**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE].Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect residents by placing them at risk of allergic reaction, decline in quality of life and death. Findings included: Record review of Resident#1's face sheet revealed, she was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Dementia (decline in cognitive function that affects daily living) in other diseases classified elsewhere, unspecified other severity, with mood disturbance (mental health conditions that primarily affect emotional states), unspecified Dementia, unspecified severity, without behavioral, other disturbance, psychotic disturbance (a condition in which one is unable to distinguish what is and is not real), mood disturbance, and anxiety, erosive (Osteo) arthritis (destruction of joint cartilage and bone erosion), other muscle weakness (Generalized), other unspecified lack of coordination, other personal history of Transient Ischemic attack ( caused by a brief blockage of blood flow to the brain) and cerebral and other infarction without residual deficits (blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen). Record review of Resident#1's MDS, dated [DATE] revealed her BIMS score was undetermined. Resident#1's functional limitation in range of motion reflected impairment on one side, coded for lower extremity (hip, knee, ankle, foot). Resident#1's functional abilities for mobility were undetermined. Record review of Resident#1's care plan, undated revealed, she was at risk for communication problem related to Dementia, at risk for impaired cognitive function/dementia or impaired thought processes r/t long term memory loss, Poor nutrition, short term memory loss, Dementia, and impaired decision making. Resident#1 had bowel/bladder incontinence r/t Alzheimer's, Confusion, Dementia, and impaired Mobility. Record review of Resident#1 EMS report, dated 07/20/25 reflected, Dispatched to nursing home for medical emergency. Upon arrival then [Resident#1] one was found in her wheelchair eyes completely swollen shut and family around her. Family reported that patient was found in her bed, by the family, covered in ants. The [Resident#1]had visible ant bites on her neck, face and eyes. The patient had Alzheimer's and was not able to communicate or provide any information. [Resident#1] was transferred to stretcher by EMS via picking patient up from the wheelchair and placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; follow standard and transmission-based precautions to prevent spread of infections for twenty eight residents (Residents #1, #6, #7, #8, #10, #11, #13, #15, #19, #20, #27, #28, #38, #41, #44, #48, #49, #52, #54, #55, #57, #60, #63, #64, #66, #69, #71, and #73) of seventy three residents reviewed for infection and two (Resident #1 and #59) of three residents observed for incontinence care and one (Resident #277) of one resident observed for wound care. The facility failed to identify the outbreak, isolate the residents and perform proper hand hygiene as per CDC guidelines. The facility failed to implement and maintain contact precautions. Residents with gastrointestinal symptoms were participating in group meetings and eating food in the dining room with residents that were not sick. Residents with gastrointestinal illness were in their rooms with residents that were not displaying symptoms. The facility failed to perform proper cleaning and decontamination of infected rooms. The facility failed to report the outbreak to the local authority. The facility failed to have a system in place to evaluate and screen employees for nausea, vomiting and diarrhea symptoms. As a result, the facility experienced an outbreak of suspected norovirus beginning on 03/17/25. 2. The facility failed to ensure CNA E changed her gloves and performed hand hygiene while providing incontinence care to Resident #1 on 03/18/25. 3. CNA A failed to wear appropriate PPE when providing incontinent care for Resident #59 who supposed to be on EBP. These failures place the residents at risk of exposure to possible infectious agents. 4. The facility failed to ensure ADON J donned the appropriate PPE during wound care for Resident #277, who was on enhanced barriers precautions, on 03/19/25. 5. The facility failed to implement and train staff on transmission-based precautions for symptomatic residents. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration and cross-contamination of pathogens and illness. An Immediate Jeopardy was identified on 03/20/25. The IJ template was provided to the facility on [DATE] at 1:40 PM. While the Immediate Jeopardy was removed on 03/24/25, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. Findings Included: 1. Record review of the facility's 24-hour report for 03/17/25 to 03/18/25 reflected Residents #15, #20, #27, #54, #55, #60, #66, and #71 had nausea and vomiting; Resident #19 had vomited twice; Resident #44 had vomited on 03/17/25 and 03/18/2025; Resident #28, #57, and had vomited once; Resident #10 and #11 had diarrhea once and was given Imodium for next diarrhea .; Resident #277 had a new order by physician to test for c.diff [Clostridioides difficile]( a bacterial infection of the colon). Record review of the facility's infection control mapping dated 3/18/25 reflected 21 residents had signs and symptoms of nausea/vomiting or diarrhea. Record review of the facility's 24-hour report dated 03/18/25 to 03/19/25 reflected Resident #7, #15, #27, #32, #50, #54, #56, #64, #60, #71, had nausea, vomiting, and diarrhea. Record review of the facility's 24-hour report dated 03/19/25 to 03/20/25 reflected Resident #8 had an episode of diarrhea; Resident #4 laxative was held due to resident having diarrhea, Resident #51 had vomiting. Resident #41 had a change of condition with diarrhea and new order for Imodium every 6 hours for diarrhea as needed. Resident #57 had administration of laxative held due to diarrhea. Resident #48 had nausea, vomiting, and diarrhea. Record review of the facility's 24-hour report dated 03/20/25 to 03/21/25 reflected Resident #1, #8, #27, #32, #41, #52, #54, #64, were on contact precautions for diarrhea. Resident #277 tested positive for c.diff [Clostridioides difficile]( a bacterial infection of the colon), isolation precautions were in place and she had no diarrhea or gastrointestinal complaints. Resident #48's administration of laxative was held due to loose stool earlier and Zofran was administered. In a confidential group interview on 03/19/25 residents stated that they had experienced loose stools, nausea, and vomiting for the past few days. They stated that they had not been on any isolation precautions, had been given Imodium and Zofran and it helped the symptoms. 2-Record review of Resident #7's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, seizure disorder, and a BIMS score of 8 (moderately impaired cognition). Resident #7 was occasionally incontinent of urine and always continent of bowl. Record review of Resident #7's care plan, dated initiated 03/20/25 revealed a focus area of: Risk for infection r/t Active communicable pathogen (GI SYMPTOMS TO INCLUDE: NAUSEA/VOMITING/DIARRHEA) . interventions included educating resident on handwashing, monitoring for signs and symptoms of active infection, and notify physician. Record review of Resident #7's physician orders revealed an order for enhanced barrier precautions with a start date of 02/28/2025 and a wound to her right shin with a start date of 02/13/25. Record review of Resident #7's POC Response History (CNAs documentation in the resident's chart) revealed Resident #7 had episodes of diarrhea on 03/16/2025 at 1:06 PM, 03/17/2025 at 6:44 PM, 03/19/2025 at 3:56 AM, 12:35 PM, and 9:33 PM and on 03/20/2025 at 2:35 PM. Record review of Resident #7's progress note dated 03/15/2025 at 3:52 AM reflected Resident complaining of nausea at this time. Per standing orders Phenergan 12.5 mg given by mouth. NP notified of nausea . Note dated 03/19/2025 at 2:09 AM reflected Resident has been complaining of loose stool this shift. In an attempt to interview Resident #7 on 03/18/2025 at 10:53 AM revealed she was non-interviewable. Observation of Resident #7 on 03/19/2025 at 9:15 AM revealed she was laying in bed asleep and had a brown stain on the seat of her pant. Further observation revealed Occupational Therapist (OT) AE entered Resident #7's room and asked if she was sick and if she wanted to get up for therapy. Resident #7 replied that she was not sick but she did not have breakfast because her stomach hurt and she wanted to go to therapy. In an interview on 03/19/25 at 10 AM with CNA G revealed she stated Resident #7 did not have any episodes of loose stools/diarrhea or vomiting and was able to use restroom herself. She stated nurses were notified for any change of condition. In an interview on 03/19/25 at 11 AM with RN AD revealed she stated Resident #7 did not have any nausea/vomiting/diarrhea and was on enhance barrier precautions due to a wound on her shin. 2-Record review of Resident #48's Quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke and cognitive communication deficit and BIMS score of 12 (moderately impaired cognition). Resident #48 was frequently incontinent of urine and always continent of bowl. Record review of Resident #48's physician orders revealed an order for Zofran dated 07/15/23: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #48's POC Response History (CNAs documentation in the resident's chart) revealed Resident #48 had episodes of diarrhea on 03/19/2025 at 9:37 PM and 03/21/2025 at 1:45 PM and 8:36 PM. Record review of Resident #48's e-MAR dated 03/18/25 through 03/24/25 reflected, Resident#48 was administered Zofran on 3/19/2025 and 03/20/2025. Record review of Resident #48's progress note dated 03/19/2025 at 6:30 PM reflected Resident was given PRN Zofran and standing order Imodium for loose stoolx3 today . Record review of Resident #48's progress note dated 03/20/2025 at 7:18 PM reflected he was administered Zofran for mild nausea and at 7:28 PM resident's Colace for constipation was held due to loose stool earlier. 3-Record review of Resident #13's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, cognitive communication deficit. Resident #13's BIMS score of 2 indicated her cognition was severely impaired. Resident #13 was frequently incontinent of urine and bowel. Record review of Resident #13's care plan dated 11/18/2024 reflected Resident #13 was at risk for impaired cognitive function/dementia or impaired thought process. Record review of Resident #13's progress note dated 03/21/2025 09:34 reflected Resident was having loose stools. Record review of Resident #13's POC Response History (CNAs documentation in the resident's chart) revealed Resident #13 had episodes of diarrhea on 03/18/2025 at 09:18 PM, 03/19/2025 at 02:27 AM, 03/19/2025 at 10:11 AM, 03/20/2025 at 03:47 AM. Record review of Resident #13's physician orders reflected resident #13 had a standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4mg by mouth, administered every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 4-Record review of Resident #49's Quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female with an initial admission date of 06/07/2022 with diagnoses included Alzheimer's disease, cognitive communication deficit. Resident #49's BIMS score of 4 indicated her cognition was severely impaired. Resident #49 was occasionally incontinent of urine. Record review of Resident #49's care plan dated 06/09/2022 reflected she was at risk for impaired cognitive function. Record review of Resident #49's progress note dated 03/21/2025 09:02 AM reflected resident is experiencing loose stools during patient care. Record review of Resident #49's POC Response History (CNAs documentation in the resident's chart) revealed Resident #49 had episodes of loose stool/diarrhea on 03/18/2025 at 08:56 PM, 03/19/2025 at 07:27 PM, 03/20/2025 at 10:22 AM and 09:59 PM. Record review of Resident #49's physician orders report reflected Resident #49 had a standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4mg by mouth, administered every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 5-Record review of Resident #54's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 03/04/2023 with diagnoses included dementia, cognitive communication deficit. Resident #54 was always incontinent of bowel and urine. Record review of Resident #54's care plan dated 03/07/2023 reflected she had ADL self-care performance deficit, cognitive deficit and physical dependence required. Record review of Resident #54's progress note dated 03/18/2025 04:49 AM reflected resident had nausea and vomiting. Record review of Resident #54' POC Response History (CNAs documentation in the resident's chart) revealed Resident #54 had episodes of loose stool/diarrhea on 03/14/2025 at 12:22 AM and 07:33 PM, 03/17/2025 at 01:02 PM, 03/18/2025 at 02:15 AM, 01:59 PM and 08:17 PM. Record review of Resident #54's order summary reflected resident #54 had an as needed standing order on 03/18/2025 for Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea, Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4 mg by mouth every 4 hours as needed for Nausea and Vomiting. 6-Record review of Resident #73's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 02/12/2025 with diagnoses included dementia, cognitive communication deficit. Resident #73's BIMS score of 3 indicated her cognition was severely impaired. Resident #73 was occasionally incontinent of urine. Record review of Resident #73's care plan dated 02/21/2025 reflected resident had bowel/bladder incontinence related to Dementia. Record review of Resident #73's progress note dated 03/18/2025 04:49 AM reflected resident #73 had nausea and vomiting. Record review of Resident #73' POC Response History (CNAs documentation in the resident's chart) revealed Resident #54 had episodes of loose stool/diarrhea on 03/14/2025 at 12:22 AM and 07:33 PM, 03/17/2025 at 01:02 PM, 03/18/2025 at 02:15 AM, 01:59 PM and 08:17 PM, 03/19/2025 at 01:46 AM and 07:03 PM. Record review of Resident #73's physician orders reflected Resident #73 had standing order on 03/18/2025 for Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 4 mg by mouth every 4 hours as needed for Nausea and Vomiting, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 2 mg by mouth every 6 hours as needed for Diarrhea. 7-Record review of Resident #69's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, and anemia. Resident#69 has a BIMS score of 09/15 indicating moderate cognitive impairment. Record review of Resident #69's care plan, dated 03/20/25, reflected she Focus. Risk for infection r/t Active communicable pathogen (GI SYMPTOMS TO INCLUDE: NAUSEA/VOMITING/DIARRHEA). Goal. Will be free of infection by review date. Will mitigate risk of transmission of a pathogen. Interventions/Tasks. Educate resident/family/caregivers regarding the importance of handwashing. Use soap and water and dry hands using disposable towels. Monitor for sign and symptoms of active infection and notify physician. Record review of Resident #69's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #69's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #69's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident#69 dated 03/18/25 through 03/24/25 reflected, Resident#69 was not administered Zofran and Imodium tablets. Record review of Resident #69's POC Response History (CNAs documentation in the resident's chart) dated 03/17/25 through 03/24/25 reflected Resident #69 had two loose stool/diarrhea on 03/18/25, and one loose stool/diarrhea on 03/19/25. 8-Record review of Resident #6's annually MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, and diabetes mellitus. Resident#6 has a BIMS score of 02/15 indicating sever cognitive impairment. Record review of Resident #6's care plan, dated 02/02/25, reflected she Focus. Has bowel/bladder incontinent r/t Dementia AND Physical ASSIST WITH ADL's. Goal. Will be free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks. Incontinent: check as required for incontinence. Wash, rinse and dry perineum Record review of Resident #6's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #6's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #6's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident #6 dated 03/18/25 through 03/24/25 reflected, Resident#6 was not administered Zofran and Imodium tablets. Record review of Resident #6's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#6 had one loose bowel movement on 03/18/25. 9-Record review of Resident #27's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension, anemia, and diabetes, mellitus. Resident#27 has a BIMS score of 02/15 indicating sever cognitive impairment. Record review of Resident #27's care plan, dated 02/02/25, reflected she Focus. Has an alteration in gastro-intestinal status r/t diarrhea, nausea, vomiting. Goal. Will remain free from discomfort, complications or s/sx related to gastro-intestinal alterations through review date. Will mitigate risk of transmission of a pathogen. Interventions/Tasks. Contact isolation precautions. Record review of Resident #27's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #27's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #27's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident #27 dated 03/18/25 through 03/24/25 reflected, Resident#27 was not administered Zofran and Imodium tablets. Record review of Resident #27's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#27 had one loose bowel movement on 03/20/25. Interview on 03/20/25 at 09:40 AM, CNA A denied residents (Resident#6, Resident #59, Resident#27, Resident#69) had diarrhea in the last four days (03/17/25, 3/18/25, 3/19/25, and 3/20/25). She stated she was notified about the residents' symptoms during the shift change and getting report from the outgoing CNAs. CNA A stated do not have any resident with diarrhea in the unit now. Interview on 03/20/25 at 09:45 AM, LVN C denied residents (Resident#6, Resident #59, Resident#27, Resident#69) had diarrhea in the last four days (03/17/25, 3/18/25, 3/19/25, and 3/20/25). She stated there was no residents with diarrhea in the unit in the last four days. She stated residents (Resident#6, Resident #59, Resident#27, Resident#69) complained of nausea, and vomiting. She stated report the signs and symptoms to DON, MD, and family. In an interview on 03/20/25 at 10:58 AM with CNA N revealed she was out sick, and she denied having any gastrointestinal symptoms. She stated she had. 10-Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she was a 94 -year-old female admitted to the facility on [DATE] with diagnoses included dementia and cognitive communication deficit. Resident #1's BIMS score of 9, which indicated Resident #1' cognition was moderately impaired, Resident #1 was incontinent of bowel and bladder. Record review of Resident #1's Nurse note dated 03/18/25 at 7:02 AM reflected, Resident had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth administered x 1 for diarrhea. Will continue to monitor. Record review of Resident #1' POC Response History (CNAs documentation in the resident's chart) revealed Resident #1 had one episode of loose stool/diarrhea on 3/18/25 at 7:07 AM and another episode on 3/19/25 at 4:21 AM. Interview on 03/20/19 at 8:40 AM, with CNA E revealed that Resident #1 had diarrhea yesterday, CNA E said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 03/20/25 at 08:59 AM, with LVN I revealed that CNA E, on morning shift on 03/18/25 reported to her Resident #1 had diarrhea. She stated Resident #1 had another episode or diarrhea on 03/19/25. In an observation on 03/18/25 at 09:57 AM, CNA E and CNA F entered Resident #1's room to provide peri care. Both staff washed their hands and put on gloves CNA E unfastened the resident brief and she cleaned her front pubic area with several wipes. CNA E with the soiled gloves on she rolled the resident on her side by pushing her by the back, and the thigh. She removed the soiled brief and discarded it. CNA F held resident. CNA E removed and discarded her gloves, she sanitized hands and donned clean gloves, she wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA E removes gloves, sanitized hands, and donned clean gloves. She placed a clean draw sheet and brief under the resident. Both staff then rolled the resident over, and CAN F pulled the clean sheet under the resident. the staff closed the resident brief, repositioned her in bed, and covered the resident. Both staff then removed their gloves and washed their hands. In an interview on 03/18/25 at 10:10 AM, CNA E stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA E stated she contaminated Resident #1's shirt when she pushed her by her back with soiled gloves. CNA E stated failing to provide proper care exposed the resident to infections. CNA E stated she did not realize she had soiled gloves on when she pushed resident to turn her on the side. 11-Record review of Resident #59's quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (High blood pressure), anxiety disorder, and non-pressure chronic ulcer right foot (a persistence open sore or wound that develops on the skin, often on the legs .). Resident#59 has a BIMS score of 01/15 indicating sever cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including incontinent care. Record review of Resident #59's care plan, dated 02/02/25, reflected she Focus. ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds. Goal. Will be free from complications related to infections through the review date. Interventions/Tasks. Use Enhanced Barrier Precautions. Record review of Resident #59's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO status. Record review of Resident #59's physician orders reflected an order dated 03/20/25: Monitor each shift for nausea, vomiting, diarrhea. Notify MD for any of the symptoms. Record review of Resident #59's physician orders reflected an order dated 03/18/25: Zofran oral tablet 4 mg give by mouth every 4 hours as needed for nausea, and vomiting. Record review of Resident #59's physician orders reflected an order dated 03/18/25: Imodium A-D oral tablet 2 mg give by mouth every 6 hours as needed for diarrhea. e-MAR review for Resident#59 dated 03/18/25 through 03/24/25 reflected, Resident#59 was not administered Zofran and Imodium tablets. Record review of Resident #59's Tasks titled Bowel movement/Bowel continence dated 03/17/25 through 03/24/25 reflected Resident#59 had 2 episodes of loose stool/diarrhea on 03/18/25, and 4 episodes of loose stool/diarrhea bowel movement on 03/19/25. Observation on 03/18/25 at 11:01 AM, of Resident #59's incontinent care, provided by CNA A, revealed CNA A washed hands and donned gloves and no gown. There was a signage and supplies for EBP outside of the Resident#59's room at the left side of the entrance. Interview on 03/18/25 at 11:20 AM, CNA A stated Resident #59 has a wound and that way there was a signage and the supplies for EBP in front of the room. CNA A stated she forget to wear required PPE when she went to provide incontinent care for Resident#59. CNA A the risk to resident development of infection. CNA A stated she had been in serviced on EBP. Record review of of CNA A's competency skills revealed she was competent in prevention and control of infections and donning and doffing PPE . 12-Record review of Resident #277's Comprehensive MDS assessment dated [DATE] reflected she was an 84 -year-old female admitted to the facility on [DATE] with diagnoses included pressure ulcer of sacrum, dementia, and cognitive communication deficit. Resident #1's BIMS score of 15, which indicated Resident #277's cognition was intact, Resident #277 was always incontinent of bowel and bladder. In an observation of wound care on Resident #277 by ADON J on 03/19/25 at 12:06 PM, revealed Resident #277 was on Enhanced barriers precautions. There was signage on the right side of the door that informed visitors/staff she was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. ADON J placed gauze, pair of scissors, a calcium alginate dressing (a soft comfortable, highly absorbent dressing), wound cleanser and dry dressing on the bed side table after she cleaned it. ADON J entered the resident's room without any form of PPE, there was PPE cart outside the door of the room. She washed her hand and donned clean gloves and she proceeded to wound care for Resident #277 without wearing gown. She performed wound care without other concerns, she washed hands and left the room. In an interview with ADON J on 03/19/25 at 12:30 PM, she stated she was supposed to wear gown and gloves when providing wound care to resident on enhanced barrier precaution and stated she had failed to do that. She stated failing to wear the proper PPE during wound care created a risk of cross contamination. 13-Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), dementia, and need for assistance with personal care. Resident #28's BIMS score of 3, which indicated Resident #28' cognition was severely impaired. Record review of Resident #28's nurse's note dated 03/17/25 at 11:46 PM, reflected, Vomiting x1 noted. Medical doctor notified. Record review of Resident #28's nurse's note dated 03/11/25 at 6:56 AM, reflected, Resident had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth. Administered x 1 for diarrhea. Will continue to monitor. Record review of Resident #28's POC Response History (CNAs documentation in the resident's chart) revealed Resident #28 had one episode of diarrhea on 3/18/25 at 7:07 AM. Interview on 03/20/25 at 8:59 AM, with CNA F revealed she worked on 03/18/25 on the 6 AM to 2 PM shift on hall 100. She stated Resident #28 had diarrhea when she changed her in the morning. She stated she reported it to the nurse. Interview on 03/20/25 at 8:59 AM, with LVN I revealed on 03/18/25 in the morning she was told by the CNA F that Resident #28 had diarrhea. She stated she notified the physician and received order to give Imodium and to continue to monitor for symptoms. 14-Record review of Resident #63's quarterly MDS assessment dated [DATE] reflected she was a 75-year- old female admitted to the facility on [DATE] with diagnoses included hypertension (elevated blood pressure), osteoarthritis and bipolar disorder. She was cognitively impaired. Review of Resident #63's nurse's note dated 03/18/25 at 6:55 AM, revealed Resident #63 had episode of diarrhea. Medical doctor gave new order to initiate as needed standing order for Imodium 2 mg by mouth. Administered x1 for diarrhea. Will continue to monitor. Record review of Resident #63's POC Response History (CNAs documentation in the resident's chart) revealed Resident #63 had one episode of diarrhea on 3/18/25 at 6:48 AM, and at 6:28 PM and on 3/19/25 at 4:11 PM. Interview on 03/20/25 at 8:59 AM, with CNA F revealed she worked on 03/18/25 on the 6 AM to 2 PM shift on hall 100. She stated Resident #63 had a large loose stool when she changed her in the morning. She stated she reported it to the nurse. Interview on 03/20/25 at 8:59 AM, with LVN I revealed on 03/18/25 in the morning she was told by the CNA F that Resident #63 had diarrhea. She stated she notified the physician and received order to give Imodium and to continue to monitor for symptoms. In an interview with the DON on 03/18/25 at 12:53 PM, she stated she was aware that some residents had symptoms of diarrhea, nausea and vomiting since last night. She stated nurses notified the physician and received order for medication and monitoring. She stated the facility do not isolate residents with symptoms of diarrhea and vomiting if they had less than 3 episodes in 24 hours. In an interview with the Medical Director on 03/18/25 at 03:05 PM, he stated the nurse called him yesterday to report residents with gastrointestinal symptoms (diarrhea, vomiting and nausea). He stated, Norovirus going around. He stated he treated symptoms with medication, and he stated residents with symptoms should isolated, and not eating in the dining with other residents. He stated isolation is a standing order for the facility to prevent spread of the infection. In a follow up interview with the DON on 03/18/25 at 03:47 PM, she stated if a resident had symptoms of diarrhea, nausea and vomiting the staff would monitor, follow doctor's orders, and follow facility protocol which was to isolate resident if having more than 3 episodes of diarrhea. In an email from the Administrator on 03/18/25 at 3:05 PM, reflected the following residents had nausea/vomiting/diarrhea symptoms: Resident#8 and #41- as of the end of the day of 03/19/25 there were no additional residents, and one employee, CNA N, was out sick. In an email from the Administrator on 03/20/25 at 9:23 AM, reflected the following residents had nausea/vomiting/diarrhea symptoms was Residents #6, #10, #11, #15, #19, #20, #27,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of 22 residents reviewed for notification of changes. The facility failed to promptly identify and intervene for an acute change in a resident's condition related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with increased confusion, poor wound healing, hyperglycemia (elevated blood sugar levels), and septicemia (bacterial blood infection). LVN B (Agency Nurse) failed to consult with the physician or physician assistant when Resident #1's blood sugars were greater than 200 on 9/24/2023. LVN A failed to consult with the physician or physician assistant when Resident #1's blood sugars were greater than 200 on 9/25/2023 and 10/18/2023. This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. Moreover, this failure is likely to cause severe injury, serious harm, serious impairment, or death in residents with medical histories positive for sepsis, chronic kidney disease, infections, cancer, and diabetes. This failure resulted in the identification of Immediate Jeopardy (IJ) on 10/27/2023 at 5:30 PM. While the immediacy was removed on 10/30/23 at 8:15 PM, the facility remained out of compliance at a scope of isolated and severity level of actual harm due to the facility's need to monitor the implementation of the plan of removal. Findings included: Record Review of the Resident #1's history and physical, dated 6/16/2022, revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia. Record Review of Resident #1's physician orders on 10/25/2023 at 2:00 PM revealed physician order dated 6/16/2022, reflected blood glucose checks one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone. Record review of Resident #1's September and October 2023 MAR reflected the resident had blood sugars greater than 200 on the following dates: 9/24/2023 3:28 PM - BS 258 checked by LVN B (Agency Nurse) 9/25/2023 11:35 AM - BS 340 checked by LVN A Record review of the MAR dated 09/25/23 Wound care doctor here making rounds, continue wound care, chest x-ray obtained significant findings, right pleural effusion orders sent to doctors' PA await orders. 10/18/2023 8:56 AM - BS 226 checked by LVN A Record review of the MAR revealed that the Blood Glucose was Monitored BS 226.0 - 10/18/2023 08:56 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s) Record review of hospital records, dated 10/23/23, reflected Resident #1 was transported to the emergency department by EMS for hyperglycemia and a foul-smelling sacral decubitus ulcer (pressure injury). Hospital records reflected Resident #1 had a glucose level of 724. Resident #1 was given IV fluid bolus and started on a broad-spectrum vancomycin (antibiotic) and ceftriaxone (antibiotic). The hospital records reflected Resident #1 was started on an insulin drip for hyperkalemia (high potassium) and hyperglycemia (elevated blood sugar). In a telephone interview on 10/25/2023 at 10:10 AM, EMT A reported on the evening of 10/23/2023, Resident #1's visiting family called 911 out of concern for Resident #1's present condition of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. Interview with Resident #1's Family Member on 10/31/23 at 4:00PM revealed on 10/23/2023 at 8:00 PM, Resident #1's visiting family reported to nursing staff their observation of a new wound on the residents' inner thigh and expressed concern about Resident #1's declining condition. Resident #1's family member stated the nurse on duty stated she did not know how the wound occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family member stated they reported their concerns to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family member stated they called 911 out of urgent concern for Resident #1's symptoms of increased confusion, weakness, low appetite, and weight loss. They stated that when EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. The family member stated that the ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). Interview with Resident #1's family member stated EMS arrived at the facility on 10/23/23 to find the resident with a blood sugar greater than 600. After hospital admission, ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). In an interview with the Interim DON on 10/25/2023 at 4:20 PM revealed she never met Resident #1 and was not familiar with her medical history because she started working at the facility on the morning of 10/25/2023. The Interim DON stated she expected for nurses to contact the physician anytime a resident's blood sugar was greater than 200 or lower than 70. DON stated the nurses were expected to monitor and notify the physician when blood sugars were too high because they were the ones doing the finger sticks. In an interview and record review with LVN A on 10/26/2023 at 11:25 AM, LVN A stated she did not notice any change in condition when caring for Resident #1. After record review of the September - October 2023 glucose labs, LVN A identified the spikes in the blood sugar values. When questioned about what parameters of glucose levels should a nurse notify the doctor, LVN A stated values less than 70 or higher than 200 and insulin dependent residents have sliding scale orders. Record review of nursing notes revealed she reported to the RP a decline in the resident's condition for the last 3 weeks but spikes in glucose levels ranging from 226 to 340 were not reported to the RP or the residents' physician as a change in condition. LVN A stated she was following orders to check the residents' glucose once a week. LVN A could not explain why she did not notify the physician of the abnormal results. LVN A stated, I messed up. In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's glucose monitoring orders, MDS, and Care Plan the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated, Unless the resident reports an intolerance for daily testing, then I would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of request for changing glucose testing days for Resident #1. Record review of the physician orders revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications. Review of the facility's policy for Significant Change in Condition, Response, revision dated 06/2019 reflected, the nurse shall use his/her clinical judgment and shall contact the physician based on urgency of the situation. The facility was notified of the identification of an Immediate Jeopardy on 10/27/23 at 5:30PM. The Administrator was provided the immediate jeopardy template on 10/27/23 at 5:30PM. The facility's plan of removal was accepted on 10/28/23 at 9:00AM and included the following: Facility's Plan of Removal Per the information provided in the IJ Template given on 10/27/23, the facility failed to properly identify and intervene for an acute change in a resident's condition related to type two diabetes, resulting in the family calling 911 to transport the resident to the hospital. Immediate Action The Medical Director was notified of IJ on 10/27/2023 at 5:50 pm by the Clinical Resource. Resident 40010 was transferred to the hospital on [DATE]. Family and Physician were aware of the transfer. She is not returning to the facility per the family. Record review of Train the trainer in-service was given by the Clinical Market Leader and completed for company Directors of Nursing, ADON and Clinical Resources. Training and knowledge checks for change in condition/notifications, blood glucose monitoring orders and signs/symptoms of hypo/hyperglycemia will be completed with all nursing staff. This training will be completed by 10/27/23. This training was provided by company Directors of Nursing, ADON and Clinical Resources. This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Record review of all residents requiring oral hypoglycemic medications were reviewed for orders and glucose monitoring. Each of their physicians were contacted and gave orders for daily blood glucose monitoring. Each resident and/or responsible party were notified and consented to the new orders. Orders were placed. Blood sugar thresholds were added to each resident's chart for additional monitoring through [facility electronic medical record's system] An ad hoc meeting regarding items in the IJ template was completed on 10/27/2023. Attendees will include the Medical Director, Clinical Resources, Administrator, and ADON and included the plan of removal items and interventions. The company Directors of Nursing, ADON or Clinical Resource will verify staff knowledge with 10 nursing staff weekly. The Clinical Resource or ADON will verify blood glucose level documentation daily. Diabetic residents receiving oral hypoglycemics will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the Clinical Resource, ADON, and Administrator. The Clinical Resource and Administrator will be responsible for ensuring this meeting is held weekly. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 10/30/2023, the investigator confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring interviews on 10/28/2023 through 10/30/2023 with 8 staff and 3 agency staff across two shifts to include 6AM-2PM, 2PM-10PM (ADON A, CNA A, CNA B, CNA C, LVN C, LVN D, LVN E, DON, and ED) indicated they had been in-serviced on blood sugar parameters and how to identify and report changes of condition. Review of nursing notes revealed the facility notified physicians of the need to change glucose monitoring to daily testing for residents on oral hyperglycemic medications. Physician orders were updated to test diabetic residents' blood sugars daily; it was documented in the nursing notes that residents/RPs was notified and educated about the glucose monitoring risks and benefits. Interview with Executive Director on 10/30/2023 6:47 PM revealed that he did not feel comfortable with making clinical decisions for residents, he trusted his clinical staff to manage that. He stated After Change in Condition (CIC) training he feels more comfortable and understands the importance more proactive in addressing changes in a residents' condition. He stated When the incident with the Resident #1 happened, the family was very upset, and I felt they wanted more than we could offer. We were giving the best care we could for their mother, but their expectations need to be more realistic. In retrospect I feel the situation could have been handled differently. If they would have given us the opportunity to investigate the issue. We originally thought the family was upset about the wound on their mother's leg, not her symptoms at the time. That's why we only self-reported abuse. We have now changed our blood sugar monitoring protocols so we can catch changes earlier. We have a lot of agency clinical staff, so it is difficult for the nurses to know every resident's norm. While the immediate jeopardy was removed on 10/30/2023 at 8:14PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as based on the comprehensive assessment of the resident; in that: The facility failed to promptly identify and intervene for complications of acute hyperglycemia (high blood sugar) for one (Resident #1) of 22 residents reviewed for hyperglycemia related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. Moreover, this failure is likely to cause severe injury, serious harm, serious impairment, or death in residents with medical histories positive for sepsis, chronic kidney disease, infections, cancer, and diabetes. This failure resulted in the identification of Immediate Jeopardy (IJ) on 10/27/2023 at 5:30 PM. While the immediacy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at scope of isolated and a severity level of actual harm due to the facility's need to monitor the implementation of the plan of removal). Findings included: Record review of Resident #1's history and physical, dated 6/16/2022, revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia. Review of Resident #1's care plan, reflected the following: Date revised: 02/07/23, Focus: [Resident #1] has Diabetes Mellitus r/t diabetes mellitus d/t underlying condition with diabetic neuropathy. Goal: Will have no complications related to diabetes through the review date. Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Check skin when assisting with ADLS . Review of Resident #1's physician orders on 10/25/2023 at 2:00 PM revealed physician order dated 6/16/2022, reflected blood glucose checks one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone. Resident #1's September and October 2023 MAR reflected the resident had blood sugars greater than 200 on the following dates: 9/24/2023 3:28 PM - BS 258 checked by LVN B (Agency Nurse) 9/25/2023 11:35 AM - BS 340 checked by LVN A Record review of the MAR dated 09/25/23 Wound care doctor here making rounds, continue wound care, chest x-ray obtained significant findings, right pleural effusion orders sent to doctors' PA await orders. 10/18/2023 8:56 AM - BS 226 checked by LVN A Record review of the MAR revealed that the Blood Glucose was Monitored BS 226.0 - 10/18/2023 08:56 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s) Record review of hospital records, dated 10/23/23, reflected Resident #1 was transported to the emergency department by EMS for hyperglycemia and a foul-smelling sacral decubitus ulcer (pressure injury). Hospital records reflected Resident #1 had a glucose level of 724. Resident #1 was given IV fluid bolus and started on a broad-spectrum vancomycin (antibiotic) and ceftriaxone (antibiotic). The hospital records reflected Resident #1 was started on an insulin drip for hyperkalemia (high potassium) and hyperglycemia (elevated blood sugar). In a telephone interview on 10/25/2023 at 10:10 AM EMT A reported on the evening of 10/23/2023 Resident #1's visiting family called 911 out of concern for Resident #1's present conditions of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. Interview with Resident #1's Family Member on 10/31/23 at 4:00PM revealed on 10/23/2023 at 8:00 PM, Resident #1's visiting family reported to nursing staff their observation of a new wound on the residents' inner thigh and expressed concern about Resident #1's declining condition. Resident #1's family member stated the nurse on duty stated she did not know how the wound occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family member stated they reported their concerns to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family member stated they called 911 out of urgent concern for Resident #1's symptoms of increased confusion, weakness, low appetite, and weight loss. They stated that when EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. The family member stated that the ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection). Interview with Resident #1's family member stated EMS arrived at the facility on 10/23/23 to find the resident with a blood sugar greater than 600. In an interview with the Interim DON on 10/25/2023 at 4:20 PM revealed she never met Resident #1 and was not familiar with her medical history because she started working at the facility on the morning of 10/25/2023. The Interim DON stated she expected for nurses to contact the physician anytime a resident's blood sugar was greater than 200 or lower than 70. DON stated the nurses were expected to monitor and notify the physician when blood sugars were too high because they were the ones doing the finger sticks. In an interview and record review with LVN A on 10/26/2023 at 11:25 AM, LVN A stated she did not notice any change in condition when caring for Resident #1. After record review of the September - October 2023 glucose labs, LVN A identified the spikes in the blood sugar values. When questioned about what parameters of glucose levels should a nurse notify the doctor, LVN A stated values less than 70 or higher than 200 and insulin dependent residents have sliding scale orders. Record review of nursing notes revealed she reported to the RP a decline in the resident's condition for the last 3 weeks but spikes in glucose levels ranging from 226 to 340 were not reported to the RP or the residents' physician as a change in condition. LVN A stated she was following orders to check the residents' glucose once a week. LVN A could not explain why she did not notify the physician of the abnormal results. LVN A stated, I messed up. In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's glucose monitoring orders, MDS, and Care Plan the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated, Unless the resident reports an intolerance for daily testing, then I would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of request for changing glucose testing days for Resident #1. Record review of the physician orders revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications. Review of the facility's policy for Significant Change in Condition, Response, revision dated 06/2019 reflected, the nurse shall use his/her clinical judgment and shall contact the physician based on urgency of the situation. The facility was notified of the identification of an Immediate Jeopardy on 10/27/23 at 5:30PM. The Administrator was provided the immediate jeopardy template on 10/27/23 at 5:30PM. The facility's plan of removal was accepted on 10/28/23 at 9:00AM and included the following: Facility's Plan of Removal Per the information provided in the IJ Template given on 10/27/23, the facility failed to properly identify and intervene for an acute change in a resident's condition related to type two diabetes, resulting in the family calling 911 to transport the resident to the hospital. Immediate Action The Medical Director was notified of IJ on 10/27/2023 at 5:50 pm by the Clinical Resource. Resident 40010 was transferred to the hospital on [DATE]. Family and Physician were aware of the transfer. She is not returning to the facility per the family. Train the trainer in-service was given by the Clinical Market Leader and completed for company Directors of Nursing, ADON and Clinical Resources. Training and knowledge checks for change in condition/notifications, blood glucose monitoring orders and signs/symptoms of hypo/hyperglycemia will be completed with all nursing staff. This training will be completed by 10/27/23. This training will be provided by company Directors of Nursing, ADON and Clinical Resources. This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Residents requiring oral hypoglycemic medications were reviewed for orders and glucose monitoring. Each of their physicians were contacted and gave orders for daily blood glucose monitoring. Each resident and/or responsible party were notified and consented to the new orders. Orders were placed. Blood sugar thresholds were added to each resident's chart for additional monitoring through [facility electronic medical record's system] An ad hoc meeting regarding items in the IJ template was completed on 10/27/2023. Attendees will include the Medical Director, Clinical Resources, Administrator, and ADON and included the plan of removal items and interventions. The company Directors of Nursing, ADON or Clinical Resource will verify staff knowledge with 10 nursing staff weekly. The Clinical Resource or ADON will verify blood glucose level documentation daily. Diabetic residents receiving oral hypoglycemics will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the Clinical Resource, ADON, and Administrator. The Clinical Resource and Administrator will be responsible for ensuring this meeting is held weekly. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 10/30/23, the investigator confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring interviews on 10/28/2023 through 10/30/2023 with 8 staff and 3 agency staff across two shifts to include 6AM-2PM, 2PM-10PM (ADON A, CNA A, CNA B, CNA C, LVN C, LVN D, LVN E, DON, and ED) indicated they had been in-serviced on blood sugar parameters and how to identify and report changes of condition. Review of nursing notes revealed the facility notified physicians of the need to change glucose monitoring to daily testing for residents on oral hyperglycemic medications. Physician orders were updated to test diabetic residents' blood sugars daily; it was documented in the nursing notes that residents/POAs were notified and educated about the glucose monitoring risks and benefits. Interview with Executive Director on 10/30/2023 6:47 PM revealed that he did not feel comfortable with making clinical decisions for residents, he trusted his clinical staff to manage that. He stated After Change in Condition (CIC) training he feels more comfortable and understands the importance more proactive in addressing changes in a residents' condition. He stated When the incident with the Resident #1 happened, the family was very upset, and I felt they wanted more than we could offer. We were giving the best care we could for their mother, but their expectations need to be more realistic. In retrospect I feel the situation could have been handled differently. If they would have given us the opportunity to investigate the issue. We originally thought the family was upset about the wound on their mother's leg, not her symptoms at the time. That's why we only self-reported abuse. We have now changed our blood sugar monitoring protocols so we can catch changes earlier. We have a lot of agency clinical staff, so it is difficult for the nurses to know every resident's norm. While the immediate jeopardy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for one (Resident #1) of one resident reviewed for feeding tube nutrition and care. LVN C placed a temporary GT after Resident #1's GT dislodged on 11/05/22. LVN C failed to obtain an X-ray confirmation, the most accurate method for tube placement verification. LVN C failed to verify and follow facility policy and procedures for when a GT can be replaced within the facility, by whom, or in the hospital. As of 12/05/22, there was no evidence the facility completed nursing training or competency skills checkoffs with LVN C before or after he placed the GT. No training or in-services were conducted with all nursing staff on GT policy and procedure to prevent a recurrence, in that nurses do not reinsert a GT if clogged, becomes dislodged, or use a foreign object to keep the GT hole open. LVN C continued to work every weekend, double shifts through 12/04/22. Resident #1 was hospitalized and had severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall). These failures resulted in an identification of an Immediate Jeopardy (IJ). The DON and E.D. were notified and an IJ template was provided on 12/05/22 at 4:58 PM. While the IJ was removed on 12/06/22, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents with enteral feeding tubes or if tubes not designed or intended for enteral feeding are used for replacement at risk of at risk of actual or potential physical harm. Findings included: A record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions and diagnoses of DM {a group of diseases that result in too much sugar in the blood}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, ESRD {kidneys no longer function well enough to meet a body's needs}, non-Alzheimer's Dementia {a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease}, malnutrition, Depression (other than bipolar), and surgical procedure involving PEG tube placement. Resident #1's BIMS score was 03, which indicated severe cognitive impact per staff assessment. The MDS reflected one-person physical assist with bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. Resident #1 required two-person physical assist with transferring between surfaces and toilet use. The admission MDS assessment reflected Resident #1 presented with a feeding tube. As of 12/05/22, Resident #1 remained admitted to an acute care hospital. A review of Resident #1's digital care plan indicated: - Focus: Has potential nutritional problem r/t poor intake and presence of peg tube [Initiated: 10/26/22; Revision on: 11/08/22] - Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. [Initiated: 11/08/22; Target Date: 11/06/22] Will tolerate ordered diet through the review date [Initiated: 11/08/22; Target Date: 11/06/22] - Interventions: Diet as ordered by the physician. Res is on a MCS, DM2 diet with thin liquids. [Initiated: 10/26/22; Revision on: 11/08/22] Meals in dining room if resident is in agreement. [Initiated: 10/26/22] Monitor and report to MD as needed for any s/s of : decreased appetite, N/V, unexpected weight loss, c/o stomach pain, etc. [Initiated: 10/26/22] Provide assistance (set-up, limited, extensive, total) with meals as needed. [Initiated: 10/26/22] Provide supplements as ordered, Resource 2.0 [Initiated: 10/26/22; Revision on: 11/08/22] A review of Resident #1's clinical physician orders reflected an undated banner Special Instructions: Charge Nurses Res is SKILLED for CELLULITIS TO ABDOMINAL WALL. Pls chart on the infection and site daily and what you are doing to provide care and monitoring at the top of the page. Active clinical physician orders reflected: - Start Date 10/24/22: Enteral Feed orders: - every shift TYPE OF FEEDING TUBE Dx: not eating (d/c date: 10/31/22) - every shift FORMULA: Jevity 1.5 at 40 mL/hr X 22HR to provide 880 cc/cal/day. On at 9PM, Off 8AM for 2 Hrs. Start again 10AM [Hold from 10/31/22 to 11/01/22] (d/c date: 11/02/22) - every shift Check gastric residual prior to each bolus feeding. hold feeding for residual >100 cc and notify MD (d/c date 11/03/22) - every shift check g-tube placement and patency prior to each feeding/flushing/medication administration (d/c date: 11/09/22) - every shift flush tubing with 5 mL-10 mL water between each medication administration [Hold from 10/31/22 to 11/01/22] (d/c date: 11/03/22) - every shift flush G-tube with 30 mL - 50 mL of water before and after medication administration (d/c date: 11/03/22) - every shift mix each medication with 5 - 10 mL of water then administer meds per g-tube (d/c date: 11/03/22) - every shift may crush/combine medication for administration if not contraindicated and mix with 4 oz of water. May use slow push to facilitate consumption (d/c date: 10/31/22) - every shift elevate head of bed at 30-45 degrees while feeding is going on [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every shift rinse syringe after each use [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every night shift every Wed change syringe [Hold from 10/31/22 to 11/01/22] (d/c date: 11/09/22) - every day shift inspect and monitor gastrostomy stoma for signs & symptoms of local infection such as: redness; pain; tenderness; unusual odor; drainage or discharge; hypergranulation of tissue (an excess of granulation tissue that fills the wound bed to a greater extent than what is required and goes beyond the height of the surface of the wound resulting in a raised tissue mass) surrounding stoma. Notify MD if s/s noted (d/c date: 11/09/22) - Start Date 10/24/22: Cleanse G-tube stoma with NSS, pat dry and apply dry dressing every night shift (d/c date: 10/26/22); Cleanse G-tube stoma with NSS, pat dry and apply dry dressing every 24 hours as needed (d/c date: 10/26/22) - Start Date 10/26/22: Clean G-tube site with NSS, pat dry, cover with dry dressing. Initial and date every night shift and when soiled (d/c date: 11/09/22) - Start Date 11/02/22: Abdomen KUB (X-ray performed to assess the abdominal area for causes of abdominal pain) every shift for pain. [Completed 11/02/22] - Start Date 11/02/22: LCS diet, Mechanical soft texture, thin liquids consistency (d/c date: 11/09/22) - Start Date 11/07/22: Hold G-tube flushes/administration until after KUB completed and reported to provider (Completed; d/c date: 11/09/22) - Start Date 11/07/22: Abdomen KUB STAT for PAIN. [Completed 11/07/22] - Start Date 11/07/22: Send to ER for further evaluation and G-tube replacement Review of nurse daily skilled note dated 11/04/22 at 11:00 AM, entered by LVN D indicated . Overall skin description is clean, dry, and intact . PEG-tube intact and patent. Dressing clean dry and intact. No c/o pain or discomfort. Bowel sounds active in all 4 quadrants. A review of the nurse notes for Resident #1 dated 11/05/22 at 9:08 AM, entered by LVN C, indicated Resident #1 refused medications during the morning med pass. Resident #1 was guarding the GT site and stated, I feel a stabbing pain in my stomach. Upon inspection [by LVN C], GT was missing, and the site was closed. LVN C wrote that Resident #1 said she did not pull GT out and must have come out while she was sleeping. Resident #1 refused PRN pain medication when offered by LVN C. The nurse's note reflected LVN C called the NP and was awaiting a callback. A review of the nurse notes for Resident #1 dated 11/05/22 at 9:34 AM, entered by LVN C, indicated, NP called back new order for STAT KUB order placed online and called into [diagnostic laboratory and imaging service provider]. A review of the nurse notes for Resident #1 dated 11/05/22 at 4:41 PM, entered by LVN C, indicated the NP was called and notified of KUB results: The moderate constipation is unchanged. The gastrostomy tube is not clearly visualized LVN C wrote that new orders were received from NP for GI consult and to place a temp cath to the stoma site. A review of the nurse notes for Resident #1 dated 11/05/22 at 5:28 PM, entered by LVN C indicated temp cath placed, verified by air auscultation. 5 cc residual returned. A review of the nurse notes for Resident #1 dated 11/07/22 at 11:54 AM, entered by LVN A, indicated that Resident #1 was crying and stated that her abdomen hurt around the GT site. LVN A reported concern to MD and received orders to hold GT flush until after KUB. Resident #1 ate 80% of breakfast and tolerated all medications by mouth. A review of the nurse notes for Resident #1 dated 11/07/22 at 1:38 PM, entered by LVN A, indicated Change in Condition: Abdominal pain. LVN A entered another nurse note at 2:23 PM that she canceled the KUB and sent Resident #1 to the ER. A review of the emergency department clinical report dated 11/07/22 indicated Resident #1 had abdominal pain that started with peg tube replacement 11/5/22 and was still present and worsening. A review of hospital medical records for inpatient stays dated 11/07/22 to 11/10/22 indicated [Resident #1] had a PEG tube placed about 4 weeks ago . earlier in the last week pulled the PEG tube out herself. It was placed back in. She [Resident #1] has severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall) . [Admitting physician] will remove the PEG tube today (11/07/22). The medical records revealed a Physical Examination of the abdomen severe tenderness to palpation along the indurated area surrounding the PEG tube insertion site. Abdominal wall PEG tube insertion site and green drainage. Large area of induration [a hardening of an area of the body as a reaction to inflammation] surrounding the PEG tube site. The medical records revealed a diagnostic study, CT of the abdomen and pelvis: . Soft tissue thickening about tube in the abdominal wall with multifocal soft tissue air, correlate for infectious process. Assessment and Plan indicated Abdominal wall cellulitis. To consult infectious disease and general surgery due to CT scan showing pockets of air in the abdominal wall. Start IV antibiotics. Record review of a hospital radiology report for Resident #1 dated 11/07/22 indicated: CT abdomen/pelvis. Admit reason - burning in G-tube and abdominal pain. Findings: G-tube in stomach, no inflated balloon is seen. There is soft tissue thickening about the tube in the abdominal wall . correlate for infectious process. Clinical Impression: Abdominal wall infection Record review of a hospital med/surg inpatient nursing record dated 11/07/22 at 9:20 PM indicated [Resident #1] has an IV device that is saline locked for intermittent infusion therapy . Wound A: peg tube stoma; Surrounding Tissue: excoriated (surface of the skin damaged); Interventions: clean with normal saline, change dressing. ABD dressing applied and secured with tape. Patient is confused and kept on removing the dressing. Additional notes indicated peg tube draining stomach content. Stoma is excoriated and no bleeding. Redness observed under the left breast. Documentation dated 11/07/22 at 10:00 PM indicated patient continued to remove dressing and stoma draining gastric content. Documentation dated 11/0/2022 at 11:00 PM indicated patient voiced pain on her stoma. Instructed not to pull on the stoma. Dressing adjusted. A review of the hospital med/surg discharge form dated 11/10/22 indicated discharge Resident #1 to SNF via ambulance with medication reconciliation and education documents. During an interview on 11/15/22 at 1:28 PM, the DON said that Resident #1 was received as a new admit after receiving a new PEG tube. The DON stated the Dietician decided to stop enteral feedings since Resident #1 was eating food orally and tolerating well. The DON stated a nurse notified her that the PEG tube came out, Resident #1 was sent to the hospital to replace the PEG tube and returned with an infection. The DON said before Resident #1 was re-admitted to the SNF, she had pulled the PEG tube out again and was sent back to the hospital. The DON was not present when Resident #1 was sent to the hospital on [DATE] or 11/14/22, it was her first day back to work (11/15/22); therefore, had not seen the abdominal wound. An interview and observation on 11/16/22 at 12:07 PM at the hospital revealed Resident #1 in bed receiving incontinent care from a skilled nurse and patient care representative. Resident #1 appeared confused and required cues and prompted to follow instructions. Resident #1's abdomen and left breast fold present skin breakdown with pink/white discoloration and crusting. An approximate 5 cm diameter opening in the mid-upper right abdomen, packed with wound gauze, was observed when the skilled nurse pulled back the dressing for investigator visualization of the wound site. Resident #1 could not hold a meaningful conversation and was considered non-interviewable. During an interview on 11/17/22 at 11:37 AM, ADON M said she was familiar with Resident #1, but was out for family emergency when the resident sent out to the hospital on [DATE] and 11/10/22. ADON M stated her understanding of the policy was to notify the MD, and to send the resident to hospital if GT dislodged. ADON M stated she has not trained any nurses, received training, or performed skills check off with nurses on GT placement. ADON M stated she did not think nurses replacing a GT in the facility was part of policy and procedure. ADON M stated during walking rounds on 11/14/22, Resident #1 was observed sitting up to the WC. ADON M said that LVN A had told her about Resident #1's skin condition on return from hospital, 11/11/22 and ADON M wanted to see the wound site during dressing change. ADON M said that she discovered the skin damage surrounding the opening of the old PEG site. ADON M described the skin damage as inflamed, pale discoloration. ADON M stated that she had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. During an interview on 11/17/22 at 12:14 PM, LVN A said that she was familiar with Resident #1. LVN A stated she sent Resident #1 to the hospital on [DATE] after the resident was observed in the fetal position, crying, holding stomach, complaining of pain - rated pain level a 12 and a 15, on a scale of 1 - 10. LVN A said that upon assessment, she discovered bulging around the peg site that felt hard to touch. LVN A said that she also noticed the PEG tube was different from the initial PEG tube and noted some dull greenish drainage around the peg insert site. LVN A said after reading progress notes she found that LVN C had replaced the PEG tube after it was pulled out on 11/05/22. LVN A said that she was not aware that LVNs were allowed to replace PEG tubes, never received training, or was checked off for competency in replacing PEG tubes. LVN A said that she notified the NP, called for a KUB as ordered, and the resident was sent to the hospital shortly after. During a telephone interview on 11/17/22 at 2:03 PM, the DON said that she worked with LVN C at another facility and hired him on at this SNF. The DON said that at the other facility, the nurses were allowed to replace PEG tubes, but did not complete competency skills check off for PEG tube placement at this facility. The DON said that she placed a call to LVN C to send a copy of skills check off from other facility. The DON stated that this facility policies allow nurses to place G-tubes as needed. During an interview on 11/17/22 at 2:57 PM, LVN B said she had never replaced, received training or competency skills check off for GT placement. A record review of weekend schedules revealed LVN C worked the weekends of 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. A record review of an In-service Training Report dated 12/01/22, subject: G-Tube, was conducted by ADON M, ADON N, and the DON. There was one resident currently admitted to the facility with a GT. Resident #1 remained in the hospital. The attendance record reflected seven nurses attended - LVN A, LVN D, RN K, LVN G, LVN F, and RN L, who worked the day of the In-service Training. LVN C did not attend on that day. During an interview on 12/05/22 at 9:00 AM, the DON said that she was unaware that LVN C replaced Resident #1's GT prior to surveyor entrance and after reading the 24-hour report for the weekend of 11/05/22 and 11/06/22. The DON said her expectation for the nursing staff was to send residents out and not to replace GT without training and skills check off. The DON said she would conduct training and skills checkoff herself or arrange with an approved trainer to host classes on GT placement. The DON stated the P & P reflected the procedure on GT replacement was to send a resident to the hospital. The DON said that skills training for GT replacement was necessary for competency and to prevent harm to residents. The DON indicated that no trainings or competencies were provided to LVN C. The DON verified LVN C worked each weekend as scheduled following the placement of the temporary catheter - 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During a phone interview on 12/05/22 at 10:43 AM, the NP said that she received a couple of calls from the SNF regarding Resident #1 pulling her GT out. The NP said that she gave LVN C orders to follow SNF P & P and to send Resident #1 to the hospital. The NP said she did not give LVN C orders to place a temporary cath or temporary GT. The NP stated the risk of PEG tube replacement if a nurse does not have the training or skills is accidental peritoneal (the tissue that lines the abdominal wall and pelvic cavity) placement of the tube. Also, the resident can get an infection or aspirate on stomach contents if the GT is placed incorrectly and used. During a phone interview on 12/05/22 at 11:16 AM, LVN C indicated that Resident #1 did not want to take meds by mouth and asked to be administered by GT. LVN C stated he raised the sheet, discovered that GT was not in place, and found it on the floor beside the bed - the GT bulb still inflated. LVN C stated he did not recall entering an order from the NP to place a temp cath. LVN C said he verified placement by air auscultation and stomach content withdrawal. LVN C said he discovered leaking around the GT site from the end of the temp cath he placed when he assisted Resident #1 up to the wheelchair. LVN C stated the dressing around the GT site was a little saturated with pink colored gastric content from breakfast. LVN C said he retrieved and placed a [NAME] Valve Closed Enteral Tube Valve [a three-way stop cock intended for use in conjunction with gastric or feeding tubes and maintains a closed system] at the end of the temp cath to prevent leaking and changed the dressing around the cath insert site. LVN C said he had to change the dressing again after an hour due to leaking. LVN C said that he did not receive training or skills checkoff for temporary cath placement or GT replacement at this SNF. LVN C stated the risk of replacing the GT is inserting it in the wrong place, or the resident could be allergic to the material. LVN C verified working the following weekends: 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During an interview on 12/05/22 at 12:42 PM, ADON N indicated nursing staff was not allowed to insert/replace a GT. ADON N said he recently conducted an in-service on 12/01/22 with nurses, reviewing the policy that stated nursing staff should not use a DeClogger to clear obstructed GTs, replace, or place foreign objects in GT entry sites to prevent from closing. ADON N stated he had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. During an interview on 12/05/22 at 3:16 PM, LVN D stated she would call the physician if a GT became dislodged. She stated if the physician ordered her to place a temporary catheter, she would find someone to help her as she has never inserted a GT or catheter into a resident's stoma before. LVN D stated she did not know the facility's P&P related to nursing staff inserting a GT. An attempt on 12/06/22 at 4:00 PM to reach the Medical Director by telephone was unsuccessful. Review of the facility's Gastrostomy Tube Nursing Clinical Policy/Procedure, policy number: NCLN; revised 10/2020 indicated the following: Procedures: Daily checklist for gastrostomy tubes: - Check for pain, discomfort, or pressure around the tube site. - Check the tube exit site for skin irritation, inflammation, or other signs of infections, gastric leakage, or feeding formula leakage . - Report Changes in GI Symptoms - Report changes in GI Symptoms to the physician immediately. These symptoms may indicate feeding tube malfunction or improper tube placement. The policy did not reflect procedures for nursing staff to replace a GT after dislodgement. A record review of ASPEN Safe Practices for Enteral Nutrition Therapy practice recommendations and rationale for monitoring the feeding tube https://aspenjournals.onlinelibrary.[NAME].com/doi/epdf/10.1177/0148607116673053 Reflected the following: Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for verification of tube placement when concerns arise regarding dislodgement or placement. The E.D. and DON were notified on 12/05/22 at 4:58 PM that an IJ situation was identified due to the above failures and an IJ template was provided. The facility's Plan of Removal was accepted on 12/06/22 and included: - The facility completed staff education on the facility's policy regarding gastrostomy tubes in that the facility does not allow nurses to reinsert gastrostomy tubes (12/05/22) - An audit of all residents with gastrostomy tubes (12/05/22) - LVN C suspended and will not work until he has met with the DON and received training (12/05/22) - New hire/agency orientation packet enhanced to include the facility's GT policy on dislodgement and methods allowed to clear an obstructed GT (12/05/22) - An ad hoc meeting with QAPI Committee regarding the items in the IJ Template (12/05/22) On 12/06/22 the surveyor confirmed the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with nurses on 12/06/22 [LVN A at 2:09 PM; LVN D at 2:12 PM; LVN E at 2:16 PM; LVN F at 2:25 PM; LVN G at 2:40 PM; RN K at 3:00 PM; RN I at 3:39 PM; and LVN J at 3:50 PM] indicated they participated in an in-service training about gastrostomy tubes. The nurses stated their understanding of the procedure was to send residents to the hospital, and nurses are not to reinsert a GT. Each nurse said in their own words that they would assess the resident, call the physician, and send the resident out to ER if GT becomes dislodged. On 12/06/22 at 1:50 PM, the E.D. and DON were informed the IJ was removed; however, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nurses had 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 one (Resident #1) of one resident reviewed for monitoring and care of feeding tubes. LVN C placed a temporary GT after Resident #1's GT dislodged on 11/05/22. LVN C failed to obtain an X-ray confirmation, the most accurate method for tube placement verification. LVN C failed to verify and follow facility policy and procedures for when a GT can be replaced within the facility, by whom, or in the hospital. As of 12/05/22, there was no evidence the facility completed nursing training or competency skills checkoffs with LVN C before or after he placed the GT. No training or in-services were conducted with all nursing staff on GT policy and procedure to prevent a recurrence, in that nurses do not reinsert a GT if clogged, becomes dislodged, or use a foreign object to keep the GT hole open. LVN C continued to work every weekend, double shifts through 12/04/22. Resident #1 was hospitalized and had severe abdominal wall pain with induration (area of hardness or deep thickening of the skin, that can result from edema, inflammation, or infiltration) and cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin of the abdominal wall). These failures resulted in an identification of an Immediate Jeopardy (IJ). The DON and E.D. were notified and an IJ template was provided on 12/05/22 at 4:58 PM. While the IJ was removed on 12/06/22, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm. Findings included: A record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had medically complex conditions and diagnoses of DM {a group of diseases that result in too much sugar in the blood}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, ESRD {kidneys no longer function well enough to meet a body's needs}, non-Alzheimer's Dementia {a decline in mental ability severe enough to interfere with daily life - Alzheimer's is a specific disease}, malnutrition, Depression (other than bipolar), and surgical procedure involving PEG tube placement. Resident #1's BIMS score was 03, which indicated severe cognitive impact per staff assessment. The MDS reflected one-person physical assist with bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. Resident #1 required two-person physical assist with transferring between surfaces and toilet use. The admission MDS assessment reflected Resident #1 presented with a feeding tube. As of 12/05/22, Resident #1 remained admitted to an acute care hospital. A review of Resident #1's clinical physician orders reflected the following: - Start Date 11/07/22: Hold G-tube flushes/administration until after KUB completed and reported to provider (Completed; d/c date: 11/09/22) - Start Date 11/07/22: Abdomen KUB STAT for PAIN. [Completed 11/07/22] - Start Date 11/07/22: Send to ER for further evaluation and G-tube replacement On 11/05/22, LVN C placed a temporary G-tube after Resident #1's G-tube was dislodged. There was no evidence the facility completed nursing training or competency skills checkoffs with LVN C prior to him placing a G-tube. On 11/07/22, LVN A assessed Resident #1's abdomen after complaints of pain and discovered Resident #1's G-tube had been replaced and there was swelling around the peg site, felt hard to touch. Resident #1 was sent to ER and admitted for abdominal infection related to gastric tube replacement. Review of a nurse progress note for Resident #1 dated 11/05/22 at 9:08 AM, entered by LVN C indicated during morning med pass resident was refusing med pass. When asked what was wrong, she stated, I feel a stabbing pain in my stomach. Resident #1 noted to be guarding at G-tube site upon inspection noted residents g-tube to be missing, site is closed resident stated that she didn't pull it out and that it must have come out when she was sleeping. Asked resident if she would like any prn pain mediation but she refused again med pass. Call made to NP awaiting call back . A review of the nurse note for Resident #1 dated 11/05/22 at 4:41 PM, entered by LVN C, indicated the NP was called and notified of KUB results. LVN C wrote new orders were received from NP for GI consult and to place a temp cath to the stoma site. A review of the nurse note for Resident #1 dated 11/05/22 at 5:28 PM, entered by LVN C indicated temp cath placed, verified by air auscultation. 5 cc residual returned. A record review of Resident #1's physician order did not reflect orders on 11/05/22 for a KUB or to place a temporary gastric tube after Resident #1's G-tube became dislodged. A record review of weekend schedules revealed LVN C worked the weekends of 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. A review of the nurse notes for Resident #1 dated 11/07/22 at 11:54 AM, entered by LVN A, indicated that Resident #1 was crying and stated that her abdomen hurt around the GT site. LVN A reported concern to MD and received orders to hold GT flush until after KUB. Resident #1 ate 80% of breakfast and tolerated all medications by mouth. A review of the nurse note for Resident #1 dated 11/07/22 at 1:38 PM, entered by LVN A, indicated Change in Condition: Abdominal pain. LVN A entered another nurse note at 2:23 PM that she canceled the KUB and sent Resident #1 to the ER. During an interview on 11/17/22 at 12:14 PM, LVN A said that she was familiar with Resident #1. LVN A stated she sent Resident #1 to the hospital on [DATE] after the resident was observed in the fetal position, crying, holding stomach, complaining of pain - rated pain level a 12 and a 15, on a scale of 1 - 10. LVN A said that upon assessment, discovered bulging around the peg site that felt hard to touch. LVN A said that she also noticed the PEG tube was different from the initial PEG tube and noted some dull greenish drainage around the peg insert site. LVN A said after reading progress notes she found that LVN C had replaced the PEG tube after it was pulled out. LVN A said that she was not aware that LVNs were allowed to replace PEG tubes, never received training, or was checked off for competency in replacing PEG tubes. LVN A said that she notified the NP, called for a KUB as ordered, and was sent to the hospital shortly after. Review of emergency department clinical report dated 11/07/22 indicated abdominal pain that started with peg tube replacement 11/5/22 and is still present and worsening. During a phone interview on 11/17/22 at 2:03 PM, the DON said that she worked with LVN C at another facility and hired him on at this SNF. The DON said that at the other facility, the nurses were allowed to replace PEG tubes, but did not complete competency skills check off for PEG tube placement at this facility. The DON said that she placed a call to LVN C to send a copy of skills check off from other facility. The DON stated that this facility policies allow nurses to place G-tubes as needed. Review of LVN C's employee records indicated he was hired on January 7, 2022. The file indicated he was appropriately screened prior to hire and all background checks were done according to the law. There was no evidence of training or completed skills checklist in LVN C's personnel file. During an interview on 12/05/22 at 9:00 AM, the DON said that she was unaware that LVN C replaced Resident #1's GT prior to surveyor entrance and after reading the 24-hour report for the weekend of 11/05/22 and 11/06/22. The DON said her expectation for the nursing staff was to send residents out and not to replace GT without training and skills check off. The DON said she would conduct training and skills checkoff herself or arrange with an approved trainer to host classes on GT placement. The DON stated the P & P reflected the procedure on GT replacement was to send a resident to the hospital. The DON said that skills training for GT replacement was necessary for competency and to prevent harm to residents. The DON indicated that no trainings or competencies were provided to LVN C. The DON verified LVN C worked each weekend as scheduled following the placement of the temporary catheter - 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During a phone interview on 12/05/22 at 10:43 AM, the NP said that she received a couple of calls from the SNF regarding Resident #1 pulling her GT out. The NP said that she gave LVN C orders to follow SNF P & P and to send Resident #1 to the hospital. The NP said she did not give LVN C orders to place a temporary cath or temporary GT. The NP stated the risk of PEG tube replacement if a nurse does not have the training or skills is accidental peritoneal (the tissue that lines the abdominal wall and pelvic cavity) placement of the tube. Also, the resident can get an infection or aspirate on stomach contents if the GT is placed incorrectly and used. During a phone interview on 12/05/22 at 11:16 AM, LVN C indicated that Resident #1 did not want to take meds by mouth and asked to be administered by GT. LVN C stated he raised the sheet, discovered that GT was not in place, and found it on the floor beside the bed - the GT bulb still inflated. LVN C stated he did not recall entering an order from the NP to place a temp cath. LVN C said he verified placement by air auscultation and stomach content withdrawal. LVN C said he discovered leaking around the GT site from the end of the temp cath he placed when he assisted Resident #1 up to the wheelchair. LVN C stated the dressing around the GT site was a little saturated with pink colored stomach content from breakfast. LVN C said he retrieved and placed a [NAME] Valve Closed Enteral Tube Valve [a three-way stop cock intended for use in conjunction with gastric or feeding tubes and maintains a closed system] at the end of the temp cath to prevent leaking and changed the dressing around the cath insert site. LVN C said he had to change the dressing again after an hour due to leaking. LVN C said that he did not receive training or skills checkoff for temporary cath placement or GT replacement at this SNF. LVN C stated the risk of replacing the GT is inserting it in the wrong place, or the resident could be allergic to the material. LVN C verified working the following weekends: 11/05/22 & 11/06/22; 11/12/22 & 11/13/22; 11/19/22 & 11/20/22; 11/26/22 & 11/27/22; and 12/03/22 & 12/04/22. During an interview on 12/05/22 at 12:42 PM, ADON N indicated nursing staff was not allowed to insert/replace a GT. ADON N said he recently conducted an in-service on 12/01/22 with nurses, reviewing the policy that stated nursing staff should not use a DeClogger to clear obstructed GTs, replace, or place foreign objects in GT entry sites to prevent from closing. ADON N stated he had not received training, trained LVN C or any nurses, or performed a skills check-off with nurses on GT placement. Review of the facility's Gastrostomy Tube Nursing Clinical Policy/Procedure, policy number: NCLN; revised 10/2020 indicated: - Procedures: Daily checklist for gastrostomy tubes: Check for pain, discomfort, or pressure around the tube site. Check the tube exit site for skin irritation, inflammation, or other signs of infections, gastric leakage, or feeding formula leakage. Daily treatment or dressings per physician orders. - Report Changes in GI Symptoms Report changes in GI Symptoms to the physician immediately. These symptoms may indicate feeding tube malfunction or improper tube placement. A record review of ASPEN Safe Practices for Enteral Nutrition Therapy practice recommendations and rationale for monitoring the feeding tube retrieved from https://aspenjournals.onlinelibrary.[NAME].com/doi/epdf/10.1177/0148607116673053 reflected: Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for verification of tube placement when concerns arise regarding dislodgement or placement. - The facility completed staff education on the facility's policy regarding gastrostomy tubes in that the facility does not allow nurses to reinsert gastrostomy tubes (12/05/22) - An audit of all residents with gastrostomy tubes (12/05/22) - LVN C suspended and will not work until he has met with the DON and received training (12/05/22) - New hire/agency orientation packet enhanced to include the facility's GT policy on dislodgement and methods allowed to clear an obstructed GT (12/05/22) - An ad hoc meeting with QAPI Committee regarding the items in the IJ Template (12/05/22) On 12/06/22 the surveyor confirmed the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with nurses on 12/06/22 [LVN A at 2:09 PM; LVN D at 2:12 PM; LVN E at 2:16 PM; LVN F at 2:25 PM; LVN G at 2:40 PM; RN K at 3:00 PM; RN I at 3:39 PM; and LVN J at 3:50 PM] indicated they participated in an in-service training about gastrostomy tubes. The nurses stated their understanding of the procedure was to send residents to the hospital, and nurses are not to reinsert a GT. Each nurse said in their own words that they would assess the resident, call the physician, and send the resident out to ER if GT becomes dislodged. On 12/06/22 at 1:50 PM, the E.D. and DON were informed the IJ was removed; however, the facility remained out of compliance at an isolated scope and a severity of actual harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.