for confusion, diaphoresis (cold and clammy), paleness of skin, confusion, agitation and anxiety. ADON E stated the nurses did chart by exception, but for an acute condition, they were supposed to chart for three days or as long as the treatment was in place. An interview with CNA F on [DATE] at 2:25 PM revealed he remember Resident #3 and was talking to him around 10:00 PM, a few hours before he died. He said they were talking about sports and two local sports teams and nothing seemed off or out of the ordinary. CNA F stated Resident #3 had been in the hospital recently but he did not know what for, but that night, he was up in his wheelchair and then CNA F laid him down for bed before his shift was over. An interview with the VPCS on [DATE] at 2:47 PM revealed after Resident #3's low blood sugar reading of 40 and subsequent intervention of Glucagon, the nurses on the oncoming shifts that day should have been monitoring the resident for signs and symptoms of hypoglycemia such a confusion and lethargy. She stated the shift to shift report should be given between nurses and they were supposed to print out the 24 hour report and utilize that as well when they did their walking rounds for continuity of care. If there was a change in the resident's condition, such as a fall, a blood sugar that had to be recovered for example and there was any intervention done, it should be reported to the oncoming nurse. VPCS stated, That is what I expect for out of the norm, a prudent nurse to communicate to the oncoming shift so there is continuity of care. 2) Record review of Resident #4's Face Sheet (not dated) reflected he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Hypertension, Major Depressive Disorder, Atherosclerotic Heart Disease, Angina Pectoris, Dementia, Generalized Anxiety Disorder, Diabetes, Hyperlipidemia, Schizophrenia and Parkinson's Disease. Resident #4's attending physician was listed as [MD O] and the nurse practitioner was listed as [NP M]. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed no hearing, speech or vision issues, a BIMS score of 03 which indicated severe cognitive impairment, no signs of delirium, psychosis or rejection of care. Resident #4 had no range of motion limitations but did need help from staff with all ADLs. Resident #4 did not have any assessed health conditions related to shortness of breath, did not use oxygen therapy and was not on hospice services. Resident #4 was prescribed high-risk medication which included an antipsychotic, antidepressant and an anticoagulant. Review of Resident #4's care plan initiated on [DATE] and last revised on [DATE] did not reflect any care areas related to respiratory issues or need for oxygen or related interventions. Record review of NP M's last documented visit on [DATE] with Resident #4 reflected a chief complaint/nature of presenting problem as, Leukocytosis (a condition where your blood has too many white blood cells, which fight infections and diseases), AMS, Abnormal labs, falls x 2. Resident #4 had a non-healing ankle wound that was being treated and a recent white blood cell count of 14 and continued leukocytosis. He was on an antibiotic and seen and examined in his room. He reported malaise and workup so far negative. The Nursing staff report decreased appetite. NP M reviewed Resident #1's recent labs from [DATE] and documented, CBC 16.1, 8.5, 25.5, 561; BMP 131, 4.4, 101, 22, 25, 1.1, 68. NP M documented her plan as, Plan 1. Leukocytosis: Workup so far negative. Currently on cefdinir until [DATE]; 2. Obtain blood cultures x 2 both negative, no growth after 5 days; 3. Obtain echocardiogram; 4. Consult hemo/Onco for further workup: new onset leukocytosis, thrombocytosis, anemia, weakness, negative infection workup; 5. Health shake 3 times daily with each meal; 6. Continue weekly lab work as ordered previously; 7. Continue all medication as ordered in PCC. Record review of Resident #4's physician order [initiated by NP M] dated [DATE] reflected, 2-view Chest X-ray to rule out infiltrates (abnormality in the lung). Record review of Resident #4's x-ray-Chest 1-view dated [DATE] reflected it was reviewed by the radiology clinic at 6:01 PM and reported at 6:01 PM. The chest x-ray was noted on the findings to be compared to his last x-ray a year earlier on [DATE]. The findings indicated Resident #4 had widespread bilateral nodular lung opacities (haziness around the lung with nodule growth) and a small right pleural effusion (fluid around the lungs). The impression reflected, There are widespread bilateral nodular lung opacities. This is consistent with severe pulmonary edema or pneumonia. Consider CT correlation to exclude neoplasm. The findings are worse compared with prior. Record review of nursing progress notes from [DATE] for Resident #4 reflected no indication the physician or physician extender [NP M] and RP was notified of Resident #4's chest x-ray results. Record review of the following pertinent nursing notes for Resident #4 reflected: -[DATE] 12:52 PM- Type: eINTERACT SBAR Summary for Providers-Situation : The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: BP 120/70, Pulse:70; R 18; Temp: 97.9; Weight: 202.2 lb; O2 96 %; Blood Glucose: 123.0 . Outcome of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other; Functional Status Evaluation: General weakness . Primary Care Provider responded with the following feedback: A. Recommendations: obtain Urine for UA with C&S; New Testing Orders: [blank]; C. New Intervention Orders: [blank] [e-signed by LVN A]. - [DATE]- Nurse's Note- PA in facility to visit with her residents today. Information given to PA regarding noted increased weakness and sleepiness. The resident is afebrile and without noted signs and symptoms of respiratory distress. New orders received to obtain urine for UA with C&S to rule out UTI and a 2-view chest x-ray to rule out infiltrates [e-signed by LVN A]. -[DATE]- Upon shift change at [10:05 PM], CNA called this nurse into resident's room. On getting to room, resident found in his wheelchair unresponsive in the bathroom. Resident assessed, put in bed and CPR initiated immediately while the other nurse, [staff] called 911. 911 crew arrived at [10:25 PM] and took over from the nurses. All efforts made by 911 crew to resuscitate the resident failed. The 911 crew left at [11:00 PM]. DON, resident family and MD notified of the change of condition. At [11:30 PM] Police arrived and took report from the nurses. At [midnight] resident pronounced by DON [e-signed by LVN P]. -[DATE]-Resident laying in bed. intubated with IV to right AC. skin cold and clammy. No signs of life present. No respirations, no rise and fall of chest. no carotid or Apical Pulse. Pupils set non-reactive to light. Death pronounced at 12:00 A.M. [e-signed by DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a charge nurse starts their shift, they should look in the lab book and the radiology book to see who has pending results and then continue to check throughout the shift to see if they have come in. If the charge nurse does not see the results, then they should call and follow up with a phone call. If the findings come back negative, the physician should still be notified to see if there are any new orders. With Resident #4, LVN A could not remember if NP M was notified of his chest x-ray findings. She said the results for Resident #4's x-ray would have come in after her shift was over at 2:00 PM that day. An interview with LVN C on [DATE] at 3:21 PM revealed the results of any x-rays were supposed to be logged under the resident's name in PCC with the results. LVN C stated she was at the facility the night Resident #4 died, but was not assigned to his hall. LVN C stated her shift was over and she heard his nurse calling for help so she went to see what happened and ended up helping the nurse do CPR. LVN C stated when she saw Resident #4, staff had already started CPR and she thought he was already expired by then. An interview with the DON on [DATE] at 4:40 PM revealed she did not remember Resident #4, but if a lab or x-ray came back with abnormal findings or normal findings, the charge nurse should still contact the doctor to let them know the results because the doctor may order antibiotics or prn oxygen. The DON said, But if the resident was already on antibiotics and no respiratory issue, the doctor probably would have just continued with current orders with antibiotics. The DON stated she was not sure what was going on with Resident #4 and she was new to the facility in [DATE]. The DON stated, But if he was already having respiratory issues, the doctor may not have done more intervention, but they should have been notified. An interview with ADON E [DATE] at 1:53 PM revealed she was one week new to the facility so she was not familiar with Resident #4. However, for x-ray results, ADON E stated the doctor should be called with the results regardless if the resident had a pre-existing condition or was already on medications for an infection. She reviewed the x-ray which reflected Resident #4 had lung opacities that were white spots which could mean usually pneumonia. She said it also reflected pulmonary edema which was water in lungs and pleural effusion was water around the lung. ADON E stated, These things are ordered because there was a concern, you would notify them because they doctor might want to change the antibiotic. An interview with the VPCS on [DATE] at 2:47 PM revealed if a resident had known issues to the point where the doctor ordered an x-ray, then the doctor should be contacted with the results of that x-ray. VPCS stated, How do we know there are no new orders because we haven't reached out to the doctor? An interview with NP M on [DATE] at 3:27 PM revealed she recalled that Resident #4 was not critical but she remembered doing a workup on him and was surprised he had passed way. She said he had a slightly elevated white blood cell count on [DATE] prior to his death but he was not on her radar to be declining. NP M stated, As a matter of fact, he walked and went to the dining room every day. NP M remembered ordering a chest x-ray on the day of his death and thought she got the results, but then said she may have been notified after his death. She reviewed her clinical notes and charting system and looked at the x-ray image and findings. NP M then stated she had seen Resident #4 on [DATE] and he died later that night. She said she did not see where his chest x-ray results were told her prior to his death but she was notified when he died. When she had seen Resident #4 that morning on [DATE], she ordered a work up on him. He had an elevated white blood cell count and the nursing staff said he had altered mental status and recent falls. NP M stated Resident #4's labs had been abnormal prior to that visit because he had recently been in the hospital for an ankle wound which caused the elevated white blood cell count. When Resident #4 returned to the facility, his WBC was 15.2 and stayed that way but she did blood cultures and the WBC count started trending down. When NP M saw Resident #4 on [DATE], his WBC was 14 and he had no issues with breathing that she observed. She stated the chest x-ray she ordered was standard procedure to look for something. NP M stated she thought Resident #4 had pneumonia back in February 2024, so if she was looking for something going on, she would typically order a 2-view x-ray, a UA and some lab work. She stated on [DATE], Resident #4 was already on cefdinir, an antibiotic for the ankle wound. When she reviewed the x-ray she ordered during the interview, she stated, I am thinking it came back after he expired. I am reading it now. Looks like he had pulmonary edema. He was not short of breath when I saw him, that would have been a whole different ballgame. That morning he was up, went to dining room, went to breakfast and then he came back to his room and going to the bathroom. NP M continued and stated, You can get flash pulmonary edema and they can literally die right on the floor. It can happen for whatever reason, maybe a little CHF, fine one minute, not the next. NP M said with flash pulmonary edema, usually there would be a report that the resident was foaming at the mouth and that was flash edema. She said there were no reports of that. NP M stated she was working up the change of condition with the two fall and was looking for a possible UTI. She did not feel the WBC was a concern because he admitted with that and his wound, So that in and of it itself is not concerning.&[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for two (Residents #3 and #4) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #3 was accurately assessed, monitored, and treated for a change of condition he had with a blood sugar of 40 at 8:15 AM during the morning shift on [DATE]. There was no documented evidence the facility monitored the residents' change of condition after that shift. Resident #3 died later that night on the overnight shift around 2:05 AM with a cause of death as unknown. 2. The facility failed to ensure Resident #4 was accurately assessed, monitored and treated for a change in condition on [DATE]. The facility had no documented evidence they monitored the resident after the initial change was observed. The NP was notified and ordered a chest x-ray. The x-ray results indicated there were abnormal findings which included widespread bilateral nodular lung opacities and small right pleural effusion opacities which was consistent with severe pulmonary edema or pneumonia. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 PM. The IJ template was provided to the facility's VPCO on [DATE] at 1:30 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: 1) Record review of Resident #3's Face Sheet (not dated) reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnosis of Diabetes Type 2 without complications. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he had no hearing, speech or vision issues and a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 has no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #3 had limited function range of motion in both of his lower extremities, used a wheelchair for mobility and required substantial/maximum assistance from staff for all ADLs. He had an ostomy and indwelling catheter and was always incontinent of bowel and bladder. Resident #3 had identified shortness of breath when laying flat (dyspnea), was five feet two and weight 162 pounds. Resident #3 has one unhealed and unstageable pressure ulcer and one arterial/venous stasis ulcer. He received high-risk drug medication that included an anticoagulant, a diuretic and hypoglycemic medication. Further review revealed Resident #3 did not receive hospice services. Record review of Resident #3's care plan dated [DATE] reflected, Focus Area: Diabetes Mellitus-I will be free from any s/sx of hypoglycemia through the review date; Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #3's [DATE] physician orders reflected he was prescribed Metformin HCI Oral Tablet 500 MG two tablets by mouth two times a day for diabetes (start date [DATE]). Resident #3 also had the following orders, 1. If blood sugar below 70 and resident unable to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as ordered, and re-check BS in 15 minutes and may repeat protocol if indicated remaining with the resident, keep resident comfortable and safe and monitor VS. Hold all diabetic medications and if no improvement notify MD; 2. If blood sugar is less than 70 and patient is ABLE to swallow immediately give 4 oz juice or 5-6 oz soda recheck BS in 15 minutes and repeat juice if needed. If resident is UNABLE to swallow immediately administer oral glucose paste to buccal mucosa, glucagon as directed and re-check BS in 15 minutes remaining with the resident, keep comfortable and safe, monitor VS, hold all diabetic medications and notify MD as needed; 3. If BS less than 70 and patient is unresponsive immediately administer oral glucose paste, glucagon as directed. Remain with resident, monitor VS, keep safe and hold all diabetic (medication). Further review revealed Resident #3 did not have a physician's order to check his blood sugar routinely or PRN. Record review of Resident #3's clinical chart reflected the following blood sugar readings were documented in his e-chart: [DATE] (40), [DATE] (100), [DATE] (139) (Note: Hypoglycemia occurs when the sugar level in the blood is below 60 mg; extremely low blood sugar can trigger seizures, loss of consciousness, impaired cognitive function and increased risk of falls). Record review of Resident #3's [DATE] MAR reflected he was administered the Metformin as ordered for diabetes. Record review of Resident #3's prealbumin, CMP and CBC dated [DATE] reflected abnormal values: for *pre-albumin of 11 which was considered low (reference range was 17-34); *creatinine low at 0.5 (reference range was 07-1.3); *glucose was high at 144 (reference range was 74-109); *white blood cell count was high at 10.6 (reference range was 3.6-10.20, *red blood cell count was low at 2.81 (reference range was 4.6-5.63) and *platelet count was high at 469 (reference range was 152-348). Further review revealed PA I was notified by the charge nurse and no new orders were given related to the labs. Record review of Resident #3's nursing progress notes reflected: -[DATE]- Resident was readmitted back into the facility at 7pm from [hospital] on a stretcher with eyes open respiration even heart sound normal- Dx Sepsis, Diabetes , HTN, Asthma ,and decompressive laminectomies. Resident is alert and oriented x 1 able to make needs known wound noted on the coccyx and the left tibia, swollen to both hand and staples to the neck and back was removed, trach was intact, catheter was draining at gravity , resident was resting calmly in his room with no difficulty MD notified and the DON [e-signed by LVN B]. -[DATE]-eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition-At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 108/76 Position: Lying r/arm; Pulse: 68, Respirations 18.0, Temp 97.6, Weight 165.1 lb, Pulse Oximetry: O2 96%, Blood Glucose 40.0-[DATE] 08:15; .Resident/Patient had the following medications changes in the past week: no; .Resident/Patient is on: Hypoglycemic medication(s)/Insulin; Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other, Functional Status Evaluation: General Weakness, Behavioral Status Evaluation: [blank] Respiratory Status Evaluation: [blank], Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50, Abdominal/GI Status Evaluation: [blank], GU/Urine Status Evaluation: [blank], Skin Status Evaluation: [blank], Pain Status Evaluation: Does the resident/patient have pain? [blank]; Neurological Status Evaluation: [blank]; Nursing observations, evaluation, and recommendations are: Pt b/s is up to 81; Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: continue to monitor pt.; B. New Testing Orders: Other-- glucagon Injection; C. New Intervention Orders: Other- glucagon injection [e-signed by DON and LVN K]. -[DATE] (2:05 AM): Nurse making round at this time, noticed resident not responsive, assessed by nurse, resident did not respond to touch /verbal command. This nurse call code blue, CPR initiated while other nurse call 911. [e-signed by LVN L]. -[DATE]: 911 crew arrived and took over from nurse [e-signed by LVN L]. -[DATE]: 911 crew left the facility after all efforts made by them to resuscitate resident failed [e-signed by LVN L]. -[DATE]: Upon assessment resident noted without active signs of life. skin cool and dry no respirations no rise and fall of the chest, no carotid or apical pulse no blood pressure pupils non-reactive to light. death pronounced at 4:12 A.M/ [e-signed by the DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a resident's blood sugar was low when checked, the charge nurse was supposed to check the physician's standing orders for blood sugar, if it got to a certain level, then orange juice was given if the resident was able to swallow and there was also glucagon. LVN A stated when the blood sugar was checked and below a certain level, there were protocols to follow and the doctor had to be notified. LVN A stated a dangerously low blood sugar was anything below 70. She stated blood sugar checks were documented on the MAR, as well as in a nursing progress notes if it had to be re-checked. LVN A stated a change of condition was anything that was not ordinary for the resident, such as a change in consciousness, labs, blood pressure and blood sugar changes. When a change of condition occurred, LVN A stated a change of condition form, nursing note and SBAR had to be completed. LVN A stated that she had been the nurse for Resident #3 in the past and thought he had recently come back from a hospital visit and all she remembered was he had a trach and was always pleasant. She stated she was not working with him on the day his blood sugar was 40. An interview with LVN B on [DATE] at 2:49 PM revealed Resident #3 was on her hall and he had a recent surgery on his back the week prior. He had gone to the hospital to for a planned appointment to remove staples from his neck and was there for three to four days when the hospital had originally stated it would only take one day. When he re-admitted to the facility, LVN B stated he was not the same as he was prior but did not give specifics. She stated she was working the 2-10pm shift the day of his death and he had been in the dining room for dinner eating. She brought him back to his room after dinner and rounded on him again before her shift was over and everything was okay. The next morning, she found out he had died after her shift. LVN B stated, There was nothing acute happening with him on my shift. He did not have a low blood sugar on my shift. If he had a low blood sugar, he was in the dining room, I fed him .even if it went low, he would have been given Glucagon after my shift was over. We checked his blood sugars. He can talk, he can tell us what he wants. There was nothing out of the ordinary for me. He ate, I didn't have any reason to worry. LVN B stated if a resident's blood sugar was 40, she would have called the doctor but already be in the process of sending the resident out to the hospital even before the doctor said so, because 40 is too low on my watch, that is an automatic send out for me unless the doctor says to keep and give medications. But 40 is too low for glucagon to help enough. LVN B stated symptoms of low blood sugar could be nausea and vomiting, aggression, sweating and sleeplessness. LVN B stated the protocol for a low blood sugar reading was for the nurse to initial the MAR to ensure that the blood sugar was checked and was okay. If the blood sugar was not okay and low, then the nurse would administer Glucagon, document in nursing notes and do and E-Interact form. LVN B stated there was not a place on the MAR to indicate emergency glucose was given, only in the nursing notes. If the nurse administered glucagon, the nurse was supposed to re-check it in 15 minutes to see where blood sugar level was and document it in a nursing progress note because it was an issue and also document in the 24 hour report. The doctor would also be contact and if the blood sugar value did not elevate with intervention, notify doctor again to get further orders. LVN B stated she did not remember being told on that date of the low blood sugar of 40 ([DATE]) that there had been a change of condition. She said if an agency nurse was working that morning, she would not have rounded with them because they are always wanting to leave, so I don't remember anything about a low blood sugar. LVN B stated when a resident's blood sugar was low, the charge nurse was supposed to consult with the doctor, then give Glucagon or an orange juice supplement that can push the blood sugars back up, then re-assess the resident. LVN B stated a dangerously low blood sugar was anything below 70. She said blood sugars were documented on the MAR. LVN B stated a change of condition was if a resident's vitals were below their norm or they were restless or in pain. An interview with LVN L on [DATE] at 3:21 PM LVN L stated she was the charge nurse for Resident #3 on the night he died. She had picked up the overnight shift and came in around 11:00 PM on [DATE]. She stated nothing had been reported to her by the afternoon/evening nurse [LVN B]. She said during her first rounds, Resident #3 was asleep in his room but woke up and said hello when LVN L came into the room. Then on her second round about two in the morning, LVN L stated she went into his room and discovered he was not breathing. She said most of the time when she rounded, she went into the residents' rooms and turned the light on and pat them and say hello, just checking. When she did that with Resident #3, she said papacita, when nothing, he did not respond and he had no pulse. LVN L stated they started CPR and someone called 911. EMTs arrived and worked on him for a long time but could not bring him back. LVN L stated there were protocols for hypoglycemia on every resident and if the resident could still talk and was alert, the first protocol was to give oral glucose and if the blood sugar did not come up, Glucagon was available. If the resident was still unresponsive, the nurses could then use glucose gel. She stated it was whatever the facility protocol said on the MAR and it had to be followed step by step. LVN L stated a dangerously low blood sugar was anything less than 70. Once Glucagon was given, LVN L stated the nurse would go back and check the blood sugar in 15 minutes, document the findings in a nursing note all that had been done, call 911 if the blood sugar does not rise and notify the doctor. LVN L stated a change of condition was anything different from the residents' norm. An interview with the DON on [DATE] at 4:40 PM revealed she was working at the facility the morning of [DATE], Resident #3's low blood sugar reading of 40. She stated a CNA came to tell her one of the nurses wanted her help. When the DON got to Resident #3's room, the nurse was at the door and said his blood sugar reading was 40. The DON assessed Resident #3 and his breathing and vitals at that time were normal, But he was doing what they do when their blood sugar is low, like they try to respond but can't, but want to. I told him [Resident #3] he was fine and his blood sugar was low. The DON stated Resident #3 was given Glucagon, and she told the nurse [LVN K] to check it again in 10-15 minutes. When LVN K checked it again, she gave a glucagon injectable, did not know remember what the blood sugar value was. The DON stated, When someone's blood sugar is in the 40s, they can't swallow so I don't like using the gel. The DON stated, So he came back around and it was a normal day after that. The DON stated she felt Resident #3 died because of his disease process. She stated his health was already poor and he had been getting treatment for multiple venous/stasis ulcers and wound care for pressure ulcers. An interview with CNA D on [DATE] at 12:30 PM revealed she was working the morning on [DATE] when Resident #3's blood sugar was 40. CNA D stated she was passing breakfast trays to the rooms and went into Resident #3's room and he was snoring but would not wake up when she tried to rouse him; she felt something was not right. She knew he was a diabetic so went to tell the nurse who was a PRN nurse (LVN K) who came to his room. LVN K also tried to wake Resident #3 up, but he would not wake up and it was then they knew something was wrong. The charge nurse checked his blood sugar and it was 40. CNA D stated she was present when the reading of 40 was done. She said LVN K did the glucose gun on him twice. After that, he woke up, was thirsty and wanted to get up out of bed. Soon after, a family member was present who sat with him in the dining room while he ate, he was talking and chatting with the family member and staff. CNA D stated Resident #3 told LVN K thank you so much for helping him while he was in the dining room, So he perked back up. CNA D stated LVN K told the family member about the low blood sugar and that he needed to be watched by the following shifts and she would leave a note for the nurses on the shifts. CNA D stated she remembered the morning PRN charge nurse telling the afternoon oncoming charge nurse [LVN B] to check Resident #3's blood sugar because it had been 40. Then the very next day, CNA D stated that Resident #3 was gone and they had already picked up his body by the time she got into work CNA D was worried Resident #3 may have died from a diabetic coma and said, I know from experience you need to monitor at least 48 hours. An attempt to interview MD H on [DATE] at 1:34 was unsuccessful; there was no option to leave a voice mail. An attempt to interview PA I on [DATE] at 1:36 PM was unsuccessful and there was no option to leave a voice mail. An interview with the secondary physician extender listed on Resident #3's Face Sheet [PA J] occurred on [DATE] at 1:43 PM. PA J stated she stopped going to the facility three weeks prior and her role was to work in physiatry and rehab only. However, speaking in general terms, PA J stated from a provider's point of view, the facility should notify the doctor for any low blood sugar, they had standing order to follow which included glucose tablet, then they should re-check the blood sugar and call the doctor back to see what they want to do. An interview with ADON E on [DATE] at 1:53 PM revealed she was week new to the facility so her information was limited. ADON E stated for a low blood sugar of 40, the resident would be at risk of a diabetic coma, so the doctor should be contacted to let them know what the charge nurse's interventions were, the blood sugar reading, the medications administered and then find out what they want the charge nurse to do. ADON E stated that for a blood sugar of 40, her nursing judgement would have sent Resident #3 to the hospital. ADON E stated Resident #3 should have been monitored after his change of condition for three days. She said the charge nurse would monitor and look for confusion, diaphoresis (cold and clammy), paleness of skin, confusion, agitation and anxiety. ADON E stated the nurses did chart by exception, but for an acute condition, they were supposed to chart for three days or as long as the treatment was in place. An interview with CNA F on [DATE] at 2:25 PM revealed he remember Resident #3 and was talking to him around 10:00 PM, a few hours before he died. He said they were talking about sports and two local sports teams and nothing seemed off or out of the ordinary. CNA F stated Resident #3 had been in the hospital recently but he did not know what for, but that night, he was up in his wheelchair and then CNA F laid him down for bed before his shift was over. An interview with the VPCS on [DATE] at 2:47 PM revealed after Resident #3's low blood sugar reading of 40 and subsequent intervention of Glucagon, the nurses on the oncoming shifts that day should have been monitoring the resident for signs and symptoms of hypoglycemia such a confusion and lethargy. She stated the shift to shift report should be given between nurses and they were supposed to print out the 24 hour report and utilize that as well when they did their walking rounds for continuity of care. If there was a change in the resident's condition, such as a fall, a blood sugar that had to be recovered for example and there was any intervention done, it should be reported to the oncoming nurse. VPCS stated, That is what I expect for out of the norm, a prudent nurse to communicate to the oncoming shift so there is continuity of care. 2) Record review of Resident #4's Face Sheet (not dated) reflected he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Hypertension, Major Depressive Disorder, Atherosclerotic Heart Disease, Angina Pectoris, Dementia, Generalized Anxiety Disorder, Diabetes, Hyperlipidemia, Schizophrenia and Parkinson's Disease. Resident #4's attending physician was listed as [MD O] and the nurse practitioner was listed as [NP M]. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed no hearing, speech or vision issues, a BIMS score of 03 which indicated severe cognitive impairment, no signs of delirium, psychosis or rejection of care. Resident #4 had no range of motion limitations but did need help from staff with all ADLs. Resident #4 did not have any assessed health conditions related to shortness of breath, did not use oxygen therapy and was not on hospice services. Resident #4 was prescribed high-risk medication which included an antipsychotic, antidepressant and an anticoagulant. Review of Resident #4's care plan initiated on [DATE] and last revised on [DATE] did not reflect any care areas related to respiratory issues or need for oxygen or related interventions. Record review of NP M's last documented visit on [DATE] with Resident #4 reflected a chief complaint/nature of presenting problem as, Leukocytosis (a condition where your blood has too many white blood cells, which fight infections and diseases), AMS, Abnormal labs, falls x 2. Resident #4 had a non-healing ankle wound that was being treated and a recent white blood cell count of 14 and continued leukocytosis. He was on an antibiotic and seen and examined in his room. He reported malaise and workup so far negative. The Nursing staff report decreased appetite. NP M reviewed Resident #1's recent labs from [DATE] and documented, CBC 16.1, 8.5, 25.5, 561; BMP 131, 4.4, 101, 22, 25, 1.1, 68. NP M documented her plan as, Plan 1. Leukocytosis: Workup so far negative. Currently on cefdinir until [DATE]; 2. Obtain blood cultures x 2 both negative, no growth after 5 days; 3. Obtain echocardiogram; 4. Consult hemo/Onco for further workup: new onset leukocytosis, thrombocytosis, anemia, weakness, negative infection workup; 5. Health shake 3 times daily with each meal; 6. Continue weekly lab work as ordered previously; 7. Continue all medication as ordered in PCC. Record review of Resident #4's physician order [initiated by NP M] dated [DATE] reflected, 2-view Chest X-ray to rule out infiltrates (abnormality in the lung). Record review of Resident #4's x-ray-Chest 1-view dated [DATE] reflected it was reviewed by the radiology clinic at 6:01 PM and reported at 6:01 PM. The chest x-ray was noted on the findings to be compared to his last x-ray a year earlier on [DATE]. The findings indicated Resident #4 had widespread bilateral nodular lung opacities (haziness around the lung with nodule growth) and a small right pleural effusion (fluid around the lungs). The impression reflected, There are widespread bilateral nodular lung opacities. This is consistent with severe pulmonary edema or pneumonia. Consider CT correlation to exclude neoplasm. The findings are worse compared with prior. Record review of nursing progress notes from [DATE] for Resident #4 reflected no indication the physician or physician extender [NP M] and RP was notified of Resident #4's chest x-ray results. Record review of the following pertinent nursing notes for Resident #4 reflected: -[DATE] 12:52 PM- Type: eINTERACT SBAR Summary for Providers-Situation : The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: BP 120/70, Pulse:70; R 18; Temp: 97.9; Weight: 202.2 lb; O2 96 %; Blood Glucose: 123.0 . Outcome of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Other; Functional Status Evaluation: General weakness . Primary Care Provider responded with the following feedback: A. Recommendations: obtain Urine for UA with C&S; New Testing Orders: [blank]; C. New Intervention Orders: [blank] [e-signed by LVN A]. - [DATE]- Nurse's Note- PA in facility to visit with her residents today. Information given to PA regarding noted increased weakness and sleepiness. The resident is afebrile and without noted signs and symptoms of respiratory distress. New orders received to obtain urine for UA with C&S to rule out UTI and a 2-view chest x-ray to rule out infiltrates [e-signed by LVN A]. -[DATE]- Upon shift change at [10:05 PM], CNA called this nurse into resident's room. On getting to room, resident found in his wheelchair unresponsive in the bathroom. Resident assessed, put in bed and CPR initiated immediately while the other nurse, [staff] called 911. 911 crew arrived at [10:25 PM] and took over from the nurses. All efforts made by 911 crew to resuscitate the resident failed. The 911 crew left at [11:00 PM]. DON, resident family and MD notified of the change of condition. At [11:30 PM] Police arrived and took report from the nurses. At [midnight] resident pronounced by DON [e-signed by LVN P]. -[DATE]-Resident laying in bed. intubated with IV to right AC. skin cold and clammy. No signs of life present. No respirations, no rise and fall of chest. no carotid or Apical Pulse. Pupils set non-reactive to light. Death pronounced at 12:00 A.M. [e-signed by DON]. An interview with LVN A on [DATE] at 2:27 PM revealed when a charge nurse starts their shift, they should look in the lab book and the radiology book to see who has pending results and then continue to check throughout the shift to see if they have come in. If the charge nurse does not see the results, then they should call and follow up with a phone call. If the findings come back negative, the physician should still be notified to see if there are any new orders. With Resident #4, LVN A could not remember if NP M was notified of his chest x-ray findings. She said the results for Resident #4's x-ray would have come in after her shift was over at 2:00 PM that day. An interview with LVN C on [DATE] at 3:21 PM revealed the results of any x-rays were supposed to be logged under the resident's name in PCC with the results. LVN C stated she was at the facility the night Resident #4 died, but was not assigned to his hall. LVN C stated her shift was over and she heard his nurse calling for help so she went to see what happened and ended up helping the nurse do CPR. LVN C stated when she saw Resident #4, staff had already started CPR and she thought he was already expired by then. An interview with the DON on [DATE] at 4:40 PM revealed she did not remember Resident #4, but if a lab or x-ray came back with abnormal findings or normal findings, the charge nurse should still contact the doctor to let them know the results because the doctor may order antibiotics or prn oxygen. The DON said, But if the resident was already on antibiotics and no respiratory issue, the doctor probably would have just continued with current orders with antibiotics. The DON stated she was not sure what was going on with Resident #4 and she was new to the facility in [DATE]. The DON stated, But if he was already having respiratory issues, the doctor may not have done more intervention, but they should have been notified. An interview with ADON E [DATE] at 1:53 PM revealed she was one week new to the facility so she was not familiar with Resident #4. However, for x-ray results, ADON E stated the doctor should be called with the results regardless if the resident had a pre-existing condition or was already on medications for an infection. She reviewed the x-ray which reflected Resident #4 had lung opacities that were white spots which could mean usually pneumonia. She said it also reflected pulmonary edema which was water in lungs and pleural effusion was water around the lung. ADON E stated, These things are ordered because there was a concern, you would notify them because they doctor might want to change the antibiotic. An interview with the VPCS on [DATE] at 2:47 PM revealed if a resident had known issues to the point where the doctor ordered an x-ray, then the doctor should be contacted with the results of that x-ray. VPCS stated, How do we know there are no new orders because we haven't reached out to the doctor? An interview with NP M on [DATE] at 3:27 PM revealed she recalled that Resident #4 was not critical but she remembered doing a workup on him and was surprised he had passed way. She said he had a slightly elevated white blood cell count on [DATE] prior to his death but he was not on her radar to be declining. NP M stated, As a matter of fact, he walked and went to the dining room every day. NP M remembered ordering a chest x-ray on the day of his death and thought she got the results, but then said she may have been notified after his death. She reviewed her clinical notes and charting system and looked at the x-ray image and findings. NP M then stated she had seen Resident #4 on [DATE] and he died later that night. She said she did not see where his chest x-ray results were told her prior to his death but she was notified when he died. When she had seen Resident #4 that morning on [DATE], she ordered a work up on him. He had an elevated white blood cell count and the nursing staff said he had altered mental status and recent falls. NP M stated Resident #4's labs had been abnormal prior to that visit because he had recently been in the hospital for an ankle wound which caused the elevated white blood cell count. When Resident #4 returned to the facility, his WBC was 15.2 and stayed that way but she did blood cultures and the WBC count started trending down. When NP M saw Resident #4 on [DATE], his WBC was 14 and he had no issues with breathing that she observed. She stated the chest x-ray she ordered was standard procedure to look for something. NP M stated she thought Resident #4 had pneumonia back in February 2024, so if she was looking for something going on, she would typically order a 2-view x-ray, a UA and some lab work. She stated on [DATE], Resident #4 was already on cefdinir, an antibiotic for the ankle wound. When she reviewed the x-ray she ordered during the interview, she stated, I am thinking it came back after he expired. I am reading it now. Looks like he had pulmonary edema. He was not short of breath when I saw him, that would have been a whole different ballgame. That morning he was up, went to dining room, went to breakfast and then he came back to his room and going to the bathroom. NP M continued and stated, You can get flash pulmonary edema and they can literally die right on the floor. It can happen for whatever reason, maybe a little CHF, fine one minute, not the next. NP M said with flash pulmonary edema, usually there would be a report that the resident was foaming at the mouth and that was flash edema. She said there were no reports of that. NP M stated she was working up the change of condition with the two fall and was looking for a possible UTI. She did not feel the WBC was a conce[TRUNCATED]