**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for resident rights. The facility failed to notify the MD when Resident #1, who was a diabetic resident, had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on [DATE] and was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C (three month average of blood sugar) of 13 (normal range is below 5.7). An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication). Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on [DATE] when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital. At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on [DATE]. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's e-chart under the vitals sections reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was re-admitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 [reference range is 65-110). Record review of Resident #1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP was notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Record review of progress notes after the elevated blood glucose level on 09/17/24, reflected Resident #1 was not eating and the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation reflected he was admitted to the ER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed in the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3(three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM, revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CBC, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and his sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization, the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's primary attending physician [Phy B] for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now had a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow up interview with the DON on 10/23/24 at 12:38 PM, revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so PHY B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with PHY B on 10/23/24 at 1:33 PM, revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. PHY B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, PHY B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM, revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM, revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and on her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 09/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-hour communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1C every six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM, revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with another weekend nurse on the hall (name unknown). They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do anything. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A if Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? RN A responded to that CNA that she was overridden by the DON. CNA F stated, Now he was getting worse, [RN A] ended up sending him out. I told her he is a full code and has been like this all day and you have let this happen your whole shift and passing it along to the next shift, so she finally sent him out. It looked like he was dying. He had never been like that before. He had been declining for that past week since I had taken care of him, not eating. CNA F said she had told the weekday nurse earlier in the week to see if maybe they could do a UA or labs, but she did not know if any of that got done. CNA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of five residents reviewed for neglect. 1. The facility neglected to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on [DATE] and was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C (three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility neglected to have a system in place for Resident #1, who was no longer on hyperglycemic medication, to have routine blood glucose monitoring in the facility via daily, weekly or monthly checks for the past 12 months. 4. The facility neglected to complete an Hemoglobin A1C on Resident #1 every six months to monitor any increases in his blood glucose. An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLS to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication) Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP when she completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on [DATE] when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital . At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on [DATE]. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's clinical chart reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was re-admitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 (reference range is 65-110). Record review of Resident #1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP were notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Dietary and nursing progress notes after the elevated blood glucose level reflected Resident #1 was not eating; the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation reflected he was admitted to the ER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3(three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM, revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CMP, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and high sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good on that sugar, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization, the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's attending ([NAME]) for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now has a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow-up interview with the DON on 10/23/24 at 12:38 PM revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so Physician B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with Physician B on 10/23/24 at 1:33 PM revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. Physician B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, Physician B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 9/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew Resident #1 had an BMP lab ordered, but was not aware of the results. She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-hour communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1Csevery six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with some other weekend nurse on the hall. They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do nothing. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A is Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? RN A responded to that CNA that she was overridden by the DON. CNA F stated, Now he was getting worse, [RN A] ended up sending him out. I told her he is a full code and has been like this all day and you have let this happen your whole shift and passing it along to the next shift, so she finally sent him out. It looked like he was dying. He had never been like that before. He had been declining for that past week since I had taken care of him, not eating. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration of his willingness to eat then a change in condition which included him becoming unresponsive. At the hospital, Resident #1 was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility charge nurses across all shifts failed to check Resident #1's blood glucose when he experienced a decline and a change of condition during the two weeks after an abnormal lab glucose value of 334 on 09/17/24 to being sent out to the hospital on [DATE]. Additionally, the facility did not contact the MD or NP to notify them of the elevated blood glucose level. Only prior to calling sending Resident #1 to the ER, did the charge nurse attempt to check Resident #1's blood glucose, but it could not register on the glucometer and indicated HI [high]. 3. The facility failed to have routine blood glucose monitoring in the facility via daily, weekly or monthly checks for Resident #1 for the past 12 months. 4. The facility failed to have a system in place to routinely monitor Resident #1 blood glucose via an A1C lab every six months. An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLS to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication). Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP when she completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on [DATE] when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital . At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on [DATE]. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's clinical chart reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was re-admitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 (reference range is 65-110). Record review of Resident 1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP were notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Dietary and nursing progress notes after the elevated blood glucose level reflected Resident #1 was not eating; the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation from reflected he was admitted to the ER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3 (three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CMP, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and high sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good on that sugar, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization, the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's attending ([NAME]) for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now has a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow up interview with the DON on 10/23/24 at 12:38 PM revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so Physician B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with Physician B on 10/23/24 at 1:33 PM, revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. Physician B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, Physician B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 9/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew Resident #1 had an BMP lab ordered, but was not aware of the results. She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-horu communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1Csevery six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with some other weekend nurse on the hall. They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do nothing. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A is Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had impaired cognition and was a high fall risk, was provided with adequate supervision to prevent her from eloping from the facility. On 10/16/23 Resident #1, who resided on the second floor and used a wheelchair for mobility, used the stairs to get to the bottom floor and was found outside of the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 10/16/23 and ended on 10/20/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 10/30/23, revealed the resident was an [AGE] year-old female, who was admitted to the facility 02/21/2022. Resident #1 had diagnoses which included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes (elevated levels of blood sugar), unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was 00, indicative of severe cognitive impairment. Resident #1 normally used a wheelchair for mobility. Record review of Resident #1's care plan, dated 10/04/23, reflected: Focus: Revised Date: 08/07/22 Resident is at risk for spontaneous fractures r/t my diagnosis of Osteoporosis, osteoarthritis and being a high risk for falls. Goal: Resident will be free from injury/complications r/t osteoporosis daily through next 90-day review. Interventions: Assist with mobility as needed and using assistive devices. Focus: Revised Date: 03/10/2023 Resident at risk for falls r/t to my poor balance, weakness, dementia and osteoarthritis. Non-injury fall on 11/13/22 - trying to get out of bed independently. Resident actual had a fall on 02/22/23. Actual fall 03/09/23. Goal: I will be free from falls during my stay. Interventions: Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Provide me with assistive devices for mobility as needed. Focus: Date Initiated: 10/01/23, Revised 10/30/23: Resident is at risk for elopement looking for people and things that aren't here., Not being able to make good safety decisions. 10/16/23 Goal: I will remain safe within the Unit thru my next review. Goal: At risk for elopement related to: History of Elopement, Wandering. Goal: Will remain safe during placement at facility. Interventions: Encourage family to bring in personal possessions. Involve patient in preferred activities. Redirect patients from doors. Focus: Date Initiated: 10/16/23 Resident is an elopement risk/wanderer as evidenced by History of attempts to leave facility unattended, Impaired safety awareness, Intrudes on the privacy or activities of others. Goal: Resident will be able to be redirected when wandering. Resident will be safe at facility. Interventions: Involve resident in group activities. Provide resident with safe place to wander if necessary. Encourage resident to stay in common areas of building for observation if needed. When wandering, redirect resident to another activity. Focus: Date Initiated 10/17/23 At risk for elopement related to: History of Elopement, Wandering. Goal: Will remain safe during placement at facility. Interventions: Redirect patients from doors. Focus: Date Initiated 10/17/23 Patient is at risk for falls/injuries r/t cognitive impairment, fall history, gait and balance. Goal Resident will acknowledge risks for falling and agree to prevention strategies. Noncompliance with safety needs. Resident will have no falls/injuries daily through next 90day review. Safety measures will be maintained to prevent or lessen any injury from fall. Interventions: Assess for any adaptive equipment needed. Encourage use if necessary. Focus: Date Initiated 10/17/23 At risk for injury d/t wanders: Goal: Resident will be able to be redirected when wandering. Resident will be safe at facility daily during stay. Interventions: Encourage resident to stay in common areas of building for observation if needed. Record review of the facility Incident by Incident report, from 08/01/23 - 10/30/23, revealed Resident #1 eloped on 10/16/23. Review of the facility's Provider Investigation Report dated 10/21/23 reflected the following: Incident Date 10/16/23 at 11:00 AM Social Worker saw Resident #1 ambulating outside the 500 Hallway exit stairwell, presumably after having descended the stairwell from the resident hallways upstairs. This occurred on Monday, October 16, around 11am. Social Worker brought resident back into the facility and close to the nurses. It appears that resident was able to exit the 500 Hallway stairwell after walking down the stairs by herself. Staff reported that they didn't hear an alarm sound, but it's possible that the alarm was drowned out by other call lights or alarms going off at the time. The Assigned CNA of that hallway was, at the time, having a conservation with Director of Nursing and Administrator in the DON office downstairs. Other staff on the second-floor report not hearing alarm that sounds when exit doors pushed. All staff training regarding alarm sounds are responses. Front entryway also locked at all times going forward with codes available for able to minded to enter and exit. Secondary alarms installed to ensure sufficient alarms will sound. Total Fire was contacted to adjust setting on the alarm system. Elopement Books were created and placed at the nurse's station. All residents were reviewed with new wander/elopement assessments. Record review of Resident #1's Elopement Risk Assessment Tool completed on 07/14/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently with or without the use of an assistive device. Resident #1's was cognitively impaired with poor decision-making skills. Resident #1 assessment summary revealed resident was not at risk for elopement. Record review of Resident #1's Elopement Risk Assessment Tool completed on 10/16/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently with or without the use of an assistive device. Resident #1 have hearing, vision, or communication problems. Resident #1 had wandering behaviors. Resident #1 verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors. Resident #1 was at risk for elopement and wandering. Record review of Resident #1's Pain Assessment-Post Incident completed on 10/16/23 revealed no pain reported. Record review of Resident #1's progress notes, documented by RN A on 10/16/23 at 14:41 [2:41PM], reflected: Resident exited the facility through the 500 Hall emergency exit door to the parking lot. She was seen by a staff member and assisted back in the building. On assessment resident has no visible injuries and denies pain. [family member] notified. Record review of Resident #1's progress notes, documented by Social Worker on 10/16/23 at 17:14 [5:14PM], reflected: Seen resident outside, holding on the wall on the side of the building I ran over and gave her my jacket because she said she was cold called DON to let her know that [resident] was outside in her wheelchair was not with her, DON and CNA came with wheelchair. We assist resident back upstairs to her floor. We noticed that she came down. Service hall 500 wheelchair was on top of the steps. [Resident] went downstairs to get outside to the side of the building. Nurse assist [resident] to make sure she does not have any bruising on her. Make sure she was not in pain check vitals Social worker educated staff on elopement reached out to [family member] to notify her about the elopement her that we was concerned that we think that is best for her to go to a memory care unit that has a lockdown system, [family member] would like to go over therapy notes to see how her mother went down the steps. She stated that she will notify me on her next step. If she decides to move her mom. Observation and interview on 10/30/23 beginning at 9:43 AM revealed Resident #1 in the hallway sitting in her wheelchair. Resident #1 was not a good historian and could not recall leaving the facility. Resident #1 denied having any pain. Observation from the 500 Hall stairwell exit door of the facility on 10/30/23 at 10:40 AM revealed exit door on the second level had a 15 second egress release followed by an alarm. Observed a two-story stairwell that leads to the 100 Hall and an exit door. The exit door was located on the left side of the main entrance door. There was some landscaped grass and a small parking lot in front of the facility and then the main service road. Observed the 100 Hall and 500 Hall to have an additional alarm on the back of the door. Interview on 10/30/23 at 11:02 AM with the Maintenance Director revealed when he was made aware of Resident #1's elopement, he was called to check the exit doors and he found all the exits door to be operating correctly. The Maintenance Director stated he was surprised to know Resident #1 was able to go down the stairs, he stated he had never seen Resident #1 walk before. He stated Resident #1 would always be in her wheelchair. The Maintenance Director stated it is unsure how she was able to open the door and the alarms did not go off. He stated he believed someone had gone through the door earlier but had not pulled it all the way to ensure it latched and that was why it did not sound. The Maintenance Director stated staff are not allowed to use the fire exit stairwells, and if they do, they will get a write up. The Maintenance Director stated all the exit doors codes were changed monthly and he would check the doors weekly. He stated after Resident #1's incident, all the exit doors are checked daily by nursing staff and himself. He stated they have added additional alarms on the exit doors that will sound if the doors are not latched within 30 second after being open. He stated he had conducted alarm drills with the Administrator, he stated the drills consist of him opening an exit door and the nurse assigned to the hall will call code pink and find the missing resident. He stated he had conducted 2 drills, he stated they were supposed to have one today 10/30/23; however, the Administrator was out today, so they will complete the drill tomorrow. Interview on 10/30/23 at 11:10AM with RN A revealed he was the nurse assigned on 300 Hall and was the nurse for Resident #1 on 10/16/23. RN A stated on 10/16/23 he was called by the Social Worker and she informed him Resident #1 was found outside leaning on the door by the 500 Hall stairwell exit. RN A stated he had asked Resident #1 how she was able to exit the facility; however, resident would only speak Spanish and it was hard to understand her. RN A stated Resident #1 wheelchair was found by the stairwell on the 500 Hall exit door. RN A stated the last time he observed Resident #1 was around 11:00 AM - 11:15 AM around the nurse's station. RN A stated he could not recall the exact time but it was before lunch time when the Social Worker contacted him. He stated it had to be prior to 11:35 AM because that was the time, he had contacted the doctor to notify him of the elopement. RN A stated Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. RN A stated he was surprised to know Resident #1 was able to ambulate and made it down the stairwell from the second floor. He stated Resident #1 was assessed and no injuries were noted. He stated he did not hear any alarms going off. An attempt was made to contact CNA B on 10/30/23 by phone; however, there was no response. Interview on 10/30/23 at 11:58 AM with CNA E by phone revealed she was the CNA assigned on 300 Hall on 10/16/23. CNA E stated Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. She stated she was on break when Resident #1 eloped. CNA E stated she could not recall the exact time she last seen resident prior to her elopement. CNA E stated when she returned from break Resident #1 was on the hallway around noon. She stated around 1:30 PM she assisted Resident #1 with her ADL's and she appeared fine and did not complain of any pain. CNA E stated she was informed Resident #1 exited through the 500 Hall exit door. She stated she did not hear any alarms go off. Interview on 10/30/23 at 12:23 PM with Social Worker revealed on 10/16/23 around 11:15 AM -11:20 AM she was at the pharmacy store parking lot located next to the facility and from far away she observed someone leaning on the wall closed by the 500 Hall exit stairwell door. She stated the 500 Hall exit stairwell door is located on the left side of the entrance door to the facility. Social Worker stated when she arrived at the facility, she observed it was Resident #1 leaning on the wall. She stated she approached Resident #1 and asked her how she got out; she stated Resident #1 was not able to say how but only said she was cold and wanted to get back inside. She stated she immediately contacted the DON and asked her to bring a wheelchair outside. She stated they took Resident #1 inside around 11:30 AM and was assessed by the nurse. She stated no injuries were noted. Social Worker stated they found Resident #1 wheelchair on the stairwell of 500 Hall. Social Worker showed Surveyor a picture from her phone with a timestamp of 11:42 AM of how they found Resident #1 wheelchair being at the edge of the stairwell on the second floor. She stated when they opened the exit door from the 500 Hall the alarm went off, so they believed someone had gone through the door earlier but had not pulled it all the way to ensure it latched and that was why it did not sound. Interview on 10/30/23 at 12:59 PM with the DON revealed Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. She stated Resident #1 had been working with therapy and has been able to move more and walk with assistance. The DON stated this was the first time Resident #1 had eloped. She stated Resident #1 was last seen right before lunch time around 11:15AM in the hallway. She stated the facility Social Worker found her outside around 11:25 AM. The DON stated Resident #1 was outside for less than 10 -15 minutes. The DON stated they found Resident #1 wheelchair by the 500 Hall stairwell. She stated no one heard any alarms. She stated all staff were re-educated on code pink and alarm drills were done by the Maintenance Director and the Administrator so all staff knew what to do in case a resident went missing. She stated exit door checks were being done daily by the Maintenance Director. Additional alarms were placed on the doors. She further stated there was an elopement assessment done on all the residents after the incidents and there was one additional resident identified and measures were put in place to prevent any further incidents. She stated Resident #1 was placed on 15 minutes safety checks for about 10 days to ensure no other elopement behaviors. Interview on 10/30/23 at 3:26 PM with the Administrator via phone call revealed on Monday 10/16/23 at around 11:00 AM the Social Worker found Resident #1 outside the facility by the 500 Hall stairwell exit. The Administrator stated his understanding was Resident #1 exited through the fire stairwell on the 500 Hall. He stated Resident #1 walked down the stairwell by herself. The Administrator stated there are two doors at the bottom of the stairwell one that leads to the 100 Hall; however, a code was needed to open the door and the other door leads to the outside of the facility. He stated the CNA on the 500 Hall was CNA B; however, during the elopement CNA B was in the DON's office. He stated the exit doors had a 15 second egress in which an alarm will sound if code is not put in and the alarm will stop after 15 seconds. He stated staff are not allowed to use the fire exit stairwells. The Administrator stated Total Fire completed their quarterly fire alarm testing on 10/27/23 and he was able to consult with them regarding additional security alarms. However, in the meantime he had implemented additional alarms on the back of the doors that will go off after 30 second if the doors are not latched correctly. This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/30/23 at 4:45 PM. The DON and the Social Worker were notified. The DON was provided with the IJ template on 10/30/23 at 5:00 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 10/16/2023, Resident Safety Checks, Wandering and Elopements, Monitoring Wandering patients, Elopement binders at the nurse stations and Ensure Exit Stairwells are secure. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Interviews on 10/30/23 from 11:10 AM through 5:20 PM with RN A, Social Worker, CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, LVN I, LVN J, CNA K, LVN L and CNA N who work the shifts of 6:00 AM-2:00 PM and 2:00 PM-10:00 PM were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, emergency preparedness missing person/elopement drills, and door checks. Observation on 10/30/23 at 10:40 AM and then 5:45 PM revealed exit doors on the second level were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There was an additional louder alarm added so they could be heard throughout the facility, if the doors do not latch after being open within 30 seconds the second alarm added will sound. To turn off the alarm a code must be put in. Record review of the facility Resident Safety Checks every 15 minutes for Resident #1, start date 10/16/23 at 12:15 PM through 10/26/23. Record review of the facility Exit alarms checks; All exits, starting date 10/16/23 through 10/30/23, revealed door checks were conducted by Maintenance Director and Nursing staff. Record review of the facility Resident Safety/Exit Alarms drills revealed drills were conducted by the Administrator on 10/16/23 and 10/20/23. Record review revealed an elopement assessment was completed on all the residents on 10/16/23 to identify any additional risk residents. One additional resident was identified as being at risk for elopement. Record review of facility Elopement binder located on the first and second floor nurses station revealed two residents face-sheets which one was Resident #1 being at risk of elopement. Record review of the facility's Elopement/Unsafe Wandering policy and procedure, revised March 2019, reflected the following: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .